This study was conducted in the obstetrics and gynecology department of the Gabriel Touré University Hospital in the Bamako district, a leading hospital in Mali’s capital specializing in the management of serious obstetric complications. The department receives patients from across the district and surrounding regions, making it a center for the management of complex cases, particularly those related to pre-eclampsia.

This is a descriptive cross-sectional study conducted over a 12-month period, from January 1 to December 31, 2022. This approach allows us to analyze the prevalence of pre-eclampsia and to examine the risk factors, complications and maternal -fetal prognosis in multiparous patients in a hospital setting.

The study population consisted of all patients admitted to the obstetrics and gynecology department of the Gabriel Touré University Hospital during the study period and diagnosed with pre-eclampsia. The patients were divided into three groups according to their parity:

1) Criteria inclusion

Patients meeting the following criteria were included in the study:

2) Exclusion criteria

The following were not included in the study:

We used exhaustive sampling, including all patients meeting the inclusion criteria during the study period. A total of 858 cases of pre-eclampsia were identified among 4225 obstetric admissions during this period.

The data was collected from various sources:

The data was entered and processed using IBM SPSS Statistics version 21. The following parameters were analyzed:

The results were considered significant when the p-value was less than 0.05.

The study was conducted in accordance with the ethical principles of medical research. Approval was obtained from the ethics committee of Gabriel Touré Hospital, and informed consent was obtained from the patients for the use of their clinical data in this study.

Out of a total of 4225 obstetric admissions, 858 patients were diagnosed with pre- eclampsia, representing a frequency of 19.99% in the obstetrics and gynecology department of the Gabriel Touré University Hospital. The incidence of pre-eclampsia in multiparous women was 37.72%, compared to 39.5% in primiparous women and 22.5% in pauciparous women, as shown in Table 1 .

The mean age of primiparous women was 20 years, with a range from 13 to 41 years, while the mean age of multiparous women was 32 years, with a range from 20 to 44 years, with a chi-square value of 17.583, 4 degrees of freedom (df), and a p-value of 0.000. The age distribution is characterized by a high proportion of primiparous women under 20 years of age (56.6%) and older multiparous women, with 37.7% being over 35 years old, as shown in Table 2 .

The most frequent clinical signs in patients with pre-eclampsia include headaches (38.1% in primiparous and 37.1% in multiparous) with RR: 0.92 [0.80 - 1.07], epigastric pain and visual disturbances, with a predominance of epigastric pain in multiparous (46.2%) with RR; 1.06 [0.87 - 1.28].

Chi-square: 417.583 df: 4 P = 0.000.

Proteinuria detected by urine dipstick is a key indicator in the diagnosis of pre-eclampsia. According to the results, 61.4% of primiparous women had 3-cross proteinuria (2 g/dL), and 48.2% of multiparous women had similar proteinuria. Multiparous women also had a higher proportion of 1-cross proteinuria (18.7%) compared to primiparous women (8%), as shown in Table 3 , with a Chi-square value of 21.114, degrees of freedom (df) of 2, and a p-value of 0.02.

Further investigations confirmed renal involvement in 7% of cases, observed through elevated serum creatinine levels. Obstetric ultrasound revealed placental insufficiency in 32% of cases, with signs of intrauterine growth restriction (IUGR) in 45% of fetuses, highlighting the direct impact of pre-eclampsia on fetal development. Liver function tests showed elevated liver transaminase levels in 121 (42.2%) primiparous women compared to 68 (42.0%) of pauciparous women and 106 (39.7%) of multiparous women with a Chi-square: 3.780 with a p: 0.820.

The management of patients with pre-eclampsia in our study was based on standardized measures to control blood pressure and prevent complications. Nicardipine, an antihypertensive drug, was administered in 40% of cases, and magnesium sulfate, used to prevent eclampsia, was administered to 88.2% of primiparous women, 77% of pauciparous women, and 73% of multiparous women. Corticosteroid therapy was used to promote lung maturation in premature fetuses in 18% of multiparous and pauciparous cases.

Blood transfusions were administered in 52% of multiparous women due to complications such as anemia and thrombocytopenia observed in these patients. The use of magnesium sulfate and antihypertensive drugs is crucial for managing severe forms of preeclampsia, as shown in Table 4 .

The mode of delivery was chosen based on the progression of the pregnancy and complications associated with pre-eclampsia. Of the 326 multiparous women included, 72% delivered by cesarean section, primarily due to pre-eclampsia complications such as eclampsia, refractory hypertension, and acute fetal distress. In contrast, 28% of patients delivered vaginally, mainly those with a less severe form of pre-eclampsia, without major complications affecting fetal health.

Observed maternal complications included eclampsia, refractory hypertension, HELLP syndrome, acute kidney injury (AKI), acute pulmonary edema (APE), and stroke. Among patients with pre-eclampsia, 15.3% of multiparous women developed eclampsia compared to 67.9% of primiparous women and 16.8% of pauciparous women, with a relative risk (RR) of 0.69 [0.54 - 0.88]. However, multiparity was associated with a higher incidence of placental abruption (59.3%) compared to primiparous women (16.2%), with an RR of 1.30 [1.08 - 1.57]. Multiparous women showed a higher risk of developing placental abruption and acute renal failure, which could be due to obstetric history and advanced maternal age as shown in Table 5 .

The fetal prognosis in cases of preeclampsia is also concerning. Among patients with preeclampsia, primiparity was associated with low birth weight in 40.1% of cases, compared to 36.8% for multiparous women, with a relative risk (RR) of 0.95 [0.79 - 1.14], reflecting a high incidence of prematurity and intrauterine growth restriction (IUGR). Furthermore, the Apgar score at 1 minute was 0/10 in 42.3% of newborns from multiparous mothers, and 0.95% of newborns from multiparous mothers had an Apgar score at 5 minutes between 4 and 7/10. This indicates signs of neonatal distress, although many newborns survived with appropriate intensive care, as shown in Table 6 and Table 7 .

Complications such as eclampsia and HELLP syndrome remain the leading causes of maternal death and stillbirth. The overall maternal mortality rate was 5.6%, or 46/858. Multiparous women had a higher mortality rate of 26 cases (54.1%) compared to 10 cases (20.8%) for primiparous women, with a relative risk (RR) of 1.09 [0.87 - 1.37], particularly due to complications related to refractory hypertension. Among stillbirths, 64.9% were fresh stillbirths, with a higher proportion in multiparous women (71.2%).

The main limitations of this study include selection bias, as only patients treated at a referral center were included. This may lead to an overestimation of the prevalence of pre-eclampsia in the general population, since the most severe cases are more likely to be referred to these facilities. Furthermore, the absence of certain clinical data, such as postpartum monitoring and long-term complications, is another significant limitation, restricting the scope of conclusions regarding the long-term prognosis of multiparous women.

This study revealed a pre-eclampsia prevalence of 37.72% among multiparous women, which is higher than in previous studies conducted in West Africa, where the prevalence in multiparous women generally ranges from 0.4% to 1.5% [7] [9] . This higher prevalence in our study could be explained by several factors, including the nature of the hospital, which is a referral center for serious obstetric pathologies, the lack of routine prenatal care, and the medical history of multiparous patients, which puts them at higher risk of pre-eclampsia complications [14] . A study conducted in Mali at a similar facility reported a prevalence of 5% [15] , which appears to be more consistent with our findings.

It is interesting to note that preeclampsia in multiparous women is often less frequently diagnosed at an early stage, largely due to the pathophysiological adaptations these patients develop over the course of multiple pregnancies. This observation is supported by previous research indicating that preeclampsia in multiparous women is often less obvious due to the absence of overt clinical symptoms in early pregnancy [14] [19] . This situation underscores the need for closer monitoring of multiparous women to enable the rapid diagnosis of more severe forms of this condition.

The results of our study confirm the findings of previous work which demonstrated that advanced maternal age, particularly over 35 years, is a major risk factor for pre-eclampsia [14] . In our study, the multiparous women were older (mean age 32 years), which is consistent with data from the literature suggesting that maternal aging leads to an increased risk of pre-eclampsia, often associated with a history of chronic hypertension and gestational diabetes [15] [16] [20] .

The influence of obstetric history on the development of preeclampsia in multiparous women was also observed in this study. Indeed, factors such as previous pregnancies with hypertensive complications or a planned cesarean section for similar reasons increase the risk of recurrence of the condition [14] . This relationship has been well established in previous studies, which found that women who experienced preeclampsia during a previous pregnancy have an increased risk of developing it again [16] [19] .

The management of preeclampsia in multiparous women, as in primiparous women, relies on antihypertensive treatment to control blood pressure, as well as continuous monitoring to prevent serious complications such as eclampsia and acute renal failure. In our study, the management of preeclampsia in multiparous women included the use of medications such as nicardipine and magnesium sulfate, in accordance with international guidelines [14] [19] . However, the management of these patients often remains complex due to their obstetric history and associated comorbidities.

It is important to emphasize that despite the use of effective treatments, the management of preeclampsia in our setting remains challenging, particularly due to limited resources and the lack of specialized intensive care in some healthcare facilities. Previous studies have also highlighted the lack of access to specialized care and advanced treatments, which can lead to serious complications in multiparous women [14] [15] . Improvements in access to specialized care, training of medical staff, and rigorous monitoring of multiparous women would be crucial steps in improving the management of this condition.

The question of the mode of delivery in multiparous patients with preeclampsia is complex and depends on the severity of the condition. As in many studies, cesarean section was indicated in 72% of cases in our study, primarily due to the increased risks to the mother and fetus, including eclampsia, refractory hypertension, and signs of acute fetal distress. This high proportion of cesarean sections also reflects the trend observed in other African studies, where severe preeclampsia, associated with serious maternal complications, often justifies this obstetric approach [15] [19] .

However, vaginal delivery was also considered for some patients, particularly those with mild or moderate pre-eclampsia without severe complications. The use of instrumental intervention in 15% of cases highlights the need for continuous monitoring during labor and rapid intervention to preserve fetal well-being. These observations align with international recommendations that advocate individualized assessment of the mode of delivery for women with pre-eclampsia, taking into account the risks to both the mother and the fetus [14] .

The maternal complications observed in our study, such as eclampsia and refractory hypertension, are well documented in the literature. Eclampsia, in particular, remains one of the most severe manifestations of preeclampsia and is often responsible for maternal deaths in developing countries, where access to resuscitation care and necessary medical equipment is limited [14] [17] . The elevated rates of eclampsia and acute kidney injury in our study confirm that multiparous women are more likely to develop serious complications due to the late detection of the condition and underlying comorbidities.

Regarding fetal outcomes, our study shows a high incidence of prematurity and low birth weight, which is consistent with the results of previous studies that observed a correlation between preeclampsia and these fetal complications [15] . Prematurity, often due to placental insufficiency, remains one of the leading causes of neonatal mortality and morbidity in patients with preeclampsia [19] . Perinatal mortality is very high in our study compared to those reported by African authors. Stillbirth and early neonatal death were predominant in multiparous women. Prematurity was the main complication and major cause of morbidity and mortality in our setting, primarily due to insufficient technical facilities and the lack of human and financial resources necessary for the care of premature infants.

Improving prenatal care, including the administration of corticosteroids for fetal lung maturation, could help improve these fetal outcomes, as suggested by international recommendations [14] .