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GRAND MULTIPARITY AND MATERNAL OUTCOME IN ABSENCE OF ADEQUATE ANTENATAL CARE.

Byline: Nadia Rashid Khan, Saima Perveen, Zareena Begum, Rashida Qayyum and Rukhsana Malik

ABSTRACT

Objective: To find out the effect of grand multiparity on maternal outcome in absence of adequate antenatal care.

Methodology: All un-booked grand multipara with singleton pregnancy at term admitted to Gynae A Unit, Lady Reading Hospital Peshawar were included in the study. Cross sectional study was carried out from 1st June 2012 to 1st Dec 2012. Assessment was done by detailed history, general physical examination, per-abdominal and per-vaginal examination and by obstetrical ultrasound. Mothers were assessed for antenatal and obstetrical complications, mode of delivery and post-partum complications.

Results: A total of 50 patients were included in the study. Regarding antenatal complications 6(12%) patients had anemia, 2(4%) had pregnancy induced hypertension, 4(8%) had pre-eclampsia, 2(4%) had eclampsia and 36(72%) didn't had complications. Regarding obstetrical complications 3(6%) patients had placenta previa, 3(6%) had placental abruption, 7(14%) had mal presentation, 3(6%) had obstructed labor and 34(68%) didn't had complications. Regarding post partum complications 5(10%) patients had post partum hemorrhage due to uterine atony, 4(8%) had post partum hemorrhage due to retained placenta, 2(4%) had perineal tears, 3(6%) had subtotal hysterectomy and 36(72%) didn't had complications.

Conclusion: In the absence of adequate antenatal care, there was increased likelihood of perinatal complications in grand multiparous women.

Key Words: Grand multiparity, Maternal outcome, Antenatal care

INTRODUCTION

Any woman having more than 5 children is referred to as grand multiparous1. Due to poor antenatal care and advanced maternal age, pregnancy and delivery in grandmultipara are at higher risk2. The incidence of grand multiparity alongwith its complications is still high in developing countries. It is an important part of antenatal screening to identify women whose pregnancies are at risk of complications to reduce adverse outcome3.

In developing countries where obstetricians are working with inadequate facilities are very anxious about grandmultiparity. Due to advancement of family planning the grand multipara has almost disappeared in western countries but it still exists in developing countries1. Grandmultiparity is more common in low socio economic societies and is associated with serious consequences to fetus, mother, and family in the absence of adequate antenatal care4.

Pregnancy and delivery are at high risk in these patients due to poor antenatal care, closely spaced pregnancies, lack of effective contraception, advanced maternal age and inadequate health services5. Grandmultiparas who are giving birth in remote areas where there are inadequate health services, maternal mortality rate is especially high6.

Regarding systemic complications grand multiparas are at high risk of developing hypertension, diabetes, anemia and obesity.7 While regarding obstetric complications these women are at increased risk of malpresentations, obstructed labour, placenta previa, placenta abruption, retained placenta, ruptured uterus, post partum hemorrhage, caesarian sections and caesarian hysterectomy. All these can lead to increase maternal and perinatal mortality7.

Despite a low socio-economic status a favorable outcome can be achieved in these patients with hospital delivery and modern medical care. Pregnancy and labour should be closely monitored in these patients and early intervention should be considered if things are not progressing smoothly6.

The purpose of our study was to find out the obstetrical complications, mode of delivery and post partum complications of un-booked grand multiparous women, so as to propose certain recommendations to increase awareness about antenatal care and providing efficient health care facilities to these women at door step to improve the outcome.

METHODOLOGY

All unbooked grand multiparous mother of any age, with singleton pregnancy at term, free of medical disorders admitted to Gynae A Unit, Lady Reading Hospital Peshawar, taken from emergency department were included in the study. Patients with congenital abnormality, with multiple pregnancies and with pregnancy of 40 Years###1(2%)

###Total###50(100%)

Table 2: Antenatal complications (n=50)

###Antenatal complications###Percentage

###Anemia###6(12%)

###Pregnancy Induced Hypertension###2(4%)

###Pre eclampsia###4(8%)

###Eclampsia###2(4%)

###No Complications###36(72%)

###Total###50(100%)

Table 3: Obstetrical complications (n=50)

###Obstetrical complications###Percentage

###Placenta Previa###3(6%)

###Placental Abruption###3(6%)

###Mal-presentation###7(14%)

###Obstructed Labour###3(6%)

###No Complications###34(68%)

###Total###50(100%)

Table 4: Mode of delivery (n=50)

###Mode of Delivery###Percentage

###Forcep Delivery###2(4%)

###Vacuum Delivery###00(00%)

###Caesarean Section###10(20%)

###Vaginal Delivery###38(76%)

###Total###50(100%)

Table 5: Post-partum complications (n=50)

###Post Partum Complication###Percentage

###Post Partum Haemorrhage (Atony)###5(10%)

###Post Partum Haemorrhage (Retained Placenta)###4(8%)

###Post Partum Haemorrhage (Perineal Tears)###2(4%)

###Subtotal hystrectomy due to Uterine Atony###3(6%)

###No Complications###36(72%)

###Total###50(100%)

Our study shows that 4% patients had pregnancy induced hypertension, 8% had pre-eclampsia and 4% had eclampsia. This is comparable to the study performed by Rayamajhi et al3 where 5% patients had PIH, 10% had pre-eclampsia and 3% had eclampsia.

Anemia in grand multiparas is due to frequent pregnancies, poverty and malnutrition12. The risk of cardiac failure, thromboembolism and infection is also high in these patients13. In our study 12% cases were anemic; whereas Rayamajhi et al3 showed in their study that 13% cases were anemic.

Placenta previa is commonly encountered in older grand multiparas. Maternal age and parity strongly correlate for placenta previa14. In our study the incidence of placenta previa was 6%; similar results were shown in the study conducted by Begum2 where 7% cases had incidence for placenta previa.

One of the potentially serious obstetric problem that tends to threaten fetal viability, neonatal mortality and morbidity and maternal health and wellbeing is placental abruption 15. Age and parity are the two major factors responsible for placental abrouption in grand multiparas. In a study conducted at Ayub Teaching Complex, Abbottabad, the incidence of placental abruption was 7.07% and in 74% of these patients, hypertension was the causative factors 2. In our study the incidence of placental abruption was 6%.

Grand multiparas are prone to various fetal mal-presentations 16. Fetal size and congenital abnormalities, reduced tone of abdominal muscles and pendulous belly are usually suspected as causative factors 17. Failure to predict and manage these mal-presentations directly affect the outcome of labor with increases perinatal morality and maternal morbidity and mortality 16. In the study performed by Rayamajhi et al 3, the incidence of malpresentations was 16.98% while in our study it was 14%.

Failure of descent of fetal presenting part in the birth canal for mechanical reasons inspite of good uterine contraction results in obstructed labour18. Fetal congenital abnormalities, cephalopelvic disproportion, mal-position and mal-presentation are important risk factors for obstructed labour. Mal-presentation is more common than cephalopelvic disproportion in grand multiparas19. The incidence of obstructed labour was 5.6 % in study conducted by Begum2 while in our study 6% had obstructed labour.

In our study 76% patients had spontaneous vaginal delivery where as 20% were delivered by caesarean section, almost all were emergency caesarean sections and 4% delivered by outlet forceps. Rayamajhi et al3 in their study found that 73.5% of grand multiparas had spontaneous vaginal delivery, 5.66% had instrumental delivery and 15.1% had caesarean section. Similarly the study done by Begum2 shows that 73.8% deliveries were spontaneous vaginal, 4.60% outlet forceps deliveries and 21.6% were caesarean section.

The reason for increase occurrence of post-partum hemorrhage in grand multiparas is that in third stage of labour uterus tends to remain inert if faced with minor degree of disproportion20. In grand multiparas due to decrease in muscular tissues and increase in fibrous tissues of uterus, uterine atony is more common. Uterine atony is associated with operative deliveries, instrumental deliveries, retained placenta, placenta previa and abruptio placenta21. Our data shows the incidence of post-partum hemorrhage due to uterine atony is 10% which is comparable to 11.3% in Nigerian study2. Our incidence of retained placenta was 8% which is comparable to 5.6 % in study by Rayamahji et al3.

There was no maternal death in our study. Similarly there was also no maternal death in study performed by Rayamajhi et al3.

CONCLUSION

In the absence of adequate antenatal care, there was increased likelihood of perinatal complications in grand multiparous women. Grandmultiparity itself is not as hazardous as lack of care during pregnancy and delivery.

RECOMMENDATIONS

In grand multiparas excellent obstetrical outcome needs active interventions by improving literacy rate, safe and effective contraception, provision of good health care facilities and by increasing awareness about facilities.

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Publication:Journal of Postgraduate Medical Institute
Article Type:Report
Geographic Code:9PAKI
Date:Mar 31, 2017
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