Relation of risk factors, management, and outcome of preeclampsia patients at Haji Adam Malik Hospital, Medan Indonesia 2014-2015

Background: Preeclampsia is one of the biggest causals of the maternal and fetal mortality rate. Preeclampsia has many etiology and pathophysiology which is having its timeline during the pregnancy process. It also has many risk factors such as age, gravida status, etc. In this study, we tried to find any correlation between risk factor, management with the output of the preeclamptic patient during January 2014 to December 2015. Methods: All of the preeclamptic patients who terminated/ delivered at Adam Malik General Hospital during the period will be included (n=87). The data were collected from the medical record and served on the table to correlates between risk factor and management with the output of the preeclamptic patient and their infant (via APGAR). Results: The most common management were MgSO4 and Nifedipine, with the most delivery path were cesarean section. We didn’t find any significant correlation between risk factor and management with the output. There was no significant correlation between Age and gravida status with 1 minute APGAR (p=0,887 and p=0,92) and 5 minute APGAR (p=0,759 and p=0,496). Conclusion: The most common management was MgSO4 and nifedipine, cesarean section was the most delivery path. We didn’t find any correlation between APGAR score and any risk factor.


INTRODUCTION
Pre -eclampsia is a pregnancy complication characterized by an increase in blood pressure with proteinuria and or an increase in renal function, liver and decreased platelet levels in pregnant women who with no history of hypertension. This syndrome appears at the end of the second until the third semester of pregnancy. Symptoms diminish or disappear after delivery; thus, the definitive treatment will have to be terminating the pregnancy. Pre -eclampsia could impact both the mother and the fetus. Maternal complications include HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), pulmonary edema, renal impairment, bleeding, placental abruption and even maternal death. Complications in infants may include premature birth, fetal distress, low birth weight or intrauterine fetal death (IUFD). 1 The incidence of pre -eclampsia in the United States ranges from 2 -6% of healthy nulliparous pregnant women. In developing countries, the incidence of pre -eclampsia ranges from 4 -18%. Mild pre -eclampsia disease occurs 75%, and severe pre -eclampsia occurs 25%. Out of all the occurrences of pre -eclampsia, about 10% of pregnancies are less than 34 weeks of age. The pre -eclampsia incidence is increasing in women with a history of pre -eclampsia, multiple pregnancies, chronic hypertension and kidney disease. In primigravida pregnant women, especially younger age is more prone to suffer from pre -eclampsia than those of multigravida. Other predisposing factors are the age of pregnant women under 25 years old or over 35 years, hydatidiform mole, polyhydramnios, and diabetes. Blood pressure is considered normal if systolic is between 100 -120 mmHg and diastolic between 60 -80 mmHg. 1 The incidence rate of pre -eclampsia ranges from 5 -15% of all pregnancies worldwide. In the Cipto Mangunkusumo hospital, there were over 400 -500 cases or 4000 -5000 deliveries per year. There are several hypotheses about the etiology of pre -eclampsia including ischemic placenta, immune -related and genetic factors. Recently, endothelial dysfunction is thought to play a role in the pathogenesis of pre -eclampsia. 1 Pre -eclampsia aggravates over 5% -7% of all pregnancies. Proteinuria and hypertension are the mostly found clinical manifestations, as kidneys Department of Obstetrics and Gynecology -Faculty of Medicine University of North Sumatera -H. Adam Malik General Hospital Medan are the most affected organ (glomerular endotheliosis). The pathogenesis of pre -eclampsia is complex; there are many interactions of genetics, immunology, and environmental factors. It has been suggested that pre -eclampsia is a two -stage disease. The first stage is asymptomatic, characterized by abnormal placental development during the first trimester resulting in placental insufficiency and the excessive release of placental material into the maternal circulation. It will lead to the second symptomatic stage, where pregnant women present with characteristics of hypertension, renal impairment, and proteinuria, all of which will cause them risk of HELLP syndrome (hemolysis, high liver enzymes and low platelet function), eclampsia, and another organ damage. 5 Infant mortality rate (IMR) in Indonesia is still relatively high. It was recorded 51 per 1000 live births in 2003. The most frequent cause of infant mortality was reported due to perinatal disorders. There were about 2 -27% of all perinatal deaths caused by low birth weight and premature birth. 2

METHOD
This study is a descriptive study. Samples were obtained by examining and collecting data of all patients' medical records with severe pre -eclampsia diagnoses with or without other diagnoses of diseases. Data were tabulated and presented in the form of frequency distribution tables. Data analysis was performed by univariate and bivariate analysis with statistic program (SPSS v17). Table 1 explains the characteristics of women with pre -eclampsia were found mostly in the age of 20 -35 years (62.1%). Moreover, pre -eclampsia was found highest in pregnant women within multigravida (37.9%) and nullipara group (43.7%), while found lowest in secundigravida (20.7%) and primipara group (21.8%).

Characteristics of Women with Preeclampsia (PE)
Based on hospital admission time, slightly more proportion of pre -eclampsia was found in women with gestational age ≥37 weeks (55.2%). Whereas in respect to gestational age during childbirth, slightly more proportion of pre -eclampsia found in the group of gestational age ≥37 weeks (56.3%). Most pregnant women with pre -eclampsia were found in the no risk factor group (52.9%), followed by combination of several risk factors (11.5%), history of PE (8%), age > 40 years (6.9%), twin pregnancy (5.7%), history of hypertension (4.6%), history of diabetes (2.3%) and history of IVF / TRB (1.1%) respectively. Table 2 shows the mean duration of hospital care for women with pre -eclampsia in the ward was 5.24 ± 2.706 days, whereas mean duration of care in HCU was 0.37 ± 0.79 days and mean duration of care in ICU was 0.46 ± 2.37 days. It indicates that women with pre -eclampsia were treated longer in the ward and only for a few hours in HCU or ICU. Based on table 3, most pre -eclampsia patients who were hospitalized did not use ventilators (95.4%).

Characteristics of Laboratory Results
Based on the table 4, most women with preeclampsia presented with proteinuria ≥ +2 (73.6%) and serum albumin <3.5 mg / dl (86.2%).  Table 5 shows that the most drug used to mothers with pre -eclampsia was nifedipine (93.1%) and only a small proportion received a combination of anti -hypertensive therapy (5.7%). Almost all patients also received anti -convulsive MgSO 4 at a dose of 1 mg/hr. Table 6 explains most women with pre -eclampsia had labored by surgical operation per abdomen (79.3%), followed by using instruments (11.5%) and spontaneous labor (8%). As for indication for labor choices, most patients had no indication (54.0%), followed by indication of deteriorating fetus condition (14.9%), laboratory deterioration (13.8%) and combinations (2.3%) respectively.

Overview of the Infants
Based on table 7, the proportions of infants with birth weight of <2500 gr (48.3%) and ≥2500 gr (51.7%) were relatively balanced. Based on APGAR score, it shows a group of APGAR scores ≥7 (64.4%) was higher than APGAR scores <7 (35,6). Moreover, regarding perinatal complications, most infants did not have a perinatal complication (62.1%), whereas 17.2% had mild asphyxia complication and the rest presented with stillbirth and moderate/severe asphyxia with 10.3% in each group.

Overview of Maternal Complications
Based on

The Association of Pre -eclampsia and Maternal Complication with the APGAR Score
Based on table 9, most infants in both groups of APGAR score of <7 and >7 had no complications with the percentage of 72.2% and 70.6% respectively. In the group of APGAR score <7, a small number of complications were found, such as HELLP syndrome (8.3%), Renal insufficiency/failure (5.6%), sepsis (2.8%) and partial HELLP syndrome (2.8%). Small proportions of complications were also found in the group of APGAR score >7, with partial HELLP syndrome being the most occurred complication (9.8%), HELLP syndrome (7.8%) and the lowest number of complications were Renal insufficiency/ failure, pulmonary edema and CVA with 2% each. Resemble APGAR score at minute 1; Table 10 shows most infants in both APGAR score <7 and >7 at minute 5 had no complications with the percentage of 70.6% and 71.4% respectively. In the group of APGAR score <7, a few complications occurred with other complications having the highest number (11.8%), followed by HELLP syndrome, renal insufficiency/failure and sepsis with 5.9%. No partial HELLP syndrome, pulmonary edema, CVA or combination of complications was found within the group. As for infants in the group of APGAR score ≥7, partial HELLP and HELLP syndrome shared the same proportion of 8.6%, and the lowest number of complications were pulmonary edema, CVA, and others with 1.4% each.

The Association of Risk Factors with Labor Management
Fisher exact analysis was used to analyze the correlation of risk factor with labor management. The results of the analysis are shown in table 11. Based on table 11, women with pre -eclampsia of age group 20 -35 years mostly gave birth per abdomen (79,6%). It is followed by labor using an instrument (13%), and the lowest was by stimulation/ induction (1,9%). As for the age group <20 and > 35 years, the majority of the patients also gave birth per abdomen (78.8%), followed by spontaneous birth (12.1%), and the lowest by using instruments (9.1%). Statistical analysis showed no significant difference between different types of the labor of women with pre -eclampsia based on age group. Based on parity, it is shown that pre -eclampsia patients within all three groups; primigravida, secundigravida and multigravida had given birth mostly per abdomen with the proportion of 76.3%, 84.2%, and 80.0% respectively. In primigravida group, it was followed by labor with instruments (15.8%) and the lowest proportion was spontaneous birth (7.9%). A similar proportion was found in secundigravida group for labor with instruments (15.8%). Whereas in multigravida group, spontaneous birth came as second highest after per abdomen birth with 13.3%, followed by labor with instruments and stimulation/induction with 3.3% each. Statistical analysis showed no significant difference between different types of the labor of women with pre -eclampsia based on parity. These results also indicate that the labor process of mothers with pre -eclampsia was generally per abdomen.

The Association of Risk Factors with Neonatal Outcomes/APGAR Score
Fisher exact analysis was used to analyze the correlation of risk factor with APGAR score at minute 1 and minute 5. The results of the analysis are shown in table 12 and table 13. Based on table 12, infants with APGAR minute 1 score of <7 and ≥7 were mostly born from mothers with pre -eclampsia in the age group of 20 -35 years with 61.3% and 62.5% respectively. Statistical analysis did not show any significant difference between different groups of APGAR scores at minute 1 based on age group. Regarding parity, infants with APGAR minute 1 score of <7 and ≥7 were mostly born from mothers with a history of a primigravida with 44.4% and 43.1% respectively. The lowest numbers came from mothers with a history of secundigravida parity for both groups which were 22.2% and 21.6% respectively. Statistical analysis showed no significant difference between different groups of APGAR score at minute 1 based on parity.

ORIGINAL ARTICLE
Based on table 13, infants with APGAR 5 minutes score of <7 and ≥7 were mostly born from mothers with pre -eclampsia of age group 20 -35 years with 58.8% and 62.9% respectively. Statistical analysis did not show any significant difference between different groups of APGAR score at minute 5 based on age group. Based on parity, the majority of infants with APGAR 5 minutes score of <7 and ≥7 were born from mothers with pre -eclampsia with a history of primigravida which were 52.9% and 41.4% respectively. The lowest number of births came from mothers with partial secundigravida with 11.8% and 24.3%