EVALUATION OF COAGULATION PROFILE IN PATIENTS WITH PREGNANCY INDUCED HYPERTENSION IN PATIENTS

Pregnancy induced hypertension (PIH) is one of the most common causes of both maternal and neonatal morbidity and associated with adverse pregnancy outcomes.Profound changes in coagulation and fibrinolytic system occur during normal pregnancy causing hypercoagulable state. Early identification of high risk women and monitoring derangements in their coagulation system are surely pivotal in the prevention of complications. Hence, this study was undertaken to compare the coagulation profile in pre-eclamptic and eclamptic patients with normotensive pregnant patients Hypertension is one of the common medical complications of pregnancy and contributes significantly to maternal and perinatal morbidity and mortality. Hypertension is a sign of an underlying pathology which may be pre-existing or appear for the first time during pregnancy. Various haematological


ISSN: 2320-5407
Int. J. Adv. Res. 6(6), 501-506 502 Introduction:-Hypertensive disorders complicates 5 to 10 % of all pregnancies ,contribute significant to perinatal and maternal mortality and morbidity. According to systematic review by WHO hypertensive disorders account for 16% of maternal deaths in developed countries 1 . Hypertensive disorders in pregnancy is one of the commonest medical disorders in pregnancy diagnosed by obstetricians in clinical practice and is one of the major causes of maternal & perinatal morbidity and mortality 2 . Approximately 1,00,000 women die worldwide per annum because of eclampsia 2 .It is said that preeclampsia and eclampsia contribute to death of a woman every 3 minute worldwide 3. Preeclampsia is a common dangerous condition for both mother and baby and is also predictable in onset and progression.
Hypertension is one of the most common medical complications of pregnancy. It contributes significantly to maternal and perinatal morbidity and mortality. Hypertension is a sign of an underlying pathology which may be pre-existing or appear for the first time during pregnancy 4 . Hypertension affects 7-15% of all pregnancies. It is associated with 16 % of all maternal mortality and 20% of all perinatal mortality in India 4,5 .
Pregnancy induced hypertention (PIH) is defined as hypertension that develops as the direct result of the gravid state. It includes, i) Gestational hypertension, ii) Preeclampsia, iii) Eclampsia.
Hematological abnormalities such as thrombocytopenia and decrease in some plasma clotting factors may develop in preeclamptic women 6 .
In pregnancies with preeclampsia coagulation cascade is generally activated. Preeclampsia is a highly thrombotic and pro-coagulant state with platelet activation and thrombin and fibrin formation. About 20% of patients have altered coagulation 7 . Profound changes in coagulation and fibrinolytic system occur during normal pregnancy causing hypercoagulable state. The prothrombotic state may culminate in a process of chronic disseminated intravascular coagulation (DIC) leading to changes in kidney and placenta 8 . These underlying coagulation abnormalities increase the risk of bleeding complications especially during operative deliveries. These subtle changes consistent with DIC occurring in pre-eclampsia and are potentially serious 9 .In the mother, pre-eclampsia may cause premature cardiovascular diseases, such as chronic hypertension, heart disease and stroke. Later in life, while children born after pre-eclamptic pregnancies and who are relatively small at birth, have an increased risk of stroke, coronary heart disease and metabolic syndrome in adult life 10 . Thus, early identification of such high risk women and monitoring derangements in their coagulation system are surely pivotal in the prevention of complications.Hence, this study was undertaken to compare the coagulation profile in pre-eclamptic and eclamptic patients with normotensive pregnant patients.

Aims And Objectives:
Evaluation of coagulation profile in PIH patients.

Materials And Methods:
The study was carried out in the department of gynaecology and obstetrics SKIMS srinagar. One hundred cases diagnosed as PIH with Blood Pressure of ≥ 140/90 mm of Hg detected after 20th weeks of gestation were included in the study. Clinical details were collected from all cases. The cases with pre-existing hypertension and associated co-morbid diseases such as diabetes mellitus, auto immune disorders, ITP, neoplastic diseases, heart diseases and cases on anti-coagulants were excluded from the study. After obtaining consent, under aseptic precaution, venous blood was collected in sodium citrate vacutainer tube. Sample was tested for coagulation profile i.e. PT, aPTT, D-Dimer in fully automated coagulation analyser (CA-1500). PIH cases were classified in to following categories: A.Gestational hypertension.1) Mild gestational hypertension, 2) Severe gestational hypertension.

Statistical Methods:
The recorded data was compiled and entered in a spreadsheet (Microsoft Excel) and then exported to data editor of SPSS Version 20.0 (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as Mean±SD and categorical variables were summarized as frequencies and percentages. Graphically the data was presented by bar diagrams. Analysis of variance (ANOVA) was employed to compare coagulation profile in different categories of PIH. A P-value of less than 0.05 was considered statistically significant.

Results:-
One hundred cases diagnosed as PIH were analysed for coagulation profile. Of 100 cases majority i.e. 36% of the patients were of the age group 25-30 years. (Table. 1) The age of the youngest patient was 20 years and that of oldest was 40 years. 25to 30 years is the commonest age group for gestational hypertension (GH), both mild (15cases) and severe (7cases). An equal number of severe GH was also seen in the 26 to30 age group. Mild and severe pre-eclampsia was more frequent in the 26 to 30 age group, (16 and 8 cases respectively). This probably indicates that severity of complications increases with the age of the patient. (Table. 2) of the hundred PIH cases.    This table shows value of aPTT increases with severity of PIH with maximum value in severe preeclampsia (31.61±2.89); also D dimers were in in higher range in severe preeclampsia as compared to others. So APTT and Ddimer can predict the severity of PIH and helps us to plan and manage patient accordingly to decrease maternal and fetal morbidity and mortality.

Discussion:
Preeclampsia is an idiopathic multisystem disorder specific to human pregnancy and the puerperium 5 .Hematological abnormalities such as thrombocytopenia and decrease in some plasma clotting factors may develop in preeclamptic women 2 . Subtle changes suggesting disseminated intravascular coagulation (DIC) is one of the serious outcome of preeclampsia. Thus, coagulation testing is to be done in these patients to rule out DIC 6,7 and HELLP (hemolysis, enzyme elevation and low platelet) syndrome. From the historical point of view, earlier it was stated that only serial measurements of platelet count was adequate for intrapartum screening 8 . Later, combination of platelet count and aPTT 6 platelet count and liver function tests 9 ,platelet count and lactatedehydrogenase 7 , platelet count and antithrombin 10 were suggested for early detection and screening of the patients with peeclampsia. It was observed that abnormal PT, aPTT and fibrinogen levels with platelet counts of less than 100,000/mm3 were seen in preeclampsia. So the physician can safely follow the platelet counts of the patients with severe preeclampsia 8 Prolonged PT,aPTT and D-Dimer was seen in 5 cases ,20 cases and 38 cases respectively in our study and increased mean aPTT of 31.61±2.89 and increased D-Dimer of 0.34±0.31 in severe preeclampsia patients was noted. Hence we emphasize that raised aPTT, D-Dimer are alarming signs for aggressive treatment.

Conclusion:-
The coagulation parameters, especially aPTT and D-dimer can be used to monitor the progression of gestational hypertention to preeclampsia. Raised aPTT and D-dimer are fairly good indicators of severe preeclampsia and needs aggressive treatment.