Sub-Saharan African Journal of Medicine

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 5  |  Issue : 3  |  Page : 93--98

Prevalence and pattern of medical disorders in pregnancy at the time of delivery at Lagos University Teaching Hospital, Lagos, Nigeria


Ochuwa Adiketu Babah, Emmanuel Owie, Ephraim O Ohazurike, Opeyemi Rebecca Akinajo 
 Department of Obstetrics & Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria

Correspondence Address:
Ochuwa Adiketu Babah
Department of Obstetrics & Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos
Nigeria

Abstract

Objective To determine the prevalence and pattern of various medical conditions in pregnancy and also determine their impact on fetal and maternal outcome. Study Design A cross-sectional analytic study was conducted using labor ward data obtained over a period of 5 years (2013–2017). All women delivered at Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria, with or without medical condition complicating pregnancy at the time of admission to labor ward were included in the study. Their sociodemographic parameters, nature of medical condition, fetal weight, fetal outcome, APGAR scores, and maternal outcome were extracted from the delivery register. Data analysis was done using SPSS version 23. Results The prevalence of medical conditions complicating pregnancy was found to be 24.5%. The five commonest medical conditions complicating pregnancy are hypertensive disorders of pregnancy, human immunodeficiency virus (HIV) infection, sickle cell disease, diabetes mellitus, and hepatitis. The trend has remained relatively constant in the last 5 years. Maternal mortality rate in affected women was 0.4% compared to 0.3% for women without medical disorder in pregnancy, p = 0.298; while perinatal mortality rate was 6.4 and 7.1%, respectively, p = 0.850. Conclusion Despite the high prevalence of medical disorders in pregnancy, which puts pregnancy at high risk, the maternal and perinatal outcome is comparable to that of women without any medical disorder complicating pregnancy if managed in a tertiary hospital with adequate facility for emergency obstetric care and good neonatal facility.



How to cite this article:
Babah OA, Owie E, Ohazurike EO, Akinajo OR. Prevalence and pattern of medical disorders in pregnancy at the time of delivery at Lagos University Teaching Hospital, Lagos, Nigeria.Sub-Saharan Afr J Med 2018;5:93-98


How to cite this URL:
Babah OA, Owie E, Ohazurike EO, Akinajo OR. Prevalence and pattern of medical disorders in pregnancy at the time of delivery at Lagos University Teaching Hospital, Lagos, Nigeria. Sub-Saharan Afr J Med [serial online] 2018 [cited 2019 Dec 8 ];5:93-98
Available from: http://www.ssajm.org/text.asp?2018/5/3/93/263567


Full Text



 Introduction



A number of medical disorders do occur in pregnancy with negative impact on maternal and fetal outcome. The occurrence of certain medical disorders in pregnancy may also influence the mode of delivery. Earlier studies have focused on specific medical conditions in pregnancy, with hypertensive disorders in pregnancy being the most commonly studied.[1],[2],[3],[4] This may be so because hypertensive disorders and sepsis have been listed as being among the leading causes of maternal deaths worldwide.[5]

In a multicenter study in China by Ye et al., it was found that there were significant differences in the prevalence of hypertensive disorders of pregnancy between geographical regions, with North China showing the highest prevalence of 7.44% and Central China having the lowest prevalence of 1.23%.[6] Different prevalence have also been reported in Nigeria. [1],[2],[3],[4] This goes to show that the pattern of medical disorders may vary from place to place.

An earlier study by Agwu et al., in Ebonyi State, Nigeria, had looked at the prevalence of medical disorders in pregnancy in women admitted during the antenatal period.[7] It is, however, important to note that a number of unbooked women will present in labor with a number of complications of which medical disorder is one. Second, the awareness of some of these medical disorders by pregnant women is low in some cases. For instance, hepatitis B virus infection (HBV) awareness among antenatal clinic attendees at a district hospital in Nairobi, Kenya, was found to be 12.2%.[8] The implication of this is that in situations where routine screening is not being practiced, some of these medical disorders may be missed or diagnosed late at the time of delivery. This does not give room for optimal care and may affect maternal and/or fetal health adversely. Earlier studies have also found that 87 to 94% of women will report at least one health problem in the immediate puerperium.[9],[10]

By determining the prevalence and pattern of medical disorders in pregnancy at the time of delivery, we will be able to formulate or modify health policies to facilitate early recognition of these problems and institute treatment promptly prior to delivery or prepare for complications that may arise in the puerperium. It will also give room towards distribution of resources such as adequate provision of appropriate medications and diagnostic equipment and serve as a basis for the development of protocols to improve standard of care in all health facilities that care for pregnant women. It will also enhance identification of areas where manpower training should be directed.

Although hypertensive disorder is most widely studied of the medical complications in pregnancy, there is still paucity of data from developing countries of its pattern and presentations.[11] Adequate information on the prevalence and pattern of other medical disorders such as thyroid disease, cardiac disease, and asthma, among others, are generally lacking in the literature. This endeared our interest in conducting this study. The aim of this study, therefore, was to determine the prevalence and pattern of various medical conditions in pregnancy at the time of delivery and also determine their impact on fetal and maternal outcome.

 Methodology



This was a cross-sectional analytic study. The study was conducted at the College of Medicine, University of Lagos (CMUL)/Lagos University Teaching Hospital (LUTH), the largest tertiary health institution in Lagos State, Nigeria. All deliveries conducted at LUTH from January 1, 2013 to December 31, 2017, complicated by at least one medical condition were included in the study. All women who delivered during the same period and without any medical disorder in pregnancy were also included as controls.

Information was collected from the labor ward register, and this included sociodemographic data, booking status, nature of medical disorder in pregnancy, fetal birth weight, fetal outcome, APGAR scores at 1 and 5 minutes and maternal outcome. Fetal outcome was defined in this study as baby being alive or dead at the time of delivery. Maternal outcome was defined as the mother being alive or dead during or after delivery.

The primary outcome measures were maternal and fetal outcome at delivery. The secondary outcome measures were fetal birth weight, APGAR score <7 at 1 minute, and APGAR score <7 at 5 minutes. The data obtained were analyzed using IBM SPSS statistics version 23. Rates were calculated and presented as percentages. Chi-squared (χ2) test was used to test for association between categorical variables where applicable. The proportion of babies with low APGAR (score <7) in both groups was also compared using Chi square. Fischer’s exact test was used to compare variables where the value in a cell is <5. Student’s t-test was used to compare mean gestational age at delivery and fetal birth weight between the cases and controls. The odd of a patient with a medical condition having a particular mode of delivery was calculated and the odds ratio (OR) was presented with their 95% confidence intervals (CI). A p-value of less than 0.05 was considered to be significant. Missing data were excluded from statistical analysis.

 Results



Clinical profile of patients

A total of 4883 women delivered during the period of study (January 1, 2013 to December 31, 2017). Of these, 3686 (75.5%) were apparently healthy parturients, while 1197 (24.5%) had at least one medical condition complicating pregnancy at the time of delivery. The mean age ±SD of the study population was 31.8 ± 6.2 years, with median parity of 1. Booked patients comprised 3764 (76.9%), while unbooked patients comprised 1119 (22.9%).

Secular trend in prevalence of medical disorders in pregnancy at delivery

The prevalence of medical conditions in pregnancy was relatively constant over the 5-year study period (p = 0.128). The overall prevalence of medical condition in pregnancy at the time of delivery was found to be 24.5%. [Table 1] shows the yearly prevalence of medical conditions complicating pregnancy.{Table 1}

Pattern of medical disorders pregnancy

HIV infection was the commonest medical condition in pregnancy in 2013. Subsequently, hypertensive disorders in pregnancy topped the list. Sickle cell disease was found to be the third commonest medical condition in pregnancy all through the 5 years studied, while gestational diabetes was the fourth. Hepatitis, occasionally alternating with cardiac disease in pregnancy ranked fifth among the commonest medical conditions in pregnancy. Overall prevalence of the various medical conditions complicating pregnancy showed the following five commonest medical conditions complicating pregnancy: hypertension, HIV infection, sickle cell disease, diabetes mellitus, and hepatitis. [Table 2] gives details of these findings.{Table 2}

Antenatal care and delivery in women with medical disorders in pregnancy

Women with medical conditions complicating pregnancy are less likely to have antenatal care compared to healthy parturients; the proportion of unbooked patients was found to be 368/1197 (30.7%) and 749/3686 (20.3%), respectively, p = 0.000. Their mean ± SD gestational age at delivery was found to be significantly lower than in healthy parturients, 36.3 ± 3.2 and 37.6 ± 3.1 weeks, respectively, p = 0.000. Caesarean section rate in women with medical condition in pregnancy was higher than in the control group (86.9 vs. 47.2%). Surprisingly, the rate of instrumental delivery was lower than in the control group (0.4 vs. 0.9%). [Table 3] gives detail summary of the mode of delivery in both groups. For those who had vaginal delivery, labor was found to be significantly shorter in women with medical conditions in pregnancy compared to healthy parturients, 7.17 ± 3.60 and 8.03 ± 4.33 hours, respectively, p = 0.027.{Table 3}

Comparative study of maternal and fetal outcome in pregnancies complicated by medical disorders and pregnancies without medical disorders

The mean birth weight of babies of mothers whose pregnancy was complicated by at least one medical condition was found to be significantly lower than that of healthy parturients, 2.71 ± 0.87 and 3.05 ± 0.74 kg, respectively, p = 0.000. A larger number of babies of mothers with medical condition, 256/1197 (21.4%), had APGAR score at 1 minute <7 compared to babies of healthy mothers, 568/3686 (15.4%), p = 0.000. APGAR score at 5 minutes was found to be <7 in 40/1197 (3.3%) of babies of mothers with medical condition and 135/3686 (3.7%) of babies whose mothers were apparently healthy, p = 0.338. The overall perinatal mortality rate was comparable in both groups, being 6.4% in pregnancies complicated by medical disorder and 7.1% for pregnancies that are not complicated by any medical disorder (p = 0.422). Maternal mortality rate was similar in both groups, 0.4% for women with medical disorder in pregnancy and 0.3% for controls, p = 0.298.

 Discussion



Our study showed a prevalence of 24.5% for medical disorders in pregnancy at delivery, a rate not far from what (20–27%) was reported in some studies where a wide range of medical disorders were also assessed.[12],[13] Hypertension was found to be the most common medical condition in the women studied with its various manifestations. This is not surprising as hypertension has been found to be one of the commonest medical disorders in pregnancy.[14],[15] However, in a similar study conducted in Ebonyi state, Nigeria, malaria ranked first and hypertension ranked second among the medical disorders examined.[7] This is probably because the study was conducted on antenatal women, while our study was conducted on women presenting for delivery. Hypertensive diseases continue to be a leading cause of maternal mortality and studies have shown increase in their incidence due a rising trend in obesity.[16],[17] In fact, a study conducted in Ethiopia puts the case fatality rate to be the highest in the world due to a delay in initiation of treatment occasioned by the delay in seeking healthcare by the affected patients.[18] This emphasizes the need for awareness creation among our pregnant patients and making healthcare more readily accessible to them.

The prevalence of malaria was very low in this study because malaria prophylaxis in pregnancy is widely practiced in Lagos, Nigeria. In a survey conducted by Rabiu et al. in private health facilities in Lagos State, Nigeria, it was found that 85.3% of doctors offer malaria prophylaxis to pregnant women.[19] Second, women who develop clinical malaria during the antenatal period can be treated prior to delivery. Only one patient, who was an unbooked nullipara, had complicated malaria (cerebral malaria with severe anemia) in this study and died before delivery could be effected. This emphasizes the need for health education of our women on the need for good antenatal care during pregnancy.

Our study showed a sharp decline in the prevalence rate of HIV infection among the pregnant women studied from the first year where it ranked first as the commonest medical condition in pregnancy to second place in the remaining 4 years. One possible reason for this could be the national decrease in the prevalence rate of HIV infection among pregnant women from 4.1 to 3.0%.[20],[21] Another and more plausible reason could be the cost of management of the patient at our center. For many years, the HIV-infected pregnant women received antenatal care and had caesarean sections almost free of charge with the support of PEPFAR, but from 2014 thereabout patients then had to pay for their surgeries, which led to their moving to other cheaper centers in droves. Despite these reasons, HIV infection still ranking second overall among the medical conditions gives credence to the fact that the burden of HIV infection in our environment is enormous.

Medical disorders were more likely to be found in the unbooked pregnant women in our study. This is in consonance with findings by Aggarwal et al.[22] and Gonied,[23] where a significant proportion of the medical disorders were found in the unbooked patients in comparison to the booked. However, the reverse was the case in the study by Agwu et al.[7] This probably was because, as they adduced, the unbooked patients presented in labor and there was not enough time to diagnose their medical conditions and also there was regrettably poor documentation of patients’ records.

Expectedly, patients with medical disorders in this study were more likely to have preterm births and caesarean sections. A sizable number of them were unbooked and had not received optimal care, and usually when they are referred, either they or their fetuses come in some form of distress that would warrant urgent delivery. These findings were in agreement with those in some other studies.[24],[25]

The statistically significant lower fetal birth weight in mothers with medical disorders found in our study was also found in some other studies.[24],[25],[26] Some of these medical diseases, especially hypertensive disorders, negatively impact fetal growth through uteroplacental insufficiency, leading to intrauterine growth restriction. Also, the fact that many of these women give birth early due to medical or surgical intervention would account for lower fetal birth weights.[24]Studies have shown the findings of poorer APGAR scores in neonates born to mothers with medical disorders when compared to healthy mothers.[27],[28] Not surprisingly, similar result was gotten in our study where a statistically significant proportion of neonates born to mothers with medical disorders had poorer APGAR scores in 1 minute. However, at 5 minutes the proportion was similar as their APGAR scores improved significantly. This can be attributed to the intensive resuscitative measures given to the neonates in our center.

Many studies have shown a staggering perinatal mortality rate (9.9–22.7% vs. 3.1–3.9%)[25],[29],[30] and maternal mortality rate (12.1 vs. 1%)[29] in patients who had specific medical disorders in pregnancy when compared to those without medical diseases. In contrast however, our study showed a comparable perinatal mortality rate (6.4 vs. 7.1%) and maternal mortality rate (0.4 vs. 0.3%) in mothers who had medical disorders versus those who did not have medical disorders, respectively. The reason for this is unknown. However, we believe that this unusual finding of a lower perinatal mortality rate, though not statistically significant in women with medical conditions complicating pregnancy at the time of delivery could be due to the masking effects of the some obstetric complications such as abruption placenta and obstructed labor in women without medical conditions, even though some of the women with medical condition also had some obstetric complications. Another possible reason is the timely and adequate intervention given to these women with medical conditions when they presented to us as well as the aggressive neonatal care given to their babies.

In conclusion, the prevalence of medical disorders in pregnancy at delivery in LUTH is high with hypertensive diseases most prominent among them. The perinatal and maternal outcomes in patients with these disorders are comparable to those in patients without the disorders if the patients are adequately managed in centers with adequate facilities and trained manpower like ours.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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