• Users Online: 314
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 153-157

Analytical study to determine the impact of jaundice in pregnancy on maternal and perinatal outcome


Department of Obstetrics and Gynaecology, PCMS, Bhopal, Madhya Pradesh, India

Date of Submission22-Jun-2020
Date of Decision02-Aug-2020
Date of Acceptance10-Aug-2020
Date of Web Publication22-Sep-2020

Correspondence Address:
Prachi Kushwaha
Department of Obstetrics and Gynaecology, PCMS, Bhopal, Madhya Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AIHB.AIHB_63_20

Rights and Permissions
  Abstract 


Background: Jaundice in pregnancy carries a grave prognosis for both the foetus and the mother, and is responsible for 12% of maternal deaths. Liver disease is a rare complication of pregnancy, but when it occurs it may do so in a dramatic and tragic fashion for both the mother and infant. Materials and Methods: Data were collected as prospective Hospital based observational study at tertiary care centre. After the preliminary assessment with regard to the inclusion and exclusion criteria, informed consent was obtained from all patients. Thorough history was taken and physical examination was done. Demographic details of each patient were obtained. Relative investigations were done. Results: Out of 300 patients, 287 were healthy and alive and 13 patients died. The maternal mortality was 4.33%. Out of the total 13 maternal deaths, 4 cases died due to hepatic encephalopathy, 3 due to disseminated-intravascular coagulation and 3 due to sepsis with multiorgan failure. Mortality was due to HELLP- Hemolysis Elevated Liver enzymes and Platelet count in two cases and due to acute fatty liver in one case. In 126 (42%) cases, the mode of delivery was lower segment caesarean section, 138 (46%) cases had normal vaginal delivery, while 36 (12%) cases had undergone abortion. A total of 114 (38%) cases delivered full-term live baby and 78 (26%) cases delivered preterm live baby. Full-term intrauterine foetal death (IUFD) was seen in 15 (5%) cases and preterm IUFD was seen in 69 cases (23%). There was neodeath in 24 (8%) babies. The total perinatal mortality was 36.0%. Conclusion: The present study shows that although liver dysfunction is infrequently seen in pregnancy, it can result in severe maternal and foetal compromise. Jaundice in pregnancy should be managed as a team with the collaboration of the department of obstetrics, internal medicine, gastroenterology, anaesthesia and critical care so that early diagnosis and aggressive management can prevent and reduce foeto–maternal morbidity and mortality.

Keywords: Disseminated-intravascular coagulation, HELLP, intrauterine foetal death, lower segment caesarean section


How to cite this article:
Tiwari R, Kushwaha P, Meravi A. Analytical study to determine the impact of jaundice in pregnancy on maternal and perinatal outcome. Adv Hum Biol 2020;10:153-7

How to cite this URL:
Tiwari R, Kushwaha P, Meravi A. Analytical study to determine the impact of jaundice in pregnancy on maternal and perinatal outcome. Adv Hum Biol [serial online] 2020 [cited 2020 Dec 5];10:153-7. Available from: https://www.aihbonline.com/text.asp?2020/10/3/153/295839




  Introduction Top


'The life of a mother is the life of a child: Two blossoms on a single branch'.

Jaundice is yellow discolouration of the skin, conjunctiva, sclera and mucosa associated with rise in serum bilirubin above 2 mg/dl.

Jaundice affects a small percentage of pregnant women, yet it takes a major toll on the health of both the mother and foetus, especially in developing countries like India. It complicates 3%–5% of pregnancies and is one of the important causes of maternal and neonatal morbidity and mortality worldwide.[1] It is responsible for 12% of maternal deaths.

Liver disease is rare in pregnancy, but when it occurs, it may cause dramatic poor foeto–maternal outcome.

Intra Hepatic Cholestasis of Pregnancy (IHCP) is the most common liver disease in pregnancy, with prevalence ranging between 0.3% and 5.6%.[2],[3],[4] Hepatitis E Virus (HEV) infection has achieved notoriety, with its association with pregnancy and reports of increased risk of acute liver failure leading to high maternal and infant mortality in Southeast Asia.[5],[6]

Early interventions and prevention of these illnesses is a priority today and, therefore, included in universal screening programmes in antenatal visits and part of reproductive health programmes. Pregnancy with jaundice is considered a high-risk pregnancy.[7] Jaundice in pregnancy, while relatively rare, has potentially serious consequences for maternal and foetal health. Management of pregnant women with liver disease is a common clinical scenario, and one that can be challenging is the need to consider not only the expectant mother, but also the unborn foetus in treatment decisions.

Aims and objectives

The aim and objective was to determine the impact of jaundice in pregnancy on maternal and foetal outcome.


  Materials and Methods Top


The present study titled “Analytical study to determine the impact of jaundice in pregnancy on maternal and perinatal outcome” is a prospective, randomised, hospital-based, observational study carried out in the Department of Obstetrics and Gynaecology, Sultania Zanana Hospital, Gandhi Medical College, Bhopal, Madhya Pradesh, India.

Study population

A total of 300 antenatal patients with jaundice were included in the study, who were admitted during the study period from December 2015 to November 2016 at Sultania Zanana Hospital, Bhopal.

Inclusion criteria

  • All women with jaundice complicating pregnancy admitted in Sultania Zanana Hospital, Bhopal.


Exclusion criteria

  • Previously diagnosed cases of cholelithiasis, choledocholithiasis and known chronic liver disease
  • After the preliminary assessment with regard to the inclusion and exclusion criteria, informed consent was obtained from all patients. Thorough history was taken and physical examination was done. Demographic details of each patient were obtained. Relative investigations were done.


A thorough clinical examination was done which included general physical examination and systemic and obstetric examination.

  • Nature, duration and complication of pregnancy and labour was noted
  • Management of pregnancy and labour was followed
  • Foeto–maternal outcome was seen.


The data obtained were subjected to statistical analysis. The data so obtained were compiled systematically. A master table was prepared, and the total data were subdivided and distributed meaningfully and presented as individual tables along with graphs.

Statistical procedures were carried out in two steps:

  1. Data compilation and presentation
  2. Statistical analysis.


Statistical analysis was done using Statistical Package for Social Science (SPSS Version 20; Inc., Chicago, IL, USA). Data comparison was done by applying specific statistical tests to find out the statistical significance of the comparisons. Quantitative variables were compared using mean values and qualitative variables using proportions. Data were analysed using Chi-square test. Statistical significance level was fixed at P < 0.05.


  Results Top


Majority of the patients were in the age group of 20–29 years (76%), followed by 30–40 years (16%) and 15–19 years (8%). The mean age of the patients was 24.9 years.

Jaundice was more prevalent amongst lower class. A total of 144 cases (48%) were of upper lower class and 126 cases (42%) were of lower class.

Jaundice was more prevalent amongst rural cases (76%) as compared to urban cases (24%).

Out of the 300 cases, most of the cases (56%) were primigravida, 42% were multigravida and 2% were grand multipara.

Jaundice was more prevalent during the III trimester (82%) as compared to the II (14%) and I trimesters (4%).

Serum bilirubin level in pregnant women with jaundice was as follows: mean serum bilirubin level was 9.050 ± 5.45 mg/dl and its range was 1.2–20.0 mg/dl. Out of the 300 cases, in most of the cases (42%), its level was 6–10 mg/dl. In most of the cases (73%), platelet count was 1–3 lakh, while in 23% of cases; it was <1 lakh.

[Table 1] shows that in most of the (50%) cases, jaundice was caused by viral hepatitis and in 23% of cases, it was caused by HELLP syndrome. In 150 cases of viral hepatitis, jaundice was caused by hepatitis B virus in 108 cases (72%) and hepatitis E was responsible for jaundice in 24 cases (16%). Jaundice was caused by hepatitis C virus in 12 cases (8%). Hepatitis A was responsible for jaundice in six (4%) cases. In 23% of cases, jaundice was caused by HELLP syndrome.
Table 1: Aetiology of jaundice amongst pregnant women with jaundice

Click here to view


Out of the 300 patients, 287 were healthy and alive and 13 patients died. Maternal mortality was (4.33%) [Table 2].
Table 2: Maternal outcome amongst pregnant women with jaundice

Click here to view


Out of the total 13 maternal deaths, 4 cases died due to hepatic encephalopathy, 3 due to disseminated-intravascular coagulation (DIC) and 3 due to sepsis with multiorgan failure. Mortality was due to HELLP in two cases and due to acute fatty liver in one case [Table 3].
Table 3: Aetiology of maternal mortality in pregnant women with jaundice

Click here to view


Maternal mortality is more in lower class as compared to middle class. Out of the 13 maternal deaths, most of the deaths (8 cases, 61.5%) occurred in lower class, three deaths (23.1%) occurred in upper lower class and two deaths (15.4%) occurred in lower middle class [Table 4]].
Table 4: Association of socioeconomic status with maternal outcome

Click here to view


Maternal mortality was more prevalent amongst rural population as compared to urban. Out of the 13 maternal deaths, nine deaths (69.2%) belonged to rural population and four deaths (30.8%) belonged to urban area [Table 5].
Table 5: Association of locality with maternal outcome

Click here to view


In 126 (42%) cases, the mode of delivery was lower segment caesarean section (LSCS) and 138 (46%) cases had normal vaginal delivery, while 36 (12%) cases had undergone abortion [Table 6].
Table 6: Mode of delivery amongst pregnant women with jaundice

Click here to view


Most of the patients had preterm delivery. In 150 cases (50%), delivery was preterm and in 114 cases (38%), it was full term. Thirty-six cases (12%) had an abortion. Prematurity is very common in pregnant women with jaundice [Table 7].
Table 7: Pregnancy outcome amongst pregnant women with jaundice

Click here to view


A total of 114 (38%) cases delivered full-term live baby and 78 (26%) cases delivered preterm live baby. Full-term intrauterine foetal death (IUFD) was seen in 15 (5%) cases and preterm IUFD was seen in 69 cases (23%). There was neodeath in 24 (8%) babies. The total perinatal mortality was 36.0%. Perinatal mortality was quite high amongst jaundiced patients [Table 8].
Table 8: Foetal outcome amongst pregnant women with jaundice

Click here to view



  Discussion Top


We undertook a prospective study to evaluate the impact of jaundice on maternal and foetal outcome in women admitted with jaundice to a tertiary care centre. In the present study, jaundice was found in 1.7% of pregnant women attending our institute.

In accordance with our study, Krishnamoorthy et al.[8] reported the incidence of jaundice to be 0.29%. In a study conducted by Singh et al. in 2015, at the Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, amongst total 1960 admissions, 78 (3.97%) presented with jaundice.

In our study, in most of the cases (150, 50%), jaundice was caused by viral hepatitis and in 69 (23.1%) cases, it is was by HELLP. Intrahepatic cholestasis of pregnancy and acute fatty liver of pregnancy were responsible for jaundice in 14 (4.6%) and 23 (7.4%) cases, respectively. Haemolytic jaundice and hyperemesis gravidarum caused jaundice in 19 (6.5%) and 16 cases (5.5%), respectively. Nine cases (2.8%) were undetected.

Similar to our study, Krishnamoorthy et al., 2016,[8] reported that viral hepatitis was the cause in 51% of cases, comparable to the study by Shukla et al.,[9] who reported 57% and Harshad et al.[10] reported 47% cases of viral hepatitis.

In the present study, increasing age proved to be a substantial issue for the development of liver diseases in pregnant female as maximum cases were found in between 20 and 29 years of age (76%). Acharya et al[11] stated that liver disease in pregnant female is more commonly seen in younger age group i.e. < 25 year (59%) and 25-35 year (30%) Nath et al.[12] reported that the most common age group to be affected was 25–29 years (39%) followed by 21–24 years (36%).

According to our study, jaundice is more prevalent amongst lower class. Most of the patients belonged to upper lower and lower class. Out of the 300 study participants, 144 cases (48.0%) were of upper lower class and 126 cases (42%) were of lower class.

Perinatal mortality is more prevalent in lower class as compared to middle class. Out of 108 perinatal mortality, 61 (56.5%) were reported in lower socioeconomic status (SES) class patients, 38 (35.2%) were reported in upper lower class patients and only 9 (8.3%) in middle class patients.

Maternal mortality was evidenced more in lower class as compared to middle class. Out of the 13 maternal deaths, most of the deaths (8, 61.5%) occurred in lower class, 3 (23.1%) deaths occurred in upper lower class and 2 (15.4%) deaths occurred in lower middle class.

Similar to our study, Krishnamoorthy et al.[8] reported that about 92% of their patients belonged to lower socioeconomic class and 86% were consuming unsafe water.

According to our study, jaundice is more prevalent amongst rural population as compared to urban population. Out of the 300 cases, 228 cases (76%) were from rural locality and 72 cases (24%) were from urban locality.

Perinatal mortality is more prevalent amongst rural population as compared to urban. Out of 108 perinatal mortality, 86 (79.6%) were amongst rural population and 22 (20.4%) were amongst urban population.

Maternal mortality is more prevalent in rural population as compared to urban population. Out of 13 maternal deaths, 9 (69.2%) were in rural population and 4 (30.8%) were in urban population.

Similar to our study, Nagaria et al.[13] reported that 58.53% of their cases presented from rural area. This might be due to poor sanitation, lack of clean and safe drinking water and delay in seeking medical facility.

In our study, we found that out of the 300 cases, most of the cases (168, 56%) were primi, 126 cases (42%) were multi and 6 cases (2%) were grandmultipara, which means jaundice is more common in the first pregnancy and chances of liver disease in pregnancy decrease with multiple child birth.

In accordance with our study, Nagaria et al.[13] showed that 78% of the women were either primigravidas or second gravid. According to Nath et al.,[12] most patients were primigravida (38%).

In our study, jaundice was seen more prevalent during the III trimester as compared to the II or I. Out of the 300 cases of jaundice in pregnant women, most of the 246 cases (82%) were reported in the III trimester, 42 cases (14%) were reported in the II trimester and 12 cases (4.0%) were reported in the I trimester.

In accordance with our study, Krishnamoorthy et al.[8] reported that the maximum incidence of jaundice was in the 3rd trimester and the complications were also high during that period.

Maternal mortality was 4.33%. A total of 13 mothers died and 287 were healthy and alive. Four mothers (30.8%) died due to hepatic encephalopathy, three died due to disseminated-intravascular coagulation (DIC) and three died due to sepsis with multiorgan failure. Mortality was seen due to Hemolysis Elevated Liver enzymes and Platelet count (HELLP) in two cases and due to acute fatty liver in one case.

Krishnamoorthy et al.[8] showed that 7.8% of the patients died, 35% of the patients developed complications and 58% had uneventful recovery. Nearly 9.8% of the patients had atonic Postpartum Haemorrhage (PPH), 5.8% had DIC and 7.8% had hepatic encephalopathy. Abruption, hepatorenal failure and oesophageal varices were seen in 3.9% each.

In our study, out of the 300 cases, in 126 (42%) cases, the mode of delivery was LSCS and in 138 (46%) cases, it was normal vaginal delivery, while 36 (12%) cases had undergone abortion. In 150 (50%) cases, delivery was preterm and in 114 (38%) cases, it was full term. Thirty-six (12%) cases had abortion. Most of the patients had preterm delivery. Prematurity is more common. A total of 114 (38%) cases delivered full-term live baby and 78 (26%) cases delivered preterm live baby. Full-term IUFD and preterm IUFD were seen in 15 (5%) and 69 (23%) cases, respectively. There was neodeath in 24 babies (8%). The total perinatal mortality was 36.0%. Perinatal mortality is quite high amongst jaundiced patients. Perinatal mortality is more prevalent amongst lower class as compared to middle class. Out of 108 perinatal mortality, 61 (56.5%) were amongst lower SES class patients, 38 (35.2%) in upper lower class patients and only 9 (8.3%) in middle class patients.

In accordance with our study, Krishnamoorthy et al.[8] reported that preterm deliveries were 48.8% (26.6% live births and 22.2% intrauterine deaths). The perinatal mortality in this study was 35.5%. Rathi et al.[14] reported a perinatal mortality of 35.4% and Kumar et al.[15] reported a perinatal mortality of 26.5%.


  Conclusion Top


The present study shows that although liver dysfunction is infrequently seen in pregnancy, it can result in severe maternal and foetal compromise. Viral hepatitis is the most common cause of jaundice in pregnancy. Generating public awareness about the various routes of transmission of the different types of infective hepatitis, improving sanitary conditions and habits, imparting health education and knowledge of preventive measures and conducting routine and regular antenatal check-ups and viral markers as a part of routine antenatal screening can help in reducing the burden of jaundice in pregnancy.

Jaundice in pregnancy should be managed as a team with the collaboration of the department of obstetrics, internal medicine, gastroenterology, anaesthesia and critical care so that early diagnosis and aggressive management can prevent and reduce foeto–maternal morbidity and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jain RK. Management of jaundice in pregnancy. Med Update 2010;20:470-6.  Back to cited text no. 1
    
2.
Reyes H, Gonzalez MC, Ribalta J, Aburto H, Matus C, Schramm G, et al. Prevalence of intrahepatic cholestasis of pregnancy in Chile. Ann Intern Med 1978;88:487-93.  Back to cited text no. 2
    
3.
Marschall HU, Wikström Shemer E, Ludvigsson JF, Stephansson O. Intrahepatic cholestasis of pregnancy and associated hepatobiliary disease: A population-based cohort study. Hepatology 2013;58:1385-91.  Back to cited text no. 3
    
4.
RH Lee, TM Godwin, J Greenspoon, M Incerpi, et al. The prevalence of intrahepatic cholestasis of pregnancy in a primarily Latina Los Angeles population. J Perinatol 2006;26:527-32.  Back to cited text no. 4
    
5.
Patra S, Kumar A, Trivedi SS, Puri M, Sarin SK. Maternal and fetal outcomes in pregnant women with acute hepatitis E virus infection. Ann Intern Med 2007;147:28-33.  Back to cited text no. 5
    
6.
Mark H Kuniholm, Robert H Purcell, Geraldine M McQuillan, Ronald E Engle, Annemarie Wasley, Kenrad E Nelson et al. Epidemiology of hepatitis E virus in the United States: Results from the third national health and nutrition examination survey, 1988–1994. J Infect Dis 2009;200:48-56.  Back to cited text no. 6
    
7.
Hay JE. Liver disease in pregnancy. Hepatology 2008;47:1067-76.  Back to cited text no. 7
    
8.
Jayanathi Krishnamoorthy, Anuradha Murgesan et al. Jaundice during pregnancy: Maternal and fetal outcome. Int J Reprod Contracept Obstet Gynecol 2016;5:2541-45.  Back to cited text no. 8
    
9.
Shukla S, Mehta G, Jais M, Singh A. Prospective study on acute viral hepatitis in pregnancy: Sero-prevalence and fetomaternal outcome of 100 cases. J Biosci Tech 2011;2:279-86.  Back to cited text no. 9
    
10.
Harshad D, Walter KK, Ross D, Lakshmi P. Pregnancy-associated acute liver disease and acute viral hepatitis: Differentiation, course and outcomes. J Hepatol 2008;49:930-5.  Back to cited text no. 10
    
11.
Neema Acharya, Sourya Acharya, Samarth Shukla, RitujaAthvale, Shaveta. Study of jaundice in Pregnency. Global J Med Res Gynecol Obstet 2013;13:21-26.  Back to cited text no. 11
    
12.
Jayanti Nath, Garima Bajpayi, Reena Sharma et al. A clinical study on jaundice in pregnancy with special emphasis on fetomaternal outcome. IOSR J Dent Med Sci 2015;14;116-9.  Back to cited text no. 12
    
13.
Nagaria T, Agarwal S et al. Fetomaternal outcome in jaundice during pregnancy. J Obstet Gynecol India 2005;55:424-7.  Back to cited text no. 13
    
14.
Rathi U, Bapat M, Rathi P, Abraham P. Effect of liver disease on maternal and fetal outcome – A prospective study. Indian J Gastroenterol 2007;26:59-63.  Back to cited text no. 14
[PUBMED]  [Full text]  
15.
Kumar A, Beniwal M, Kar P, Sharma JB, Murthy NS. Hepatitis E in pregnancy. Int J Gynaecol Obstet 2004;85:240-4.  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

Top
 
 
  Search
 
Similar in PUBMED
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed156    
    Printed7    
    Emailed0    
    PDF Downloaded27    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]