COMPARISON OF INTRAPARTUM AND NEONATAL OUTCOME AMONG GRAND MULTIPARA AND MULTIPARA.
Objective: To compare the frequency of intrapartum and neonatal complications among grand multipara with age matched multipara.
Study Design: Case-Control Study.
Place and duration of Study: Department of Obstetrics and Gynaecology, Military Hospital, Rawalpindi, from June 2008 to December 2008.
Patients and methods: Sixty five grand multipara (Para Greater than 5) and 65 multipara (Para 2-4) aged between 20 to 40 years, with singleton pregnancy of up to 40 weeks and presenting in spontaneous labour were selected. Grand multipara (group A) were analysed during labour for Intrapartum complications and neonatal complications. These were then compared with multipara (group B).
Results: The mean age of women in group A was 36.40 +- 3.320 years and in group B was 32.60 +- 4.650 years. The mode of delivery in both groups was not significantly different (p-value Greater than 0.05). The rate of postpartum haemorrhage was however significantly higher in grand multipara (13.83 Percent vs. 3.07 Percent , p-value Less than 0.05) as compared with multipara. Malpresentation was more commonly seen among grand multipara in which 10 (15.38 Percent) women presented with malpresentation as compared with multipara group in which 3 (4.61 Percent) had malpresentation (p-value Less than 0.05). Macrosomia (wt. of baby[greater than or equal to] 4 kg) was significantly (p-value Less than 0.05) more commonly seen in grand multipara as compared with multipara group i.e. 10 vs. 4 babies.
Conclusion: Postpartum haemorrhage, malpresentation and macrosomia are seen significantly and specifically more commonly in grand multiparas. Grand multiparity should be considered as high risk pregnancy and should be treated with extra care.
Grand multiparity is defined as parity equal to or greater than five previous life births1. The term "Grand Multipara" was introduced in 1934 by Solomon, who called the grand multipara the "Dangerous Multipara"1. Since then grand multipara has been recognized as high risk case. In 1997-99 in UK the maternal mortality rate was 35 Percent among women of parity 4 or more2.
Currently in developed countries, grand multiparity is becoming rare (3-4 Percent of all births)3. However, the religious and social dynamics of society in our country have led to continuing high incidence of grand multiparity. The average number of children in any family is 7. This tendency towards bigger families is not only restricted to Pakistani nation but it also happens in some other communities like Saudi, Qatari and Palastenian4.
The grand multipara is often considered a clinical entity as certain complications during pregnancy; delivery and puerperium are thought to occur with increased risk in these women1,5,6. They are at particular risk of intrapartum and neonatal complications1 such as abruptio placentae7, malpresentation1,8, abnormalities of third stage of labour1,9, instrumental delivery, obstetric hemorrhage1,6, preterm birth5, shoulder dystocia1, macrosomia1,8 and fetal distress6, 10.
Many studies have explored the relationship between grand multiparity and obstetric complications, but the results remain uncertain5,9,10. Some studies have reported increased risk3,10 whereas other have reported only minor risks or even lower frequencies of certain complications among grand multipara1,9,10. In Pakistan the incidence of grand multiparity along with its complications remains high6.
The main aim of our study was to determine whether grand multipara were really at high risk for intrapartum and neonatal complications or not and also to provide information that can be used by clinicians to treat grand multipara with adequate care for selective complications while avoiding unnecessary procedures and cost.
PATIENTS AND METHODS
This case-control study was conducted in patients admitted to labour ward of the Department of Obstetrics and Gynaecology, Military Hospital (MH) Rawalpindi from 6th June 2008 to 6th December 2008. Sixty five grand multipara and 65 multipara women in spontaneous active labour with singleton pregnancy were selected by non - probability purposive sampling. Age of patients included was between 15 to 45 years (WHO criteria for CBA). Patients with history of gestational diabetes mellitus, pregnancy induced hypertension, parity Greater than 10, previous history of caesarean delivery, postdate pregnancy and those who required induction of labour were excluded from the study.
Demographic data was collected regarding age and educational status of the patient. Confounding variables were controlled by taking information about socioeconomic status, number of antenatal visits and by having a strict inclusion/ exclusion criteria. Informed written consent was taken from the patient.
A detailed history was taken from each patient and relevant clinical examination was done. Initial investigations included haemoglobin estimation, blood group, urine analysis, plasma glucose levels and recording of fetal heart rate pattern on CTG.
Grand multipara (parity Greater than 5) and multipara (parity of 2-4) were analysed during active labour for intrapartum complications inclusive of postpartum haemorrhage (PPH), placental abruption, malpresentation, cord prolapse, macrosomia, caesarean delivery, instrumental delivery and for neonatal complications inclusive of preterm birth (delivery at Less than 37 weeks of gestation), neonatal outcome (one minute APGAR score Less than 3 or five minute APGAR score Less than 5) and new born transfer to neonatal intensive care unit. Clinical evaluation of patients was verified by a senior colleague. Patient was observed for up to 24 hours after delivery.
Neonatal complication was defined as complication in a newly born infant, usually the first four weeks of life. Intrapartum complication was defined as complication occurring during labour. Multipara were defined as any woman who has given birth two or more times and grand multipara as woman who has given birth five or more times.
All the data was entered in SPSS version 12 for analysis. Frequencies (as percentages) were calculated for socioeconomic status, complications during labour and neonatal outcome. A chi square test was used to compare mode of delivery, degree of postpartum haemorrhage and APGAR score of baby between two groups. A t-test was used to compare the gestational age, duration of labour and weight of baby. A p-value of Less than 0.05 was considered statistically significant.
This study included two groups of patients i.e. 65 in multipara group and 65 in grand multipara group. The age of patients in multipara group ranged from 20 to 44 years while in grand multipara group it ranged from 20 to 45 years (Table-1).
Majority of the participants of both groups were illiterate and belonged to lower income class. Since the study was conducted in Military Hospital most of the women were booked, 55 in multipara and 52 in grand multipara group were booked with the hospital. The mean gestational age of patients at time of delivery was almost the same in the two groups (p-value Greater than 0.05) (Table-1).
Table 1: Patients Demographic Data.
###MUltipara (n = 65)###Grand Multipara (n = 65)
Maternalage###Mean +- SD###32.6 +- 4.65###36.4 +- 3.32
###Illiterate###39 (65 Percent)###49 (75.39 Percent)
Educational Status###Under matric###17 (26.15 Percent)###10 (15.38 Percent)
###Matric and above###9 (13.84 Percent)###6 ( 9.23 Percent)
Socioeconomic status###Low income###47 (72.3 Percent)###52 (###80 Percent)
###Low middle###18 (27.69 Percent)###13 (###20 Percent)
Antenatal booking status###Booked###55 (84.61 Percent)###52 (###80 Percent)
###un booked###10 (15.38 Percent)###14 (21.53 Percent)
Gestationalage###Mean +- SD###38.5 +- 2.45###37.7 +- 2.05
Among the intrapartum complications, the rate of postpartum haemorrhage was significantly higher in grand multipara (p-value Less than 0.05) as compared with multipara group. Similarly the rate of malpresentation was also significantly higher in grand multipara in which 10 (p-value Less than 0.05) presented with malpresentation and in multipara it was in only 3 (Table-2). Insignificant difference was seen in the rate of other intrapartum complications like placental abruption (p-value Greater than 0.05), cord prolapse (p-value Greater than 0.05), shoulder dystocia (p-value Greater than 0.05) and retained placenta (p-value Greater than 0.05, Fig 1).
There was insignificant difference in duration of labour (p-value Greater than 0.05) among the two groups (Table-2). The comparison of mode of delivery in both groups also did not show any statistically significant difference (p-value Greater than 0.05, Table 2).
Table 2: Comparison of intrapartum and neonatal complications among grand multipara and multipara.
###MUltipara (n = 65)###Grand Multipara (n = 65)
Postpartum haemorrhage###2 ( 3.07 Percent)###9 (13.65 Percent)###0.027
Malpresentation###3 ( 4.6 Percent)###10 (15.38 Percent)###0.041
###Less than 12 hrs.###47 (72.30 Percent)###54 (83.07 Percent)
Duration of Labour###12-23 hrs###10 (15.38 Percent)###7 (10.76 Percent)###0.309
###Greater than or Equal to 24 hrs###8 (12.30 Percent)###4 ( 6.15 Percent)
###Normal vaginal###37 (56.92 Percent)###40 (61.53 Percent)
Mode of delivery###Vacuum###5 ( 7.69 Percent)###3 ( 4.6 Percent)###0.172
###Forceps###4 ( 6.15 Percent)###2 (3.07 Percent)
###Caesarean section###19 (29.30 Percent)###20 (30.76 Percent)
###Less than 2.5 kg (low)###5 ( 7.69 Percent)###11 (16.92 Percent)
Birth weight of babies###2.5 - 3.9 kg (normal)###56 (86.15 Percent)###44 ( 67.6 Percent)###0.044
###Greater than or Equal to 4 kg (macrosomic)###4 ( 6.15 Percent)###10 (15.38 Percent)
APGAR score at 1###Less than 6###4 ( 6.15 Percent)###7 (10.76 Percent)###0.344
min###Greater than or Equal to 6###61 ( 93.8 Percent)###58 (89.23 Percent)
APGAR score at 5###Less than 6###4 ( 6.15 Percent)###6 ( 9.23 Percent)###0.510
min###Greater than or Equal to 6###61 ( 93.8 Percent)###59 ( 90.7 Percent)
NICU admission###3 ( 4.6 Percent)###4 ( 6.15 Percent)###0.698
However, the most common mode of delivery was normal vaginal delivery in 37 (56.92 Percent) and 40 (61.53 Percent) in multipara and grand multipara group respectively. The caesarean section rate was almost same but the other modes of delivery like vacuum and forceps were comparatively high in multipara group.
The comparison of birth weight showed that there was significant difference in birth weights of babies in the two groups. In grand multipara group the rate of macrosomic (wt. [greater than or equal to] 4 kg) babies was significantly (p-value Less than 0.05) higher as compared to multipara group. There was no significant difference in the number of low birth weight (wt. [?] 2.5 kg) babies and also in the rate of normal birth weight babies in the two groups. The bad APGAR score at 1 minute and at 5 minutes (p-value Greater than 0.05) was not significantly different in both multipara and grand multipara groups. The rate of admission of babies in NICU (p-value Greater than 0.05) was also almost same in both groups (Table-2).
Grand multiparas are considered at high risk for certain intrapartum and neonatal complications for many decades. In developed countries grand multiparity is becoming rare (3-4 Percent of all pregnancies)11, however in developing countries grand multiparity is still common because of cultural and religious beliefs and lack of effective family planning program12. The incidence of grand multiparity is high in our country. Begum6 reported an incidence of 26 Percent and Yasir et al13 33.6 Percent which is alarmingly high as compared to developed countries.
Grand multiparity in this study increased with increasing maternal age. This trend is also seen in other studies which reveal that grand multiparity is significantly associated with advanced maternal age3,11,12. Majority of the grand multiparas belonged to low socioeconomic class and were illiterate as seen in previous studies6,13. However as this study was conducted in Military Hospital, majority of the patients were booked with regular antenatal check-ups. Despite this, certain intrapartum complications like malpresentation, postpartum haemorrhage and neonatal complications like macrosomia were seen more commonly among grand multipara.
Hoque et al also demonstrated that in modern health care setting, where majority of the patients are well booked, grand multiparity is associated with a significantly increased risk of complications and poor pregnancy outcome compared to lower parity11. In contrast, studies conducted in Jewish population revealed that grand multiparity is not a risk factor for mothers who have access to modern health care facilities and relatively stable socioeconomic status13.
In this study, pregnant women with known medical disorders like Pregancy Including Hypertension (PIH), Gestational Diabetes Mellitus (GDM), and anaemia were excluded so that complications associated with grand multiparity alone in low risk women could be evaluated. The mean gestational age at time of delivery was almost same among two groups.
This demonstrates that grand multipara are not at an increased risk for preterm delivery as also suggested by other studies3,12. Grand multipara had significantly higher rate of malpresentation as compared to multipara. Abro et al14 and Jacquemyn et al15 in their studies also concluded that grand multipara are high risk obstetric patients and that intrapartum and neonatal complications like malpresentation and macrosomia are seen more commonly in them.
Primary postpartum haemorrhage (PPH) has many potential causes but the commonest is uterine atony, responsible for 80 Percent of cases. When uterus fails to contract, it leads to continuous blood loss from placental site. Grand multiparity is one of the important and common risk factors that promote uterine atony. Grand multiparas are therefore considered to be at higher risk for PPH.
In this study, PPH was seen significantly more frequently among grand multipara as compared to multipara. This correlation could be due to the fact that most of the grand multiparas belonged to low socioeconomic class. Bibi et al16 also found that grand multiparity was a strong risk factor for primary PPH. Yasir et al13 and Humphrey5 also found higher rate of PPH among grand multiparas. On the other hand there are a few studies which suggest that the risk is no greater than for women of low parity1,4,11.
The duration of labour among majority of grand multiparas was less than 12 hours and was not significantly different than that for multiparas. Frequency of prolonged labour and dystocia was also the same among the two groups. This is in conformity with data of Horace who did not find an increased risk of dystocia3.
Though there was a higher rate of normal vaginal and lower rate of assisted/instrumental (vacuum, forceps) deliveries in grand multipara compared to multipara, the difference was statistically insignificant. This was likely as grand multipara women had well developed birth canal and better obstetric mechanisms at delivery3. The rate of caesarean section was also not significantly different among the two groups. This finding is contrary to that of Hiasat whose study suggested that rate of caesarean section increases with increasing maternal age and parity17. This could be due to the fact that his study included patients with certain antenatal complications like placenta previa, pre-eclampsia, anaemia etc. which were excluded from present study.
The rate of other intrapartum complications like abruptio placentae, cord prolapse, shoulder dystocia and retained placenta were not significantly different among the two groups as also confirmed by Roman et al3 and Humphrey5 in their studies. This was however in contrast to other studies which demonstrated an increased risk of these complications in grand multipara6,7,13.
The neonates of the grand multiparas are at a higher risk of macrosomia, preterm birth, congenital malformation and neonatal intensive care unit stay. Macrosomia is responsible for intrapartum complications like birth trauma, shoulder dystocia , birth asphyxia, obstructed labour and increased rate of instrumental delivery13. Among the neonatal complications; macrosomia was significantly more commonly seen in grand multipara group as compared to multipara. Increased incidence of macrosomia in grand multipara has also been confirmed in other studies6,12-15. However, there was no difference in APGAR Score and NICU admission among the two groups as also shown in other studies12.
Majority of the patients included in this study were booked and were provided with adequate antenatal, intrapartum and neonatal care. Despite this, there were certain intrapartum and neonatal complications like PPH, malpresentation and macrosomia which are specifically associated with grand multiparity. Therefore, grand multipara should be considered as high risk pregnancies and treated vigilantly to avoid these complications.
Postpartum haemorrhage, malpresentation and macrosomia are seen significantly and specifically more commonly in grand multiparas. Grand multiparity should be considered as high risk pregnancy and should be treated with extra care. As the incidence of grand multiparity in our country is high due to cultural, religious and social reasons, strategies are needed to guide the women to seek and adopt effective family planning methods in order to avoid grand multiparity.
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Combined Military Hospital Badin, Combined Military Hospital Khairan, Combined Military Hospital
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|Publication:||Pakistan Armed Forces Medical Journal|
|Date:||Dec 31, 2012|
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