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Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 208-213

Maternal-perinatal outcome in pregnancies complicated by preeclampsia: Looking at early and late onset disorders

1 Department of Obstetrics and Gynecology, Niger Delta University, Wilberforce Island, P.M.B.071, Bayelsa State, Nigeria
2 Department of Child Health, University of Benin Teaching Hospital, Benin City, Nigeria
3 Department of Obstetrics and Gynecology, University of Benin Teaching Hospital, Benin City, Nigeria

Date of Submission29-May-2020
Date of Decision22-Jul-2020
Date of Acceptance10-Sep-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Ikeanyi Eugene M
Department of Obstetrics and Gynecology, Niger Delta University, Wilberforce Island, P.M.B. 071, Bayelsa State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_37_20

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Background: Globally, preeclampsia; an idiopathic pregnancy-related proteinuric hypertensive disorder remains one of the major causes of maternal and perinatal morbidity and mortality, worst so in low resources settings. Accumulating evidence indicates that the outcome is influenced by the gestational age at onset of the disorder. Aim: We investigated the perinatal and maternal outcomes of pregnancies complicated by preeclampsia and in addition compared the early onset and late onset types. Materials and Methods: An analytical observational study was carried on all cases of preeclampsia managed in tertiary hospital between 2013 and 2019. The participants were comparatively studied for maternal and perinatal outcomes. Results: The incidence of preeclampsia was 7.1%. About a third 31.9% were early onset and 68.1% late onset disease. Maternal complications were frequent in preeclampsia; 24.5% eclampsia, an incidence of eclampsia of 56/3474 (1.61%), 74.2% cesarean section, 23.6% severe proteinuria, 12.2% anemia, 11.4% postpartum hemorrhage, 3.1% pulmonary edema, 1.7% thrombocytopenia, 0.9% hemolysis, elevated liver enzymes and low platelet syndrome and acute renal failure, respectively. These were more frequent in late preeclampsia but severer in early onset disease. Case fatality rate was 1.75% and maternal mortality ratio 117.7/100,000 live births. Mean gestational age at delivery in preeclampsia was 35.4 weeks with 51% preterm births and 28.8% small for gestational age neonates with early onset disease contributing more than twofold. The perinatal mortality was high at 21.4%; a perinatal mortality rate of 14.2/1000 total births with 6-fold among early onset disease mostly from iatrogenic prematurity. Conclusions: The incidence of preeclampsia was high, maternal morbidity though more common among late onset disease, was severer among the early onset disease which also had worse adverse perinatal outcomes.

Keywords: Early onset, late onset, maternal, morbidity, mortality, Nigeria, outcomes, perinatal, preeclampsia

How to cite this article:
Eugene M I, Alphonsus N O, Assumpta U IR. Maternal-perinatal outcome in pregnancies complicated by preeclampsia: Looking at early and late onset disorders. Saudi J Health Sci 2020;9:208-13

How to cite this URL:
Eugene M I, Alphonsus N O, Assumpta U IR. Maternal-perinatal outcome in pregnancies complicated by preeclampsia: Looking at early and late onset disorders. Saudi J Health Sci [serial online] 2020 [cited 2021 Jun 14];9:208-13. Available from: https://www.saudijhealthsci.org/text.asp?2020/9/3/208/300290

  Introduction Top

Preeclampsia is a pregnancy-associated disorder that is marked by hypertension and proteinuria that typically manifests after the 20th week of pregnancy. It complicates about 5%–15% of pregnancies globally[1],[2],[3],[4] and causes severe multisystem complications including cerebral hemorrhage, impaired renal, hepatic, respiratory, hematological, and placental functions. Over 98% of its complications occur in the less developed countries.[5] Increasing evidence indicates that the outcome is related to the gestational age at the onset of the disorder.[1] The early onset disorder develops prior to 34 completed weeks of gestation but mostly after the 20th week; considered by some authorities to be a different disease entity developing from different hemodynamic state from the late onset variety which develops thereafter.[1],[6],[7] It is associated with high maternal and perinatal mortality and morbidity worldwide. Evidence from the scientific literature indicates that preeclampsia is associated with increased maternal death and perinatal death.[2] The etiology of preeclampsia is still largely unknown and mostly shrouded in several theories, however, there is overwhelming evidence in the literature to suggest a central role of placenta in pathophysiology of preeclampsia.[1],[8] A pregnancy complicated by preeclampsia is a challenge to the expectant mother, immediate family and the care provider. This is mostly from the increased threat to maternal and fetal lives on the one hand, and the management decision-making especially when the pregnancy is remote from maturity coupled with the overall hospital financial burden on the other hand. The management requires expeditious delivery in most cases to save the mother and less so the fetus. When the pregnancy is remote from term, the management becomes very challenging. In such a case, immediate delivery is associated with high fetal harm and wastage. At this point, it is challenging counseling the mother on the immediate ending of the remotely premature pregnancy and deciding in the face of increased risks of fetal adverse outcomes and maternal multisystem damage on further prolongation of such pregnancy to improve fetal viability by conservative management.

This study investigated the maternal and fetal outcomes of pregnancies complicated by preeclampsia and compared the impact of the timing of the onset of the disorder. This will engender adequate interventions to mitigate the adverse outcomes and improve the quality of maternal and fetal lives in pregnancy complicated by preeclampsia.

  Materials and Methods Top

This analytical observational study took place at Niger Delta University Teaching Hospital. This is a tertiary health institution domicile at Okolobiri, Bayelsa State in Niger Delta region of Nigeria. The state is one of the oil-rich states with a population of people from Bayelsa, across Nigeria and other parts of the world. The main occupations of her indigenous population are farming, trading, and fishing. Relevant data on the mothers, pregnancy and fetal outcomes were extracted directly from the participants, their hospital folders, labor ward, and theater records from October 2013 to November 2019 using structured questionnaire and EPI INFO spreadsheet. The criteria for the diagnosis of preeclampsia were according to Upadya and Rao.[2] and the report of the American College of Obstetricians and Gynecologists' Task Force on hypertension in pregnancy[9] that defined hypertension as systolic blood pressure of 140 mmHg or greater or and the diastolic blood pressure (DBP) of 90 mmHg or greater and significant proteinuria; the presence of ≥300 mg in 24-h urine or 30 mg% (1 + on dipstick testing) two random catheter specimens of urine samples 6 h apart in a woman known to be normotensive and nonproteinuric before the pregnancy and before the 20th week of gestation. All cases of chronic hypertension, proteinuric hypertension prior to 20 weeks' gestation and nonproteinuric gestational hypertension or pregnancy induced hypertension were excluded. The cases with onset prior to 34 completed weeks of gestation from the 1st day of the last menstrual cycle or diagnosed with early ultrasound were the early onset preeclampsia while those diagnosed thereafter; the late onset preeclampsia.[1] The two arms (subsets) of preeclampsia were compared for the participants' characteristics and outcomes. All the mothers who met the eligibility criteria that gave the consent following one on one counseling were prospectively recruited into the study. Maternal variables collected were: sociodemographic characteristics (age in years, marital status, parity, education, spouse occupation, social class), long interpregnancy interval (LIPI), maternal complications; cesarean section, estimated blood loss, postpartum hemorrhage, antepartum hemorrhage, eclampsia, transfusion, mortality, and long hospital stay. Fetal variables were neonatal birth weight, gestational age at birth, stillbirth, and small for gestational age, Apgar score (5 min). The study was supported by the institutional ethical approval. Data were analyzed using EPI computer statistical software and Instat package as appropriate. EPI INFO Version 3.5.1 developed by Center for disease control and prevention (CDC) in Atlanta Georgia USA released August 2008 and Instat software developed by GraphPad software Inc. California, USA. Statistical significance was set at P < 0.05.

Nulliparity was defined as lack of a previous delivery of a viable fetus of at least 24 completed weeks (28 weeks in Nigeria) of gestation from the last normal menstrual period. Preterm delivery was a delivery before 37 completed weeks of gestation. Low birth weight was birth weight <2500 g. For this study, LIPI was interpregnancy interval >50 months[10] while long hospital stay was >3 and >8 days' postpartum hospital admission for vaginal and cesarean deliveries, respectively.

  Results Top

A total of 245 cases of preeclampsia complicated 3474 deliveries that took place within the period of this study; a preeclampsia incidence of 7.1%. Sixteen (6.5%) cases had incomplete records and were excluded from further analysis.

[Table 1] shows the selected characteristics of the participants. About one half (31.9% vs. 68.1%) the proportion of those who had late onset had early onset disease. About nine out of every 10 of the participants were married at the time of the study. This was similar (91.8% vs. 89.1%, P = 0.64) in the two arms of the participants. More than half (55.0%) of the participants did not have prenatal care and comparatively more than a double the early onset group did not have prenatal care and this was statistically significant (odds ratio [OR] = 2.3, P = 0.01). About two out of every five (37.1%) of the participants had their first childbirth and the two arms were statistically different (P = 0.02) while over three-fifths of them were in their second or more childbirth. Only about one in 10 participants were grand multipara. The mean age of the participants was 30.6 ± 6.6 years. Over three-fifths (61.6%) majority of them were within 20 and 34 years of age while about a third (29.7%) were 35 years or over and teen mothers 8.7%. Nonetheless, the two arms were similar in age (P = 0.2). Close to 42% of the participants were of low socioeconomic class. Both arms were similar in age, social class, and marital status (P > 0.05). Approximately 30% of the participants had the history of previous preeclampsia/eclampsia with the early onset disease subset more than three folds and this was statistically significant (OR = 3.4, P < 0.001). About a third 68/229 (29.7%) of the participants had LIPI preceding their index pregnancies. This was statistically similar in the two subsets (28.8% vs. 30.1%, OR = 0.94, P = 0.88).
Table 1: Sociodemographic characteristics of mothers by subset of preeclampsia (n=229)

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As shown in [Table 2], the subjects had 531 composite maternal complications at 34.3% versus 65.7% for early and late onset groups, respectively; a mean of about two complications per participant. A breakdown of the complications indicated an incidence of eclampsia of 56/3474 = 1.61%. There was no statistical significant difference in the incidence of eclampsia between those who had early and late onset disorders (P = 0.9). The rate of cesarean section was about 74.2%. Again though the early onset group was less prone to cesarean delivery 68.5% versus 76.9%, there was no statistical significant difference between the two arms (P = 0.20). Close to a half; 45.4% of the participants had an overall mean long hospital stay of 12.6 ± 7.6 days and a range of 4–55 days. The value was 9.2 ± 5.7 days with a range of 4–25 days for those that had vaginal delivery and 14.3 ± 7.9 days with a range of 9–55 days for those who had cesarean delivery. Those that had early onset disease were statistically significant more than twice more likely to have long hospital stay (P = 0.02). Comparatively, the early onset disease was associated with higher systolic (P < 0.001) and DBP (P < 0.001) respectively. These were statistically significant. Similarly, the early onset disease was more than thrice associated with severe proteinuria and this was statistically significant (P < 0.001) This was reflected in the higher rate of acute renal damage among early onset subset (2.7% vs. 0.0%) though this cannot be subjected to statistical test. The incidence of anemia among the participants was 12.2% the late onset group had significantly more blood loss (P = 0.03) and subsequently suffered more anemia; this too was statistically significant (P < 0.05). The rate of thrombocytopenia was 1.7% and more among early onset group 4.1% versus 0.6%. The difference however, was not statistically significant (P = 0.1). The incidence of hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome was 2.7% and the two cases occurred only among the early onset group. Five (3.1%) of the participants suffered acute pulmonary edema and this occurred similarly in the subsets (2.7% vs. 3.2, OR = 0.85, P = 1.00). Four of the mothers died from the disorder; a fatality rate of 1.75%; maternal mortality ratio of 4/3398 live births or 117.7/100,000 live births.
Table 2: Maternal complications by subset of preeclampsia (n=229)

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[Table 3] shows the perinatal complications. The overall mean gestational age at delivery of the neonates was 35.4 ± 4.1 weeks; range of 22–42.6 weeks. The corresponding values were 30.6 ± 3.3 weeks and 22–37 weeks for early onset and 37.5 ± 2.2 weeks and 34–42.6 weeks for late onset disease. The 6.9 days difference of the means of the two arms was statistically significant (P < 0.001) more than a half (50.7%) of the neonates were delivered preterm with about 28% under 34 completed weeks of gestation. Comparable proportion; 52.0% were born low birth weight. There was significant difference between the two arms. About a quarter (25.3%) of the neonates had birth asphyxia with early onset arm about four folds more likely to suffer birth asphyxia. This was statistically significant (P < 0.001). About a third (28.8%) was small for gestational age with neonates of early onset arm more than twice more affected and this was statistically significant (P < 0.01) About a fifth (21.4%) of the neonates suffered perinatal death, a perinatal mortality rate of 14.42/1000 live births. This was more than six folds more among the neonates of early onset arm. This was also statistically significant (P < 0.001).
Table 3: Perinatal complications by onset of preeclampsia (n=229)

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  Discussions Top

The incidence of preeclampsia in this study was 7.1%. This was higher than 1.2%–3.3% from other reports in southern Nigeria[11],[12] and 5% in the USA[12] but within the range of 3%–10% of global pregnancies in the literature.[13] The mean age of 30.6 years of the participants was similar to that of another report in the literature.[14]

Preeclampsia from this data was high among the nulliparous mothers (37.1%) but lower than 44.1% reported from Calabar[12] and low socioeconomic mothers (42.0%) in keeping with another report.[15] The incidence of eclamptic seizure of 1.6% in these data were within a report of 0.5%–2%[15] and comparable to another report in the literature.[4] Lower incidence of eclampsia is a reflection of the settings with much earlier presentation and timely aggressive intervention on preeclampsia. The higher incidence of eclampsia is in most part due to behavioral factors; delay or nondetection of preeclampsia with early intervention and not due to biological difference or absolute higher incidence of preeclampsia. There was a high rate of recurrence of preeclampsia in this data with early onset subset more than a three-fold more likely to have had a previous episode of the disorder. LIPI of up to 5 years' duration seem a potent risk factor for preeclampsia, with no discriminatory influence on the subsets. It is in the literature that LIPI is a risk factor for gestational hypertensive disorders.[10],[16] This was corroborated by reports from other researchers.[17],[18] There was a high rate of maternal morbidity in this study. This appeared to be more prevalent among late onset subgroup but severer morbidity occurred among early onset counterpart. For instance, the early onset group had severer hypertension, therefore, were more prone to acute renal failure with consequent severer proteinuria. The early onset subset was also more complicated by HELLP syndrome therefore thrombocytopenia and longer hospital stay. The observed severer complications in early onset subset can be attributed to the clinical practice to delay delivery by conservative management of the gestation to gain time to increase the maturity of the fetus to enhance its extrauterine survival. Five of the participants suffered acute pulmonary edema slightly commoner among the late onset subgroup. This may be attributed to the high cardiac output low total vascular resistance associated with the late onset subset.[1] The placenta remains central and the seat of pathogenesis of preeclampsia-eclampsia and the disorder continues to deteriorate till the placenta is separated from the victim. The rate of anemia on admission appeared high in preeclampsia and this was observed to be more prevalent among the late onset group. There are yet conflicting cause–effect reports on the relationship between anemia and preeclampsia.[19],[20],[21] Accruing evidence in the literature in support of anemia especially severe anemia as a risk factor for preeclampsia/eclampsia attributes it to deficiency of micronutrients; zinc, calcium, magnesium, and antioxidants in severe anemia.[19],[20],[21] The increased risk of preeclampsia may be attributed to the associated reduction of antioxidant micronutrients in anemia with resultant vascular endothelial oxidative stress-related damage and consequent preeclampsia. The high cesarean delivery rate of 74.2% was comparable to 71.2% reported in a similar work[12] This is because abdominal delivery is expeditiously offered as the standard line of the management for severe and rapidly progressive preeclampsia with viable fetus and unfavorable cervix.

The preeclampsia case fatality of 1.75% and the maternal death ratio of 117.7/100,000 live births was high. Globally, about 50,000 mothers are lost annually to eclampsia and the figure was as low as 1% in the USA.[15]

The overall mean gestational age at delivery of preeclampsia neonates was 35.4 weeks while for the early onset and late onset the corresponding values were 30.6 and 37.5 weeks, respectively. The rate of preterm delivery of 51% was high in this data with a comparable low birth weight. This was obviously more among the early onset subgroup. Similarly, a third of neonates by preeclampsia mothers in these data were small for gestational age with those of early onset disease twice more prone. This is due to relatively earlier and longer insult from impaired feto-placental unit perfusion in early onset group. It is in the literature that early onset disease is associated with low volume high total vascular resistance.[1] The perinatal death of 21.4% (a perinatal mortality rate of 14.2/1000 total births) was higher than 12% in another report.[15] The neonates of early onset disease group more than six-fold suffered perinatal deaths mostly due to iatrogenic prematurity. Immediate delivery in severe early onset preeclampsia increases neonatal morbidity, long hospitalization, and mortality mainly due to prematurity.[22] On the other hand, expectant management causes increased maternal adverse outcome and further increases odds of intrauterine fetal death.[22]

The findings of a hospital based data more so a referral center cannot be generalizable to the general population. Multicenter or primary population data will be more generalizable.

  Conclusions Top

Preeclampsia is a challenging pregnancy-associated medical disorder with increased fetal and maternal adverse outcomes especially when it is early in onset. Preconception care, optimal pregnancy timing, quality prenatal care, and labor management backed with sensible decision on the timing of the ending of the gestation are indicated to ameliorate the associated adverse outcomes of this disorder.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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