Maternal Risk Factors of Premature Delivery in Dr Soetomo Hospital (Martono Tri Utomo, Ernawati, Baksono Winardi)

41
MATERNAL RISK FACTORS OF PREMATURE DELIVERY IN DR SOETOMO HOSPITAL

Martono Tri Utomo
1
, Ernawati
2
, Baksono Winardi
2

1
Department of Child Health,
2
Department of Obstetric and Gynecology
Medical Faculty, Airlangga University-Dr Soetomo Hospital Surabaya


ABSTRAK

Prematuritas adalah suatu kondisi neonatus yang lahir sebelum 37 minggu kehamilan. Kondisi yaitu ibu hamil, ibu muda atau tua
dan penyakit dari ibu dapat meningkatkan risiko memiliki bayi prematur. Desain penelitian adalah studi kasus kontrol. Data
dikumpulkan secara retrospektif dari data pendaftaran neonatus yang lahir dan ibu mereka di Rumah Sakit Dr Soetomo antara
tanggal 1 Januari 2009 untuk Desember 2009.Data dari neonatus bawaan (berat badan lahir, usia kehamilan, skor Apgar) dan data
dari ibu (usia , preeklamsia, dini pecahnya membran) dikumpulkan. Total 2089 kasus dimasukkan untuk studi ini, 430 kasus
neonatus prematur dan 1659 adalah fullterm faktor risiko yang secara signifikan cases.The neonatus meningkat untuk prematuritas
adalah usia ibu lebih tua dari 35 tahun (OR 1,372, 95% CI 1,007-1,869), dini pecahnya membran (PROM) (OR 1,556, 95% CI
1,206-2,006), perdarahan antepartum (OR 7,504, 95% CI 4,112-13,695), dan pre-eklampsia (OR 1,704, 95% CI 1,345-2,252).
Faktor risiko yang signifikan untuk kelahiran prematur adalah usia ibu yang lebih tua dari 35 tahun, dini pecahnya membran,
perdarahan antepartum, dan preeklamsia.


ABSTRACT

Prematurity is a condition of neonate that born before 37 weeks of gestation. The conditions of the pregnant mother i.e, young or old
mother and disease of the mother can increase the risk of having the premature baby. Study design was case control study. The data
was retrospectively collected from registration data of neonates that was born and their mother in Dr Soetomo Hospital between 1
January 2009 to Desember 2009.Data of the inborn neonate (birth weight, gestational age, Apgar score) and the data of mother
(age, preeclampsia, premature rupture of the membrane) was collected. Total of 2089 cases was included to this study, 430 were
premature neonate cases and 1659 were fullterm neonate cases.The risk factors that significantly increased for prematurity were
mothers age older than 35 years (OR 1.372 , 95% CI 1.007 1.869), premature rupture of the membrane (PRoM) (OR 1.556, 95%
CI 1.206 2.006), antepartum bleeding (OR 7.504, 95% CI 4.112 13.695), and pre-eclampsia (OR 1.704, 95% CI 1.345 2.252).
The significant risk factor for premature delivery were mothers age older than 35 years, premature rupture of the membrane,
antepartum bleeding, and preeclampsia.

Keyword: maternal risk, premature delivery

Correspondence: Martono Tri Utomo, Department of Child Health, Airlangga University School of Medicine,
Dr Soetomo Hospital Surabaya Jl Prof Moestopo 6-8 phone 031-5501681. Fax 031-5501748, email:
martono@mitra.net.id atau martonotriutomo@yahoo.com.au. Mobile phone: +628123215306


INTRODUCTION

Premature neonate is defined as infants born before 37
weeks of gestation and usually is accompanied with low
birthweight infant that defines as babies weighing less
than 2500 g. Prematurity is the main cause of morbidity-
mortality in developed countries newborns, and it is
responsible of most none malformed newborn deaths,
and half congenital neurological disability. The
incidence in America is 12% of all live birth (de Sanjose
1991, Lee 2008).

In industrialised countries about 5-7%o of liveborn
babies are of low birthweight and 4-9% are preterm, the
overall incidence of prematurity in the world is around
11% (de Sanjose 1991, Goldenberg 1998). In Indonesia
the prevalence of low birth weight infants is 9% or
411.000 patients in a year 2002, the low birth can cause
some morbity and mortality. The most common cause
of death in neonate is low birth weight (34,72%)
(Damanik 2007).

Some of the maternal factors may influences the
premature delivery such as disease of the mother
(preeclampsia, antepartum haemorrhage or multipara
mother) and mothers age (less than 18 years or more
than 35 years) (de Sanjose 1991, Feresu 2004, Mansour
2002, Ventura 2009, Al-Dabbagh 2006). If we know the
condition of the mother that may increase the premature
delivery we could closely monitor this mother so the
premature delivery can be anticipated. The objective of
this study was to determine the maternal risk factor of
premature delivery.

Folia Medica Indonesiana Vol. 47 No. 1 January - March 2011 : 41-45

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MATERIAL AND METHODS

Study design was case control study. The data was
retrospectively collected from medical record of
pregnant women and neonate that was born in Dr
Soetomo Hospital between 1 January 2009 to Desember
2009. Data of the inborn neonate (birth weight,
gestational age, Apgar score) and the data of pregnant
mother (age, preeclampsia, premature rupture of the
membrane) was collected. The sample was grouped in
the premature neonate and fullterm neonate, and low
birth weight infant and normal birth weight infant.

The maternal risk factors were compared between the
premature and fullterm neonate.. Inclusion criteria was
preterm and fullterm neonate that was born in Dr.
Soetomo hospital. The exclusion criteria was postdate
neonate. Data are presented in distribution tabulation
and data analysis was performed with a computer
assisted statistical package (SPSS ver. 12.0). Chi square
was used to analyze the data. Risk factors were
calculated with odds ratio and 95% Confidence Interval,
p values less than 0.05 was considered significant.


RESULTS

The collected data from 1 January 2009 until 31
December 2009 have been reviewed the registration
data of the neonates that was born and their mother at
Dr Soetomo hospital. There were 2128 cases and 39
patients was excluded because of post date neonate. The
premature neonate was 430 cases and the fullterm
neonate was 1659 cases. From the table 1, the
characteristics patient of premature neonate and fullterm
neonate was showed that in the premature infant the
mother age younger than 18 years and mother older than
35 years were more frequent than fullterm neonate.
Percentage of caesarian section in premature infants
were also more frequent than fullterm neonate (42.3 %
vs 29.6%). From the table 2. the significant maternal
risk factors of premature delivery was mothers age
more than 35 years, premature rupture of the membrane
(PRoM), antepartum bleeding and preeclampsia. The
highest risk factor of premature delivery was
antepartum bleeding (OR 7.504 95% CI 4.112
13.695). From table 3, the mothers age > 35 years had
risk of preeclampsia 1.799 times than mother age 18
35 years.




Table 1. Characteristics of the mother and neonate that delivered in Dr Soetomo hospital January December 2009


Characteristics
Premature
neonate
Fullterm
neonate
(n = 430) (n = 1659)
Mothers condition
Mothers age
- < 18 years 9 (2.1 %) 30 (1.8%)
- 18-35 years 345 (80.2 %) 1383 (83.4%)
- > 35 years 76 (17.7%) 246 (14.8%)
Maternal disease
- ProM 105 (24.4%) 286 (17.2%)
- Antepartum bleeding 31 (7.2%) 17 (1%)
- Preeclampsia 104 (24.2%) 257 (15.5%)
Mode of delivery
- Spontaneous delivery 224 (52.1%) 964 (58.1%)
- Caesarian section 182 (42.3%) 491 (29.6%)
- Vacum extraction 5 (1.2%) 112 (6.8%)
- Forceps extraction 5 (1.2%) 30 (1.8%)
- Manual aid 6 (1.4%) 50 (3%)
- Breech delivery 3 (0.7%) 6 (0.4%)
- Others 5 (1.1%) 5 (0.4%)
Neonate condition
- Birth weight (g) 2176 + 678 3037+ 495
- Birth weigh < 2500 g 276 (64,2%) 170 (10.2%)
- Asphyxia 81 (18.8%) 90 (5.4%)

Maternal Risk Factors of Premature Delivery in Dr Soetomo Hospital (Martono Tri Utomo, Ernawati, Baksono Winardi)

43
Table 2. Maternal risk factors of premature delivery in Dr Soetomo hospital January December 2009

Maternal risk factors p value OR 95% CI
Mothers age < 18 years 0.803 1.106 0.501- 2.440
Mothers age > 35 years 0.045* 1.372 1.007 1.869
PRoM 0.001* 1.556 1.206 2.006
Antepartum bleeding 0.000* 7.504 4.112 13.695
Pre-eclampsia 0.000* 1.704 1.345 2.252
*p < 0.05 = significant


Table 3. Age- related risk factors of disease

Age-related risk factors P value OR 95% CI
Mothers age < 18 years
- PRoM 0.639 0.810 0.335 1.957
- Antepartum bleeding 0.123 2.996 0.692 12.977
- Preeclampsia 0.402 0.642 0.226 1.826
Mothers age > 35 years
- PRoM 0.252 0.813 0.570 1.159
- Antepartum bleeding 0.178 1.703 0.778 3.730
- Preeclampsia 0.000* 1.799 1.318 2.456
*p < 0.05 = significant



DISCUSSION

Prematurity is a condition that baby born before 37
weeks of gestation. Detection of prematurity can be
performed using some methods such as from history,
low abdominal USG (in uterine) or by Balard score
(after the baby birth) (Lee 2008). Premature delivery is
common condition in developing country, in this study
the premature cases was 430 (20,2%). This incidence
was higher than the incidence with the other study (5% -
16,4%) (de Sanjose 1991, Lee 2008, Feresu 2004). Low
birth weight infants usually accompanied the
prematurity, the prevalence of low birth weight infant in
this study revealed 446 cases (20.8%), in the premature
group 276 cases (64.2%) and in the fullterm group 170
(10.2%). In this study the incidence of low birth weight
infant is higer than the other study 5,5% - 11,2% (de
Sanjose 1991, Mansour 2002).

The risk of prematurity by mothers condition is
published by some author, i.e, mothers condition (race,
parital status, sosioeconomic, education), disease of the
mother (hypertension, preeclampsia, gestational
diabetes, anxiety, antepartum bleeding, infection) ,
maternal age (younger than 20/18 years or older than
38/40 years) (Forde 1993, Tan 1994, Katwijk 1998,
Goldenberg 1998, Jolly 2000, Akinbami 2000, Al-
Dabbagh 2006, Jahromi 2008, Khashu 2009, Mansour
2002, Mendoza 2008, Hack 1991, Mohsin 2003,
Martius 1998). Because of limitation of the data from
registration, in this study the risk of prematurity by
mothers condition only the risk of mothers age < 18
years, mothers age > 35 years, premature rupture of the
membran (PRoM), antepartum bleeding and pre-
eclampsia were studied.

In this study the mother ages younger than 18 years
was not significantly correlate with the risk of
premature delivery. This result is different with the
previous study. (Martius 1998, Akinbami 2000). The
different age criteria of young mother is younger than
20 years that was performed by other study (Mansour
2002, Mendoza 2008, Hack 1991, de Sanjose 1991).
Some conditions usually occur in the mothers age
younger than 18 years that contribute to the premature
delivery are sosioeconomic, health factor, inadequate
education, difficulty in psychosocial, gained less weight
during pregnancy (Akinbami 2000, Forde 1993). The
condition of the mothers age younger than 18 years in
this study is not correllate with the prematurity may be
caused by some factors, i.e. psychosocial support from
all family (grandmother or other family), good antenatal
care, and education of care the pregnancy by midwife or
doctor. The other factors, in this study showed that
young mother not associated with the PRoM,
antepartum bleeding and preeclamsia that may cause the
premature delivery.

The other risk factor, i.e.mothers age more than 35
years was increasing the risk of premature delivery by
1.4 times. Mother age more than 35 years as prematurity
risk factors is consistent with other studies (Tan 1994,
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Katwijk 1998, Jolly 2000, Jahromi 2008, de Sanjose
1991). Mothers age more than 35 years have some
complications i.e preeclampsia, anemia, placenta previa
that may induce the premature delivery (Tan 1994).
Age-related risk factors that most reported are
hypertension, diabetes, high parity, uterine myomas and
a history of infertility (Katwijk 1998, Jolly 2000,
Jahromi 2008). In this study, the association age-related
disease that were examined (i.e, premature rupture of
the membrane, ante partum bleeding, and preeclampsia)
and the significant age-related disease in mother age
more than 35 years was pre-eclampsia. In this study the
old women have the risk of 1.799 higher to be
preeclampsia. This result is lower than the previous
study with the risk of 4,39 (Jahromi 2008).

Premature rupture of the membrane is one of the risk
factors of premature delivery, this finding is consistent
with previous study (Goldenberg 1998, Khashu 2009,
Mansour 2002). Premature rupture of the membrane is a
condition that the amnion membrane is rupture so the
risk of infection from the urinary tract can be increased
if the baby is born after 18 hours of the ruptured
membrane. In the premature, the process of expectant
management or proceed the delivey if there spontaneous
onset of labor or clinical evidence of sepsis. The
intervention that applied to this condition is giving
prophylaxis antibiotics, corticosteroid antenatally to
increase the maturation of lungs in the preterm neonate
(Gibbs 2003). Infection of the membrane can also
release prostaglandins that can induce preterm delivery
(Guinn 2003, Cunningham 2001).

In this study, the risk of ante partum bleeding to
premature delivery is 7.5 times higher than non
antepartum bleeding. The previous study showed the
consistnent finding, the risk of antepartum bleeding
were around 3.05 - 3.2 (Feresu 2004, Mansour 2002),
but higher risk until 5.0 - 9.22 (Martius 1998, Ventura
2009). Antepartum bleeding is the serious and
emergency condition of the pregnant woman. The
condition can be caused by placenta previa or abruptio
placenta. The delivery process must be done based on
the condition of the mother. The neonate have to be
delivered regardless of gestational age to save the
mother (Cunningham 2001).

Preeclampsia is also the emergency condition of the
pregnant woman. The ultimate choice treatment of
preeclampsia is to deliver the baby regardless the
gestational age. The delivery process is depend on the
severity of preecalmpsia. In the mild preeclampsia the
conservative treatment can be done and the pregnancy is
maintained until fullterm but in the close observation.
When the conservative treatment is failed or the patient
become to severe preeclampsia or eclampsia, the
delivery process must be done. In the preeclampsia
there are also some changes in blood vessels such as
vasospasm and ischemia with subsequent end-organ
derrangement (Cunningham 2001). In this study the risk
of preeclampsia to premature delivery was 1.704 higher
than non preeclampsia mother. The previous study
showed the similar result with the risk of 2.5-5
(Mansour 2002, Martius 1998, Khashu 2009).

In this study, the maternal condition i.e, mother age
younger than 18 years, mother age older than 35 years,
premature rupture of the membrane, antepartum
bleeding, and preeclampsia waere noted as significant
risk factor for prematurity. The antenatal intervention
should aware this condition so the premature delivery
can be anticipated or prevented. Mother with that
condition should be routinely controlled to the medical
staff or hospital so the morbidity or mortality of the
mother and neonate can be decreased.


CONCLUSION

Maternal conditions i,e mother age older than 35 years,
premature rupture of the membrane, antepartum
bleeding, and preeclampsia increased the risk of
premature delivery.


ACKNOWLEDGMENT

Lyly Ekawati, Ariani Setyowati, and Choiriyah that help
to collect the registation data of neonates that was born
and their mother in the Dr. Soetomo Hospital.


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