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Maternal Hemoglobin, Preterm Pains, Failure of Tocolysis, Preterm Birth, Small for Gestational Age Neonate | OMICS International
ISSN: 2376-127X
Journal of Pregnancy and Child Health
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Maternal Hemoglobin, Preterm Pains, Failure of Tocolysis, Preterm Birth, Small for Gestational Age Neonate

Chhabra S* and Chopra S
Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences, India
*Corresponding Author : Chhabra S
Department of Obstetrics & Gynaecology
Mahatma Gandhi Institute of Medical Sciences
Sevagram, 442102, Wardha, Maharashtra, India
Tel: 917152284645
E-mail: [email protected]
Received date: Feb 26, 2016; Accepted date: Mar 21, 2016; Published date: Mar 26, 2016
Citation: Chhabra S, Chopra S (2016) Maternal Hemoglobin, Preterm Pains, Failure of Tocolysis, Preterm Birth, Small for Gestational Age Neonate. J Preg Child Health 3:235. doi:10.4172/2376-127X.1000235
Copyright: © 2016 Chhabra S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: Small for gestational age (SGA) babies have higher perinatal mortality, morbidity, sequelae. Iron deficiency anaemia in mother significantly increases SGA. Objective: To know relationship between SGA neonate, preterm pains, preterm births with anaemia in mother. Material methods: Analysis of case records of primigravida who delivered single live SGA baby, with equal controls (appropriate for gestational age) over 5 years. Results: Of 27,984 who delivered, 1500 (5.36%) were study subjects, as per inclusion, exclusion 1190 (79.3%) were anaemic, 1002(66.8%) controls anaemic, significant difference. Amongst study 41.8% (628) were mildly, 33.6% (505) moderately, 3.8% (57) severely anaemic, 20.7% nonanaemic, 620 (41.3%) controls, mildly 352(23.5%), moderately 30(2%), severely anaemic, 33.2% nonanaemic. Most study, controls were of 20-29 years. Significantly more nonanaemic study cases were labourers (9.6%), compared to controls (2.6%). With SGA baby, risk of preterm birth increasing with severity of anaemia. Of 50, (8.0%) with mild anaemia SGA babies, who had preterm pains, tocolytics were able to arrest birth in 12%.Preterm births were 7.2% in nonanaemic, 5.5% mildly anaemic, 14.5% moderatly,43.9% severe (p < 0.05). Preterm birth arrest by tocolytics decreased from 22.7% without anaemia to 16.7% with severe, 12% with mild, 8.8% moderate anaemia (p < 0.05). Amongst study subjects, 21(3.3%) with mild anaemia, 17(3.4%) moderate anaemia, 10(17.5%) severe anaemia, 9(2.9%) nonanaemiac had birth weight 1000-1499 gms., 142(22.6%) with mild anaemia, 276(54.6%) moderate anaemia,47(82.5%) severe anaemia, 8(2.6%) with no anaemia had weight 1500-1999 gms. 465(74.1%) with mild anaemia, 212 (42%) moderate anaemia, 293 (94.5%) no anaemia had weight 2000-2499 gms. MBW decreasing with increasing severity of anaemia.

Keywords
Nutrition; Mortality; Morbidity; Anaemia; Tocolytics
Abbreviations
MBW-Mean birth weight; SGA-Small for gestational age; AGA-Appropriate for gestational age
Background
Small for gestational age (SGA) is a major cause of perinatal mortality, morbidity and long term sequelae too [1-4]. The standard criteria for SGA is birth weight below the 10th percentile for a given gestational age. SGA is reflective of life course science, in that birth weight is influenced by maternal health and social factors prior to pregnancy, during pregnancy and has implications for the health of the infant through childhood and into adulthood. Infants with birth weight below the 10th percentile are at an increased risk for neonatal, infant morbidity and mortality [5], permanent deficits in growth and neurocognitive development problem in childhood, and at an increased risk for development of adult chronic diseases [6]. Maternal environmental, nutritional, and hormonal influences including anaemia, become increasingly important in later weeks of pregnancy for baby´s health [3,7-12]. Anaemia (Hb < 11 g/dl), particularly iron deficiency anaemia significantly increases the occurrence of SGA [13-19].
Objective
Study was done to know relationship between SGA neonate, preterm pains, and preterm births in women who were anemic near birth time.
Material and Methods
Case control study was carried out after obtaining approval from institute’s ethics committee. Anaemia was defined as Hb < 11 g/dl. (mild Hb-9.0 g/dl-10.9 g/dl, moderate Hb- 7.0 g/dl- 8.9 g/dl and severe Hb < 7.0 g/dl). Case records of study subjects, primigravida who had delivered singleton live SGA baby (birth weight less than 10th percentile of the mean for that gestation), irrespective of gestation at delivery with no congenital anamoly in the baby, over 5 years were analyzed with equal controls with similar criteria, but with AGA baby mothers had no evidence of hypertensive disorders, antepartum haemorrhage, diabetes, renal disease or haemoglobinopathy. Haemoglobin at the time of admission was recorded in each case. Details of delivery were recorded including gestation, attempts at arrest of pains, mode of delivery (vaginal/caesarian birth). Statistical analysis was done in EPI- info 6 software. Z test by analysis of variance (ANOVA) and univariate analysis.
Results
Of 27, 984 who delivered, 1500 (5.36%) became study subjects (SGA baby). Of them 1190 (79.3%) were anaemic and among the controls (AGA babies), 1002 (66.8%) were anaemic (p < 0.05). Of 1190(79.3%) study subjects with anaemia, 628 (41.8%) had mild, 505 (33.6%) moderate, 57(3.8%) severe anaemia and only 310(20.7%) were nonanaemic. Amongst the controls, 620 (41.3%) had mild, 352(23.5%) moderate, 30(2%) severe anaemia and 498(33.2%) were nonanaemic (Table 1).
More study subjects were moderately 33.6% and severely anaemic 3.8% than controls 23.5% and 2.0% respectively (P value < 0.001 highly significant difference).
Most of the study subjects and controls were of 20-29 years, with insignificant (p > 0.05) difference between the mean age of the study subjects and controls. In the study subjects 0.6%and amongst controls 0.3% were ≤ 19 years, significant difference (p > 0.05). Amongst study subjects 667(44.5%) were housewives, 162(10.8%) labourers, 641(42.7%) were farmers and 30(2%) were office workers. Among the Controls also 43.4% were house wives, 8.8% labourers, 45.8% farmers and 2% were office workers. However significantly more (p < 0.05) study subjects (mothers with SGA babies) without anaemia were labourers (9.6%) compared to controls without anaemia (2.6%). Of all mothers with SGA babies and preterm births {160, (10.66% of all mothers with SGA babies)}, 45(28.13%) had mild anaemia, 73(45.62%) moderate, 25(15.62%) severe anaemia and only 17(10.62%) were not anaemic. With SGA babies, the risk of preterm birth was more in all anaemic women, the risk increasing with the severity of anaemia. Vaginal and cesarean births were almost equal in study subjects with mild, moderate and no anaemia but women with severe anaemia had more often vaginal birth.
In 50 women with mild anaemia and SGA babies, (8.0% of all with mild anaemia and SGA baby), who had preterm pains, tocolytics were able to arrest preterm birth in 6(12%). Similarly amongst moderately anaemic cases with SGA babies, of 80 with preterm pains (15.8% of all with moderate anaemia and SGA baby), preterm birth was arrested in 7 (8.8%). Of 30 women with severe anaemia and SGA baby and preterm pains (52.6% of severely anaemic mothers with SGA babies), preterm birth was arrested in 5 (16.7%) women. Of 22 nonanaemic women with SGA babies, with preterm pains (7.1% of nonanaemic women with SGA babies), preterm birth was arrested in 5(22.7%). Preterm births were almost equal in cases of SGA with no anaemia and mild anaemia (7.2% and 5.5% respectively), but increased to 14.5% in women with moderate anaemia and 43.9% in cases of severe anaemia (p < 0.05). Preterm birth arrest by tocolytics decreased from 22.7% in women without anaemia to 12% in women with mild anaemia and 8.8%in women with moderate anaemia (p < 0.05). In severe anaemia the percentage of women with preterm pains was more than 50%, so in around 16% pains could be arrested for some time. In mildly anaemic women with SGA babies, there were 45(7.2%) preterm births {42 (93%) vaginal+3(7%) caesarean births}, 583(92.8%) term births {400 (68.7%) vaginal+183(31.3%) caesarean}, overall [442 (70.4%) vaginal and 186(29.6%) cesarean births]. In moderately anaemic cases with SGA babies there were 73(14.5%) pretermbirths {65(89%) vaginal + 8(11%) caesarean}, 432(85.5%) term births {278(64.4%) vaginal + 154(35.6%) caesarean}, overall [343(67.9%) vaginal and 162(32.1%) cesarean births. In severely anaemic cases with SGA, there were 25 (43.9% of 57) preterm births {24 (96%) vaginal + 1(4%) caesarean}, 32 (56.1% of 57) term births {19(59.4%) vaginal + 13(40.6%) caesarean}, overall [43(75.4%) vaginal and 14(24.6%) cesarean births].
In nonanaemic women with SGA baby there were 17(5.5%of 310) preterm births {14(82.4%) vaginal + 3(17.6%) caesarean}, 293(94.5%) of 310 term births {200(68.3%) vaginal + 93(31.7%) caesarean births}, overall {214(69%) vaginal and 96(31%) caesarean births} (Table 2).
Amongst all vaginal births (1042), 145(13.9%) were preterm and 897(86.1%) term and among all caesarean births (458), 15(3.3%) were preterm and 443(96.7%) term births (Table 3).
Among the study subjects, 32 (5.1%) babies of 628 women with mild anaemia, 25 (4.95%) of 505 women with moderate anaemia, 14(24.6%) of mothers with severe anaemia and 16 (5.16%) of 310 women without anaemia were admitted to Neonatal Intensive Care Unit (NICU). Thus the NICU admissions were almost similar for women with mild, moderate and no anaemia but significantly more babies of women with severe anaemia had NICU admission. This was because of many preterm births in this group.
In study subjects without anaemia (310), 9(2.9%) babies had weight between 1000-1499 g, 8(2.6%) between 1500-1999 g and 293 (94.5%) between 2000-2499 g. The minimum and the maximum birth weight were 1346 g and 2485 g respectively and the MBW 2134.64+161.1 g. In study subjects with mild anaemia (628), in 21 (3.3%) babies weight was between 1000-1499 g, 142 (22.6%) between 1500-1999 g and 465(74.1) between 2000-2499 g, the minimum and the maximum birth weight were 1284 g and 2496 g respectively and the MBW was 2116.74+149.2 g. In study subjects with moderate anaemia (505), 17(3.4%) babies weight was between 1000-1499 g, 276 (54.6%) between 1500-1999 g and 212(42%) between 2000-2499 g, the minimum and the maximum birth weight were 1230 g and 2300 g respectively and the MBW was 1913.83+127.1 g. In study subjects with severe anaemia (57), 10 (17.5%) babies weight were between 1000-1499 g and 47 (82.5%) between 1500-1999 g, the minimum and the maximum birth weight were 1100 g and 1950 g respectively and the MBW was 1650.36+167.4 g, MBW decreasing with increasing severity of anaemia.
Discussion
SGA is a crude surrogate for FGR but it clearly identifies a high-risk group; SGA infants are more likely to experience adverse perinatal and neonatal outcomes, and suffer long-term health sequale. SGA is the single biggest risk factor for stillbirth [2]. Of the three million lives lost to stillbirth each year, over half are SGA babies. The SGA baby is at four times the risk of perinatal death compared with its appropriately grown counterpart [20] and stillbirth rates are more than doubled when FGR remains undetected [21]. Detection of FGR in late pregnancy, must be an imperative part of antenatal care; both to facilitate timely delivery, minimizing the risk of stillbirth and ensuring optimal surveillance in labour, the time of greatest hazard to the GR foetus. As socioeconomic disadvantages increase, so does the risk for SGA. Young mothers (<18) and older mothers (>35) also are at higher risk for delivering a SGA baby [22,23]. SGA is associated with the development of chronic diseases in adulthood including coronary heart disease, stroke, and hypertension and type II diabetes [24]. Research also reveals possible links between SGA and future development of osteoporosis and depression. The increased risk for these diseases may be due to long term effects of abnormal nutrient supply to the fetus [25].
In the study done by Lackman to test the null hypothesis that size at birth relative to fetal or neonatal growth standards is not a significant variable related to the risk of spontaneous preterm delivery, when fetal growth standards were applied, there was a significant increase in the risk of spontaneous preterm delivery when birth weight was outside the AGA range. In contrast, when neonatal growth standards were applied, the risks of spontaneous preterm delivery in GR, borderline GR, and large-for-gestational-age babies were significantly lower, because of an underestimation in the number of fetuses with abnormal size at birth, delivered prematurely. Fetal growth standards are more appropriate in predicting the impact of birth weight category on the risk of spontaneous preterm delivery than are neonatal growth standards. When fetal standards are applied, the risks of preterm birth in both extreme abnormal birth weight categories (FGR and large for gestational age) are 2 to 3-fold greater than the risk among AGA babies. Garite also reported that FGR is an important reason for preterm birth. Donald reported that the incidence of intubation at birth, seizures during the first day of life, and sepsis were also significantly increased among term infants with birth weights at or below the 3rd percentile. These differences persisted after adjustment for the mother's race and parity and the infant's sex. Gilbert reported that FGR was found more often with prematurity and may represent an important risk factor to check for in women who present with preterm labor. Telatar et al. [26] have reported significantly higher prevalence of SGA babies among anemic mothers compared to non-anaemic.
Ronnenberg et al. [27] report that both mild and moderate anaemia are significantly associated with birth weight less than normal at all gestations. Iron-deficiency anaemia alone was associated with a 242 g less MBW in the study. The risk of LBW (<2500 g) and SGA were significantly greater among women with anaemia compared with nonanaemic controls. Acharya et al. [28] reported that when 101 women who had delivered SGA babies were compared with 202 women who had delivered AGA babies, anaemia in pregnancy in third trimester was significantly associated with SGA. In a study by Msuya et al. [29] with, 47.4% anaemic cases (35.3% mild, 9.9% moderate and 2.1% severe anaemia), the risk of SGA babies was 1.6 times and 4.8 times higher for babies born to women with moderate and severe anaemia, respectively compared to nonanaemic women, irrespective of impact of different sociodemographic factors in both preterm (<37 weeks) and term (37-42 weeks) infants. In the present study most study subjects and controls (only primigravida) most of 20-29 years, with insignificant difference between the mean age of study subjects and controls significantly (p < 0.05), more study subjects without anaemia (9.6%) were labourers compared to controls without anaemia (2.6%). Effect of physical work, with less of rest was obvious. All these factors need to be remembered while planning management of such cases.
Of all mothers with SGA preterm births (160), 45(7.2%) women had mild, 73(14.5%) moderate, 25(43.9%) had severe anaemia and only 17(5.5%) were not anaemic. The risk of preterm births with growth retarded babies was more in all anaemic women, the risk increasing with the severity of anaemia. Probably what leads to FGR also leads to preterm pains. Vaginal and cesarean births were almost equal in study subjects with mild, moderate and no anaemia, but women with severe anaemia had more vaginal births, probably due to more preterm births and other factors.
Of 50 women with SGA babies and mild anaemia, who had preterm pains, (8.0% of mildly anaemic with SGA babies), tocolytics were able to arrest preterm birth in 6(12%). Similarly in moderately anaemic with SGA babies of 80, with preterm pains, (15.8% of moderately anaemic with SGA babies), preterm birth was arrested in 7 (8.8%). In 30 women with preterm pains, (52.6% of cases of severely anaemic with SGA babies) preterm birth was arrested in 5 (16.7%) women. In women with FGR without anaemia, of 22 women with preterm pains, (7.1% of without anaemia with SGA), preterm birth was arrested in 5 (22.7%) women. Preterm births were almost equal in nonanemic with SGA and mild anaemia (7.2% and 5.5% respectively) but increased to 14.5% in women with moderate anaemia and 43.9% in severe anaemia (p < 0.05). The arrest of preterm birth with tocolytics decreased from 22.7% in women without anaemia to 12% in women with mild anaemia and 8.8% in women with moderate anaemia (p < 0.05). Because more than 50% with severe anaemia had preterm pains, in around 16% pains could be arrested. reported that risk of low Apgar score, operative deliveries and admission to NICU were significantly increased in women with low hematocrit. Lone et al. have investigated the relationship between maternal anaemia and perinatal outcome in a cohort of 629 pregnant women of which 313 were anaemic at 33 to 37 weeks and in labour. The risk of SGA baby and preterm delivery among the anaemic women was 1.9 and 4 times more respectively than the non-anaemic women. Rasmussen reported that strong evidence exists between maternal hemoglobin concentration and preterm birth and birth weight. In the present study the difference between the MBW of the babies of moderately anaemic women with SGA, nonanaemic with SGA, was significant (p < 0.01) with higher MBW in without anaemia and SGA. Similarly there was significant difference between the MBW of severely anaemic with SGA and without anaemia and SGA. There was significant difference between the MBW of mild anaemia with SGA, moderate anaemia with SGA and severe anaemia with SGA, birth weight decreasing with the severity of anaemia. Swain et al. [30], Bodeau-Livinec et al. [31] reported that compared with women without anaemia (Hb ≥ 110 g/L) during the third trimester, women with severe anaemia (Hb < 80 g/L) were at higher risk of LBW after adjustment for potential confounding factors as was in the present study also.
In the present study, primigravida with no disorders and mild anaemia and SGA (628), in 21(3.3%) women birth weight was between 1000-1499 g, 142(22.6%) between 1500-1999 g and 465 (74.1%) between 2000-2499 g. The minimum and the maximum birth weight were 1284 g and 2496 g respectively and the MBW was 2116.74 + 149.2 g. In study subjects with moderate anaemia (505), 17(3.4%) women had babies with weight between 1000-1499 g, 276 (54.6%) between 1500-1999 g and 212 (42%) between 2000-2499 g. The minimum and the maximum birth weight were 1230 g and 2300 g respectively and the MBW was 1913.83 + 127.1 g. In study subjects with severe anaemia (57), 10(17.5%) with birth weight between 1000-1499 g and 47 (82.5%) between 1500-1999 g. The minimum and the maximum birth weight were 1100 g and 1950 g respectively and the MBW was 1650.36 + 167.4 g. In study subjects without anaemia (310), in 9(2.9%) women birth weight was between 1000-1499 g, 8(2.6%) between 1500-1999 g and 293 (94.5%) between 2000-2499 g. The minimum and the maximum birth weight were 1346 g and 2485 g respectively and the MBW was 2134.64 + 161.1 g.
There was significant difference between the MBW of the babies of the women having mild anaemia and SGA, moderate anaemia and SGA, severe anaemia and SGA and without anaemia and SGA, with the MBW increasing with the increase in hemoglobin concentration. Thus anaemia is associated with SGA and moderate and severe anaemia caused a significant decrease in MBW. Anaemic women have more often preterm pains, and response to tocolysis is less leading to more often preterm birth. Anaemia significantly increases the admissions to NICU among SGA babies.
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