Risk factors and poor prognostic factors of preeclampsia in Ibn Rochd University Hospital of Casablanca: about 401 preeclamptic cases

Preeclampsia is a gestational pathology that complicates 2 to 8% of pregnancies and is one of the major causes of maternal and fetal morbidity and mortality worldwide. The aim of this work was to study the epidemiological profile of preeclampsia in Casablanca and to identify risk factors as well as factors of poor maternal and fetal prognosis. 401 preeclamptic cases were collected in the gynecology-obstetrics “C” Service of Lalla Meryem Maternity of Ibn Rochd University Hospital of Casablanca (2010-2011) were included in this study and a statistical analysis with the SPSS software version (16.0) was performed. We used the Chi-2 test to analyze qualitative variables and Student's test and ANOVA (analysis of variance) for quantitative variables. The incidence of preeclampsia was (7.1%). The epidemiological profile was that of a primipara (57.6%), average age 30 years and (66.8%) of pregnancies were not followed. Multiparity was a factor of poor maternal prognosis (p = 0.007). The low gestational age and no prenatal care were factors of maternal as well as fetal prognosis. Risk factors frequently found in our patients were obesity (15.21%) and chronic hypertension (5.73%) as vascular-renal history; abortion (16.46%) and perinatal death (5.24%) as obstetric history. Preeclampsia is a common obstetric pathology in our context. Better prenatal care and early diagnosis could reduce its incidence.


Introduction
Preeclampsia is a gestational pathology, defined as the association of pregnancy-induced hypertension (BP≥140/90mmHg) and proteinuria of (≥300mg/24h) after 20 weeks of gestation [1]. It affects approximately 0.5 to 7% of pregnancies [2] and is a leading cause of maternal and fetal morbidity and mortality worldwide [3]. This rate is higher in low socioeconomic status and areas with high prevalence of cardiovascular diseases [4]. Several risk factors have been proposed to characterize women at high risk of preeclampsia, including nulliparity, older age, chronic hypertension, and pregnancy diabetes mellitus [5]. Moreover, patients with preeclampsia are at increased risk of developing cardiovascular disease, renal and neurological disorders later in life which determines the risk profile of the child' future health [6]. It is a complication of pregnancy, which also has long-term effects on maternal health [7] and is one of the major causes of premature delivery usually medically indicated for the benefit of the mother in developed countries, which leads to infant morbidity and substantial excess health care expenditure [8]. Since, the mechanisms of diseases onset remains unclear and currently, no therapeutic approaches are available to either treat or prevent preeclampsia, which just still based on the prevention of the malignant hypertension and ending the pregnancy [1]. Furthermore, there is no real predictive factors of this pathology [9]. However, the identification of prognostic factors of pregnant women at risk of preeclampsia could be of great importance so as to improve the prognosis of our patients and their childbirths. Incidence of preeclampsia throughout the world varies according to the authors, the studied population and the definition used. It also differs between different ethnic groups, from one country to another and even from one region to another within the same country. In the US, the frequency had increased from 3.4% to 3.8% over the last 30 years [10]. In France, the incidence of preeclampsia was estimated to 1-3% in nulliparous patients and between 0.5 to 1.5% in multiparous patients [11]. In Spain, the frequency was 1 to 2% [4].
In Anglo-Saxon countries, the incidence ranges from 3 to 7% in primiparae and 1 to 3% in multiparous [3]. In black Africa, the prevalence of preeclampsia was of around 25% [12]. Frequency of preeclampsia was found to be 44% in sub-Saharan Africa [13]. In a Senegalese study, a frequency of 14.9% was found in relation to all the hypertensive states associated with pregnancy [14]. In Morocco, the exact epidemiological situation of preeclampsia remains little investigated. The aim of this work is to evaluate the epidemiological profile of preeclampsia in Casablanca and to identify risk factors as well as factors of poor maternal and fetal prognosis factors by a retrospective study including 401 preeclamptic patients.

Methods
Retrospective study was conducted during the two-year period from the first January 2010 to 31 December 2011, at the Department of

Bivariate analysis
Factors of poor maternal prognosis: maternal age, gestational age, parity and non-prenatal follow-up are reported as factors of poor maternal prognosis in our study ( Table 4).
Factors of poor fetal prognosis: poor fetal prognosis factors found in our study are the advanced maternal age and low gestational age (Table 5).

Discussion
The frequency of preeclampsia in Casablanca is 7.07%. Moroccans studies noted a variable rate between frequencies found in other cities ranging from 50 to 73% [15]. Therefore, this rate was 44% in sub-Saharan countries 44% [13], compared with developed countries that reported a frequency of 0.5-7% [3,10,11]. In our study, the mean maternal age of our preeclamptic patients are 30 years. This trend can be explained by the increased frequency of marriage and early pregnancies in this age group in our context. Young maternal age between 25 and 35 years has been reported to be as a risk factor for preeclampsia in several studies [12]. According to various authors [8], is the advanced maternal age that constitutes a factor of poor maternal prognosis. Numerous studies have reported a risk of preeclampsia multiplied by 2 to 4 for women over 35 years of age [11]. In our study, preeclamptic patients age under than 24 years of age are significantly more at risk of eclampsia, while those aged > 34 years are significantly more at risk for acute renal failure, acute edema of the lung. The frequency of prematurity in our study is significantly higher in our preeclampsic patients over 34 years of age compared to those aged 24 to 34 years and those aged less than 24 years. Thus, we suggest that the advanced maternal age is a factor of poor prognosis in our study. The development of preeclampsia at an early gestational age (<34 weeks of gestation) have been associated with significant maternal and perinatal morbidity and mortality [6]. In our study, preeclampsia patients with a gestational age (<34 weeks of gestation) has worse prognosis compared to those patient with a gestational age (≥34 weeks of gestation), which is often accompanied by complications such as (HELLP Syndrome,  [3]. Thus, early gestational age (<34 weeks of gestation) may be considered as a factor of poor maternal and fetal prognosis. Preeclampsia complicates 2 to 8% of pregnancies worldwide [6]. Much research reported that primigesity and primiparity predispose to preeclampsia: the proportion of preeclampsia is high in primigravida and primipara women, regardless of their age [16]. The incidence of preeclampsia was more frequent in nulliparous than primiparous and multiparous [17]. In our study primiparous as a maternal prognosis are the most exposed group. Similar results have been reported primiparity as a risk factor of preeclampsia and its proportion was variable in the literature [18]. Therefore, other risk factors found in the literature include the advanced maternal age and multiparity [3]. In our study, multiparous preeclampsia patients have more complications compared to primiparous, with a significantly higher frequency of HELLP syndrome. These results support the fact that multiparity is a factor of poor maternal prognosis. In our study, preeclampsia patients present a medical history with high frequency of vasculo-renal antecedents. These antecedents (obesity, hypertension, diabetes, nephropathy, cardiopathy) increase the risk of preeclampsia by the vascular lesions that they determine [8]. Obesity is the most common risk factor, followed by chronic hypertension and diabetes in our study. These three factors have often been presented as a risk factors for pre-eclampsia [19]. In women with pre-gestational diabetes, preeclampsia complicates 10% to 20% of pregnancies, three times more than reported in normal pregnancies with higher risk of preeclampsia in patients with type 1 diabetes and pregestational microalbuminuria [20]. Obesity confers a high risk of fetal and maternal consequences of preeclampsia [21]. In our study, preeclampsia patients have an obstetric history in order of frequency: abortion, perinatal death, pre-eclampsia, eclampsia and/or retroplacental hematoma. There is no significant difference in maternal or fetal complications in patients with or without obstetric history. However, gynecological and surgical history are less present in preeclampsia patients. In our study, preeclampsia patients having no obstetric follow-up have a worse prognosis compared to those whose pregnancy was followed, with a significantly higher rate of HELLP syndrome, Eclampsia and maternal death, which is similar to the results found in some other studies that have reported the strong association of the complication of HELLP syndrome with the increased risk of maternal morbidity and mortality [22]. Thus, the non-prenatal follow-up represent a factor of poor maternal prognosis in our study.

Conclusion
Preeclampsia is still a public health problem due to its high incidence and the presence of many severe cases in our context. It is one of the main causes of maternal and fetal morbidity and mortality. In this study, obesity and chronic hypertension were the most frequent risk factors as a vasculo-renal history, followed by abortion and perinatal death as obstetric history. In this context, only earlier diagnosis and closer monitoring could improve the prognosis of our preeclamptic patients in order to reduce its incidence.

Competing interests
The authors declare no competing interests.

Authors' contributions
Meriem Benfateh, wrote and finalized the manuscript, she was also