ABSTRACT
Background:The grandmultipara has almost disappeared in the western countries, but still common in developing countries like Nepal.Over 98% of all maternal mortalities occur in developing countries. Although all pregnancies and deliveries are potentially at risks. This risk increases for both the mother and fetus from the fifth delivery onward. There are very few studies concerning grandmultipara and pregnancy outcome and current textbook also vague on the subject. This study aimed to determine the extent of increased risk associated with "Grandmultiparity" in Nepalese Women.
Methods: It was prospective hospital based case studies of mothers.97 women of parity 4 and above who gave birth in three hospitals of Nepal during 8 months in 2055 BS (1998 / 1999) formed the study group. Obstetric performance of these grandmultipara was compared with 14488 general obstetric patients who delivered in a one-year period (2055 BS) at Maternity Hospital, Thapathali, Kathmandu.
Results: The women of grandmultipara were found to be significantly more likely to suffer from anemia, pregnancy induced hypertension, eclampsia, antepartum haemorrhage Placenta praevia, abruptio placenta, malpresentation, obstructed labour, multiple pregnancy and postpartum haemorrhage. Cesarean Section was found to be 3 times greater in the grandmutipara. They were also significantly more at risk of associated with preterm delivary, low birth weight, intrauterine death of fetus, stillbirth, & neonatal death.
Conclusions: Grandmultiparity is a high risk factor in pregnancy for Nepalese women. Most of these complications can be prevented or avoided with good health education, antenatal care, maternal and child health & general health services.
INTRODUCTION
Maternal and perinatal morbidity and mortality are major health problems in developing countries like Nepal. Throughout the world 58500 women die every year as a result of Pregnancy and childbirth. Over 98% of all maternal mortality occur in developing countries.1 Many factors contribute to this sorry scenario. Poverty, hunger, illiteracy civil wars, political instability, government policies, lack of health facilities, unawareness about existing facilities, lack of transportation, geographical barriers, harmful cultural and social practice are a few of them. Many of these contributing factors are preventable.
One of the important areas in which we can contribute significantly is the care of pregnant women. Antenatal care goes a long way in preventing pregnancy complications. One of the important aspects of antenatal care is recognition of high risk pregnancy. All pregnancies and deliveries are potentially at risk. However there are certain categories of pregnancies where the mother, the fetus or the neonate is in a state of increased jeopardy. About 20 to 30% of pregnancies belong in this category. If we desire to improve obstetric results, this group must be identified and given extra care. Even with adequate antenatal and intranatal care, this small group is responsible for 70 to 80 percent of perinatal mortality and morbidity2.
There are many adverse factors identified as high risks and grandmultiparity is one of them. For several decades grandmultiparity has been viewed with great caution. Grandmultiparity has been reported to be related to increased incidence of obstetric complications. In 1934 Solomons published a paper entitled " The Dangerous Multipara", emphasizing that maternal morbidity and mortality increases steadily and speedily after the fifth pregnancy.3 Many papers have since confirmed a higher rate of obstetric and neonatal complications in highly parous women. An increased incidence of hypertension, preeclampsia, malpresentation, diabetes, antepartum and postpartum hemorrhage, anemia, preterm labour, large for date infants, perinatal mortality and neonatal jaundice have all been reported in the grandmultiparity 4,5,6,7,8,9. Some studies conclude that with good antenatal and perinatal care those risks could be reduced or even avoided altogether10.
In developing countries like Nepal, there is a dearth of maternal and child health care services. Only 15%of the population have access to health services and 6% of births are attended by trained personnel 11. In rural areas antenatal care is provided by traditional birth attendants (TBA) and village health workers. For them it is important to develop a simple risk indicators, so that, they can refer high risk pregnancies to an urban medical center.
The present study intends to find out the existing situation among Nepalese woman in terms of the grandmultiparity and pregnancy outcome, giving more emphasis on the perinatal period. Such studies were not done here. There is also a paucity about this in textbooks. This study was conducted in three separate hospitals of Nepal. (1) Maternity hospital (Shree Panch IndraRajya Laxmi Prasuti Griha) Thapathali, Kathmandu, where approximately 14000 deliveries are conducted per year. (2) Western Regional Hospital, Pokhara, and (3) United Mission Hospital Tansen, Palpa.
OBJECTIVES
General Objectives
The general objective of this study is to learn the pregnancy outcome for Nepalese women, in relation to grandmultiparity, after 28 weeks of gestation.
Specific Objectives
I)To find out the relationship between mode of delivery and grandmultipara.
II)To find out the relationship between fetal outcome and grandmultipara.
LITERATURE REVIEW
There is no universally accepted definition of grandmultiparity, which makes comparison among different studies difficult. Current postgraduate textbooks are vague on the subject 13. In Europe a woman is considered grandmultiparity from fifth and onward deliveries whereas in North America the term refers to women of parity seven and above. It also differs within investigator to investigator from the same region. The criteria vary from a parity of four (Solomans, 1934), through five (Nso for 1987, Mwanbingu et al 1988), six (Evaldson, 1990), seven (Fuchs et al, 1988), eight (Otam, 1979), to ten or more (Silva, 1992)14.. In this part of the world women in their fifth or more delivery are taken as grandmultiparas. Despite a lack of precise definition of grandmultiparity, it has become standard undergraduate and postgraduate teaching that, grandmultiparity constitutes an obstetric risk factor. It is common practice to see women of high parity more frequently in the antenatal period and to book them for confinement in a specialist unit 15.
L.M.Irvine et al 14 in their study of 229 cases of grandmultipara, found significantly more anemia in GMP Group 22% Vs 16% in control (p<0.01). The overall Cesarean section was 12% in control and 14 % GMP. There were 3 stillbirths in the GMP group and none in control.
Critina Tai et al15 did a retrospective comparative study of one year (1988) at University Hospital Kulalumpur in which 477 women aged less than 35 years, of parity 5 and above, were studied. There were 406 women of parity 5 and 6 and 71 women of parity 7 and above. These two groups together comprised 7.5% of the obstetric population for that year. Obstetric performance in the 2 groups of GMP ware compared with 1,135 women aged 25 to 34 years, having their second baby during the same period. Their main finding was that anemia was significantly higher in both GMP groups. Women of parity 5 and 6 had a 1.47 relative risk of anemia (95% confidence interval) compared with the control group (P<0.01). The relative risk of anemia in the very high parous group (parity 7 and above) compared with woman of parity 5 & 6 was 1.58 (95% confidence interval). Apart from anemia, there was not much difference in pregnancy outcome between the para 5 & 6 group and the control group. But in the highly parous group, hypertension preeclampcia, preterm delivery, and perinatal death occurred significantly more when compared with the lower parity group. The relative risk of Hypertension/ preeclampcia in the very highly parous group was 5.75 (95% CI) preterm delivery 3.98, perinatal death 3.26 (p<0.05).
Tambo TG et al 16 in their comparative analysis of GMP and a control group of second and third paras. They found that GMP was associated with increased frequency of abnormal presentations and positions. The perinatal mortality was high, 23.5% compared with none in the control group.
Fuchs-k et al17 did a comparative analysis of 5785 GMP with general obstetric populations as control. They found that face and breech presentations as well as transverse lie were twice as frequent, and brow presentations were three times more frequent, in the GMP group. PPH was four times more frequent, and premature separation of placenta twice as frequent. Rupture of uterus was about 20 times more frequent. Forceps delivery and C/S rate were twice as frequent, while vacuum extraction was 5 fold more frequent in GMP.
Chang –A et al9 in their retrospective analysis of women delivered between July 1974 & Jun 1975 at the Mater Mothers Hospital concluded that hypertension, preeclampsia, anemia, unstable lie, malpresentation and retained placenta were more frequent in GMP.
Goldman GA et al 10 examined the outcome of delivery in 1700 women in their fifth or more delivery and compared with two other groups: 622 primiparas and 735 multiparas, at Tel Aviv University Hospital. In their study the antenatal care was good. They concluded that in GMP macrosomia was markedly higher. But with excellent prenatal and intranatal care GMP need not be considered as a high-risk obstetric category in their population.
In a study undertaken at Saudi Arabia by Evaldson- GR 18 during one year period, from April 1985 to March 1985,it was reported that in GMP, recurrent disease, especially diabeties mellitus and gestational diabeties, primary uterine inertia, and fetal heart rate abnormality were more frequent than in the other groups. The incidence of placenta praevia, number of C/S, also were significantly higher in GMP, as was Perinatal morbidity. No differences in mortality were reported.
These studies show that GMP is associated with a greater risk of complications, during pregnancy, delivery and the postpartum period. With good antenatal and perinatal care services, most of the complications can be avoided.
METHODOLOGY
This was a prospective hospital - based case study. This study was conducted in three different hospitals of Nepal, in the year 2055 BS (1998-1999):Maternity Hospital (Shree Panch Indra Rajya Laxmi prasuti Griha). Thapathali, Kathmandu is a central hospital. It has tertiary care facilities for obstetric and gynecology patients. About 14000 deliveries occur yearly in this hospital. Duration of study in this hospital lasted from, 10th Bhadra to 3rd kartik 2055 (21 Aug to 20 Oct 1998).
Western Regional Hospital, at Pokhara is a regional general hospital. It has some of the tertiary care facilities, including obstetric services. This hospital is one of the better- managed governmental hospitals of Nepal, supported by INF Nepal. It is a referral hospital for surrounding districts. Duration of study in this hospital lasted from 12th Jestha to 2nd Shrawan 2055 (26 May to 18th July 1998).
United Mission Hospital, Tansen, Palpa is one of the reputed hospitals in the western hills region, managed by United Missions to Nepal. It is providing general medical and surgical services, including obstetric services, in the region. The study period in this hospital was from 9th Kartik to 23rd Falgun 2055 (26,0ct 1198 to 7 march 1999).
During this period, 248 grandmultiparas came across in these hospitals, but only 97 were included in this study, because they fulfilled the following criteria: -
- Pregnant for fifth time or more, with 4 previous viable births.
- No previous gynecological surgery or C/S.
- No history of surgical or medical complications.
- No other surgical or medical diseases at present, other than present - pregnancy related.
Before commencing the study the questionnaire was pretested for one week. On that basis, some of the questions were adjusted. Permission was granted from hospital before the commencement of the study.
All persons included in the study were informed about the nature of the study and their right to refuse to be interviewed. Only those who gave consent were included in the study. Then a structured questionnaire was administered to recruited cases, and a detail history was obtained. It included information regarding identification, age, residence, occupation, education, and socio-economic status.
Obstetric history, including age at marriage, gravida, para, living children, youngest child, abortion, last menstrual period (LMP), antepartum haemorrhage (APH) and pregnancy induced hypertension (PIH) was also obtained. A thorough physical examination of the women was carried out next. It was comprised of general, cardiovascular system and respiratory system examination. A full abdominal examination was conducted, ascertaining fundal height, fetal lie, position and presentation and fetal heart rate. Then a pelvic examination was done, and stage of labour ascertained.
All women were then followed up until the time of discharge. All particulars regarding the nature of labour, duration, mode of delivery, indication for intervention and complications, if any, were noted. Fetal outcome in terms of weight was recorded. Apgar score, morbidity, and mortality were recorded. Any woman leaving the hospital without delivery was excluded from the study. 14,488 total deliveries of one year, 2055 BS, in the Maternity Hospital Kathmandu 19 ware taken as control, for comparison.
Data entry and Analysis
A master chart was made and data from the questionnaire was transferred to the chart. Then statistical tabulation and analysis was done. These findings were compared with the control from general obstetric patients (Total deliveries). Using EPI Info version 6, chi-squire was calculated. The final results have been presented in tables and diagrams, and conclusions were drawn.
RESULTS
Altogether 97 eligible GMP's came across during this study: 29 at Western Regional Hospital (WRH), Pokhara; 34 at Maternity Hospital (MH), Kathmandu; and 34 United Mission Hospital (UMH), Tansen. GMP's constitute 8.68 % among total hospital deliveries (based on data analysis of UMN Tansen). Statistics from these three hospitals differ to some extent, as they represent three different regions of Nepal, which is shown in table number 1.
Table No.1.
Particulars / MHK* / W R H P# / U M H T@ / TOTALNo / % / No / % / No / % / No / %
GMP / 34 / 29 / 34 / 97
Normal delivery / 16 / 47.06 / 13 / 44.83 / 9 / 26.47 / 38 / 39.18
Abnormal delivery / 18 / 52.94 / 16 / 15.17 / 25 / 73.53 / 59 / 60.82
CS / 12 / 35.29 / 7 / 24.14 / 9 / 26.47 / 28 / 28.87
Instrumental delivery / 0 / 0 / 1 / 3.45 / 3 / 8.82 / 04 / 4.12
Placenta Praevia / 3 / 8.82 / 1 / 3.45 / 3 / 8.82 / 7 / 7.17
Abruptio Placenta / 1 / 2.94 / 0 / 0 / 1 / 2.94 / 2 / 2.05
APH / 5 / 14.71 / 4 / 13.79 / 8 / 25.53 / 17 / 17.40
PPH / 3 / 8.82 / 2 / 6.90 / 5 / 14.70 / 10 / 10.31
Malpresentation / 4 / 11.76 / 0 / 0 / 1 / 11.76 / 3 / 8.19
Obstructed labor / 2 / 5.88 / 0 / 0 / 1 / 2.94 / 3 / 3.07
PIH / 3 / 8.82 / 2 / 6.90 / 2 / 5.88 / 7 / 7.17
Eclampsia / 1 / 2.94 / 0 / 0 / 0 / 0 / 1 / 1.02
Anemia / 22 / 64.71 / 24 / 82.76 / 19 / 55.88 / 65 / 67.01
IUD / 1 / 2.94 / 1 / 3.45 / 3 / 8.82 / 5 / 5.15
Still birth / 1 / 2.94 / 1 / 3.45 / 1 / 2.94 / 3 / 3.07
NND / 1 / 2.94 / 0 / 0 / 2 / 5.88 / 3 / 3.09
Premature delivery / 11 / 32.35 / 7 / 24.14 / 9 / 26.47 / 27 / 27.83
Past nature delivery / 3 / 8.82 / 1 / 3.45 / 5 / 14.71 / 9 / 9.83
Illiterate / 20 / 58.82 / 17 / 58.62 / 25 / 73.53 / 62 / 63.92
*MHK- Maternity Hospital, Kthmandu
#WRHP-Western Regional Hospital, Pokhara
@UMHT- United Mission Hospital, Tansen
Among 97 GMP 54.64% were of para 4 & 25.77% were para5, mean parity being 4.83, and range, 4 to 10 parity.
Mean age of marriage among GMP was 17(avg) years, with range from as
early as 10 years of age to 27 years of age.
Mean age of GMP was 32.76, with range from 22-44 year.
63.92 % of GMP were illiterate and only one GMP had education of bachelor level.
Pregnancy events: -
Anemia in pregnancy, defined as hemoglobin of lees than 10g/100ml, was very high in GMP. It was present in 65 (67.01%) of GMP. Some of these observations were clinical, Some of the haemogram results were of postpartum period or postoperative period.
Pregnancy induced hypertension was present in 7 (7.17%) and eclampsia in 1(1.03%) GMP. In control eclampsia was 0.21%. In study group eclampsia was 5 times more common. Multiple pregnancy was 4.09% (3 twin & one triplet) in study & 1.19% in control.
Anteparrtum haemorrhage, defined as bleeding per vaginum after 28 weeks of pregnancy but before the birth of the baby was 17 (17.40%) in GMP. History of one or more Abortion present in 16 (16.38%) of GMP.
Intrapartum events: -
Out of 97 GMP's, 59 (60.82%) had abnormal delivery, which in the control was 22.08%. Thus, abnormal delivery in GMP's was nearly 3 times higher than in the control group.
The overall caesarean section was 9.60% in control, and 28.87% in GMP. This is also 3 times higher. The rates of instrumental deliveries were not much different, 4.6 in general and 4.09 in the study group.
Premature delivery, defined as delivery before 37 completed weeks, in this study was 27.83% in GMP's and 2.92% in controls. Postmature delivery,defined as delivery occurring after 2 weeks of expected date of delivery , in the study was 9.28%.
Main reasons for C/S was placenta praevia, which was 7.17%, malpresentation 8.19%, fetal distress 6.16,% abruptio placenta 2.05%.
Postpartum events
Postpartum hemorrhage, blood loss in excess of 500ml following birth of the baby, was 10.31 % in GMP and 0.97% in the controls which was highly significant; (p<0.0000)
Fetal outcome
Low birth weight, birth weight less than 2.5 kgs, was 33.33 % in GMP & 12.5% in general delivery (p<0.0000). Birth weight more than 4 kgs was 4.12% in GMP. Mean birth weight was 2.74 kgs. with SD 1.27 in the study group.
The number of neonates with Apgar Score less than 7 at 1 minute was 37.19% and at 5 minutes it was 9.57%.
Congenital malformation (Anencephaly) was 1.02% in GMP & 0.62% in general obstetrics (p<0.54).
Intrauterine death in GMP was 5.15 and 1.42 % in general obstetrics (p<0.15).
Stillbirth was 3.09in GMP & 0.93in general obstetric (P<0.07).
Neonatal death was 3.09% in GMP & 1.39-% in general obstetric (p<0.16)
There was no maternal mortality in the GMP, 4 death in general delivery I; e 2.76/10000 birth. These comparative data's are shown in the table below with p value.
Comparison between the study and General Delivery
Particulars / G M P (n=97) / General delivery19 (n=14488) / DifferenceNo. / % / No. / %
Normal delivery / 38 / 39.18 / 11289 / 77.92 / p< 0.0000
Abnormal delivery / 59 / 60.82 / 3199 / 22.08 / p< 0.0000
CS / 28 / 28.87 / 1391 / 9.6 / p< 0.0000
Instrumental delivery / 4 / 4.12 / 667 / 4.6 / p<1.00
Premature delivery / 27 / 27.83 / 422 / 2.92 / p< 0.0000
Multiple Pregnancy / 4 / 4.09 / 173 / 1.19 / p<0.03
Breech / 1 / 1.03 / 213 / 1.47 / p<1.00
Eclampsia / 1 / 1.03 / 31 / 0.21 / p<0.21
LBW / 34 / 33.33 / 1817 / 12.54 / p<0.0000
Congenital anomalies / 1 / 1.03 / 90 / 0.62 / p<0.45
IUD / 5 / 5.15 / 206 / 1.42 / p<0.01
Still birth / 3 / 3.09 / 135 / 0.93 / p<0.07
NND / 3 / 3.09 / 202 / 1.34 / p<0.16
PPH / 10 / 10.31 / 141 / 0.97 / p<0.0000
Maternal death / 0 / 0 / 4 / 0.000276
Performing C/S of a GMP under supervision of Dr.Olak Jirel
Anencephaly Neonate of a GMP
Premature baby of GMP
DISCUSSION
Grand multiparous patients have been considered to be at higher risk of developing antenatal, intranatal and postnatal complications. These complications include gestational diabetes, hypertension, anemia, placental abruption, placenta praevia, antepartum, haemorrhage, premature labour, malpresentations, primary uterine inertia, postpartum haemorrhage, and perinatal mortality 14,15,16,17.
This study is the first of its kind in Nepal. This study was done to determine the extent of increased risks associated with GMP. A total of 97 women formed the study group. The data were compared with general obstetric patients who underwent delivery in the Maternity Hospital, Kathmandu in the same year, 2055 BS.
GMP's constitute about 8.68% of hospital deliveries in the study, which was quite high. In a similar study done in Malaysia in 1988, the number of GMP's was 7.5%.15 It was 3% in a study at London done in 1990.14