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Article

Epidemiological Management of Preeclampsia–Eclampsia Cases in the Intensive Care Unit Before and During the Health Crisis

by
Miryam Lora-Loza
1,*,
Jean Neil Hernández Angulo
2,
José Elías Cabrejo Paredes
1,
Maribel Díaz Espinoza
1 and
Jean Carlos Zapata Rojas
1
1
School of Postgraduate Studies, Master’s Program in Health Services Management, Cesar Vallejo University, Trujillo Campus, Trujillo 13001, La Libertad, Peru
2
School of Postgraduate Studies, Cesar Vallejo University, Yurimaguas Campus, Yurimaguas 16501, Loreto, Peru
*
Author to whom correspondence should be addressed.
COVID 2026, 6(4), 65; https://doi.org/10.3390/covid6040065 (registering DOI)
Submission received: 19 December 2025 / Revised: 11 January 2026 / Accepted: 19 January 2026 / Published: 11 April 2026
(This article belongs to the Section COVID Public Health and Epidemiology)
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Abstract

Health crises hinder the provision of intensive care for critical obstetric conditions such as preeclampsia and eclampsia, where timely decision making and system capacity directly impact maternal and fetal outcomes. This study compared the clinical and epidemiological profile and care processes in the ICU for cases of preeclampsia and eclampsia before and during the COVID-19 health crisis in Alto Amazonas, Loreto (Peru), using a comparative mixed-method approach. Quantitative data were obtained from ICU medical records for two periods (2015–2019 and 2020–2022). Categorical variables were compared using exact methods (Fisher’s exact test for 2 × 2 tables and exact procedures for scatter tables with multiple categories), and continuous variables were compared using nonparametric tests where appropriate. The most notable change was an increase in the frequency of cesarean sections during the health crisis, which should be interpreted with caution given the small sample size and potential changes in admission criteria and system limitations. Other clinical indicators and discharge status showed no clear evidence of substantial differences between the periods. Qualitative findings highlighted systemic limitations affecting continuity of care, particularly those related to timely access to safe blood products and referral pathways. These results align with SDG 3 (Good Health and Well-being) and support strengthening preparedness, referral coordination, and the availability of essential resources to protect maternal health during large-scale emergencies.

1. Introduction

Recent health crises have posed unprecedented challenges to health systems, requiring rapid adaptation to public health emergencies and increased hospital demand. In this context, preeclampsia and eclampsia have been identified as critical obstetric complications, characterized by hypertension and proteinuria, which may progress to seizures and lead to fatal consequences for both the mother and the fetus [1]. Worldwide, the incidence of this condition ranges from 2% to 8% of pregnancies and is influenced by genetic, environmental, and socioeconomic factors [2,3]. In Mexico, the incidence of preeclampsia is 47.3 cases per 1000 births. This variability underscores the need to implement region-specific public health strategies to reduce prevalence and improve maternal and neonatal outcomes [4,5]. In this regard, Sustainable Development Goal 3 of the United Nations (UN) emphasizes reducing maternal mortality and ensuring universal access to reproductive health, highlighting the importance of strengthening health systems and antenatal care [6].Global health crises, such as the COVID-19 pandemic, have profoundly affected the capacity and quality of care in intensive care units (ICUs), highlighting the vulnerability of health systems during large-scale emergencies [5]. In Latin America, these crises exacerbated obstetric complications, particularly preeclampsia and eclampsia, which are responsible for high maternal and perinatal morbidity and mortality [7,8]. In Peru, maternal mortality due to preeclampsia and eclampsia increased by 44.4% in 2021, with 133 additional deaths compared with previous years [9,10]. This increase reflected the direct impact of crises on the quality of antenatal and obstetric care, as well as limited access to health services for pregnant women. If not adequately managed, preeclampsia and eclampsia can have fatal consequences, underscoring the urgent need to strengthen medical care, particularly in disadvantaged areas where resource scarcity hinders the management of these critical conditions [11].
In light of the above, it is important to emphasize that the evolution of the epidemiological management of preeclampsia and eclampsia in ICUs reflects changes and advances in strategies, procedures, and outcomes related to the treatment of these conditions during health crisis periods. Before the health crisis, management strategies primarily focused on early identification and treatment based on standardized protocols aimed at reducing maternal and perinatal mortality [12]. However, during the health crisis caused by the COVID-19 pandemic, significant changes occurred in these protocols due to resource restructuring and the implementation of additional safety measures, which affected ICU bed availability and specialized medical staff [13]. Resource scarcity compelled health systems to prioritize the most severe cases and adapt clinical management protocols to optimize outcomes, highlighting the need to develop more flexible and adaptive management strategies during crisis situations [14].
Accordingly, this study examined how the clinical and epidemiological profile and the care processes of patients with preeclampsia–eclampsia admitted to the ICU changed before and during the COVID-19 health crisis in Alto Amazonas, Loreto (Peru), between 2015 and 2022. In this manuscript, epidemiological management refers to an integrated set of surveillance, clinical, and organizational processes used in the ICU to identify, document, and manage preeclampsia–eclampsia cases, including diagnostic documentation, obstetric decision-making, referral pathways, and discharge outcomes. Given the limited mixed-methods evidence from resource-constrained Amazonian settings describing period-related changes in ICU obstetric care, this retrospective mixed-methods clinical–epidemiological study combined a quantitative comparison of ICU cases across both periods with in-depth interviews with local specialists to contextualize protocol adaptations and system constraints.

2. Materials and Methods

2.1. Study Methodology

This study adopted a mixed-methods approach, combining quantitative and qualitative methods, with a clinical–epidemiological and ethnographic design. The quantitative component was retrospective, based on ICU medical records, whereas the qualitative component drew on in-depth accounts from healthcare personnel involved in ICU care during the study periods. The study aimed to describe and compare period-related changes in ICU management of preeclampsia and eclampsia by integrating record-based quantitative comparisons with qualitative accounts from healthcare personnel. The methodology was guided by established principles in health research and clinical epidemiology [15].
The study variables included clinical management and the epidemiological profile of preeclampsia and eclampsia in patients admitted to the ICU. The independent variable was the study period (before and during the COVID-19 pandemic), while dependent variables included clinical characteristics (type of preeclampsia, severity, signs and symptoms) and epidemiological characteristics (age, marital status, personal and obstetric history Variable operationalization followed indicators previously defined in the literature [16].

2.2. Participants

The quantitative component included 48 ICU medical records of patients with a confirmed diagnosis of preeclampsia or eclampsia, distributed across two periods: 33 records prior to the health crisis (2015 to 2019) and 15 records during the crisis (March 2020 to April 2022). The qualitative component included healthcare professionals who provided direct and continuous care to these cases during both periods (n = 48) and were selected using non-probability convenience sampling. Inclusion criteria for the quantitative component were a confirmed diagnosis documented in institutional medical records and ICU admission; for the qualitative component, direct participation in ICU care processes was required. Professional profiles and eligibility criteria were defined to ensure that testimonies accurately reflected period-specific clinical experience.

2.3. Tools

For the quantitative component, a structured data extraction form was used to retrieve sociodemographic, obstetric, clinical, and management variables from medical records. For the qualitative component, a semi-structured interview guide was used to explore healthcare professionals’ perceptions of changes in clinical and epidemiological management before and during the COVID-19 health crisis, including perceived advantages and disadvantages of ICU care pathways for preeclampsia and eclampsia.

2.4. Data Collection and Analysis

Clinical data were retrospectively extracted from institutional records and consolidated into an anonymized database for analysis. Categorical variables were summarized as frequencies and percentages. Continuous variables were summarized as mean and standard deviation or as median and interquartile range, depending on their distribution. For comparisons across periods, continuous variables were assessed based on data behavior and analyzed using the Mann–Whitney U test when distributional assumptions were not met, whereas parametric alternatives were used when assumptions were satisfied. Categorical variables were compared using independence tests and, when necessary due to small cell counts, exact methods were applied, including Fisher’s exact test for 2 × 2 tables and exact procedures with Monte Carlo estimation for RxC tables. Statistical significance was set at p < 0.05. All analyses were performed using IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, USA). Clinical records were grouped by period: pre-crisis (2015 to 2019) and crisis (March 2020 to April 2022). For descriptive purposes, mean ± standard deviation was reported for continuous variables with normal behavior, whereas non-parametric estimation was retained when normality assumptions were not met [15].
For the qualitative component, semi-structured interviews were conducted with healthcare professionals involved in continuous ICU care of preeclampsia cases during the study periods. Interviews focused on perceived changes in care processes, decision-making pathways, resource constraints, and perceived advantages and disadvantages of the management approach. Narratives were anonymized and analyzed using an inductive thematic content approach, enabling the identification of recurrent concepts and their co-occurrence patterns. During interpretation, quantitative and qualitative findings were integrated to triangulate period-related changes and contextualize statistical patterns from the perspective of physicians and staff [17,18].
Ethical considerations were taken into account at all stages of this study. This research was conducted in accordance with the principles set forth in the Declaration of Helsinki and the guidelines of the Belmont Report, ensuring respect for the autonomy, confidentiality, and non-discrimination of the participants. Furthermore, approval was obtained from the relevant ethics committees, and informed consent was obtained from the healthcare professionals interviewed, thus guaranteeing their voluntary participation and confidentiality.

3. Results

Table 1 summarizes the clinical and epidemiological profile of preeclampsia–eclampsia cases admitted to the ICU before and during the COVID-19 health crisis. Cesarean delivery was more frequent during the crisis period than in the pre-crisis period (93.3% vs. 24.2%, p < 0.001). The distribution of severe preeclampsia with severe features was similar across periods (84.8% vs. 86.7%, p = 1.000). Median gestational age distribution was comparable (p = 1.000), and discharge status did not differ significantly between periods (p = 0.662). No statistically significant differences were observed for the remaining indicators using the corresponding exact procedures.

3.1. Quantitative Results

Table 2 summarizes the distribution of perceived advantages and disadvantages of the clinical profile management approach for ICU care of preeclampsia–eclampsia across periods. Because several categories had sparse counts, comparisons of category distributions across periods were performed using Fisher–Freeman–Halton exact tests with Monte Carlo approximation. Before COVID-19, the most frequently selected advantages were high cost/benefit (18/48, 37.4%) and simplicity (15/48, 31.3%), while during the COVID-19 pandemic, fast service predominated (23/48, 47.9%), followed by high cost/benefit (19/48, 39.6%). Overall, the distribution of advantage categories differed between periods (p < 0.001). Regarding disadvantages, lack of sequentiality was more frequent before the COVID-19 pandemic (25/48, 52.1%), while limited personal references (19/48, 39.6%) and false interpretations (13/48, 27.8%) became more prominent during the COVID-19 pandemic; the overall distribution of disadvantages also differed between periods (p = 0.009). Estimates should be interpreted with caution given the reduced number of observations during the pandemic period.
Table 3 summarizes the period-related changes in the epidemiological management profile of preeclampsia–eclampsia cases admitted to the ICU before and during the COVID-19 health crisis. Fisher–Freeman–Halton exact tests with Monte Carlo approximation showed a significant change in the distribution of advantage categories between periods (p = 0.011). Conversely, the distribution of disadvantage categories did not differ significantly between periods (p = 0.655). Estimates should be interpreted with caution given the reduced number of observations during the pandemic period.

3.2. Qualitative Results

Co-Occurrence of Concepts

The qualitative analysis identified recurring concepts related to period-specific changes in clinical decision-making, obstetric management, and pandemic-related constraints. The co-occurrence network (Figure 1) summarizes how frequently these concepts appeared together in healthcare professionals’ narratives, highlighting thematic clusters around clinical management, cesarean decision-making, referral dynamics, and resource limitations in ICU care.
The co-occurrence network (Figure 1) summarizes how frequently concepts appeared together in healthcare personnel narratives, highlighting clusters related to clinical management, cesarean decision-making, referral dynamics, and resource constraints.

4. Discussion

This comparative mixed-method study examined whether the clinical and epide-miological management of severe cases of preeclampsia—eclampsia admitted to an intensive care unit differed before and during the COVID-19 health crisis in a re-source-limited Amazonian setting, integrating quantitative comparisons with the perspectives of physicians and staff [19].
Across the periods, most clinical presentation indicators were comparable in the available records. The most striking between-period difference was the marked increase in cesarean sections during the crisis period (p < 0.001). This finding should be interpreted with caution and framed as an association rather than a direct causal effect of the pandemic. Multiple period-related factors may have contributed, including delayed presentation, ICU bed constraints, biosafety requirements, and period-specific changes in referral and triage practices that may have favored expedited definitive obstetric care [20].
Prenatal care indicators showed a high proportion of insufficient prenatal fol-low-up in both periods, suggesting persistent barriers to timely prenatal care and risk detection. Furthermore, the lower frequency of the “proteinuria only” category during the crisis period should not be interpreted as an absence of proteinuria. Severe preeclampsia can be defined and treated based on target organ dysfunction, even when proteinuria is absent or undocumented [21]. In addition, COVID-19 may present with overlapping clinical features that can mimic or confound the diagnosis of hypertensive disorders of pregnancy [22]. Prospective evidence has also described a preeclampsia-like syndrome associated with severe COVID-19 [23]. In this context, the observed change is plausibly related to differences in documentation and categorization, together with a stronger clinical emphasis on target organ dysfunction during the crisis period [24,25,26,27].
Short-term intensive care unit discharge outcomes and major obstetric complications showed no marked differences between the periods in the available dataset. This context suggests that crisis-period management may have prioritized timely delivery, while short-term ICU outcomes in the available records did not show a clear between-period shift. However, the small sample size for the crisis period and the possibility of period-specific changes in referral thresholds and intensive care unit admission practices limit definitive attribution.
In the qualitative component, period-related changes were more clearly articulated by clinicians and staff. In this context, the prominence and connectivity of “clinical management” and “cesarean sections” in the co-occurrence map should be interpreted as an indicator of thematic salience in staff narratives rather than as a quantitative estimate of effect size or a statistical inference. The clustering of concepts related to intervention protocols, training, biosafety, and resource constraints is consistent with period-related adaptations aimed at maintaining critical obstetric care under uncertainty and operational strain. The reported advantages focused on faster decision making and emergent coordination, whereas the reported disadvantages emphasized less sequential care, limited personalization, and a greater risk of misinterpretation. These perceptions are consistent with a clinical setting where time pressure and resource limitations increase reliance on rapid decisions and informal heuristics, particularly during a crisis [28].
The co-occurrence network complements these insights by highlighting logistical constraints, staffing disruptions, and biosafety pressures as recurring contextual fac-tors that can influence decision making in preeclampsia—eclampsia scenarios. From a health systems perspective, the findings support strengthening surveillance, staffing, coordinated referrals, and standardized yet adaptable protocols that safeguard critical obstetric care during health emergencies [29,30,31].
Limitations
The key limitations include the reduced number of clinical records in the crisis period (15 versus 33 pre-crisis), which limits precision and statistical power for record-based quantitative comparisons. Additional limitations are the retrospective, single-center design and the possibility of incomplete clinical records. In the perception-based component, comparisons relied on retrospective ratings from the same group of healthcare professionals across both periods, which may introduce recall bias. Future multicenter studies with larger samples and prospective designs would improve external validity and help clarify operational mechanisms during health emergencies.

5. Conclusions

In this mixed-methods ICU comparison, the crisis period was associated with a substantial increase in cesarean sections among severe preeclampsia–eclampsia cases, while most clinical presentation indicators and short-term discharge outcomes showed no marked differences between periods. Qualitative findings suggest that crisis-related limitations and biosafety pressures may have shifted decision making toward accelerated definitive management, with potential confounding from period-specific changes in referral and ICU admission practices. Strengthening prenatal care, improving documentation, and implementing resilient, standardized, and adaptable protocols may help protect maternal outcomes during future health emergencies.

Author Contributions

Conceptualization, M.L.-L. and J.N.H.A.; methodology, M.L.-L. and J.E.C.P.; formal analysis, J.N.H.A. and M.D.E.; research, M.L.-L., J.N.H.A. and J.C.Z.R.; data curation, J.E.C.P. and M.D.E.; writing (preparation of the original draft, M.L.-L. and J.N.H.A.; revision (revision and editing, all authors); supervision, M.L.-L. All authors have read and agreed to the published version of the manuscript.

Funding

This research did not receive external funding.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki (1975, revised in 2013). It is a retrospective observational analysis based on routine medical records, without intervention or direct contact with patients in the quantitative component. Data were analyzed anonymously or coded, with access restricted to the research team. The project was institutionally registered, and its implementation was approved within the university research system (Resolution of the Vice-Rectorate for Research No. 313-2021-VI-UCV; registered in Trilce on 26 June 2021).

Informed Consent Statement

Informed consent was obtained from all healthcare professionals who participated in the qualitative phase of this study. For the quantitative phase, data were collected from anonymized medical records, ensuring confidentiality and the protection of personal information.

Data Availability Statement

The data presented in this study are available from the corresponding author upon reasonable request. For ethical and confidentiality reasons, they are not publicly available.

Conflicts of Interest

The authors declare no conflicts of interest.

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Covid 06 00065 g001
Figure 1. Network of co-occurrence of concepts in the clinical management of preeclampsia and eclampsia in ICU patients before and during COVID-19. Node size represents the frequency of mention of each concept, and links represent co-occurrence in healthcare personnel narratives. Node colors are used only for visual differentiation of concepts and do not indicate statistical weighting, effect size, or centrality.
Figure 1. Network of co-occurrence of concepts in the clinical management of preeclampsia and eclampsia in ICU patients before and during COVID-19. Node size represents the frequency of mention of each concept, and links represent co-occurrence in healthcare personnel narratives. Node colors are used only for visual differentiation of concepts and do not indicate statistical weighting, effect size, or centrality.
Covid 06 00065 g001
Table 1. Clinical and epidemiological profile of preeclampsia—eclampsia in ICU patients, treated before and during the health crisis.
Table 1. Clinical and epidemiological profile of preeclampsia—eclampsia in ICU patients, treated before and during the health crisis.
Clinical and Epidemiological Profile of Preeclampsia–EclampsiaCases Before COVID-19 (2015–2019)Cases During COVID-19 (2020–2022)p-Value
Clinical Profile
Type of preeclampsia–eclampsia 1.000
With severe features28 (84.8%)13 (86.7%)
Without severe features5 (15.2%)2 (13.3%)
Signs and symptoms 0.298
Proteinuria5 (15.2%)0 (0.0%)
Liver disorder6 (18.2%)4 (26.7%)
PA + Proteinuria1 (3.0%)0 (0.0%)
All of the above21 (63.6%)11 (73.3%)
Delivery method p < 0.001
Normal25 (75.8%)1 (6.7%)
Cesarean section8 (24.2%)14 (93.3%)
Obstetric complications 1.000
HELLP syndrome + eclampsia29 (87.9%)13 (86.7%)
Other4 (12.1%)2 (13.3%)
Condition at the time of discharge 0.662
With treatment29 (87.9%)12 (80.0%)
Deceased4 (12.1%)3 (20.0%)
Epidemiological profile
Age 0.768
Average age (years)29.4 ± 5.330.1 ± 4.9
Gestational age 1.000
<27 weeks4 (12.1%)2 (13.3%)
28–36 weeks29 (87.9%)13 (86.7%)
Marital status 0.542
Married3 (9.1%)0 (0.0%)
Cohabitant30 (90.9%)15 (100.0%)
Level of education 0.583
Without instruction2 (6.1%)0 (0.0%)
Primary27 (81.8%)13 (86.7%)
Secondary4 (12.1%)2 (13.3%)
Personal background 1.000
Diabetes/hypertension27 (81.8%)13 (86.7%)
Diabetes6 (18.2%)2 (13.3%)
Poor obstetric history 0.094
Previous CST3 (9.1%)3 (20.0%)
Previous preeclampsia1 (3.0%)1 (6.7%)
Preeclampsia/gestational diabetes21 (63.5%)11 (73.3%)
CST + preeclampsia8 (24.2%)0 (0.0%)
Prenatal care 1.000
Revised5 (15.2%)2 (13.3%)
Not controlled28 (84.8%)13 (86.7%)
Note. Categorical variables are compared between periods using Fisher’s exact test in 2 × 2 tables and using exact tests with Monte Carlo estimation when appropriate due to table size or low expected counts. Continuous variables are compared using the Mann–Whitney U test when appropriate. A p-Value < 0.05 is considered significant. Significant p-values are shown in bold; values are reported as n (%) unless otherwise indicated.
Table 2. Characterization of the management of the clinical profile of preeclampsia—eclampsia in ICU patients treated before and during COVID-19.
Table 2. Characterization of the management of the clinical profile of preeclampsia—eclampsia in ICU patients treated before and during COVID-19.
Characterization of the Management of the Clinical Profile of Preeclampsia–EclampsiaBefore COVID-19 (2015–2019)During COVID-19 (2020–2022)p-Value
Advantagesn%n%p < 0.001
Simplicity1531.324.17
Fast service816.72347.92
High cost/benefit1837.41939.58
The suspected agents were identified714.648.33
Total48100.0048100.00
Disadvantagesn%n%p = 0.009
The risk was not quantified714.624.17
It lacked sequentiality2552.11429.17
Limited personal references1122.91939.58
It leads to false interpretations510.41327.80
Total4810048100.00
Note. Category distributions were compared between periods using Fisher–Freeman–Halton exact tests with Monte Carlo approximation. Statistical significance was set at p < 0.05. Values are reported as n (%).
Table 3. Characterization of the management of the epidemiological profile of preeclampsia—eclampsia in ICU patients, treated before and during COVID-19.
Table 3. Characterization of the management of the epidemiological profile of preeclampsia—eclampsia in ICU patients, treated before and during COVID-19.
Characterization of the Management of the Epidemiological Profile of Preeclampsia–EclampsiaBefore COVID-19 (2015–2019)During COVID-19 (2020–2022)p-Value
Advantagesn%n%0.011
Structured in indicators1122.936.3
Easy to verify and reference for treatments2858.91633.3
It allows us to know the prevalence and incidence714.62041.7
It allows for the analysis of the medical–social context24.2918.8
Disadvantagesn%n%0.655
It does not provide adequate information about the risks24.21429.2
It lacks sequentiality1122.9612.5
It does not provide complete case references1837.52347.9
It leads to false interpretations1735.4510.4
Total4810048100.00
Note. The p-values correspond to exact Fisher–Freeman–Halton tests (Monte Carlo approximation) for between-period comparisons of category distributions. Statistical significance was set at p < 0.05.
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MDPI and ACS Style

Lora-Loza, M.; Hernández Angulo, J.N.; Cabrejo Paredes, J.E.; Díaz Espinoza, M.; Zapata Rojas, J.C. Epidemiological Management of Preeclampsia–Eclampsia Cases in the Intensive Care Unit Before and During the Health Crisis. COVID 2026, 6, 65. https://doi.org/10.3390/covid6040065

AMA Style

Lora-Loza M, Hernández Angulo JN, Cabrejo Paredes JE, Díaz Espinoza M, Zapata Rojas JC. Epidemiological Management of Preeclampsia–Eclampsia Cases in the Intensive Care Unit Before and During the Health Crisis. COVID. 2026; 6(4):65. https://doi.org/10.3390/covid6040065

Chicago/Turabian Style

Lora-Loza, Miryam, Jean Neil Hernández Angulo, José Elías Cabrejo Paredes, Maribel Díaz Espinoza, and Jean Carlos Zapata Rojas. 2026. "Epidemiological Management of Preeclampsia–Eclampsia Cases in the Intensive Care Unit Before and During the Health Crisis" COVID 6, no. 4: 65. https://doi.org/10.3390/covid6040065

APA Style

Lora-Loza, M., Hernández Angulo, J. N., Cabrejo Paredes, J. E., Díaz Espinoza, M., & Zapata Rojas, J. C. (2026). Epidemiological Management of Preeclampsia–Eclampsia Cases in the Intensive Care Unit Before and During the Health Crisis. COVID, 6(4), 65. https://doi.org/10.3390/covid6040065

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