Hypertensive Pathologies in Peripartum: Complications and Maternal and Neonatal Outcome ()
1. Introduction
Hypertensive disorders during pregnancy are divided into four entities, namely: chronic hypertension, isolated hypertension, preeclampsia and preeclampsia added to chronic hypertension [1]. This pregnancy-induced hypertensive syndrome forms a heterogeneous group of disease states, the common denominator of which is an increase in blood pressure during pregnancy [2]. In relation to the different types of hypertension during pregnancy, preeclampsia complicates 2% to 8% of pregnancies and is one of the three main causes of maternal morbidity and mortality in the world [3]. In the Democratic Republic of Congo, Sengeyi et al. [4], in a study on hypertensive disorders during pregnancy at the University Clinics of Kinshasa, found on 101 pregnant hypertensive patients 72 cases of preeclampsia, i.e. a frequency of 71%. These authors have shown that among the hypertensive pathologies of pregnancy, preeclampsia is the entity that affects the maternal and fetal prognosis. In our environment, there is no study carried out on the theme of hypertensive pregnancy pathologies. This work is carried out in a very specific context in our community to try to propose a plan that would reduce by three quarters the maternal mortality rate through good care. The aim of this work was to determine the frequency of hypertensive pathologies in the peripartum, to determine the maternal and neonatal morbidity factors associated with preeclampsia on the one hand, and on the other hand, to other forms of hypertension in the peripartal period.
2. Methodology
This was a descriptive cross-sectional study carried out in two hospitals in the city of Lubumbashi in the Democratic Republic of Congo, the Lubumbashi university clinics and the south Gecamine hospital from January 2013 to March 2014 We constituted an exhaustive non-probabilistic sample of 142 hypertensive patients with as inclusion criteria, having presented a systolic blood pressure (PAS) ≥ 140 mmHg and or a diastolic blood pressure (PAD) ≥ 90 mmHg in peripartum that is i.e. the ante, per and postpartum period. The study variables were blood pressure (BP) in the parturient, clinical, gynecological and obstetric parameters. Note that a second BP sample was taken one hour after the first sample from hypertensive patients and it was the second sample that was used in the study [5] [6].
A second BP sample was taken one hour after the first sample in hypertensive patients and it was the second sample that was used in the study [7]. Two types of validated sphygmomanometer have been used, the manual or aneroid hand-held sphygmomanometer type Primus Stabil 3 aneroide sphygmomanometer [8] and the electronic arm tensiometer type Nissei DSK-1011 [9]. Data encoding and analysis was done with Microsoft Excel and SPSS 21.0 software. We performed the relative frequency calculation and the association measurement. The significance level was p ≤ 0.05 with a 95% confidence interval.
3. Results
3.1. Sociodemographic and Clinical Parameters
Our study involved 142 hypertensive patients whose average age was 29 ± 7.5 years and (63.4%) of them were between 19 and 34 years old. The average parity was 3.4 ± 2.8 deliveries and (53.5%) of hypertensive patients had a gestational age between 37 and 42 weeks with a predominance of monofetal pregnancies at (92.3%). In (73.2%) the hypertensive patients followed the Near Birth Consultations and in the course of this there was a notion of history of hypertension in (3.5%) whereas (54.9%) of the patients reported being diagnosed with hypertension during antenatal care. According to the clinic, (51.4%) of the patients had developed isolated hypertension and the type of hypertension according to albuminuria reveals that albuminuria was significant in (48.6%) of the patients who presented with preeclampsia and associated chronic hypertension. Almost (78.2%) of the hypertensive patients had received antihypertensive medical treatment and in (61.9%) of the hypertensive patients, they delivered vaginally.
3.2. Hypertensive Patients According to the Study Site and the Types of Hypertension
The majority of hypertensive patients came from Gécamines-Sud hospital (5.4%). Regarding the types of hypertension, 51.4% of the patients had developed an isolated hypertension whereas pre-eclampsia was diagnosed in 47.2% of the cases.
In Table 1, the factors that were significantly associated with preeclampsia compared to other types of hypertension: 1) primiparas were twice as likely to have preeclampsia as other types of hypertension. 2) The risk of developing preeclampsia compared to the types of hypertension was 4.57 when the hypertensive patient presented either a moderate MAP or a severe MAP. 3) Pregnant women who did not follow ANC were twice as likely to develop preeclampsia as other types of hypertension.
From the 37th week of amenorrhea, hypotrophy was represented in 41.4% of cases in pre-eclamptic patients and in patients who had presented other types of hypertension, it was represented in 11.5% of cases (Table 2).
The risk for pre-eclamptic patients of giving birth to a hypotrophic newborn was increased by 5.41 compared to other types of hypertension.
Table 3 shows that neonatal hypoxia at the 5th minute of life was 34.4% in preeclampsia and 11.4% in other types of hypertension. In preeclamptics, the risk of hypoxia in the 5th minute of life was 3.02 (CI 1.44 - 6.34) compared to
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Table 1. Hypertensive patients based on factors associated with preeclampsia.
MAP: medium arterial pressure; ANC: prenatal consultations.
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Table 2. Association between types of hypertension and birth weight depending on the term of pregnancy.
AW: Amenorrhea week.
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Table 3. Association between types of hypertension and APGAR at the 5th minute.
other types of hypertension. Discussion during the study period, 142 cases of hypertension was identified in a population of 2988 patients, representing a prevalence of 4.8%. This prevalence is limited because it related to the perinatal period. In developed countries, the frequency of hypertension during pregnancy varies from 5% to 10% [6]. The steady increase in the prevalence of obesity, metabolic syndrome, and hypertension is also accompanied by an increase in the prevalence of hypertension in pregnancy [10]. In Africa prevalences vary from one country to another: 2.99% in Antanarivo [11], 8.2% in Yaoundé [12], 8.6% in Bamako [13], 17.05% in Niger [14], and 6.6% in Kinshasa [4]. In relation to the different types of hypertension in peripartum, in our series, isolated hypertension was the most common hypertensive type at 51.4% followed by preeclampsia at 47.2%. Some studies carried out in hospitals have found frequencies that can be superimposed on ours such as that of Madagascar where isolated hypertension was the predominant hypertensive form at 52% [11]. In Dakar, preeclampsia was the main hypertensive entity at 47% [15], other studies, on the other hand, found frequencies of preeclampsia higher than ours, 54% in Bamako [16], 71% in Kinshasa [4]. Several authors have found significant statistical links between primiparity and preeclampsia, including Meviel et al. [17] who noted in their work that primiparity multiplies by 2 the risk of presenting preeclampsia (OR = 2.67; CI [1.67 - 4.29]), Boubacar et al. [16] found that 44.5% of primiparas had developed preeclampsia (p = 0.00). In our study, primiparity was observed in 60.3% of cases in preeclamptics with a risk for the primiparous to present preeclampsia of 2.47 (CI 1.25 - 4.91) compared to other types of HBP. The mechanisms allowing the semiallogenic trophoblastic cell to invade maternal tissues by thwarting the maternal processes of self-recognition may be defective. An immunological reaction therefore occurs due to the patient’s first exposure to trophoblastic villi containing antigens of fetal and therefore paternal origin. Thus the hypothesis of an immunological maladaptation in the occurrence of preeclampsia is evoked [18]. The risk of developing preeclampsia compared to types of hypertension was 4.57 when the hypertensive patient had either moderate or severe MAP. Patients with mild hypertension generally have as good a prognosis as in normal pregnancies.
In contrast, maternal and perinatal morbidity is substantially increased during severe hypertension and the rates of placental abruption, cesarean delivery, intrauterine growth retardation and prematurity are comparable to those observed in severe preeclampsia. These patients should therefore benefit from follow-up identical to that established during severe pre-eclampsia [19]. We found that 63.2% of patients who had not followed ANC were pre-eclamptic and had 2.4 times the risk of pre-eclampsia (CI 1.06 - 5.62) compared to the types of hypertension. In Morocco, Laghzaoui et al. [20] reported that among pre-eclamptics, pregnancies not followed exceeded 70%. Although regular monitoring of pregnancy does not prevent the occurrence of preeclampsia, it still allows early detection and prevention of its development towards complications. All told, prenatal consultations are therefore a preferred means of reducing the occurrence of these complications [21]. We believe that the relationship established between the non-follow-up of ANC and preeclampsia, in our study, should be considered in the sense that patients at risk of developing preeclampsia were not detected early during pregnancy, because according to Sibai et al. [22], the early detection of women at risk of preeclampsia is considered to be a key to the development of a preventive treatment whose effectiveness could depend on the earliness of its introduction. The risk for pre-eclamptic patients of giving birth to a hypotrophic newborn was increased by 5.41 compared to other types of hypertension. Ngwe et al. [23], in a case-control study, found that the risk for a hypertensive pregnant woman of having a fetus in IUGR was 2 times higher than for a non-hypertensive pregnant woman (OR = 2.44).
According to the recommendations of the National College of French Gynecologists and Obstetricians [24], preeclampsia multiplied the risk of RCIU, by a factor of 5 to 12 depending on the severity of the attack. Indeed, previously, Meekins et al. [25] have shown that in the case of preeclampsia, the invasion of the decidual arterioles by the extravillous cytotrophoblasts decreases by 56% and that the invasion of the myometrial arteries decreases from 76% to 18%. To this defect of invasion is added a defect in their endothelial remodeling by the extravillous cytotrophoblasts. Endothelial cells are not replaced by trophoblasts, and the smooth muscle cell layer is not changed. Thus the uterine arterioles have a smaller diameter and retain their vasoconstrictor potential [26]. Subsequently, this results in a decrease in uteroplacental flow, which disrupts fetal-maternal exchanges [27]. In preeclamptics, the risk of hypoxia in the 5th minute of life was 3.02 (CI 1.44 - 6.34) compared to other types of hypertension. Fatoumata et al. [28] found a significant association between preeclampsia and weak APGAR. Neonatal hypoxia at the 5th minute is correlated with cerebral palsy and death [29]. Although neonatal depression would be related to placental ischemia, we believe that the circumstances of childbirth coupled with measures of neonatal resuscitation would be avenues to be investigated later to establish the causal links.
4. Conclusion
Isolated hypertension was the most frequent hypertensive form in peripartum. Preeclampsia was significantly the hypertensive entity significantly associated with the parameters of maternal and neonatal morbidity. For the future, we suggest carrying out more in-depth studies in order to be able to look for other factors of maternal, fetal and neonatal comorbidity in relation to hypertensive gravidary pathologies in our environment.
Author Contribution
All the authors of this article have made a significant contribution to the design, implementation and/or analysis and interpretation of the data, to the development of the article and to the critical review of its intellectual content.