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IMPACT OF MATERNAL ANEMIA ON PERINATAL OUTCOME.

Byline: Rabiah Anwar, Kashif Razzaq and Nusrat Noor

Keywords: Anaemia, APGAR score, Preterm delivery, Stillbirth, Low birth weight.

INTRODUCTION

Anemia is one of the most common medical problem affecting pregnant women. Maternal anemia is a risk factor for poor pregnancy outcome. During pregnancy, physiological anaemia occurs due to expansion of plasma volume causing decline in haemoglobin. That's why The World Health Organization defines anemia in pregnant females as haemoglobin level of 11g/ dl or less while normal limit was <12g/dl for anemia in non-pregnant women1. The most frequent type of anemia during pregnancy is iron deficiency anemia. According to an estimation, about 56 million pregnant women (41.8% of total) are affected with anemia, largely because of iron deficiency1. Mean corpuscular volume (MCV) increases in pregnancy so reduction in MCV usually seen in iron deficiency is not considered a reliable marker in pregnancy. For diagnosis of iron deficiency anemia bivariate criteria (checking of haemoglobin and serum ferritin level) is used2.

Maternal anemia has great effect on fetal health. Hypoxia due to anemia is a key factor in development of placental blood vessels. Moreover, placental maturity is required for spontaneous induction of labor3. Iron deficiency anemia during pregnancy is a known risk factor for preterm birth, low birth weight and small for gestational age babies4. It is also responsible for increased perinatal morbidity and mortality due to increase in preterm birth and intrauterine growth restriction5. Fetal wellbeing score i.e. Appearance, pulse, grimace, activity, respiration (APGAR) score, is also significantly decreased during the first and 5th minute after delivery in newborns of anaemic ladies6. The extent to which placental changes caused by maternal anemia affects fetal development, growth and pregnancy outcome is not clearly understood7.

The objective of this study was to determine if anaemic mothers have more poor perinatal outcomes like preterm birth, low birth weight, poor APGAR score value and still birth than nonanaemic mothers. Preterm babies, babies with low birth weight and low APGAR score requires NICU admission. Neonatal intensive care requires the use of technologically advanced treatment methods which are expensive and are not feasible for our poor population. The rationale behind our study was to identify areas to which intervention should be focused on improving maternal care and perinatal outcomes thus reducing NICU load because of preterm and low birth weight babies and to add to our research on maternal anaemia and its perinatal effects.

MATERIAL AND METHODS

The study was conducted in department of gynae/obs PNS Shifa Karachi for the period of six months from April 2017 to September 2017. PNS Shifa Karachi is a referral institute and a tertiary care hospital catering for large number of army and civilian personnel. A total number of 3986 women were delivered during the study period. Six hundred and forty three pregnant ladies fulfilled the inclusion criteria. Patients were selected by non probability consecutive sampling. Out of which 342 were anaemic and 301 were nonanaemic. Participants were divided in to two groups, those having iron deficiency anemia were included in group A and those not having were included in group B. The anemic group was defined as having hemoglobin level below 11g/dl and serum ferritin level 11g/dl.

The ladies included were between 20 and 35 years of age, had gestational age of 28-42 weeks, singletone pregnancy, spontaneous vaginal delivery.

The ladies having multiple pregnancy, delivery by cesarean section, previous history of preterm delivery, obstetrical complications (polyhydromnios, oligohydromnios) or medical illness (such as DM, preeclampsia/eclampsia, endocrinopathies and haemoglobinopathies) except anaemia were excluded in order to control for confounding factors. As preterm delivery can recur in next pregnancy, a past history of preterm delivery per se can cause preterm delivery rather than anaemia. That's why the ladies with previous history of preterm delivery were also excluded.

Informed consent was taken from all participants.

Women were interviewed in urdu. On the day after delivery, the data were recorded on a predesigned questionnaire that recorded BMI, haemoglobin estimation at first antenatal visit, at 28-32 weeks (because maximum haemodilution at this gestational age and anemia develops at this time), at 33-37 weeks and in labor, iron supplementation intake or not, gestational age at delivery, perinatal outcome ( live birth, still birth, intrauterine fetal death), intrauterine growth restriction. The weight of newborn and then APGAR score at 1 and 5 minutes were recorded. The exact gestational age of pregnant women was determined according to last menstrual cycle that had been confirmed with ultrasound diagnostic procedure.

Preterm delivery was defined as delivery before 37 completed weeks of gestation.

Low birth weight considered if baby weighed <2,500g at term at birth.

IUGR was defined as fetal growth (measured by ultrasound) less than 10th centile for that gestational age.

Still birth was birth of fetus with no sign of life.

Data was analyzed using statistical software SPSS version 13.0.

Descriptive statistics were used to calculate Mean +- SD for age.

Sociodemographic characteristics were independent variables.

Frequency and percentage were collected. Stratifications was done with regard to age, parity, education, employment status and monthly income. Chi-square test was applied for the comparison among groups.

Results are expressed in frequency, relative risk (RR) and 95% confidence interval (CI).

Difference was considered significant at pa$?0.05.

Table-I: Age of patient.

Group of Patient###Mean###N###Std. Deviation

anaemic patient###26.2485###342###4.72526

Non-anaemic patient###25.4252###301###4.30796

Total###25.8631###643###4.54982

Table-II: Demographics and socioeconomic characteristics of anemic and non-anemic groups.

###Anemic group (n=342)###Non-anemic group (n=301)

Characteristics

###Number###Percentage###Number###Percentage

Parity

Para 1###116###34###160###53.2

Para 2-3###165###48###124###41.2

Para 4-5###61###18###17###5.6

Education Status

Illiterate###196###57.3###180###59.8

Primary qualified###83###24.2###74###24.5

Matric pass###48###14###32###10.6

HSSC pass###15###4.4###15###4.9

Monthly Income

20,000 Rs###46###13.5###49###16.27

RESULTS

A total of 643 pregnant ladies fulfilled the inclusion criteria, 342 (53.18%) anaemic and 301 (46.81%) nonanaemic. Group A included all anemic ladies while non-anemic patients were labelled as group B. Mean age of patient was 25.8 +- 4.54, with maximum age 37 and minimum 20 years. Age among the 2 groups is shown in table-I. Demographics and socioeconomic characteristics are displayed in table-II.

Monthly income was also calculated as it is important in etiology of anaemia. Income was divided in 4 groups as 20,000 rupees per month. It was found that 93 (27.1%) cases in anaemic group and 54 (17.94%) had earnings less than 10,000 rupees. However, 46 (13.4%) in anaemic and 49 (16.27%) patients were in above 20,000 rupees per month group. Perinatal outomes in both the groups have been depicted in table-III.

There were 229 (66.9%) cases of preterm delivery in group A compared to 44 (14.66%) in group B. Low birth weight (LBW) was observed in 124 (36.2%) cases in anaemic group and in 44 (14.6%) cases in non-anemic group. There were 5 (1.4%) cases of stillbirth in anemic group as compared to 2 (0.66%) in non anemic women. In group A, new born of 109 (31.8%) cases showed Appearance, Pulse, Grimace, Activity, Respiration (APGAR) score <5 at 1 minute compared to 14 (4.6%) cases in the other group. Similarly, the score <7 at 5 minutes was observed in 70 (20.4%) deliveries in group A and 12(3.98%) in group B.

In group A, 41 (12%) cases of IUGR were observed whereas, 14 (5%) were in group B.

Table-III: Perinatal outcomes in anaemic and nonanaemic pregnant ladies.

###Anaemic group###Non anaemic

Variables###RR###95% CI###p-value

###(N=342)###group (N=301)

###yes###229 (66.9%)###44 (14.6%)

Preterm birth###4.5###3.4-6.0###<0.001

###no###113 (33%)###257 (85.37%)

Low birth###yes###124 (36.3%)###44 (14.6%)

###2.48###1.8-3.3%###<0.001

weight###no###218 (63.7%)###257 (85.3%)

###yes###42 (12.2%)###13 (4.3%)

IUGR###2.84###1.55-5.1###<0.001

###no###300 (87.7%)###288 (95.7%)

Perinatal###yes###47 (13.7%)###49 (16.3%)

###0.84%###0.5-1.2###0.37

mortality###no###295 (86.3%)###252 (83.7%)

###yes###5 (1.5%)###2 (0.66%)

Stillbirth###2.2###0.4-11.2###0.46

###no###337 (98.5%)###299 (99.3%)

APGAR < 5 at 1###yes###109 (31.9%)###14 (4.65%)

###6.85###4.01-11.6###<0.001

min.###no###233 (68.1%)###287 (95.3%)

APGAR < 7 at 5###yes###70 (20.5%)###12 (3.98%)

###5.1###2.8-9.2###<0.001

min###no###272 (79.5%)###289 (96.0%)

DISCUSSION

Anemia is a common problem in pregnant ladies of developing countries. Its prevalence is very high in South Asia, such as India, Pakistan and Bangladesh1. Local studies show 69.9% prevalence in Pakistan and 46% in India8,9. In our study, we found 53.18% anemic pregnant ladies which is very high.

Demographic parameters are significant risk factors of anemia in pregnancy. A study in Bangladesh found high parity and illiteracy as contributing risk factors of anemia10. During pregnancy, anaemia is more common in ladies with high parity because in these ladies iron reserves are depleted due to recurrent pregnancies. Anaemia develops when increased iron needs could not be met during pregnancy in lady with poor iron reserves and inadequate dietary intake11.

Anaemia is associated with suboptimal pregnancy outcomes such as low birth weight, IUGR and preterm birth. It causes deterioration of fetal growth due to lack of oxygen flow to placental tissue12. Neonatal birth weight is an important indicator of obstetric care and health status. LBW is a major problem in developing countries and determinant of childhood morbidity and infantile death. We found a high frequency (36.2%) of low birth weight babies in anaemic ladies. Risk of low birth weight in our study was 2.48. Many other studies in low and middle income countries show that anaemic motherA's newborn weighed less than nonanaemic mother4,7,13-15. According to a study in India, 58% of low birth weight newborn's mother were anaemic9. A local study in KPK Pakistan also shows higher incidence of low birth weight newborn in anaemic mother as compared to nonanaemic mother16.

In our study, we observed 4.5 relative risk of preterm birth among anaemic mother. A local study conducted at civil hospital Karachi shows 2.63 times higher risk of preterm birth17. Similarly, another local study shows 4 times risk of preterm birth in anaemic lady18. Consistent with our study, other studies also show higher risk15,17. At the sametime, a few studies did not find significant effect of iron deficiency anaemia during pregnancy on preterm birth and small for gestational age newborn19.

The complication of preterm labor and pregnancy related infections have causal relationship with each other. Maternal infection during pregnancy is well-known risk factor for preterm labour. The relationship of anaemia and infections may be due to adverse effect on immune function by altering the proliferation of T and B lymphocytes, reducing the bactericidal activity of phagocytes and neutrophils20.

Main causes of perinatal mortality are prematurity, birth anoxia, still birth and intrauterine death. In our study, risk of still birth was 2.2 compared to 1.75 times in study done in civil hospital Karachi17. Whereas, another local study shows 2.5 times risk18. In India, 100% mothers of stillborn and intrauterine death were anaemic9. Our finding of higher risk of intrauterine death and overall perinatal mortality amongst anaemic mothers was slso demonstrated in many studies8,15. In one study conducted in England showed that compared with women with haemoglobin [greater than or equal to]11 g/l, the risk of stillbirth and perinatal death was five and three fold higher in women with moderate severe anaemia (haemoglobin 7 and with lower risk of birth asphyxia. Risk of poor APGAR score <5 at 1 minute and <7 at 5 min were observed in anaemic ladies in this study. This study shows 5.1 RR whereas a study conducted in Civil Hospital Karachi shows 1.6 RR of low APGAR in anaemic ladies17. Another local study shows 1.8 times Low APGAR score risk at birth in anaemic mothers18.

This study has its limitations. It was conducted in tertiary care hospital which is not representative of the country. Since most women in Pakistan deliver at home, the burden of anaemia can be expected to be much higher outside the hospital setting. Likewise efforts were made to limit confounders with strong exclusion criteria but conditions such as malaria, nutritional deficiencies of folate and vit B12 as well as human immune deficiency virus can trigger anaemia.

CONCLUSION

In conclusion, maternal anaemia has increased risk of delivery of premature and LBW babies, IUD, low APGAR score at 1 minute and 5 minute. The improvement achieved in the developed world is largely due to more effective prevention, diagnosis and treatment of anaemia. Iron supplementation may improve lymphocyte stimulation thus decreased risk of antenatal, intrapartum and postpartum infection and preterm delivery. We therefore propose that routine iron supplementation should be given during pregnancy and postpartum to cover losses during delivery and lactation. Obstetricians play important role by making women aware of iron rich diet, especially, green leafy vegetables during their antenatal visits. Moreover, community health worker have to effectively emphasize the health, hygeine and dietary advice and disseminate effects of anemia.

CONFLICT OF INTEREST

This study has no conflict of interest to be declared by any author.

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Publication:Pakistan Armed Forces Medical Journal
Geographic Code:9PAKI
Date:Apr 30, 2019
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