Hyperinsulinemia and Preeclampsia among Pregnant Women: A Quantitative Study

Hypertensive disorders in pregnancy complicate 1 in 10 pregnancies, often associated with maternal and neonatal mortality and morbidity. The study was done on 100 pregnant women’s attending antenatal clinic of SreeBalaji Medical College & Hospital, Chromepet, Chennai, during the period from December 2013 ­ May 2015. All women who met the inclusion and exclusion criteria were taken intothe study. Fasting insulin was calculated at 18 ­22weeks of gestation, and then follow up of caseswas donefor signs of development of Pregnancy­induced hypertension (PIH). In the hypertensive group, the bulk of the patients were between the ages of 25 and 30. As (P > 0.05), there is no statistical Significance in correlation between age and (PIH) in our study. Out of 100 cases studied, 64 cases (64%) had hyperinsulinemia. The remaining 36 cases (36%) had normal insulin values. The prevalence of PIH associated with hyperinsulinemia was 58% in our study. This test showed sensitivity of 87%, specificity of 82%, positive predictive value of 90%, negative predictive value 77% and diagnostic accuracy was 92%.


INTRODUCTION
Pregnancy is a physiological stress associated with many complex and interrelated biochemical, physiological and anatomical alterations occurring in the body. More emphasis is laid on the biochemical changes seen in the blood during the normal pregnancy and are Original Research Article exaggerated in various complications of pregnancy.Hypertensive disorders of pregnancy, one of the commonest complications of pregnancy, are a leading cause of maternal mortality. The hypertensive disorders of pregnancy are high in developing countries. Collectively these disorders complicate 510% of all pregnancies [1].
Hypertension in pregnancy is also responsible for fetal and infant mortality as well as 46% of infants born small for gestation [2]. Similarly it was estimated that 310% of infants are growth restricted. Fetal growth restriction is associated with substantiate perinatal morbidity and mortality [3,4,5].

MATERIALS AND METHODS
This study is a prospective study which involves a group of 100 women who attend the antenatal clinic of SreeBalaji Medical College and Hospital. The purpose of this study is to estimate fasting insulin as a predictor of pregnancy induced hyper tension.
The values are tabulated. Subsequently the subjects were followed up for regular antenatal care at 2 weekly intervals until 36 weeks & weekly thereafter until delivery and 4 weeks after delivery till 12 weeks. The primary outcome is the development of gestational hypertension.
The statistical analysis has been carried out with IBM SPSS Version 20. Categorical variables will be analyzed with chi square test. Continuous variables are presented as Mean (SD). For normally distributed data (e,g., BMW, Age, and BP) between groups' analyses was done. For statistical significance, a two tailed probability value of less than 0.05 will be considered. Table  1 shows, 66% in pregnancy induced hypertension group, remaining 34% are in normal group.   Table 2 shows, In the present study, 10% had family history of pregnancy induced hypertension, whereas remaining 90% were nil significant.

RESULTS
Of the 25 vaginal deliveries, 12 were spontaneous; one case was induced with misoprostol and12 cases with prostaglandin E2 gel. All the cases were monitored alternately by antepartum surveillance and CTG. ARM and Oxytocin acceleration was done in as per necessary with close monitoring of fetal heart rate. 3 cases required forceps extraction and 2 cases vacuum application (Table 3).
Of the total cases, 8 women had previous LSCS, repeat LSCS was done for them.In rest 62 cases and Emergency LSCS was done in view of both abnormal CTG pattern and fetal distress, failed induction.
In the present study, babies of 56.06% (37/66) with hyperinsulinemia had NICU stay which indicates adverse perinatal outcome compared to normal insulin levels and 20.58%(7 /34) of the babies born to cases with normal insulin levels had NICU stay (Table 4).

DISCUSSION
In 5 to 10% of pregnant women, hypertension develops, making it the leading cause of maternal death in our country and around the world. Establishing an accurate diagnosis of preeclampsia and proceeding with early treatments after it is established is one strategy to lessen the impact of arterial hypertension on maternal mortality.Preeclampsia is diagnosed when a pregnant woman has high blood pressure (> 140/90 mm Hg) after the 20th week of pregnancy (without a previous history of arterial hypertension) and substantial proteinuria (>300 mg in 24 hours). [6,7].
These symptoms are now thought to be a late symptom of an illness that has been present since the first trimester of pregnancy. Because of this "diagnostic delay," numerous tests have attempted to diagnose preeclampsia as soon as possible, sometimes even before the patient develops arterial hypertension.Doppler ultrasonography examination of maternal and foetal circulation, as well as uric acid, have been reported as early diagnostic tests for preeclampsia [8,9]. Hyperinsulinemia has been seen in patients with pregnancyinduced hypertension, according to the investigations. In both crosssectional and cohort studies, pregnancyinduced hypertension has been linked to hyperinsulinemia.The majority of women with hyperinsulinemia had pregnancyinduced hypertension, according to the current study. In our study, the prevalence of PIH associated with hyperinsulinemia was 58 %. At 1220 weeks of pregnancy, fasting insulin was determined, and cases were followed up on for symptoms of PIH development. This test showed sensitivity of 87%, specificity of 82%, positive predictive value of 90%, negative predictive value 77% and diagnostic accuracy was 92%.
All the cases were monitored by ante partum surveillance. In the present study, 25women had vaginal deliveries. Of these, 12 had spontaneous onset of labour while others were induced. One case was induced with misoprostol and12 cases with prostaglandin E2 gel, after assessing their Bishop's score. Indication for induction was severe preeclampsia. During labour, ARM and Oxytocin acceleration was done when required with close monitoring of fetal heart rate.3 cases required forceps and in 2 cases vacuum was applied.
In the present study, babies of 56.06% (37/66) with hyperinsulinemia had NICU stay which indicates adverse perinatal outcome (in terms of neonatal complications which included birth asphyxia, Meconium aspiration syndrome, hyperbilirubinemia, respiratory distress syndrome, etc) compared to normal insulin levels in which 20.58% (7 /34) of the babies had NICU admission. Whereas, Gupta [10] 55.1% of cases with hyperinsulinemia had NICU admission. The prevalence of PIH associated with hyperinsulinemia was 58% in our study. This test showed sensitivity of 87%, specificity of 82%, positive predictive value of 90%, negative predictive value 77% and diagnostic accuracy was 92%. Early screening for preeclampsia may allow vigilant antenatal surveillance and appropriate timing of fetal delivery in order to avoid serious sequelae. Preeclampsia is frequently described as a state of insulin resistance [11]. Many features of insulin resistance like hypertension, hyperinsulinemia, glucose intolerance and lipid abnormalities are associated with this condition [12]. Insulin resistance, inflammation and atherosclerosis appear to be linked via the metabolic syndrome. Insulin resistance 1s associated with elevated levels of various proinflammatory markers which cause endothelial dysfunction and initiate the atherosclerotic cascade [13]. In several studies conducted postpartum, women with a history of preeclampsia have been shown to be more insulin resistant when compared with women with normotensive pregnancy [1416].

CONCLUSION
The high frequency of preeclampsia in women with diabetes underscores the need for more study into the pathogenesis, prognostic markers, therapy, and longterm health consequences of preeclampsia in this population. From this study, we can conclude that pregnant women with increased insulin values are likely develop pregnancy induced hypertension. The occurrence of preeclampsia is significantly linked to increased insulin resistance. Insulin resistance can thus be utilized as a biomarker for preeclampsia diagnosis.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT AND ETHICAL APPROVAL
Informed consent was obtained from all study participants and as per international standard or university standard written ethical approval has been collected and preserved by the author(s). ICH /GCP guidelines were followed.