Maternal and Neonatal Outcomes in Hypertensive Disorders during Pregnancy: A Hospital-Based Study

Spine 4.5 mm Print ISSN 2666-3481 Online ISSN 2666-349X Volume 4 • Issue 2 • July-December 2022 Indian Journal of Physical Therapy and Research ● Volume 4 ● Issue 2 ● July-December 2022 ● Pages ***-*** Indian Journal of Physical Therapy and Research www.ijptr.org An official peer reviewed publication of KAHER Institute of Physiotherapy Original Article Maternal and Neonatal Outcomes in Hypertensive Disorders during Pregnancy: A Hospital‑Based Study Uma Kole, Sudha Raddi, Anita Dalal1 Department of OBG Nursing , KLE Academy of Higher Education and Research, Institute of Nursing Sciences, 1Department of OBG, JNMC, Belagavi, Karnataka, India Abstract Context: Pregnancy is a physiological phenomenon, and each pregnancy is unique and valuable in its own way. Hypertensive diseases during pregnancy begin throughout pregnancy and disappear entirely after birth. Hypertensive disorders in pregnancy (HDP), including pregnancy-induced hypertension (HTN), chronic HTN (CHTN), (superimposed) preeclampsia, and eclampsia, are responsible for increased perinatal morbidity and mortality. Aim: The aim of this study was to investigate the prevalence and perinatal effects in women with hypertensive disease during pregnancy. Setting and Design: Hospital based cross section study was conducted on pregnant women. Methods and Materials: A hospital-based cross-sectional study was carried out from September 2019 to August 2021 on women whose pregnancies were complicated by HTN disorders. Mothers of the baby suffering from systemic diseases were excluded from the study. Statistical analysis used: Descriptive and inferential statistical analysis was conducted. Results: In the present study results the prevalence of gestational HTN at 8.49%, preeclampsia at 18.10%, severe preeclampsia at 8.75%, and CHTN was 2.28%. It was shown that the prevalence of hypertensive disease is 38%. A significant difference was found between the maternal age group of mothers suffering from HTN disorders during pregnancy with mean gestational age in weeks F = 124.6477, P = 0.0001 at a 5% level. Furthermore, a significant statistical difference was observed with different maternal age groups having different mean Apgar scores at 1 min with F = 81.0233, P = 0.0001. Conclusion: Prenatal HTN is one of the leading causes of maternal and neonatal death. Despite having all of the resources and several government programs in both urban and rural areas, many women suffer from HDP in both locations (rural and urban). Hence, management, as well as awareness among pregnant women regarding hypertensive diseases in pregnancy, is required. Keywords: Eclampsia, Hypertensive disorders, Perinatal outcome, Preeclampsia, Pregnancy induced hypertension, Pregnancy Address for correspondence: Mrs. Uma Kole, KLE Academy of Higher Education and Research, Institute of Nursing Sciences, Nehru Nagar, Belagavi, Karnataka, India. E‑mail: koleuma@gmail.com Access this article online Quick Response Code: Website: www.ijptr.org DOI: This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com 10.4103/ijptr.ijptr_111_22 Received: 12‑07‑2022, Revised: 28‑11‑2022, Accepted: 13‑12‑2022, Web Published: 19‑01‑2023 How to cite this article: Kole U, Raddi S, Dalal A. Maternal and neonatal outcomes in hypertensive disorders during pregnancy: A hospital-based study. Indian J Phys Ther Res 2022;4:127-32. © 2023 Indian Journal of Physical Therapy and Research | Published by Wolters Kluwer - Medknow 127 Kole, et al.: Maternal and Neonatal Outcomes in Hypertensive Disorders INTRODUCTION Pregnancy is a physiological phenomenon, and each pregnancy is unique and valuable in its own way. Hypertensive diseases during pregnancy begin throughout pregnancy and disappear entirely after birth.[1] Hypertensive disorders in pregnancy (HDP), including pregnancy‑induced hypertension (HTN), chronic HTN (CHTN), (superimposed) preeclampsia, and eclampsia, are responsible for increased perinatal morbidity and mortality.[2] Preterm deliveries are caused by almost 8%–10% of HDP,[3] and premature birth is recorded by 50% of women with severe preeclampsia or eclampsia.[4] Preeclampsia and eclampsia are the leading causes of perinatal fatalities in underdeveloped nations, accounting for 25% of all cases.[5] Many research studies on maternal and neonatal problems are conducted in developed nations. The incidence of hypertensive disorders is outweighed in developing countries. [6] The etiopathogenesis of hypertensive disorder of pregnancy is vasospasm and endothelial dysfunction as a consequence of uteroplacental blood flow. This results in decreased placental perfusion, leading to decreased supply of oxygen and nutrients necessary for the growth and development of the fetus and well‑being. This directly increases the incidence of intrauterine growth restriction (IUGR), and low birth weight, and so does the perinatal mortality and morbidity. Decreased perfusion of major organs can cause brain edema, bleeding, and seizures are a risk for mothers.[7] For any disease process to be prevented, methods for identifying those who are highly susceptible to the disorder must be available. Despite the fact that numerous clinical and biochemical tests have been proposed for the early detection or prediction of preeclampsia, the majority of them are still either too costly or sophisticated to be widely utilized in the majority of developing countries. Currently, there is no preeclampsia screening test available that is both accurate and affordable and which can be suggested for use in the majority of developing nations. There is insufficient evidence to support the widespread use of uterine artery Doppler and first‑trimester maternal blood indicators for the early diagnosis of preeclampsia, particularly in settings with limited resources.[8] Furthermore, there is a lack of thorough epidemiological data on prenatal mortality and morbidity in underdeveloped nations, particularly in rural regions. Health improvements 128 cannot be assessed without precise population data. Furthermore, without proper vital registration centers, rates are frequently underestimated. Existing Indian health registration systems have been unable to capture all pregnancies and their outcomes, particularly in rural regions where the majority of Indians live.[9] Inequities in health‑care facilities between urban and rural regions may be responsible for a newborn death rate differential of 47–370 per 1000, which is connected with hypertensive problems in pregnancy.[10] In contrast, the incidence and risk of adverse perinatal outcomes from hypertensive disease during pregnancy vary by country, population, and race/ geographic location. Therefore, the aim of this study was to investigate the prevalence and perinatal effects in women with hypertensive disease during pregnancy. SUBJECTS AND METHODS A hospital‑based cross‑sectional study was carried out from September 2019 to August 2021 on women whose pregnancies were complicated by HTN disorders. Mothers of the baby suffering from systemic diseases were excluded from the study. • Gestational HTN was diagnosed in hypertensive women over 20 weeks gestation with no development of proteinuria or systemic evidence of preeclampsia • CHTN was diagnosed in hypertensive women before pregnancy or <28 weeks of gestation • Preeclampsia is defined as women with blood pressure ≥140/90 mmHg, with or without proteinuria at least twice at 4‑h intervals at 28 weeks of gestation. Eclampsia is diagnosed when a seizure occurs in a woman with high blood pressure, which is not thought to be due to any other cause. Data collection Face‑to‑face interviews were conducted at tertiary care hospitals in Belagavi city. Data were collected on demographic characteristics, maternal age, educational qualification, registered cases (from the first visit), occupation, parity, gestational age (GA), weight gain, mode of delivery, birth weight, and Apgar score. Table 1: Prevalence of evidence of hypertension Types of HTN GHTN PE SPE CHTN Total Number of respondents Percentage of respondents 298 635 307 80 1320 8.49 18.10 8.75 2.28 100.00 HTN: Hypertension, GHTN: Gestational HTN, PE: Preeclampsia, SPE: Severe preeclampsia, CHTN: Chronic HTN Indian Journal of Physical Therapy and Research | Volume 4 | Issue 2 | July-December 2022 Kole, et al.: Maternal and Neonatal Outcomes in Hypertensive Disorders RESULTS Results revealed the prevalence of gestational HTN (GHTN) at 8.49%, preeclampsia at 18.10%, severe preeclampsia at 8.75%, and CHTN at 2.28%. The study found out the prevalence of hypertensive disease is 38% [Table 1]. According to the findings around 12 per 1000 live births/ births of perinatal mortality is observed among women suffering from hypertensive disorders which were avoidable with proper prenatal monitoring and care. Table 2 revealed that a statistical difference was found with birth weight as compared to the maternal age group of mothers suffering from HTN disorders during pregnancy F = 3.8459, P = 0.0092, mean Apgar score at 1 min and at 5 min F = 81.0233, P = 0.001 and F = 63.5466 P = 0.001, GA in weeks F = 124.6477, P = 0.0001, and mean placental weight F = 24.2539, P = 0.0001 at 5% level. Table 3 revealed the association between demographic profiles with the prevalence of evidence of HTN. Considering the maternal age group out of 783, between 18 and 21 years of age 26.17% (78) were suffering from GHTN, 25.67% (163) had preeclampsia, 25.08% (77) had eclampsia, and 11.25% (9) were suffering from CHTN. Table 2: Distribution of perinatal mortality Distribution of perinatal mortality-1320 Hypertensive Early neonatal Stillbirth PM per 1000 disorders in pregnancy death live births (%) 11.6 GHTN 6 20 PE 7 64 SPE 3 43 CHTN 8 3 HTN: Hypertension, GHTN: Gestational HTN, PE: Preeclampsia, SPE: Severe PE, CHTN: Chronic HTN The association between maternal age and the prevalence of hypertensive disorders during pregnancy was statistically significant with Chi‑square – 43.3900, P = 0.0001. Similarly, a statistically significant association was found between the area of residence and the prevalence of hypertensive disorders during pregnancy. The association between an obstetrical score of a mother and the prevalence of hypertensive disorders was statistically significant with Chi‑square – 20.0310, P = 0.0001. The association between religion and the prevalence of hypertensive disorders during pregnancy is statistically significant with Chi‑square – 28.2040, P = 0.0300. The association between the type of family and prevalence of hypertensive disorders during pregnancy was found statistically significant with Chi‑square – 40.1700, P = 0.0001 Table 4. DISCUSSION In the present study, the prevalence of HDP is 38%. It was observed that there were 8.49% (298) of mothers suffering from gestational HTN, 18.10% (635) and 8.75% (307) had preeclampsia and preeclampsia, and 2.28% (80) had CHTN. A study done by Mehta et al. found a 6.9% of prevalence. [11] Subki et al. reported a prevalence of gestation HTN at 29.5%, preeclampsia at 54.9%, and eclampsia at 8%.[12] In our study, it was shown that birth weight is much lower at a younger age – 22 to 25 years – than it is at a later age (26 to 29 years). Panda et al. reported findings that were comparable concerning both young and elderly mothers’ significant perinatal mortality with low birth weight problems.[13] It was shown that preterm or extremely preterm births accounted for nearly three‑fourths of perinatal Table 3: Comparison of maternal age groups with birth weight, gestational age, Apgar, and placental weight by one-way ANOVA Maternal age group 18–21 years 22–25 years 26–29 years 30+ years Total F P Birth weight Mean SD GA Mean SD Apgar 1 Mean SD Apgar 5 Mean SD Placental weight Mean SD 2637.33 568.05 2585.67 589.43 2665.37 560.96 2647.39 700.80 2606.49 584.18 3.8459 0.0092* 38.68 1.75 37.13 2.88 36.73 3.37 36.53 3.64 36.91 3.36 124.6477 0.0001* 6.92 1.10 6.25 1.96 5.81 2.35 5.74 2.54 6.31 1.92 81.0233 0.0001* 8.00 1.45 7.40 2.19 6.82 2.67 6.74 2.91 7.48 2.17 63.5466 0.0001* 373.97 72.20 368.59 228.35 339.94 97.57 329.90 102.88 332.56 86.99 24.2539 0.0001* Pair-wise comparisons by Tukey multiple post hoc procedures 18-21 years versus 22-25 years 18-21 years versus 26-29 years 18-21 years versus 30+years 22-25 years versus 26-29 years 22-25 years versus 30+years 26-29 years versus 30+years 0.5758 0.9209 0.9997 0.0061* 0.9166 0.9977 0.0001* 0.0001* 0.0001* 0.0001* 0.1270 0.0220* 0.0001* 0.0001* 0.0001* 0.0110* 0.0012* 0.0012* 0.0001* 0.0001* 0.0001* 0.1293 0.0002* 0.0004* 0.9146 0.0001* 0.0001* 0.0035* 0.0007* 0.0001* SD: Standard deviation, GA: Gestational age, * significance p value <0.05 Indian Journal of Physical Therapy and Research | Volume 4 | Issue 2 | July-December 2022 129 130 Table 4: Association between demographic profile with the prevalence of evidence of hypertension Demographic profile Percentage GHTN Percentage PE Percentage SPE Percentage CHTN Percentage Total χ2 P 1328 786 65 9 60.69 35.92 2.97 0.41 180 103 14 1 60.40 34.56 4.70 0.34 358 245 27 5 56.38 38.58 4.25 0.79 161 129 15 2 52.44 42.02 4.89 0.65 44 34 2 0 55.00 42.50 2.50 0.00 2071 1297 123 17 16.7420 0.1600 456 859 534 339 20.84 39.26 24.41 15.49 78 86 65 69 26.17 28.86 21.81 23.15 163 261 127 84 25.67 41.10 20.00 13.23 77 127 65 38 25.08 41.37 21.17 12.38 9 35 21 15 11.25 43.75 26.25 18.75 783 1368 812 545 43.3900 0.0001* 143 1542 482 21 6.54 70.48 22.03 0.96 16 214 61 7 5.37 71.81 20.47 2.35 40 470 121 4 6.30 74.02 19.06 0.63 25 219 58 5 8.14 71.34 18.89 1.63 4 58 17 1 5.00 72.50 21.25 1.25 228 2503 739 38 12.7800 0.3850 1601 587 73.17 26.83 233 65 78.19 21.81 505 130 79.53 20.47 236 71 76.87 23.13 67 13 83.75 16.25 2642 866 16.2510 0.0030* 33 106 228 463 871 487 1.51 4.84 10.42 21.16 39.81 22.26 4 11 44 65 108 66 1.34 3.69 14.77 21.81 36.24 22.15 10 22 72 136 261 134 1.57 3.46 11.34 21.42 41.10 21.10 4 7 36 77 119 64 1.30 2.28 11.73 25.08 38.76 20.85 0 1 7 14 43 15 0.00 1.25 8.75 17.50 53.75 18.75 51 147 387 755 1402 766 22.5100 0.3140 910 1278 41.59 58.41 140 158 46.98 53.02 318 317 50.08 49.92 150 157 48.86 51.14 30 50 37.50 62.50 1548 1960 20.0310 0.0001* 1158 992 38 52.93 45.34 1.74 126 163 9 42.28 54.70 3.02 253 370 12 39.84 58.27 1.89 101 193 13 32.90 62.87 4.23 30 48 2 37.50 60.00 2.50 1668 1766 74 78.8910 0.0001* 1611 270 43 43 221 73.63 12.34 1.97 1.97 10.10 210 43 1 8 36 70.47 14.43 0.34 2.68 12.08 446 107 7 11 64 70.24 16.85 1.10 1.73 10.08 204 55 4 8 36 66.45 17.92 1.30 2.61 11.73 59 13 3 0 5 73.75 16.25 3.75 0.00 6.25 2530 488 58 70 362 28.2040 0.0300* 1106 1082 0 50.55 49.45 0.00 134 163 1 44.97 54.70 0.34 275 359 1 43.31 56.54 0.16 147 156 4 47.88 50.81 1.30 35 44 1 43.75 55.00 1.25 1697 1804 7 40.1700 0.0001* 689 1499 2188 31.49 68.51 100.00 97 201 298 32.55 67.45 100.00 167 468 635 26.30 73.70 100.00 99 208 307 32.25 67.75 100.00 22 58 80 27.50 72.50 100.00 1074 2434 3508 7.6320 0.1060 Hb: Hemoglobin, HTN: Hypertension, GHTN: Gestational HTN, PE: Preeclampsia, SPE: Severe PE, CHTN: Chronic HTN, * significance p value <0.05 Kole, et al.: Maternal and Neonatal Outcomes in Hypertensive Disorders Indian Journal of Physical Therapy and Research | Volume 4 | Issue 2 | July-December 2022 Maternal Hb Normal Hb Mild Moderate Severe Maternal age group 18-21 22-25 26-29 30+ Age at marriage <18 18–22 23–27 28–32 Area of residence Rural Urban Education level Illiterate Informal education Primary Secondary Degree Others Obstetric score Primi Multi Monthly expenditure and savings ≤5000 5001–10,000 ≥10,001 Religion Hindu Muslim Christian Jain Others Type of family Nuclear Joint Extended Food habits Vegetarian Nonvegetarian Total None Kole, et al.: Maternal and Neonatal Outcomes in Hypertensive Disorders mortality (61%) in women with the antepartum start of HDP, which was statistically significant with P = 0.0092. According to Endeshaw and Berhan’s report, 71% of all perinatal fatalities in women with HDP were in preterm or extremely preterm deliveries.[14] Neonatal morbidity was higher in women with severe preeclampsia; according to Panda et al.,[13] the majority of the difficulties were due to premature births. It follows that HDP most likely exposed a number of infants to preterm birth and associated problems. Cincotta RB and Brennecke[15] claim that women with HDP are more likely to give birth prematurely. Reported that women with HDP are more likely to birth their babies prematurely. A higher risk of perinatal mortality in infants with prenatal HDP, as described by Chhabra and Gandhi,[16] may be congruent with the finding of a strong association between lower GA, low birth weight, and perinatal death. The findings showed that mothers with HTN problems who were younger – <25 years old – had preterm births with low birth weight and low Apgar scores, among other things. In addition, a reduced placental weight incidence was noted, which might have a negative impact on the fetus’s growth and development and lead to IUGR. According to research by Akbar et al.,[17] neonates primarily had preterm‑related issues when their mothers had severe preeclampsia. The pathogenesis of hypertensive illness is significantly influenced by maternal characteristics, such as maternal age. It has been shown that moms under the age of 25 years are more prone than mothers between the ages of 26 and 30 years to suffer from HTN problems. Women from rural areas showed a greater prevalence of HTN disorders during pregnancy as compared to moms in urban areas. According to Panda et al.,[13] maternal mortality was observed among women from lower and middle‑class socioeconomic backgrounds as well as among women older than 35 years. Preeclampsia has long been considered an illness of primiparity. Accordingly, the majority of the moms were anemic or undernourished and belonged to lower socioeconomic classes. Primi mothers have a 44.18% higher prevalence of hypertensive disease pathology. According to Shruthi and Thenmozhi,[18] 60.7% of the moms with HTN were primigravida. The majority of them did not finish high school and did not get routine prenatal care due to a lack of access to health centers’ factors. Results inferred that HDP is associated with a greater threat of poor perinatal outcomes regardless of where the women live. Women with Pregnancy induced hypertension (PIH), preeclampsia, and eclampsia had 53.18% emergency cesarean section and have premature babies with low birth weight. When compared with all labor, 39.3% had a lower‑segment cesarean section as the mode of delivery reported by Shruthi and Thenmozhi.[18] A similar finding was reported by Levine et al.,[19] in which the abdominal route (including Lower segment Caesarian ‑Section (LSCS) and hysterectomy) is the common method of termination of pregnancy with a slightly higher incidence rate than our study (65.6%). Patients with a poor knowledge level are more likely to have a high incidence of severe chronic hypertension , superimposed preeclampsia, and eclampsia in this series, according to Indonesian research. [19] These findings demonstrated that a lack of awareness as well as a healthy lifestyle has a crucial role in the development of HTN problems during pregnancy. These disparities might be caused by socioeconomic level, racial factors, and other demographic factors such as parity and age. Women who acquire hypertensive issues early in pregnancy, according to prior research, are difficult to control. The potential advantage of delayed delivery in terms of greater fetal maturity must be weighed against the danger of hypoxia and severe growth limitation.[1] To enhance the result, it suggests that mothers with HTN problems should be properly counseled and managed with suitable neonatal critical care facilities. When summing up the maternal parameters such as maternal age, area of residence, obstetric care, monthly saving, religion, and type of family plays a vital role in one pregnancy and significantly affects its outcome. These variables are mostly preventable if there is improved knowledge of routine antenatal follow‑up, prompt identification, and referral so that essential intervention may be carried out at the right time to avoid fetal and maternal health disasters. Recommendations Pregnancy is an opportunistic time for health‑care providers to promote positive health activities, thus optimizing the health of pregnant women with potential short‑ and long‑term benefits for both mother and child. Physical exercise during pregnancy could prevent excessive gestational weight gain, promote insulin sensitivity, and reduce systemic inflammation and oxidative stress, leading to improved endothelial function, as well as promoting placental angiogenesis, factors that lower the risks of developing Pre eclampsia (PE) during pregnancy.[20,21] Indian Journal of Physical Therapy and Research | Volume 4 | Issue 2 | July-December 2022 131 Kole, et al.: Maternal and Neonatal Outcomes in Hypertensive Disorders CONCLUSION 6. One of the major factors of maternal and neonatal mortality is HTN during pregnancy. Despite having all of the resources and several government programs in both urban and rural areas, many women suffer from HDP in both locations (rural and urban). This condition affects all women, from illiterate to literate, regardless of where they live. We must prioritize excellent prenatal care and offer enough health education, registration of all pregnant women, early diagnosis of high‑risk pregnancies, and effective and prompt management to reduce maternal, fetal, and perinatal fatalities. 7. 8. 9. 10. 11. Limitations The study had certain limitations as it was a hospital‑based study; hence, the results of the study could be generalized to hospitals only. For the community, a further community‑based study should be done using a larger sample size. 12. 13. Financial support and sponsorship Nil. 14. Conflicts of interest There are no conflicts of interest. 15. REFERENCES 1. 2. 3. 4. 5. 132 16. Lakshmikanth J, Ashoka C, Rani SU. 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