Association of Lipid Profile in Pregnancy with Pre-eclampsia

Association of Lipid Profile in Pregnancy with Pre-eclampsiaAssociation of Lipid Profile in Pregnancy with Pre-eclampsia, gestational Diabetes Mellitus and Preterm deliveryBabita Ghodke*,1, Raghuram Puskuru2, Varshil Mehta3, Kunal Bhuta41Associate Professor, 2Senior resident, 3Intern, 4Junior ResidentDepartment of Medicine, MGM Medical College, Navi Mumbai, India.AbstractIntroduction During last two trimesters of maternity, glucose is sp atomic number 18d (for the foetus) small-arm the concentration of fatty acids in plasma increases which can create complications manage Preeclampsia, Gestational diabetes mellitus and preterm delivery.Aim To paper the association of blood serum lipide trains during abet and 3rd trimester with the development of pregnancy associated diseases like preeclampsia, GDM and preterm.Methods and Materials The present deal was carried out at MGM Hospital, Navi Mumbai, India. cc antenatal cases from October, 2012 to October 2014 were enrolled after ta king an informed consent. Statistical analyses were performed using Statistical Package for Social Sciences (SPSS) version 20. All reported p-values argon two-tailed, and confidence intervals were calculated at the 95% level.Results In pre-eclamptic patients, the tight Systolic blood line Pressure was 151.40 mm/Hg and nasty diastolic blood mechanical press was 74.03 mm/Hg in third trimester. In pre-eclamptic patients, the fee-tail serum triglyceride levels in second trimester was 204.00 mg/dl while 243.20 md/dl in third trimester. In Gestational Diabetes Mellitus patients, the blind drunk serum triglyceride was 214.33 mg/dl in second trimester while 230.50 mg/dl in third trimester. In patients with preterm, the imply triglycerides levels 212.83 mg/dl and 240.16 mg/dl in second and third trimester respectively. In pre-eclamptic patients the humble serum cholesterol levels in second trimester was 210 mg/dl, while in third trimester, it was 243.60 mg/dl. In GDM patients, the m ean serum cholesterol was 223.50 mg/dl and 242.83 mg/dl in second and third trimester respectively. 213.33 mg/dl and 243.66 mg/dl were the means cholesterol levels in second and third trimester respectively in patients with preterm. Out of total 200 patients 168 had no complications, while 20 10% had preeclampsia, 6 3% had Gestational Diabetes Mellitus and 6 3% had preterm deliveries.ConclusionAn association in the midst of maternal early pregnancy triglyceridaemia, and the subsequent risk of preeclampsia, gestational diabetes and preterm deliveries was observe. Occurrence of Preeclampsia, Gestational Diabetes and Preterm deliveries cannot be predicted based on the values of Serum Cholesterol, HDL-Cholesterol, LDL-Cholesterol and very low density lipoprotein-Cholesterol. Hence estimation of lipid profile is strongly recommended during pregnancy to prevent pernicious final result of hyperlipidaemia associated with pregnancy.Keywords Lipid Profile, Gestational Diabetes Mellitus, P reterm, Preeclampsia, Pregnancy related disease.1. IntroductionPregnancy is a physiological process which causes profound changes in the body. It submits to an increase in demands for metabolic fuels and also causes alteration in hormonal levels which whitethorn cause few changes in lipid profile during pregnancy 1.During last two trimesters, glucose is spared (for the foetus) while the concentration of fatty acids in plasma increases which introduces to Gestational Diabetes Mellitus (GDM) and Gestational Hypertension (GHTN) respectively. Freinkel had described this process as accelerated starvation, and facilitated anabolism 2.GDM and GHTN can lead to peri and postpartum complications. Pregnancy is often also complicated with diseases which can hamper Cardio-Vascular System. GDM and GHTN are few of them which can develop type 2 diabetes and systemic hypertension in later part of life 3,4.In our previous study, we showed that total cholesterol, triglycerides, LDL-cholesterol, VLDL -cholesterol increases in last two trimesters. The increase is even greater in third trimester, when compared to the second. However, HDL-Cholesterol levels are decreased in third trimester when compared to that of second. The study concluded that the estimation of lipid profile is highly recommended during pregnancy due to its association with high levels of triglycerides which may lead to Pre-eclampsia, GDM and preterm delivery 5.The present study is a continuation of our previous study and here, it evaluates the clinical significance of the lipid profile level in pregnancy and its effect on the development of pregnancy induced diseases like GDM, pre-eclampsia and preterm.2. AimTo study the association of serum lipid levels during second and third trimester with the development of pregnancy associated diseases like preeclampsia, GDM and preterm.3. Material, Methods, Ethics, Statistical Analysis, Inclusion and Exclusion CriteriaThe present study is a continuation of our previous st udy and the material, methods, ethics, inclusion and exclusion criteria could be obtained from our previous study 5. In brief, the present study was conducted at Mahatma Gandhi Mission Hospital, Navi Mumbai, India. A total of 200 pregnant local women were enrolled from October 2012 to 2014. Out of the 200 subjects, 10 developed GHTN in late third trimester which was detected after 32nd week during follow-up which were also included. The venous blood sample was collected from all subjects for measurement of lipid profile in the 16th week and 32nd week of gestation for analysis.All pregnant women with a singleton pregnancy with a gestational age of 13-28 weeks, regardless of parity and gravida were included. Pregnant women in whom hypertension (HTN) was detected before 14 weeks and those with diseases or complications like chronic HTN, Diabetes, Renal Disorders and Thyroid Disorders, Obstetric and Foetal Complications (Hydrops foetalis, inseparable foetal anomalies) were excluded.St atistical analyses were performed using Statistical Package for Social Sciences (SPSS) version 17.0. All reported P values are two-tailed, and confidence intervals were calculated at the 95% level. The data was presented using frequencies, percentages, descriptive statistics followed by charts and graphs. Level of significance was set at 5%. All p-values less than 0.05 were treated as solid.4. ResultsThe mean age of patients was 24.87 years with a SD of 2.7 years. The minimum age was 18 years and the maximum age was 30 years.4.1 Blood PressureThe mean Systolic Blood Pressure (SBP) in second trimester was 117.03 mm/Hg with a SD of 10.33 mm/Hg. In third trimester, it was increased to 120.77 with a SD of 14.675.In pre-eclamptic patients, the mean SBP was 151.40 with a SD 6.05. (p =0.00) in third trimester. There was a highly significant statistical difference in the mean blood pressure values among rule and pre-eclamptic women in third trimester.The mean Diastolic Blood Pressure in o ur study in third trimester was 72.11 mm/Hg with a SD of 6.88 mm/Hg. In third trimester, the mean SBP was increased to 74.03 with a SD of 8.616. In pre-eclamptic patients the mean was 92.00 with a SD 2.59 (p =0.00). There was a highly significant statistical difference in the mean blood pressure values among ruler and pre-eclamptic women in third trimester. Out of total 200 patients 168 had no complications, while 20 had preeclampsia, 6 had GDM and 6 had preterm deliveries.4.2 Association of Triglycerides with Preeclampsia, GDM and PretermThe beneath tabularise (figure 1) indicates the 95% confidence interval for triglyceride levels for patients with outcomes of Preeclampsia, GDM and Preterm. The mean triglyceride level in second trimester was 188.68 mg/dl with a standard deviation of 20.88 mg/dl. In third trimester, the mean triglyceride (TG) level was increased to 216.78 mg/dl with a standard deviation of 20.09 mg/dl 5.In pre-eclamptic patients, the mean serum triglyceride leve ls in second trimester was 204.00 with a SD 18.904 (p =0.00), while in third trimester, the mean was 243.20 with a SD of 15.58 (p =0.00). There was significant statistical significance observed between serum triglyceride levels and pre-eclampsia in both second and third trimesters (figure 1). matterTrimesterMeanNSDSEM95 % CILower environUpper BoundPreeclampsiaSecond Trimester204.002018.904.23195.71212.29Third Trimester243.202015.583.48236.37250.03GDMSecond Trimester214.33618.647.61199.42229.25Third Trimester230.50617.036.95216.88244.12PretermSecond Trimester212.83611.994.90203.24222.43Third Trimester240.1767.733.16233.98246.35 send off 1. Association of Triglycerides with Preeclampsia, GDM and Preterm4.3 Association of Cholesterol with Preeclampsia, GDM and PretermThe below dishearten (figure 2) indicates the 95% confidence interval for cholesterol levels for patients with outcomes of Eclampsia, GDM and Preterm.In pre eclamptic patients the mean serum cholesterol levels in second trimester was 210.75 with a SD 24.248 (p =0.320), in third trimester, the mean was 243.60 with a SD of 25.84 (p =0.826). There was no statistical significance observed between serum cholesterol and pre-eclampsia in both second and third trimesters.Compared to the approach pattern value of 200mg/dl, cholesterol level is raised in normal pregnancy. In pre- eclamptic women cholesterol level is raised more than the values in normal pregnancy. egressTrimesterNMeanSDSEM95% CILower BoundUpper BoundPreeclampsia2nd Trimester20210.7524.255.42199.401222.103rd Trimester20243.6025.855.78231.50255.69GDM2nd Trimester6223.5025.1610.27197.09249.903rd Trimester6242.8327.1411.08214.35271.31Preterm2nd Trimester6213.3320.238.25192.10234.553rd Trimester6243.6627.20011.10215.12272.21 augur 2. Association of Cholesterol with Preeclampsia, GDM and Preterm4.4 Association of HDL Cholesterol with Preeclampsia, GDM and PretermThe below table (figure 3) indicates the 95% confidence interval for HDL cholesterol levels for patients with outcomes of Preeclampsia, GDM and Preterm.In third trimester, the mean serum HDL Cholesterol (HDL-C) level in normal patients was 42.78 with a SD of 4.31, in pre eclamptic patients the mean was 45.60 with a SD 4.12 Compared to the normal value of 40-60 mg/dl, HDL-Cholesterol level is within normal range in normal pregnancy. In pre-eclamptic women HDL-C level was higher than normal pregnancy but within normal range.In pre eclamptic patients the mean serum HDL Cholesterol levels in second trimester was 51.8 with a SD 5.8 (p =0.040), in third trimester, the mean was 45.60 with a SD of 4.1 (p =0.006). There was significant statistical significance observed between serum HDL -Cholesterol and pre-eclampsia in both second and third trimesters.OutcomeTrimesterNMeanSDSEM95% CILower BoundUpper BoundPreeclampsia2nd Trimester2051.805.841.3049.0654.533rd Trimester2045.604.12.9243.6747.52GDM2nd Trimester652.007.072.8844.5759.423rd Trimester641.167.272.9733.5248.80Prete rm2nd Trimester649.006.132.5042.5655.433rd Trimester645.504.031.6441.2649.73Figure 3. Association of HDL Cholesterol with Preeclampsia, GDM and Preterm4.5 Association of LDL Cholesterol with Preeclampsia, GDM and PretermThe below table (figure 4) indicates the 95% confidence interval for LDL cholesterol levels for patients with outcomes of Preeclampsia, GDM and Preterm.In third trimester, the mean serum LDL-Cholesterol level in normal patients was 137.80 with a SD of 13.67, in preeclamptic patients the mean was 137.80 with a SD 11.5. Compared to the normal value of 130 mg/dl 5, triglyceride level is raised in normal pregnancy. In preeclamptic women LDL-C level was same as in normal pregnancy (figure 4). In preeclamptic patients the mean serum LDL-C levels in second trimester was 92.7 with a SD 18.2 (p =0.943), in third trimester, the mean was 137.8 with a SD of 11.5 (p =0.996). There was no significant statistical significance observed between serum LDL-C levels and pre-eclampsia in both second and third trimesters.OutcomeTrimesterNMeanSDSEM95% CILower BoundUpper BoundPreeclampsia2nd Trimester2092.7018.224.0784.17101.233rd Trimester20137.8011.592.59132.37143.22GDM2nd Trimester696.8331.3912.8163.89129.773rd Trimester6150.169.884.03139.79160.54Preterm2nd Trimester684.506.122.5078.0790.923rd Trimester6127.8310.644.34116.66139.00Figure 4. Association of LDL Cholesterol with Preeclampsia, GDM and Preterm4.6 Association of VLDL Cholesterol with Eclampsia, GDM and PretermThe below table (figure 5) indicates the 95% confidence interval for VLDL cholesterol levels for patients with outcomes of Eclampsia, GDM and Preterm.In third trimester, the mean serum VLDL-Cholesterol (VLDL-C) level in normal patients was 35.88 with a SD of 6.5, in pre eclamptic patients the mean was 39.7 with a SD 7.1. Compared to the normal value of 35 mg/dl 5, VLDL-C level is raised in normal pregnancy. In pre- eclamptic women VLDL-C level was increased more than that in normal pregnancy.In p re eclamptic patients the mean serum VLDL-C levels in second trimester was 30.9 with a SD 7.9 (p =0.93), in third trimester, the mean was 39.7 with a SD of 7.1 (p =0.016). There was no significant statistical significance observed between serum VLDL-C levels and pre-eclampsia in second trimester but significance was found in third trimesters.OutcomeTrimesterNMeanSDSEM95% CILower BoundUpper BoundEclampsia2nd Trimester2030.957.931.7727.2334.663rd Trimester2039.707.111.5936.3643.03GDM2nd Trimester627.166.012.4520.8533.473rd Trimester634.005.652.3028.0639.93Preterm2nd Trimester625.663.981.6221.4829.843rd Trimester636.836.962.8429.5244.14Figure 5. Association of VLDL Cholesterol with Eclampsia, GDM and Preterm4.7 Mean values of lipid parameters with outcome in 2nd and 3rd trimesterThe mean values of Serum cholesterol, Serum TG, HDL-C, LDL-C, VLDL-C are given in figures 6 and 7.TrimesterOutcomeSerum Cholesterol mg/dlSerum Triglycerides mg/dlHDL-CHOLESTEROL mg/dlLDL-CHOLESTEROL mg/dlVLDL- CHOLESTEROL mg/dlSecond TrimesterPreeclampsia210.75204.0051.8092.7030.95GDM223.50214.3352.0096.8327.16Preterm213.33212.8349.0084.5025.66Third TrimesterPreeclampsia243.60243.2045.60137.8039.70GDM242.83230.5041.16150.1634.00Preterm243.66240.1645.50127.8336.83Figure 6. Mean values of lipid parameters with outcome in 2nd and 3rd trimesterFigure 7. Comparison of Lipid parameters between second and third trimester4.9 Complications outcome distributionOut of total 200 patients 168 had no complications, while 20 10% had preeclampsia, 6 3% had Gestational Diabetes Mellitus and 6 3% had preterm deliveries (Figure 8).ComplicationNo of CasesPercentageNo Complication16884%Pre-eclampsia2010%GDM63%Preterm63%Total200100%Figure 8. Distribution according to Complications5. DiscussionHypercholesterolemia is known to cause excessive lipid peroxidation and synchronous diminution in antioxidant activity which may result in an imbalance between peroxidases and antioxidants, leading to oxidative stress. O xidative stress and elevated atherogenic index may lead to atherogenicity in Pre-eclampsia 6.5.1 TriglyceridesIn a study conducted by Arnon Wiznitzer et. al., to prove the association of lipid levels during gestation with preeclampsia and GDM in 9911 pregnant women, they observed that the composite endpoint (GDM or preeclampsia) occurred in 1209 women (12.2%). During the index pregnancy, GDM was diagnosed in 638 women (6.4%) while Preeclampsia was diagnosed in 625 pregnancies (6.3%) 7.In a study by Lorentzen et al., it was observed that the mean triglyceride concentrations of pre-eclampsia patients were higher than normal pregnant women at 16-18 weeks 8.Later, a large prospective cohort study conducted in Norway by Clausen et al. (2001) also demonstrated that women with triglycerides preceding(prenominal) 212 mg/dL (2.4 mmol/L) had a five-fold increased risk (95% CI 1.1-23.1) of early onset pre-eclampsia (onset before 34 weeks) compared with those with triglycerides levels 133 mg/d L 9.A study done by S. Niromanesh et. al., to compare the outcomes of forty five pregnant women who had high TG levels (195 mg/dl) with 135 pregnant women having TG levels 10.In a study done by Kandimalla et. al., comprising 156 pregnant women attending antenatal clinic visits were included prior to 20 weeks and were analysed for lipid levels. 102 participants were followed until delivery and were monitored for pre-eclampsia. They reported that mean triglyceride levels were found significantly higher in the pre-eclampsia group. Women with triglycerides above 130 mg/dL had increased risk of pre-eclampsia compared with those with triglycerides levels of 91 mg/dL or less 11.In the present study, compared to the normal value of 150 mg/dl 12, during second trimester, the 95% CI for triglyceride level with Preeclampsia was between 195.71 and 212.29, the 95% CI for triglyceride level with outcome GDM was between 199.42 and 229.25 while the 95 % CI for triglyceride with preterm outcome was between 203.24 and 222.43. Hence, we can conclude that triglyceride level of more than 195 mg/dl during second trimester can lead to complications like Preeclampsia, and triglycerides greater than 199.42mg/dl lead to GDM and levels above 203.24mg/dl lead to Preterm delivery. During third trimester, the 95% CI for triglyceride level with Preeclampsia was between 236.37 250.03, the 95% CI for triglyceride level with outcome GDM was between 216.88 244.12 and the 95 % CI for triglyceride with preterm outcome was between 233.98 and 246.35. Hence, we can conclude that triglyceride level of more than 236 mg/dl during second trimester can lead to complications like Preeclampsia, triglyceride level of more than 216.88 mg/dl leads to GDM and triglyceride level of more than 233.98mg/dl leads to Preterm delivery (figure 1). Our findings correlate with the findings of a study done by Kandimalla et. al 11.5.2 Cholesterol