PROOF COVER SHEET Author(s):
K.-Y.-N. Phoa, P. Chedraui, F.-R. Pe´rez-Lo´pez, J-F. Wendte, S. Ghiabi, T. Vrijkotte, and P. Pinto
Article title: Perinatal outcome in singleton pregnancies complicated with preeclampsia and eclampsia in Ecuador Article no:
IJOG_A_1107532
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Journal of Obstetrics and Gynaecology, 2015; Early Online: 1–4 ß 2015 Taylor & Francis ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2015.1107532
ORIGINAL ARTICLE
Perinatal outcome in singleton pregnancies complicated with preeclampsia and eclampsia in Ecuador K.-Y.-N. Phoa1, P. Chedraui2,3, F.-R. Pe´rez-Lo´pez4, J-F. Wendte5, S. Ghiabi1, T. Vrijkotte5 & P. Pinto6 1
Academic Medical Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands, 2High Risk Pregnancy Labor and Delivery Unit, Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador, 3Institute of Biomedicine, Research Area for Women’s Health, Facultad De Ciencias Me´dicas, Universidad Cato´lica De Guayaquil, Guayaquil, Ecuador, 4Department of Obstetrics and Gynecology, Facultad De Medicina, Lozano Blesa University Hospital, Universidad De Zaragoza, Zaragoza, Spain, 5Department of Social Medicine, Academic Medical Centre Amsterdam, Amsterdam, the Netherlands, and 6Neonatal Department, Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador
Preeclampsia in Ecuador is an understudied subject since available epidemiological data are scarce. The aim of this study was to describe perinatal outcome among singleton pregnancies complicated with preeclampsia and eclampsia in a sample of low-income Ecuadorian women. Pregnant women complicated with preeclampsia (mild and severe) and eclampsia (defined according to criteria of the ACOG) delivering at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Guayaquil, Ecuador were surveyed with a structured questionnaire containing maternal (socio-demographic) and neonatal data. Perinatal outcomes were compared according to severity of clinical presentation. A total of 163 women with preeclampsia [mild (23.9%), severe (68.7%) and eclampsia (7.4%)] were surveyed. Perinatal mortality and stillbirth rate was similar among studied groups (mild vs. severe preeclampsia/eclampsia cases). However, severe cases displayed higher rates of adverse perinatal outcomes: lower birth Apgar scores, more preterm births, and more low birth weight and small for gestational age infants. Caesarean-section rate and the number of admissions to intensive or intermediate neonatal care were higher in severe cases. A similar trend was found when analysis excluded preterm gestations. In conclusion, in this specific low-income Ecuadorian population perinatal outcome was adverse in pregnancies complicated with severe preeclampsia/eclampsia. Keywords: Preeclampsia, Ecuador, perinatal outcome, low income, perinatal mortality, eclampsia
Introduction Preeclampsia and eclampsia are frequent complications of pregnancy, with prevalences that vary from 2.5% to 8% and 1% to 3%, respectively. Both are related to significant maternal/ perinatal mortality and morbidity in developed and developing countries (World Health Organization 2012; Abalos et al. 2013). In addition, it is calculated that for every woman that dies, there are 20 other that suffer severe complications or disability (Health Canada 2004; Abalos et al. 2014). In developing countries preeclampsia causes 10–15% of maternal deaths (World Health
Organization 2012; Abalos et al. 2014); despite reports indicating that these rates decrease with appropriate prenatal care (Lo et al. 2013; Vasquez et al. 2014). Adverse perinatal outcomes have also been reported (i.e. prematurity, low birth weight) with these pregnancy-related complications; however, mostly described in developed countries (Delahaije et al. 2014; Schaap et al. 2014). For this reason in the twenty-first-century preeclampsia and eclampsia are still a health care burden. In Latin America, preeclampsia remains an understudied subject and to date the assessment of perinatal outcome according to the severity of the disease has scarcely been performed (Abalos et al. 2013; Salazar-Pousada et al. 2014; Vogel et al. 2014). We have previously reported a higher rate of preeclampsia and eclampsia among young pregnant adolescents (Hidalgo et al. 2005). Nevertheless, a clear description of clinical outcomes related to preeclampsia as well as the comparison according to disease severity is still lacking in our population. These figures will help develop simple specific population based management algorithms (North et al. 2011; Leung et al. 2014). Hence, the aim of the present study was to describe perinatal outcome among singleton pregnancies complicated with preeclampsia (mild and severe) and eclampsia in a sample of lowincome Ecuadorian women.
Materials and methods Study design and participants This was a cross-sectional study performed during a three-month period at the Labour and Delivery Unit of the Enrique C. Sotomayor Obstetrics and Gynecology Hospital, after Institutional Review Board approval. For this, a convenience sample of women of any age delivering a singleton fetus of 20 weeks or more complicated with preeclampsia or eclampsia (hypertension, edema and proteinuria) were considered eligible cases. The Sotomayor Hospital is one of the four health care facilities managed by the Junta de Beneficencia de Guayaquil, a private non-profit organisation that provides partially subsidised health care and education to the low-income population of Guayaquil and its surroundings (Junta de Beneficencia
Correspondence: P. Chedraui, MD, PhD, High Risk Pregnancy Labor and Delivery Unit, Enrique C. Sotomayor Obstetrics and Gynecology Hospital, Pedro Pablo Go´mez s/n y 6 de Marzo, PO BOX 09-01-4671, 090307 Guayaquil, Ecuador. Tel: + (5934) 241-3300 (Ext) 3050 – 3079. Fax: + (5934) 220-6958. E-mail:
[email protected]
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de Guayaquil 2014). Low income was defined as a total monthly family income of less than $USD 600 (El indice de Precios al Consumidor (IPC) Canastas 2015). Preeclampsia cases were further divided into two categories: mild and severe. The American College of Obstetricians and Gynaecologists (ACOG) standard was used to define severity of preeclampsia (mild and severe) and eclampsia (American College of Obstetricians and Gynecologists 2013). Mild preeclampsia was defined as a blood pressure 140 (systolic) or 90 mmHg (diastolic) however5160 (systolic) or 110 mmHg (diastolic) after 20 weeks of gestation in a woman whose blood pressure had previously been normal, without any sign of maternal or foetal compromise. Severe preeclampsia was defined on the basis of at least one of the following: blood pressure than 160 (systolic) or 110 mmHg (diastolic), evidence of foetal (oligohydramnios, growth restriction) or maternal end organ compromise (acute renal failure, acute pulmonary edema, etc.). Eclampsia was defined as women with preeclampsia who present cerebral symptoms, tonic-clonic convulsions and/or coma. Women who did not fit into the ACOG standards for preeclampsia and eclampsia or had a multiple gestation were excluded. Eligible cases were sorted according to the neonatal, delivery and/or postpartum log book and then invited directly to participate at the postpartum ward (directly after labour) or in the following days during their hospital stay. All eligible approached patients provided consent to participate in a oneon-one interview (questionnaire lasting approximately 20 min) and also to access maternal and neonatal data from their corresponding medical records.
age were respectively defined as having a birth weight of510th and490th percentile for their corresponding gestational age (Ballard et al. 1979). Low birth weight was defined as a weight52500 g (Valero De Bernabe et al. 2004). Preterm birth was defined as that occurring at537-week gestation. Non-ill neonates were placed in the neonatal ward for a minimum of 24 hours and then discharged with the mother; otherwise, they were admitted to one of the following units: the neonatal intensive care (NICU) or the intermediate neonatal care unit.
Statistical analysis Statistical analysis was performed using SPSS Version 22.0 (IBM SPSS, Armonk, NY, USA) after stratification for mild preeclampsia and severe preeclampsia/eclampsia. The Kolmogorov– Smirnov test was used to determine the normality of the distribution of continuous data. Data are presented as means ± standard deviations (for normally distributed data), medians/interquartile ranges (for non-normally distributed data), and frequencies/percentages. The comparison of maternal and neonatal continuous measures was performed with the Mann–Whitney U test (non-parametric test/non normally distributed data) or the Student’s t-test (parametric test/normally distributed data). The chi-square test or Fisher’s exact test (for cases including cero values) were used to compare percentages. All calculated p values were two-sided and the significance level set at50.05.
Results Outcome measures
Maternal data A structured questionnaire was used to assess maternal demographic characteristics. Data related to pregnancy outcome were retrieved from patients’ medical records. General maternal data included: age (years), parity (nulliparous or multiparous), midarm circumference (cm), place of residency (rural, urban or urban-marginal), educational level (years), marital status (single, married or cohabiting) and a history of preeclampsia in the previous pregnancy. Mid-arm circumference was used to measure maternal adiposity as in many cases pre-pregnancy or admission weight was difficult to obtain. Measurement was performed as previously reported (Mahomed et al. 1998). Other maternal data included: smoking, drinking or working (during pregnancy). Route of delivery (caesarean section or vaginal delivery) and the presence of intrapartum meconium staining were also recorded.
Perinatal data Neonatal charts were reviewed and retrieved data included: gestational age at birth (weeks), condition of infant (live or dead), infant anthropometry (weight [g], length [cm] and head circumference [cm]), and Apgar scorings (1st and 5th minute of birth). Perinatal death was defined as that occurring between 24-week gestation and 29 days after birth in the hospital. This indicator was further divided as stillbirths (occurring before birth) and neonatal deaths (after birth). Gestational age was defined as the final estimate recorded by the physician who did the first neonatal examination immediately after birth and/or based on last menstrual period. Small and large for gestational
A total of 163 singleton gestations complicated with preeclampsia were surveyed [mild (23.9%), severe (68.7%) and eclampsia (7.4%)]. Maternal demographic characteristics according to the severity of clinical presentation are shown in Table I. No significant differences were observed among compared groups (mild vs. severe preeclampsia/eclampsia cases) in relation to general maternal demographic data. Perinatal mortality and stillbirth rate was similar among studied groups. However, severe cases displayed higher rates of adverse perinatal outcomes: lower birth Apgar scores, more preterm births, and more low birth weight and small for gestational age infants. Caesarean-section rate and the number of admissions to intensive or intermediate neonatal care were higher in severe cases (Table II). A similar trend was observed even after excluding preterm gestations from analysis.
Discussion The present study found that there were more severe preeclampsia and eclampsia cases than mild ones; however, with no maternal deaths. One explanation for this is that a high rate of patients attended at our hospital have inadequate prenatal care (Paredes et al. 2005); hence, preeclampsia cases tend to come in later when disease has progressed to a more severe stage, consequently involving more term and severe cases. Severe preeclampsia and eclampsia are still major direct causes of maternal death, and referrals to more complex centres (World Health Organization 2012; Abalos et al. 2013, 2014). Indeed, Sotomayor hospital receives the most number of cases of preeclampsia of low-income women of the city of Guayaquil, surroundings and even nationwide. Severe preeclampsia and eclampsia cases were managed by caesarean section in a higher rate than mild cases. Current evidence indicates that the use of
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Perinatal outcome in preeclampsia and eclampsia
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Table I. Maternal demographic characteristics according to the severity of preeclampsia presentation. Maternal data Maternal age (years) Nulliparous Preeclampsia in previous pregnancy Maternal mid-arm circumference (cm) Single mother Educational level (years) Rural residence Smoking during pregnancy Alcohol consumption during pregnancy Currently working
Mild preeclampsia Severe/eclampsia n ¼ 39 n ¼ 124 p value* 26.2 ± 6.9 12 (30.8) 0 (0)
27.7 ± 8.0 44 (35.5) 4 (3.2)
NSa NSb NSc
30.8 ± 5.1
30.0 ± 3.9
NSa
4 (10.2) 9.4 ± 3.7 9 (23.0) 9 (23.0) 0 (0)
15 (12.0) 8.8 ± 3.8 32 (25.8) 20 (16.1) 0 (0)
NSb NSa NSb NSb NSc
0 (0)
0 (0)
NSc
Data are presented as mean ± standard deviations, medians [interquartile ranges], frequencies or percentages (n, %). NS, non-significant; NCIU, neonatal intensive care unit. *p value as determined with the Student’s t-testa, the chi-square testb or the Fisher’s exact testc.
this surgical procedure may reduce maternal mortality (Chu et al. 2012, Goldenberg et al. 2014). Since the aetiology of preeclampsia is unknown, pregnancy termination seems to be the only treatment for severe cases and under an individualised manner (i.e. balancing maternal and foetal risks). Severe preeclampsia/ eclampsia cases presented lower gestational age at birth and more preterm births, small for gestational age and low birth weight neonates as compared to mild cases. Our findings are similar to those of Buchbinder et al. (2002) and Hauth et al. (2000), both reporting in the United States more adverse perinatal outcomes (i.e. lower gestational age, birth weight and more admissions to intensive and intermediate care) among severe preeclampsia cases. Yu¨cesoy et al. (2005) have described similar adverse outcomes in Turkish women with severe preeclampsia, as compared to mild cases and chronic hypertension. Our studied cohort was from a low socio-economic background, with low education and mostly coming from rural areas, characteristics found in previous studies (Paredes et al. 2005; Salazar-Pousada et al. 2010). Although prenatal care and other social demographic characteristics were not the focus of this study, it is expected that lower health education and inadequate prenatal care (mostly seen in rural living women) will have a major negative impact over outcomes which basically relate to a delay in early diagnosis. In developing countries, assessment of socio-demographic risk factors and strict clinical prenatal care remain the only pathways to prevent preeclampsia related complications; despite, advances in early predictive models using biochemical markers (Montagnoli and Larciprete 2014; Chedraui et al. 2015). Two forms of preeclampsia have been described that of early or delayed onset (Tranquilli 2014). Reports indicate that preeclampsia is a progressive disease; hence, early diagnosis is essential for management (American College of Obstetricians and Gynecologists 2013). In developed countries there are more preeclampsia cases of early onset than delayed onset. Contrary to this, more women with preeclampsia come to Sotomayor Hospital, to deliver with severe forms, from rural areas and having had inadequate prenatal care (Paredes et al. 2005). Our data indicate that there is an urgent need to enhance the awareness of the benefits prenatal care in the early detection of preeclampsia at our facility in order to
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Table II. Perinatal outcome according to the severity of preeclampsia presentation. Perinatal outcome data Stillbirth Perinatal death Gestational age at birth (weeks) Neonatal weight (g) Infant length (cm) Infant head circumference (cm) Preterm Small for gestational age Low birth weight (52500 g) Apgar score at 1st min Apgar score at 5th min Apgar score at 5th min 57 Admission to NICU or intermediate care Delivery by caesarean section Meconium staining
Mild preeclampsia Severe/eclampsia n ¼ 39 n ¼ 124 p value* 1 (2.6) 4 (10.3) 39 [2]
5 (4.0) 17 (13.7) 37 [5]
NSa NSa 0.007b
3133 [773] 48.8 [4] 34.0 [3]
2307 [1277] 46.0 [7] 32.0 [4]
50.001b 50.001b 50.001b
5 6 8 8 9 2 3
(12.8) (15.4) (20.5) [0] [0] (5.1) (7.7)
42 (33.9) 55 (44.3) 65 (52.4) 7 [2] 9 [1] 15 (12.0) 42 (33.9)
0.01a 0.001a 50.001a 0.004b 0.05b NSa 0.001a
23 (59.0)
103 (83.0)
0.001a
13 (33.3)
32 (25.8)
NSa
Data are presented as mean ± standard deviations, medians [interquartile ranges], frequencies or percentages (n, %). NS, non-significant; NCIU, neonatal intensive care unit. *p value as determined with the chi-square testa or the Mann–Whitney U testb.
improve perinatal outcome and decrease disease related complications. Finally, as for the limitations of this study, one can mention its cross-sectional nature and the sample size. Hence, our results cannot be totally extrapolated to the entire Ecuadorian population. We did not include a comparative study group without preeclampsia; this may also be seen as a potent limitation. Despite these limitations, the study has its strengths: (a) data are drawn from a specific low-income population majorly coming from rural and marginal areas of the Ecuadorian coast, basically that attended at Sotomayor Hospital, and (b) it is the first to draw baseline figures for Ecuador and determine that severity of disease imposes a negative impact on perinatal outcome. Despite the aforementioned limitations our data points out to the fact that in Ecuador preeclampsia and eclampsia is also a public health concern with a negative impact on perinatal outcome. In our scenario antenatal care requires urgent attention and improvement; moreover if women with preeclampsia are progressing to severe forms and are coming from rural areas, were early detection is not being carried out. In conclusion, in our specific low-income population pregnancies complicated with severe preeclampsia/eclampsia presented adverse perinatal outcomes. In order to decrease this negative impact we propose improving awareness of this problem to the general population and to health care providers, especially those working in rural areas. The Millennium Development Goals have placed maternal health at the core of the struggle against poverty and inequality, as a matter of human rights. Declaration of interest: The authors report no conflicts of interest and are alone responsible for the content and writing of the paper. The study was partially supported by the B/024535/09 AECID (Agencia Espan˜ola de Cooperacio´n Internacional para el Desarrollo) grant from the Spanish Ministerio de Asuntos Exteriores y Cooperacio´n.
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