European Journal of Cardiovascular Medicine

1) To estimate the perinatal mortality and morbidity among growth restricted fetuses of normotensive pregnant women, who are delivered at IMCH Kozhikodeat or after 34 weeks.

2)To analyze the socio- economic, health and demographic factors associated with fetal growth restriction

This cross-sectional study was conducted in the Dept of OBG, Government Medical College, Kozhikode (IMCH), a tertiary care center of North Kerala, India from first November 2008 to 30^th April 2009.

All growth restricted babies born in IMCH during the study period and their mothers were included in the study.

Institutional ethics committee approval was obtained. Written informed consent was obtained from the subjects after explaining the motive of the study and they were ensured that the information collected, shall be kept confidential.  A total of 109 IUGR babies born to normotensive mothers and 167 IUGR babies born to hypertensive mothers, who fulfilled the inclusion criteria were included in the study.

Inclusion criteria

All singleton growth restricted fetuses detected by clinical examination and confirmed by USG, of pregnant woman who are delivering at or after 34 weeks in IMCH Kozhikode.

The mothers of these babies were also included in the study. They were grouped as normotensives and hypertensives.

Exclusion criteria

Hypertensive mothers with other illness were excluded from the study.

Multiple pregnancy with growth restriction were also excluded from the study. Babies born outside IMCH but being referred to IMCH were also excluded.

Study procedure

The investigator collected data from subjects using proforma, by personal interview and using maternal and baby case sheets. Maternal data regarding socio-demographic variables including age, domicile (rural/ urban), socio-economic status [7], data regarding gestational age, nature of ANC, past obstetric history including parity.Past history of any medical or surgical illness, antenatal and intrapartum complications, mode of delivery, birth weight of baby, APGAR score and other baby details were collected.Everyday data was collected and each subject was followed up in the postnatal ward. Babies who were admitted in neonatal ICU were followed up for 7 days and data regarding neonatal mortality and morbidity were collected.

OPERATIONAL DEFINITIONS [8,9]

Registered gravida: Four or more antenatal visits

Stillbirth: Birth of a baby with no signs of life Preterm stillbirth: Stillbirth occurring before 37 weeks

Post-term stillbirth: Stillbirth occurring after 41 weeks

Antepartum stillbirth: Intrauterine fetal demise occurred before the onset of labor

Intrapartum stillbirth: Intrauterine fetal demise occurred duringlabor.

Perinatal death: Death of babies occurring either during pregnancy or labor or within first week of neonatal period.

Perinatal morbidity: Any illness occurring in the baby Fetal during the first 7 days of life.

Fetal growth restriction: Fetus with estimated weight (using USG morphometric parameters HC, AC, BPD, FL) less than 10^th percentilefor the GA.

Normotensive - Blood pressure never > 140/90 mm Hg.

Hypertensive - BP> 140/90 mmHg on at least 2 occasions 6 hours apart.

 Statistical analysis

  Performed using SPSS 16.0. Pearson’s chi-square test and Fischer’s exact test. Statistical significance was assumed at a p value of < 0.05.

There were 109 growth restricted babies born to normotensive mothers and 167 growth restricted babies born to hypertensive mothers, who fulfilled the criteria during the study period.

In both normotensive and hypertensive groups, majority of mothers were in the age group of 21-30 years. A systematic review had shown that older mothers have increased risk for fetal growth restriction, but majority of mothers with fetal growth restriction in present study were in the 20-30 years group [10]. High prevalence of early completion of family before 35 years in Indian culture can explain the higher number of births and stillbirths among this age group [11].

Socio demographic and feto maternal characteristics among normotensives with fetal growth restriction

BPL: Below poverty line; APL: Above poverty line

Fetal growth restriction occurred more in rural women compared to urban women and women below poverty line had more fetal growth restriction compared to the women above poverty line and the difference was statistically significant.All women with fetal growth restriction gave history of attending antenatal clinics during the current pregnancy. A total of 19(17.4%) women were referred from periphery and 90 (82.6%) women were booked with this Institution among normotensive group. There were 39 (35.8%) multies and 70 (64.2%) primis. Fetal growth restriction was more in Primiscompared to multiparas, but the difference was not significant (p=0.585). A total of 50(45.9%) babies were male and 59 (54.1%) were female babies and the difference in gender was notfound to be significant (p=0.249)

MATERNAL MEDICAL CONDITIONS AMONG NORMOTENSIVE MOTHERS

Among the 4 mothers with heart disease, 2 had rheumatic heart disease, 2 had congenital heart disease. (1 ASD, 1 VSD). One baby had ASD same as that of mother.Babies of both PGDM mothers had hypoglycemia, one baby had cleft lip and cleft palate and other had polycythemia. Both babies were admitted in ICU. Among two mothers with epilepsy, one had a baby with spina bifida occulta and the baby had hypoglycemia and was admitted in NICU. Among two mothers with SLE, none of the babies had congenital heart block. Among 2 mothers with hyperthyroidism, one of the babies had birth asphyxia.

In this study labor was induced in 60.8% normotensive mothers and 64.2% hypertensive mothers. Perinatal outcome of FGR babies born after induced delivery did not differ from those with spontaneous delivery.

 Vaginal delivery was the commonest mode of delivery in both groups. P=0.661.

Mode of delivery and APGAR

There were 16 cases of birth asphyxia (23.5%) among the FGR babies delivered vaginally and 4 cases of birth asphyxia (11.8%) among those delivered by caesarean section. Hence babies delivered by caesarean section had a better APGAR than those delivered vaginally. p=0.001. Among 8 babies with breech presentation, 2 had assisted breech delivery and both had APGAR< 1’7 and babies delivered by caesarean section had APGAR >1’7. p=0.894.

SEX OF BABY and FGR

Systematic review had shown that older mothers have increased risk but majority of mothers with poor perinatal outcome in present study were in the 20-30 yrs group [10]. High prevalence of early completion of family before 35 years in our culture can explain the higher number of births and stillbirths among this age group [11]. Lack of awareness in young women about pregnancy complications may contribute to the less favorable outcomes of pregnancy.

The stillbirth rate was 36.6/1000 IUGR babies in normotensive mother group and 53.8/1000 IUGR babies in hypertensive group.

SBR in India varies from 13 to 26.48/1000 births and this wide interstate variation may be due to differences in population characteristics and the risk factors [12,13].

 Perinatal mortality rate was 64.2/1000 IUGR babies in normotensive group and 101/1000 IUGR babies in hypertensive group. The reason for high perinatal mortality rate in our study was due to referral of all high-risk cases from periphery and even from neighboring districts to our hospital which is a referral tertiary care center

Analysis revealed that obstetric score had no influence on stillbirth as there was no significant difference between primies and multies in the present study and similar result was shown in a study from Hyderabad [14] But another study reported an increased risk of stillborn in first and after fifth pregnancy [15]

The study revealed that most of mothers were from rural areas. This is in concurrence to a study from Bihar state [15]. Higher rate of SBs among rural population indicates the need of improved obstetric care and emergency services in the villages. Results revealed that most of the mothers with FGR were below poverty line. Socioeconomic status influences the health seeking behavior of women in accessing emergency obstetric care [16]. Many national programs are there to improve maternal care but worst outcomes are more in women from rural areas suggesting the need for improving the quality of obstetric care in rural settings.

There were 16 cases of birth asphyxia (23.5%) among the FGR babies delivered vaginally and 4 cases of birth asphyxia (11.8%) among those delivered by caesarean section. Hence babies delivered by caesarean section had a better APGAR than those delivered vaginally. p=0.001. [17] Among 8 babies with breech presentation, 2 had assisted breech delivery and both had APGAR< 1’7 and babies delivered by caesarean section had APGAR >1’7. p=0.894. Similar results were seen in a study from Nepal.[18]

Intrapartum stillbirths drop by 1.6/1000 births with every percentage rise in caesarean section rates from 0-8% in low middle income countries [19]. Antepartum stillbirths indicate the need for improving the quality of antenatal care. Early detection of high-risk pregnancies and need based termination should be ensured [20]. Prompt diagnosis of hypertensive disorder in pregnancy, universal screening for detection of gestational diabetes mellitus, multidisciplinary management for diabetes mellitus, early pick up of fetal growth restriction and follow up with Doppler studies are can prevent many fetomaternal complications [10]. But there are limitations in peripheral health services system in terms of man power and facilities. Expertise is needed for Doppler studies which is a hurdle in peripheral health centers. Antenatal care by skilled health care professionals and early diagnosis with prompt effective management is very important in improving the obstetric outcomes [21].

 Early detection and timely intervention of high-risk cases appears very crucial for better fetomaternal outcome in such conditions [22].

Mothers belonging to low socio-economic status have high risk of delivering babies with growth restriction. This is because of inadequate dietary intake, increased physical activity, passive smoking, increased rate of infections and low educational levels leading to decreased awareness regarding health care facilities. Primis have increased risk of having growth restricted babies. Male babies are found to have higher rates of perinatal mortality and morbidity. But exact reason for this is not understood. Perinatal morbidity and mortality were high in babies of hypertensive mothers. NICU admissions were high in babies of hypertensive mothers. The major cause of perinatal mortality and morbidity was birth asphyxia in growth restricted babies of both normotensive and hypertensive groups.

Even though all cases were registered for ante natal care, a major proportion of cases were antepartum stillbirths indicating the need for improving the quality of antenatal care in peripheries and importance of timely referral of high-risk cases. More awareness should be generated among young women regarding the need for early detection and management of medical co morbidities like hypertension and diabetes in pregnancy. Third trimester growth scan will help in picking up the cases with fetal growth restriction.

The study stress on the importance of regular antepartum and intrapartum surveillance, regular growth monitoring by USG and plotting on customized growth charts. Early detection of FGR and delivery at appropriate time and place having appropriate neonatal facilities help to reduce perinatal morbidity and mortality.

The study highlights the importance of institutional deliveries of women combined with effective antenatal care. Hence health education and awareness among the people and primary health workers regarding this health issue is necessary in bringing down the maternal and neonatal morbidity and mortality.

Strengths and Limitations

The present study was done in a single institute. Relatively smaller sample size was a limitation.  However, multicentric studies with larger sample size would have better results. The Study provided insight on the perinatal outcome of growth restricted babies and causes which are important in planning the preventive strategies

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