Evaluation of Total Protein and Lipid Profile in Pre-eclamptic Patients Attending Antenatal Care
Chapter One
AIM AND OBJECTIVES
AIM
To estimate total protein and lipid levels in women with preeclampsia and in women with normotensive pregnancy in Federal Medical Center, Owerri.
OBJECTIVES
- To compare the mean total protein and lipid level in preeclamptic women and normotensive women in FMC, Owerri.
- To determine the relationship between the mean total protein and lipid levels and age, parity and gestational age in the two
- To determine the correlation between mean total protein and lipid levels and the severity of the
CHAPTER TWO
LITERATURE REVIEW
HISTORY OF PREECLAMPSIA
Preeclampsia is almost certainly the result of multiple factors. Although it is thought that abnormal placentation and placental function is a central predisposing factor, there are also a host of contributing, often related factors that complicates finding a specific mechanism for preeclampsia.10 Seizure disorder in pregnancy was recognized as early as 400 B.C. by Hippocrates. During the time, the term eclampsia emerged, a Greek word that literally translated to “shine forth” implying sudden development.28 Later in the mid nineteenth century, in Guy’s hospital, it was found that the women with seizures also had albuminuria.29
With the advent of sphygmomanometer, it was noticed that this condition was preceded by raised blood pressure, hence the name pre-eclampsia. Nevertheless, only a small percentage of these women (0.05%-0.1%) will subsequently develop fits (eclampsia), the reason the term preeclampsia received criticism.30 In the very recent past, preeclampsia was referred to as toxemia of pregnancy, a term that originated in the erroneous belief that toxins in the blood was responsible for the condition.31,32 The mistaken term has since been dropped.
Edema was originally considered as an important sign to make a diagnosis of preeclampsia but has presently been deemphasized as a diagnostic criterion because edema is a common physiologic response in pregnancy.33 However, rapidly increasing edema is worth reporting to the clinician.
CLASSIFICATION OF HYPERTENSION IN PREGNANCY
Hypertension is defined as systolic blood pressure of ≥140 mmHg and/or diastolic blood pressure of ≥ 90 mmHg measured on two separate occasions at least 4-6 hours apart. There are different classifications of hypertension in pregnancy and includes but not exclusive to the classification by the International Society for the Study of Hypertension in Pregnancy (ISSHP), and the classification by The National High Blood Pressure Education Program (NHBPEP). For the purpose of this study, the classification by ISSHP shall be elucidated. According to ISSHP, hypertension in pregnancy is classified thus: preeclampsia-eclampsia; gestational hypertension; chronic hypertension (essential or secondary); preeclampsia superimposed on chronic hypertension.34
Preeclampsia is gestational hypertension with proteinuria. Eclampsia refers to seizures that cannot be attributed to other causes in a woman with pregnancy induce hypertension. Gestational hypertension is defined as de novo arterial hypertension occurring after 20 weeks of gestation without proteinuria which returns to normal within 12 weeks post-partum. Chronic hypertension is hypertension predating pregnancy or noted before 20 weeks of gestation without proteinuria or hypertension. It usually persists after 12 weeks postpartum. Preeclampsia superimposed on chronic hypertension is the appearance of de novo proteinuria starting after 20 weeks of gestation in a known hypertensive.34
PROTEINURIA
The gold standard for diagnosing abnormal proteinuria in pregnancy is a 24 hour urinary protein ≥300 mg per day.35 Spot urine protein/creatinine ratio, a value ≥ 30 mg per mmol (0.26 mg/mg, usually rounded to 0.3 mg/mg) also represents significant proteinuria.36 In the absence or unavailability of 24 hour measure of proteinuria, or spot urine protein/creatinine ratio, dipstick testing provides reasonable assessment of proteinuria especially when values are > 1 g/liter, i.e 2+.36, 37 However, the use of dipstick is not as accurate as the 24 hour urine measure of proteinuria38.
CHAPTER THREE
METHODOLOGY
STUDY SETTING
This study was conducted among pregnant women receiving antenatal care in the Department of Obstetrics and Gynecology of the Federal Medical Center (FMC), Owerri, Imo State, south-east Nigeria. FMC, Owerri is a tertiary health facility which provides health care to the people in the city of Owerri as well as neighboring towns and semi-urban settlements. It also receives patronage from other big cities such as Aba and Umuahia in Abia State, and Port-Harcourt in Rivers State. The average antenatal attendance rate in the center per month is 3,058 and about 19.65% of these are booking visits. An average of 350 deliveries take place every month in its labor ward.
Imo state has an estimated population of about 4.6 million people with about 470,000 of this residing in the Owerri area. An estimated 130,000 (26.87%) of this are women of reproductive age.81 Owerri is mostly inhabited by civil servants and traders with varying financial capabilities. Transportation business as well as artisanry is also practiced. Many inhabitants of the suburbs are farmers.
STUDY POPULATION
The study population wascomprised of 2 groups of pregnant women. Group A: Women with established diagnosis of preeclampsia as cases. Group B: Normotensive pregnant women as controls
Group A was further divided into 2 subgroups comprising those with mild and those with severe preeclampsia.
STUDY DESIGN
The study was a case control study of preeclamptics as cases and normotensive pregnant women controls.
CHAPTER FOUR
RESULTS
Table 1 shows that a large proportion of the women studied and their husbands had tertiary education, 69% and 61.2% respctively. Most of the patients were either civil servants (31%) or traders (27.6%) or housewives (27.6%). Only a small pecentage were students (13.8%).
CHAPTER FIVE
DISCUSSION
Preeclampsia is the commonest medical disorder in pregnancy and has remained a disease of theories. Many researchers in the last decade have tried to identify the relationship between dyslipidemia and preclampsia. In this study, the cases and the controls were matched for age and parity. It was found that the participants were ages between 20 and 40 which is the reproductive age group. The mean age for the cases and controls was similar to the findings in some other studies.27,72,88 Pre-eclampsia was found most in primigravidae representing 60% of those with mild form of the disease and 31.6% of those who had severe disease. This is in keeping with available body of knowledge.89
This study showed a significantly higher values of tryglyceride and very low density lipoprotein in the preeclamptic groups when compared with the normotensive group. This finding has been commonly demonstrated in other studies.75-78,88,90 There was no significant difference in the values of total cholesterol, and low density lipoproptein. This is comparable with other studies.78,88 Singh et al, apart from finding a significant difference in very low density lipoprotein, also found a significant difference in the values of total cholesterol and low density lipoprotein.74,91 This is in contradistinction to the findings of this study. The difference might be due to variation in the study population. While in this study women were selected from 20 weeks gestational age and above, in the above study by Singh et al, the study population was chosen from pregnant women prior to 20 weeks gestational age.
This study also found a significant difference in all lipid fractions in the age group 26 to 30 years. A similar finding was seen in the age group of 36 to 40 years where all lipid fractions but the high density lipoprotein was found to be significantly different across the groups. This may indicate an increase in the chances of dyslipidemia with increasing age as is known.79,92
The period between the late second trimester and early third trimester (26-30 weeks) and period around term (36-40weeks) showed significantly higher values of triglyceride and very low density lipoprotein in the preeclamptic groups albeit abnormal. There was also a significant difference in the values of HDL in the gestational age group 26-30 weeks. This is similar to the findings of Irinyenikan et al where triglyceride, high density lipoprotein and very low density lipoprotein where significantly higher in the third trimester in preeclamptics when compared to normotensive women.27 Other studies have made a similar suggestion.79,93
Primigravidity is a common risk factor for preclampsia and studies have often depicted the disease condition commonly occurs in primigravidae.14 In this study, it was equally found that primigravidity was not just a risk factor for the disease but the findings of statistically significant difference in the triglyceride and very low density lipoprotein was reflective reflective of what was found in the general population studied.
There was a positive correlation between serum levels of triglyceride and very low density lipoprotein with the severity of the disease. In this study even though it is only that of VLDL that shows a strong positive correlation. This is similar to what was found in some other studies.27,75 The study by El Khouly NI et al did not find a positive correlation between VLDL and the severity of the disease probably due to the recruitment of women of gestational age of less than 20 weeks in the study population. It is believed that the elevated level of very low density lipoprotein is due to hypertriglyceridemia leading to enhanced entry of very low density lipoprotein that carries endogenous triglyceride into circulation and by doing so gets deposited on the maternal uterine and renal vascular endothelium causing injury to it.94
STRENGTH AND LIMITATION OF THE STUDY DESIGN
The controls were gotten from eligible consenting normotensive women following each preeclamptic recruited for this study and in doing so, the cases and the controls were matched for age and parity limiting bias that could have arisen if it was done otherwise. The large sample size of 116 as compared to the studies above gives this study a better power.
The limitation in this study design is the fact that dietary differences in the patients were not taken into consideration. The outcome of this study will be difficult to apply in patients who will develop preeclampsia early, say around 20 weeks of gestational age because of the choice of women (≥ 20 weeks gestation) recruited for this study.
CONCLUSION
The preeclamptic parturients in Imo State have higher lipid levels than their normotensive counterparts. Even though there is a rise in the lipid fractions during pregnancy, the increment is greater in preeclamptic women especially in the levels of triglyceride and very low density lipoprotein. The rise in the level of very low density lipoprotein is directly proportional to the severity of the disease.
RECCOMMENDATION
In the face of disappointing biochemical and clinical tests done in predicting the women at risk of developing the disease, testing the triglyceride levels and very low density lipoprotein in high risk women could be useful in the early detection of parturients who will develop the disease and subsequently improve their outcome.
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- Moodley J. Maternal deaths associated with hypertensive disorders of A population based study of hypertension in pregnancy. 2004;23:247-256.
- Sibai BM, Caritis S, Hauth J. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units What we have learned about preeclampsia. Semin Perinatol 2003;27:239.
- Hutcheon JA, Lisonkova S, Joseph KS. Epidemiology of Preeclampsia and the pther hypertensive disorders of Best Pract Clin Obstet Gynecol 2011;25:391.
- Audu LR, Ekele A ten year review of maternal mortality in Sokoto, Northern Nigeria. W Afr J Med 2002;2(1):74-76.
- Sibai prevention of preeclampsia: a big disappointment. Am J Obstet Gynecol 1998; 179:1275-1278.
- Kuklina EV, et Hypertensive Disorders and Severe Obstetric Morbidity in the United States. Obstet Gynecol 2009;113:299-306.
- Maternal Morbidity in 2005: estimates developed by WHO, UNICEF, UNFPA and The World Bank, Geneva, World Health Organisation, 2007.
