October 2008, Volume 58, Issue 10

Original Article

Pregnancy outcome in teenagers in East Sauterne of Iran

Khooshideh Maryam  ( Department of Gynaecology )
Shahriari Ali  ( Department of Anaesthesiology Zahedan University of Medical Sciences, Zahedan , Iran. )

Introduction

Adolescent pregnancies are associated with maternal and foetal complications and teenage pregnancies have been considered high-risk1. Previous studies have shown that young mothers and their new borns are more at risk of pregnancy-induced hypertension, anaemia, obesity, low birth weight and preterm birth2,3. The studies have also found association between teenage pregnancy and ante partum foetal death4-6.
Pregnancies in adolescents are also associated with social and economic risk factors, which are independent for adverse outcomes of pregnancy7. Studies revealed that childbearing at an early age have been associated with infant homicide8, pregnant teenagers often live in abusive and secluded environments9,10. Teenage pregnancies might be exposed more to recreational drugs, tobacco, alcohol, emotional stress and suboptimal antenatal care, all of which have been defined as independent risk factors for complicated perinatal outcome11. Authors have suggested that age < 15 is very critical, below which the risk of infant death, very low birth weight (<1500 g) and preterm birth (less than 32 weeks) is elevated compared to older adolescent mothers12. Scholl et al. have found that adolescent pregnant are  high-risk due to factors more common among this age group, such as low gynaecologic age, biologic immaturity, inadequate prenatal care, poverty, minority status, and low pre pregnancy weight, all of these might continue to influence the outcome of subsequent pregnancies13.
The objective of the present study was to compare perinatal outcomes between 13 and 19 years old primiparous teenagers and 20-29 years old primiparous women.

Subjects and Methods

A retrospective cohort study was carried out on 10,352 pregnant women,  comparing pregnant teenagers with older gravidas. The study was approved by the local ethics committee. The study population included primiparous singleton teenage women aged 13-19 years, and primiparous 20-29 years in Zahedan, a selected population of religious Muslim women in Iran. In these societies marriage at a young age is routine and also pregnancy at an early age is desired. Teenagers were grouped into low teens (16 years and younger) and high teens (17-19 years old). Prenatal and hospital records were studied for all women under age 29 who were referred to Ali-ebne Abitaleb hospital serving a high-risk inner city population, during the 24-months period extending from January 2003 through January 2005. A chart review was performed for all women in study groups. Demographic details, mode of delivery, gestational age at delivery, newborn's weight, frequency of prenatal visits and any maternal complications were recorded. Maternal age was defined as age in completed years at delivery, and full weeks were calculated to describe the gestational age.  Primiparous were selected in order to have more similar and homogenous groups and to exclude factors that may contribute to preterm delivery in multiparous women, e.g. short inter-pregnancy interval and previous preterm birth. The outcome variables were preterm birth (birth less than 37 completed weeks of gestation) and IUGR (weight less than the tenth percentile for gestational age). Mothers with any underlying disease were excluded.  Prenatal care was considered inadequate if the number of antenatal visits was less than the mandatory number after taking into account the length of gestation, by the 25th week of gestation there should have been at least two visits, by week 26-29, at least three visits, by week 30-33, at least four visits and by week 34 or more, at least five visits included and if the number of visits were equal or more than these numbers considered fair to good and adequate.14 The analysis was performed using students' t-test, chi-square test and the relative risk ratio, p-value less than 0.05 was considered statistically significant.

Results

Out of 10,352 primiparous women aged 13-29 years, 156 (1.51%) were 13-16 years old and 1076 (10.39%) were 17-19 and 9120 (88.09%) were 20-29 years old at delivery. Demographic data were compared between teenagers group and 20-29 years group (Table 1). The mean age for teenage mothers was 16.8 ± 0.19 years, with a minimum age of 13 years, and the mean age for 19-29 years was 23.2 ± 0.31 years. Most teenagers had fair to good prenatal care. Mean number of prenatal visits was 7 ± 2.1 (4-14). Most of them (85.3%) had their prenatal care at the managed care or community based clinics.[(t1)]
The weight of young gravidas was significantly less than older women, when they presented for prenatal care (p < 0.001). The obstetric outcomes were compared in teenage groups and older women (Table 2). Proportions of IUGR and preterm births were significantly higher among the infants of mothers aged 13-19 years than women aged 20-29 years (p<0.001). Majority 83.8% (8675/10352) of the patients had normal vaginal delivery, while only 16.2% (1677/10352) underwent caesarean section. The incidence of caesarean was not significantly different between teenagers and 20-29 years old group.[(t2)]
Pre eclampsia or eclampsia was seen among 22 cases (1.8%) of teenagers and 138 cases (1.5%) of older women and there was no significant difference between the groups. No increase in the incidence of placental abruption was observed in teenagers group. Rate of placenta praevia in teenagers group (0.9%) was higher than 20-29 years group (0.2%) (p=0.001).[(t3)]
All newborns except one had an Apgar score of > 7. Also the obstetric outcomes were compared in all three groups (Table 3) and variables within the two teenage sub groups were also compared (Table 4). The mean age was 15.1 years for low teens and 17.8 for high teenagers. Proportions of  IUGR and preterm births were higher among the infants of mothers aged 16 years or less compared with women aged 17-19 years (p<0.001).There were no significant differences in preeclampsia and placental abruption and placenta praevia between low teens and high teens. The incidence of caesarean in low teens (< 16 years old) was higher than high teens (p= 0.01).[(t4)]

Acknowledgement

The authors would like to thank the maternal health care unit of Ali-ebne Abitaleb Zahedan Hospital for their cooperation.

References

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Abstract

 Objective: To determine the age at diagnosis of hypothyroidism, to signify the effect of delayed diagnosis on the clinical presentation of hypothyroidism and hence to emphasize the need for early diagnosis by cost effective neonatal screening.
Methods: The study was a descriptive case series carried out at the Department of Paediatrics, Allied Hospital, Faisalabad from 2004 to 2006. One hundred consecutive cases of hypothyroidism from birth to twelve years of life were included. The age at presentation and age related clinical features were determined.
Results: The age at diagnosis ranged from birth to 16 years. Male to female ratio was 1:1. Congenital hypothyroidism was more common than acquired(92% VS 8%). Maximum number of cases (42%) were diagnosed between 1-5 years of age while only 14% were diagnosed before 3 months of age . Developmental delay (66%), constipation (51%) and lethargy (37%) were more common symptoms while common signs were pallor (65%), short stature (61%), coarse facies (53%), wide anterior fontanellae (46%) and coarse skin (42%).
Conclusion: Early diagnosis by neonatal screening and commencement of treatment is recommended to prevent the effects of delayed diagnosis (JPMA 58:545; 2008).

Patients and Method

This study was conducted in the department of Paediatrics during 2004-2006 at the Allied Hospital, the largest teaching Hospital of Faisalabad (Pakistan) where patients are referred from rural as well as urban areas.
Hundered consecutive cases of hypothyroidism diagnosed on the basis of history, clinical examination and confirmed by thyroid profile, both from outpatient and emergency departments of the Paediatric Ward, Allied Hospital were evaluated to make the epidemiological significance of the study.
Age specific clinical presentations were identified. These children were divided into 4 groups. Group A (birth to < 3 months), Group B (3 months to < 1 year) Group C (1 year to < 5 years) and Group D (5 years and above).
History details were recorded. Questions specifically asked in group A were feeding problems (choking during feeding and poor feeding), respiratory problems (noisy breathing, apnoea and respiratory distress), delayed passage of meconium (> 72 hours after birth), prolonged neonatal jaundice (lasting for > 2 weeks) and hypothermia (baby being cold as reported by parents and/or documented by health staff). Constipation was considered when there was history of passage of stools after the interval of > 3 days and/or use of some laxatives or suppositories for the passage of stools. Eruption of teeth were considered to be delayed when there were no sign of eruption even after 12 months of age.
Examination details were also recorded. Growth parameters were plotted on standard weight and height charts and classified according to modified Gomez classification(Grade I:70-80% of the expected weight,Grade II:60-70% of the expected weight and Grade III:less than 60% of the expected weight). Children were classified having short stature when their height was below 3rd centile on growth charts.13,14 Development was assessed according to Denver development scoring. Hearing was assessed by distraction hearing test and by audiometry in children above 5 years. Pallor was identified by clinical examination and confirmed by haemoglobin estimation and peripheral film. Facies were considered coarse if these were not resembling with other family members and included depressed nasal bridge, macroglossia and lowset anterior hair line.
Anterior and posterior fontanellae were considered wide if these measured above normals (Normal range for anterior fontanellae is 20 + 10mm and for posterior fontanellae is < 0.5cm) and patent if AF remained open after 18 months and PF after 3 months of life. Goitre was classified into grade I-IV according to WHO classification. (Grade0:no goiter,Grade I:palpable of thumb size,Grade II:visible with neck in extended position, GradeIII:visible with neck in normal position,GradeIV:visible fom distance of 10 m).15
Thyroid profile including free T3, T4 and TSH were done in all cases. T3 and T4 were assayed using RIA (radioimmunoassay) while TSH was assayed using IRMA (immunoradiometric assay). Reference values for T3,T4 and TSH were 2.5 -5.8 pM, 11.5-23.0 pM and 0.17-4.05 mIU/L respectively. We considered TSH value of >20 mIU/ L for the diagnosis of hypothyroidism.
In children above 5 years differentiation between congenital and acquired hypothyroidism was based on normal physical and mental development. Thyroid antimicrosomal and antithyroglobulin antibodies were tested under the suspicion of autoimmune thyroiditis. Endemic cretinism was diagnosed in cases of acquired hypothyroidism on the basis of presence of deafness and neuromuscular disorders
Ultrasonographic or TCM 99 scanning of thyroid gland and FNAC were done as indicated. Other related investigations included haemoglobin, peripheral film and Xrays for assessment of bone age.
Data was entered and descriptive statistics were analysed using SPSS soft ware version 10 and presented through frequency tables.

Discussion

Hypothyroidism and its late diagnosis is still a problem in our set up as 100 cases of hypothyroidism were diagnosed over a 3 year period.
Congenital hypothyroidism is more common than acquired1 consistent with the present study where 92% cases of congenital hypothyroidism versus 8% cases of acquired hypothyroidism were seen. Autoimmune thyroiditis is reported to be the most common cause of acquired hypothyroidism in children above 5 years,8,16 contrasts with this study where Hashimotos thyroiditis and endemic goiter were present in equal proportion. The increased incidence of endemic cretinism in this study is because of referral of large number of patients from Gojra, Toba Tek Singh, Jhang, Chiniot and Sargodha being situated along the river banks and considered as iodine deficient areas.
Female to male ratio in CH is 2:1 while in acquired hypothyroidism it is 3-4:1,1,8 but in this study it was 1:1, similar to that reported by Hachicha M et al.17 This is due to seeking medical advice more for males in our society.
Given the protean clinical manifestations, detection of CH based on signs and symptoms alone, many cases may be delayed to 6-12 weeks of age or older.1,18,19 Same is evident from our study where only 14% (n=14) were detected before 3 months of age.
Delay in the diagnosis and hence treatment is still a common problem in our community as only 26% (n=26) were under one year and 74% (n=74) were diagnosed after one year of age. The majority, 42% (n=42) fell into the age group C (1-<5years). The reasons for the delayed diagnosis are the uneducated parents, who rarely notice or give less importance to the mild to moderate deviation of physical and mental growth as well as constipation, feeding difficulties and other vague non-specific symptoms in infancy.Parents are unaware regarding importance of early diagnosis and commencement of therapy. Lastly, hypothyroidism is usually considered as an uncommon problem among the general practitioners and its clinical features are related to other common illnesses. Thus it is essential that all paediatricians and clinicians be vigilant in recognizing the early clinical manifestations of congenital hypothyroidism. It is the awareness which needs to be enhanced among general practitioner and parents regarding the importance of early diagnosis and commencement of therapy to prevent the effects of delayed diagnosis.
The early symptoms and signs of hypothyroidism are prolonged gestation, delayed passage of meconium, prolonged unconjugated hyperbilirubinaemia, hypothermia, feeding problems, noisy breathing, hoarse cry, large fontanellae, umbilical hernia and cold dry skin1,20 similar to that reported in the present study.
Delayed diagnosis of hypothyroidism can lead to retardation of physical and mental growth,21-23 evident from the fact that as compared to children under one year of age in this study developmental delay was present in 38% (n=10) cases, while it was present in 100% (n=42) cases from 1-< 5 years of age. Developmental delay was present in 56% (n=14) cases in children above 5 years due to inclusion of acquired hypothyroidism with normal D.Q(developmental quotient) in this age group.
Kandemir N24 has revealed permanent height deficit in late diagnosed congenital hypothyroidism. Similary short stature was present in 100% cases (n=42) from one to 5 years of age signifying the need for early diagnosis and treatment of congenital hypothyroidism for prevention of physical and mental retardation.
Pallor is a common clinical feature of hypothyroidism secondary to defective stimulation of bone marrow by low thyroxine level and is refractory to treatment with haematinics.25 For the same reasons pallor was noted in 65% (n=65) cases of hypothyroidism.
Goitre is seen in congenital hypothyroidism especially those with thyroid dysgenesis and in acquired hypothyroidism (autoimmune thyroiditis and endemic cretinism).26 In the present study, goiter was present in 7% (n=6) cases of CH and 100% (n=8) cases of acquired hypothyroidism. Not all newborn infants with thyroid dyshormonogenesis have a palpable goiter1 which is similar to our study, possibly because the palpation of thyroid in infants is difficult and that goiter had not been searched for carefully enough in every case.
Less frequent manifestations of hypothyroidism include menorrhagia present in one case in this study. Delayed puberty is a sequelae of untreated hypothyroidism also present in one case.
An increased frequency of hypothyroidism occur in children with trisomy,21 Turner syndrome, Klinefelter syndrome or other autoimmune diseases including diabetes mellitus type I27,28. Same is evident from this study that out of 92 cases of CH, 2 were associated with Down syndrome and two with nephrotic syndrome. Out of 4 cases of autoimmune thyroiditis one was associated with Turner syndrome and another with type I diabetes mellitus and Addison disease as a part of polyglandular autoimmune disease type II. The presence of associated syndromes lead to delayed recognition of hypothyroidism as features of hypothyroidism are related to the associated syndrome. This was the reason that all these patients presented and were diagnosed after 5 years of age.
Delayed bone age was consistent in all cases of CH, similar to other studies described.1,19 Data suggesting clinical features and age at  diagnosis of hypothyroidism is lacking in Pakistan, so we compared the results with those of Havaldar PV et al.19

Conclusion

 Delay in the diagnosis and the sequelae of untreated CH on physical and mental growth are of utmost concern and their prevention is desirable, therefore high index of clinical suspicion with a close observation for early features of congenital hypothyroidism is warranted for early intervention. In the future, nation wide screening for hypothyroidism is strongly recommended.

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