A Retrospective Study of Neonatal Outcome in Preeclampsia at the University Hospital of the West Indies: A Resource-limited Setting

A Retrospective Study of Neonatal Outcome in Preeclampsia at the University Hospital of the West... Abstract Aim This study aimed to determine the outcome of neonates born to women with preeclampsia at the University Hospital of the West Indies (UHWI). Methods This was a retrospective descriptive study looking at the outcome of all babies born to women with preeclampsia and control babies born to normotensive women at the UHWI over a 20-month period. Maternal and neonatal demographic data and course of admission for admitted neonates were recorded. Descriptive analyses were performed. Results Neonates born to women with preeclampsia were more likely to be low birth weight [odds ratio (OR = 2.8; confidence interval (CI): 2.2–3.5], small for gestational age (OR = 2.3; CI: 1.9–2.9) or premature (OR = 2.5; CI: 2.0–3.0). They had a lower mean 5 min Apgar score than babies born to normotensive women p<0.05. They were also more likely to be admitted to the neonatal unit 67 (59%) compared with neonates of normotensive women 13 (13%) p<0.001. The main reason for admission was prematurity. Eighteen neonates, all born to women with preeclampsia, died, and the main cause of death was prematurity. Conclusion Adverse neonatal outcome was noted in neonates born to women with preeclampsia, and this was predominantly related to prematurity and its complications. neonatal outcome, preeclampsia and neonatal outcome, preeclampsia and outcome, low birth weight, intrauterine growth restriction INTRODUCTION Preeclampsia is defined as gestational blood pressure elevation with proteinuria that develops after 20 weeks’ gestation. Primarily, a disease of pregnancy, it is a multisystem disorder that affects approximately 2–8% of pregnancies [1]. Although its pathogenesis is incompletely understood, it is a major cause of maternal and neonatal morbidity and mortality [1, 2]. Previous studies in the literature have documented that women with preeclampsia are at increased risk of having labor induced and undergoing an operative delivery. Saadat et al. [3] in Taiwan found that a third of women with preeclampsia underwent induction of labor because of worsening preeclampsia. They also documented that a third of women with preeclampsia had an operative delivery. Similarly, Browne et al. [4] from Ghana noted that nearly 90% of the women with preeclampsia in their study were delivered by cesarean section, and Omani-Samani et al. [5] in Iran documented a 2-fold increased risk of operative delivery for women with preeclampsia. Researchers in the UK [6] and Australia [7] have also noted an increase in the rate of operative deliveries in women with preeclampsia. Studies from both low- and middle-income countries (LMICs) [3–5, 8] as well as the USA [9, 10], the UK [6] and Australia [7] also document that babies born to these women have an increased risk of being born prematurely and of being low birth weight (LBW) and small for gestational age. Additionally, researchers in LMICs have noted that these babies have low 5-min Apgar scores and are at increased risk of being admitted to the neonatal unit, of requiring respiratory support and of dying [3, 4, 11, 12]. Ashley et al. [13], in looking at the singleton perinatal deaths in Jamaica between September 1987 and August 31 1988 as part of a national perinatal morbidity and mortality survey, noted that antenatal death, death from immaturity and all perinatal deaths combined were statistically significantly associated with highest diastolic blood pressure, highest level of proteinuria and antenatal eclamptic fit, respectively. The reported incidence of antenatal preeclampsia was 4.0% and of eclampsia was 7.1 per 1000 for Jamaica at the time of the study [14]. Fletcher et al. [15] in a 10-year review at the University of the West Indies found that women with preeclampsia had significantly poorer pregnancy outcome with earlier delivery, lower fetal weight, Apgar scores and placental weight than controls and non-proteinuric hypertensives. The literature supports a relationship between preeclampsia and poor neonatal outcome. Documenting the outcome of babies born to women with preeclampsia at the University Hospital of the West Indies (UHWI) will help to define the spectrum of morbidity and mortality, which will then inform clinical practice in an effort to improve outcome. This study aimed to document the outcome of babies born to women with preeclampsia at the UHWI. METHODS Study design This was a retrospective descriptive study to examine the outcome of all singleton babies born alive to women with preeclampsia and control singleton babies born alive to women without preeclampsia and who were also normotensive at the UHWI over a 20-month period. Setting The UHWI is located in urban Jamaica and is a university-affiliated institution. The neonatal unit at the UHWI comprises a 24-bed level 11 Newborn Special Care Unit and a 6-bed level 111 Neonatal Intensive Care Unit (NICU). At the time of the study, four consultant pediatricians, two of whom had specialist training in neonatology, were responsible for medical care of the neonates. Any woman accessing antenatal care at the UHWI who is assessed as being at risk for preeclampsia is followed up in a ‘High Risk’ clinic. If a diagnosis of preeclampsia is made, the woman is admitted for inpatient management, and close monitoring of these women continues perinatally. Population All singleton neonates born alive to women with preeclampsia at the UHWI between 1January 2010 and 31 August 2011 were included in this study. A control singleton neonate born alive nearest in time after the index case to a mother who did not have preeclampsia and who was normotensive was also included in the study. In a few instances, there was no control neonate born between the deliveries of two cases. Babies who were transferred to the UHWI from other hospitals and all stillbirths were excluded from the study. Procedure Cases and controls were identified from the labor ward admission book. Maternal demographic data (age, gravidity, parity, mode of delivery) and neonatal demographic data (gender, birth weight, gestational age if premature, Apgar score) were recorded. Neonates admitted to the neonatal unit were identified from the neonatal unit admission book. The medical records of all neonates admitted to the neonatal unit were reviewed, and data on reason for admission, interventions and outcome of admission were recorded using a data extraction sheet. Outcome measures were prematurity, LBW, small for gestational age, Apgar scores, admission to the neonatal unit and neonatal death. Definitions Preeclampsia: Hypertension (systolic blood pressure ≥140 or diastolic blood pressure ≥90 on two occasions at least 4 h apart) and proteinuria (300 mg/day or ≥1+ on dipstick) detected for the first time after 20 weeks' gestation. Preterm infant: An infant born before 37 completed weeks of gestation. Low birth weight: Birth weight <2500 g regardless of gestational age Small for gestational age (SGA): Any neonate whose birth weight was <10th percentile on the WHO growth charts for term infants and the Fenton preterm growth charts for preterm infants. Data analysis Descriptive analyses were performed. Analysis of differences between babies born to women with preeclampsia and those born to women without preeclampsia who were normotensive was determined using the Student’s t-test for continuous variables and the chi-squared test for categorical variables. Statistical significance was taken at the level p<0.05. Statistical analyses were performed using the Statistical Package for the Social Sciences version 14 (SPSS Inc., Chicago, IL). Ethical approval Ethical approval for the conduct of this study was granted by the UWI Mona Research Ethics Committee. RESULTS Maternal demographics In total, 218 neonates were entered into the study, 114 (52%) were born to women with preeclampsia and 104 (48%) were born to women who did not have preeclampsia and were normotensive during pregnancy. The mean ± SD maternal age for women with preeclampsia and for normotensive women was 30.3 ± 6.2 and 27.6 ± 5.8 years, respectively (p=0.001). In total, 37 (33%) of the women who had preeclampsia and 28 (27%) of the normotensive women were primigravida. Women with preeclampsia [78 (68%)] were more likely to be delivered by cesarean section than women who did not have preeclampsia [28 (27%); odds ratio (OR) = 2.6; confidence interval (CI): 1.9–3.7; p < 0.001]. For women with preeclampsia, 37 (47%) of the operative deliveries were done on an urgent basis, and 34 (44%) were done on an emergency basis as compared with 8 (29%) for each, respectively, for women who did not have preeclampsia p < 0.001. The most common indications for operative delivery in women with preeclampsia were severe preeclampsia/impending eclampsia [38 (49%)] and fetal jeopardy [20 (26%)], whereas for women who did not have preeclampsia, they were failed induction [10 (36%)] and previous cesarean section [10 (36%)], respectively. Women with preeclampsia who delivered vaginally were more likely to be induced [23 of 36 (64%)] than women who did not have preeclampsia [19 of 76 (25%); OR = 5.0; CI: 2.1–12.0; p<0.001]. Neonatal demographics There were 114 neonates born to women with preeclampsia, 57 (50%) males and 57 (50%) females, and 104 neonates born to normotensive women, 49 (47%) males and 55 (53%) females. The mean birth weight and gestational age of babies born to women with preeclampsia were significantly less than that of babies born to women who did not have preeclampsia (Table 1). The mean 5-min Apgar score of neonates born to women with preeclampsia was also significantly lower than that for neonates born to normotensive women. Table 1 Birth demographics for neonates born to women with preeclampsia and controls born to women without preeclampsia at the UHWI 2010–11 Variable Cases N = 114 Mean ±SD Controls N = 104 Mean±SD Independent sample t-test p-value Gestational age (weeks) 35.3±3.7 38.6±1.4 <0.001 Birth weight (kg) 2.2±0.9 3.2±0.4 <0.001 APGAR 1 min 7.1±2.4 8.1±1.6 <0.001 APGAR 5 min 8.5±1.5 9.0±0.8 0.002 Variable Cases N = 114 Mean ±SD Controls N = 104 Mean±SD Independent sample t-test p-value Gestational age (weeks) 35.3±3.7 38.6±1.4 <0.001 Birth weight (kg) 2.2±0.9 3.2±0.4 <0.001 APGAR 1 min 7.1±2.4 8.1±1.6 <0.001 APGAR 5 min 8.5±1.5 9.0±0.8 0.002 Table 1 Birth demographics for neonates born to women with preeclampsia and controls born to women without preeclampsia at the UHWI 2010–11 Variable Cases N = 114 Mean ±SD Controls N = 104 Mean±SD Independent sample t-test p-value Gestational age (weeks) 35.3±3.7 38.6±1.4 <0.001 Birth weight (kg) 2.2±0.9 3.2±0.4 <0.001 APGAR 1 min 7.1±2.4 8.1±1.6 <0.001 APGAR 5 min 8.5±1.5 9.0±0.8 0.002 Variable Cases N = 114 Mean ±SD Controls N = 104 Mean±SD Independent sample t-test p-value Gestational age (weeks) 35.3±3.7 38.6±1.4 <0.001 Birth weight (kg) 2.2±0.9 3.2±0.4 <0.001 APGAR 1 min 7.1±2.4 8.1±1.6 <0.001 APGAR 5 min 8.5±1.5 9.0±0.8 0.002 Babies born to women with preeclampsia were more likely to be LBW (OR = 2.8; CI: 2.2–3.5), small for gestational age (OR = 2.3; CI: 1.9–2.9) or premature (OR = 2.5; CI: 2.0–3.0) (Table 2). Babies born to women with preeclampsia accounted for 92% of LBW babies, 93% of small for gestational age babies and 93% of premature babies in the study population (p < 0.001). The mean ± SD birth weight of term neonates born to women with preeclampsia (2.86 ± ±0.5 kg) was significantly less than that of the term neonates born to normotensive women (3.20 ± 0.4 kg; p < 0.001). Term neonates born to women with preeclampsia were also more likely to be LBW (OR = 2.6; CI: 1.9–3.6) and small for gestational age (OR = 3.0; CI: 2.0–4.4) than term neonates born to normotensive women. Table 2 Comparison of neonates born to women with preeclampsia and controls born to women without preeclampsia at the UHWI 2010–11 Variable Cases N = 114 n (%) Controls N = 104 n (%) Total Fisher’s exact test p-value Premature 54 (47) 4 (4) 58 <0.001 LBW 66 (58) 6 (6) 72 <0.001 Very LBW 29 (25) 1 (1) 30 <0.001 Small for gestational age* 27 (31) 2 (2) 29 <0.001 Neonatal admission 67 (59) 13 (13) 80 <0.001 Neonatal deaths 18 (28) 0 (0) 18 0.023 Variable Cases N = 114 n (%) Controls N = 104 n (%) Total Fisher’s exact test p-value Premature 54 (47) 4 (4) 58 <0.001 LBW 66 (58) 6 (6) 72 <0.001 Very LBW 29 (25) 1 (1) 30 <0.001 Small for gestational age* 27 (31) 2 (2) 29 <0.001 Neonatal admission 67 (59) 13 (13) 80 <0.001 Neonatal deaths 18 (28) 0 (0) 18 0.023 * Asymmetrical. Table 2 Comparison of neonates born to women with preeclampsia and controls born to women without preeclampsia at the UHWI 2010–11 Variable Cases N = 114 n (%) Controls N = 104 n (%) Total Fisher’s exact test p-value Premature 54 (47) 4 (4) 58 <0.001 LBW 66 (58) 6 (6) 72 <0.001 Very LBW 29 (25) 1 (1) 30 <0.001 Small for gestational age* 27 (31) 2 (2) 29 <0.001 Neonatal admission 67 (59) 13 (13) 80 <0.001 Neonatal deaths 18 (28) 0 (0) 18 0.023 Variable Cases N = 114 n (%) Controls N = 104 n (%) Total Fisher’s exact test p-value Premature 54 (47) 4 (4) 58 <0.001 LBW 66 (58) 6 (6) 72 <0.001 Very LBW 29 (25) 1 (1) 30 <0.001 Small for gestational age* 27 (31) 2 (2) 29 <0.001 Neonatal admission 67 (59) 13 (13) 80 <0.001 Neonatal deaths 18 (28) 0 (0) 18 0.023 * Asymmetrical. In total, 80 neonates were admitted to the neonatal unit, 67 (59%) were born to women with preeclampsia and 13 (13%) to normotensive women. Neonates born to women with preeclampsia accounted for 98% of the LBW babies and all of the small for gestational age babies requiring admission p < 0.001. The major reasons for admission for the neonates born to women with preeclampsia were prematurity [37 (56%)] and respiratory distress [11 (17%)]. The major reasons for admission for neonates born to normotensive women were respiratory distress [4 (31%)] and neonatal jaundice [4 (31%)]. In total, 9 (13%) of the neonates born to women with preeclampsia received mechanical ventilation, 7 (10%) received bubble continuous positive airway pressure (CPAP) ventilation and 17 (25%) received oxygen via a headbox. No neonate born to normotensive women required mechanical ventilation or bubble CPAP, with three (23%) receiving oxygen via a headbox. In total, 18 neonates, 11 (61%) males and 7 (39%) females, died; all were born to women with preeclampsia. In total, 17 (94%) of the non-survivors were delivered by cesarean section, 10 (59%) on an urgent basis and 7 (41%) on an emergency basis. The indications for an operative delivery were fetal jeopardy 8 (47%), impending eclampsia 6 (35%), intrauterine growth restriction 2 (12%) and eclampsia 1 (6%). All 18 neonates were very LBW (<1500 g) and premature, and 11 neonates (85%) had a birth weight <1000 g. Nine (50%) of the non-survivors were managed with mechanical ventilation and two (11%) with bubble CPAP. The cause of death was prematurity in 12 (67%) cases, sepsis in 3 (17%) cases, pneumonia in 1 (6%) case, intraventricular hemorrhage in 1 (6%) case and nonimmune hydrops in 1 (6%) case. DISCUSSION In this study, women with preeclampsia were more likely to have labor induced and were also more likely to have an operative delivery. Neonates born to these women were more likely to be LBW, premature and small for gestational age when compared with neonates born to women without preeclampsia. They also had a greater incidence of neonatal admissions and mortality. Almost 70% of women with preeclampsia were delivered via cesarean section, the commonest reason being worsening preeclampsia/impending eclampsia. Results from our study match closely with those of previous studies, which have documented an increased rate of operative delivery in women with preeclampsia [3–7]. This increased risk for operative delivery is not unexpected especially in the case of severe preeclampsia where maternal or fetal health or both are at risk, and urgent abdominal delivery is often the route of delivery to mitigate against adverse perinatal outcome. Preterm delivery often occurs in a pregnancy complicated by preeclampsia because the risk to mother and fetus of continuing the pregnancy to term outweighs the benefit. In our study, women with preeclampsia were more likely to deliver a preterm neonate than controls. This is also in keeping with previously published studies [3–10, 15, 16]. The mean birth weight of neonates in our study born to women with preeclampsia was significantly less than that for neonates born to women without preeclampsia. However, when the preterm neonates were excluded, the mean birth weight of babies born to women with preeclampsia was still significantly lower than that of those born to normotensive women. Thus, the lower birth weight is more likely a reflection of the effect of preeclampsia on placental function and fetal growth rather than that of prematurity alone. Once delivered, the Apgar scores for neonates born to women with preeclampsia were noted to be lower than those of neonates born to normotensive women. This may be reflective of the effect of preeclampsia on uteroplacental function and the resultant predisposition to fetal hypoxia resulting in intrauterine depression. This finding is also consistent with previous studies in the literature [7, 8, 15]. Almost 60% of the neonates born to women with preeclampsia in our study were admitted to the neonatal unit. Of those admitted, more than half had respiratory compromise, and we were unable to make a definitive underlying etiological diagnosis in many of these babies, although in some of the preterm babies, lung immaturity and surfactant insufficiency may have been contributory factors. This increased need for neonatal admission and respiratory support has been previously documented [7, 11, 12]. Neonatal outcome was worse for babies born to women with preeclampsia in our study; there was a 15% mortality rate, and all the deaths occurred in very LBW neonates born to women with preeclampsia. A similarly high mortality rate was documented by Ramsewak et al. [16], who noted that 18% of neonates (1000–2000 g) born to women with preeclampsia did not survive. Bassaw etal. [17] in a 6-year perinatal audit in Trinidad documented that neonates born to women with preeclampsia accounted for 10% of neonatal mortality. Browne et al. [4] in Ghana noted an adjusted relative risk of neonatal death of 18.41 for babies born to women with preeclampsia, and Kim et al. [12] in Korea documented a 20% incidence of death in babies born to women with preeclampsia. This disturbing trend of excess mortality in neonates born to women with preeclampsia seems to be predominant in LMICs. In our setting, the sequelae of prematurity were major contributors to neonatal mortality, and this may be linked to resource constraints that limit technological advances such as mechanical ventilation, surfactant replacement therapy and total parenteral nutrition needed for the care of these infants. If Jamaica and other LMICs are to achieve Goal 3 of the Sustainable Developmental Goals [18] and decrease neonatal mortality to at least 12 per 1000 live births, focus will have to be placed on decreasing the contribution of preterm birth to mortality. As part of this thrust, decreasing the incidence of preterm birth secondary to maternal preeclampsia will be critical. Interventions to improve morbidity and mortality in these neonates will have to be targeted at the timely and appropriate obstetric management of women with preeclampsia and the provision of adequate resources for the management of prematurity in the affected neonates. By virtue of this being a retrospective study, data collection was limited by what information was recorded. Additionally, this study was conducted in a single tertiary level, university-affiliated institution that accepts in utero transfer of women with high-risk pregnancies, so the findings may not be representative of all hospitals in Jamaica. CONCLUSION Adverse neonatal outcome was noted in neonates born to women with preeclampsia, and the mainstay of decreasing mortality and morbidity in these neonates will involve optimizing obstetric and neonatal care at the UHWI. References 1 Duley L. The global impact of pre-eclampsia and eclampsia . Semin Perinatol 2009 ; 33 : 130 – 7 . Google Scholar CrossRef Search ADS PubMed 2 ACOG Practice Bulletin No. 33 . Diagnosis and management of pre-eclampsia and eclampsia . Obstet Gynecol 2002 ; 99 : 159 – 67 . PubMed 3 Saadat M , Nejad SM , Habibi G , et al. Maternal and neonatal outcome in women with pre-eclampsia Taiwan . J Obstet Gynecol 2007 ; 46 : 255 – 9 . 4 Browne JL , Vissers KM , Antwi E , et al. Perinatal outcomes after hypertensive disorders in pregnancy in a low resource setting . Trop Med Int Health 2015 ; 20 : 1778 – 86 . Google Scholar CrossRef Search ADS PubMed 5 Omani-Samani R , Ranjbaran M , Amini P , et al. Adverse maternal and neonatal outcomes in women with preeclampsia in Iran . J Matern Fetal Neonatal Med 2017 ; 18 : 1 – 5 . Google Scholar CrossRef Search ADS 6 Lydakis C , Beevers M , Beevers DG , et al. The prevalence of pre-eclampsia and obstetric outcome in pregnancies of normotensive and hypertensive women attending a hospital specialist clinic . Int J Clin Pract 2001 ; 55 : 361 – 7 . Google Scholar PubMed 7 Heard AR , Dekker GA , Chan A , et al. Hypertension during pregnancy in South Australia, part 1: pregnancy outcomes . Aust N Z J Obstet Gynaecol 2004 ; 44 : 404 – 9 . Google Scholar CrossRef Search ADS PubMed 8 Khader YS , Batieha A , Al-Njadat RA , et al. Preeclampsia in Jordan: incidence, risk factors, and its associated maternal and neonatal outcomes . J Matern Fetal Neonatal Med 2018 ; 31 : 770 – 6 . Google Scholar CrossRef Search ADS PubMed 9 Xiao R , Sorensen TK , Williams WA , et al. Influence of pre-eclampsia on fetal growth . J Matern Fetal Neonatal Med 2003 ; 13 : 145 – 6 . Google Scholar CrossRef Search ADS PubMed 10 Jelin AC , Cheng YW , Shaffer BL , et al. Early-onset pre- eclampsia and neonatal outcomes . Matern Fetal Neonatal Med 2010 ; 23 : 389 – 92 . Google Scholar CrossRef Search ADS 11 Adu-Bonsaffoh K , Ntumy MY , Obed SA , et al. Perinatal outcomes of hypertensive disorders in pregnancy at a tertiary hospital in Ghana . BMC Pregnancy Childbirth 2017 ; 17 : 388. Google Scholar CrossRef Search ADS PubMed 12 Kim HY , Sohn YS , Lim JH , et al. Neonatal outcome after preterm delivery in HELLP syndrome . Yonsei Med J 2006 ; 47 : 393 – 8 . Google Scholar CrossRef Search ADS PubMed 13 Deanna A , McCaw-Binns A , Foster-Williams K. The perinatal morbidity and mortality survey of Jamaica 1986–1987 . Paediatr Perinat Epidemiol 1988 ; 2 : 138 – 47 . Google Scholar CrossRef Search ADS PubMed 14 Thomas P , Ashley D , Bernard GW. Incidence, risk factors and outcomes of hypertensive disorders of pregnancy in Jamaica . Clin Exp Hypertens 1990 ; B9 : 169 – 98 . 15 Fletcher H , Forrester TE , Wilks R , et al. Hypertension in pregnancy at UHWI: is our extreme caution warranted? West Indian Med J 1991 ; 40(Suppl. 1) : 31 . 16 Ramsewak S , Roopnarinesingh S. The T. Obstetric factors affecting outcome in low birthweight infants . West Indian Med J 1986 ; 35 : 166. Google Scholar PubMed 17 Bassaw B , Roopnarisingh S , Sirjusingh A. An audit of perinatal mortality . West Indian Med J 2001 ; 50 : 42 – 6 . Google Scholar PubMed 18 Transforming our world: the 2030 Agenda for Sustainable Development. https://sustainabledevelopment.un.org/post2015/transformingourworld © The Author(s) [2018]. Published by Oxford University Press. All rights reserved. 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A Retrospective Study of Neonatal Outcome in Preeclampsia at the University Hospital of the West Indies: A Resource-limited Setting

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Abstract

Abstract Aim This study aimed to determine the outcome of neonates born to women with preeclampsia at the University Hospital of the West Indies (UHWI). Methods This was a retrospective descriptive study looking at the outcome of all babies born to women with preeclampsia and control babies born to normotensive women at the UHWI over a 20-month period. Maternal and neonatal demographic data and course of admission for admitted neonates were recorded. Descriptive analyses were performed. Results Neonates born to women with preeclampsia were more likely to be low birth weight [odds ratio (OR = 2.8; confidence interval (CI): 2.2–3.5], small for gestational age (OR = 2.3; CI: 1.9–2.9) or premature (OR = 2.5; CI: 2.0–3.0). They had a lower mean 5 min Apgar score than babies born to normotensive women p<0.05. They were also more likely to be admitted to the neonatal unit 67 (59%) compared with neonates of normotensive women 13 (13%) p<0.001. The main reason for admission was prematurity. Eighteen neonates, all born to women with preeclampsia, died, and the main cause of death was prematurity. Conclusion Adverse neonatal outcome was noted in neonates born to women with preeclampsia, and this was predominantly related to prematurity and its complications. neonatal outcome, preeclampsia and neonatal outcome, preeclampsia and outcome, low birth weight, intrauterine growth restriction INTRODUCTION Preeclampsia is defined as gestational blood pressure elevation with proteinuria that develops after 20 weeks’ gestation. Primarily, a disease of pregnancy, it is a multisystem disorder that affects approximately 2–8% of pregnancies [1]. Although its pathogenesis is incompletely understood, it is a major cause of maternal and neonatal morbidity and mortality [1, 2]. Previous studies in the literature have documented that women with preeclampsia are at increased risk of having labor induced and undergoing an operative delivery. Saadat et al. [3] in Taiwan found that a third of women with preeclampsia underwent induction of labor because of worsening preeclampsia. They also documented that a third of women with preeclampsia had an operative delivery. Similarly, Browne et al. [4] from Ghana noted that nearly 90% of the women with preeclampsia in their study were delivered by cesarean section, and Omani-Samani et al. [5] in Iran documented a 2-fold increased risk of operative delivery for women with preeclampsia. Researchers in the UK [6] and Australia [7] have also noted an increase in the rate of operative deliveries in women with preeclampsia. Studies from both low- and middle-income countries (LMICs) [3–5, 8] as well as the USA [9, 10], the UK [6] and Australia [7] also document that babies born to these women have an increased risk of being born prematurely and of being low birth weight (LBW) and small for gestational age. Additionally, researchers in LMICs have noted that these babies have low 5-min Apgar scores and are at increased risk of being admitted to the neonatal unit, of requiring respiratory support and of dying [3, 4, 11, 12]. Ashley et al. [13], in looking at the singleton perinatal deaths in Jamaica between September 1987 and August 31 1988 as part of a national perinatal morbidity and mortality survey, noted that antenatal death, death from immaturity and all perinatal deaths combined were statistically significantly associated with highest diastolic blood pressure, highest level of proteinuria and antenatal eclamptic fit, respectively. The reported incidence of antenatal preeclampsia was 4.0% and of eclampsia was 7.1 per 1000 for Jamaica at the time of the study [14]. Fletcher et al. [15] in a 10-year review at the University of the West Indies found that women with preeclampsia had significantly poorer pregnancy outcome with earlier delivery, lower fetal weight, Apgar scores and placental weight than controls and non-proteinuric hypertensives. The literature supports a relationship between preeclampsia and poor neonatal outcome. Documenting the outcome of babies born to women with preeclampsia at the University Hospital of the West Indies (UHWI) will help to define the spectrum of morbidity and mortality, which will then inform clinical practice in an effort to improve outcome. This study aimed to document the outcome of babies born to women with preeclampsia at the UHWI. METHODS Study design This was a retrospective descriptive study to examine the outcome of all singleton babies born alive to women with preeclampsia and control singleton babies born alive to women without preeclampsia and who were also normotensive at the UHWI over a 20-month period. Setting The UHWI is located in urban Jamaica and is a university-affiliated institution. The neonatal unit at the UHWI comprises a 24-bed level 11 Newborn Special Care Unit and a 6-bed level 111 Neonatal Intensive Care Unit (NICU). At the time of the study, four consultant pediatricians, two of whom had specialist training in neonatology, were responsible for medical care of the neonates. Any woman accessing antenatal care at the UHWI who is assessed as being at risk for preeclampsia is followed up in a ‘High Risk’ clinic. If a diagnosis of preeclampsia is made, the woman is admitted for inpatient management, and close monitoring of these women continues perinatally. Population All singleton neonates born alive to women with preeclampsia at the UHWI between 1January 2010 and 31 August 2011 were included in this study. A control singleton neonate born alive nearest in time after the index case to a mother who did not have preeclampsia and who was normotensive was also included in the study. In a few instances, there was no control neonate born between the deliveries of two cases. Babies who were transferred to the UHWI from other hospitals and all stillbirths were excluded from the study. Procedure Cases and controls were identified from the labor ward admission book. Maternal demographic data (age, gravidity, parity, mode of delivery) and neonatal demographic data (gender, birth weight, gestational age if premature, Apgar score) were recorded. Neonates admitted to the neonatal unit were identified from the neonatal unit admission book. The medical records of all neonates admitted to the neonatal unit were reviewed, and data on reason for admission, interventions and outcome of admission were recorded using a data extraction sheet. Outcome measures were prematurity, LBW, small for gestational age, Apgar scores, admission to the neonatal unit and neonatal death. Definitions Preeclampsia: Hypertension (systolic blood pressure ≥140 or diastolic blood pressure ≥90 on two occasions at least 4 h apart) and proteinuria (300 mg/day or ≥1+ on dipstick) detected for the first time after 20 weeks' gestation. Preterm infant: An infant born before 37 completed weeks of gestation. Low birth weight: Birth weight <2500 g regardless of gestational age Small for gestational age (SGA): Any neonate whose birth weight was <10th percentile on the WHO growth charts for term infants and the Fenton preterm growth charts for preterm infants. Data analysis Descriptive analyses were performed. Analysis of differences between babies born to women with preeclampsia and those born to women without preeclampsia who were normotensive was determined using the Student’s t-test for continuous variables and the chi-squared test for categorical variables. Statistical significance was taken at the level p<0.05. Statistical analyses were performed using the Statistical Package for the Social Sciences version 14 (SPSS Inc., Chicago, IL). Ethical approval Ethical approval for the conduct of this study was granted by the UWI Mona Research Ethics Committee. RESULTS Maternal demographics In total, 218 neonates were entered into the study, 114 (52%) were born to women with preeclampsia and 104 (48%) were born to women who did not have preeclampsia and were normotensive during pregnancy. The mean ± SD maternal age for women with preeclampsia and for normotensive women was 30.3 ± 6.2 and 27.6 ± 5.8 years, respectively (p=0.001). In total, 37 (33%) of the women who had preeclampsia and 28 (27%) of the normotensive women were primigravida. Women with preeclampsia [78 (68%)] were more likely to be delivered by cesarean section than women who did not have preeclampsia [28 (27%); odds ratio (OR) = 2.6; confidence interval (CI): 1.9–3.7; p < 0.001]. For women with preeclampsia, 37 (47%) of the operative deliveries were done on an urgent basis, and 34 (44%) were done on an emergency basis as compared with 8 (29%) for each, respectively, for women who did not have preeclampsia p < 0.001. The most common indications for operative delivery in women with preeclampsia were severe preeclampsia/impending eclampsia [38 (49%)] and fetal jeopardy [20 (26%)], whereas for women who did not have preeclampsia, they were failed induction [10 (36%)] and previous cesarean section [10 (36%)], respectively. Women with preeclampsia who delivered vaginally were more likely to be induced [23 of 36 (64%)] than women who did not have preeclampsia [19 of 76 (25%); OR = 5.0; CI: 2.1–12.0; p<0.001]. Neonatal demographics There were 114 neonates born to women with preeclampsia, 57 (50%) males and 57 (50%) females, and 104 neonates born to normotensive women, 49 (47%) males and 55 (53%) females. The mean birth weight and gestational age of babies born to women with preeclampsia were significantly less than that of babies born to women who did not have preeclampsia (Table 1). The mean 5-min Apgar score of neonates born to women with preeclampsia was also significantly lower than that for neonates born to normotensive women. Table 1 Birth demographics for neonates born to women with preeclampsia and controls born to women without preeclampsia at the UHWI 2010–11 Variable Cases N = 114 Mean ±SD Controls N = 104 Mean±SD Independent sample t-test p-value Gestational age (weeks) 35.3±3.7 38.6±1.4 <0.001 Birth weight (kg) 2.2±0.9 3.2±0.4 <0.001 APGAR 1 min 7.1±2.4 8.1±1.6 <0.001 APGAR 5 min 8.5±1.5 9.0±0.8 0.002 Variable Cases N = 114 Mean ±SD Controls N = 104 Mean±SD Independent sample t-test p-value Gestational age (weeks) 35.3±3.7 38.6±1.4 <0.001 Birth weight (kg) 2.2±0.9 3.2±0.4 <0.001 APGAR 1 min 7.1±2.4 8.1±1.6 <0.001 APGAR 5 min 8.5±1.5 9.0±0.8 0.002 Table 1 Birth demographics for neonates born to women with preeclampsia and controls born to women without preeclampsia at the UHWI 2010–11 Variable Cases N = 114 Mean ±SD Controls N = 104 Mean±SD Independent sample t-test p-value Gestational age (weeks) 35.3±3.7 38.6±1.4 <0.001 Birth weight (kg) 2.2±0.9 3.2±0.4 <0.001 APGAR 1 min 7.1±2.4 8.1±1.6 <0.001 APGAR 5 min 8.5±1.5 9.0±0.8 0.002 Variable Cases N = 114 Mean ±SD Controls N = 104 Mean±SD Independent sample t-test p-value Gestational age (weeks) 35.3±3.7 38.6±1.4 <0.001 Birth weight (kg) 2.2±0.9 3.2±0.4 <0.001 APGAR 1 min 7.1±2.4 8.1±1.6 <0.001 APGAR 5 min 8.5±1.5 9.0±0.8 0.002 Babies born to women with preeclampsia were more likely to be LBW (OR = 2.8; CI: 2.2–3.5), small for gestational age (OR = 2.3; CI: 1.9–2.9) or premature (OR = 2.5; CI: 2.0–3.0) (Table 2). Babies born to women with preeclampsia accounted for 92% of LBW babies, 93% of small for gestational age babies and 93% of premature babies in the study population (p < 0.001). The mean ± SD birth weight of term neonates born to women with preeclampsia (2.86 ± ±0.5 kg) was significantly less than that of the term neonates born to normotensive women (3.20 ± 0.4 kg; p < 0.001). Term neonates born to women with preeclampsia were also more likely to be LBW (OR = 2.6; CI: 1.9–3.6) and small for gestational age (OR = 3.0; CI: 2.0–4.4) than term neonates born to normotensive women. Table 2 Comparison of neonates born to women with preeclampsia and controls born to women without preeclampsia at the UHWI 2010–11 Variable Cases N = 114 n (%) Controls N = 104 n (%) Total Fisher’s exact test p-value Premature 54 (47) 4 (4) 58 <0.001 LBW 66 (58) 6 (6) 72 <0.001 Very LBW 29 (25) 1 (1) 30 <0.001 Small for gestational age* 27 (31) 2 (2) 29 <0.001 Neonatal admission 67 (59) 13 (13) 80 <0.001 Neonatal deaths 18 (28) 0 (0) 18 0.023 Variable Cases N = 114 n (%) Controls N = 104 n (%) Total Fisher’s exact test p-value Premature 54 (47) 4 (4) 58 <0.001 LBW 66 (58) 6 (6) 72 <0.001 Very LBW 29 (25) 1 (1) 30 <0.001 Small for gestational age* 27 (31) 2 (2) 29 <0.001 Neonatal admission 67 (59) 13 (13) 80 <0.001 Neonatal deaths 18 (28) 0 (0) 18 0.023 * Asymmetrical. Table 2 Comparison of neonates born to women with preeclampsia and controls born to women without preeclampsia at the UHWI 2010–11 Variable Cases N = 114 n (%) Controls N = 104 n (%) Total Fisher’s exact test p-value Premature 54 (47) 4 (4) 58 <0.001 LBW 66 (58) 6 (6) 72 <0.001 Very LBW 29 (25) 1 (1) 30 <0.001 Small for gestational age* 27 (31) 2 (2) 29 <0.001 Neonatal admission 67 (59) 13 (13) 80 <0.001 Neonatal deaths 18 (28) 0 (0) 18 0.023 Variable Cases N = 114 n (%) Controls N = 104 n (%) Total Fisher’s exact test p-value Premature 54 (47) 4 (4) 58 <0.001 LBW 66 (58) 6 (6) 72 <0.001 Very LBW 29 (25) 1 (1) 30 <0.001 Small for gestational age* 27 (31) 2 (2) 29 <0.001 Neonatal admission 67 (59) 13 (13) 80 <0.001 Neonatal deaths 18 (28) 0 (0) 18 0.023 * Asymmetrical. In total, 80 neonates were admitted to the neonatal unit, 67 (59%) were born to women with preeclampsia and 13 (13%) to normotensive women. Neonates born to women with preeclampsia accounted for 98% of the LBW babies and all of the small for gestational age babies requiring admission p < 0.001. The major reasons for admission for the neonates born to women with preeclampsia were prematurity [37 (56%)] and respiratory distress [11 (17%)]. The major reasons for admission for neonates born to normotensive women were respiratory distress [4 (31%)] and neonatal jaundice [4 (31%)]. In total, 9 (13%) of the neonates born to women with preeclampsia received mechanical ventilation, 7 (10%) received bubble continuous positive airway pressure (CPAP) ventilation and 17 (25%) received oxygen via a headbox. No neonate born to normotensive women required mechanical ventilation or bubble CPAP, with three (23%) receiving oxygen via a headbox. In total, 18 neonates, 11 (61%) males and 7 (39%) females, died; all were born to women with preeclampsia. In total, 17 (94%) of the non-survivors were delivered by cesarean section, 10 (59%) on an urgent basis and 7 (41%) on an emergency basis. The indications for an operative delivery were fetal jeopardy 8 (47%), impending eclampsia 6 (35%), intrauterine growth restriction 2 (12%) and eclampsia 1 (6%). All 18 neonates were very LBW (<1500 g) and premature, and 11 neonates (85%) had a birth weight <1000 g. Nine (50%) of the non-survivors were managed with mechanical ventilation and two (11%) with bubble CPAP. The cause of death was prematurity in 12 (67%) cases, sepsis in 3 (17%) cases, pneumonia in 1 (6%) case, intraventricular hemorrhage in 1 (6%) case and nonimmune hydrops in 1 (6%) case. DISCUSSION In this study, women with preeclampsia were more likely to have labor induced and were also more likely to have an operative delivery. Neonates born to these women were more likely to be LBW, premature and small for gestational age when compared with neonates born to women without preeclampsia. They also had a greater incidence of neonatal admissions and mortality. Almost 70% of women with preeclampsia were delivered via cesarean section, the commonest reason being worsening preeclampsia/impending eclampsia. Results from our study match closely with those of previous studies, which have documented an increased rate of operative delivery in women with preeclampsia [3–7]. This increased risk for operative delivery is not unexpected especially in the case of severe preeclampsia where maternal or fetal health or both are at risk, and urgent abdominal delivery is often the route of delivery to mitigate against adverse perinatal outcome. Preterm delivery often occurs in a pregnancy complicated by preeclampsia because the risk to mother and fetus of continuing the pregnancy to term outweighs the benefit. In our study, women with preeclampsia were more likely to deliver a preterm neonate than controls. This is also in keeping with previously published studies [3–10, 15, 16]. The mean birth weight of neonates in our study born to women with preeclampsia was significantly less than that for neonates born to women without preeclampsia. However, when the preterm neonates were excluded, the mean birth weight of babies born to women with preeclampsia was still significantly lower than that of those born to normotensive women. Thus, the lower birth weight is more likely a reflection of the effect of preeclampsia on placental function and fetal growth rather than that of prematurity alone. Once delivered, the Apgar scores for neonates born to women with preeclampsia were noted to be lower than those of neonates born to normotensive women. This may be reflective of the effect of preeclampsia on uteroplacental function and the resultant predisposition to fetal hypoxia resulting in intrauterine depression. This finding is also consistent with previous studies in the literature [7, 8, 15]. Almost 60% of the neonates born to women with preeclampsia in our study were admitted to the neonatal unit. Of those admitted, more than half had respiratory compromise, and we were unable to make a definitive underlying etiological diagnosis in many of these babies, although in some of the preterm babies, lung immaturity and surfactant insufficiency may have been contributory factors. This increased need for neonatal admission and respiratory support has been previously documented [7, 11, 12]. Neonatal outcome was worse for babies born to women with preeclampsia in our study; there was a 15% mortality rate, and all the deaths occurred in very LBW neonates born to women with preeclampsia. A similarly high mortality rate was documented by Ramsewak et al. [16], who noted that 18% of neonates (1000–2000 g) born to women with preeclampsia did not survive. Bassaw etal. [17] in a 6-year perinatal audit in Trinidad documented that neonates born to women with preeclampsia accounted for 10% of neonatal mortality. Browne et al. [4] in Ghana noted an adjusted relative risk of neonatal death of 18.41 for babies born to women with preeclampsia, and Kim et al. [12] in Korea documented a 20% incidence of death in babies born to women with preeclampsia. This disturbing trend of excess mortality in neonates born to women with preeclampsia seems to be predominant in LMICs. In our setting, the sequelae of prematurity were major contributors to neonatal mortality, and this may be linked to resource constraints that limit technological advances such as mechanical ventilation, surfactant replacement therapy and total parenteral nutrition needed for the care of these infants. If Jamaica and other LMICs are to achieve Goal 3 of the Sustainable Developmental Goals [18] and decrease neonatal mortality to at least 12 per 1000 live births, focus will have to be placed on decreasing the contribution of preterm birth to mortality. As part of this thrust, decreasing the incidence of preterm birth secondary to maternal preeclampsia will be critical. Interventions to improve morbidity and mortality in these neonates will have to be targeted at the timely and appropriate obstetric management of women with preeclampsia and the provision of adequate resources for the management of prematurity in the affected neonates. By virtue of this being a retrospective study, data collection was limited by what information was recorded. Additionally, this study was conducted in a single tertiary level, university-affiliated institution that accepts in utero transfer of women with high-risk pregnancies, so the findings may not be representative of all hospitals in Jamaica. CONCLUSION Adverse neonatal outcome was noted in neonates born to women with preeclampsia, and the mainstay of decreasing mortality and morbidity in these neonates will involve optimizing obstetric and neonatal care at the UHWI. References 1 Duley L. The global impact of pre-eclampsia and eclampsia . Semin Perinatol 2009 ; 33 : 130 – 7 . Google Scholar CrossRef Search ADS PubMed 2 ACOG Practice Bulletin No. 33 . Diagnosis and management of pre-eclampsia and eclampsia . Obstet Gynecol 2002 ; 99 : 159 – 67 . PubMed 3 Saadat M , Nejad SM , Habibi G , et al. Maternal and neonatal outcome in women with pre-eclampsia Taiwan . J Obstet Gynecol 2007 ; 46 : 255 – 9 . 4 Browne JL , Vissers KM , Antwi E , et al. Perinatal outcomes after hypertensive disorders in pregnancy in a low resource setting . Trop Med Int Health 2015 ; 20 : 1778 – 86 . Google Scholar CrossRef Search ADS PubMed 5 Omani-Samani R , Ranjbaran M , Amini P , et al. Adverse maternal and neonatal outcomes in women with preeclampsia in Iran . J Matern Fetal Neonatal Med 2017 ; 18 : 1 – 5 . Google Scholar CrossRef Search ADS 6 Lydakis C , Beevers M , Beevers DG , et al. The prevalence of pre-eclampsia and obstetric outcome in pregnancies of normotensive and hypertensive women attending a hospital specialist clinic . Int J Clin Pract 2001 ; 55 : 361 – 7 . Google Scholar PubMed 7 Heard AR , Dekker GA , Chan A , et al. Hypertension during pregnancy in South Australia, part 1: pregnancy outcomes . Aust N Z J Obstet Gynaecol 2004 ; 44 : 404 – 9 . Google Scholar CrossRef Search ADS PubMed 8 Khader YS , Batieha A , Al-Njadat RA , et al. Preeclampsia in Jordan: incidence, risk factors, and its associated maternal and neonatal outcomes . J Matern Fetal Neonatal Med 2018 ; 31 : 770 – 6 . Google Scholar CrossRef Search ADS PubMed 9 Xiao R , Sorensen TK , Williams WA , et al. Influence of pre-eclampsia on fetal growth . J Matern Fetal Neonatal Med 2003 ; 13 : 145 – 6 . Google Scholar CrossRef Search ADS PubMed 10 Jelin AC , Cheng YW , Shaffer BL , et al. Early-onset pre- eclampsia and neonatal outcomes . Matern Fetal Neonatal Med 2010 ; 23 : 389 – 92 . Google Scholar CrossRef Search ADS 11 Adu-Bonsaffoh K , Ntumy MY , Obed SA , et al. Perinatal outcomes of hypertensive disorders in pregnancy at a tertiary hospital in Ghana . BMC Pregnancy Childbirth 2017 ; 17 : 388. Google Scholar CrossRef Search ADS PubMed 12 Kim HY , Sohn YS , Lim JH , et al. Neonatal outcome after preterm delivery in HELLP syndrome . Yonsei Med J 2006 ; 47 : 393 – 8 . Google Scholar CrossRef Search ADS PubMed 13 Deanna A , McCaw-Binns A , Foster-Williams K. The perinatal morbidity and mortality survey of Jamaica 1986–1987 . Paediatr Perinat Epidemiol 1988 ; 2 : 138 – 47 . Google Scholar CrossRef Search ADS PubMed 14 Thomas P , Ashley D , Bernard GW. Incidence, risk factors and outcomes of hypertensive disorders of pregnancy in Jamaica . Clin Exp Hypertens 1990 ; B9 : 169 – 98 . 15 Fletcher H , Forrester TE , Wilks R , et al. Hypertension in pregnancy at UHWI: is our extreme caution warranted? West Indian Med J 1991 ; 40(Suppl. 1) : 31 . 16 Ramsewak S , Roopnarinesingh S. The T. Obstetric factors affecting outcome in low birthweight infants . West Indian Med J 1986 ; 35 : 166. Google Scholar PubMed 17 Bassaw B , Roopnarisingh S , Sirjusingh A. An audit of perinatal mortality . West Indian Med J 2001 ; 50 : 42 – 6 . Google Scholar PubMed 18 Transforming our world: the 2030 Agenda for Sustainable Development. https://sustainabledevelopment.un.org/post2015/transformingourworld © The Author(s) [2018]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Journal of Tropical PediatricsOxford University Press

Published: Mar 24, 2018

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