Determination of Risk Factors for Pre-eclampsia and Eclampsia in a Tertiary Hospital of India: A Case Control Study

Pre-eclampsia among Pregnant Women Admitted to the Department of Obstetrics and Gynaecology of a Tertiary Care Centre

Introduction

Pre-eclampsia is a pregnancy-related hypertensive disorder with maternal and neonatal complications. Many studies are done regarding the prevalence of pre-eclampsia in Nepal but ascertaining the maternal risk factors and fetal outcomes are important. The aim of this study was to find out the prevalence of pre-eclampsia among pregnant women admitted to the Department of Obstetrics and Gynaecology of a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among pregnant women admitted to the Department of Obstetrics and Gynaecology of a tertiary care hospital from 13 July 2023 to 29 September 2023 after obtaining ethical approval from the Institutional Review Committee. Convenience sampling method was used. Point estimate was calculated at a 95% Confidence Interval.

Results

Among 5065 patient, pre-eclampsia was seen in 44 (0.87%) (0.61-1.13, 95% Confidence Interval). A total of 16 (36.36%) cases of pre-eclampsia were in the age group 25-29 years and 30 (68.18%) of them were nulliparous. A total of 38 (86.36%) of the newborns of the pre-eclamptic cases had low birth weight. The APGAR score of newborns at the 1 minute after birth was 26 (59.09%) followed by the newborns who needed re-evaluation 16 (36.36%). The APGAR score recorded at 5 minutes showed maximum newborns with normal APGAR score 40 (90.90%).

Conclusions

The prevalence of pre-eclampsia among pregnant women was found to be lower than other studies done in similar settings.

Keywords

maternity; Nepal; pre-eclampsia; prevalence.

Risk Factors of Pre-eclampsia: A Hospital-Based Case-Control Study

Introduction Pre-eclampsia is a pregnancy-specific hypertensive disorder and is one of the leading causes of maternal and infant morbidity and mortality in India and worldwide. Evidence of the association between various risk factors and pre-eclampsia is scarce in developing countries. As pre-eclampsia remains a leading cause of maternal mortality and morbidity, focusing on the causes and risk factors of pre-eclampsia during antenatal surveillance would prevent maternal deaths and reduce the maternal mortality rate. Our study aimed to determine the risk factors of pre-eclampsia. Materials and methods An unmatched case-control study was conducted at Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR), Burla, Odisha, taking 100 cases of pre-eclampsia and 100 controls without pre-eclampsia from January 2021 to January 2023. The study population included patients admitted to the Obstetrics & Gynecology labor room. Study participants were selected randomly from the labor room thrice weekly. Data were collected using a predesigned pre-tested questionnaire and case report format. Data were analyzed using IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States). Appropriate statistical tests (Odds ratio, proportions, Chi-square test) were applied, and the final interpretation was made. Results Family history of hypertension (AOR = 4.2), history of chronic hypertension (AOR = 13.7), and AB blood group (AOR = 3.6) were found to be significant risk factors for pre-eclampsia. No significant association was found between pre-eclampsia and factors such as mother's age, caste, mother's education, type of family, socioeconomic status, education and occupation of husband, family history of diabetes mellitus, parity, history of abortion, and anemia. Conclusion Risk factors identified in the present study can be used to identify women at risk of pre-eclampsia during antenatal check-ups to minimize the complications of pre-eclampsia in both the mother and the fetus.

A clinical study of perinatal and maternal morbidity and mortality in gestational hypertension, preeclampsia and eclampsia

In India, hypertensive disorders complicating pregnancy are common and continue to be responsible for the largest proportion of perinatal deaths resulting from prematurity and IUGR and are major contributors to perinatal and maternal morbidity and mortality. The aim: The present study is undertaken to analyse the cases of preeclampsia and eclampsia, including consequences concerning preterm delivery, IUGR, IUD and stillbirth and for the evaluation of a safe motherhood program at the population level. Materials and methods: The present study was conducted on 105 selected cases from the census (sample of 12,589 patients) of pregnancy-induced hypertension (gestational hypertension, preeclampsia and eclampsia). Results: Hypertensive cases complicating pregnancy of the foetal deliveries conducted during the study period, out of which Gestational hypertension (GTN) cases reported were 44. Preeclampsia (PE) cases were 39, severe preeclampsia (SPE) were 1 and Eclampsia cases were 21. Labetalol alone was used in 62 cases, and 44 babies were born without any complications. As an anticonvulsant magnesium sulphate (MgSO4, 7H2O) was used in all cases of imminent eclampsia and eclampsia (MgSO4 PRITCHARD Regime) in a total number of 38 cases. Preterm / prematurity was the most common cause of perinatal death. The total number of NICU admissions was 42 (40 %). Conclusions: The early use of anti-hypertensive drugs, the optimum timing of delivery, strict fluid balance, and anticonvulsants in cases of eclampsia will help to achieve a successful outcome. Early transfer to a specialist centre is important, and the referral centres should be well-equipped to treat critically ill patients.

Incidence and Predictors of Pre-Eclampsia Among Pregnant Women Attending Antenatal Care at Debre Markos Referral Hospital, North West Ethiopia: Prospective Cohort Study

Background

Pre-eclampsia is a pregnancy-induced hypertension that occurs after 20 weeks of gestation. It is the leading cause of maternal and perinatal morbidity and mortality globally, but it is higher in developing countries. In Ethiopia, conducting research on the incidence and predictors of pre-eclampsia is crucial due to the paucity of information.

Methods

A prospective cohort study was undertaken using 242 pregnant women between November 1, 2018 and March 30, 2019 at Debre Markos Referral Hospital. All eligible women who fulfilled the inclusion criteria were included in this study. Data were entered into the epic-data Version 4.2 and analyzed using the STATA Version 14.0 software. The Cox-proportional hazard regression model was fitted and Cox-Snell residual test was used to assess the goodness of fit. Pre-eclampsia free survival time was estimated using the Kaplan–Meier survival curve. Both bivariable and multivariable Cox-proportional hazard regression models were fitted to identify predictors of pre-eclampsia.

Results

The overall incidence rate of pre-eclampsia was 3.35 per 100 person-years. Having a pre-existing history of diabetes mellitus [AHR=2.7 (95% CI=1.43–8.81)], having a history of multiple pregnancy [AHR=3.4 (95% CI=2.8–6.9)] and being ≥35 years old age [AHR=2.5 (95% CI=1.42–3.54)] were the significant predictors of pre-eclampsia.

Conclusion

The incidence of pre-eclampsia was high in this study. Having (pre-existing diabetes and multiple pregnancy) and being ≥35 years old age were the significant predictors of pre-eclampsia. Inspiring pregnant women’s health-seeking behavior should provide a chance to diagnose pre-eclampsia early to prevent the medical complication of pre-eclampsia.

Identification of High-Risk Pregnancies in a Remote Setting Using Ambulatory Blood Pressure: The MINDI Cohort

Background: Ambulatory blood pressure is a potential tool for early detection of complications during pregnancy, but its utility in impoverished settings has not been assessed. This cross-sectional study aimed to determine whether maternal infections, nutrient deficiencies and inflammation (MINDI) were associated with four measures of maternal blood pressure (BP) and to determine their association with symphysis-fundal-height (SFH). Methods: Environmental and dietary factors, intake of iron and a multiple-nutrient supplement (MNS), markers of inflammation, protein, anemia, folate, vitamins B₁₂, A and D status, and urogenital, skin, oral and intestinal nematode infections were measured in indigenous pregnant Panamanian women. Stepwise multiple linear and logistic regression models explored determinants of systolic and diastolic blood pressure (SBP, DBP), hypotension (SBP < 100 and DBP < 60), mean arterial pressure (MAP), elevated MAP (eMAP), and pulse pressure (PP). Associations of BP with intestinal nematodes and with SFH Z scores (≥16 wk) were also explored. Results: Despite absence of high SBP or DBP, 11.2% of women had eMAP. Furthermore, 24.1% had hypotension. Linear regression showed that hookworm infection was associated with higher SBP (P = 0.049), DBP (P = 0.046), and MAP (P = 0.016), whereas Ascaris was associated with lower DBP (P = 0.018) and MAP (P = 0.028). Trichomonas was also associated with lower SBP (P < 0.0001) and MAP (P = 0.009). The presence of Trichuris (OR: 6.7, 95% CI 1.0-44.5) and folic acid deficiency (OR: 6.9, 95% CI 1.4-33.8) were associated with increased odds of eMAP. The odds of low BP was higher in the presence of Ascaris (OR: 3.63 ± 2.28, P = 0.040), but odds were lowered by MNS (OR: 0.35 ± 0.11, P = 0.001), more intake of animal-source foods/wk (OR: 0.7, 95% CI 0.5-0.9) and by higher concentrations of IL-17 (OR: 0.87 ± 0.05, P = 0.016). Conclusion: MINDI were bi-directionally associated with blood pressure indicators. In this MINDI cohort, infections, nutrients and cytokines both raised, and lowered BP indices. The presence of eMAP identified pregnant women at risk of hypertension whereas low PP was associated with lower SFH. Therefore, MAP and PP may help in detecting women at risk of adverse pregnancy outcomes in settings with limited access to technology.

Cohabitation duration, obstetric, behavioral and nutritional factors predict preeclampsia among nulliparous women in West Amhara Zones of Ethiopia: Age matched case control study

BACKGROUND

Preeclampsia is a major cause of maternal and perinatal mortality in developing countries. Identifying its risk factors is essential for early diagnosis and management. However, there has been a paucity of information on predictors of preeclampsia among nulliparous women in a resource limited setting. This study bridges the gap in this regard by examining the association of cohabitation duration, obstetric, behavioral and nutrition factors with preeclampsia among nulliparous women in West Amhara Zones of Ethiopia.

METHODS

Age matched case-control study design was employed among 110 preeclamptic and 220 non-preeclamptic women who came for delivery services at Felege Hiwot, Addis Alem, and Debre Tabor hospitals. Double population proportion formula with an assumption of 95% confidence interval, 80% power and a 2:1 control to case ratio was used to calculate sample size. Epi data 3.1 and SPSS 20 were used for data entry and analysis, respectively. Magnitudes of cohabitation duration, obstetric, behavioral and nutritional factors among nulliparous women with preeclampsia and their controls were calculated and the differences were tested with a Chi-square test. Conditional bivariable and multivariable logistic regression analysis were fitted to identify predictors of preeclampsia. Odds ratio along with their 95% confidence interval were used to identify the strength, direction and significance of association. Ethical clearance was secured from the research ethics committee of the School of Public Health in Addis Ababa University.

RESULTS

A total of 107 cases and 214 controls completed the interview giving a response rate of 97.27% for both cases and controls. Short cohabitation duration (AOR = 2.13, 95% CI (1.10, 4.1)), unplanned pregnancy (AOR = 2.35, 95% CI (1.01, 5.52)), and high body weight (AOR = 2.00, 95% CI (1.10, 3.63)) were found to be significant risk factors for preeclampsia. Whereas, antenatal advice about nutrition (AOR = 0.52, 95% CI (0.29, 0.96)), vegetable intake (AOR = 0.42, 95% CI (0.22, 0.82)) and fruit intake during pregnancy (AOR = 0.45, 95% CI (0.24, 0.87)) were protective factors for preeclampsia.

CONCLUSION

Special attention should be given to nulliparous women with short cohabitation duration, unplanned pregnancy, and high body weight to minimize the effect of preeclampsia. Nutritional counseling shall be stressed during antenatal care follow ups.

The need for implementation of first trimester screening for preeclampsia and fetal growth restriction in low resource settings

Background: Preeclampsia [PE] and fetal growth restriction [FGR] is a major cause of perinatal morbidity in both developed and developing countries but the disease leaves a severe impact in developing countries, due to the late presentation of cases where prevention and treatment becomes impossible. Routine antenatal ultrasound and health checkups in periphery are usually done in first trimester for dating and viability scan, in midtrimester for anomaly scan and in third trimester for safe confinement. Underlying disorder of deep placentation which is unidentified can lead to increased maternal morbidity and fetal compromise between 26 to 34 weeks of gestation The complications present at an irreversible stage where there is no sufficient time even for referral to tertiary care center. Frequent antenatal visits as suggested by WHO would definitely bring down maternal mortality but this increased surveillance when offered to all might be a huge burden to health care providers in low resource settings. An acceptable screening test should help in triaging the high risk group in first trimester itself targeting about only one third of the population for prophylactic therapy and increased antenatal surveillance.The objective of this study is to evaluate the performance and feasibility of different screening protocols in low resource settings.Methodology: Screening for PE and FGR was done at the 11-14 weeks aneuploidy scan as per FMF guidelines. Group I included 6289 women whose risk prediction was done with maternal characteristics [MC], mean arterial pressure [MAP] and Uterine artery Doppler [UAD]. Group II included 2067 women whose risk was predicted with MC, MAP, UAD and PAPP-A. Group III included 576 women whose risk prediction included all parameters with PLGF.Results: Two thousand five hundred fifty-seven cases were screen positive in group I and 602 were screen positive in group II. In group III which included PLGF, 24 were positive for early onset PE and 36 for late onset PE. The number needed to treat [NNT] was 35.9, 29.1 and 10% in Group I, II and III respectively. The detection rate [DR] for PE and FGR was 60% in Group I and DR for FGR in Group II was 85%. In Group III, for early onset PE the DR was 98% and 68% for late onset PE.Conclusion: Screening for PE with available resources in the periphery needs to be implemented to avoid its grave complications. Traditional screening for PE by NICE guidelines can be adopted but may have a detection rate of only 30-40%. Though screening by ACOG criteria may have good detection rates but more than two thirds of the population would become screen positive which nullifies this approach as a good screening methodology in low resource settings. Multiparametric approach for screening in first trimester serves as a better screening tool to enable higher detection rate of disease with least false positive rates. Uterine artery Doppler when combined with maternal characteristics and mean arterial pressure could achieve a detection rate of about 60% and would still target only one third of the population for increased antenatal surveillance. This requires training healthcare professionals in the periphery for this approach and this should be our prime focus in the current scenario. Inclusion of serum biochemistry would still bring down the target population to 10% and increase the DR and can be considered as an additional test in economically feasible population. In low resource settings a better screening approach to PE would be a combination of maternal history, biophysical or biochemical parameters whichever is feasible considering the economy and availability of resources.

Incidence and Risk Factors of Pre-Eclampsia in the Paropakar Maternity and Women's Hospital, Nepal: A Retrospective Study

This study aims to determine the incidence of pre-eclampsia and distribution of risk factors of pre-eclampsia at Paropakar Maternity and Women's Hospital, Kathmandu, Nepal. A retrospective study included 4820 pregnant women from 17 September to 18 December 2017. Data were obtained from the medical records of the hospital's Statistics Department. Associations between the risk factors and pre-eclampsia were determined using logistic regression analysis and expressed as odds ratios. The incidence rate of pre-eclampsia in the study population was 1.8%. Higher incidence of pre-eclampsia was observed for women older than 35 years (Adjusted Odds Ratio, AOR)= 3.27; (Confidence Interval, CI 1.42-7.52) in comparison to mothers aged 20-24 years, primiparous women (AOR = 2.12; CI 1.25-3.60), women with gestational age less than 37 weeks (AOR = 3.68; CI 2.23-6.09), twins pregnancy (AOR = 8.49; CI 2.92-24.72), chronic hypertension (AOR = 13.64; CI 4.45-41.81), urinary tract infection (AOR = 6.89; CI 1.28-36.95) and gestational diabetes (AOR = 11.79; CI 3.20-43.41). Iron and calcium supplementation appear to be protective. Age of the mothers, primiparity, early gestational age, twin pregnancy, chronic hypertension, urinary tract infection and gestational diabetes were the significant risk factors for pre-eclampsia. Iron and calcium supplementation and young aged women were somewhat protective.

Risk factors and potential protective factors of pregnancy-induced hypertension in China: A cross-sectional study

A cross-sectional study was conducted to the reported factors and assesses possible protective factors for pregnancy-induced hypertension (PIH) in China. The data of pregnant women who delivered between October 2016 and September 2017 were collected from a birth registry. The primary outcome was the occurrence of PIH. Secondary outcomes were delivery before 34 gestational weeks and other adverse obstetric outcomes of PIH. Among the 99 535 women enrolled, 5731 women (5.8%) developed PIH. BMI had a positive correlation with the primary and two secondary outcomes (adjusted OR = 2.05, 2.56, 1.87, respectively, for overweight; adjusted OR = 4.44, 3.90, and 2.63, respectively, for obesity). Otherwise, calcium supplementation during pregnancy was a potential protective factor for those outcomes (adjusted OR = 0.87, 0.14, and 0.44, respectively). These results provide a basis for PIH prevention strategy in the Chinese public health sector. Calcium supplementation and lowering the BMI might have the potential benefit on reducing the prevalence of PIH in selected women.