Patient's profile with Hypertension in Pregnancy Patients

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Patients Profile with Hypertension in Pregnancy

at Sanglah Hospital in 2009-2010Profil Penderita Hipertensi Dalam Kehamilan

di RSUP Sanglah Denpasar Tahun 2009-2010

Hendrik Sutopo, I Gede Putu Surya

Department of Ostetri!s and "#ne!olog#$

%edi!al &a!ult# of Uda#ana Uni'ersit#(

Sanglah Hospital Denpasar - )ali

Abstract

Objective To report the profile of patients with Hypertension in Pregnancy (HIP)

at Sanglah Hospital Denpasar from !!" until !#!$

!etho"s % retrospecti&e descripti&e study from all HIP patients at SanglahHospital Denpasar, 'ali during anuary !!" until Decemer !#!$

#es$ltsThe pre&alence of HIP at Sanglah Hospital was ",*+, which consists of

#$+ gestational hypertension, !$#"+ chronic hypertension, #$*-+ mild preeclampsia,

.$/!+ se&ere preeclampsia, !,.*+ superimposed preeclampsia, and !$+ eclampsia$

0rom all of HIP cases, we found that the ma1ority were nulliparous (./,*+),

primipaternality (2*$#+), and known hypertension at term (2#$"+)$ 3ost of the cases

was found at maternal age 4 *2 years (#.,-+), followed y age 5 ! years (#*$./+)$

3ost of the cases had %nte 6atal 7are (%67) fre8uency 9 . times (-",!"+), and the

most of them had %67 at midwife (2,/-+) then followed at :;Gyn (.!,#+)$ The

ma1ority of the cases were referral case (-,*"+) with the ma1ority cases were referred

y midwi&e (,.2+)$ 0rom all of the cases, we found that total preterm laour was

*2,#.+, perinatal mortality was ",*+ and maternal mortality was #$#-+$

%oncl$sionThe pre&alence of HIP at Sanglah Hospital was higher than pre&ious

years$ The most of HIP cases already had %67 y health care pro&iders, and the

ma1ority health care pro&iders were midwi&e and :;Gyn$ Therey, the 8uality of %67

seems necessary to e impro&ed y earlier refferal system, so the cases can e treated

earlier$

&eywor"shypertension in pregnancy, preeclampsia and eclampsia, descripti&e

Correspondence: Hendrik Sutopo, Department of :stetrics and Gynecology, SanglahHospital, Denpasar$ Telephone< !#-=-#22/-, >mail


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aies orn from preeclamptic patients

has intrauterine growth restriction.$

Preeclampsia also increases the

perinatal mortality in de&eloped

countries up to 2 times higher#$

In Indonesia, the incidence of HIP

range from *$. to $2+ and it is still the

second cause of maternal death (.+),

after hemorrhagic post partum2$ 0rom

the pre&ious studies at Sanglah Hospital,

it was reported that the pre&alence of

HIP during !!. until !!2 was -$!-+

(mild P> $.-+, se&ere P> $2/+, and

eclampsia !$-#+)-, and during !!

until !!* was 2$*+ (mild P> $!*+,

se&ere P> $.-+, and eclampsia

!$*"+)/$ In #""/ at Sanglah Hospital, a

special study reported that the

pre&alence of se&ere preeclampsia was

#$+ andeclampsia was !$2+$

There are many risk factors for HIP,

especially preeclampsia, which can e

grouped into the following risk factorsSCTS

During years period of the study

*,-/" deli&eries were recorded and

found *.* or "$*+ cases of HIP, which

consists of gestational hypertension

#$+, chronic hypertension !$#"+,

mild preeclampsia #$*-+, se&ere

preeclampsia .$/!+, superimposed

preeclampsia !$.*+ and eclampsia!$+$

The pre&alence of HIP in the

maternal age 5! years was #*$./+, for

age !=*2 years was $!.+ and for the

age 4*2 years was #.$-+$ 3ost of the

cases (2*$#+) were primipaternality$ It

was re&ealed that ./$*+ from all cases

were nulliparous, followed y *$//+

were the second or third pregnancy, and

#*$""+ were the fourth or more

pregnancy$ 6ulliparous was the ma1ority

in each group for mild preeclampsia

(.-+), se&ere preeclampsia (./$.!+),

and eclampsia (-*$*+)$

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0rom all the cases, we otained

-"$!"+ patient had %67 fre8uency

more than . times, and /$"+ had

%67 fre8uency etween # to . times$

3ost of the cases had %67 at the

midwi&e (2$/-+), followed y :;Gyn

(.!$#+)$ :nly $"2+ of the cases who

ne&er check their pregnancy$ In e&ery

sugroup of HIP is almost entirely

dominated y the fre8uency of %67 4

.B, which are //$-+ for gestational

hypertension, #!!+ for chronic

hypertension, -+ for mild

preeclampsia, -.$/+ for se&ere

preeclampsia, #$2+ for SiP>, and -*,

**+ for eclampsia$

3ost of HIP cases at Sanglah

Hospital (-$*"+) were referral case

and the ma1ority referrer (.$+) was

midwi&e$ >specially for the eclampsia

group, the ma1ority referral cases came

from other hospitals (2$"+)$

3a1ority of the cases (2#$"!+)

were known to ha&e high lood pressureat term or 4*/ weeks$ 0or each

sugroup of HIP, which were

preeclampsia (/!+), superimposed

preeclampsia (.*$/2+), and se&ere

preeclampsia (2$-+) were known for

high lood pressure at the gestational

age etween 4=*/ weeks$ 0rom

se&ere preeclampsia group, the most of

systolic pressure ("#$*+) was in the

range of #-!=#/" mmHg and diastolic

pressure (/*$""+) was in the range of

##!=##" mmHg$ 0or eclampsia group,

-!+ systolic lood pressure was

otained at the range of #-!=#/" mmHg

and also -!+ diastolic lood pressure

was otained at the range of ##!=##"

mmHg$

The proportion of H>P

syndrome from all the HIP cases was

#2$/+$ The highest pre&alence of

H>P syndrome was found in

eclampsia group (.-$#2+), followed y

the se&ere preeclampsia (#$.+) and

superimposed preeclampsia (#$/2+)$

3ost of seiEures in eclampsia occured

during the antepartum period (!+)$

@hile the pre&alence of intrapartum and

postpartum seiEures was #!+,

respecti&ely$

3a1ority deli&ery mode of HIP

cases were spontaneous &aginal deli&ery

(*-$..+), followed y 7esarean Section

(7S) (*.$##+) and forceps eBtraction

(2$./+)$ >specially for the se&ere

preeclampsia group, the ma1ority of

deli&eries assisted y forceps eBtraction

(.-$.+) followed y 7S (.$//+)$ In

the eclampsia group, 2*$**+ were orn

y 7S$ :nly !$/+ of the HIP caseswere treated y conser&ati&e treatment

ecause of preterm gestational age$

0rom all HIP cases we otained the

rate infants irth weight less than 2!!

grams was *2$#.+$ 3ean while, the

pre&alence of ICGA was $+$ The

perinatal mortality rate was "$*+,

which consists of *$!+ intrauterine

fetal demise and -$#+ early neonatal

mortality$ @hen &iewed from the total

numer of perinatal deaths at Sanglah

Hospital, its otained that #*$2+ of

perinatal mortality associated with HIP$

0rom total ! cases of all maternal

mortality at Sanglah Hospital, it was

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found four cases of maternal mortality

related to HIP (!+)$ The four maternal

cases was #$#-+ from total HIP cases$

These four cases respecti&ely were (#)

se&ere preeclampsia with pneumonia

and sepsis, () eclampsia with multi=

organ failure, (*) eclampsia with solutio

placenta complicated y DI7, and (.)

eclampsia with complications of 7F%

(cerero&ascular accident)$ 0rom all

maternal deaths, 2!+ of them suffered

H>P syndrome$

0rom all HIP cases, it was otained

that patients length of stay in hospital

etween !=* days were 2$//+, .=/

days were *"$".+, and =#! days were

.$--+$ :nly $-+ were stay more than

#! days in hospital$

DIS7CSSI:6

0rom this study was found that the

pre&alence of HIP (included the mild

P>, se&ere P>, and eclampsia) washigher when compared with the

pre&ious years at Sanglah Hospital$

The difference of pre&alence can

e influenced y many factors such as

patient characteristics, genetic factors,

etter referral system and etter %67

8uality to screen HIP cases$ 0or patient

characteristics, it was influence y

maternal age 5! years or 4*2 years,

nulliparous, or primipaternality*,##,#$ 0or

genetic factors, currently in 'ali and

especially at Sanglah Hospital, many

patients came from other 'alinese

ethnic$ Since the patients were more

pluralistic, it needs further in&estigation

whether genetic factors (e$g certain

ethnic) influence the occurrence of HIP$

:n the other hand, the refferal system

could ha&e an important factor that

could alter the pre&alence rate of HIP$

There was a tendency that patients with

se&ere preeclampsia or eclampsia in

'ali will e referred to Sanglah Hospital

ecause of some reasons$ @e elie&ed

that these refferal system could increase

the proportion of HIP cases at Sanglah

Hospital, which in turn could affected

the data that we otained$

HIP cases mostly found in the age

group4 *2 years and was followed y

age group 5! years$ These result was

similar to most studies that show a =

shaped cur&e for relationship etween

maternal age and the incidence#.$ :lder

or younger maternal age mean higher

risk for HIP, ut higher incidence in

those who more than *2 years old*, #.$

'ased on the numer of pregnancies, we

otained the highest pre&alence of HIPwas in nulliparous and primipaternality$

These findings was also fit with the

literatures, where it was suspected

associate with immunological processes

ecause of eBposure to paternal

antigens*,#,#*$ High pre&alence rate of

HIP on primipaternality cases should e

gi&en more attention when perform

%67$ %ssociated with the risk for

preeclampsia, primipaternality should

e regarded as nulliparous#*, #.$

3ost patients with HIP had %67

fre8uency 9 .B$ 3ost of them checked

their pregnancy at midwife and then

followed y :;Gyn, and only $"*+

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cases were ne&er control their

pregnancy$ This suggests that the %67

program had a good co&erage and the

midwife was the primary health

pro&ider for %67$ 'ut in most cases

(2#$"!+) high lood pressure known

when gestational age at term$ @hile the

literature says the ma1ority of HIP cases

known in late pregnancy or near term#.$

This differentiation maye related to the

8uality of the %67 which was still

unoptimal$

%t Sanglah Hospital, the

pre&alence of H>P syndrome appears

to e related with se&erity of the

disease$ It otained from our study that

2!+ of maternal deaths were

accompanied y the presence of H>P

syndrome$

0rom total cases of HIP, the

ma1ority deli&ery mode were

spontaneous &aginal deli&ery (*-$..+),

followed y 7S (*.$##+) and forceps

eBtraction (2$./+), whereas only!$"+ with &acuum eBtraction$

>specially for se&ere preeclampsia, the

deli&ery mode ma1ority assisted y

forceps eBtraction (.-$.+)$ It seems

that we need further e&aluation to

determine the est deli&ery method for

HIP cases, especially for se&ere

preeclampsia and eclampsia, so

maternal and perinatal moridity rate

could e kept as low as possile$

3aternal mortality rates from HIP

cases at Sanglah Hospital was #$#-+$

%fter we counted from the total ! cases

of all maternal deaths in =years periode

of this study, maternal deaths related to

HIP was counted as many as . cases

(!+)$ This was consistent with the

literature in de&eloped countries, where

maternal mortality rate related to HIP

was etween #2=!+*,#,#.$

7:67CSI:6

The pre&alence of HIP at Sanglah

Hospital is higher than pre&ious years$

HIP cases were dominated y se&ere

preeclampsia$ The ma1ority of HIP

characteristic patients were nulliparous

and primipaternality$ 3ost of the cases

already had %67 y health care

pro&iders, which are midwi&es and

doctors$ Therey the 8uality of %67

might e necessary to e impro&ed y

earlier refferal system to referal hospital,

so the cases can e treated earlier$

A>0>A>67>S

#$ Aoerts 3, Pearson G, 7utler ,indheimer 3$ Summary of 6H'I

@orking Group on Aesearch on

Hypertension During Pregnancy$

Hypertension !!* .#< .*/=.2$

$ @orld Health :rganiEation$ Gloal

Program to 7on8uer Preeclampsia ;

>clampsia$ !!$ 7itied !#! %ug$

J %&ailale from , ed$ DanforthMs ostetrics and

gynecology$ #!th edition$

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Philadelphia< ippincott @illiams N

@ilkins, !!< 2=--$

.$ %uer , 7amoin , Guillonneau 0,

Aigourd F, 7heli ST, educ 3, et

al$ Serum Profile in Preeclampsia and

Intra=uterine Growth Aestriction

Ae&ealed y iTA%O Technology$

ournal of Proteomics !#! /*

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Patient's profile with Hypertension in Pregnancy Patients