Pregnancy Induced Hypertension Accompanied With Anemia: Potential Stunting of Newborns

Introduction: Pregnancy induced hypertension (PIH) of anemia pregnant women is a major contributor to adverse birth outcomes of newborns. This research aims to assess the association between pregnancy induced hypertension of anemia pregnant women and poor birth outcomes of newborns, especially body length of newborns at delivery. Material and Methods: One hundred and eight pregnant women are enrolled according to the inclusion criteria. Sociodemographic data, anthropometric measurements, obstetric profiles (gravida), and data of systolic and diastolic blood pressure were collected in this study. Trained midwives drew blood samples from pregnant women as the study samples to measure their hemoglobin (Hb) concentrations and to assess their anemia. Gestational age (GA), types of delivery, anthropometric measurements of newborns (length, weight, head circumference, abdominal circumference and chest circumference) were conducted at delivery. Univariate and bivariate linear analyses were conducted to compare birth outcomes of newborns for each group Results: Of the total 108 pregnant women as the study samples, 25 pregnant women had blood pressures at normal level and normal Hb concentrations, 36 pregnant women had pregnancy induced hypertension (PIH), 29 pregnant women had anemia and 18 pregnant women had pregnancy induced hypertension (PIH) of anemia pregnant women respectively. All groups showed significantly different characteristics of pregnant women in terms of age (p = 0,027), height (p = 0,019), weight (p = 0.000), body mass index (BMI) (p = 0,001), Hb concentration (p = 0.000), systolic blood pressure (p = 0.000), diastolic blood pressure (p = 0.000). Mean length of newborns was significantly lower in pregnancy induced hypertension (PIH) with anemia pregnant women (p = 0.001). Statistical tests showed that there were negative correlations between maternal Hb concentrations and birth length (p = 0.024) as well as blood pressure and birth length (p = 0.000). Conclusion: The average length of newborns in pregnancy induced hypertension (PIH) and pregnancy induced hypertension (PIH) of anemia pregnant women was statistically significant shorter length (stunting) than the normal group. Thus, it is suggested that women who give birth with these conditions should pay more attention to the intake of good nutrition in the first 5 years of their children (the gold period) to prevent long-term adverse effects.


Design of the Study and Sample Population
In this prospective cross-sectional study, association between maternal blood pressure(BP) and Hb concentrations(third trimester) with birth outcomes of newborns were assessed for normal tension, PIH, anemia and PIH is accompanied with anemia.Flowchart of the study is indicated in Figure 1.All pregnant women were screened from June until December 2017from Sitti Khadijah 1 Hospital for Mother and Child Health Makassar, South Sulawesi, Indonesia.108 pregnant women were scereened by health officers according to the inclusion criteria that include singleton gestation, planned delivery at the same hospital and willingness to participate.Exclusion criteria were determined for pregnant women who had history of preterm delivery, obstetric complication, chronic hypertension and other medicalcomplications. Pregnancy induced hypertension (PIH)was classified according to systolic and diastolicblood pressures; normal blood tension (<140/90 mmHg) and pregnancy induced hypertension (PIH) (≥ 140/90 mmHg), whereas,conditions of anemia were classified intoboth non-anemia (> 11gr/dL) and anemia (≤ 11 gr/dL) based on Hb concentrations.Consent formswere signed by pregnant woman who had willingness to participate after the explanation of the study.The total 108 pregnant women were enrolled that consisted of 25 respondents with normal blood pressurewithout anemia, 36 respondents with pregnancy induced hypertension (PIH)without anemia, 29 respondents with normal blood pressure with anemia and 18 respondents with pregnancy induced hypertension (PIH)with anemia were sampledusingthe purposive sampling method.

Data Collection
On days during pregnant women, antenatal care checks, sociodemographic data, anthropometric and obstetric profiles were collected using questionnaires.Blood pressureswere measured using sphygmomanometery and maternal antopometric measurements (height and weight) were performed by the midwifes using the standardized techniques.3 cc blood samples were analyzed in the laboratory to check for the concentrations of Hb.Types of delivery, gestational age, anthropometricof newborns (length, weight, head circumference, abdominal circumference and chest circumference) were measured at birth using the standardized techniques within 24 hours of birth.Length of newborn were measured using infantometer (cm), weights of newborns were measuredusingan electronic baby scale (gr), and head, abdominal and chest circumference of newborns were measured using non-stretchable tapes (cm).Neonates with birth weight at< 2500 gr were classified in the low birth weight and newborns with length < 47 cm were classified as the stunting.

Ethical Considerations
This study received ethical clearance from the Research and Ethics Committee of Faculty of Medicine, Hasanuddin University and was registered in 1074/H4.8.4.5.31/PP36-KOMETIK/2017.

Data Management and Analysis
Descriptive analyses were presented as mean ± standard deviation and frequencies for categorical variables.Bivariat analyses were analyzed and processed using Chi-Square test, ANOVA, Kruskal-Wallis test to determine the differences between all groups at 5% level of significance.Spearman's correlation were used to determine further correlations.Data were analyzed using the Statistical Package for Social Science (SPSS) version 22 for Windows.

Sociodemographic and Maternal Anthropometric Profiles
As indicated in Table 1, of 108 pregnant women, 25 pregnant women had normal conditions of blood pressure and normal Hb concentrations, 36 had hypertension, 29 had anemia and 18 had pregnancy induced hypertension (PIH) is accompaniedwith anemia during pregnancy.Level of education, working status, types of delivery and gestational age (GA)did not show statistically significant differences for each group, whereas, age, height, weight, body mass index (BMI: kg/m 2 ), Hb concentration, systolic and diastolicblood pressure showed statistically significant differences for each group (p = 0.027; 0.019; 0.000; 0.001; 0.000, 0.000; 0.000).

Birth Outcomes of Newborns
Mean length and weight of newborns were statistically significant lower in pregnancy induced hypertension (PIH) is accompaniedwith anemia (p = 0,001) [Table 2].

Discussion
This study showed that stunting in newborns occured in pregnant women with pregnancy induced hypertension (PIH) and pregnancy induced hypertension (PIH) is accompanied with anemia.In terms of risk factors, there were differences in age, weight, BMI, Hb concentration, systolic and diastolicblood pressure between normal group, pregnancy induced hypertension (PIH) group, anemia group and pregnancy induced hypertension (PIH) is accompaniedwith anemia group.Pregnant women with PIH had the highest mean of age (32 years) and the greatest score of weight (72.6 kg).Referring tothe mean body height and mean BMI, the group of pregnant women with pregnancy induced hypertension (PIH) is accompanied with anemia had the highest mean (157.67 cm) and (30,4) compared to other group.Other studies have shown similar results that pregnant women with PIH were older than normal pregnant women (Qiu et al., 2007;Bilano et al., 2014;Ye et al., 2014;Muti et al., 2015;Townsend, O'Brien, & Khalil, 2016;Zhang et al., 2017;Berhe et al., 2018).Ages over 35 years and overweight are always associated with a risk of developing hypertension during pregnancy with ORs were 1.8; OR 2.39; OR 1.8 repectively (Ye et al., 2014;Townsend, O'Brien, & Khalil, 2016).
Bivariate tests showed the birth outcomes of newborns, especially for the newborn's length in the normal group, pregnancy induced hypertension (PIH), anemia and pregnancy induced hypertension (PIH) is accompanied with anemia were significantly different (p = 0,001) with mean values of body lengthswere 48.4; 46.4; 48.6 and 46.8 respectively.The correlation tests showed that there were negative correlations between hemoglobin level and length of newborn.It means that if the hemoglobin level increases, then length of newborns will be smaller.Another findings showed that there was no statistically difference in length of newborn of male sex in the mother with anemia dan normal hemoglobin (Gaur, 2015), but this finding is incompatible with other studiesin which normal hemoglobin leveles aremore likely to produce outcomes with normal anthropometry of newborns (Verhoeff et al., 2001;Ghimire & Ghimire, 2013;Madaan et al., 2013;Kaur et al., 2015;Manthan, 2015;Tunkyi & Moodley, 2017).These discrepancieswere supposed to be affectedby very small sample sizes and most of the samples had hypertension in pregnancy but not anemia.
Systolic and diastolic blood pressure also had a negative correlation with length of the newborn.It means that if the systolic and diastolic blood pressure increases, then length of newborn will be smaller, and these findings are in line with previous findings that blood pressure beyond normal limits in pregnant women lead to poor anthropometry in newborns including newborns with stunting conditions (Bilano et al., 2014;Kheir, Ali, & Kononna, 2014;Muti et al., 2015;Irwinda, Raymond, & Nembo, 2016;Khader et al., 2017;Ukah et al., 2017).
Results of the study showed that PIH condition gave more effects inlength of newborn length with 0,6 cm smaller than PIH is accompanied with anemia, but their mean length of newborn remained abnormal which called stunting (< 47 cm).Although the mean length of newborn in PIH group (46.3 cm) was smaller than PIH is accompanied with anemia (46.8 cm) [Table 3], the PIH and anemia in preganant women could not be ignored because it could be used as two spectrums of pathological mechanisms that equally had an adverse effect on length of newborn.
Dietary intake is an important factor to the growth and development of newborns during the first 24 months of their life, hence nutritional dietary intake becomes an increasingly important factor afterwards (Investigators, 2017).The condition of newborn stunting is even associated with the poor life of children, and it couldincrease obesity and chronic diseases and the disruption of both both physical and psychic optimal growth and likely to have long-term harmful consequences in cognitive ability, school performance and will ultimately could give adverse effects to the development of a nation (Berkman et al., 2002;Grantham-McGregor et al., 2007;Victora et al., 2010;UNICEF, 2013;Danaei et al., 2016;Sinha et al., 2018).Therefore, it is suggested to enhance efforts to prevent the long-term adverse effects of newborn stunting by performing early and exclusive brestfeeding with on-time intake, high quality feeding and appropriate micronutrient interventions to their children (Jack & Deborah, 2000;Danaei et al., 2016;Investigators, 2017;Sinha et al., 2018;Worku et al., 2018).

Conclusion
The average length of newborns in pregnant women with PIH and PIH is accompained with anemia was significantly significant shorter (stunting) than normal pregnant women.The presence of PIH and anemia arethe important predictors of the cause of newborn stunting.It is suggested that women who give birth with these conditions should pay more attention to the intake of good nutrition in the first 5 years of their children's life (the gold period) to prevent long-term adverse effects.

Figure 1 .
Figure 1.The Flowchart of the Study

Table 1 .
Comparison of sociodemographic and anthropometric profile b ANOVA; c Kruskal-Wallis.

Table 2 .
Comparison of Birth Outcomes of Newborns