32

PRE-ECLAMPSIA – A PATTERN OF FETO-MATERNAL OUTCOME IN WESTERN

RAJASTHAN: A RETROSPECTIVE ANALYSIS1 2 3Dr Ashok Kumar Kumawat , Dr. Rizwana Shaheen , Dr. Indra Bhati

ABSTRACT

Background : Pre-eclampsia is a multiorgan disorder unique to pregnancy typically

characterized by blood pressure ≥140/90 mmHg after 20 weeks gestation associated

with proteinuria ≥300 mg/24 h or ≥1+dipstick. Preeclampsia and the other hypertensive

disorders of pregnancy remain leading causes of maternal and perinatal morbidity and

mortality, complicating 5 to 10 percent of all pregnancies and together they form one

member of the deadly triad, along with haemorrhage and infection. Objective : To study

maternal outcomes in terms of severity, complications of pre-eclampsia; and maternal

mortality and foetal morbidity and mortality.

Material and Methods : This was a retrospective observational study over July 2018 to

June 2019 at Mathura Das Mathur hospital, Dr S N Medical College, Jodhpur Rajasthan.

The diagnosis of all cases was made on the basis of history, clinical examination and

ultrasonography.

Results : Total 100 patients were analysed in this study. Majority of the women studied

(67%) were in age group of 20-30 years; 72% were term and 28 % were preterm; and

most common mode of delivery was caesarean section (61%), Various maternal

complications arising due to preeclampsia were also studied, and it was found that

abruption was seen in 6%, HELLP/DIC was seen in 4% patients, eclampsia in 3%,

pulmonary oedema in 2%%, NICU admission in 9% whereas maternal mortality

occurred in 1% of patients. Foetal outcome also observed in the form of prematurity,

IUGR, Birth asphyxia and neonatal intensive care unit admission.

Conclusion : Pre-eclampsia is one of the most common medical complications of

pregnancy associated with significant maternal and neonatal morbidity.

Keywords : Pre-eclampsia, Maternal and foetal outcome.

Introduction:

“Safe pregnancy is a beautiful voyage

ending with birth of two lives But, if

gets affected by preeclampsia,

becomes a journey through a ring of

fire”

Hypertensive disorders are among

the most common medical disorders

during pregnancy and continue to be

the major cause of maternal and

perinatal morbidity and mortality.

Pre-eclampsia is a mult iorgan

disorder unique to pregnancy

typically characterized by blood

pressure ≥140/90 mmHg after 20

weeks gestation associated with

p r o t e i n u r i a ≥ 3 0 0 m g / 2 4 h o r

≥1+dipstick.1,2 Pre-eclampsia and the

other hypertensive disorders of

pregnancy remain leading causes of

maternal and perinatal morbidity and

mortality, complicating 5 to 10

percent of all pregnancies and

together they form one member of

t h e d e a d l y t r i a d , a l o n g w i t h

haemorrhage and infection. Of these

ORIGINAL RESEARCH ARTICLE

rd1 - 3 year resident, 2- Sr. Prof. & Unit Head, 3 - Sr. Professor & HOD

Department of Obstetrics & Gynecology

MDM Hospital, Dr. S. N. Medical College, Jodhpur

Corresponding Author - Dr. Ashok Kumar Kumawat

33

disorders, preeclampsia syndrome is

the most dangerous, affecting 3.9

percent of all pregnancies globally.3

The WHO reviews of maternal mortality

wor ldwide suggest 16 percent

mater n a l d eath s in d eve lop ed

countr ies due to hypertens ive

disorders.4 Importantly, more than

half of these hypertension-related

deaths are preventable.5 India

accounted for 19% of maternal deaths

worldwide.6 Five percent of maternal

deaths in India are due to hypertensive

disorders.7

Pre-eclampsia can affect virtually every

o r g a n s y s t e m l e a d i n g t o

thrombocytopenia, renal insufficiency,

liver dysfunction, pulmonary edema,

visual disturbances, cerebrovascular

and cardiovascular complications,

placental abruption, acute renal

failure, disseminated intravascular

coagulation, multiple organ system

failures, postpartum haemorrhage

and maternal death. Prematurity,

intrauterine growth restriction, fetal

distress, neonatal asphyxia, low birth

weight, stillbirth and perinatal death

are fetal and neonatal complications to

be anticipated and dealt with when the

m o t h e r h a s p r e e c l a m p s i a . 8

Preeclampsia is a principal cause of

fetal morbidity and mortality, also the

leading reason of maternal ICU

a d m i s s i o n s , a n d r e s p o n s i b l e

for15–20% of materna l deaths

worldwide.9

Delivery of the infant and placenta is

the only effective treatment. Delivery

at an earlier gestational age, however,

is associated with an increased risk of

adverse neonatal outcome.10 Women

with preeclampsia have an increased

rate of cesarean section consequent

upon the high incidence of intrauterine

growth restriction, fetal distres, and

prematurity10. Cesarean section on

the other hand increases the risk of

cardiopulmonary morbidity associated

with pre-eclampsia.11 This is due to the

altered hemodynamics in women with

pre-eclampsia, particularly in an

emergent situation.

AIMS

1. To study the distribution pattern

of pre-eclampsia among

different group of patients with

special reference to age, parity,

booked/ unbooked status and

gestational age at presentation.

2. To study maternal outcomes in

terms of severity, complications

of pre-eclampsia, and maternal

mortality.

3. To study foetal morbidity and

mortality.

MATERIALS AND METHODS

This was a retrospective study done

during one year period from July 2018

to June 2019 at Mathura Das Mathur

hospital, Dr S N Medical college,

Jodhpur, Rajasthan. This study was

done by analysis of hospital records of

patients admitted with diagnosis of

pre-eclampsia after approval by the

ethical committee of the institution.

Blood pressure was measured using

standard parameters with a proper

size cuff with patient in sitting position.

Proteinuria was measured using

dipstick method and ≥1+ on at least two

occasions was taken as positive.

Inclusion criteria were patients with

diagnosis of preeclampsia. Exclusion

criteria were patients with chronic

r e n a l d i s e a s e , s y s t e m i c l u p u s

34

erythematosus, connective tissue

disorder, molar pregnancy, thyroid

disorder, and diabetes.

All patients were evaluated for fetal

and maternal condition using various

biochemical and radiological test.

Biochemical test includes complete

blood count, liver function test, kidney

function test, urine for proteins with

dipstick/24 h urine collection, and

fundus examination. Fetal state was

assessed using ultrasonography and

nonstress test wherever required.

Patients were managed as per clinical

protocols, progression of disease, and

fetomaternal condition.

RESULTS:

A total of 100 patients were analysed in

this study.Majority of the studied

women (67%) were in mean age group

of 20-30 years, with 14% below 20 years

and 19% above 30 years. In our study,

62% were primigravida and 38% were

multigravida; 72% were term and 28%

were preterm. In 61% of patients mode

of delivery was caesarean section and

39% were vaginally delivered. Out of

the 100 babies 57% babies weigh

>2500gm, and 32% babies weight

between 1500-2500gm and 11% were

lesser than 1500gm.

Various maternal complications arising

due to preeclampsia were also studied,

and it was found that abruption was

seen in 6%, HELLP/DIC was seen in 4%

patients, eclampsia in 3%, pulmonary

oedema in 2%%, NICU admission in 9%

whereas maternal mortality occurred

in 1% of patients.

In all cases, fetal outcome was also

observed in the form of prematurity,

IUGR, Birth asphyxia , neonatal

intensive care unit admission. It was

seen that prematurity was present in

28% of patients, 4% of babies had

IUD/still birth, 16% of babies had birth

asphyxia, 7% of babies had IUGR

whereas NICU admission was seen in

12.5% of patients.

Discussion

Preeclampsia, which occurs only in the

presence of placenta, continues to be a

major cause of maternal and perinatal

morbidity and mortality world-wide.

We observed that chances of pre-

eclampsia were significantly higher in

younger age group (20-30 years).

Similar results have also been obtained

by various authors Yadav et al12 and

Singh A et al13.

Nulliparity has also been found to be

associated with pre-eclampsia. We also

observed that pre-eclampsia occurred

more frequently in primigravida (62%)

as compare to multigravida (38%).

35

Sibai and Cunningham14 reviewed a

number of worldwide studies and

concluded that the incidence of pre-

eclampsia in nulliparous populations

was more than that for multiparous. It

could be because of the failure of

normal invasion of trophoblastic cells

that leads to maladaptation of the

spiral arterioles.15

We also studied distribution of pre-

e c l a m p t i c c a s e s a c c o r d i n g t o

gestational age of presentation and

severity. It was observed that most of

the cases (72%) occurred at advanced

gestational age (>37 weeks) and

preterm in 38% cases. Similar results

have also been observed by Sajith et

al.16

We also observed that 61 out of 100

(61%) patients were delivered by lower

segment cesarean section (LSCS), and

39 patients were delivered by vaginally.

S imi lar resul ts have a lso been

observed by Yelmizaitun et al. (2010).17

This finding was in contrast with other

authors Chaim et al18 (2008) Yadav et

al19 (1997) in India (14.8%). This

difference in LSCS rate may be due to

difference in medical facilities and

quality of antenatal care (ANC) in

different parts of the world.

This present study showed that among

all partial HELLP and HELLP syndrome

and DIC were the most common

maternal complications seen in 9% of

patients; whereas PPH in 7% and

pulmonary edema each was seen in

2%; eclampsia developed in 3% and

maternal mortality rate was 1%. Similar

results have also been obtained by

Murphy and Stirrat (2000)20. In their

study, 21% had developed HELLP/ELLP

syndrome, 1.4% had eclampsia. In

another study conducted by Minire et

al. (2013),21 lower complications rate

were reported. In their study, 3.2%

patients had eclampsia, 4.2% had

HELLP syndrome, and 5.58% had

pulmonary edema, whereas DIC was

seen in 0.46% of patients. Higher

complication rates in our study could

be because of late patient presentation

for medical care.

Prematurity was the most common

complication associated with pre-

eclampsia, which was seen in 28%

cases. These results lower than

observed by Tuffnell et al22 (65.3%)

and Singhal et al.23(66%). Birth

Asphyxia was observed in 16%

patients. Similar results were also

observed by Singhal et al. (2009)23 who

found the risk of birth asphyxia

(21.43%). It could be because these

studies were conducted in different

c o u n t r i e s w h e r e p a t i e n t ' s

socioeconomic background and

medical facilities are better.

CONCLUSION :

“Prevention is Better Than Cure”

But this is not completely true for

pre–eclampsia. Since it cannot be

c o m p l e t e l y p r e v e n t e d , t i m e l y

diagnosis of high-risk patients and

prompt treatment in mild stage is the

key to prevent complications. This

study highlights various risk factors

and complications both to mother and

fetus for pre-eclampsia. Therefore, the

study advocates more research into

the field of pre-eclampsia to develop

effective strategy for prediction and

prevention of adverse outcomes.

Routine screening for hypertensive

diseases of pregnancy (HDP) based on

measurement of blood pressure

36

among all pregnant women should be

practised as recommended by WHO

and where resources are available, it is

desirable to do urinary protein analysis

a t e v e r y a n t e n a t a l v i s i t a s a

complement to routine blood pressure

measurement in remote areas of India

like our western Rajasthan.

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