Relationship between Nutritional Pattern and Occurrence of Pre-Eclampsia and Eclampsia among Primigravidae

Background: Nutritional status during pregnancy influences the course of pregnancy, fetal development, and long-term health of the mother and child. Nutritional deficiencies are common in women of reproductive age in developing countries. Epidemiological and biological evidence suggest that acute or chronic specific nutritional deficiencies can contribute to severe maternal morbidity such as pre-eclampsia. Early detection through simple screening measures and diligent prenatal care can predict or prevent many effects of preeclampsia. Therefore, seeking early and regular prenatal care throughout pregnancy is essential. Objectives: to find out the relationship between nutritional status and occurrence of pre-eclampsia and eclampsia among primigravidae. Methods: in an exploratory, descriptive, retrospective study, a convenient sample of 120 pregnant women was picked up from the high-risk pregnancy outpatient clinics, pre-eclamptic unit and ICU of El-Shatby Maternity University Hospital and Gamal Abdel Nasser Health Insurance Hospital. The study subjects were divided equally into pre-eclamptic and non pre-eclamptic groups. Inclusion criteria included age between 20-35 years, primigravida, from 20-40 weeks of gestation, have no previous medical diseases and willing to participate in the study. Two validated tools were developed and used by the researchers to collect the necessary data; an interview schedule to collect basic data such as sociodemographic characteristics and history of pregnancy and nutritional status assessment sheet to assess nutritional habits and daily dietary intake. Results: calcium and folic acid supplementations were less taken by the study group, compared to the control group. Hemoglobin level and number of meals/day were statistically lower among the study group, compared to the control group. Animal proteins, fruits and vegetables were also statistically occasionally taken by the study group, compared to the control group. In addition, daily consumption of fats, proteins, iron, vitamins A, B1 and B2 was statistically less than daily requirement among the study group, compared to the control group. Conclusion: less adequate daily intake of proteins, fats, fruits, and vegetables among the pre-eclamptic group was a factor in the incidence of preeclampsia. In addition, lack of diet rich calcium and calcium supplementation during pregnancy increased the risk of pre-eclampsia. Moreover, low hemoglobin level was significantly linked to the occurrence of preeclampsia. Pre-eclampsia was also associated with insufficient daily intake of vitamins in the diet such as vitamin A, B1 & B2.


INTRODUCTION
( In many developing countries, pregnancy associated physiologic changes can be aggravated by under-nutrition.There is a link between nutritional problems and development of pre-eclampsia. (3,4)Excess calories, over consumption of salt, insufficient proteins, reduced calcium and zinc intake, low magnesium and potassium as well as reduced folate and vitamin C intake are associated with pre-eclampsia. (5-8) Dyslipidemia of pre-eclampsia was also documented.In addition, iron has been reported as abnormal in pre-eclampsia.(9-11)   Meanwhile, vitamin E has been reported to be reduced among patients with severe preeclampsia.(12,13)   Pre-eclampsia is part of a spectrum of hypertensive disorders that complicate pregnancy. (14)It occurs in up to 5% of all pregnancies and in 10% of first pregnancies.
Its greatest impact is in developing countries, where it accounts for 20-80% of the strikingly increased maternal mortality.(15,16)   Preeclampsia usually occurs in the second half of pregnancy and can be mild or severe. (3)Mild pre-eclampsia is characterized by high blood pressure (140/90 or more), swelling (pitting edema 1+or more), and protein in urine (proteinuria 0.3 g or more) (1+ or more on dipstick).Severe pre-eclampsia occurs when the systolic blood pressure is ≥160 mmHg; the diastolic blood pressure is ≥ 110 mmHg.It is also accompanied by proteinuria (i.e., urinary excretion of ≥0.5 g protein in a 24-h specimen or 3 + to 4 + on dipstick). ( Patients with severe pre-eclampsia display end-organ effects and may complain of severe headache that is frontal and throbbing.Visual disturbances and severely impaired vision can also manifest.(3,15,18)   Manifestations also include altered mental status, nausea or vomiting, dizziness, dyspnea and oliguria with less than 500 ml per 24 hours, as well as rapidly increasing or nondependent edema, which results in rapid weight gain.In addition, they include gastrointestinal complaints of sudden, new-onset, and constant epigastric pain as well as clonus as a sign of neuromuscular irritability. (14,19)On the other hand, eclampsia is an extension of preeclampsia process.Women with eclampsia suffer convulsions or "fits", coma, heart failure, shock, fat and bleeding in their livers, and often death. ( The most serious consequences of pre- The epidemiology of pre-eclampsia, being more common in poor women, long ago suggested that nutrients might be involved in the disorder.Numerous conflicting hypotheses were advanced but the testing of these hypotheses has either been done poorly or not at all.Review of the available data indicates very few studies that provide useful insights. ( The aim of this study is to find out the relationship between nutritional status and occurrence of pre-eclampsia and eclampsia among primigravidae.

RESULTS
Table 1 shows number and percent distribution of women according to their socio-  6 shows number and percent distribution of women according to daily dietary intake of minerals.Less than 1000 mg of calcium was taken daily by 90% & 75% of the study and the control groups respectively.
Less than 27 mg of iron was also taken daily by 100% & 93.33% of both groups respectively.
Meanwhile, 2000 mg or less of sodium was taken daily by equal percent (91.67%) of both groups.A statistically significant difference was found between both groups concerning daily intake of iron (P=0.042).

DISCUSSION
Nutritional status during pregnancy influences the course of the pregnancy, fetal development, and the long-term health of the mother and child. (26)Women are more likely to suffer from nutritional deficiencies because of their increased requirements during reproductive period, particularly those of low socio-economic status.Globally, 50 percent of all pregnant women are anemic, and at least 120 million women in less developed countries are underweight. (27)Underweight can lead to increased rates of illness and mortality. ( The exact causes of pre-eclampsia and eclampsia are not known.For many years, diet has been suggested to play a role in preeclampsia.The hypotheses have been diverse and often mutually exclusive.Thus, increased and reduced dietary sodium, protein, fats or carbohydrates were proposed as possible etiological factors.Rarely were these hypotheses appropriately tested in trials. Not surprisingly, many care providers became disenchanted with these hypotheses and the role of nutrition has not been extensively studied in recent years.(16,29)   The present study revealed that the daily dietary intake of both groups did not satisfy the nutritional requirement of pregnancy.The diet of pre-eclamptic group was less adequate in proteins and fats as compared to the non-preeclamptic group (Table 4 & 5).The defect in the daily intake of proteins and fats among the pre-eclamptic group may be a factor in the the disorder (Table 4 & 6).This finding is similar to that of Sifakis and Pharmakides (2000) (42) and Rayman et al (2002) (11) who reported that iron status parameters were found to be abnormal in pre-eclampsia.
Significantly lower daily intake of vitamin A (Retinol) by the study group was thought to contribute to the occurrence of pre-eclampsia in the present study (Table 7).This finding is in line with that of Zhang et al (2001) Significantly insufficient daily intake of vitamin B 1 (Thiamin) may also be associated with pre-eclampsia in the present study (Table 7).This lower intake will subsequently lowers The daily intake of vitamin B 2 (Riboflavin) was also found to be significantly lower among the pre-eclamptic group b in the present study (Table 7).Similarly, it was reported that women who are deficient in this vitamin are more likely to develop preeclampsia than women with normal levels.
Therefore, vitamin B 2 supplementation may correct the deficiency. (45)Moreover, the daily intake of vitamin B 3 (Niacin) was less than required for pregnancy among a sizeable percent of the study group.(Table 7) This finding is not reassuring because one of the most vital functions of Niacin is its important role for the building of placenta. (46,47)So, its deficiency will lead to abnormal placental development, which is being central to the development of pre-eclampsia.(15,16,20)   Lack of folic acid supplementation was thought to increase the risk of pre-eclampsia in the present study, although the majority of pre-eclamptic and non-pre-eclamptic groups consumed less folic acid rich diet.(

CONCLUSION AND RECOMMENDATIONS
Based on the findings of the present study, it can be concluded that less adequate daily intake of proteins, fats, fruits, and vegetables among the pre-eclamptic group was a factor in the incidence of pre-eclampsia, rather than the defect in total energy.In addition, lack of diet Nutrition during pregnancy is important.Pregnant women's food has a direct effect on the course of pregnancy and normal fetal development as well as the long-term health Bull High Inst Public Health Vol.41 No.4 [2011] of the mother and child.The foods a pregnant woman eats are the main source of the include seven major classes of nutrients; carbohydrates, proteins, fats, vitamins, minerals, fibers, and water.These nutrient classes can be categorized as either macronutrients (needed in relatively large amounts) or micronutrients (needed in smaller quantities).The macronutrients are carbohydrates, proteins, fats, fibers, and water.The micronutrients are minerals and vitamins.
is an exploratory, descriptive, retrospective study, which was conducted at the high-risk pregnancy outpatient clinics as well as pre-eclamptic units and ICUs of El-Shatby Maternity University Hospital and Gamal Abdel Nasser Health Insurance Hospital.The study comprised a convenient sample of 120 pregnant women who were divided equally into two groups.The study group included pregnant women with mild pre-eclampsia; severe pre-eclampsia and eclampsia, 20 women from each category, while the control group involved 60 pregnant women free from pre-eclampsia and eclampsia.Women whose age ranged between 20-35 years, primigravidae, from 20-40 weeks of gestation, have no previous medical diseases and willing to participate in the study were selected Two tools were developed and utilized for data collection; tool one: a structured interview schedule which involved data related to socio-demographic characteristics such as age, level of education, occupation, residence, etc. as well as history of pregnancy such as follow-up visits, and nutritional supplementations.Tool two: nutritional status assessment sheet, which included data about laboratory investigations such as hemoglobin level (Hb) and albumenurea as well as dietary intake (nutritional habits and daily dietary intake).Permissions for data collection were obtained from the responsible authorities of the study settings.Tools were developed by the researcher after extensive review of relevant and recent literature and were tested for content validity by a jury of 10 experts in the related field.An informed Bull High Inst Public Health Vol.41 No.4 [2011] oral consent to participate in the study was obtained from each woman and confidentiality of the collected data was ensured.A pilot study was carried out on 12 women (6 women from each study setting), who were excluded from the study subjects.The aim of this pilot study is to ascertain the relevance of the tools; detect any problem peculiar to the statements and estimate the time needed to complete the tools.Following this pilot study, the tools were reconstructed and made ready for use.Data were collected over a period of 8 months starting from the beginning of February till the end of September 2009.Women of the study group were interviewed and assessed during their attendance in high-risk pregnancy outpatient clinic (mild pre-eclamptic women), stay in pre-eclamptic unit (severe pre-eclamptic women) or stay in ICU (eclamptic women).Women of the control group were interviewed and assessed during their attendance in antenatal clinic.The average time needed to complete the interview schedule and physical assessment ranged between 45 to 60 minutes depending upon the degree of understanding and response of the interviewee.Interview and physical assessment were conducted individually and in total privacy to assure confidentiality of information and its utilization only for the purpose of the research.Both groups were assessed for hemoglobin level, blood pressure to assess degree of hypertension and albumenurea to assess the amount of protein loss.Dietary intake was assessed by 24 hour recall; kinds and amount of food taken during the last 24 hours were roughly reported by each woman then calculated by the researcher with the help of nutritional specialist and book into the amount of different essential nutritional elements.Then comparison between both groups was done.Analysis of data was carried out by the researcher.The collected data was categorized, coded, computerized, tabulated and analyzed using arithmetic mean and standard deviation as well as Chi Square test at 5% level.
energy level, which leads to pre-eclampsia as indicated by the study carried out by Roberts et al (2003).
rich calcium and calcium supplementation during pregnancy increased the risk of preeclampsia.Moreover, low hemoglobin level was significantly linked to the occurrence of pre-eclampsia.Pre-eclampsia was also associated with insufficient daily intake of vitamins in the diet such as vitamin A, B 1 & B 2 .Based on the findings of the present study, it was recommended that maternity nurses should emphasize regular antenatal visits to screen pregnant women and identify those who are at high risk for pre-eclampsia.During which they should give them health teaching about the importance of nutrition as well as kinds and amounts of foods that should be taken or avoided.

Table 1 : Percent distribution of women according to their socio-demographic characteristics χ 2
(P): Chi Square Test & P for χ

Table 3 : Number and percent distribution of women according to their laboratory investigations
2FET (P): Fisher Exact Test & P for FET *: Significant ≤ 0.05