Open Journal of Obstetrics and Gynecology, 2012, 2, 311-317 OJOG
http://dx.doi.org/10.4236/ojog.2012.23065 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)
Characteristics of symptoms of imminent eclampsia: A
case referent study from a tertiary hospital in Tanzania
John France, Projestine S. Muganyizi
Department of Obstetrics & Gynecology, Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
Received 24 April 2012; revised 26 May 2012; accepted 10 June 2012
ABSTRACT
Background: Maternal mortality in developing coun-
tries is unacceptably high with eclampsia being con-
sistently among the top causes. As yet, primary pre-
vention of this complication is not possible since
causes of pre-eclampsia are largely unknown and bio-
chemical, hematological and radiological markers
have proved unsuitable for routine prediction of
eclamptic fits. Although headache, visual disturbance,
abdominal pain, nausea, and vomiting are routinely
elicited when managing pre-eclampsia and have been
reported to predict eclamptic fits, the literature at-
tempting to characterize them is scanty. We soug ht to
establish characteristics of the prodromal symptoms
of eclampsia and compare them with similar symp-
toms as experienced by normotensive pregnant women
at Muhimbili National Hospital (MNH) in Tanzania.
Methods: This study was conducted at MNH in 2010
by enrolling 123 eclamptic and 123 normotensive
women. Women in the two groups were interviewed
about their experiences and characteristics of head-
ache, visual disturbances, abdominal pain, nausea
and vomiting using a semi structured questionnaire.
The severity, nature and other characteristics of the
symptoms were assessed using standard scale/meth-
ods and data compared among the two groups. Re-
sults: Prodromal symptoms of eclampsia were pre-
sent in 90% of eclamptic women. Headache was more
frequent among eclamptic women (88%) than the
normotensive (43%), p < 0.001). The symptom was
also more perceived as severe among eclamptic
(46.3%) than the normotensive (5.7%), p < 0.001. The
most frequent location for headache was frontal in
65.7% of eclamptic women compared to frontal
(41.5%) or generalized (39.6%) for the normotensive.
Likewise, visual problems were significantly more
frequent among eclamptic women (39%) compared to
the normotensive (3%), p < 0.001. Upper abdominal
pain was significantly more reported by eclamptic
(36%) than normotensive women (0.9%), p = 0.001.
The general occurrence of abdominal pain, nausea
and vomiting was not significantly different in the
two groups. The time lag from development of a sym-
ptom to eclamptic fit was up to seven days for most
symptoms except visual disturbances of which 98%
developed fits within 12 hours. Conclusion: Whereas
the prodromal symptoms of eclampsia and similar
symptoms in normotensive women were common, the
characteristics of headache and visual disturbance
differ significantly in the two groups. The knowledge
of these differences could be utilized to improve the
quality of management of pre-eclamptic women in
order to prevent eclampsia.
Keywords: Eclampsia; Symptoms; Headache; Blurring
of Vision; Abdominal Pain; Tanzania
1. INTRODUCTION
Pre-eclampsia (PE) is a multisystem hypertensive disor-
der of unknown cause that is unique to human pregnancy.
It is characterized by abnormal vascular response fol-
lowing placentation that leads to functional changes such
as increased systemic vascular resistance, enhanced plate-
let aggregation, activation of coagulation system and
endothelial cell dysfunction [1,2].
Symptoms that accompany pre-eclampsia are a result
of generalized vasospasms, fibrin and platelet deposition
and occlusion of blood flow to vital organs. In severe
cases the liver is affected where sub capsular haemor-
rhage, necrosis and edema of the liver cell occurs pro-
ducing epigastric pain and impaired liver function [3].
The brain becomes edematous and this in conjunction
with vasospasm hypertension and disseminated intra-
vascular coagulation (DIC) can produce cerebral under
perfusion, ischaemia, and necrosis of blood vessel re-
sulting in headaches, visual disturbances and cerebro-
vascular accident [4,5].
Pre-eclampsia affects 5% to 10% of all pregnancies
and is not confined to any population group [6,7]. Glob-
ally eclampsia accounts for 12% maternal mortality

J. France, P. S. Muganyizi / Open Journal of Obstetrics and Gynecology 2 (2012) 311-317 312
mostly in the developing countries where the incidence
of eclampsia is high and quality of care of pre-eclamptic
women is low [8-13]. The case fatality rate for clampsia
is less than 1% in many developed countries and gener-
ally above 5% in developing countries [7,9-12].
The exact incidence of eclampsia in Tanzania is un-
known and the few available data are hospital based. An
estimated 67 cases of eclampsia occur per 10,000 births
in Dar es Salaam community [14]. At Muhimbili Na-
tional Hospital (MNH) where eclampsia is among the top
two causes of maternal mortality the incidence of eclam-
psia ranges from 200 - 504 per 10,000 births with a case
fatality rate of about 5% [14-16].
In spite of intense basic research, the etiology and
pathophysiology of pre-eclampsia and eclampsia is still
not fully understood [17,18]. Currently there are no reli-
able methods suitable for routine screening for both pre-
eclampsia and eclampsia, hence primary prevention of
pre-eclampsia is not possible. The validity of biochemi-
cal, hematological and radiological markers to predict
eclampsia has been practically insufficient to recommend
their routine use [13,18-23]. The absence of clear diag-
nostic markers to predict the risk of progression from
pre-eclampsia into eclampsia has made researchers to
investigate symptoms that can be used to predict the on-
set of eclampsia [21,24-26].
Headaches and visual symptoms, epigastric abdominal
pain, nausea and vomiting have been consistently re-
ported as important premonitory symptoms for eclamptic
fits [24-26]. One systematic review has recently reported
the usefulness of these symptoms in predicting complica-
tions of pre-eclampsia compared with when they are not
present [21,25], but others have cautioned on the reliance
on such routine risk factors to predict maternal outcomes
[27]. Although these symptoms are routinely elicited
when managing pre-eclampsia patients, they are poorly
defined. The few studies that have attempted to investi-
gate premonitory symptoms have neither included de-
tailed descriptions of the individual symptoms nor com-
pared them with similar complaints in normotensive
pregnant women [24]. Moreover, it is well known that
the occurrence of neurological symptoms such as head-
ache and gastrointestinal symptoms of nausea and vo-
miting may be exaggerated in normal pregnancy due to
physiological changes [28-31]. Furthermore, in the trop-
ics such symptoms might be confused with symptoms
due to parasitic infections such as malaria of which
pregnant mothers tend to be vulnerable [8,31]. Given this
background the current study was designed in order to
determine distinguishing clinical features of the prodro-
mal symptoms of eclampsia. Our results were expected
to contribute to improvement in the recognition and
management of severe pre-eclampsia and prevention of
eclampsia.
2. METHODS
2.1. Study Settings
This hospital based case referent study was conducted
from April to August 2010 at MNH in Dar es Salaam,
Tanzania. MNH is one of the four referral hospitals in
Tanzania. It offers specialized obstetric services for Dar
es Salaam city which is the biggest in Tanzania, and its
suburbs. The city of Dar es salaam is estimated to have a
population of 3.4 million people according to the 2002
national population census with an annual growth rate of
4.3%. There are 3 districts in Dar es Salaam; Ilala, Te-
meke and Kinondoni. Each district has a district hospital
which provides emergency obstetric care. However most
of obstetric emergencies in Dar es Salaam are referred to
MNH. In addition patients are also referred from nearby
regions. Apart from the referred patients, a substantial
number of patients with or without obstetric complica-
tion come directly from home.
2.2. Study Sample
For the cases, the population constituted eclamptic women
admitted in ICU at MNH with a diagnosis of Eclampsia.
Eclampsia was defined according to the working proto-
col as development of generalized fits in a woman with a
blood pressure of 140/90 mmHg or higher and proteinu-
ria of + or higher on dipstick without any recognizable
cause. Referents were normotensive women who sought
maternity services (i.e. including mothers cared in labor
ward or due to other obstetric reasons including routine
antenatal clinic attendance) at MNH around the time of
admission of a case to ICU.
All consecutive admissions to ICU with a diagnosis of
eclampsia and who met the criteria were prospectively
enrolled as cases until the desirable sample size was re-
alized. For every enrolled eclamptic woman, one referent
woman who best matched the case in terms of age, parity,
gestation age, status and mode of delivery was identified.
The matching variables corresponded to the status of the
case at the onset of the fit. For example, if the fit oc-
curred before labor, the match was a normotensive preg-
nant woman who is not in labor among mother who were
seeking maternity services at around the time of admis-
sion of the patient and who made the best match with the
rest of matching variables (i.e., age, parity, gestation age).
Mothers were excluded from the study if they were of
unsound mind, had developed eclampsia more than 72
hours after delivery, or could not communicate verbally.
In sample size estimation, we wished to compare the
incidence of visual disturbance among eclamptic women
with the referent women. The incidence of visual distur-
bance was taken as 32% for eclamptics. We hypothesized
that the incidence among referent group of women would

J. France, P. S. Muganyizi / Open Journal of Obstetrics and Gynecology 2 (2012) 311-317 313
be lower, say 15%. Thus the calculated minimum re-
quired sample size would be 216, that is, 108 eclampsia
and 108 referent women assuming 95% confidence and
power of 80% [32].
2.3. Data Collection
Data were collected using interviewer administered semi
structured and checklist questionnaires. Information was
obtained both directly from the women and from the case
notes. Women who had experienced eclamptic fits were
asked their experiences with the occurrence and charac-
teristics of headache, visual disturbances, abdominal pain,
nausea and vomiting preceding their fit(s).
2.4. Data Analysis
Data were coded and entered into computer using Epi
data program. The software used for analysis was IBM
SPSS statistics 19. Comparison of proportions used x2
and Fischer exact test. Continuous or ordinal data were
compared using a t-test with the assumption of equal
variance.
In the analysis, the location of headache was described
according to standard anatomical divisions of the head
and its severity using a four grade scale (4GS). Accord-
ing to the 4GS pain severity was scored as; no pain (0),
mild (1), moderate (3) and severe pain (4). The 4GS has
been found to be as effective as the visual analogue scale
(VAS) by other researchers [33]. Visual symptoms were
characterized as blurring, blind sports, photophobia, and
total blindness consistent with other studies [34-36].
Other symptoms include abdominal pain (type and loca-
tion) and nausea/vomiting.
3. RESULTS
During the study period 130 eclamptic women were
admitted, of which 7 did not fulfill the inclusion criteria.
Thus, 123 were enrolled for the study as cases and were
matched with 123 normotensive women (referents) to
make up a total of 246 women for the study. For ecla-
mptic women, age ranged from 16 to 37 years with a
median of 22 years. The mean gestation age was 35.5
weeks and the mean parity was 2. A total of, 83 (68%)
eclamptic women had delivered and 40 (32%) had not
delivered at the time of interview (Table 1).
Majority of eclamptic women (70%) were between 20 -
35 years of age. Most of them were primipara (68%),
about half of them were at term.
As seen from Table 2, generally a significantly bigger
proportion of eclamptic women presented with morbid
symptoms (90%) compared with normotensive mothers
(54%). Headache and visual problems in particular were
significantly more frequent in eclamptics than in referent
Table 1. Characteristics of eclamptic and normotensive women.
Data presented as n (%).
Characteristic Eclamptic Normotensive Total
Age (yrs)
<20 36 (29.0) 35 (29.0) 71 (29.0)
20 - 35 86 (70.0) 86 (70.0) 172 (70.0)
>35 1 (1.00) 2 (1.00) 3 (1.00)
Parity
Primigravida 82 (67.0) 85 (69.0) 167 (68.0)
Multipara 41 (33.0) 38 (31.0) 79 (32.0)
Gestation Age (weeks)
<28 3 (2.40) 1 (1.00) 4 (2.00)
28 - 37 52 (42.3) 54 (44.0) 106 (43.0)
≥37 68 (55.3) 68 (53.0) 136 (55.0)
Delivery
Delivered 83 (68.0) 86 (70.0) 169 (69.0)
Undelivered 40 (32.0) 37 (30.0) 77 (31.0)
Table 2. The proportion of women presenting with symptoms
of or similar to imminent eclampsia during the index pregnancy.
Data presented as n (%).
Characteristic Eclamptics
n = 123 Normotensive n = 123 p value
Headache
Yes 108 (88.0) 53 (43.0) <0.001
No 15 (12.0) 70 (57.0)
Visual problem
Yes 48 (39.0) 4 (3.00) <0.001
No 75 (61.0) 119 (97.0)
Abdominal pain
Yes 58 (47.0) 47 (38.0) 0.156
No 65 (53.0) 76 (62.0)
Nausea
Yes 74 (60.0) 66 (54.0) 0.303
No 49 (40.0) 57 (46.0)
Vomiting
Yes 76 (62.0) 71 (58.0) 0.516
No 47 (38.0) 52 (42.0)
One or more symptoma
Yes 111 (90.0) 66 (54.0) <0.001
No 12 (10.0) 57 (46.0)
aHeadache, visual problems, abdominal pain and nausea/vomiting.

J. France, P. S. Muganyizi / Open Journal of Obstetrics and Gynecology 2 (2012) 311-317 314
group [(88% vs 43%) and (39% vs 3%) respectively].
Eclamptic headache was characteristically more severe
among cases with a mean score of 2.07 (±0.99 SD)
compared with 0.65 (±0.85 SD), (95% CI: 1.18 - 1.65)
for referents. As can be seen in Tabl e 3, 46.3% of the
cases reported severe headache compared to 5.7% of the
referent group. The location of headache among eclamp-
tic women was mainly frontal (65.7%) in contrast to
frontal (41.5%) or generalized locations (39.6%) for the
referent women.
Table 3. Characteristics of symptoms as experienced by eclamp-
tic and normotensive women during the index pregnancy. Data
presented as n (%).
Characteristic Eclamptics
n = 108 Normotensive n = 53 p value
Headache severity
Mild 12 (11.1) 29 (54.7)
Moderate 46 (42.6) 21 (39.6) <0.001
Severe 50 (46.3) 3 (5.70)
Site of headache
Frontal 71 (65.7) 22 (41.5)
Occipital 4 (3.70) 1 (1.90)
Parietal 11 (10.2) 7 (13.2) 0.01
Vertex 5 (4.60) 2 (3.80)
Generalized 17 (15.7) 21 (39.6)
Site of abdominal pain
Upper 21 (36.2) 4 (8.50)
Lower 32 (55.2) 26 (55.3) <0.001
General 5 (8.60) 17 (36.2)
Type of pain
Dull aching 12 (20.7) 5 (10.6)
Colicky 21 (36.2) 17 (36.2)
Cramping 8 (13.8) 16 (34.0) <0.321
Burning 7 (12.1) 2 (4.30)
Other 10 (17.2) 7 (14.9)
Severity of nausea
Non severe 44 (60.0) 45 (68.0)
Severe 20 (27.0) 15 (23.0) 0.529
Very severe 10 (13.0) 6 (9.00)
Type of vomiting
Projectile 4 (5.00) 0 (0.00) 0.121
Non projectile 72 (95.0) 71 (100.0)
Very few (3%) normotensive women reported visual
problems (Table 3). Regarding eclamptic women who
presented with visual problems, the complaints were
blurring of vision (94%), blind spots (67%), photophobia
(21%) and total blindness (15%).
Although abdominal pain was commonly reported by
both the cases and referent women, upper right quadrant
abdominal pain was significantly more reported by
eclamptic women(36.2%) than the normotensive (8.5%),
p = 0.001. Nausea and vomiting were not significantly
different in occurrence, severity and character among the
two groups.
Among eclamptic women who presented with head-
ache (89%) or abdominal pain (71%), fits occurred
within 7 days of the symptom. Almost all mothers (98%)
who reported visual problems had fits within 12hours.
Most cases of nausea (63%) and vomiting (62%) preced-
ed eclamptic fits by more than 7 days (Table 4).
4. DISCUSSION
Eclampsia continues to lead as a cause of maternal
deaths despite the availability of effective prophylactic
treatment. The clinical challenge lies in predicting which
women with a diagnosis of pre-eclampsia will soon pro-
gress into eclampsia. Headache, visual disturbances, ab-
dominal pain, nausea, and vomiting are the most consis-
tent prodromal symptoms of eclampsia. These symptoms
have the potential to alert health service providers on
Table 4. Time elapse from onset of symptoms to development
of fits among eclamptic women.
Characteristic Number Percent
Headache (n = 108)
0 - 7 days 96 89.0
>7 days 12 11.0
Abdominal pain (n = 58)
0 - 7 days 41 71.0
>7 days 17 29.0
Nausea (n = 74)
0 - 7 days 27 37.0
>7 days 47 63.0
Vomiting (n = 76)
0 - 7 days 29 38.0
>7 days 47 62.0
Visual problems (n = 48)
0 - 12 hours 47 98.0
>12 hours 1 2.00

J. France, P. S. Muganyizi / Open Journal of Obstetrics and Gynecology 2 (2012) 311-317 315
which patient is most likely to benefit from prophylactic
treatment for eclampsia while minimizing potentially
harmful interventions and cost [24,25]. Although the
ability of these symptoms to predict adverse maternal
outcomes is supported by some researchers [21,25] it has
been questioned by others [27]. Moreover, similar symp-
toms are common among normal pregnant mothers and
can be confused with symptoms caused by tropical infec-
tions such as malaria [8,28-31]. With this background it
was imperative to attempt to characterize the prodromal
symptoms and distinguish them from similar symptoms
usually experienced by normotensive women in preg-
nancy.
We found that prodromal symptoms occurred in 90%
of eclamptic women which is within the 41% to 91%
range commonly reported in literature [24,25,37,38]. In
the current study, among the prodromal symptoms, head-
ache was the most experienced (88%) by eclamptic
women which is comparable with the 81% incidence in a
recent study of eclamptic women in Nothern Tanzania
[24]. In addition, our study proves that headache is sig-
nificantly commoner among eclamptic than non eclamp-
tic pregnant women.
Headache and visual disturbance are recognized neu-
rological manifestations of severe pre-eclampsia that
share a common pathophysiological base [22,26,31]. It
was therefore not surprising to note that visual distur-
bance was the second most frequent prodromal symptom
in the current study-a pattern which has been reported by
others [24,34,39]. Among eclamptic women headache
was characteristically frontal and severe with the first
eclamptic fit occurring within one week of its onset in
contrast to headache among the normotensive women in
whom it was frontal or generalized and mild in severity.
There are few studies that have described prodromal
symptoms of eclampsia. Katz and colleagues in USA
noted that eclamptic mothers described headache as “the
worst headache of their lives” [26,31]. Frontal headache
in relation with eclampsia has also been reported by
some [18], but not supported by others who variably de-
scribe it as bitemporal, occipital, diffuse or only occa-
sionally frontal [26,31]. It is unclear whether the differ-
ence is a true variation among study populations or it is
due to study biases. Further studies are needed to clarify
this difference.
Visual problems were reported by two fifth of all
eclamptic women with blurring of vision being the most
common presentation, followed by blind spots, photo-
phobia and total blindness. Although the incidence of
visual problems ranked second to headache, it is the most
ominous symptom as in almost all eclamptic women fits
occurred within 12hours of its onset. This is probably
because the changes like brain oedema, microvascular
thrombosis and necrosis that cause visual symptoms
would almost immediately lead to epileptic fits [22]. In
support to this notion, visual problems were rarely re-
ported in normotensive mothers with only 4 women pre-
sented with visual complaints.
The presentation with upper right quadrant abdominal
pain, was statistically significantly higher in eclamptics
than normotensive mothers probably due to its linkage
with liver pathophysiological changes in severe pre-
eclampsia. Upper abdominal pain, as is the case with
nausea and vomiting, are all linked with liver injury [17,
21,25,26] but the importance of these symptoms in pre-
dicting eclampsia has been unsatisfactory due to low
sensitivity. Other types of abdominal pain, nausea and
vomiting were largely indistinguishable from similar
symptom experiences by normotensive mothers. This
implies that the symptoms represent a more heterogene-
ous group caused by a variety of factors.
The interpretation of our findings is limited in that the
patients’ account on prodromal symptoms was retrospec-
tive hence subject to recall bias. However, a short dura-
tion for the symptoms (during index pregnancy) and the
design to interview the mothers immediately after an
eclamptic fit should have minimized such a bias. Our
decision to interview eclamptic mothers rather than reli-
ance on the case note records is one of the strengths of
this study in contrast to similar studies that have used
retrospective data [21,25-26]. The characteristics of the
prodromal symptoms established by this study could be
used to develop a prediction model for eclampsia in the
process to improve management of pre-eclamptic pa-
tients and prevention of eclampsia.
In conclusion, headache, abdominal pain, nausea and
vomiting are common during pregnancy whether or not
complicated by eclampsia but visual disturbances were
not as common in normotensive mothers. The characte-
ristics of headache and visual disturbances can be reason-
ably distinguished among eclamptics and normotensive
women. Visual disturbance is the most ominous for
occurrence of eclamptic fit within twelve hours. General
abdominal pain, nausea and vomiting are heterogeneous
and not distinguishable among eclamptic and normo-
tensive women.
5. ACKNOWLEDGEMENTS
The authors gratefully acknowledge the cooperation of the participant
mothers, and members of academic staff in the department of Obstetrics
and Gynecology (MUHAS) for useful inputs during proposal develop-
ment and MNH administration for permission to conduct the study.
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