RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
SYNOPSIS
OF
DISSERTATION
STUDY OF CORRELATION OF MATERNAL HEMOGLOBIN WITH BIRTH WEIGHT, GESTATIONAL AGE AND CORD BLOOD HEMOGLOBIN
Submitted by
Dr. SUMAN FATHIMA
M.B.B.S.
POST GRADUATE STUDENT IN
PAEDIATRICS (M.D)
Under the guidance of
Dr. RAMALINGE GOWDA NISARGA
MBBS, DCh, MD
PROFESSOR AND HEAD,
DEPARTMENT OF PAEDIATRICS
DEPARTMENT OF PAEDIATRICS
ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES,
B.G.NAGARA-571448
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATEAND ADDRESS
(in block letters) / Dr. SUMAN FATHIMA
P.G. IN PAEDIATRICS,
ADICHUNCHANAGIRI INSTITUTE OF
MEDICAL SCIENCES, B.G. NAGARA,
MANDYA DISTRICT -571448
2. / NAME OF THE INSTITUTION /
ADICHUNCHANAGIRI INSTITUTE OF
MEDICAL SCIENCES, B.G.NAGARA.3. / COURSE OF STUDY AND SUBJECT /
M.D. IN PAEDIATRICS
4. / DATE OF ADMISSION TO COURSE / 31ST MAY 20125. / TITLE OF THE TOPIC / STUDY OF CORRELATION OF MATERNAL HEMOGLOBIN WITH BIRTH WEIGHT, GESTATIONAL AGE AND CORD BLOOD HEMOGLOBIN
6. / BRIEF RESUME OF INTENDED WORK
6.1 NEED FOR THE STUDY
6.2 REVIEW OF LITERATURE
6.3 OBJECTIVES OF THE STUDY / APPENDIX-I
APPENDIX-IA
APPENDIX-IB
APPENDIX-IC
7 / MATERIALS AND METHODS7.1 SOURCE OF DATA
7.2 METHOD OF COLLECTION OF DATA : (INCLUDING SAMPLING PROCEDURE IF ANY)
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER ANIMALS, IF SO PLEASE DESCRIBE BRIEFLY.
7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3 / APPENDIX-II
APPENDIX-IIA
APPENDIX-IIB
YES
APPENDIX-IIC
YES
APPENDIX-IID8. / LIST OF REFERENCES /
APPENDIX – III
9. / SIGNATURE OF THE CANDIDATE /10. /
REMARKS OF THE GUIDE
/ The study will be helpful in establishing the relationship between maternal haemoglobin level and their neonatal outcomes in our hospital.11 / NAME AND DESIGNATION
(in Block Letters)
11.1 GUIDE / Dr. RAMALINGE GOWDA NISARGA
MBBS, DCh, MD
PROFESSOR AND HEAD,DEPARTMENT OF PAEDIATRICS,
AIMS, B.G. NAGARA-571448
11.2 SIGNATURE OF THE GUIDE
11.3 CO-GUIDE (IF ANY) / -
11.4 SIGNATURE / -
11.5 HEAD OF DEPARTMENT / Dr. RAMALINGE GOWDA NISARGA
MBBS, DCh, MD
PROFESSOR AND HEAD,DEPARTMENT OF PAEDIATRICS,
AIMS, B.G. NAGARA-571448
11.6 SIGNATURE
12 / 12.1 REMARKS OF THE CHAIRMAN
AND PRINCIPAL / The facilities required for the investigation will be made available by the college
Dr. M.G SHIVARAMU M.B.B.S., MD
PRINCIPAL,
AIMS, B.G. NAGARA.
12.2 SIGNATURE
APPENDIX-I
6.BRIEF RESUME OF THE INTENDED WORK:
APPENDIX –I A
6.1 NEED FOR THE STUDY:
Anaemia is the most common nutritional deficiency disorder in the world. WHO has estimated the prevalence of anemia in pregnant women is 14 % in developed and 51% in developing countries and 65-75 percent in India.1
About one third of the global population (over 2 billion) are anaemic and India has reported high prevalence of anemia in pregnancy.2
Adverse perinatal outcome in the form of preterm and small for gestational age (SGA) babies and increased perinatal mortality rates have been observed in neonates of anemic mothers.
According to WHO criteria Haemoglobin (Hb) concentration of less than 11 gm/dl and haematocrit of <0–33 is declared as anaemia in pregnancy.3
Degrees of anemia
Anemia of pregnancy has been graded into 3 categories depending upon haemoglobin levels (WHO 1986)
1. Mild – 9. To 11 gm/dl
2. Moderate – 7.1 – 9 gm /dl
3. Severe < 7
ICMR categories of Anemia4
Category / Anemia severity / Hb levels1 / Mild / 10-10.9
2 / Moderate / 7-10
3 / Severe / <7
4 / De-compensated / <4
During pregnancy, plasma volume increases by 50 per cent, red cell mass increases by up to 25 per cent and there is a consequent fall in Hb concentration, haematocrit and red cell count because of haemodilution, and this is called physiologic anaemia of pregnancy.5
Anaemia is the commonest medical disorder of pregnancy. Around 30-50 per cent of women become anaemic during pregnancy, with iron deficiency being responsible in more than 90 per cent of cases. The incidence of folate deficiency is around 5 per cent (though it is often under diagnosed) and this is almost always the cause of Megaloblastic anaemia in pregnancy, with vitamin B12 deficiency being rare6
In India, the prevalence of anaemia is high because of
1. Low dietary intake, poor iron (less than 20 mg /day) and folic acid intake (less than 70 mg/day);
2. Poor bioavailability of iron (3-4% only) in phytate and fibre-rich Indian diet; and
3. Chronic blood loss due to infection such as malaria and hookworm infestations7,8
Other causes:
1. Anemia before pregnancy
2. Recurrent pregnancies
3. Early teenage pregnancies
4. Multiple pregnancies
The extent up to which, maternalanaemia effectsmaternaland neonatal health is still uncertain.Maternal iron deficiency and anaemia render the offspring vulnerable for developing iron deficiency and anaemia right from infancy.
Foetal consequences of anaemia
Studies to define the effect of maternal anaemia on the foetus indicate that different types of de-compensation occur with varying degrees of anaemia. Most of the studies suggest that a fall in maternal haemoglobin below 11.0 g/d1 is associated with a significant rise in perinatal mortality rate. There is usually a 2 to 3-fold increase in perinatal mortality rate when maternal haemoglobin levels fall below 8.0 g/d1 and 8-10 fold increase when maternal haemoglobin levels fall below 5.0 g/dl. A significant fall in birth weight due to increase in prematurity rate and intrauterine growth retardation has been reported when maternal haemoglobin levels were below 8.0 g/dl9,10.
Anemia effect on fetus11
1. In neonates of anemic mothers adverse perinatal outcome in the form of preterm and SGA babies and increased perinatal mortality rates have been observed.
2. Babies born to iron deficient mothers, have little or no iron stores and are at risk of infection and poor growth.
3. Studies have suggested behavioural abnormalities in children with iron deficiency and poor performance in the BAYLEY scale of infant development.
4. Increased incidence of hypertension and cardiovascular disease in adult life.
5. Intrauterine growth restriction (IUGR).
6. Preterm birth.
7. Intrauterine death (IUD) due to severe placental insufficiency.
8. Long term consequences in babies born to mothers with severe anemia have reduced cognitive skills and impaired schooling later. This is said to be due to the deficiency of chemical mediators in fetal brain as a result of maternal iron deficiency.
The weight of the infant at birth is a powerful predictor of infant growth and survival, and is dependent on maternal health and nutrition during pregnancy. Birthweight is the single most important marker of adverse perinatal, neonatal and infantile mortality and infant and childhood morbidity.12
Birth weight has been universally used as a measure of intrauterine growth, because of its correlation with gestational age.
WHO has estimated 5 million neonatal deaths globally occur every year. According to WHO 2010 in India 55-60 % of infant death occur in neonatal period. Over 80 % of all neonatal deaths in both the developed and developing countries occur among the low birth weight babies.12
About twenty nine percentof infant mortality is associated with lowbirth weight (LBW)in India and about 25-35% of babies in India are LBW.13
LBW- the international definition of low birth weight adopted by the 29th world health assembly is a birth weight of less than 2500 gm.14
Low birth weight leads to an impaired growth of the infant with its attendant risks of a higher mortality rate, increased morbidity, impaired mental development and the risk of chronic adult disease.
Preterm is defined as a baby with a gestation of less than 37 completed weeks (up to 36 weeks or less than 259 days15.
Preterm birth, is the major clinical problem associated with perinatal mortality, serious neonatal morbidity and moderate to severe childhood disability.
Preterm infants are at higher risk for a number of acute and chronic disorders, including nosocomial infections, hypothermia, respiratory distress syndrome, aspiration, patent ductus arteriosus, necrotizing enterocolitis, intraventricular hemorrhage.
Long term consequences in preterm babies being retinopathy of prematurity, developmental disability, chronic lung disease, poor growth, increased rate of post natal illness cerebral palsy and re-hospitalisation and severe learning problems.
Most of the neonatal deaths are associated with preterm delivery and birth weight under 1500g. Thus, birth weight is considered to be important determinant of the chances of an infant to survive, grow and mature.
Cord blood refers to the sample of blood collected from the umbilical cord when the baby is born. Cord blood hemoglobin is an important index of hematologic status in newborns at birth and gives a clue to the state of health of both pregnant mothers and their newborns. It is also routinely been used in diagnosis of neonatal anemia and polycythemia.
Hemoglobin increases with advancing gestational age: at term, cord blood hemoglobin is 16.8g/dL (14-20g/dL); hemoglobin levels in very low birth weight (VLBW) infants are 1-2g/dL below those in term infants. A hemoglobin value less than the normal range of hemoglobin for birth weight and postnatal age is defined as anemia16
The mean cord blood haemoglobin value for the baby in Western Europe is reported to be 16.8 g/100 ml and it has been suggested that any value below 13.6 g/100 ml should be considered as foetal anaemia. Prevalence of foetal anaemia is high in areas where malaria and iron deficiency anaemia in pregnancy are common.
Birthweightandgestationalagehave traditionally been used as strong indicators for the risk of neonatal death.
Inview of importance attached to increased prevalence of low maternal hemoglobin and a lot of maternal and fetal complications, associated with it the present studywill becarried out at Adichunchanagiri Institute of Medical Sciences, B.G Nagara with the purposeto knowthe association between maternal hemoglobin levels and its effect on the newborn baby through the study of gestational age at birth, cord blood haemoglobin level and the newborn birth weight. This would provide base line data for indigenous population and can be compared with similar reports.
APPENDIX –I B
6.2 REVIEW OF LITERATURE
The importance of anemia as a major public health problem throughout the world is commonly recognized. Anemia in pregnancy is a common problem in most developing countries and a major cause of morbidity and mortality especially in malaria endemic areas. Fifty seven percent women amongst the anemic mother had low birth weight babies. Children with APGAR score< 7 were more amongst anemic women as compared to non-anemic. Anemia Apart from the risk to the mother, is also responsible for increased incidence of premature births, low birth weight babies and high perinatal mortality.17
WHO has estimated that prevalence of anaemia in developed and developing countries in pregnant women is 14 per cent in developed and 51 per cent in developing countries and 65-75 percent in India. About one third of the global population (over 2 billion) are anaemic.18
The prevalence of anaemia among newborn babies from 36 anaemic pregnant women was 22.2% which three of neonates were female while five of them were male. There were also significant differences in neonatal weight, length and head circumference among anaemic and non-anaemic groups as maternal haemoglobin and hematocrit levels rise, a considerable increase is observed in the weight, length and head circumference of neonates born to normal mothers than those to the anaemic ones.19
A positive correlation between the mother’s haemoglobin and haematocrit in the third trimester and her infant’s haemoglobin and haematocrit at 9 months of age has been found in several studies. Also gestation time mean haemoglobin concentration of cord blood increases during the last two weeks of gestation and continues to increase in infants born after the 40th week of pregnancy as a result of progressive oxygen lack.20
Lone et al., in a multivariate analysis of their study population showed that the risk of low birth weight babies in the anaemic population was 1.9 times higher (95% CI= 1.0–3.4) They also studied 626 pregnant women and found that preterm birth risk was 4 times, low birth weight risk was 1.9 times, low APGAR score was 1.8 times and intrauterine fetal death was 3.7 times more common in anemic pregnant women compared to non anemics.21
Jones et al also found an increased incidence of low birth weight babies in anaemic mothers, how ever the difference from the non anaemic group in their study was non significant (p=0.11).22
Singla et al., have reported that the birth weight, head circumference, chest circumference, mid-arm circumference and crown heel length were significantly lower in infants born to mothers with moderate and severe anaemia, in comparison to infants born to nonanaemic mothers They found that the levels of haemoglobin, serum iron; transferrin saturation and ferritin were significantly low in the cord blood of anaemic women than non anaemic ones, indicating that, iron supply to the fetus was reduced in maternal anaemia.23
In several studies, a U-shaped association was observed between maternal hemoglobin concentrations and birth weight. Abnormally high hemoglobin concentrations usually indicate poor plasma volume expansion, which is also a risk for low birth weight.24
In an analysis of 3728 deliveries in Singapore, 571 women who were anemic at the time of delivery had a higher incidence of preterm delivery than did those who were not anemic, but no other differences ineither pregnancy complications or neonatal outcomes wereobserved.25
In the Jamaican Perinatal Mortality Survey of > 10 000 infants in 1986, there was an <50% greater chance of mortality in the first year of life for those infants whose mothers had not been given iron supplements during pregnancy.26
Colomer et al analyzed the relation between the hemoglobin concentration of pregnant women and the risk of anemia in their infants at 12 months of age. Infants born to anemic mothers were more likely to become anemic themselves, when feeding practices, morbidity and socioeconomic status were controlled for.27
In study conducted by Elise M. Laflamme 64.3 % of anemic subjects experienced some type of birth complications, only 15.4 % of non anemic subjects faced these problems.28
Levy A et al. in their retrospective study, evaluated the preterm birth and birth weights of the anemic pregnant women and determined the maternal anemia as an independent risk factor for preterm birth and low birth weight, no association was found with bad perinatal outcome in their study.29