Complication In Grand Multi Parity

Complication In tremendous Multi Parity luxe multi relation is the condition of giving deport later the 28th weeks of gestation, avocation 5 or much previous viable babies. Grand multiparae is relative to obstetric performance is labeled risque riskiness of infection. juicy risk maternity is define as maven in which the mother, fetus or new-sprung(a) will be at change magnitude risk of morbidity or mortality at or after birth. The risk to the mother and tiddler is relatively senior amply in first pregnancy and whence this risk decline during second, terce and then s clinical depressionly rises with increasing comparison by the sixth pregnancy risks exceeds these of 1st and after that rises steeply with each pregnancy1.Grand multiparous bind been considered to be at high risk of exploitation antenatal tortuousnesss. These ramifications include gestational diabetes, hypertension, anemia, placental abruption, placenta previa, preterm labour, mal-presentation, m al-position, fetopelvic disproportion and intra-partum complication, uterine intertia, dysfunctional labour, uterine rupture, intrauterine closing, marosomia and subsequent operative delivery with its consequent risk of motherly mortality and morbidity2,3. Postpartum haemorrh suppurate also more than(prenominal) ordinary in molar concentration multipara. Munim noted in her understand PPH was three times more parkland in high-minded multipara4. Grand multi similarity account to increase two(prenominal) motherly and perinatal morbidity and mortality5,6.It is generally accepted that GMP is risk work out of obstetric complication notwithstanding recently a few reports have appeared in the literature showing that this might be fiction quite than fact. Toohey et al, Fayed et al, and Kaplan et al, addressed the obstetric performance of great cubic yard multipara but they concoluded that much(prenominal) women were not a high risk sort out7,8,9. Brunner et al, in 1992 con cluded that grand multi likeness should be regarded as an obstetric risk factor, mainly because of the higher relative frequency of placental complication and with good obstetric care in that location should be no advice affects to the mother or newborn10.The incidence of grand multipara has decrease in most western countries in recent days collectable to better socioeconomic status and high use of contraception11,12,13. In third world countries like Pakistan the large families are still super acid. Grand multi conservation of conservation of simile is a common problem in this part of world and when added to imprint socioeconomic status, it importantly increases the risk to mother and fetus8,14,15.OBJECTIVESThe objective of our consider wereTo oppose obstetrical complications betwixt grand multiparae and clinical depression parity women.To psychoanalyse the frequency of maternal(p) and perinatal mortality associated with complications of grand multi parity.OPERATIONA L DEFINITION howling(a) MULTIPARAEGrand multiparae is charwoman who has delivered five-spot or more babies after 28 weeks, weighing more than 500 grams.LOW MULTIPARAE clinical depression multiparae is woman who has delivered slight than five (para 1-4).HYPOTHESISobstetricalal complication are more in grand multiparae than the blue parity women.MATERIAL AND METHODSSETTINGSThis interpret was conducted in Obstetric / Gynaecology Unit-I, well-mannered hospital, Karachi and Sheikh Zaid Women Hospital Larkana.DURATION OF schooling iodine year from 1st July 2008 to 31st March 2009 at Civil Hospital Karachi and 1st April 2009 to 30th June 2009 at Sheikh Zaid Women Hospital Larkana.SAMPLE coat A total of 200 pregnant women were selected randomly, were divided into ii assemblys with light speed women in each assembl sequence. class I consistent of women with parity five or more, and group II consisting of women with parity one to four.SAMPLING proficiencyProbability.SAMPLE SELEC TIONSample selection was done harmonize to the undermentioned inclusion and exclusion.INCLUSION CRITERIAAll pregnant multiparous women.EXCLUSION CRITERIAPrimigravida.STUDY DESIGNComparative, cross atomalDATA COLLECTION PROCEDUREA 200 women were admitted in our ward through out patient section or touch, or referred by private clinics or traditional birth attendants were selected.These cases were divided into two groups. Group I consistent of hundred women of parity five or more and group II consistent of 100 women were admitted during the analogous period with parity one to four.On admission patients recital was interpreted in detail. Age, parity, socioeconomic status, detailed obstetrical memorial, past history were recorded and previous record was received to detect antenatal complication including anaemia, PIH, APH, and malpresentation , pre-term labour. Anemia was taken as haemoglobin of 11 g/dl, PIH was delimit as blood pressure of 140/90 millimeter hydrargyrum after 20 weeks of gestation with or without protenuria on two or more occasion 6 hours apart. Bleeding from genital tract after 24 weeks gestation was taken as APH. Ultrasonography was done in non-booked cases when there was suspicious of malpresentation which was delineate as presenting part of fetus in other than cephalic in relation to maternal pelvis. Preterm labour was defined as labour before 37 complete weeks gestation.During labour patients were man epochd according to units protocol and partogram recording was used to evaluate the progress of labour. The intrapartum complications included drawn-out labour and ruptured uterus.Mode of delivery was also recorded. After delivery, the patients were monitor for 24 hours for primary PPH which was taken as blood loss estimated to be more than 500ml after normal vaginal delivery and 1000ml after cesarean section. The maternal close if any was recorded with its cause in detail.Neonates were fol meeked for neonatal complication which i ncluded, LBW, macrosomia, perinatal death. Birth weight of 2.5 kg was taken as LBW and 4.2 was taken as macrosomic babies. Admission to neonatal intensive care unit. Perinatal deaths (PND) included all intrauterine death (IUD) and early neonatal deaths (ENNDs). Data was collected through special proforma, neonatal follow up recorded was also entered in the very(prenominal) proforma.statistical ANALYSISData analysis was performed through SPSS version-10.0.Frequencies and percentages were computed for presentation of all monotonic variables of the necessitate including age, booking status, stylus of delivery, pregnancy related complications, intrapartum and postpartum complications, maternal and fetal mortality, and birth weight. Chi-square test was applied to oppose age, booking status, mode of delivery, pregnancy related complications, intrapartum and postpartum complications and birth weight in the midst of low parity and high parity groups. Fishers exact test was applied t o discriminate maternal and fetal mortality and nursery care admissions between low parity and high parity groups due to typically low evaluate count ( 5). Statistical significance was taken at p 0.05.RESULTSCommonest age group in both scan groups was 20 25 years in which total 76 patients were observed, up to now this age group was substantively higher (46% vs. 30%, p=0.001) in low parity group that high parity group slice older age group of the study 36 40 years was higher in high parity group than low parity group (4% vs. 15%). So the age distribution was significantly different in two groups (Table-1). almost of the patients in my study were unbooked, i.e. 131 % (Table-2). Booking status between two groups was statistically undistinguished (p=0.344).Anemia was significantly higher in high parity group than low parity group (89% vs. 62%, P = 0.001) while abruptio placentae, PIH and malpresentations were significantly higher in high parity group than low parity group (p 0.01). Placentae previa, preterm labour and twin pregnancy were insignificant between two groups (Table-3).Out of 200 women in this study, 21 (10.5%) underwent caesarean section and 179 (89.5%) normal vaginally delivered (Figure-1). In high parity group, proportion of women who underwent caesarean section was significantly higher in high parity group than low parity group (16% vs. 5%, p=0.011).Intrapartum and postpartum complications found insignificant between two groups at p 0.05 (Table-4).No maternal death was observed in low parity group but one (1%) maternal mortality was observed in high parity group, however rest of maternal mortality rate was insignificant (p = 0.999) between two groups (Figure-2).Significantly high number of fetal mortalities was observed in high parity group than low parity group (16% vs. 4%, P = 0.999) (Figure-3).We observed 8% NICU admissions in high parity group that was not statistically significant (p 0.213) as compared with 3% NICU admissions in l ow parity group (Figure-4).Table 1 AGE statistical distribution(n = 200)Age (years)GroupTotalLow parity(n = 100)High parity(n = 100)20 2546*307626 3040296431 3510263636 40415*19* Shows significant difference (X2 = 18.6, d.f = 3, p = 0.001)Low parity Parity 2-4, High parity Parity 4Table 2 analogy OF BOOKING positioning(n = 100)BookingGroupTotalLow parity(n = 100)High parity(n = 100)Booked322355Unbooked6269131Referred6814* Significant difference (X2 = 2.13, d.f = 2, p = 0.344) bring up Booked = 3 or more antenatal visits.Unbooked = 3 or no antenatal visits.Table 3 COMPARISON OF pregnancy RELATED COMPLICATIONS BETWEEN both GROUPS(n = 100)ComplicationsGroupp-valueLow parity(n = 100)High parity(n = 100)Anemia62890.001Placentae Previa570.55Abruptio placentae211*0.018Preterm labour560.760Pregnancy induced hypertension414*0.024Malpresentation215*0.001Twin pregnancy240.68* Shows statistically significant difference at p 0.05.Figure-1 COMPARISON OF MODE OF DELIVERY BETWEEN twain G ROUPS* Significant difference (X2 = 6.44, d.f = 1, p = 0.011)Table 4 COMPARISON OF INTRAPARTUM AND POSTPARTUM COMPLICATIONS BETWEEN TWO GROUPSComplicationsGroupp-valueLow parity(n = 100)High parity(n = 100)Obstructed labour340.70Ruptured uterus11Retained placentae020.50Postpartum hemorrhage240.68* Shows statistically significant difference at p 0.05Low parity Parity 2-4High troupe Parity 4Figure-2 COMPARISON OF MATERNAL OUTCOME BETWEEN TWO GROUPS* Significant difference (p = 0.999)Figure-3 COMPARISON OF FETAL OUTCOME BETWEENTWO GROUPS* Significant difference (Fishers exact test, p = 0.005)Figure-4 COMPARISON OF NURSERY admission BETWEEN TWO GROUPS(n1 = n2 = 100)* Significant difference (Fishers exact test, p = 0.213).Low parity Parity 2-4High parity Parity 4NICU = Neonatal intensive care unitDISCUSSIONThis comparative, cohort study was conducted in largest hospital of Karachi to find out whether grand multi parity is risk factor for obstetrical complication when compare to low parity. Despite of availability of modern obstetric facilities, women in our society not intend to buzz off book for antenatal care because they are too busy at their home and lack of awareness about health care, We found in our study that most of the patients in both groups coming in Civil Hospital, Karachi were non-booked and referred from different areas with complications. Unbooked 13% and 14% referred from different areas. In our study the grand multipara were older then low parity women. Increased age of GMP women put them additional risk for complication. As our study was not age matched study. So, the age matched study should be done for the proper risk assessment. This study shows that antenatal complication such as anemia was more common in grand multiparae. A Salick, et all also found same result in their studies 16. Anemia is more common in grand multipare because of poor nutrition, repeated pregnancies, low socioeconomic status. Pregnancy induced hypertension (PIH) wa s more common in our study, these women were relatively older than low parity and my study was not age matched study. Munim S, et al., found in her study statistically significance difference in the induced of the PIH that was 15.4% in grand multipare compared to the 9.3% in low parity women 4. Although the patients in here study were booked patients, she reported that higher prevalence of these complications may be explained on the change magnitude age of these women. In spite of increased incidence of PIH the superimposed pre-eclampsia and eclampsia was no more common in my study.4. Regarding the antepartum haemorrhage, abruptio placentae is more common in GMP. Although number of placenta previa was increased in grand multi parity than low parity but not statistically significant.Heija AA, also found in his study that abruptio placentae is more common in grand multipareae. He state that the high parity is significant etiological determinant of placental abruption 2.The malpresen tation was more common in grand multipare especially breech was more common than the low parity. Malpresentation in grand multipara is common because increasing laxity of front tooth abdominal wall musculature, failing to act as a genus Gallus to encourages and maintain a longitudinal lie, encourages malpresentation 17.Preterm labour was same in both groups. Aziz FA, studied the grand multipare Sudanese women and found the incidence of pre-term labour was increased in these women 18.The intra partum complication like blockade labour result was same in both groups in both cases patients was referred and reason was abnormal fetal position. we found 1 case of Ruptured uterus in each group, both these are patient were referred from private hospital, both were older age, both were mismanaged with syntocynon but low parity woman was survive and grand multiparous woman was die.Our study showed no statistical difference in postpartum haemorrhage between both groups. Page L in her series of study has reported that same result. She found no direct association between grand multiparae and PPH.63 Some other studies have shown that increased risk of PPH is associated with increased age not with increasing parity. Munim et al, noted in her study PPH was three times more common in grand multiparae 4.Our study showed caesarean section is significantly increased in grand multipare than the low parity, this because of malpresentation and obstructed labour, antepartum haemorrhage.One maternal death found in my study this unfortunate woman belong to low socioeconomic class, had obstructed fatigue due to macrosomic baby and mismanaged with syntocinon referred in state of shock despite of emergency laparotomy, blood transfusion, and resuscitation she could not survive because she was already anemic had bleed a lot and die due to cardiac failure.As regard the neonatal outcome parity is considered as important factor in find the birth weight of baby. Many investigators have repo rted association of LBW with grand multiparae.But in my study low birth weight was common in low parity as compare to grand multiparae. in that location was no significant increased incidence macrosomic babies in grand multiparae, compare with international literature.In our study perinatal mortality was significantly increased in grand multi parity it mainly because of abruptio placenta, PIH, obstructed labour and preterm birth. coatingIt is concluded from my study that antenatal complications like pregnancy induced hypertension, abruptio placenta, anaemia, malpresentation, cesarean section deliveries and perinatal mortality were more common in grand multiparae then the low parity group and multi parity is still a study obstetric hazards in our set up with higher incidence of complications.