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MATERNAL AND PERINATAL OUTCOME AMONG MULTIPLE PREGNANCIES DELIVERING AT BUGANDO MEDICAL CENTRE AND SEKOU TOURE REGIONAL HOSPITAL IN MWANZA, TANZANIA SR. LETISIA MARKUS GANDYE (MD) A dissertation to be submitted in partial fulfillment of the requirement for the award of degree of Masters of Medicine in Obstetrics and Gynecology of Catholic University of Health and Allied Sciences i CERTIFICATION The undersigned certify that they have read and hereby recommend acceptance for examination by Catholic University of Health and Allied Sciences (CUHAS). A dissertation entitled: Maternal and Perinatal outcome among multiple pregnancies delivering at Bugando Medical Centre and Sekou Toure Regional Hospital in Mwanza Tanzania. This dissertation has been submitted with approval of the following supervisors: SUPERVISORS 1. Dr. A.Kajura MD, M.MED, Catholic University of Health Sciences Signature...Date Dr. Albert Kihunrwa MD, M.MED, Catholic University of Health Sciences Signature...Date Associate Professor Balthazar Gumodoka, Catholic University of Health Sciences Signature...Date... i DECLARATION AND COPYRIGHT I, Sr Letisia M. Gandye, hereby myself declare that the work presented in this dissertation has not been presented and will not be presented to any other University for similar or any other degree award. Signature...Date... This dissertation is copyright material protected under the Berne Convertion, the Copyright Act 1999 and international and national enactments, in that behalf on intellectual property. It may not be reproduced by any means, in full or in part, except for short extracts in fair dealing, for research or private study, critical scholarly review or discourse with an acknowledgement, without written permission of the Dean of the School of Graduate Studies on behalf of both the author and Catholic University of Health and Allied Sciences (CUHAS). ii DEDICATION This dissertation is dedicated to the Almighty God for His Blessings has provided throughout my studies. iii ACKNOWLEDGEMENTS I have all the right to thank God for everything He did to me during my studies. I extend my sincere gratitude and acknowledgements to the following people: Dr A. Kajura, Dr A. Kihunrwa and Associate Professor Balthazar Gumodoka for their guidance, correction, suggestions, dedication and time spend to make this work successful. Head of department and all consultants in the department of Obstetrics and Gynecology at Catholic University and Bugando Medical Centre for their advice and contribution during the course of this work. Special thanks to the Staticians Dr Mazigo and Dr Kidenya for their dedication to make this work successful. I would like to extend my sincere gratitude for the tireless efforts of Dr Museveni N Justine in the process of making this document attractive as it is right now. I also thank all the nurses for their assistance given during the period of data collection. Thanks to my fellow Post graduate students for support, encouragement and useful suggestion. My sponsor Embassy of Belgium and Belgian Technical Cooperation (BTC) for the financial support during my study. Last but not the least, my heartfelt thanks go to all women who participated in this study, without them this work would have not been possible. Last, I would like to thank those not mentioned above for their assistance in one way or another to make this work successful iv TABLE OF CONTENTS CERTIFICATION... i DECLARATION AND COPYRIGHT... ii DEDICATION... iii ACKNOWLEDGEMENTS... iv LIST OF ABBREVIATIONS... viii OPERATIONAL DEFINITIONS... ix ABSTRACT... x CHAPTER ONE INTRODUCTION Background Problem Statement Justification of the study Hypothesis Alternative Hypothesis Null Hypothesis Objectives Broad objective Specific Objectives... 4 CHAPTER TWO LITERATURE REVIEW Epidemiology of multiple pregnancies Maternal Morbidity and Mortality Perinatal Morbidity and Mortality... 7 CHAPTER THREE... 9 v 3.0 METHODOLOGY Study area Study design Study population Eligibility criteria Inclusion criteria Exclusion criteria Sample size determination Sampling techniques Data Collection Variables Data Aanalysis Ethical Cconsideration CHAPTER FOUR RESULTS Social demographic characters Obstetric Information Maternal Complications : Perinatal complications of participant s babies CHAPTER FIVE DISCUSSION CHAPTER SIX Conclusion Recommendations REFFERENCES APPENDICES vi LIST OF TABLES Table 1: Maternal Demographic Data Table 2: Obstetric Clinical Information Table 3: Maternal Complications Table 4: Perinatal Complications vii LIST OF ABBREVIATIONS ART. Assisted reproduction technology BMC.... Bugando Medical Centre BP. Blood Pressure CUHAS Catholic University of Health and Allied Sciences DBP.. Diastolic blood pressure DIC Disseminated intravascular coagulopathy DZ Dizygotic ESHRE. European Society of Human Reproduction and Embryology GA..... Gestation age ICU. Intensive Care Unit LUTH Lagos University Teaching Hospital MCH... Mother and Child Health MNH.. Muhimbili National Hospital MZ. Monozygotic NICU.. Neonatal Intensive Care Unit O/G. Obstetrics and Gynaecology PPH. Postpartum Haemorrhage PROM. Premature Rupture of Membrane SBP. Systolic Blood Pressure SVD Spontaneous Vagina Delivery TTTS... Twin to Twin Transfusion syndrome UK.. United Kingdom USA United States of America viii OPERATIONAL DEFINITIONS Abruption Placenta: is defined as the premature separation of the placenta from the uterus before delivery of the fetus. Birth weight: is the first weight of the fetus or newborn obtained within the first hour of life. Caesarean Section: Delivery of a baby by operation through the abdomen. Early neonatal death: is death of a neonate within 7 days of life. Low Birth Weight: Birth weight less than 2.5 Kilograms (kg) Maternal death: was noted at the 7 day post delivery Preterm Baby: A baby delivered before 37 weeks of gestation age Post partum Haemorrhage: Is the loss of greater than 500 milliliters (mls) of blood following vaginal delivery, or 1000 mls and above of blood following a Caesarean section. Perinatal outcome: was noted at the 7 day of life.. ix ABSTRACT Background: Multiple pregnancies are associated with an increased risk of obstetric complications as well as perinatal morbidity and mortality especially in developing countries. The present study aims to understand the maternal and perinatal outcomes of multiple and singleton pregnancies delivering at BMC and Sekou Toure Regional Hospital in Mwanza Tanzania. Material and Methods: This was a prospective cohort study conducted in Labour ward and postnatal wards at Bugando Medical Centre and Sekou Toure Regional Hospital, Mwanza. Structured questionnaires were used to collect demographic and obstetrics information. Physical examination and anthropometric investigation were done to all study participants and diagnosis of multiple pregnancies was made. For the follow-up of the health of the newborn, mothers were contacted through mobile phones on day seven and those with no mobile phone were asked to attend clinic on day seven after delivery. Results: There were 500 selected deliveries including 100 multiple pregnancies (98 twins and 2 triplets). Most common maternal complication of multiple pregnancies were preterm labour 42/100 (42%) compared to singleton who were 21/400 (5.3%), P- value 0.01, PPH 13/100 (13%), P-value 0.001) as compared to 8/400 (2%) singleton. Pre-eclampsia was commonly in multiple pregnancies 18/100 (18%), than singleton pregnancies 19/400 (4.8%), (P-value=0.02) as well as premature rupture of membrane between multiple 11/100 (11%) and singleton17/400 (4.3%) pregnancies (P-value 0.009) respectively. Maternal death was observed only in multiple pregnant 2/100 (2%). x Multiple pregnancies had higher number of lower birth weight babies 159/202 (78.7%) than singletons 30/400 (7.5%), P-value Babies born with multiple pregnant mothers had lower birth weight than those born with single to mothers (median body weight 2.1Kg versus 3.1kg, P-value 0.0001), and prematurity was more observed in multiple pregnant mothers 55/202 (27.2%) than in singletons 38/400 (9.5%), (Pvalue 0.001). Also, perinatal death 19/202 (9.4%) were higher in babies born with multiple pregnant mothers 13/400 (3.3%) than in singleton pregnant mothers (P-value 0.001). Conclusion: Women with multiple pregnancies participated in the present study had higher risk for hypertensive disorders, post partum hemorrhage and preterm labour which lead to prematurity, low birth weight, perinatal as well as maternal death. xi CHAPTER ONE 1.0 INTRODUCTION 1.1 Background Worldwide, the incidence of multiple pregnancies varies considerably. The available evidence indicates that the incidence is between 2-20 per 1000 birth [1]. Worldwide, the highest burden of multiple pregnancies has been found in sub-saharan Africa, with an average of twinning rate of 20 per 1,000 deliveries compared to 10 per 1,000 deliveries in Europe or around 5-6 per 1,000 deliveries in Asia [2-4]. There are multiple reasons associated with the increase in multiple pregnancies worldwide. Previous studies have associated the widespread of availability of ovulation inducing agents, assisted reproductive technology (ART) and a shift toward bearing children at older maternal ages when multiple gestation is more likely to occur naturally as factors contributing to increased incidence and prevalence of multiple pregnancies worldwide [5]. Other factors are genetics and environmental factors [2-4]. Traditionally, multiple pregnancies have been associated with increased incidence of adverse pregnancy outcomes including premature deliveries, pre-eclampsia, respiratory distress syndromes and mal-presentation [1-5]. Compared to singleton pregnancies, multiple pregnancies are reported to carry higher maternal as well as perinatal morbidity and mortality [6,7]. The national incidence and prevalence of multiple pregnancies and their outcomes in some of the countries including Tanzania remains unknown. In additional, identified risk factors and the observed outcomes of multiple pregnancies in other countries in sub-saharan Africa can not be simply generalized to every country in the region. Thus, for proper management of 1 women with multiple pregnancies there is a need to understand the local outcomes of multiple pregnancies compared to singleton pregnancies. 1.2 Problem Statement The national maternal and perinatal outcomes of multiple pregnant are lacking. Few published studies available in Tanzania indicate that the incidence of multiple pregnancies in Southern highlands and at the Muhimbili National Hospital was per 1000, the prevalence was 2.9% [8, 9]. However data on the outcome of multiple pregnancies compared to singletons in the North Western Tanzania is lacking. Compared to singletons, multiple pregnancies are recognised as the high risk pregnancies and are reported to be associated with increased of adverse pregnancy outcomes for both maternal and fetal such as: risk of miscarriage, pre-eclampsia, iron and folic acid deficiency anemia, polyhydramnios, preterm labour, and increased rate of caesarean section. Despite the fact that multiple pregnancies are observed in some of the health facilities in Tanzania, little is known on the maternal and perinatal outcomes among women with multiple pregnancies because there is no documentation on it. Thus it is important to conduct the study at this particular place to have awareness of risks and early detection which will guide the interventions. This might make allocation of scarce resources improper and prevent death of mothers of multiple pregnancy and their babies due to complications. 2 1.3 Justification of the study The millennium Development Goals number four and five calls for the world to reduce child morbidity and mortality as well as to improve maternal health by reducing maternal mortality and morbidities especially in developing countries. The fact that multiple pregnancy puts mothers at risk of miscarriage, pre-eclampsia (which is 2 3 times more common in multiple than singleton pregnancy), iron and folic acid deficiency anaemia, polyhydramnios, preterm labour, and increased rate of Caesarean section, there is a need to determine the perinatal and maternal complications of multiple pregnancies in our setting so that we can get the pattern of complication under this setting where resource are poor and see if could have the same outcome with other setting where there is enough resources because could be regional differences because of differences in screening, antenatal, intrapartum and perinatal care thus it might help in facilitating resources allocation, and well as the assisting in the management counseling of women with multiple pregnancies on the possible outcomes. 3 1.4. Hypothesis Alternative Hypothesis Women with multiple pregnancies are at increased risk of adverse maternal and perinatal outcomes when compared with singleton pregnancies Null Hypothesis There is no difference in terms of maternal and perinatal outcomes between multiple and singleton pregnancies Objectives Broad objective To compare maternal and perinatal outcome among women with multiple and singleton pregnancies delivering at BMC and Sekou Toure Regional Hospital in Mwanza Tanzania Specific Objectives 1. To compare the maternal morbidity among singleton and multiple pregnancies delivering at BMC and Sekou Toure Regional Hospital, Mwanza. 2. To compare the perinatal morbidity of babies born from singleton and multiple pregnancies delivering at BMC and Sekou Toure Regional Hospital, Mwanza. 3. To compare the maternal mortality among singleton and multiple pregnancies delivering at BMC and Sekou Toure Regional Hospital, Mwanza. 4. To compare the perinatal mortality of babies born from singleton and multiple pregnancies delivering at BMC and Sekou Toure Regional Hospital, Mwanza. 4 CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Epidemiology of multiple pregnancies The increase in multiple births is substantially public health concern because it causes preterm delivery which compromises the survival of neonates and increases the risk of lifelong disability [10]. Twin foetuses commonly result from fertilization of two separate ova and are termed double-ovum, dizygotic, or fraternal twins. The incidence of monozygotic twins is roughly similar among populations, but the frequency of dizygotic twins varies widely with geography, ethnicity, parity and maternal age, as well as use of assisted reproduction. Dizygotic twins result from simultaneous ovulation of two oocytes and fertilization by two different spermatozoa. Both zygotes have very different genetic constitutions, and each implants individually in the uterus and develops its own placenta, its own amnion and its own chorionic sac [11]. The highest birth rate of dizygotic twins occurs in African and the lowest birth rate in dizygotic occurs in Asia. The Yorubas of Western Nigeria have a frequency of 45.1 twins per 1000 live births and most are dizygotic [12, 13]. Monozygotic twins occurs 1 in 250 pregnancies [11]. Depending on the splitting of the primary zygote at various stages of development into two genetically identical embryonic structures, three types of monozygotic twin pregnancies are distinguished: dichorionic diamniotic if the splitting occurs before 4 days after insemination; monochorionic diamniotic when the split occurs between day 4 and day7; and, finally, monochorionic monoamniotic when it occurs more than 7 days after insemination. Monozygotic twinning occurs independently of ethnicity, maternal age, 5 parity, nutritional status and environmental factors, but the rate of occurrence may be doubled after induction of ovulation and is increased with in vitro fertilization [11]. Conjoined twins result from an arrest in division of the inner cell mass that occur in monozygotic twins when division occur after 14 days [14]. The incidence of conjoined twinning is estimated to be 1 in 50,000 to 1 in 1,00,000 deliveries [15]. The incidence appears remarkably similar throughout the world, although an incidence as high as 1 per 20,000 births has been reported from Atlanta,USA [16]. The incidence is approximately 18% of all conjoined twins in pyopagus, 1-2% in craniopagus, 40% in thoracopagus and 6% in ischiopagus [14]. The prevalence of spontaneous twin pregnancies ranges from approximately 0.6% of pregnancies in Asia and 1 to 2% in Australia, Europe and the USA to about 4% in Africa [17] and about 3.2% in Nigeria [18]. The studies in Tanzania reported an incidence of 15 to 20 per 1,000 and 30.1 per 1,000 in Southern Highlands and Muhimbili National Hospital respectively [8, 19]. 2.2 Maternal Morbidity and Mortality Multiple pregnancies are associated with increased complications when compared to singleton pregnancies. These complications include pregnancy induced hypertension, postpartum haemorrhage, preterm labour, and increased need for elective and emergency Caesarean section. The case control study done in Netherland found 21% of multiple pregnancies with pregnancy induced hypertension while it occurred in 13% in singletons. 6 In the same study 58% triplets were delivered by Caesarean section compared to 25% of singleton pregnancies and 18% twins compared to 16% singleton pregnancies [20]. In a descriptive study, done in Nigeria reported that 60% of twins in the study were delivered by Caesarean section, while 36.4% were delivered via vagina either, no maternal death was reported in this study [21]. A study done at Muhimbili reported a significant number of clients with eclampsia in multiple pregnancies being 6.9% as compared to 1.7% singleton pregnancies [19]. A prospective two years study done in Pakistan reported preterm labour as the major complications in multiple pregnancy compared to singleton (21vs 62). The mean birth weight of multiple and singleton was 2.1 and 2.9 respectively [22]. In a cross section study done in Nigeria and that of America reported multiple pregnancies were at high risk of hypertensive disorders compared to singletons pregnancies [23-25]. Several studies done in different places reported high risk of post partum hemorrhage for multiple compared to singleton [19, 22, 24, 26]. In the data base of the Latin America Centre reported unavailability of comparison of maternal death of multiple and singleton mothers delivered in developed countries while study done in Malawi reported 11.5% of maternal deaths as a complication of multiple pregnancies [24, 27]. 2.3 Perinatal Morbidity and Mortality Perinatal mortality and morbidity is significantly higher in twin than in singleton pregnancies such complications include preterm birth, intrauterine growth restriction, twin to twin transfusion and ante partum death of one of the twins [28,29]. The study done at Muhimbili National Hospital and Nigeria reported a prevalence of 93.7% and 57.1% low birth weight of multiple pregnancies compared to 21.5% and 7 24.4% singleton pregnancies respectively [9, 21]. Another study done in Nigeria reported low birth weight, low Apgar score at five minute, intrauterine growth restriction of multiple pregnancy babies compared to singleton babies [23].Again in a study done in MNH reported 9.4% still birth for twins compared to 3.4 of singleton [19]. The study done in Pakistan reported a Perinatal mortality rate of 108 per 1000 birth in twins as compared to 82 in singleton [22]. 8 CHAPTER THREE 3.0 METHODOLOGY 3.1. Study area The study was done in the labor ward, postnatal ward and NICU at Bugando Medical Centre and Sekou Toure Regional Hospital in Mwanza, Tanzania. BMC is a consultant and teaching hospital for the Lake zone of United Republic of Tanzania. Both hospitals are situated along Mwanza city. BMC is a referral centre for tertiary specialist care for six regions, including Mwanza, Mara, Kagera, Simiyu, Geita, Tabora and Kigoma. There was an estimate of 8400 deliveries, out of it 120 were multiple preg
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