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Brief Reports Indian Pediatrics 2001; 38: 174-178 |
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Perinatal Outcome in Pregnancy Associated Hypertension |
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Hypertension is one of the most common medical complication of pregnancy. It contri-butes significantly to the cause of maternal and perinatal morbidity and mortality. Hyper-tensive disorders of pregnancy predispose women to acute or chronic uteroplacental insufficiency, resulting in ante or intrapartum asphyxia that may lead to fetal death, intrauterine growth retardation and/or preterm delivery(1). This study was conducted to determine the frequency of different types of hypertensive disorders of pregnancy, the fetal neonatal outcome in them and to highlight the specific problems of these infants.
A prospective study was conducted to evaluate the perinatal outcome amongst mothers admitted with hypertensive disease during pregnancy. This study was carried out in the Department of Pediatrics and Obstetrics of Maharaja Yeshwantrao Hospital and Mahatma Gandhi Memorial Medical College, Indore over a period of one year (from October 1996 to September 1997). The study sample comprised of 405 cases admitted as hypertensive disorders of pregnancy in the Department of Obstetrics and Gynecology. One hundred cases admitted as full term normal pregnancy in labor and without any complication during pregnancy were taken as controls. Maternal data were documented with respect to age, parity, socioeconomic status, whether urban or rural, status of antenatal care, gestational age at delivery and mode of delivery. Relevant maternal investi-gations were also obtained. Fetal outcome data were documented with respect to birth weight, still birth rate, asphyxia and its degree, gestational age, neonatal complica-tions, neonatal death rate and overall perinatal loss. The hypertensive mothers were divided into the following groups: Gestational hypertension: One measurement of diastolic blood pressure equal to or greater than 110 mm Hg or two consecutive measure-ments of diastolic blood pressure equal to or greater than 90 mm Hg, 4 or more hours. Pre-eclampasia: Hypertension associated with proteinuria greater than 0.3 mg/L in a twenty four hour urine collection or greater than 1 g/L in a random sample, generalized pitting edema after twelve hours of rest in bed or weight gain of 2.3 kg (5 lb) or more in one week; or both after twenty weeks of gestation. These cases were further classified into mild and severe types. Eclampsia: Pre-eclampsia when complicated with convulsion and/or coma. Essential hypertension: The presence of sustained blood pressure of 140/90 mm Hg or higher before pregnancy or before twenty weeks of gestation. The outcome data were analyzed and compared among study and control groups.
In the study period, 5402 mothers delivered out of which 405 had hypertension. Thus, the frequency of hypertensive disorders of pregnancy was 7.49%. Twenty two (5.4%) mothers had twin deliveries. Out of these 405 cases, majority were due to toxemia of pregnancy, i.e., pre-eclampsia 204 (50.4%) and eclampsia-43 (10.6%). Only 110 (27.2%) of the hypertensive mothers were booked cases. Majority of women in the study groups, i.e., 168 (41.5%) as well as in the control group, i.e., 56 (56%) were in the age group 21-25 years. The highest number of teenage pregnancies were in the eclampsia group namely 24 (55.8%). Nulliparous women constituted 267 (65.9%) of the total study group, as compared to 49 (49%) in the control group. The perinatal mortality rate in our study in booked cases was 86.9/1000 births compared to 185.6/1000 births in mothers with emer-gency admission, i.e., 2.1 times. One hundred and thirty two (30.9%) births needed intervention in the form of forceps application or Cesarean section and fetal distress was the indication in 47 (35.6%) of these cases. Low birth weight prevalence was high (Table I). Two hundred and twenty one (51.7%) of the babies were low birth weight and 206 (48.2%) of the babies weighed above 2.5 kg in the study group as opposed to 40 (40%) and 60 (60%), respectively in the control group. Severity of hypertension also had a bearing on birth weight. Amongst the 221 low birth weight babies, 98 (44.3%) were preterm and 123 (55.7%) were term babies. Overall preterm births were 98 (23%) and intra-uterine growth retarded babies were 91 (21.3%) of the total births in mothers with hypertension.
Perinatal mortality rate was 159/1000 births in the study group as opposed to 30/1000 births in control group. There were 40 (9.4%) early neonatal deaths and 28 (6.5%) still births. Of the total 399 live births in this study, 124 (31.1%) needed admission in special care nursery for various indications. (Table I). More babies of the eclampsia group 35 (85.4%) and severe pre-eclampsia group 28 (50%) required admission as compared to the other groups. Birth asphyxia [56 (14%)] was the commonest complication. Other neonatal complications requiring admission were prematurity in 42 (10.5%), septicemia in 30 (7.5%), respiratory distress syndrome in 29 (7.3%), intrauterine growth retardation in 27 (6.8%) and neonatal hyperbilirubinemia in 24 (6%). Of the 40 early neonatal deaths, 26 (65%) were preterm and 14 (35%) were term. Twelve (30%) each of the deaths were due to birth asphyxia and septicemia. Respiratory distress syndrome in 6 (15%), pulmonary hemorrhage in 4 (10%) and intracranial hemorrhage in 3 (7.5%) were the other causes of early neonatal deaths. Only 12 (12.1%) of the live control births developed some complications.
Hypertensive disorders of pregnancy have been identified as a major world wide health problem, associated with increased perinatal morbidity and mortality. Various authors have found the frequency of hypertensive disorders of pregnancy between 7-10% which is comparable to the present study (2,3). Pre-eclampsia was documented in 3.8% in this study and it ranged from 3-10% in various other studies. Eclampsia was seen in 0.8% which is also similar to other studies(1-4). Essential hypertension cases were less in this study, probably because majority of the mothers did not receive antenatal care and were admitted as emergency cases, hence no blood pressure record during the antenatal period was available. Seventy three per cent of the study cases were emergency admis-sions, the figures being similar to other studies(2,4). The perinatal mortality was also higher in them as compared to the booked cases. This study is in conformity with the view that hypertensive disorders of pregnancy is essentially a disease of primigravidae. Age has an important influence on the incidence of hypertensive disorders of pregnancy. Young primigravidae under 20 years and all patients over 30 years have an increased chance of hypertension and hence a higher perinatal mortality (1-6). But in this study majority of the hypertensive mothers were between the ages of 20 to 25 years. This could be because the majority of conceptions take place in this age group in our country. Hypertensive disease is a disease of nullipara, as noted in this study also(1-6). Intervention was required in a large number of births, as reported by various other authors also(2,5,7).
Hypertensive disorders of pregnancy predispose women to acute or chronic uteroplacental insufficiency, resulting in ante or intrapartum anoxia that may lead to fetal death, intrauterine growth retardation and/or preterm delivery. The percentage of preterm and low birth weight babies was high in this study as seen in various earlier studies too(1-6). Prematurity was the most important factor responsible for increased perinatal morbidity and mortality which is in accordance with earlier reports(1,2,5,6). Birth asphyxia in this study also was the commonest neonatal complication(2,5). The high still birth rate is in conformity with earlier reports (T,5,6). A high perinatal mortality rate in pregnancy associated hypertension is in conformity with earlier literature. In conclusion, the frequency of hyper tensive disorders of pregnancy continues to remain high and majority are due to toxemia of pregnancy. Perinatal mortality is signifi-cantly high in mothers with hypertensive disorders. The frequency of both preterm and intrauterine growth retarded babies in higher in these mothers and birth asphyxia is the commonest neonatal complication. Contributors: JN drafted the manuscript. JB was responsible for collection, analysis and interpretation of data. PP conceived and designed the study and contributed to drafting; she will act as the guarantor.
Funding:
None
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