“COMPARISON OF SERUM CALCIUM LEVELS IN NORMAL PREGNANCY AND PREGNANCY

(1)

A DISSERTATION ON

“COMPARISON OF SERUM CALCIUM LEVELS IN NORMAL PREGNANCY AND PREGNANCY

ASSOCIATED HYPERTENSION”

Submitted to

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI, TAMILNADU

In partial fulfillment of the regulations for the award of the degree

M.S. DEGREE

OBSTETRICS AND GYNAECOLOGY Reg. No.221816703

GOVERNMENT MOHAN KUMARAMANGALAM

MEDICAL COLLEGE AND HOSPITAL,

(2)

GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE AND HOSPITAL

DECLARATION BY THE CANDIDATE

I solemnly declare that this dissertation entitled “COMPARISON OF SERUM CALCIUM LEVELS IN NORMAL PREGNANCY AND PREGNANCY ASSOCIATED HYPERTENSION" is a bonafide record of work done by me in the Department of Obstetrics and Gynaecology at Government Mohan Kumaramangalam Medical College Hospital under the guidance and supervision of Prof.Dr.S.S.SUBHA, M.D. D.G.O., Professor and Head of the Department, Department of Obstetrics and Gynaecology, Government Mohan Kumaramangalam Medical College & Hospital, Salem, TamilNadu.

Date : (Dr. S.KARTHIKA PRIYA)

(3)

GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE AND HOSPITAL

CERTIFICATE BY THE GUIDE

This is to certify that this dissertation entitled, “COMPARISON OF SERUM CALCIUM LEVELS IN NORMAL PREGNANCY AND PREGNANCY ASSOCIATED HYPERTENSION” by Dr.S.KARTHIKA PRIYA, Post graduate in Obstetrics and Gynaecology (2018-2021), is a bonafide record of work carried out under our supervision and guidance in Department of Obstetrics and Gynaecology and is submitted to The Tamilnadu Dr. M.G.R. Medical University, Chennai, for M.S.

Degree Examination in Obstetrics and Gynaecology, to be held in May 2021.

Date : Signature and seal of the Guide Place : Salem Prof. Dr. S.S. SUBHA, MD, DGO.,

Professor and Head of The Department, Department of Obstetrics and Gynaecology,

(4)

GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE AND HOSPITAL

ENDORSEMENT BY THE HEAD OF THE DEPARTMENT

This is to certify that this dissertation titled “COMPARISON OF SERUM CALCIUM LEVELS IN NORMAL PREGNANCY AND PREGNANCY

ASSOCIATED HYPERTENSION” is a bonafide work done by Dr.S.KARTHIKA PRIYA, under overall guidance and supervision of

Prof.Dr.S.S.SUBHA, M.D. D.G.O., Professor and Head of the Department, Department of Obstetrics and Gynaecology, Government Mohan Kumaramangalam Medical College & Hospital, in partial fulfillment of the requirement for the degree of M.S. in Obstetrics and Gynaecology, examination to be held in May 2021.

Date : Signature and seal of the HOD

Place : Salem Prof. Dr. S.S. SUBHA, MD, DGO., Professor and Head of The Department, Department of Obstetrics and Gynaecology,

(5)

GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE AND HOSPITAL

ENDORSEMENT BY THE DEAN OF THE INSTITUTION

This is to certify that this dissertation entitled “COMPARISON OF SERUM CALCIUM LEVELS IN NORMAL PREGNANCY AND PREGNANCY ASSOCIATED HYPERTENSION” is a bonafide work done by Dr.S.KARTHIKA PRIYA, under guidance and supervision of Prof.Dr.S.S.SUBHA,MD.,DGO., Professor and Head of the Department, Department of Obstetrics and Gynaecology, Government Mohan Kumaramangalam Medical College & Hospital, in partial fulfillment of the requirement for the degree of M.S. in Obstetrics and Gynaecology, examination to be held in May 2021.

Date : Signature and seal of the Dean Place : Salem Prof. Dr.R.BALAJINATHAN, M.D.,

DEAN

(6)

GOVERNMENT MOHAN KUMARAMANGALAM MEDICAL COLLEGE AND HOSPITAL

COPYRIGHT

I hereby declare that the Government Mohan Kumaramangalam Medical College Hospital, Salem, Tamil Nadu, India; shall have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic format for academic / research purpose.

Date : (Dr. S.KARTHIKA PRIYA)

Place : Salem Signature of the candidate

(7)

ACKNOWLEDGEMENT

First and foremost I thank the Almighty for bestowing me with countless blessings for the completion of this study

I sincerely express my heartful gratitude to our beloved Dean, Dr.R.BALAJINATHAN, MD., Dean, Government Mohan Kumaramangalam Medical College Salem for granting me permission to use the facilities of the institution for this study.

I take this opportunity to express my profound gratitude by thanking my Head of the Department and Guide Prof.Dr.S.S.SUBHA,MD.,DGO, whose kindness, guidance and encouragement enabled me to complete this study. I am greatly indebted to her, for her timely suggestions and advice which has helped me to complete my study.

I express my sincere gratitude to my Associate professors Dr.R.MANIMEGALAI MD, DGO., Dr.L.SHANMUGAVADIVU MD(OG)., for their warm attitude and making me to understand the basics of research and in correcting manuscript.

I am highly obliged to all my Assistant Professors, Department of Obstetrics and Gynaecology, Government Mohan Kumaramangalam Medical College for their evincing keen interest, encouragement and corrective comments during the study period.

(8)

My special thanks to my postgraduate colleagues for their valuable support throughout the study.

I thank my parents for their valuable support.

Last but not the least, its my patients to whom I am heartily thankful for their co-operation which made this study a complete one

.

Dr. S. KARTHIKA PRIYA

(9)

(10)

(11)

PLAGIARISM CERTIFICATE

This is to certify that this dissertation work titled “COMPARISON OF SERUM CALCIUM LEVELS IN NORMAL PREGNANCY AND PREGNANCY ASSOCIATED HYPERTENSION” of the candidate Dr.S.KARTHIKA PRIYA with registration Number 221816703 for the award of M.S., Degree in the branch of Obstetrics and Gynaecology. I personally verified the urkund.com website for the purpose of plagiarism Check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 7%

percentage of plagiarism in the dissertation.

Guide & Supervisor sign with Seal

(12)

LIST OF ABBREVIATIONS

PIH - Pregnancy Induced Hypertension IUGR - Intra Uterine Growth Retardation GFR - Glomerular Filtration Rate

BMI - Body Mass Index

CPD - Cephalo Pelvic Disproportion IE - Imminent Eclampsia

RCT - Randomised Control Trial

(13)

LIST OF TABLES

1. Table 1: Age Distribution of all the Participants 26 2. Table 2: Gestational age of the participants 29

3. Table 3a: Parity of the participants 32

4. Table 3b: Comparison of Parity of cases and controls 32 5. Table 4: Body Mass Index of the participants 34 6. Table 5a: Socioeconomic Status of the participants 37 7. Table 5b: Comparison of Socioeconomic Status of the

participants

37

8. Table 6: Systolic BP of the participants 39 9. Table 7: Diastolic BP of the participants 42 10. Table 8a: History of pregnancy induced hypertension 45 11. Table 8b: Comparison of history of pregnancy induced

hypertension

45

12. Table 9a: Urine albumin among cases and controls 47 13. Table 9b: Comparison of Urine albumin among cases and

controls

47

14. Table 10: Serum calcium levels 49

15. Table 11a: Onset of labour among cases and controls 52

(15)

17. Table 12a: Mode of delivery among cases and controls 54 18. Table 12b: Comparison of mode of delivery among cases

and controls

54

19. Table 13a: Indication of cesarean section among cases and controls

56

20. Table 13b: Comparison of the Indication of cesarean section among cases and controls

57

21. Table 14: Birth weight of the babies 59

22. Table 15a: Complications among cases and controls 62 23. Table 15b: Comparison of Complications among cases and

controls

62

24. Table 16: Inferential Statistics of Significant variables of the study

64

(16)

LIST OF FIGURES

1. Figure 1a: Age Distribution of all the Participants 27 2. Figure 1b: Comparison of Age Distribution of all the Participants 28 3. Figure 2a: Gestational age of the participants 30 4. Figure 2b: Comparison of gestational age of the participants 31 5. Figure 3: Comparison of Parity of cases and controls 33 6. Figure 4a: Body Mass Index of the participants 35 7. Figure 4b: Comparison of Body Mass Index of the participants 36 8. Figure 5: Comparison of Socioeconomic Status of the participants 38

9. Figure 6a: Systolic BP of the participants 40

10. Figure 6b: Comparison of Systolic BP of the participants 41

11. Figure 7a: Diastolic BP of the participants 43

12. Figure 7b: Comparison of Diastolic BP of the participants 44 13. Figure 8: Comparison of history of pregnancy induced hypertension 46 14. Figure 9: Comparison of Urine albumin among cases and controls 48

15. Figure 10a: Serum calcium levels 50

16. Figure 10b: Comparison of Serum calcium levels 51 17. Figure 11: Comparison of onset of labour among cases and controls 53

(17)

19. Figure 13: Comparison of the Indication of cesarean section among cases and controls

58

20. Figure 14a: Birth weight of the babies 60

21. Figure 14b: Comparison of Birth weight of the babies 61 22. Figure 15: Complications among cases and controls 63

(18)

ABSTRACT

Background

Pregnancy induced hypertension or gestational hypertension is defined by the presence of newly diagnosed hypertension in pregnant women after 20 weeks of gestation with no proteinuria. There should be at least two occasions six hours apart where the blood pressure was more than 140/90 mm of Hg. Hypertensive disorders are second most common medical disorder in pregnancy. It is a significant contributor of maternal mortality and morbidity in liaison with infection and haemorrhage.

Aim and Objective

To compare serum calcium levels in normal pregnant women and in pregnant women with associated Hypertension

To correlate serum calcium levels with severity of preeclampsia Material and Methods

The study was undertaken in 200 pregnant women. Data for the study was collected from 100 normotensive pregnant women with more than 20 weeks of gestational age (control group) and 100 Pregnancy Associated Hypertension patients (study group) admitted in the antenatal ward in Department of Obstetrics and Gynaecology in Government Mohan Kumaramangalam medical college hospital.

Cases and controls were matched. Serum calcium levels were estimated. All data were recorded in structured questionnaires, coded and entered in Microsoft Excel. The data

(19)

inferential statistics. The tests for significance were run to statistically validate the data. The results were then tabulated and visualized in Microsoft word.

Results

The mean age of cases is 27.01 years (S.D=4.6 years). The median age of cases is 26 years. It ranges between 20 and 40 years. The mean age of controls is 27.46 years (S.D=4.9 years). The median age of controls is 27 years. It ranges between 20 and 40 years.

The mean gestational age of cases is 35.13 weeks (S.D=3.02 weeks). The median gestational age of cases is 36 weeks. It ranges between 25 and 40 weeks. The mean gestational age of controls is 34.34 months (S.D=3.6 weeks). The median gestational age of controls is 34.5 weeks. It ranges between 24 and 40 weeks.

In cases, 58% of them were primi while 42% of them were multiparous. In controls, 54% of them were primi while 46% of them were multiparous. Chi-square analysis shows that the difference is statistically significant though cross tabulation shows that the two groups are similar in terms of parity.

The mean BMI of cases is 25.57 (S.D=3.1). The median BMI of cases is 25.2.

It ranges between 19 and 32. The mean BMI of controls is 22.5 (S.D=1.9). The median BMI of controls is 22.4. It ranges between 17.8 and 28.2. Student t-test shows that the BMI differs significantly between the two groups (p<0.005).

(20)

152 mm/Hg. The mean systolic BP of controls is 122 mm/hg (S.D=10.02 mm/Hg).

The range was between 110 mm/Hg and 130 mm/Hg. The median systolic BP of controls is 112 mm/Hg. Comparison of systolic BP between cases and controls shows that the mean systolic BP is higher in cases. The difference is statistically highly significant (p<0.005).

The mean diastolic BP of cases is 98.9 mm/hg (S.D=6.03 mm/Hg). The range was between 90 mm/Hg and 110 mm/Hg. The median diastolic BP of cases is 100 mm/Hg. The mean diastolic BP of controls is 75.9 mm/hg (S.D=4.44 mm/Hg). The range was between 64 mm/Hg and 80 mm/Hg. The median diastolic BP of controls is 76 mm/Hg. Comparison of diastolic BP between cases and controls shows that the mean diastolic BP is higher in cases. The difference is statistically highly significant (p<0.005).

In cases, Previous history of PIH was present in 13 cases compared to 10 cases in controls. The higher incidence of PIH is seen in cross tabulation though it is not statistically significant.

The mean serum calcium level of cases is 8.7 mg/dl (S.D=0.4 mg/dl). The median serum calcium level of cases is 8.75 mg/dl. It ranges between 8-9.6 mg/dl.

The mean serum calcium level of controls is 9.2 mg/dl (S.D=0.5 mg/dl). The median serum calcium level of controls is 9.1 mg/dl. It ranges between 8.4-10.6 mg/dl.

Comparison of mean serum calcium levels between cases and controls shows that the

(21)

Student t-test shows that BMI, Serum Calcium, Systolic BP, Diastolic BP and Birth Weight differs significantly between the two groups (p<0.005)

Conclusion

This study concludes that regular monitoring of patients for these biomarkers will aid in early diagnosis and management. Thus, monitoring serum calcium levels can be effective in preventing maternal morbidity and mortality and help to reach a favourable outcome in pregnancy.

(22)

INTRODUCTION

Pregnancy induced hypertension or gestational hypertension is defined by the presence of newly diagnosed hypertension in pregnant women after 20 weeks of gestation with no proteinuria. There should be at least two occasions six hours apart where the blood pressure was more than 140/90 mm of Hg¹. Hypertensive disorders are second most common medical disorder in pregnancy. It is a significant contributor of maternal mortality and morbidity in liaison with infection and haemorrhage². PIH is a multisystem disorder specific to pregnancy presenting with edema, elevated blood pressure and is a constituent of preeclampsia and eclampsia³. Preeclampsia is common in pregnancy with a high correlation to maternal and perinatal morbidity and mortality⁴. Early diagnosis, prevention and treatment had made hypertensive disorders a non-serious disorder in developed countries while developing countries like India continues to report high incidence of PIH⁵.

During pregnancy, a number of physiological changes take place in the mother.

This includes cardiovascular and renal function changes to accommodate the changing needs of the mother and the fetus. In normal pregnancy, following changes are observed:

a) Increase in maternal cardiac output and blood volume by 40-50%^6-8 b) Decrease in arterial blood pressure and total peripheral resistance c) Increase in renal plasma flow and GFR by 30-40%⁹

d) Increase in renin concentration, activity of renin and angiotensin-II levels¹⁰

(23)

However these changes do not occur in women with PIH. There is an increase in peripheral resistance, reduction in renal plasma flow and GFR and increased vascular responsiveness to angiotensin-II.

Studies on pregnant women are very limited and performing detailed mechanistic studies to understand PIH is not feasible. However animal models are studied to understand the pathophysiology of PIH and various factors related to it^11-13. There are a number of studies that independently study the association of PIH with various factors.

Role of calcium in pregnancy

The requirement of calcium in pregnancy is very high and if unmet leads to demineralisation of maternal skeleton, stunted fetal growth, reduced mineralisation of the fetal bones and hampers the secretion of calcium in breast-milk¹⁴. By the end of pregnancy, around 25-30 g of calcium is transferred to the fetal skeleton from the mother. The accumulation begins at the rate of 2-3 mg/day of calcium in the first trimester increasing to 250 mg/day by the end of third trimester¹⁵. Loss of calcium in breast milk during lactation is around 200-240 mg/day¹⁶. Approximately, mother loses 3-5% of maternal skeletal calcium content¹⁷. Initial studies on calcium in pregnancy led to the hypothesis that high calcium intake reduces the incidence of PIH. However, it could not be established the actual reason behind this¹⁸.

There are not many studies that determine the role of serum calcium level in

(24)

REVIEW OF LITERATURE

EPIDEMIOLOGY OF HYPERTENSIVE DISORDERS OF PREGNANCY

Hypertensive disorders are second most common medical disorder in pregnancy. It is a significant contributor of maternal mortality and morbidity in liaison with infection and haemorrhage². PIH is a multisystem disorder specific to pregnancy presenting with edema, elevated blood pressure and is a constituent of preeclampsia and eclampsia³. Preeclampsia is common in pregnancy with a high correlation to maternal and perinatal morbidity and mortality⁴. Early diagnosis, prevention and treatment had made hypertensive disorders a non-serious disorder in developed countries while developing countries like India continues to report high incidence of PIH⁵.

(25)

INCIDENCE OF HYPERTENSIVE DISORDERS OF PREGNANCY FROM POOLED DATA OF STUDIES⁴⁴

Hospital-based incidence estimates for preeclampsia systematically differ from national estimates due to the following reasons;

1. Many studies rely on discharge diagnoses

2. Studies included only nulliparous women, a group known to be at five-fold or greater risk of developing preeclampsia as compared to parous women.

3. Women who enroll in RCT to prevent preeclampsia may also be a group with characteristics that would suggest a tendency to develop hypertension in pregnancy.

4. Women seeking prenatal care at academic medical centers are a selected group who are probably at higher risk of developing pregnancy complications than would be reflected in a national sample.

5. In these studies the diagnosis is substantially contaminated with women with transient hypertension

(26)

The figure above shows the estimates from different studies (adapted from Chesley’s text book of Hypertensive Disorders of Pregnancy)

(27)

AN OVERVIEW OF NORMAL CALCIUM METABOLISM AND HOMEOSTASIS

The movement of calcium ions in and out of the body is regulated a number of organs and hormones. Calcium is essential for the maintenance of bones and teeth.

Bones store most of the calcium and are retrieved from there when necessary. The following figure shows the normal homeostasis and metabolism of calcium in the human body.

Image 1 : An overview of normal calcium metabolism

(28)

AN OVERVIEW OF CALCIUM METABOLISM IN PREGNANCY^19-23

The period of pregnancy and lactation is a demanding phase for a woman when the calcium demand increases enormously. The fetus and the neonate tend to rely on the mother for calcium. The excessive demand may at times exceed the normal daily intake of the woman. There are specific changes in the body during pregnancy to meet these changes in requirements. The major adaptation is doubling the calcium absorption during pregnancy. This adaptation in mothers also influences the way other disorders of calcium and bone are presented. The following figures show calcium metabolism in pregnancy.

Image 2: Comparison of calcium metabolism in pregnancy and lactation with normal There is an average requirement of 30 g of calcium in neonates during

(29)

During pregnancy, the calcium in the decidua of the mother helps in egg fertilisation and in the blastocyst implantation. Since then, there is a consistent increase in the rate of transfer of calcium from mother to fetus. This is aided by the doubling of calcium absorption in the mother during this phase regulated by calcitriol and other factors. The following image shows the difference in calcium levels in pregnancy.

Image 3: Calcium levels during pregnancy

(30)

RENAL HANDLING OF CALCIUM DURING PREGNANCY

The increased absorption of calcium during pregnancy is deposited in the skeleton of the mother, passed to the fetus or expelled in urine. The renal excretion of calcium increases from 12th week of gestation whereas the fasting urine calcium levels are either lower than normal or normal. This supports the idea that higher calcium levels are due to increased absorption. This increases the risk of renal stones in pregnancy.

On the other hand, low serum calcium levels are associated with pre-eclampsia and pregnancy-induced hypertension. These changes are attributed to the disturbance in the renal function as well leading to reduced creatinine clearance rather than low serum calcium. Studies show that calcium supplementation reduces the incidence of pre-eclamspia in pregnancy and there is a definite relationship between pregnancy associated hypertension and calcium metabolism.

(31)

CATEGORIES AND DEFINITION OF HYPERTENSIVE DISORDERS OF PREGNANCY

The following image shows the categories and definition of hypertensive disorders of pregnancy.

Image 4: categories and definitions of hypertensive disorders of pregnancy

(32)

Image 5: Classification of hypertensive disorders of pregnancy

The origins and consequences of preeclampsia Preeclampsia is multifactorial in origin namely;

a) Genetic factors

b) Immunological factors c) Lowered threshold

All factors end up in the activation of the endothelial cells leading to renal, cardiorespiratory, hepatic, hematological and central nervous system consequences.

The following figure shows the relationship between the origin and consequences of preeclampsia.

(33)

Image 6: Origins and consequences of preeclampsia

(34)

RISK FACTORS FOR PRE-ECLAMPSIA The major risk factors are;

a) Previous history of pre-eclampsia b) Autoimmune disease

c) Multifetal gestation d) Diabetes

e) Renal disease

f) Chronic hypertension

The following figure shows the high and moderate-risk factors

Image 7: Risk factors for pre-eclampsia

(35)

RELEVANT LITERATURE

A recent meta-analysis by Tito et al (2012) on the relationship between preeclampsia and low calcium intake revealed the following²⁴;

Mantel-Haenszel’s Method was used and patients were divided into four subgroups;

a) Adequate calcium intake b) Low calcium intake c) Low risk of preeclampsia d) High risk of preeclampsia

The study concluded that;

a) Preeclampsia is a multifactorial disease,

b) Calcium levels are negatively correlated with the incidence of hypertensive disease

c) Additional calcium intake can be used as a preventive measure during pregnancy in high-risk groups

(36)

Another meta-analysis of randomised control trials to understand the relationship between calcium supplementation, blood pressure, preeclampsia, and outcomes of pregnancy was done by Heiner et al in 1996²⁵. Fourteen trials were chosen and 2459 women were selected. The findings were differential and concluded that;

a) Low calcium levels are associated with higher incidence of hypertension in pregnancy

b) Calcium supplementation reduced the systolic and diastolic blood pressure c) Women at risk of pre-eclampsia can be advised calcium supplementation

There are also studies that contradict these findings.

Levine et al in 1996 showed that calcium supplementation did not have any significant impact in reducing preeclampsia²⁶. (Image 8)

The following study aimed to compare Serum calcium levels in Pregnancy Associated Hypertension patients and normal pregnancies and to determine the role of serum calcium level in Pregnancy Associated Hypertension and normal pregnant women

(37)

Image 8: Incidence of hypertensive disorders in the study (Levine et al, 1996)

(38)

AIMS AND OBJECTIVES OF THE STUDY

• To compare serum calcium levels in normal pregnant women and in pregnant women with associated Hypertension

• To correlate serum calcium levels with severity of preeclampsia

(39)

MATERIALS AND METHODS

STUDY DESIGN

Prospective Analytical Study STUDY POPULATION

Patients admitted in the Antenatal ward of OBSTETRICS& GYNAECOLOGY Department, Government Mohan Kumaramangalam Medical College Hospital, Salem.

STUDY POPULATION DIVIDED INTO TWO GROUPS:

GROUP 1 : Calcium levels in normal pregnant women

GROUP 2 : Calcium levels in pregnancy associated hypertension women STUDY PERIOD

One year SAMPLE SIZE

200 (100 in each group)

(40)

INCLUSION CRITERIA

Study group:

• Age 20– 40yrs

• Singleton pregnancy

• More than 20 weeks gestational age

• Primi / multi gravida

• Diagnosed Pre-eclampsia based on the criteria – BP ≥ 140/90mmHg on two separate occasions 6 hrs apart, Proteinuria more than 300mg in 24 hr urine or 1+dipstick in 2 midstream urine samples collected 4 hrs apart, with or without Edema, in more than 20 weeks gestational age.

Control Group:

• Age 20-40 years

• Singleton pregnancy

• More than 20 weeks gestational age with BP ≤ 130/80 mmHg .

• Primi / multigravida gravida

EXCLUSION CRITERIA:

• Multiple gestation

• Gestational Age <20 wks

• Associated co morbidities like gestational diabetes mellitus, chronic

(41)

METHODOLOGY

The study was undertaken in 200 pregnant women. Data for the study was collected from 100 normotensive pregnant women with more than 20 weeks of gestational age (control group) and 100 Pregnancy Associated Hypertension patients (study group) admitted in the antenatal ward in Department of Obstetrics and Gynaecology in Government Mohan Kumaramangalam medical college hospital.

Cases and controls were matched. Serum calcium levels were estimated.

PRIVACY/CONFIDENTIALITY OF STUDY SUBJECTS:

Privacy of the subjects shall be maintained.

STATISTICAL ANALYSIS

All data were recorded in structured questionnaires, coded and entered in Microsoft Excel. The data was then cleaned, checked for inconsistencies, missing values and prepared for analysis using SPSS v23. The data was then analyzed for descriptive statistics and inferential statistics. The tests for significance were run to statistically validate the data. The results were then tabulated and visualized in Microsoft word.

(42)

RESULTS

The study aimed to determine the role of serum calcium level in Pregnancy Associated Hypertension and normal pregnant women and to compare Serum calcium levels in Pregnancy Associated Hypertension patients and normal pregnancies.

The mean age of cases is 27.01 years (S.D=4.6 years). The median age of cases is 26 years. It ranges between 20 and 40 years. The mean age of controls is 27.46 years (S.D=4.9 years). The median age of controls is 27 years. It ranges between 20 and 40 years. Student t-test shows that the age does not differ significantly between the two groups (p>0.05)

The mean gestational age of cases is 35.13 weeks (S.D=3.02 weeks). The median gestational age of cases is 36 weeks. It ranges between 25 and 40 weeks. The mean gestational age of controls is 34.34 months (S.D=3.6 weeks). The median gestational age of controls is 34.5 weeks. It ranges between 24 and 40 weeks.

Comparison of gestational age between cases and controls shows that there is no statistically significant difference (p>0.05).

In cases, 58% of them were primi while 42% of them were multiparous. In controls, 54% of them were primi while 46% of them were multiparous. Chi-square analysis shows that the difference is statistically significant though cross tabulation shows that the two groups are similar in terms of parity.

(43)

It ranges between 19 and 32. The mean BMI of controls is 22.5 (S.D=1.9). The median BMI of controls is 22.4. It ranges between 17.8 and 28.2. Student t-test shows that the BMI differs significantly between the two groups (p<0.005)

Among cases; 35% came from Class IV, 32% came from Class III, 27% came from Class II and 6% came from Class V. Among controls; 35% came from Class IV, 33% came from Class III, 25% came from Class II and 7% came from Class V. Both the groups are similar in the socioeconomic status.

The mean systolic BP of cases is 151 mm/hg (S.D=7.01 mm/Hg). The range was between 140 mm/Hg and 164 mm/Hg. The median systolic BP of cases is 152 mm/Hg. The mean systolic BP of controls is 122 mm/hg (S.D=10.02 mm/Hg). The range was between 110 mm/Hg and 130 mm/Hg. The median systolic BP of controls is 112 mm/Hg. Comparison of systolic BP between cases and controls shows that the mean systolic BP is higher in cases. The difference is statistically highly significant (p<0.005).

The mean diastolic BP of cases is 98.9 mm/hg (S.D=6.03 mm/Hg). The range was between 90 mm/Hg and 110 mm/Hg. The median diastolic BP of cases is 100 mm/Hg. The mean diastolic BP of controls is 75.9 mm/hg (S.D=4.44 mm/Hg). The range was between 64 mm/Hg and 80 mm/Hg. The median diastolic BP of controls is 76 mm/Hg. Comparison of diastolic BP between cases and controls shows that the

(44)

Urine albumin was present only in cases. Among cases, 48% had 1+, 32% had 2+ and 20% had 3+ proteinuria. Cross tabulation and chi-square analysis shows that this is statistically significant and proteinuria is present only in cases.

Comparison of mean serum calcium levels between cases and controls shows that the mean serum calcium is lower in cases. The difference is statistically highly significant (p<0.005).

Among cases, Induced labour was more (53%) than spontaneous labour (47%).

Among controls, spontaneous labour was more (61%) than induced labour (39%) This shows that the need for induction is high among cases who report low calcium levels and high BP. Cross tabulation and chi-square analysis shows that this difference is statistically significant.

(45)

Among cases, caesarean section was 38% and instrumental delivery was 11%.

Vaginal delivery was 51%. Among controls, majority was vaginal delivery (72%) while caesarean section and instrumental delivery was seen in 19% and 9%

respectively. Cross tabulation and chi-square analysis shows that the difference is statistically significant (p<0.05). Cases with Lower calcium levels and high BP are associated with higher incidence of caesarean section.

Fetal distress was the major reason in cases (10), followed by CPD (9), failed induction (8), abruption (6) and others (5). Fetal distress was the major reason in controls (5) , followed by CPD (5), failed induction (2), and others (7). Cross- tabulation and chi-square analysis shows that cases with high BP and lower calcium levels are associated with higher incidence of caesarean. The difference between cases and controls is statistically significant (p<0.05).

The mean birth weight of babies of cases is 2.31 kg (S.D=0.495 kg). The median birth weight of babies of cases is 2.4 kg. It ranges between 1.2-3.2 kg. The mean birth weight of babies of controls is 2.7 kg (S.D=0.51 kg). The median birth weight of babies of controls is 2.8 kg. It ranges between 1.5-3.8 kg. Comparison of birth weight of babies between cases and controls shows that the mean birth weight is lower in cases. The difference is statistically highly significant (p<0.005).

(46)

Complications were higher among cases (37%) than controls (5%). The most common complication was Intra Uterine Growth Retardation (20%) followed by Imminent Eclampsia (11%) and abruption (6%). The incidence of complications is higher among cases. Cross-tabulation and chi-square analysis shows that the difference is statistically highly significant (p<0.005).

(47)

FINDINGS

Age Distribution

The mean age of cases is 27.01 years (S.D=4.6 years). The median age of cases is 26 years. It ranges between 20 and 40 years.

The mean age of controls is 27.46 years (S.D=4.9 years). The median age of controls is 27 years. It ranges between 20 and 40 years.

S.No Age (in years) Cases Controls

1 Mean 27.010 27.460

2 Median 26.000 27.000

3 Mode 26.0 21.0^a

4 Std. Deviation 4.6111 4.9286

5 Minimum 20.0 20.0

6 Maximum 40.0 40.0

Table 1: Age Distribution of all the Participants

(48)

Figure 1a: Age Distribution of all the Participants

26.7 26.8 26.9 27 27.1 27.2 27.3 27.4 27.5

Mean age

Cases Controls

(49)

Comparison of age between cases and controls

Figure 1b: Comparison of Age Distribution of all the Participants

Student t-test shows that the age does not differ significantly between the two groups (p>0.05)

0 5 10 15 20 25 30 35 40 45

Cases Control

(50)

Gestational Age of the participants

The mean gestational age of cases is 35.13 weeks (S.D=3.02 weeks). The median gestational age of cases is 36 weeks. It ranges between 25 and 40 weeks.

The mean gestational age of controls is 34.34 months (S.D=3.6 weeks). The median gestational age of controls is 34.5 weeks. It ranges between 24 and 40 weeks.

S.No Gestational Age ( in weeks)

Cases Controls

1 Mean 35.130 34.340

2 Median 36.000 34.500

3 Mode 36.0^a 36.0

5 Minimum 25.0 24.0

6 Maximum 40.0 40.0

Table 2: Gestational age of the participants

(51)

Figure 2a: Gestational age of the participants

33.8 34 34.2 34.4 34.6 34.8 35 35.2

Mean Gestational Age

Cases Controls

(52)

Figure 2b: Comparison of gestational age of the participants

Comparison of gestational age between cases and controls shows that there is no statistically significant difference (p>0.05).

0 5 10 15 20 25 30 35 40 45

Cases Control

(53)

Parity of the participants

In cases, 58% of them were primi while 42% of them were multiparous.

In controls, 54% of them were primi while 46% of them were multiparous.

Chi-square analysis shows that the difference is statistically significant though cross tabulation shows that the two groups are similar in terms of parity.

S.No Parity Cases (n/%) Control (n/%)

1 Multi 42 46

2 Primi 58 54

Total 100 100

Table 3a: Parity of the participants

Value df Asymp. Sig. (2- sided)

Pearson Chi-Square 22.404^a 2 .000

Likelihood Ratio 29.770 2 .000

N of Valid Cases 200

a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 9.50.

Table 3b: Comparison of Parity of cases and controls

(54)

Figure 3: Comparison of Parity of cases and controls

0 10 20 30 40 50 60 70

Multi Primi

Cases (n/%) Control (n/%)

(55)

Body Mass Index of the participants

It ranges between 19 and 32.

The mean BMI of controls is 22.5 (S.D=1.9). The median BMI of controls is 22.4. It ranges between 17.8 and 28.2.

S.No BMI Cases Controls

1 Mean 25.574 22.5616

2 Median 25.200 22.4000

3 Mode 24.5^a 22.40

4 Std. Deviation 3.1154 1.89206

5 Minimum 19.0 17.80

6 Maximum 32.4 28.20

Table 4: Body Mass Index of the participants

(56)

Figure 4a: Body Mass Index of the participants

21 21.5 22 22.5 23 23.5 24 24.5 25 25.5 26

BMI

Cases Controls

(57)

Comparison of BMI between cases and controls

Figure 4b: Comparison of Body Mass Index of the participants

Student t-test shows that the BMI differs significantly between the two groups (p<0.005)

0 5 10 15 20 25 30 35

Cases Control

(58)

Socioeconomic Status of the participants

Among cases; 35% came from Class IV, 32% came from Class III, 27% came from Class II and 6% came from Class V. Among controls; 35% came from Class IV, 33% came from Class III, 25% came from Class II and 7% came from Class V. Both the groups are similar in the socioeconomic status.

S.No Socioeconomic Status Cases (n/%) Control (n/%)

1 II 27 25

2 III 32 33

3 IV 35 35

4 V 6 7

Total 100 100

Table 5a: Socioeconomic Status of the participants

Pearson Chi-Square .169^a 3 .982

Likelihood Ratio .169 3 .982

a. 0 cells (.0%) have expected count less than 5. The minimum expected count is

(59)

Figure 5: Comparison of Socioeconomic Status of the participants

0 5 10 15 20 25 30 35 40

II III IV V

Cases Control

(60)

Systolic BP of the participants

The mean systolic BP of cases is 151 mm/hg (S.D=7.01 mm/Hg). The range was between 140 mm/Hg and 164 mm/Hg. The median systolic BP of cases is 152mm/Hg.

The mean systolic BP of controls is 122 mm/hg (S.D=10.02 mm/Hg). The range was between 110 mm/Hg and 130 mm/Hg. The median systolic BP of controls is 112 mm/Hg.

S.No Systolic BP Cases Controls

1 Mean 151.790 122.220

2 Median 152.000 112.000

3 Mode 150.0 120.0

5 Minimum 140.0 110

6 Maximum 164.0 130

Table 6: Systolic BP of the participants

(61)

Figure 6a: Systolic BP of the participants

0 20 40 60 80 100 120 140 160

Systolic BP

Cases Controls

(62)

Comparison of systolic BP between cases and controls

Figure 6b: Comparison of Systolic BP of the participants

Comparison of systolic BP between cases and controls shows that the mean systolic BP is higher in cases. The difference is statistically highly significant (p<0.005).

0 20 40 60 80 100 120 140 160 180

Cases Control

(63)

Diastolic BP of the participants

The mean diastolic BP of cases is 98.9 mm/hg (S.D=6.03 mm/Hg). The range was between 90 mm/Hg and 110 mm/Hg. The median diastolic BP of cases is 100 mm/Hg.

The mean diastolic BP of controls is 75.9 mm/hg (S.D=4.44 mm/Hg). The range was between 64 mm/Hg and 80 mm/Hg. The median diastolic BP of controls is 76 mm/Hg.

S.No Diastolic BP Cases Controls

1 Mean 98.9400 75.900

2 Median 100 76.000

3 Mode 100 70.0

5 Minimum 90 64.0

6 Maximum 110 80.0

Table 7: Diastolic BP of the participants

(64)

Figure 7a: Diastolic BP of the participants

0 20 40 60 80 100 120

Diastolic BP

Cases Controls

(65)

Figure 7b: Comparison of Diastolic BP of the participants

Comparison of diastolic BP between cases and controls shows that the mean diastolic BP is higher in cases. The difference is statistically highly significant

0 20 40 60 80 100 120

Cases Control

(66)

History of pregnancy induced hypertension

S.No History of PIH Cases (n/%) Control (n/%)

1 Yes 13 10

2 No 29 36

3 NA 58 54

Total 100 100

Table 8a: History of pregnancy induced hypertension

Chi-Square Tests

Value df Asymp. Sig. (2-

sided)

(67)

Figure 8: Comparison of history of pregnancy induced hypertension

0 5 10 15 20 25 30 35 40

Yes No

Cases Control

(68)

Urine albumin among cases and controls

Urine albumin was present only in cases. Among cases, 48% had 1+, 32% had 2+ and 20% had 3+ proteinuria. Cross tabulation and chi-square analysis shows that this is statistically significant and proteinuria is present only in cases.

S.No Urine Albumin Cases (n/%) Control (n/%)

1 1+ 48 0

2 2+ 32 0

3 3+ 20 0

4 Nil 0 100

Total 100 100

Table 9a: Urine albumin among cases and controls

Chi-Square Tests

Value df Asymp. Sig. (2-

sided)

a. 0 cells (.0%) have expected count less than 5. The minimum expected count is

(69)

Figure 9: Comparison of Urine albumin among cases and controls

0 20 40 60 80 100 120

1+ 2+ 3+ Nil

Cases Control

(70)

Serum calcium levels

S.No Serum Calcium (mg/dl) Cases Controls

1 Mean 8.738 9.239

2 Median 8.750 9.100

3 Mode 8.4^a 9.1

4 Std. Deviation .4025 .5148

5 Minimum 8.0 8.4

6 Maximum 9.6 10.6

Table 10: Serum calcium levels

(71)

Figure 10a: Serum calcium levels

8.4 8.5 8.6 8.7 8.8 8.9 9 9.1 9.2 9.3

Mean Serum Calcium

Cases Controls

(72)

Figure 10b: Comparison of Serum calcium levels

Comparison of mean serum calcium levels between cases and controls shows that the mean serum calcium is lower in cases. The difference is statistically highly

0 2 4 6 8 10 12

Cases Control

(73)

Onset of labour among cases and controls

Among cases, Induced labour was more (53%) than spontaneous labour (47%).

Among controls, spontaneous labour was more (61%) than induced labour (39%) This shows that the need for induction is high among cases who report low calcium levels and high BP. Cross tabulation and chi-square analysis shows that this difference is statistically significant.

S.No Onset of Labour Cases (n/%) Control (n/%)

1 Induced 53 39

2 Spontaneous 47 61

Total 100 100

Table 11a: Onset of labour among cases and controls Value df Asymp.

Sig. (2- sided)

Exact Sig.

(2-sided)

Exact Sig.

(1-sided)

Pearson Chi-Square 3.945^a 1 .047 Continuity Correction^b 3.402 1 .065 Likelihood Ratio 3.959 1 .047

Fisher's Exact Test .065 .032

b. Computed only for a 2x2 table

(74)

Figure 11: Comparison of onset of labour among cases and controls

0 10 20 30 40 50 60 70

Induced Spontaneous

Cases Control

(75)

Mode of delivery among cases and controls

Among cases, caesarean section was 38% and instrumental delivery was 11%.

Vaginal delivery was 51%. Among controls, majority was vaginal delivery (72%) while caesarean section and instrumental delivery was seen in 19% and 9%

respectively.

S.No Mode of Delivery Cases (n/%) Control (n/%)

1 Caesarean Section 38 19

2 Instrumental Delivery 11 9

3 Vaginal Delivery 51 72

Total 100 100

Table 12a: Mode of delivery among cases and controls

Cross tabulation and chi-square analysis shows that the difference is statistically significant (p<0.05). Cases with Lower calcium levels and high BP are associated with higher incidence of caesarean section.

(76)

Figure 12: Comparison of mode of delivery among cases and controls

0 10 20 30 40 50 60 70 80

Caesarean Section Instrumental Delivery Vaginal Delivery

Cases Control

(77)

Indication of caesarean section among cases and controls

Fetal distress was the major reason in cases (10), followed by CPD (9), failed induction (8), abruption (6) and others (5).

Fetal distress was the major reason in controls (5) , followed by CPD (5), failed induction (2), and others (7).

S.No Indication for Caesarean Section

Cases (n/%) Control (n/%)

1 Abruption 6 -

2 CPD 9 5

3 Failed Induction 8 2

4 Failure to progress 3 0

5 Fetal Distress 10 5

6 IUGR/Oligohydramnios 2 0

7 Non progress of Labour 0 5

8 Severe oligohydramnios 0 2

Total 38 19

Table 13a: Indication of caesarean section among cases and controls

(78)

Cross-tabulation and chi-square analysis shows that there is higher incidence of caesarean among cases. The difference between cases and controls is statistically significant (p<0.05).

a. 12 cells (66.7%) have expected count less than 5. The minimum expected count is .50.

Table 13b: Comparison of the Indication of caesarean section among cases and controls

(79)

Figure 13: Comparison of the Indication of caesarean section among cases and controls

0 2 4 6 8 10 12

Cases Control

(80)

Birth Wight of the Babies

The mean birth weight of babies of cases is 2.31 kg (S.D=0.495 kg). The median birth weight of babies of cases is 2.4 kg. It ranges between 1.2-3.2 kg.

The mean birth weight of babies of controls is 2.7 kg (S.D=0.51 kg). The median birth weight of babies of controls is 2.8 kg. It ranges between 1.5-3.8 kg.

S.No Birth Weight ( in Kg) Cases Controls

1 Mean 2.31 2.782

2 Median 2.40 2.800

3 Mode 2.8 2.8

4 Std. Deviation .495 .5068

5 Minimum 1.2 1.5

6 Maximum 3.2 3.8

Table 14: Birth weight of the babies

(81)

Figure 14a: Birth weight of the babies

0 0.5 1 1.5 2 2.5 3

Mean Birth Weight

Cases Controls

(82)

Figure 14b: Comparison of Birth weight of the babies

Comparison of birth weight of babies between cases and controls shows that the mean birth weight is lower in cases. The difference is statistically highly

0 0.5 1 1.5 2 2.5 3 3.5 4

Cases Control

(83)

Complications among cases and controls

Complications were higher among cases (37%) than controls (5%). The most common complication was Intra Uterine Growth Retardation (20%) followed by Imminent Eclampsia (11%) and abruption (6%). The incidence of complications is higher among cases.

S.No Complications Cases (n/%) Control (n/%)

1 Abruption 6 0

2 Imminent Eclampsia 11 0

3 Intra Uterine Growth Retardation

20 5

Total 37 5

Table 15a: Complications among cases and controls Chi-Square Tests

Value df Asymp. Sig. (2-sided)

a. 2 cells (25.0%) have expected count less than 5. The minimum expected count is 3.00.

Table 15b: Comparison of Complications among cases and controls

(84)

Figure 15: Complications among cases and controls

0 5 10 15 20 25

Abruption IE IUGR

Cases (n/%) Control (n/%)

(85)

Inferential Statistics of Significant variables of the study

Parameters t-test p-value Interpretation

Age -1.060 .290 Not Significant

BMI 8.265 .000 Statistically

significant

Gestational Age 1.681 .094 Not Significant

Serum Calcium -5.044 .000 Statistically

significant

Birth weight -7.978 .000 Statistically

significant

Systolic BP 3.901 .000 Statistically

significant

Diastolic BP 2.987 .000 Statistically

significant

Table 16: Inferential Statistics of Significant variables of the study

(86)

DISCUSSION

Pregnancy induced hypertension or gestational hypertension is defined by the presence of newly diagnosed hypertension in pregnant women after 20 weeks of gestation with no proteinuria. There should be atleast two occasions six hours apart where the blood pressure was more than 140/90 mm of Hg¹. Hypertensive disorders are second most medical disorder in pregnancy. It is a significant contributor of maternal mortality and morbidity in liaison with infection and haemorrhage². PIH is a multisystem disorder specific to pregnancy presenting with edema, elevated blood pressure and is a constituent of preeclampsia and eclampsia³. Preeclampsia is common in pregnancy with a high correlation to maternal and perinatal morbidity and mortality⁴. Early diagnosis, prevention and treatment had made hypertensive disorders a non-serious disorder in developed countries while developing countries like India continues to report high incidence of PIH⁵.

During pregnancy, a number of physiological changes take place in the mother.

This includes cardiovascular and renal function changes to accommodate the changing needs of the mother and the fetus. In normal pregnancy, following changes are observed;

a) increase in maternal cardiac output and blood volume by 40-50%^6-8 b) Decrease in arterial blood pressure and total peripheral resistance c) Increase in renal plasma flow and GFR by 30-40%⁹

(87)

However these changes do not occur in women with PIH. There is an increase in peripheral resistance, reduction in renal plasma flow and GFR and increased vascular responsiveness to angiotensin-II.

Studies on pregnant women are very limited and performing detailed mechanistic studies to understand PIH is not feasible. However animal models are studied to understand the pathophysiology of PIH and various factors related to it^11-13. There are a number of studies that independently study the association of PIH with various factors.

The requirement of calcium in pregnancy is very high and if unmet leads to demineralisation of maternal skeleton, stunted fetal growth, reduced mineralisation of the fetal bones and hampers the secretion of calcium in breast-milk¹⁴. By the end of pregnancy, around 25-30 g of calcium is transferred to the fetal skeleton from the mother. The accumulation begins at the rate of 2-3 mg/day of calcium in the first trimester increasing to 250 mg/day by the end of third trimester¹⁵. Loss of calcium in breast milk during lactation is around 200-240 mg/day¹⁶. Approximately, mother loses 3-5% of maternal skeletal calcium content¹⁷. Initial studies on calcium in pregnancy led to the hypothesis that high calcium intake reduces the incidence of PIH. However, it could not be established the actual reason behind this¹⁸.

There are not many studies that determine the role of serum calcium level in Pregnancy from the Indian population. Therefore, this study aims to assess the levels

(88)

The study aimed to determine the role of serum calcium level in Pregnancy Associated Hypertension and normal pregnant women and to compare Serum calcium levels in Pregnancy Associated Hypertension patients and normal pregnancies.

1. AGE : The mean age of cases is 27.01 years (S.D=4.6 years). The median age of cases is 26 years. It ranges between 20 and 40 years. The mean age of controls is 27.46 years (S.D=4.9 years). The median age of controls is 27 years. It ranges between 20 and 40 years. Student t-test shows that the age does not differ significantly between the two groups (p>0.05)

2. GESTATIONAL AGE : The mean gestational age of cases is 35.13 weeks (S.D=3.02 weeks). The median gestational age of cases is 36 weeks. It ranges between 25 and 40 weeks.The mean gestational age of controls is 34.34 months (S.D=3.6 weeks). The median gestational age of controls is 34.5 weeks. It ranges between 24 and 40 weeks. Comparison of gestational age between cases and controls shows that there is no statistically significant difference (p>0.05).

3. PARITY : In cases, 58% of them were primi while 42% of them were multiparous. In controls, 54% of them were primi while 46% of them were multiparous. Chi-square analysis shows that the difference is statistically significant though cross tabulation shows that the two groups are similar in terms of parity.

4. BODY MASS INDEX : The mean BMI of cases is 25.57 (S.D=3.1). The median BMI of cases is 25.2. It ranges between 19 and 32.The mean BMI of controls is 22.5 (S.D=1.9). The median BMI of controls is 22.4. It ranges between 17.8 and

(89)

Similar findings were reported by Jain et al (2010)³¹, Kumar et al (2009)³³, Punthumapol et al (2008)³⁵ , Kant et al (2019) ³⁹ and Gupta et al (2016) ⁴⁰. BMI in these studies were comparable with those of the present study

5. SOCIO ECONOMIC STATUS : Among cases; 35% came from Class IV, 32% came from Class III, 27% came from Class II and 6% came from Class V.

Among controls; 35% came from Class IV, 33% came from Class III, 25% came from Class II and 7% came from Class V. Both the groups are similar in the socioeconomic status.

6. SYSTOLIC BLOOD PRESSURE : The mean systolic BP of cases is 151 mm/hg (S.D=7.01 mm/Hg). The range was between 140 mm/Hg and 164 mm/Hg. The median systolic BP of cases is 152 mm/Hg. The mean systolic BP of controls is 122 mm/hg (S.D=10.02 mm/Hg). The range was between 110 mm/Hg and 130 mm/Hg.

The median systolic BP of controls is 112 mm/Hg. Comparison of systolic BP between cases and controls shows that the mean systolic BP is higher in cases. The difference is statistically highly significant (p<0.005).

This study is in line with the findings of the study by Levine et al (1996)²⁶ , Jafrin et al (2013)²⁸ , Gupta A et al (2016)²⁹ , and Patrelli, et al (2012)²⁴.

7. DIASTOLIC BLOOD PRESSURE : The mean diastolic BP of cases is 98.9 mm/hg (S.D=6.03 mm/Hg). The range was between 90 mm/Hg and 110 mm/Hg.

The median diastolic BP of cases is 100 mm/Hg. The mean diastolic BP of controls is

(90)

between cases and controls shows that the mean diastolic BP is higher in cases. The difference is statistically highly significant (p<0.005).

This study is in line with the findings of the study by Levine et al (1996)²⁶ , Jafrin et al (2013)²⁸ , Gupta A et al (2016)²⁹ , and Patrelli, et al (2012)²⁴.

8. PREVIOUS HISTORY OF PIH : In cases, Previous history of PIH was present in 13 cases compared to 10 cases in controls. The higher incidence of PIH is seen in cross tabulation though it is not statistically significant.

9. URINE ALBUMIN : Urine albumin was present only in cases. Among cases, 48% had 1+, 32% had 2+ and 20% had 3+ proteinuria. Cross tabulation and chi-square analysis shows that this is statistically significant and proteinuria is present only in cases.

10. SERUM CALCIUM : The mean serum calcium level of cases is 8.7 mg/dl (S.D=0.4 mg/dl). The median serum calcium level of cases is 8.75 mg/dl. It ranges between 8-9.6 mg/dl. The mean serum calcium level of controls is 9.2 mg/dl (S.D=0.5 mg/dl). The median serum calcium level of controls is 9.1 mg/dl. It ranges between 8.4-10.6 mg/dl. Comparison of mean serum calcium levels between cases and controls shows that the mean serum calcium is lower in cases. The difference is statistically highly significant (p<0.005).

11. ONSET OF LABOUR : Among cases, Induced labour was more (53%) than spontaneous labour (47%). Among controls, spontaneous labour was more (61%)

(91)

12. MODE OF DELIVERY : Among cases, caesarean section was 38% and instrumental delivery was 11%. Vaginal delivery was 51%. Among controls, majority was vaginal delivery (72%) while caesarean section and instrumental delivery was seen in 19% and 9% respectively. Cross tabulation and chi-square analysis shows that the difference is statistically significant (p<0.05). Cases with Lower calcium levels and high BP are associated with higher incidence of caesarean section.

13. INDICATIONS OF CESAREAN SECTION : Fetal distress was the major reason in cases (10), followed by CPD (9), failed induction (8), abruption (6) and others (5). Fetal distress was the major reason in controls (5) , followed by CPD (5), failed induction (2), and others (7). Cross-tabulation and chi-square analysis shows that there is higher incidence of caesarean among cases. The difference between cases and controls is statistically significant (p<0.05).

14. BIRTH WEIGHT : The mean birth weight of babies of cases is 2.31 kg (S.D=0.495 kg). The median birth weight of babies of cases is 2.4 kg. It ranges

between 1.2-3.2 kg. The mean birth weight of babies of controls is 2.7 kg (S.D=0.51 kg). The median birth weight of babies of controls is 2.8 kg. It ranges

between 1.5-3.8 kg. Comparison of birth weight of babies between cases and controls shows that the mean birth weight is lower in cases. The difference is statistically highly significant (p<0.005).

“COMPARISON OF SERUM CALCIUM LEVELS IN NORMAL PREGNANCY AND PREGNANCY

A DISSERTATION ON