NEONATAL OUTCOME OF ANTENATAL MOTHERS WITH PREGNANCY INDUCED HYPERTENSION IN ANTENATAL WARD OF KATHMANDU MEDICAL COLLEGE AND TEACHING HOSPITAL Affiliation

Methodology Prospec ve study design was conducted for the study in Obstetrics ward of Kathmandu Medical College Teaching Hospital. The popula on was the 100 antenatal mothers with pregnancy induced hypertension admi ed in antenatal ward and purposive convenient sampling technique was used to collect the data. The structured ques onnaire was designed and the data was collected through interview th technique from 1st February 2014 to 10 March 2016. The collected data was analyzed using SPSS programme.


INTRODUCTION
Pregnancy induced hypertension is responsible for high maternal and perinatal morbidity and mortality rates and is 1 one of the main public health problems.According to the Health Ministry, hypertension during pregnancy, depending on the severity level, is considered a risk factor, which, associated with individual characteris cs, unfavorable socioeconomic condi ons, certain obstetric histories and clinical problems could trigger harms to the maternal-fetal binomial.For the conceptus, the most common consequences associated with hypertension diseases are the restric on of 2 intra-uterine growth, low birth weight, and prematurity.
Pregnancy induced hypertension is a common complica on in antenatal women, which is a major cause of maternal and perinatal morbidity and mortality.Perinatal complica ons include preterm delivery, low birth weight, prematurity, intrauterine foetal death (IUFD), intrauterine growth restric on (IUGR), foetal asphyxia, acidosis, s llbirths and neonatal deaths.Maternal risks associated with gesta onal hypertension include development of uncontrolled hypertension, superimposed preeclampsia, eclampsia, HELLP syndrome (hemolysis, elevated liver enzymes and low platelets), acute renal and hepa c failure, acute pulmonary edema, cerebrovascular accidents, conges ve heart failure, intracranial hemorrhages, proteinuria more than 4-5 grams/day, microangiopathic hemoly c anemia, abrup o placenta, deep vein thrombosis (DVT), occipital lobe blindness, post-partum hemorrhages, disseminated intravascular coagula on (DIC) and /or consump ve 3 coagulopathy.
PIH has been postulated to increase significantly the risk of low birth weight both by increasing preterm birth as well as reducing fetal growth.On the other hand, PIH has been found to be associated with an increased rate of high birth weight and large-for-gesta onal age babies.These findings suggest that PIH, more specifically preeclampsia, is a heterogeneous syndrome and that preeclampsia may appear in two forms: restricted fetal growth preeclampsia 4 and normal fetal growth preeclampsia.
Pregnancies complicated with hypertension are associated with adverse fetal and maternal outcome in terms of prevalence of intrauterine growth restric on, prematurity, low birth weight, low Apgar score at birth, early neonatal death, high rates of admission to NICU and the need for resuscita on.Perinatal morbidity is increased due to spontaneous preterm labour or iatrogenic preterm induc on.Low birth weight due to prematurity/IUGR and fetal hypoxia are the main reasons for NICU admissions and early neonatal death in babies born to mothers with hypertensive disorders of pregnancy.Expectant management with temporizing treatment should be performed to lengthen gesta on which may be associated with enhanced perinatal survival.Good intensive care, close monitoring during labor, judicious ming of delivery and NICU facili es is 5 required for be er fetal and neonatal outcome in these case.
The prevalence of PIH was high.Women with PIH were at Shrestha S, et al higher risk of adverse pregnancy outcomes than those without.Poor knowledge of management of PIH and inadequate resources are a threat to the proper management of PIH.This underscores the need for human resource capacity building and resource mobiliza on for proper management of women accessing maternity services.Resources for rou ne urinalysis must be made 6 available by hospital authori es.

METHODOLOGY
A Prospec ve research design was adopted and convenience sampling method was applied to meet the objec ves of the study.The sample size was admi ed 100 antenatal mothers with the diagnosed condi on of Pregnancy Induced Hypertension to the department of obstetrics and gynecology.Ethical clearance was taken from the ins tu onal review board of KMCTH.Wri en informed consent was taken from each respondent.One-on one interview technique was used to collect the relevant data a er admission of the respondents using pre-designed structured ques onnaire th from 1st February 2014 to 10 March 2016.The researcher administered ques onnaires were used to capture demographic data, obstetric history and knowledge on PIH management.Records were reviewed for pregnancy outcomes ll discharge of the pa ent while key informants were also interviewed on pa ent management.The par cipants were enrolled for the study with following inclusion criteria that women with 20 weeks of gesta on and those who willing to par cipate in this study.
The ques onnaires consist of two parts: I. Socio demographic characteris cs of the respondents and II.Neonatal Outcome respec vely The data were entered in MS excel.
. Data were analyzed using SPSS IBM 20 version.Categorical variables were described using frequency distribu on and percentages.Con nuous variables were expressed by means and standard devia ons.Chi-square test was used for analysis of associa on between the demographic variables with the outcome of Pregnancy Induced Hypertension.P-value of <0.05 was considered sta s cally significant.

RESULTS
The findings of the study revealed that more than half of respondents (56%) were between the ages of 25-35 years, 36% were between 15-25 years and only 8% were between ages of 35-45 years.Regarding resident majority of respondents (96%) were from urban areas and only 4% were from rural area.Regarding educa on the majority of the respondents (40%) have completed intermediate level, 24% have completed gradua on, 18% have completed secondary level, 10% have completed primary and only 4% have completed post-gradua on and another 4% were illiterate.The majority of the respondents (77%) were housewife and 12% of the respondents had Rs.10000-20000 regarding monthly income.Most (91%) of the respondents followed Hindu religion and most 94% were non vegetarian.More than half (56%) of the respondents were having normal diet and 44% were having low salt diet.Among 100 pregnant mothers, more than half (58%) were from nuclear family and 42% were from joint family.
By gesta onal majority (69%) of the respondents were above 37 weeks and 31% were below 37 weeks.The majority of the respondents 50% were primigravida, 45% were mul gravida and only 5% were grand mul gravida.The most of the respondents 93% have done antenatal visit more than 4 mes whereas only 7% of the respondents have done antenatal visit less than 4 mes.The majority of the respondents 88% had no family history of hypertension and only 22% had family history of hypertension.The most of the respondents 98% were diagnosed of hypertension at third trimester and only 2% of the respondents were diagnosed of hypertension at first and second trimester respec vely.
Of the total 100 antenatal mothers, most of the respondents 87% had mild hypertension, 12% had moderate hypertension and only 1% had severe hypertension.The most of the respondents 81% used an hypertensive drugs and only 19% didn't use an hypertensive drugs.The majority of the respondents 80% diagnosed as nil proteinuria, 11% were diagnosed as trace proteinuria, 5% were diagnosed as (+), 3% were diagnosed as (++) and only 1% were diagnosed as more than (++).Regarding grading of edema, the majority of the respondents 62% had absent edema, 36% had mild edema (grade+) 2mm or less and only 2% had moderate edema (Grade++) 2-4mm indent.
The most of the babies 83% had normal weight.The most of the babies 82% had adequate for gesta onal age.Regarding Apgar score half of the babies 50% scored mild asphyxia at the first minute whereas most of the babies 93% scored no asphyxia in five minutes a er delivery.Regarding perinatal outcome 13% babies were delivered prematurity, 7% had birth asphyxia, 5% were born with low birth weight and s llbirth whereas only 1% had early neonatal death.
Among the total neonates, 25% were admi ed in NICU whereas only 2% neonates were admi ed in general ward.Regarding perinatal management outcome, 24% of the neonates has improved whereas only 2% neonates were expired.
There was no any significant associa on with weight at birth and classifica on of weight according to gesta onal age regarding neonatal outcome of pregnancy induced hypertension.There was significant associa on between gesta onal age of delivery and Apgar score at 5 minutes regarding neonatal outcome of pregnancy induced hypertension.
There was significant associa on between age and perinatal management outcome, gesta onal age of delivery and perinatal morbidity management, grading of proteinuria and perinatal morbidity management, grading of oedema and perinatal management outcome regarding neonatal outcome of pregnancy induced hypertension.

DISCUSSION
Hypertensive disorders of pregnancy have been iden fied as a major worldwide health problem, associated with increased perinatal morbidity and mortality.Studies have shown that hypertensive disorders of pregnancy predispose women to acute or chronic uteroplacental insufficiency, there by having an effect on perinatal and neonatal outcome that may result in antenatal or intrapartum anoxia that may lead to foetal death, intrauterine growth retarda on and preterm delivery.Some studies have shown that there is an increased incidence of caesarean sec ons in the mothers with PIH, and increased incidence of birth asphyxia, transient tachypnoea of newborn (TTNB), hyaline membrane disease 7 (HMD) and neonatal sepsis in newborns of these mothers.
The present study showed that, 5% of mother had s llbirth whereas only 1% was early neonatal death.This present study is similar with the study regarding pregnancy induced hypertension and the neonatal outcome conducted in the governmental maternity hospital in São Paulo city, Brazil in 2008 revealed that the frequency of s llbirths was 5.8% and 8 0.8% of early neonatal death.
The present study revealed that 54% of the babies had birth asphyxia at one minute whereas only 7% had birth asphyxia at 5 minutes respec vely.This study is contrast with the study conducted regarding Neonatal Outcome in Hypertensive Disorders of Pregnancy in a Ter ary Neonatal Unit, Soba University Hospital, Khartoum, Sudan revealed that only 8.6% of the babies had birth asphyxia during 9 delivery.
The present study showed that 25% of the babies were admi ed in NICU and only 2% babies were admi ed in general ward which is similar with the study conducted regarding the study of fetal outcome in hypertensive disorders of pregnancy in a ter ary care maternity hospital of Delhi showed that 25% of the babies were admi ed in 10 NICU respec vely.
Moreover, the present study revealed that 82% of the babies had adequate for gesta onal age, 17% had low for gesta onal age and only one percentage had high for gesta onal age.This present study is similar with the study conducted regarding neonatal mortality and morbidity in pregnancy induced hypertension in Niloufer Ins tute of Child Health showed that 76.13% had adequate gesta onal age, 21.59% had small for gesta onal age and this study is in contrast with the result that only 2% had low for gesta onal 11 age respec vely.
There was significant associa on between age and perinatal management outcome, gesta onal age of delivery and perinatal morbidity management, grading of proteinuria and perinatal morbidity management, grading of edema and perinatal management outcome regarding neonatal outcome of pregnancy induced hypertension.On contrary to this, the study conducted regarding Pregnancy Induced Hypertension and Associated Factors among Pregnant Women showed that there was significant associa on between pregnancy induced hypertension and

CONCLUSION
PIH is a common complica on in antenatal women and is a major cause of maternal and foetal, morbidity and mortality.The present study concluded that there is rise of prematurity, birth asphyxia, low birth weight and s ll birth.There is significant associa on between gesta onal age of delivery and Apgar score at 5 minutes regarding neonatal outcome of pregnancy induced hypertension.The study highlights the importance of ins tu onal deliveries of women combined with effec ve antenatal care.Hence health educa on and awareness among the people and primary health workers regarding this issue is necessary in bringing the maternal and neonatal morbidity and mortality.

RECOMMENDATIONS
Pregnant women with pregnancy induced hypertension should be encouraged to adhere to reduc on of dietary sodium intake.Con nuous teaching needs to be provided on PIH self-care knowledge to pregnant women with pregnancy induced hypertension.The client teaching Original Research Article should include the importance of weight reduc on and relevance of obesity in worsening PIH.The study should be replicated with a larger sample to foster generalizability of the findings beyond the present study sample.

LIMITATION OF THE STUDY
Limita ons reflect the rela vely small group of pregnant women, which limit our ability to draw firm conclusions on the magnitude of adverse events.The se ng was Urban so the findings couldn't be generalizable in rural ci es and community se ngs.

Table : 1
Neonatal Outcomes related to weight, weight according to gesta onal age, apgar score and perinatal outcome regarding Pregnancy Induced Hypertension (n=100).

Table 2 :
Associa on between demographic variables with weight at birth and classifica on of weight according to gesta onal age regarding pregnancy induced hypertension.

Table 3 :
Associa on between demographic variables with Apgar score regarding neonatal outcome of pregnancy induced hypertension.

Table 4 :
Associa on between demographic variables with Perinatal Morbidity Management and PerinatalManagement Outcome regarding neonatal outcome of pregnancy induced hypertension.