Indian Journal of Pharmacy and Pharmacology

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Online ISSN: 2393-9087

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Indian Journal of Pharmacy and Pharmacology (IJPP) open access, peer-reviewed quarterly journal publishing since 2014 and is published under auspices of the Innovative Education and Scientific Research Foundation (IESRF), aim to uplift researchers, scholars, academicians, and professionals in all academic and scientific disciplines. IESRF is dedicated to the transfer of technology and research by publishing scientific journals, more...


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Sindhusha, Satyavathi, Pragnasai, Deepika, Kumar, and Annapoorna: A study of risk score assessment in antenatal women and their neonatal outcome in a tertiary care hospital


Introduction

Modern medicine has made labor and delivery much safer for both the mother and the baby, but complications still occur.1 Most pregnancy-related medical complications appear to resolve at delivery or shortly thereafter. Common examples are preterm labor, preeclampsia and gestational diabetes. Women who developed such complications are known to be at increased risk of developing similar complications in future pregnancies. Women who delivered prematurely are at increased risk of recurrent preterm labor, those who had preeclampsia in subsequent pregnancies, women who developed gestational diabetes (GDM) are likely to develop it again, as are women who experienced a placental abruption, fetal growth impairment, etc.2 A high risk pregnancy is one in which antenatal women; neonate is at increased risk of morbidity or mortality before or after delivery.3 Risk scoring system provides a formalized method of recognizing, documenting and cumulating antepartum, intrapartum and neonatal risk factors in order to predict the later complications for mother and her fetus. A high-risk pregnancy may be identified by using a scoring system such as the system developed by Dutta and Das for identification of high risk mothers and Hobel for Prenatal and intrapartum high-risk screening.4 The present study was intended to use one such simple, less invasive, cost effective and easily accessible scoring system for detection of high risk pregnancy and to find the correlation between perinatal outcome and various degrees of risk.5

Materials and Methods

Study design

Prospective analytical study carried out for a period of 6 months from September 2019 to march 2020.

Study population

The study was conducted in inpatients from department of OBS & GYNC at GSL medical college and hospital, a tertiary care hospital in rajanagaram.

Sample size

A total of 200 Inpatient of pregnant women with maternal complications were taken with following inclusion and exclusion criteria.

Inclusion criteria

  1. Maternal age of 19 to35 years

  2. Greater than 28 weeks of gestational age was included

  3. Assisted Reproductive technology (ART) is included in this study

  4. Preexisting maternal disorders was included

Exclusion criteria

  1. Women who had abortion

  2. Women who had ectopic pregnancy and molar pregnancy

  3. Outpatients were not taken

200 antenatal women, more than 28 weeks admitted to obstetrics & gynaecology department from 16-09-2019to 15-03-2020 were recruited.n=120 pregnant women, who had any kind of maternal complications, were taken in the study group. A similar group of n=80 antenatal women with no complications were taken in the control group. To describe mothers and neonates “at risk”, a numerical scoring system based on the combination of the scoring system suggested by Dutta and Das and Hobel was used. A well-designed questionnaire was used to collect data. (Table 1, Table 2). The questionnaire covered variables related to socio demographic factors, family history, medical history, maternal complications. The study group were classified as low risk (1-2), moderate risk (3-5) and high risk (6and above) based on the cumulative total of their respective scores. The antenatal women were followed till delivery and the various complications encountered and treatment given was noted. Similarly, Hobel risk scoring system was done for the neonates, and they were classified as High risk and Low risk. Neonatal parameters like birth weight, Apgar score, Neonatal intensive care unit [NICU] admissions and complications were noted. Chi-square analysis was performed to test for differences in the proportions of categorical variables between the two groups. The level p<0.05 was considered as statically significant.

Dutta and Das Scoring system for the patients were classified into 3 groups:

Low risk (1-2), Moderate risk (3-5) and High risk (6 or above)

Table 1

High risk pregnancy scoring rate.6

Score

Past obstetrical factors

Score

Present obstetrical risk factors

Score

Age less than 16

2

ART conception

1

Premature rupture of membranes (rupture of membranes before 37 completed weeks)

4

Age more than 35

2

Abortions (first trimester)

1

Preterm labour pains (contractions of four in 20 min or eight in 60 min plus progressive change in the cervix /cervical dilatation greater than 1cm /cervical effacement of 80 percent of greater)

4

Parity more than 4

3

Abortions (second trimester)

2

Polyhydramnios (AFI on ultrasound is > 24cm)

4

Maternal weight (BMI<19)

3

Preterm birth (<37 weeks gestation)

2

IUGR(foetal growth <10th centile forGA)

4

Maternal weight (BMI>28)

3

Family history of recurrent abortions

1

Rhesus isoimmunisation

4

Heart disease (symptomatic)

4

Recurrent spontaneous abortions

3

Malpresentation at term

4

Heart disease (asymptomatic)

1

Postpartum haemorrhage

3

Vaginal bleeding (First trimester)

2

Moderate –severe renal disease-

(Creatinine>1.5mg/dl)

4

Hypertension/ pre-eclampsia

3

Vaginal bleeding (second trimester)

3

Chronic renal disease (Creatinine>3mg/dl)

4

Prolonged labour/difficult delivery

4

Mild anaemia (Haemoglobin <10gm %)

1

Pre GDM (insulin dependent/noninsulin dependent)

4

Still birth /neonatal death

4

Severe anemia (Haemoglobin<6gm %)

4

Chronic Hypertension (BP>140/90mmhg before pregnancy)

3

Caesarean delivery

1

Intrauterine cholestasis of pregnancy

4

Controlled epilepsy (at least 1 year free of seizures before pregnancy)

1

Foetal anomaly with heritable genetic cause

4

Minor foetal malformation

1

Uncontrolled epilepsy (recent seizure episode)

4

Foetal anomaly without heritable genetic cause

1

Major foetal malformation

4

Active immunological disease like SLE and rheumatoid arthritis

4

Radioiodine ablation within past 6 months

1

Placenta praevia

2

Immunologicaldisease (inactive for past 6 months)

2

Gynaecologicaldisease like fibroids and cysts

3

Morbid adherent placenta

4

Tuberculosis or PPD>10mm

2

Uterine malformation

3

Gestation Hypertension (blood pressure>140/90 without proteinuria

2

Pulmonary disease like asthma,pneumonia,-

bronchitis,Pulmonary tuberculosis

2

Pre-eclampsia (blood pressure>140/90mmhg with proteinuria of >300mg/dl after 20 weeks of gestation)

3

Smoking

2

Eclampsia

4

Alcoholism

2

Oligohydramnios

2

UTI(culture with>10 organisms/ml

2

Gestational diabetes (abnormal 75 glucose test,95/180/155)

3

Hobel risk scoring system for the neonates, and they were classified as High risk and Low risk. The scoring range was given by points 1-10. If the points were<10 considered as low risk and if the points were ≥10 considered as high risk.

Table 2

Hobel neonatal factors.7

General score

Prematurity<2,000 grams

10

Apgar at 5 min<5

10

Resuscitation at birth

10

Fetal anomalies

10

Dysmaturity

5

Prematurity 2,000-2,500 grams

5

Apgar at 1 min<5

5

Feeding problem

1

Multiple birth

1

Respiratory

RDS

10

Meconium aspiration

10

Congenital pneumonia

10

Anomalies of respiratory system

10

Apnoea

10

Other respiratory distress

10

Transient tachypnoea

5

Metabolic disorders

Hypoglycemia

10

Hypocalcemia

10

Hypomagnesemia or hypermagnesemia

5

Hypoparathyroidism

5

Failure to gain weight

1

Jitteriness or hyperactivity with specific causes

1

Cardiac

Major cardiac anomalies which require immediate Catheterization

10

Congestive heart failure

10

Persistent cyanosis

5

Cardiac anomalies not requiring immediate Catheterization

5

Murmur

5

Haematological problem

Hyperbilirubinemia

10

Hemorrhagic diathesis

10

Chromosomal anomalies

10

Sepsis

10

Anemia

5

CNS

CNS depression> 24 hrs

10

Seizures

10

CNS depression < 24 hrs

5

Results

According to Dutta and das scoring 13 women (10.8%) are low-risk and 38 women (31.7%) are moderate risk and 69 women (57.5%) are high risk. (Figure 1). Similar Demographic variables were used both in study and the control group. Majority of the antenatal women were in the age group of 19-25 years i.e., 75 patients (62.5%) with mean age being 39.6±32.6 years in study group and 44 patients (55%) with mean age being 26.3±17.5 years in control group (Table 3). Majority of the women were primigravida in both study group (57.1%) and control group (42.9%). Mode of delivery was predominantly by caesarean section in the study group which is statistically significant (p<0.005) (Table 4). When maternal and neonatal high-risk score are compared, we found that maternal high risk directly reflects fetal high risk. (Table 5) (Figure 2). Babies in study group had perinatal morbidity in the form of Jaundice, fetal distress, RDS and sepsis when compared to control group which was statically significant (Table 6). As per our study, number of NICU admissions in the study group was high 91(75.1%) when compared to 28 (35%) in control group which was statically significant p = <0.0001 (Table 7). The likelihood of having low birth weight babies is high in study group which is statistically significant p=<0.0001 (Table 8). The neonates with a high-risk score had high incidence of complications like jaundice, respiratory distress syndrome, sepsis, fetal distress which were statistically significant P<0.05 (Table 9). Following are the different medications used in various medical complications (Table 10). The incidence of preterm births is higher in the study group (34.1%) when compared with the control group which is statistically significant P= 0.002 (Figure 3).

Table 3

Distribution of demographics variables

S.no

Demographical variables

Category

Study group n=120

Control group n=80

1.

Maternal age

19-25

75(62.5%)

44(55%)

26-30

36(30%)

28(35%)

31-35

9(7.5%)

8(10%)

2.

Educational status

Illiterate

2(100%)

0

Primary school

33(61.1%)

21(38.9%)

Secondary school

54(61.4%)

34(38.6%)

Intermediate

18(52.9%)

16(47.1%)

Degree

13(59.1%)

9(40.9%)

3.

Socioeconomic status

Lower class

38(61.3%)

24(38.7%)

Middle class

77(62.1%)

47(37.9%)

Upper class

5(35.7%)

9(64.3%)

Table 4

Distribution of obstetrics variables

SI.no

Obstetrics variables

Category

Study group n=120

Control group n=80

P value

1.

Parity

Primi

64 (57.1%)

48 (42.9%)

0.3

Multi

56 (63.6%)

32 (36.4%)

2.

Mode of delivery

LSCS

79 (73.1%)

29 (26.9%)

0.000

Vaginal delivery

41 (44.6%)

51(55.4%)

Table 5

Maternal risk category of maternal complications in study group.

Maternal complications

High risk

Moderate risk

Low risk

P value

Hypothyroid

22 (64.7%)

10 (29.4%)

2 (5.9%)

0.4

Hypertension

18 (52.9%)

13 (38.2%)

3 (8.8%)

0.6

Oligohydramnios

13 (56.5%)

8(34.8%)

2 (8.7%)

0.8

Gestational diabetes

12 (66.7%)

3 (16.7%)

3 (16.7%)

0.2

Preeclampsia

10 (62.5%)

6 (37.5%)

0

0.3

Eclampsia

8 (66.7%)

0

4 (33.3%)

0.005

Anemia

8 (57%)

6 (42.9%)

0

0.8

Asthma

6 (85.7%)

1 (14.3%)

0

0.2

Obesity

4 (66.7%)

2 (33.3%)

0

0.6

Heart disease

3 (75%)

0

1 (25%)

0.3

Table 6

Comparison of perinatal morbidity between study group and control group

S.no

Perinatal morbidity

Study group

Control group

P value

1.

Jaundice

64(74.4%)

22(25.6%)

0.0001

2.

Fetal distress

11(100%)

0

0.005

3.

Respiratory distress

19(73.1%)

7(26.9%)

0.1

4.

Sepsis

12(66.7%)

6(33.6%)

0.5

Table 7

Comparative analysis of neonatal outcomes between study group and control group in NICU.

Neonatal outcomes

Study group

Control group

P value

Stay in NICU

0 days

26(21.6%)

52(65%)

<0.0001

1-7 days

91(75.1%)

28(35%)

>7 days

3(2.5%)

0

Table 8

Relations between various risk groups and the birth weight

Risk Group

Score

Birth weight

P value

<2.5 kg

>2.5 kg

Control group

0

4(5%)

76(95%)

< 0.0001

Low risk

1-2

5(4.16%)

9(0.13%)

Moderate risk

3-5

14(11.6%)

24(20%)

High risk

6 andabove

35(29%)

34(28.3%)

Table 9

Neonatal outcomes based on hobel risk scoring system.

Neonatal outcomes

High risk

Low risk

P value

Jaundice

64 (74.4%)

3 (25.6)

0.0001

RDS

19 (73.1%)

0

0.003

Sepsis

12 (66.7%)

0

0.003

Fetal distress

11 (100%)

0

0.004

IUGR

6(85.7%)

3 (14.3%)

0.6

Figure 1

Risk assessment of the study group according to the dutta and das scoring system.

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/ceee1580-ff4e-477c-86a6-e196d3026b6dimage1.png
Figure 2

Mirroring of maternal high risk to neonatal high risk.

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/ceee1580-ff4e-477c-86a6-e196d3026b6dimage2.png
Figure 3

Relation of maternal risk with incidence of preterm.

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/ceee1580-ff4e-477c-86a6-e196d3026b6dimage3.png

Discussion

High risk pregnancy is an important contributor for maternal and fetal morbidity and mortality. The purpose of the study was to identify the key risk factor and decrease the complications. Incidence of high risk is more in our study as compared to similar studies conducted by (Samiya et-al. and Vasavi et-al.)5, 6, 7, 8 probably because this study is conducted in a tertiary care center where many cases were referred. (Table 11)

Table 10

Medications for maternal complications.

Complications

Class

Drugs

ROA

No. of drug used

Common Dose Range

Pregnancy induced hypertension

Beta-blockers

Labetalol

Oral,IV

37(20.6%)

100mg 200mg

Metaprolol

Oral

13(7.2%)

25mg

Calcium channelblockers

Nifidepine

Oral

1(0.5%)

10mg

Amlodepine

Oral

2(1.1%)

2.5mg,5-10mg

Gestational diabetes

Fast acting insulin

Human insulin

SC

21(55.2%)

6 units

Fast and long-acting insulin

Soluble insulin and isophane insulin

SC

3(7.8%)

1.0 IU/kg

Intermediate acting insulin

NPH

SC

1(2.6%)

8-12units

Biguanides

Metformin

Oral

4(2.2%)

250mg

Eclampsia

Lactum anticonvulsants

Levetriacetam

Oral

4(2.2%)

500mg

Benzodiazepam

Diazepam

Oral

4(2.2%)

2- 10mg

Anticonvulsants

Mgso4

Oral

4(2.2%)

40mg/ml (injectable solution),1 gm/100ml (infusion solution)

Anemia

Iron supplements

Folic acid and Ferrous

Oral

4(2.2%)

-

Fe/bc/ca

Oral

64(35.7%)

Hypothyroidism

Thyroid supplement hormone

Levothyroxine

Oral

32(17.8%)

25mcg, 50mcg,75mcg

Asthma

Adernal glucocorticoid

Budesonide

Oral

4(2.2%)

0.5mg

Betamethasone

IM

10(26.3%)

12mg

Anti- asthmatic

Salbutamol

Oral

4(2.2%)

4mg

Table 11

Comparison of incidence of high-risk cases.

Study

No. of cases

Incidence of High-risk pregnancy

Present study

200

57.5%

Samiya M et al. (2005)

400

15 %

Vasavi(2016)

200

20 %

The mean duration of delivery was <37 weeks in the study group with significant (p <0.002) Mode of delivery was predominantly by caesarean section in the study group than the control group (p<0.005). The complications in which caesarean section were preferred are repeat caesarean section, hypertension, eclampsia and fetal complications like non-reassuring fetal heart rate. When neonatal complications were compared, Jaundice was significantly more (p<0.05) in study group and fetal distress was exclusively seen in the study group (p<0.005) which again emphasize the effect of maternal complications on the developing fetus and its neonatal outcomes. In terms of neonatal intensive care unit [NICU] admissions, babies in the study group were admitted more frequently for prolonged duration which is statistically significant (p<0.05). The different risk categories from the high risk scoring systems were significantly related to the severity of the disease. For example: — Eclampsia scored a higher risk when compared to the moderate risk like mild anaemia. This concludes that comprehensive risk stratification can be done with a simple risk scoring system namely Dutta and Das which is appropriate for the hospital and feasible to the staff. Furthermore, it can be introduced as a valid tool to categorise and identify all high-risk patients even without the presence of qualified physicians. We have also observed a neonatal high-risk score given by Hobel scoring system, detects all the neonates who need NICU admission and treatment. Babies with birth weight <2.5kg’s were significantly (p<0.0001) at high risk when compared to the low risk and moderate risk. This `finding is in concurrence with previous studies conducted by (Samiya et-al. and Vasavi et-al.)5, 6, 7, 8. Hence these scoring systems are used as a toolto screen all high-risk mothers and neonates and refer them to tertiary centers facilities to manage the neonates with low birth weight are available. As we know neonates with low birth weight is the main contributor for neonatal mortality and infant mortality. (Table 12).

Table 12

Risk of low birth weight.

Study

Low risk

Moderate risk

High risk

Present study

5 (4.16%)

14(11.6%)

35(29%)

Samiya M etal.

9 (12.3%)

18(17.64%)

16(48.48%)

Vasavi

6 (3 %)

6(3%)

8 (4%)

Since we have conducted this study in a tertiary care hospital and all the babies were appropriately managed. There was no neonatal mortality except in one case where there is intrauterine fetal demise due to maternal eclampsia. A varied spectrum of medications, oral and parenteral was administrated as per the protocols of the institutes and it was observed that no patient develops adverse effects to any of the medications which are mentioned in the annexure. The objective of our study was to identify high-risk pregnancy by using Dutta and Das scoring system and to prevent or at least positively modify the suboptimal perinatal outcome. The scoring system was found to have high sensitivity for predicting low birth weight, preterm births and perinatal mortality in high -risk group but low sensitivity in low -risk group. The results obtained were comparable with studies done elsewhere.

Conclusion

This study suggested that there was a significant correlation between high-risk antenatal and poor neonatal outcome. So, scoring systems, such as Dutta and Das scoring system for maternal complications and Hobel Scoring system for neonatal outcomes can be adopted, as these are valid and appropriate, non-invasive, easy and cheap tools which can be utilised even by a non-medical counsellor as a screening tool to predict pregnancies at high risk for poor neonatal outcome thereby facilitating early referral of these women to tertiary care centres. As majority of study group were in their 3rd trimester for reducing high risk pregnancies the most powerful interventions included education of women along with motivation and health care professionals for safe delivery. Early diagnosis and treatment through regular antenatal check-up and referral to the appropriate centre for the better well-being of mother and fetus is necessary because a “Stich in Time Saves Nine”.

Summary

This study was undertaken to assess the feasibility and reliability of simple scoring systems for maternal and fetal risk factors and apply them in low-resource settings. 200 women attending a tertiary care centre were screened and assigned to either study group or control group. A maternal high-risk scoring Dutta and Das score and a fetal high risk scoring Hobel score was calculated in both the groups, and they were followed till delivery and neonatal period. We came to a conclusion that these scoring systems were reliable in the prediction of high risk and can be applied in low-resource setting for timely referral.

Acknowledgment

We would like to express our heartfelt gratitude and regards to our guides Mr. Amit Kumar sir Associate professor and HOD, dept of pharmacy practice, Dr. V. Sarojini madam ex- HOD of OBGY dept of GSL General hospital for their guidance, monitoring and encouragement throughout the course of this research project. Support and guidance given by Dr. S. Annapoorna madam professor and HOD of OBGY dept of GSL General Hospital were remarkable.

Abbrevations

  1. BMI- body mass index

  2. CNS- central nervous system

  3. GDM- gestational diabetes mellitus

  4. IUGR- intrauterine growth restriction

  5. NICU- Neonatal intensive care unit

  6. RDS- respiratory distress syndrome

  7. UTI- urinary tract infection

Source of Funding

None.

Conflict of Interest

None.

References

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© This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Article type

Original Article


Article page

212-219


Authors Details

P. Sindhusha, P.J.N. Satyavathi, N. Pragnasai, P. Deepika, Amit Kumar, S. Annapoorna


Article History

Received : 14-06-2021

Accepted : 22-07-2021

Available online : 04-09-2021


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