|Year : 2020 | Volume
| Issue : 3 | Page : 141-146
Obstetric outcome of pregnancies complicated by hypertensive disorders of pregnancy
Robinson C Onoh1, Kanario A Onyebuchi2, Johnbosco E Mamah1, Bonaventure O Anozie1, Ekwedigwe C Kenneth3, Esike O U. Chidi1
1 Department of Obstetrics and Gynecology, Federal Teaching Hospital Abakaliki, Abakaliki, Ebonyi State, Nigeria
2 Federal Medical Centre, Umuahia, Abia State, Nigeria
3 National Obstetrics Fistula Centre, Abakaliki, Ebonyi State, Nigeria
|Date of Submission||18-Sep-2019|
|Date of Acceptance||21-Jan-2020|
|Date of Web Publication||7-Oct-2020|
Dr. Johnbosco E Mamah
Department of Obstetrics and Gynaecology, Federal Teaching Hospital Abakaliki, PMB 102, Abakaliki 480001, Ebonyi State
Background: Hypertensive disorders of pregnancy are of significant public health concern due to associated maternal and perinatal morbidity and mortality. Objective: To determine the trend and obstetric outcome of pregnancies complicated by hypertensive disorders in a tertiary hospital in South-East Nigeria. Materials and Methods: Patients managed for hypertensive disorders from January 1, 2012, to December 31, 2017 were recruited for the study. Case files of patients were retrieved, and information on sociodemographic variables, risk factors, and fetomaternal outcome were extracted using a pro forma. Data analysis was done using International Business Machine-Statistical Package for the Social Sciences Version 20 (IBM-SPSS Version 20, New York, USA ). Ethical clearance was obtained from the ethics and research committee of the institution. Results: During the study period, there were a total of 14,181 deliveries, of which 785 women were managed for hypertensive disorders of pregnancy, thus giving a prevalence of 5.5%. Preeclampsia accounted for 62% (487) while chronic hypertension was 4.3% (34). There was a rising trend from 2012 with a peak in 2017. About 60% (181) of the patients were not booked for antenatal care. The predominant risk factors were advanced maternal age 14.2% (43) and previous history of hypertensive disorder 13.6% (41). Almost half of the patients had caesarean section (46.4%, 140). Preterm births were recorded in 56.6% (171) of the patients. Maternal and perinatal deaths were recorded in 0.7% (2) and 16.2% (941) of the patients, respectively. Conclusion: This study showed that hypertensive disorders of pregnancy remain a significant cause of adverse maternal and perinatal outcomes in pregnancy. Adequate antenatal coverage, early diagnosis, and improved emergency obstetric care services are needed to reverse the trend.
Keywords: Hypertensive disorders, outcome, pregnancy, trend
|How to cite this article:|
Onoh RC, Onyebuchi KA, Mamah JE, Anozie BO, Kenneth EC, Chidi EO. Obstetric outcome of pregnancies complicated by hypertensive disorders of pregnancy. Sahel Med J 2020;23:141-6
|How to cite this URL:|
Onoh RC, Onyebuchi KA, Mamah JE, Anozie BO, Kenneth EC, Chidi EO. Obstetric outcome of pregnancies complicated by hypertensive disorders of pregnancy. Sahel Med J [serial online] 2020 [cited 2020 Nov 29];23:141-6. Available from: https://www.smjonline.org/text.asp?2020/23/3/141/297456
| Introduction|| |
Hypertensive disorders is a common medical disorder complicating pregnancy. It is a spectrum of diseases comprising of preeclampsia/eclampsia, gestational hypertension without proteinuria, chronic hypertension, and preeclampsia superimposed on chronic hypertension.,,, They are characterized primarily by hypertension in pregnancy irrespective of gestational age, with/without proteinuria, and/or convulsion., Among them, preeclampsia and eclampsia present a major risk due to increased maternal and perinatal morbidity and mortality.,
Worldwide, hypertensive disorders of pregnancy complicate about 5%–10% of pregnancies., Studies continue to show a rise in the prevalence and increased morbidities from these disorders of pregnancy. This has been attributed to an upsurge in the incidence of obesity even in developing countries.,,,, It has been reported that the burden of hypertension in pregnancy is more in developing countries due to ignorance, poverty, illiteracy, and lack of adequate antenatal coverage. Hospital studies in Nigeria report an incidence of between 4% and 21%.,,,, Hypertensive disorders account for about 14% of the global burden of maternal mortality and the developing countries account for the majority of these deaths.,,,,, A recent study has shown that about 24% of maternal deaths in Nigeria was from hypertensive disorders.
Our detailed search revealed that apart from the studies published by Agwu et al. and Ajah et al. at the defunct tertiary institutions in Abakaliki in 2012, no audit has been conducted on hypertensive disorders of pregnancy.
| Subjects and Methods|| |
Ebonyi State is one of the five states in the South-East geopolitical zone of Nigeria. It was created in 1996 from the largely rural areas of the preexisting Enugu and Abia states with Abakaliki as its headquarters. It has an estimated population of 2176,947 million people and occupies a land mass of 6400 km2. It shares boundaries in the West with Enugu state, Abia state in the East, Cross-river in the South and Benue state in the North. The vegetation characteristic of the area is the tropical rain forest with an average annual rainfall of 1600 mm and an average atmospheric temperature of 36°C. Ibo is the predominant ethnic group in Ebonyi State and majority practice Christianity.
The current institution which was the place of this study is a Federal government-owned tertiary health institution established in December 2011 when the Federal government acquired the then Ebonyi State University Teaching Hospital Abakaliki and merged it with the former Federal Medical Centre, Abakaliki. It is located within the center of the state capital. It receives referrals from general hospitals, mission hospitals and primary health centers as well as privately owned hospitals and clinics. It also receives referral from neighboring states.
This was a 6-year retrospective study involving all the cases of hypertensive disorders in pregnancy managed between January 1, 2012, and December 31, 2017. A case was selected if the patient was pregnant and was managed for any of preeclampsia, eclampsia, gestational hypertension, chronic hypertension, and preeclampsia superimposed on chronic hypertension. Hypertension was defined as blood pressure recorded on at least two occasions 4 h apart measuring ≥140/90 mmHg or a single recording of 160/110 mmHg or more. Urine dipstick test showing proteinuria of 2 or more pluses is considered significant for the diagnosis of severe preeclampsia taking into consideration other clinical and biochemical parameters.
Information about the patients was obtained from the obstetric registers in the labor ward, postnatal ward, antenatal ward, accident and emergency and the theater. The case notes of the patients were retrieved from the records department; data were extracted and entered into a pro forma. Data on the diagnosis, sociodemographic characteristics (age, parity, marital status, occupation, and educational attainment), booking status, gestational age, risk factors, and birth outcomes were collected.
A total of 785 women were managed for hypertensive disorders of pregnancy but only 302 case notes had complete information and were used for data analysis. This gave a retrieval rate of 38.5%. Data were analyzed using IBM-SPSS version 20 statistical software package version 20 IBM-SPSS version 20, (New York, USA). Where applicable, results were expressed in percentages, mean ± standard deviation. Level of significance was taken at P < 0.05.
Ethical approval dated 12th June 2020 was obtained from the Research and Ethics Committee of Federal Teaching Hospital, Abakaliki. Ethical approval protocol number was REC 12/06/2017-12/06/2017. Confidentiality was maintained while handling patient's case files.
| Results|| |
During the period under review, a total of 14,181 deliveries were recorded. Of this number, 785 women were managed for hypertensive disorders of pregnancy, thus giving a prevalence of 5.5%. Only 302 patients' case notes had complete information and were used for data analysis.
The mean age of the patients was 27.7 ± 5.8 years [Table 1]. Majority, 270 (89.4%) of the patients were married. A little over half, i.e. 51.7% (156) of the patients were urban dwellers. About 40.7% (123) of the population attained secondary level of education while 7.0% (21) had no formal education and 28.1% (85) of the parturient women were homemakers. In all, 59.9% (181) of the population did not book in this facility. In some cases, participants received both orthodox and unorthodox care elsewhere including private hospitals, maternity homes and traditional birth attendant's facilities.
[Table 2] and [Figure 1] show the annual prevalence of hypertensive disorders and the distribution of the individual diseases. There was a steady increase from 4.4% (107) at inception of the study in 2012 to 6.3% (146) in 2015 after which there was a decline to 5.1% (121) in 2016. Thereafter, there was a rise to 7.6% (164) in 2017. Preeclampsia was the predominant disease making up 62.0% (487) of cases, eclampsia accounted for 10.3% (81), and the least was chronic hypertension with 4.3% (34).
In [Table 3], advanced maternal age, previous history and family history of hypertensive disorders were found in 14.2% (43), 13.6% (41), and 9.6% (29) of the patients, respectively.
[Table 4] shows the events surrounding deliveries. More than half of the parturient were delivered before term 56.6 (171) with an average gestational age of 35.3 ± 3.7 at delivery. Vaginal delivery was the mode of delivery in 48.3% (146) of cases while 5.3% (16) of the women had instrumental vaginal delivery. The mean APGAR scores were 6.3 and 7.6 for the 1st and 2nd min APGAR scores, respectively. The mean birth weight was 2.5 ± 0.9 kg while 44.4% (134) of the neonates had low birth weight.
Maternal and perinatal morbidity and mortality are presented in [Table 5]. The most common maternal complication was abruptio placentae in 10.6% (32) of the parturient. HELLP syndrome was also noted in 1.7% (5) and maternal death was recorded in 2 of the women (0.7%). Birth asphyxia was observed in 13.6% (41) of the neonates while there were 49 (16.2%) perinatal deaths.
| Discussion|| |
The prevalence of hypertensive disorders in pregnancy found in this study was 5.5%. This figure is close to the 5.4% reported in India and 8.5% reported by Wolde in Jimma but less than 25.8% reported by Azubuike in Katsina and 17% reported by Singh in Sokoto. This lower prevalence might be due to the poor health-seeking behavior of women in our setting such that patients present to the hospital as a last resort, in most cases with severe disease. This is supported by the fact that about 3/5th of the patients did not book for antenatal care. Similarly, being a retrospective study, there is the attendant limitation of missing and incomplete case notes which affected the data available for analysis and ultimately the extent of information at our disposal.
The sociodemographic characteristics of the parturient women in our study mirrors what is reported from similar studies in our environment. The mean age of the patients was 27.7 ± 5.8 years with more than half (55%) of the patients falling within the age group of 20 to 29 years. This is similar to a mean age of 27.2 ± 5.6 years reported by Sotunsa in Ogun state, Southwest Nigeria but less than the 31.3 ± 5.7 years reported by Mbachu in Nnewi in the South-East. A little over half of our patients were urban dwellers which might give credence to the fact that hypertensive disorders seem to be more prevalent in urban population due to lifestyles which predisposes to obesity, a major risk factor for hypertension. The Primigravidae made up almost one-third (30.2%) of the study population.,,
Although 97.0% of the patients had at least a primary level of education, we observed that this relative high literacy level has not impacted positively on their health-seeking behavior. The patriarchal family culture in our society where women are unable to take major decisions without the consent of their husbands, ignorance, and the erroneous impression that coming to the teaching hospital increases one's chance of having an abdominal delivery were the major factors that delayed presentation to the hospital regardless of educational attainment. These findings are similar to what was reported in other studies.,,
Of the total cases of hypertensive disorders managed during the study period, we observed a progressive annual rise in prevalence starting in 2012 (4.4%) with a fall in 2016 after which it rose to a peak in 2017 (7.6%). The reason for this pattern of distribution was not immediately clear. A breakdown of the different hypertensive disorders managed during the period under review showed that preeclampsia and eclampsia were the most diagnosed hypertensive diseases and accounted for 72.3% of the hypertensive disorders. Preeclampsia and eclampsia are pregnancy specific diseases and might present with more pronounced symptoms and signs compared to other forms of hypertensive disorders, thereby making the patient present to the hospital or require referral. This might account for its predominance in our study. The predominance of preeclampsia in this study is similar to the finding reported by Mbachu et al. but different from what was reported in the study by Singh et al. where gestational hypertension was the most diagnosed hypertensive disorder. The former study cited was a retrospective study just like ours while Singh conducted a prospective study. Wolde et al. in Jimma and Ebeigbe et al. in Benin also had similar findings with ours.
Advanced maternal age, previous history of hypertensive disorders and family history of hypertension were the leading risk factors identified in our study. Advanced maternal age is a recorgnised risk factor for hypertensive disorders in pregnancy., This could be because increasing maternal age comes with increased medical disorders particularly hypertension.
Hypertensive disorders of pregnancy are associated with increased obstetric intervention rates. Premature termination of pregnancy and higher caesarean section rate among women with hypertensive disorders of pregnancy have been reported in previous studies.,,, In the present study, hypertensive disorders were responsible for preterm deliveries in 56.5% of the patients and caesarean section was the route of delivery in 46.4% deliveries. The average birth weight of neonates delivered by the patients was 2.5 ± 0.9 kg and 44.4% of the neonates were of low birth weight. Severe preeclampsia could be associated with intrauterine growth restriction and low birth weight. The management principle of stabilization and delivery by the most expeditious route implies that early onset of this disease almost always ends up in preterm delivery. Other adverse outcomes observed were abruptio placentae, birth asphyxia, and death. While hypertensive disorders accounted for the death of two (0.7%) mothers, it was responsible for 49 (16.2%) perinatal deaths. These are similar to findings reported from other studies.,, These may have been averted with earlier presentation and management.
| Conclusion|| |
In conclusion, this study has shown that hypertensive disorders of pregnancy continue to be a cause of adverse maternal and perinatal outcomes in our environment. Optimal use of antenatal care services, health education to dispel misconceptions, timely diagnosis and referral will ensure a good outcome for the mother and child.
A major limitation of this study was the difficulty with retrieving patients' case notes. In most cases, the case notes had incomplete documentation especially in the early years following the merger of the Ebonyi State University Teaching Hospital, Abakaliki with the Federal Medical Centre, Abakaliki. This makes a strong case for computerization of the health information department of hospitals in the West African sub-region.
We like to acknowledge the management of Federal Teaching Hospital Abakaliki, Southeast, Nigeria, for their support during the project.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]