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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 36  |  Issue : 3  |  Page : 468-471

Deep tongue laceration following eclampsia, Cesarean section, repair and blood transfusion- A case report


1 Department of Obstetrics and Gynaecology, Bayero University Kano, Aminu Kano Teaching Hospital, Kano State, Nigeria
2 Department of Anaesthesia, Bayero University Kano, Aminu Kano Teaching Hospital, Kano State, Nigeria

Date of Submission14-Dec-2018
Date of Decision20-Apr-2019
Date of Acceptance07-Nov-2019
Date of Web Publication22-Jan-2020

Correspondence Address:
Dr. M Yusuf
Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJOG.TJOG_95_18

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  Abstract 


Eclampsia still remains an issue of serious concern in Sub Saharan Africa. Preeclampsia is the precursor to eclampsia, in which hypertension and proteinuria are present, with or without oedema1-2. This is a case of Mrs SK, a 21year old Primigravida who was unsure of her last menstrual period, but she was said to be 9 months pregnant; she developed generalized tonic clonic convulsions with each episode lasting about 30 seconds. She sustained a V-shaped laceration affecting lower one third of the tongue with clots of blood on the affected area. A diagnosis of antepartum eclampsia was made. She was admitted into the eclamptic ward and resuscitated. Intravenous infusion and Magnesium sulphate were commenced using Zuspan Regimen. She had an emergency caesarean section and was delivered of a fresh still birth female baby who weighed 3.0kg. The lacerated tongue was repaired by maxillofacial surgeon and she was transfused with 2 pints of blood.
Eclampsia is the leading cause of maternal mortality in developing countries. Recognizing the features of preeclampsia and instituting appropriate measures is mandatory in order to prevent the progression of the disease to eclampsia with its associated complications.

Keywords: Eclampsia; laceration; tongue.


How to cite this article:
Abdullahi H M, Yusuf M, Dayyabu A L, Miko A M. Deep tongue laceration following eclampsia, Cesarean section, repair and blood transfusion- A case report. Trop J Obstet Gynaecol 2019;36:468-71

How to cite this URL:
Abdullahi H M, Yusuf M, Dayyabu A L, Miko A M. Deep tongue laceration following eclampsia, Cesarean section, repair and blood transfusion- A case report. Trop J Obstet Gynaecol [serial online] 2019 [cited 2020 Feb 23];36:468-71. Available from: http://www.tjogonline.com/text.asp?2019/36/3/468/276458




  Introduction Top


Preeclampsia is a condition in which hypertension and proteinuria with or without edema are present in a pregnant woman after 20 weeks of gestation.[1],[2] The occurrence of convulsions or fits in a woman with signs and symptoms of preeclampsia in the absence of underlying neurologic disease is termed eclampsia.[2] Preeclampsia and eclampsia are therefore the manifestations of a spectrum of clinical symptoms of the same condition. Eclampsia remains an issue of serious concern in sub-Saharan Africa.

The incidence of eclampsia varies from one part of the world to another. In developing nations, it ranges from 1 case per 100 pregnancies to 1 case per 1700 pregnancies.[3] Rates from African countries, such as South Africa, Egypt, Tanzania, and Ethiopia, vary from 1.8 to 7.1%.[4]

In Nigeria, the prevalence ranges between 2 and 16.7%.[5],[6],[7] The rates are generally higher in northern than southern Nigeria. A prevalence of between 1.75–5% was reported in Kano.[8],[9] Eclampsia accounted for 31.3% of maternal mortality from a population-based study in Northern Nigeria,[10] and it contributed 46% to maternal mortality in Kano as reported by SOGON in 2004.[11] Eclampsia remains a serious problem in African countries because of so many reasons, including poverty, ignorance, and lack of information on when and where to seek help.[12] The concept of birth preparedness and complication readiness is also not well-practiced in our settings in Africa; therefore, medical interventions may be ineffective because of late presentation of cases.[13],[14],[15]


  Case Report Top


Mrs. SK was a 21-year-old Primigravida who was unsure of her last menstrual period, but she was said to be 9 months pregnant. She was unconscious on admission; therefore, her medical history was obtained from her husband. She was well until a day prior to presentation when she started complaining of a headache, with no associated dizziness or blurring of vision. Her husband went to a chemist and bought paracetamol for her. There was no history of epigastric pain or vomiting.

She subsequently developed generalized tonic-clonic convulsions, with each episode lasting about 30 sec. Mrs. SK had no associated urinary or fecal incontinence. She convulsed twice at home, twice in a maternity clinic, and thrice at a general hospital before they finally came to our center. She was the only wife of her husband, who was a trader. She did not smoke or drink alcohol. There was no family history of hypertension, diabetes mellitus (DM), chronic cough, or sickle cell disease.

She was a young woman, unconscious, pale, anicteric, and febrile (temperature of 38.6°C) with bilateral pitting pedal edema. There was a V-shaped laceration affecting the lower one-third of her tongue with clots of blood on the affected area [Figure 1]. The central nervous system (CNS) examination revealed an unconscious patient with no meningeal signs and no focal neurological deficit. The chest was clinically clear with a respiratory rate of 22 cycles per minute. The pulse rate was 120 beats per minute (BPM), regular and of moderate volume. Her blood pressure (BP) was 170/100 mmHg and heart sounds were I and II only. The abdomen was uniformly enlarged and moved with respiration. The symphysis fundal height was 38 cm and there was a singleton fetus lying longitudinally in cephalic presentation. The fetal head was five fifths palpable per abdomen. There were no palpable uterine contractions. The fetal heart sounds were absent. Pelvic examination revealed normal external genitalia. The cervix was about 3 cm long, firm, and posterior, and the cervical os was closed.
Figure 1: Lacerated tongue with blood clots before repair

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A diagnosis of deep tongue laceration in a patient with antepartum eclampsia was made.

She was admitted into the eclamptic ward and resuscitation was commenced. Intravenous (IV) infusion of magnesium sulfate was commenced using Zuspan's regimen. A Foley's urethral catheter was inserted to monitor the urine output. Prophylactic antibiotics were also commenced.

The following investigations were carried out;

  • Packed cell volume (PCV)- 24%
  • Hemoglobin concentration- 8 gm per deciliter
  • White blood cell count (WBC)- 6.2 × 109/L
  • Differential counts- Normal
  • Platelet count- 240 × 109/L
  • Bedside clotting time- 6 min
  • Random blood sugar- 4.6 mmol/L
  • Electrolytes and urea- Within normal limits
  • Urinalysis was negative for sugar and ketones
  • Proteinuria- 3+.


Two pints of blood were grouped and cross-matched. The patient was planned for an emergency cesarean section (C-section) and repair of the lacerated tongue [Figure 2]. The theatre, anesthetists, and maxillofacial surgeons were informed after obtaining informed consent from the patient's relatives. She had an emergency C-section and delivered a fresh stillbirth female baby weighing 3.0 kg. The maxillofacial surgeon repaired the lacerated tongue and blood transfusion was commenced. She was transferred to the eclamptic ward and continued on magnesium sulfate for 24 h, parenteral antibiotics, and analgesics. She recovered fully within 48 h and graded oral sips were commenced. The second pint of blood was also transfused to her on the second postoperative day. Her vital signs remain stable and she was transferred to the postnatal ward on the fifth postoperative day with a BP of 130/90 mmHg and PCV of 30%. Mrs. SK was subsequently discharged on the tenth postoperative day after the tongue had healed and was given 2 weeks appointment.
Figure 2: The tongue after repair

Click here to view



  Discussion Top


Preeclampsia is a condition associated with hypertension, proteinuria, and edema. The occurrence of convulsions or fits in a woman with signs and symptoms of preeclampsia in the absence of underlying neurologic disease is eclampsia. Mrs. SK was a 21-year-old woman who developed eclampsia at 9 months of gestation. Studies carried out at the University College Hospital, Ibadan and Zaria show that the incidence is higher among Primigravidae and young women less than 25 years of age.[12],[16]

It is a problem of developing the nation with an incidence ranging between 1.75 to 16.7%.[5],[6],[7] Eclampsia accounted for 31.3 to 46%[10],[11] cases of maternal mortality in Northern Nigeria, and it will continue to be a problem in developing countries. This is because of the failure to recognize features of preeclampsia because of poor utilization of available maternity care services. It is also associated with low socioeconomic status of women, inadequately staffed health facilities, lack of birth preparedness and complication readiness, lack of skilled attendance at delivery coupled with inadequate infrastructure, and poor referral systems.[13]

Eclampsia is the leading cause of maternal mortality in developing countries. Recognizing the features of preeclampsia and instituting appropriate therapeutic measures is mandatory if we want to prevent the progression of the disease to eclampsia. It is logical to ensure that pregnant women have access to good antenatal care, skilled attendance at delivery, coupled with the infrastructure that allows effective referral systems and quality care.

Mrs. SK developed symptoms of preeclampsia that were not recognized by her husband, and as such interpreted it as an ordinary headache. She was also taken to two other hospitals and convulsed several times on the way before she finally arrived at our center, where she was admitted, resuscitated, and subsequently delivered. Medical interventions may be ineffective in some cases because of late presentation.[17],[18],[19] The management of eclampsia involves resuscitation, control of convulsions, control of hypertension, correction of electrolyte imbalance, and subsequent delivery of the baby by the quickest and safest means. Mrs. SK was resuscitated and the convulsions were aborted with magnesium sulfate. Various studies have confirmed the efficacy of magnesium sulfate in reducing the risk of progression from preeclampsia to eclampsia and also preventing further fits in eclamptic patients.[20],[21],[22],[23] It also does not appear to cause substantive harmful effects to the mother or baby.[24]

Complications of eclampsia include cerebral edema; stroke; blindness; deafness; pulmonary edema; aspiration pneumonitis; hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome; and disseminated intravascular coagulopathy. Others include acute kidney injury, trauma, and hepatic rupture.[25],[26] Mrs. SK developed deep tongue laceration, which was repaired in the theatre.

Orofacial injuries, such as deep tongue lacerations from eclampsia, are common in sub-Saharan Africa.[27] The majority of these injuries are because of biting or forceful insertion of hard objects into the patients' mouths by relatives. They are more likely to be associated with repeated convulsive episodes and maybe a risk factor for mortality.[27] Obstetricians and other health care providers should be familiar with measures to prevent these injuries in the eclamptic patient and when such injuries occur, seek appropriate and early dental or maxillofacial consultations. There should also be adequate health education of the populace to highlight the dangers of forceful insertion of hard objects into the mouth of eclamptic patients during convulsive episodes to reduce the risk of deep tongue lacerations and other orofacial injuries.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Abdullahi HM, Aliyu LD, Zakari M, Lawal U. A 5 Year review of the prevalence and feto-maternal outcome of eclampsia in Aminu Kano Teaching Hospital. Trop J Obstet Gynaecol 2013;30:13-17.  Back to cited text no. 8
    
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Status of Emergency Obstetric Services in six States in Nigeria. A Needs Assessment Report. SOGON. 2004.  Back to cited text no. 11
    
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Jido TA, Fada S, Galadanci HS, Garba ID. Prevalence and associated factors in the non-utilisation of maternity care services in a rural area of Kano state. Highland Med Res J 2004;2;88-91.  Back to cited text no. 12
    
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Begum MR, Begum A, Quadir E, Akhter S, Shamsuddin L. Eclampsia: Still a problem in Bangladesh. Med Gen Med 2004;6:52-4.  Back to cited text no. 13
    
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Richard F, Witter S, De Brouwere V. Innovative approaches to reducing financial barriers to obstetric care in low-income countries. Am J Public Health 2010;100:1845-52.  Back to cited text no. 14
    
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Olusanya BO, Alakija OP, Inem VA. Non-uptake of facility-based maternity services in an inner-city community in Lagos, Nigeria: An observational study. J Biosoc Sci 2010;42:341-58.  Back to cited text no. 15
    
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Oladokun A, Okewole AI, Adewole IF, Babarinsa IA. Evaluation of cases of eclampsia in university college Hospital Ibadan over a 10 year period. West Afr J Med 2000;19:192-4.  Back to cited text no. 16
    
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Richard F, Witter S, De Brouwere V. Innovative approaches to reducing financial barriers to obstetric care in low-income countries. Am J Public Health 2010;100:1845-52.  Back to cited text no. 17
    
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Olusanya BO, Alakija OP, Inem VA. Non-uptake of facility-based maternity services in an inner-city community in Lagos, Nigeria: An observational study. J Biosoc Sci 2010;42:341-58.  Back to cited text no. 18
    
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The magpie trial: A Randomised placebo-controlled trial. Lancet 2002:1;359;1877-90.  Back to cited text no. 19
    
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Duley L, Gulmezuglu AM, Henderson-Smart D. Magnesium sulphate and other anticonvulsants for women with pre-eclampsia. Cochrane Dabatase Syst Rev 2003;CD000025. doi: 10.1002/14651858.CD000025.pub2.  Back to cited text no. 20
    
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Adewole IF, Oladokum A. Magpie trial follow up study collaborative Group. The magpie trial. A Randomised trial comparing magnesium sulphate and placebo for pre eclampsia. Outcome for women at 2 years. BJOG 2007;114:300-9.  Back to cited text no. 21
    
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Adewole IF, Oladokun A, Okewole AI, Omigbodun AO, Afolabi A, Ekele B, et al. Magnesium sulphate for treatment of eclampsia. The Nigerian experience. Afr J Med Sci 2000;29:239-41.  Back to cited text no. 22
    
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Umezurike CC, Fey WPA, Whittaker RC. Experience with magnesium sulphate for the treatment of eclampsia in Aba, South-East Nigeria. Trop J Obstet Gynaecol 2004;21(Suppl 1):S20.  Back to cited text no. 24
    
25.
Elyoussoufi S, Nsiri A, Salmi S, Miguil M. Liver rupture in peripartum; about 8 cases. J Obstet Gynaecol Biol Reprod (Paris) 2007;36:57-61. Epub 2007.  Back to cited text no. 25
    
26.
Aidemir M, Bac B, Tacyildiz I, Yagmur Y, Keles C. Spontaneous liver haematoma and a hepatic rupture in hellp syndrome; a report of 2 cases. Surg Today 2002;32:450-3.  Back to cited text no. 26
    
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