Prevalence of Hypertensive Disorder of Pregnancy in North India

Aims and Objective: Hypertensive disorders of pregnancy (HDP) are among the commonest medical disorders during pregnancy constituting one of the greatest causes of maternal and perinatal morbidity and mortality worldwide . This study aimed to analyze the prevalence of hypertensive disorder of pregnancy in North India Material and Method: The study group consisted of a total of 150 pregnant women attending Maharaja Agrasen hospital OPD/IPD during their second trimester (14-20 weeks) of pregnancy from Dec 2016 to Nov 2017. Results: Out of 146 cases studied , 129 cases remained normotensive and 17 cases developed HDP. Out of 17 cases ,8 cases had mild HDPs and 9 cases had severe HDPs. The prevalence of HDP was 11.7% in present study. Conclusion: The study concluded that the incidence of hypertensive disorders in pregnancy was higher than worldwide average and hence early diagnosis and intervention through regular antenatal checkup is pivotal to prevent hypertensive disorders of pregnancy and its complications.


Introduction
Hypertensive disorders of pregnancy (HDP) are among the commonest medical disorders during pregnancy constituting one of the greatest causes of maternal and perinatal morbidity and mortality worldwide. [1][2][3][4] HDP complicate up to 5-10% of all pregnancies. 5 It accounts for 10-15% of maternal deaths specially in the developing world. 6 The spectrum of disease ranges from mildly elevated blood pressures with minimal clinical significance to severe hypertension and multi-organ dysfunction .Besides perinatal death ,HDP lead to preterm delivery, fetal intrauterine growth restriction, low birth weight. HDP can also trigger severe forms of maternal complications, such as cardiovascular and cerebrovascular diseases, liver and kidney failure, placental abruption, disseminated intravascular coagulation (DIC) and HELLP syndrome.
Hypertension in pregnancy is defined as a systolic BP of 140 mmHg and higher, and a diastolic BP of 90 mmHg and higher. Severe pregnancy hypertension is defined as SBP ≥160 mmHg or a DBP ≥110 mmHg. The systolic value was reduced from 170 mmHg by most international societies after recognition that a SBP≥160 mmHg is associated with an increased risk of stroke in pregnancy.
Hypertensive disorders during pregnancy are classified into four categories, as recommended by the National High Blood Pressure Education Program (2000) Working Group on High Blood Pressure in Pregnancy 7 : • Gestational hypertension (transient hypertension of pregnancy) • Preeclampsia-eclampsia  Diagnostic criteria for Gestational Hypertension was new onset of hypertension (≥140 mmHg systolic and/or ≥90 mmHg diastolic) after 20 weeks gestation without Proteinuria and signs of end organ dysfunction.
Diagnostic criteria for Pre-eclampsia (revised ISSHP, 2014) was Hypertension after 20 weeks gestation and the coexistence of one or more of the following new-onset conditions: 1. Proteinuria (spot urine protein/creatinine >30 mg/ mmol [0.3 g/mg] or >300 mg/day or at least 1 g/L['2 + '] on dipstick testing).

Uteroplacental dysfunction (foetal growth restriction)
Diagnostic criteria for Eclampsia was Preeclampsia associated with convulsion. The mean age of normotensive group was 27.86+/-3.71, whereas in Mild HDP and Severe HDP group was 29.87+/-4.63 and 29.11+/-4.40. There was statistically no significant difference between age of three groups.

Observation & Results
Corrected Chi-square () test ( =13.28; p=0.10 NS-Not Significant) showed that there was no significant association between age and cases of the three groups (p=0.10). Thus the cases of the three groups were more or less equally distributed over age.  One ANOVA showed that there was no significant difference between the mean age of the cases of the three groups (F 2,143 =2.11;p=0.12). Thus the cases of the two groups were age matched. Out of the 146 cases under study 129(88.4%) cases were normotensive, 8(5.5%) were Mild HDP and rest 9(6.2%) were severe HDP. In overall 17(11.7%) were HDP. Thus the prevalence of HDP was 11.7%.

Discussion
Hypertensive disorders of pregnancy (HDP) is a major challenge in overcoming pregnancy complications that are responsible for poor maternal and prenatal outcome in developed as well as underdeveloped countries of the world. These disorders comprise of chronic hypertension, gestational hypertension, preeclampsia and eclampsia.
The spectrum of HDP ranges from mildly elevated blood pressures with minimal clinical significance to severe hypertension and multi-organ dysfunction.
In my study, 150 cases were initially enrolled. However, only 146 cases (97.3%) could be evaluated for the final results. The 4 cases were lost to follow up.
These cases were divided into two groups: • Group A -who developed HDP.
• Group B -who remained normotensive Group A was divided further into two group i.e. Group A1 and Group A2 based on features of severity. Cases in Group A1 were mild hypertensive and A2 were severe hypertensive.
The mean age of the cases for my study was 27.86 (Group B normotensive) 29.87 (Group A1, mild hypertensive) and 29.11 (Group A2 ,severe hypertensive).
There was no statistically significant correlation found between the age and the occurrence of HDP which was in concordant with the results of study conducted by Vishal Sharma et al (2016) 7 , who observed that there was no statistically significant difference between age of subjects and HDP. 76.34 % of the patients in my study were between 21 and 30 years of age thus rendering a very young population morbid and at risk of mortality.
The prevalence of HDPs observed in my study is 11.7 % . Incidence of hypertensive disorders in India is found to be 10.08 % as observed through the data collected by the National Eclampsia Registry (NER) (11,266 out of 1,11,725 deliveries) over the 3 consecutive years 8, 9 . The prevalence matches out with NER data considering the fact that my study place is tertiary care centre where high risk patients having more visits.
In a study conducted by Vidyabati R K et al (2010) 10 prevalence rate of HDPs was 17.68%. In the study by Charu sharma et al (2017) 11 , the incidence of HDP came out to be 6.92%. The prevalence of hypertension during pregnancy was found to be 6.9% in the study conducted by Bharti Mehta et al(2015) 12 . Hypertensive disorders of pregnancy were reported to be 15.5, 5.38, and 8.96%, respectively, in other various hospital-based studies in India. 13,14,15

Summary & Concusion
In my study, 150 cases were initially enrolled. However, only 146 cases (97.3%) could be evaluated for the final results. The 4 cases were lost to follow up . Out of 146 cases studied , 129 cases remained normotensive and 17 cases developed HDP. Out of 17 cases ,8 cases had mild HDPs and 9 cases had severe HDPs. The prevalence of HDP was 11.7% in my study.
The mean age of the cases for my study was 27.86(Group B normotensive ) 29.87 (Group A1, mild hypertensive ) and 29.11 (Group A2 ,severe hypertensive ). There was no statistically significant correlation found between the age and the occurrence of HDP.