Original Article

Obstetrics and Gyn.

Spectrum of Grand Multiparity

KAVITHA DSOUZA, FRANCIS N.P. MONTEIRO, JAYAPRAKASH K., PRASHANTHA BHAGAVATH, SHEENA KRISHNAN

ABSTRACT
This prospective research of comparing the outcome of the grand multipara women with that of non grand multipara was conducted in one of the tertiary health care centres and teaching hospitals of southern Karnataka. The study sample comprised of 100 grand multipara women and 100 non grand multipara women who were admitted to the maternity unit during the period from June 1996 to May 1997. Most of the grandmultipara women belonged to the age group of 26 to 35 years. 87% of the non grandmultipara women were illiterate, and 59% of the grand multipara women had haemoglobin levels which were less than 10 gm%. Out of 11 cases of antepartum haemorrhage, 3 had placenta previa and 8 had abruption of the placenta. 21 patients of the grand multipara group had pregnancy induced hypertension, and 2 of the grand multiparas had pre-eclamptic toxaemia (PET). 90% of the grand multipara women and 86% of the non grand multipara women had normal vaginal deliveries. 29% of the babies of the grand multipara women weighed less than 2.5 kg and a maximum number of babies of both the grand multipara and the non grand multipara women weighed between 2.6 to 3.5 kg. There were 12 still births among the grand multiparas and two among the non grand multipara women. 12 among the grand multipara women had post partum haemorrhage (PPH), while only 4 of the non grand multiparas had PPH.

Key Words: Grand multipara; anaemia; post partum haemorrhage; non grand multipara

INTRODUCTION
The historical origins of the term grand multiparity are uncertain, and a number of definitions have been used (mostly four1 or five 2 previous viable births). [1], [2] Grand multiparity, as per the International Federation of Gynecology and Obstetrics, is the delivery of the fifth to ninth infant, whereas women who are undergoing their tenth (or more) delivery are considered to be great-grand-multiparas. [3],[4],[5],[6],[7] Grand multiparity (GMP) is considered as a dangerous and high risk clinical entity, as certain complications during the pregnancy, labour and the puerperium are thought to occur with an increased incidence in these women. In terms of the minimal risk concept: the safest babies to have are the second, third and the fourth. The hazards are greater for women in their fifth pregnancy and onwards. [8] Some complications that are classically associated with grand multiparaes include abruptio placentae, placenta previa, postpartum haemorrhage, ruptured uterus, macrosomic babies and anaemia. [9] This prospective research of comparing the outcome of the grand multipara women with that of the non grand multipara women was conducted in one of the tertiary health care centres and teaching hospitals of southern Karnataka. The purpose of this study was to evaluate the parity related complications during pregnancy and labour in the grand multiparas and to see the outcome of pregnancy and labour in them.

number of deliveries which were conducted during this period was 1635. The sample comprised of 100 grand multipara women and 100 non grand multipara women who were admitted to the maternity unit. The samples were selected by adopting a convenient sampling technique and after following pre-determined set criteriae like; grand multipara women who were delivering after the 28th week of gestation after five or more previous viable pregnancies and non grand multipara women who had three or less previous viable pregnancies. After admission to the hospital, information regarding the demographic variables of the patients, relevant medical history and details of the examination and treatment were collected. All the information was collected in preformed proformas and were then tabulated.

RESULTS
37% of the grandmultipara women belonged to the age group of 26 to 30 years, whereas 46% of the non grandmultipara women belonged to the age group of 21 to 25 years, as is depicted in [Table/Fig-1].
Grand Multipara Age < 20 21 25 26 30 31 35 36 45 Number 6 37 36 21 100 Percentage 6% 37% 36% 21% 100% NonGrand Multipara Number 12 46 34 7 1 100 Percentage 12% 46% 34% 7% 1% 100%

MATERIALS AND METHODS

[Table/Fig-1]: Age distribution of the grand and non grand multiparae

A majority (87%) of the non grandmultipara women were illiterate and 93% of the non grandmultipara women were literate, as shown in [Table/Fig-2]. [Table/Fig-3] depicts that a majority (57%)
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of the non-grand multipara women were primiparas and that 33% (2) (3) of the grand multipara women were para 7. Only one 43 year old lady was para 14. [Table/Fig-4] shows that 59% of the grand multipara women had haemoglobin levels which were less than 10 gm%, whereas only 12% of the non-grand multipara women had anaemia. Out of 11 cases of antepartum haemorrhage, 3 had placenta previa and 8 had abruption of the placenta.
Grand Multipara Variables 1. Educational status Illiterate 1 10th Above 10th 2. Annual Income a. < 10,000 b. 10,00020,000 c. > 20,000 3. Religion a. Hindu b. Muslim c. Christian Frequency 87 12 1 42 55 3 1 97 2 % age 7 70 23 42% 55% 3% 1& 97% 2% NonGrand Multipara Frequency 7 70 23 9 61 30 19 46 35 % age 7% 70% 23% 9% 61% 30% 19% 46% 35%

common post partum complications were puerperal sepsis and shock in the grand multiparas, which were absent in the non grand multiparas.
Method of Delivery Normal vaginal Delivery Vacuum Forceps L.S.C.S. Grand Multipara Frequency 90 10 100 [Table/Fig-5]: Method of Delivery N = 200 Complications of post partum 1. P.P.H. 2. Wound disease 3. UTI 4. Puerperal sepsis 5. Shock 6. Maternal death N = 200 Grand Multipara Frequency 12 5 1 1 % age 12% 5% 1% 1% NonGrand Multipara Frequency 4 1 3 % age 4% 1% 3% Percentage 90% 10% 100% NonGrand Multipara Frequency 86 3 11 100 Percentage 86% 3% 11% 100%

[Table/Fig-2]: Distribution with regard to their educational status, annual income and religion Grand Multipara Para 1 2 3 4 5 6 7 8 9 10 11 14 100 Frequency 23 33 22 11 5 5 1 Percentage 23% 33% 22% 11% 5% 5% 1% 100% 100 NonGrand Multipara Frequency 57 21 12 10 100% Percentage 57% 21% 12% 10%

[Table/Fig-6]: Postpartum Complications

DISCUSSION
This prospective research of comparing the outcome of the grand multipara women with that of the non grand multipara women was conducted in one of the tertiary health care centres and teaching hospitals of southern Karnataka which provided healthcare services predominantly to the rural population. This prospective study was conducted during the period from June-1996 to May-1997. The number of deliveries which were conducted during this period was 1635. This study was carried out on 200 patients, out of which 100 were grand multiparas and 100 were non-grand multiparas. Our study showed that 73% of the grandmultipara women be longed to the age group of 26 to 35 years. In our study, 33% of the grand multipara women were para 7. Anaemia was the com monest complication among the grand multiparas in our study. It may also be predicted that repeated pregnancies within a short span of life along with poverty, poor hygienic conditions, nutritional deficiency, widespread gastrointestinal disorders and round and hookworm infestations were the major causes of anaemia which were observed in the grand multipara women. This study showed that about 21% of the grand multiparas had pregnancy induced hypertension (PIH) because of the fact that with advancing age and increasing parity, the cardiovascular system becomes lesser and lesser competent and therefore hypertension and associated disorders are more commonly seen in this group. This study was in concurrence with the studies which were conducted by Fayed HM and Abid SF. [10] This study revealed that only 2% of the grand multiparas had pre-eclamptic toxaemia and that none of the non grand multiparas had pre-eclamptic toxaemia. The results of the present study revealed that abruption of the placenta was common among the grand multiparas (8%), whereas the occurrence of placenta previa was only 3%. Abruptio placenta is a major complication which is seen in the grand multiparas. The parity of the patients was considered to be significant factor for the occurrence of placental abnormalities. [11-18] The above studies

[Table/Fig-3]: Distribution with regard to their parity Non-Grand Multipara 12 2 1 12% 2% 1%

Grand Multipara Complications Anaemia (Hb less than 10g%) Antepartum haemorrhage Placenta previa Abruptio placenta Malpresentation Prolapse Pregnancy Induced Hypertension (PIH) PET N = 200 59 3 8 4 3 21 2 59% 3% 8% 4% 3% 21% 2%

Frequency % age Frequency % age

[Table/Fig-4]: Complications of Pregnancy

Out of 100 grand multipara women, 3 had uterine prolapse. Twenty one cases of grand multiparas had pregnancy induced hypertension, whereas among the non grand multiparas, only 1% had pregnancy induced hypertension. 2 of the grand multiparas had pre-eclamptic toxaemia (PET). 90% of the grand multipara women and 86% of the non grand multipara women had normal vaginal deliveries, as is depicted in [Table/Fig-5]. [Table/Fig-6] indicates that 12 patients who belonged to the grand multipara group had post partum haemorrhage (PPH) and that only 4 among the non grand multiparas had PPH. The least
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Kavitha Dsouza et al., Spectrum of Grand Multiparity

showed that there was a lesser incidence of APH, which can be attributed to a higher socio economic status, better nutrition and a better knowledge regarding the prenatal care of the people in the developed countries. So, the higher incidence of APH in the present study may be related to the poor socio economic status, poor nutrition and poor knowledge regarding the prenatal care of the population. In this study, 11 patients had antepartum haemorrhage, of which 7 underwent caesarean sections because of this complication (3 because of major placenta-previa and 4 because of abruption of the placenta). Post partum haemorrhage is also an important complication. In this study, 12 grand multiparas and 4 non-grand multiparas had post partum haemorrhage. Out of the 12 grand multiparas, 5 had mild PPH and 7 had severe PPH, out of which one had cardiac arrest. 10 grand multiparas had atonic PPH and 2 had disseminated intra vascular coagulation. None of the cases of PPH had maternal mortality. Since these patients were often anaemic to start with, the effects of the haemorrhage were more pronounced. The full retraction of the myometrium in the grand multipara was impaired due to aging, scarring and exhaustion. Also, atherosclerotic changes in the uterine blood vessels led to their being less easily and less efficiently clamped off.

they are still liable to the serious complications of pregnancy, which can lead to higher maternal and foetal morbidity and mortality. Preventation is always better than cure and hence grand multiparity should be prevented by effective family planning measures, by increasing the level of education and by the removal of old religious beliefs and stigmas

SUMMARY
73% of the grand multipara women belonged to the age group of 26-35 years, whereas 46% of the non-grand multiparas belonged to the age group of 21-25 years. 87% of the multiparas were illiterate, whereas 93% of the non grand multiparas were literate. A majority of the grand multiparas belonged to the muslim community, followed by Christians and Hindus. The incidence of the parity was from 5-14 in the grand multiparas, but a higher incidence of the parity (7) was also seen. A majority (57%) of the non-grand multiparas belonged to the para one group. A majority (59%) of the grand multiparas were anaemic, whereas only 12% of the non grandmultiparas had anaemia. Almost all the complications of pregnancy and labour were observed to be higher among the grand multiparas. 90% of the grand multiparas and 86% of the non-grand multiparas had normal vaginal deliveries. 10% of the grand multiparas and 11% of the non-grand multiparas had LSCS. There were no maternal deaths.

It can be concluded that in comparison with the other patients, grand multiparas are at a greater risk during pregnancy and labour. This risk can be effectively reduced with good antenatal care, but

[1] Bai J, Wong F, Bauman A, Mohsin M. Parity and pregnancy outcomes. American Journal of Obstetrics and Gynecology 2002; 186: 274-78. [2] Samueloff A, Mor-Yosef S, Seidman DS. Grand multiparity a nation wide survey. Israel Journal of Medical Sciences 1989; 25: 625-29. [3] Babinski A, Kerenyi T, Torok O, Grazi V, Lapinski RH, Bertwitz RL, et al. Perinatal outcome in grand and great grand multipara; the effects of the parity on obstetric factors. American Journal of Obstetrics and Gynecology 1999; 181: 669-74. [4] Begum S. Age and parity related problems which affect the outcome of labor in grand multiparous. Pakistan Journal of Medical Research 2004; 42(4): 179-84. [5] Kadija H Asaf. Grand multiparous still on obstetrical challenge? Pakistan Journal of Obstetrics and Gynecology 1997; 10(1-2): 24-8. [6] Bugg GJ, Atwal GS, Maresh M.Grandmultipara in a modern setting. British Journal of Obstetrics and Gynaecology 2002; 109: 249-53. [7] Sara M, Simonsen E, Lyon JL, Alder SC, Varner M. American Journal of Obstetrics and Gynaecology 2005; 106(3): 454-60. [8] Aslam M. Grand Multiparity. Pakistan Journal of Medical Sciences 1994; 10 (4): 317-21. [9] Shahid R, Mushtaq M. The compilications of grand multiparity. Pakistan Armed Forces Medical Journal 2009; Pakistan Armed Forces Medical Journal 2009; 4: 1-5. [10] Fayed HM, Abid SF, Stevens B. Risk factors in extreme grand multiparity. International Journal of Gynecology and Obstetrics 1993; 41 (1): 17-22. [11] Toivonen S, Heinonen S, Anttile M, Kosma VM, Saarikoski S. Reproductive risk factors, doppler findings, and the outcome of affected births in placental abruption. American Journal of Perinatology 2002; 19 (8): 451-60. [12] Sheiner E, Shohan-Vardi I, Hallak M, Hadar A, Gortzak-Uzan L, Katz M et al. Placental abruption in term pregnancies: clinical significance and obstetric risk factors. Journal of Maternal-Fetal and Neonatal Medicine 2003; 13(1): 45-9. [13] Abu-Heiji A, al Chalabi H, el Iloubani N. Abruptio placentae: risk factors and perinatal outcome. Journal of Obstetrics and Gynaecology Research 1998; 24(2): 141-44. [14] Williams MA, Leiberman E, Mittendorf R, Monson RR, Schoenbaun SC. Risk factors for abruptio placentae. American Journal of Epidemiology 1991; 134(9): 965-72. [15] Asaf KH. Grand multiparity: still an obstetric risk factor. Pakistan Journal of Obstetrics and Gynecology 1997; 10(1-2):24-8. [16] Rai L, Duvvi H, Rao UR, Vaidehi, Nalinii V. Severe abruptio placentae still unpreventable. International Journal of Gynecology and Obstetrics 1989; 29/2: 117-20. [17] Konje JC, Taylor DJ. Bleeding in late pregnancy. In: James DK, Steer PJ, Weiner CP, Gonik B (editors). High Risk Pregnancy Management Options, 2nd ed. USA: WB Saunders; 1999. [18] Kyrklund-Blomberg NB, Gennser G, Cnattingius S. Placental abruption and perinatal death. Paediatric and Perinatal Epidemiology 2001; 15(3): 290-7.

REFERENCES

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AUTHOR(S): 1. Dr. Kavitha Dsouza 2. Dr. Francis N.P. Monteiro 3. Dr. Jayaprakash K. 4. Dr. Prashantha Bhagavath 5. Dr. Sheena Krishnan NAME OF DEPARTMENT(S)/INSTITUTION(S) TO WHICH THE WORK IS ATTRIBUTED: 1. MBBS, MD, Associate Professor of Obstetrics & Gynaecology, A.J. Institute of Medical Sciences, Mangalore: 575004, India (Affiliated to Rajiv Gandhi University of Health Sciences, Karnataka) 2. MBBS, MD, Diplomate NB, Dip. Cyb. Law, Associate Professor of Forensic Medicine & Toxicology, A.J. Institute of Medical Sciences, Mangalore: 575004, India (Affiliated to Rajiv Gandhi University of Health Sciences, Karnataka) 3. MBBS, MD, Professor & H.O.D of Forensic Medicine & Toxicology, A.J. Institute of Medical Sciences, Mangalore: 575004, India (Affiliated to Rajiv Gandhi University of Health Sciences, Karnataka) 4. MBBS, MD, Associate Professor of Forensic Medicine & Toxicology, Kasturba Medical College, Manipal: 576104, India (Affiliated to Manipal University, Karnataka)

5. MBBS, Junior Resident, Department of Obstetrics & Gynaecology, A.J. Institute of Medical Sciences, Mangalore: 575004, India (Affiliated to Rajiv Gandhi University of Health Sciences, Karnataka) NAME, ADDRESS, TELEPHONE, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Francis N P Monteiro, MBBS, MD, Diplomate NB, Dip. Cyb. Law Associate Professor of Forensic Medicine & Toxicology, A.J. Institute of Medical Sciences, Mangalore - 575004, India. Phone: +91 9448327389 (R) E-mail: [email protected] DECLARATION ON COMPETING INTERESTS: No competing Interests.

Date of Submission: Aug19, 2011 Date of peer review: Sep01, 2011 Date of acceptance: Sep08, 2011 Date of Publishing: Nov 11, 2011

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