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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 12  |  Issue : 3  |  Page : 218-222

Correlation of various maternal factors with exaggerated hyperbilirubinemia of the newborn


1 Department of Paediatrics, Dr. D. Y. Patil Medical College and Hospital, Pune, Maharashtra, India
2 Department of Paediatrics, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Web Publication2-Feb-2018

Correspondence Address:
Dr. Sneha Taneja
House No. 350, Sector.6, Panchkula, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_9_17

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  Abstract 


Background: Maternal factors could help determine the potential incidence of hyperbilirubinemia. This study was performed with the purpose of establishing the role of the various maternal factors previously indicated as being responsible for exaggerated physiological hyperbilirubinemia in term neonates with serum bilirubin level of 12 mg/dL or more. Materials and Methodology: It was a prospective, cross-sectional study conducted from July 2012 to August 2014 in Pimpri, Pune. A total of 2000 healthy term deliveries were screened, out of which 100 neonates with exaggerated hyperbilirubinemia were included. Data were collected with maternal information. The data were analyzed using t-test (for parametric distributions). Results: During the period of study, 330 babies out of 2000 deliveries had achieved the serum bilirubin level of >12 mg/dL. Thus, the prevalence of exaggerated neonatal hyperbilirubinemia in the current study was 16.5%. There is strong association between maternal infection and serum bilirubin even when only 5 mothers had infection (Z = 2.31 and P < 0.05), whereas no correlation was found with maternal diabetes mellitus, toxemia, and oxytocin infusion. Conclusions: Maternal infection was found to have a significant effect on neonatal exaggerated hyperbilirubinemia. Therefore, interventions should be prioritized to prevent maternal sepsis. The first approach targets facility-based deliveries and requires increased provision and uptake of proper antenatal care early in pregnancy.

Keywords: Diabetes mellitus, hyperbilirubinemia, maternal infections, oxytocin, toxemia


How to cite this article:
Taneja S, Pande V, Kumar H, Agarkhedkar S. Correlation of various maternal factors with exaggerated hyperbilirubinemia of the newborn. J Datta Meghe Inst Med Sci Univ 2017;12:218-22

How to cite this URL:
Taneja S, Pande V, Kumar H, Agarkhedkar S. Correlation of various maternal factors with exaggerated hyperbilirubinemia of the newborn. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2021 Dec 9];12:218-22. Available from: http://www.journaldmims.com/text.asp?2017/12/3/218/224712




  Introduction Top


Hyperbilirubinemia is the most common problem experienced in the immediate neonatal period. Yet despite years of investigation, many aspects of neonatal jaundice remain unexplained.[1] Although the metabolism of bilirubin is now better understood, the mechanism involved in the evolution of nonhemolytic neonatal hyperbilirubinemia is still unclear.[2]

Approximately 60% term newborn and 80% preterm become clinically jaundiced in the first week of life.[3] The incidence varies with different study group. Physiological jaundice is a normal occurrence between the 2nd and 4th day of life and appears in approximately 50% of all full-term newborns. Bilirubin levels may reach 6–10 mg/dL and resolution generally occurs during the 7th or 8th day. A bilirubin level exceeding 12 mg/dL for the full-term infant is suggestive of more than normal physiology and would be considered exaggerated hyperbilirubinemia (Behrman).[4]

The present study was performed with the purpose of establishing the role of the various maternal factors previously indicated as being responsible for exaggerated physiological hyperbilirubinemia in term neonates with serum bilirubin level of 12 mg/dL or more.

Maternal age was found to be associated with the incidence of neonatal hyperbilirubinemia by some of the earlier workers. Wood et al.[5] found a reduction of jaundice as maternal age advanced. In their study, clinical jaundice was found in 90.5% of babies with maternal age under 30 years, while it was 79.5% in babies with maternal age over 30 years.

Another previously suspected variable, parity of mother was not associated with neonatal jaundice in the study done by Shalinn.[6] Gestational age was found to have influence on neonatal jaundice. Wood et al.[5] observed a gradual reduction of jaundice as gestation advances. Hyperbilirubinemia has been reported to occur with increased frequency in infants of insulin-dependent diabetic mothers.[7],[8]

Earlier studies on neonatal jaundice have given an impression that preeclamptic toxemia and even uncomplicated hypertension during pregnancy have a marked influence in reducing neonatal jaundice. Wood et al.[5] observed that toxemia produced a marked and in several instances highly significant reduction in jaundice. Several authors have reported an increased incidence of neonatal hyperbilirubinemia following induction of labor with oxytocin.[9],[10],[11],[12],[13],[14]

Aims and objectives

  1. To ascertain the prevalence of neonatal hyperbilirubinemia with serum bilirubin level of 12 mg/dL or more in full-term neonates
  2. To establish correlation of various maternal factors with hyperbilirubinemia, for example, age, gestation, parity gestational diabetes, oxytocin-induced labor, and delivery.



  Materials and Methodology Top


It was a prospective, cross-sectional study conducted from July 2012 to August 2014 at Dr. D. Y. Patil Medical College, Pimpri, Pune. A total of 2000 healthy term deliveries were screened, out of which 100 neonates with exaggerated hyperbilirubinemia were included. Review of literature shows range of exaggerated physiological hyperbilirubinemia in various studies ranges from <6% to >20%.[15],[16] In the present study, 10% incidence of hyperbilirubinemia was taken for the estimation of the sample size. With this 10% proportion and 95% confidence interval of 6%, the sample calculated was 96 using the WHO/CDC statistical package Epi Info 7 (Centers for Disease Control and Prevention (CDC), Atlanta, Georgia (US)). Hence, we included 100 neonates in the study.

Inclusion criteria

All full-term newborns admitted in the PNC ward with serum bilirubin levels more than 12 mg/dL.

Exclusion criteria

Preterm babies/low birth weight babies, postterm babies, babies with major illness (Rh and ABO incompatibility), or admitted in Neonatal Intensive Care Unit.

Newborns with serum bilirubin >12 mg/dL were evaluated for the maternal factors such as age, parity, gestation, history of diabetes and toxemia, and oxytocin infusion. Informed consent was obtained from the parents of the newborn and examination was carried out in the PNC ward. All the details were noted on the pro forma. Serum bilirubin estimation was done by Diazo technique. The data were analyzed using t-test (for parametric distributions).


  Results Top


During the period of study, 330 babies out of 2000 deliveries had achieved the serum bilirubin level of >12 mg/dL. Thus, the prevalence of exaggerated neonatal hyperbilirubinemia in the current study was 16.5%.

Etiological factors

Out of the 100 neonates studied, 27 mothers were above >30 years, and 73 mothers were <30 years. Parity of the mothers included in the study ranged from P1–P4. However, 51 of them were primigravida and 49 were multipara [Table 1].
Table 1: Distribution according to maternal age and parity in the study group

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Out of 82 mothers, 9% had diabetes mellitus.

Preeclampsia was detected in 17% of the mothers.

About 5% mothers had maternal infection.

Oxytocin was used for the augmentation of labor in about 51% of the mothers [Table 2].
Table 2: Distribution according to maternal factors

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When serum bilirubin was compared to maternal age, Z = 0.06 and P> 0.05 which shows no statistical correlation between the two factors [Table 3].
Table 3: Comparison of serum bilirubin according to maternal age in the study group

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Z = 1.09 and P is > 0.05 which is statistically not significant [Table 4].
Table 4: Comparison of serum bilirubin according to parity in the study group

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The current study showed no correlation between maternal toxemia, and exaggerated physiological jaundice as Z = 0.02 and P> 0.05.

Maternal diabetes was also not found to be statistically significant (P > 0.05), because perhaps the sample size was limited (only 9 diabetic mothers). However, there is strong association between maternal infection and serum bilirubin even when only 5 mothers had infection (Z = 2.31 and P < 0.05) [Table 5].
Table 5: Comparison of serum bilirubin according to maternal toxemia, diabetes, and infection in the study group

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Z = 1.17 and P> 0.05 which shows no statistical correlation [Table 6].
Table 6: Comparison of serum bilirubin according to oxytocin infusion in the study group

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  Discussion Top


Incidence

The incidence of hyperbilirubinemia over 12 mg/dL in newborn infants has been reported in several studies, the range of reported values in various studies ranges from <6% to >20%.[6],[15] In the present study, 16.5% of neonates were found to have exaggerated neonatal hyperbilirubinemia, while Jeffares [12] reported the incidence of neonatal jaundice to be 8.6%, Maisels [17] found it to be 15.5%. In the previous studies done by Jone in Lucknow,[18] Mumbai,[19] and Pune,[20] the incidence of physiological jaundice was observed to be 57%, 25.3%, and 47.2%, respectively. A higher incidence of hyperbilirubinemia (10.3%) was reported by Agarwal et al.[21]

Maternal factors

Maternal age

There are conflicting reports regarding the influence of maternal age on neonatal hyperbilirubinemia. In the current study, 27% of mothers are under 30 years of maternal age and 73% were over 30 years of maternal age and insignificant correlation was found with hyperbilirubinemia which is similar to the study of Osborn et al.[22] and Linn et al.[6] Such an incidence was observed in our study, probably due to high number of pregnant mothers over 30 years of age. On the contrary, a decline in the incidence of neonatal hyperbilirubinemia with advancing maternal age was observed by Wood et al.[5] (90.5% <30 years of age and 79.5% >30 years of maternal age).

Parity

In the present study, the correlation between neonatal serum bilirubin levels and maternal parity was found to be insignificant (P > 0.05). This result was similar to the study of Wood et al.[23] and Brown and Boon [24] conducted a study in Chinese women and observed, a slight increase in neonatal serum bilirubin levels with increasing parity. While Linn [6] and Osborn et al.[22] (P = 0.780) did not observe such a correlation in their study.

Maternal diabetes

A study on epidemiology of neonatal jaundice was conducted by Gale et al.,[25] at Jerusalem among 1081 neonates and observed that among all the neonates born to diabetic mothers, 0.17% newborns had serum bilirubin <12 mg/dL, while 1.56% had serum bilirubin >12.9 mg/dL, proving that high-serum bilirubin was associated with maternal diabetes mellitus. About 57.7% of newborns born to a mother with gestational diabetes mellitus were found to have neonatal hyperbilirubinemia in the study of Varghese et al.,[26] Farooq et al.[27] in his study of complications associated with gestational diabetes found the occurrence of jaundice in 9 out of 50 cases (18%). Joy and Sivakumar [28] in their study observed that 35.13% of babies had hyperbilirubinemia. In the current study, P value is > 0.05, therefore, difference is not statistically significant because perhaps the sample size was limited (100), out of which only 9 diabetic mothers were included in the study.

Toxemia

In our study, it was observed that toxemia has no influence on neonatal hyperbilirubinemia. Similarly, in Shailinn's study,[6] toxemia was not related to the occurrence of neonatal hyperbilirubinemia (odds ratio 0.86,95% confidence interval 0.76–1.11). Maisels et al.,[29] in his study on neonatal jaundice and maternal hypertension observed no significant association (P = 0.332), while Wood et al.[5] found that severity of jaundice is reduced in neonates born to mothers with toxemia. Guruvare and Kushtagi [30] concluded that in mothers with severe preeclampsia, 29.1% of the newborns had physiological jaundice.

Maternal infection

In the current study, a strong association was found between maternal infection and neonatal hyperbilirubinemia (P ≤ 0.05), although only 5 mothers had evidence of maternal infection. On the contrary, Bajpai et al.[18] in his study did not report any case due to infection or sepsis.

Oxytocin

Earlier studies on neonatal hyperbilirubinemia had shown a potential association between the use of oxytocin to induce or augment labor and neonatal hyperbilirubinemia. Several investigators have reported an increased incidence of neonatal hyperbilirubinemia following induction of labor with oxytocin. Gould et al.[31] and Wood et al.,[23] in their studies failed to reveal any significant difference between the incidence of neonatal hyperbilirubinemia following spontaneous labor and after labor induced by oxytocin. On the contrary, Smith and Wilson [32] and Friedman et al.[11] have found small effect of oxytocin in producing neonatal hyperbilirubinemia. Ghosh and Hudson [33] in their study failed to find any correlation between neonatal hyperbilirubinemia and delivery accelerated by oxytocin. Singhi and Singh [34] found 20% of cases due to oxytocin-induced jaundice, but no relation between oxytocin dose and serum bilirubin at 72 h. Jeffares MJ [12] are also of the view that oxytocin administration during labor does not alter the incidence of neonatal jaundice. Similar result was found in the current study (n = 51, P> 0.05). Oxytocin if administered with dextrose is known to cause jaundice in newborns as suggested by Wasserstrum [35] since in our hospital oxytocin is administered along with RL solution, the possibility of hyperbilirubinemia was decreased.


  Conclusions Top


Maternal infection was found to have a significant effect on neonatal exaggerated hyperbilirubinemia. Therefore, interventions should be prioritized to prevent maternal sepsis. The first approach targets facility-based deliveries and requires increased provision and uptake of proper antenatal care early in pregnancy. In the community, clean delivery practices should be prioritized. In referral centers with high-risk populations, new strategies should be developed, particularly the identification of risk factors for maternal and neonatal sepsis which can be prevented through antibiotic prophylaxis and other measures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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[Pubmed] | [DOI]



 

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