European Journal of Cardiovascular Medicine

Pregnancy is astate as sociated with changes in anatomy, physiology, biochemistry. The character is ticof normal pregnancy is developing well to lerated al lografti. efetus, developed placenta, increase in circulating steroids. As a result of this changes serial alteration in lipid profile, mainly increase in serum triglycerides, cholesterol occurs in pregnantwomen.¹

Even in normal pregnancy there is increase in plasma lipid seen, but in normal pregnancy it is nota the rogenic, may be physiological, due to hormonal control. Whenever this mechanism of adjusting physiologic hyper lipidemiais altered that lead to complications in pregnancy. So, in pregnancy if serumlipid profile sarees timatedi the lps to identify high risk casesproneforpreeclampsia.²

For the growing fetus to receive nutrients continuously despite sporadic maternal food consumption, changes in carbohydrate and lipid metabolism take place. Early in pregnancy, pancreaticbeta-cell hyperplasia, an increase in insulin secretion, and a rise in serum levels of estrogen and progesterone all alter the mother's metabolic milieu.

Hyperinsulinemia is a condition that causes an increase in peripheral glucoseuptake, a drop in fasting plasma glucose levels, an increase in tissue glycogen storage, an increase in fat storage, and adecrease in lipolysis.

During pregnancy, there are significant physiological changes in the systemichemodynamics. When attempting to measure blood pressure during pregnancy, it is criticalto recognize these variations from the non-pregnantstate.

Between 16th and 20th weeks of gestation, mean arterial pressure in pregnancy without complications reaches its lowest point. The decrease in diastolic pressure is alittle more pronounced than the decrease in systolic pressure. The decrease is typically8–10 mm Hg, or slightly under 10%, from pre-pregnancy levels. Mean arterial blood pressure gradually returns to pre pregnancy levels around the 20th week, or around the40thweekofgestation.

Preeclampsiaisspecificto pregnancy, multi system involvement. It is hyper tensived is order includes new on sethypertension and proteinuria after 20 weeks of gestation and resolves after delivery. Preeclampsia is a common medical complication in pregnancy in developingcountries. It is one of the most common causes that lead to maternal and fetal morbidity and mortality. Incidence of Preeclampsia in world is 3-5%.³ In Indiapreeclampsiacomplicates5-15%ofpregnancies.⁴Even though etiopathogenes is of preeclampsi are main obscure and poorly understood, genetic componentmay play a major role. It includes complex pathophysiological state in which regulatory 15 systems of inflammation and endothelial function area ltered beyond the normal physiological limits of pregnancy.

Endothelial dysfunction may be due to the changes in metabolism of lipoproteins. The mechanism that leads to endothelial dysfunction is not well defined. The spectrum of end othelial changes is provoked by multi plecirculating factors including alteredlipoproteins. Endo the lialdys function explains many of symptom so fpreeclampsia including proteinuria.^5,6Even before, some studies evaluated lipid profile in preeclampsia and relationship between lipidcon centration (serumtriglycerides) and severity of preeclampsia is evaluated.

AIMS:

• To study trimester specific changes in lipid profile and blood pressure

• To study maternal and fetal outcome in relation to changes in lipid profile and bloodpressure

OBJECTIVES:

1. Tomeasure blood pressure in all pregnant women along with serum lipid profile

2. Tostudy the association betweenlipidprofilechangeswithmaternalandfetaloutcomes

3. Tostudy the association betweenbloodpressurechangeswithmaternalandfetaloutcomes.

A Prospective study was carried out for a period of 24 months during January2021toDecember2022among 1000SingletonPregnant mothers attending GovernmentGeneralHospital,Guntur.

InclusionCriteria:

StudygroupconsistsofpatientsofSingletonPregnancieswithanyofthefollowingcriteria

• Allantenatalwomen
• SingletonPregnancy

ExclusionCriteria:

• Patientswithanyofthefollowingareexcluded–
• Chronichypertension,preeclampsia
• Diabetesmellitus
• Obesewomenwith prepregnancyBMI >25,Multiple pregnancy
• Withanyotherpre-existingcomorbiditiessuch asheartdisease
• Thosewhoaretakingantihypertensiveorhypolipidemicdrugs

The study was conducted after obtaining Institutional Ethics Committee clearance and approval

From respectiveauthorities. Written in formed consent was obtained from both families’ and patients. All the patients of Singleton Pregnancies who are admitted in inpatient department and out-patient will be evaluated for lipid parameters–HDLCHOLESTEROL, LDLCHOLESTEROL and SERUMTRIGLYCERIDE Sinaddition toroutine investigations. All the women were followed up regularly till delivery and lipid parameters were measured in all the women. The lipid parameters were analyzed and correlated with the corresponding maternal and fetal outcomes.

STATISTICAL ANALYSIS:

SPSS software 25.0 (SPSS, Chicago, IL, USA) was used to conduct all statistical analyses. Continuous variables are presented as the mean ± SD, while categorical variables are presented as numbers (proportion). The comparisons of TG levels among different periods or groups were performed by T test value<0.05 was considered as statistically significant.

• A total of 1000SingletonPregnant mothers attending GovernmentGeneralHospital,Guntur were followed up till delivery.
• The meanageofthestudypopulationwas 58±4.49years.35.2%belongto19-24yearsagegroup,40.9%belongto25-30yearsagegroup,23.9%belongto 31-34years agegroup.
• Out of 1000 mothers 54.9%werePrimiand45.1%wereMultigravida.
• The mean HDL level in first trimester is 53.43 ±3.23, insecondtrimesteritis49.46±2.89, inthird trimesterit is 46.95±3.09.
• The mean LDL level in first trimester is 107.02±6.55, In second trimester it is 124.62±7.81, in third trimester it is 132.11±8.99.
• The mean Triglyceride level in first trimester is 144.99±37.30, in second trimester it is 159.93±38.23, in third trimester it is 172.64±39.15. The mean Total cholesterol level in first trimester is 193.10 ± 22.35, in second trimester it is 212.40 ± 19.25, in thirdtrimesteritis232.20±22.84.
• 36 ±4.68, in second trimesterit is30.36±5.19,in third trimesterit is 33.34±5.59.
• The mean SBP in first trimesteris109.7±1.31, in second trimester it is 107.8±1.41, in third trimester it is 114.6 ±1.71mm of Hg respectively. The mean DBP in first trimester is78.44 ±5.03,in second trimesterit is 83.91±5.52, in third trimesterit is 86.85 ±5.27.
• Majority 72.2%hadNormalvaginal delivery and 27.8%had underwent
• 
  The mean Gestationalageat delivery was38.09±2.43 weeks.8±1.41, in third trimester it is 114.6 ±1.71mm of Hg respectively.

         Figure: 2 showing meanSBPin all 3 trimesters

ThemeanDBPinfirsttrimesteris78.44 ±5.03,in second trimesterit is 83.91±5.52, inthird trimesterit is 86.85 ±5.27.

Table: 1   Distribution of babies based on Birth weight in Kgs

Table1showsdistributionbasedonBirthweightinKg,30.5%hadBirthweightof

<2.5kg,48.4%hadBirthweightof2.6-3.5kg,21.1%hadBirthweightof>3.5kg.Themean Birthweightinthestudy is 2.92±0.61Kgs.

Inthestudy,22.7%werePreterm birthsand77.3%wereTermdeliveries.

About 5.9% babies had score of 4, 4.8% hadscore of 5, 26.4% had score of 6, 25.1% had score of 7, 20.2% had score of 8, 17.6%had scoreof9.

Table: 2    COMPARISON OFLIPIDPROFILEIN1^STAND2^NDTRIMESTERS

The above table shows statistically significant difference in the lipid profile of patients from 1^st trimester to 2^nd trimester with p values<0.05.

Table: 3 COMPARISON OFLIPIDPROFILEIN1^STAND3^RDTRIMESTERS

The above table shows statistically significant difference in the lipid profile of patients from 1^st trimester to 3^rd trimester with p values<0.05.

Table: 4 COMPARISON OFLIPIDPROFILEIN2^NDAND 3^RDTRIMESTERS

The above table shows statistically significant difference in the lipid profile of patients from 1^st trimester to 3^rd trimester      with p values<0.05.

Inthisstudytrimesterspecificchangesoflipidprofileandbloodpressurearetaken. The mean value of total cholesterol, triglycerides, LDL, VLDL are increased in thirdtrimesterwhencomparedtofirstandsecondtrimesterswithsignificantpvalue.

The mean systolic and diastolic blood pressure is reduced in second trimester with progressive increase till term.

The mean HDL level in first trimester is 53.43 ± 3.23, in second trimester it is 49.46 ±2.89, in third trimester it is 46.95±3.09. Whereas in the mean HDL – Cholesterol levels in second and third trimester were 49.13±6.15 mg/dl and 43.07±4.34 mg/dl respectively in Pusukuru R et al.

The mean LDL level in first trimester is 107.02 ± 6.55, in second trimester it is 124.62 ±7.81, in third trimester it is 132.11 ±8.99. Whereas the mean LDL – Cholesterol levels in second and third trimester were 92.41±18.94 mg/dl and 137.82±13.45 mg/dl respectively in a study done by Pusukuru R et al⁷.

Themean Triglyceridelevelin firsttrimesteris144.99±37.30, in second trimester it is

159.93±38.23,inthirdtrimesteritis 172.64±39.15. Whereas the mean triglyceride levels in second and third trimester were 188.68±20.88 mg/dl and 216.78±20.09 mg/dl respectively in a study done by Pusukuru R et al⁷.

The mean Total cholesterollevel in first trimester is 193.10 ± 22.35, in second trimester it is 212.40 ± 19.25, in thirdtrimesteritis232.20±22.84. Whereas the mean cholesterol levels in second and third trimester were 214.6±18.16 mg/dl and 242.65±20.44 mg/dl respectively in a study done by Pusukuru R et al⁷.

ThemeanVLDLlevelinfirsttrimesteris27.36 ±4.68, in secondtrimesterit is30.36±5.19,inthird trimesterit is 33.34±5.59 Whereas the mean VLDL – Cholesterol levels in second and third trimester were 28.22±7.66 mg/dl and 36.27±6.72 mg/dl respectively in a study done by Pusukuru R et al.

In the present study We found a significant increase in the cholesterol, triglyceride, LDL-Cholesterol and VLDL-Cholesterol level in third trimester as compared to second trimester. We found HDL-Cholesterol levels decreased in third trimester when compared to second trimester. Similar findings were reported in a study done by Pusukuru R et al⁷.

In a case control by Giuseppe Lippi et al., a comprehensive lipid and lipoprotein profile was evaluated in 57 women at different gestational ages (20 in first, 20 in second and 17 in third trimesters, respectively). They concluded that all the lipid parameters were significantly modified particularly in second and third trimester when compared to non-pregnant females as well as when compared to the values in first trimester⁸.

In a study done by Abdelhai AT, Jamil et al., a total of 115 pregnant women at different stages of pregnancy were included in the study, with 35 age-matched, healthy, non-pregnant women selected as control. They concluded that there was a significant decrease in high density lipoprotein cholesterol with increased low density lipoprotein concentrations. No significant difference was found in total cholesterol and triglycerides concentrations between pregnant women and non-pregnant controls⁹.

A study was done on 160 women {120 pregnant women during normal gestation (40 women in each trimester) and 40 non-pregnant, healthy women as control} by Idonije O. Blessing et al., to evaluate the estimated serum concentrations of total cholesterol, high density lipoprotein, low density lipoprotein and triglycerides.¹⁰

The mean SBP infirsttrimesteris109.7±1.31, in second trimester it is 107.8 ±1.41mm Hg, in third trimester it is 114.6±1.71mm Hg. The mean DBP in first trimesteris66.7±1.10mm Hg,ins econd trimester it is64.4±1.10, inthirdtrimesteritis73.3±1.35mm Hg. BP measured repeatedly by two different noninvasive devices during pregnancy and postpartum showed a statistically significant drop in mid-pregnancy, followed by a progressive increase until term. Similar findings were reported from a study done by Grindheim et al.¹¹

Grindheim et al. have followed a cohort with four visits during pregnancy to evaluatechange in blood pressure which showed similar mid trimester drop in blood pressure insecond trimester.¹¹

The majority of previous studies did not measure pre-pregnancy BP, and reports on the pattern of BP changes were usually limited within the pregnancy. Studies reporting a mid-trimester BP drop were heterogeneous with respect to measurement device, time of measurement, study design, inclusion criteria, sample size, and statistical methods.

Some of the previous observations were descriptive and statistical approaches were outdated. Repeated measurement nested within individuals are highly dependent on each other, and neglect of this intra-class correlation by treating each measurement as an independent observation will lead to erroneous statistical conclusions¹². Our finding contradicts the work by Nama et al¹³. that reported a progressive increase in mean SBP and DBP throughout healthy pregnancy without mid-trimester BP drop.In that study, participants were homogenous population (white normotensive and primiparous women), and statistical methods were robust in dealing with intra-class correlation. Their finding undermines the widely accepted mid-trimester drop in BP. However, the homogeneity of study population limited the generalization of their conclusion. Moreover, the timing of measurement was categorized into several intervals in that study and most of the related studies owing to the deficiency of models to deal with sparse longitudinal data.

Moderate rise in serum triglycerides, LDL, VLDL, total cholesterol in third trimester is physiological. Thereisphysiologicalmidtrimesterfallinblood pressure. Understanding the physiological changes and being aware of the reference values aidsin spotting altered blood pressure readings and changes in lipid profiles, which can helpin the early diagnosis of pathological diseases that can affect both maternal and fetaloutcome.

Conflict of Interest: Nil

Finding Sources: Nil

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