Risk Factors for Congenital Heart Disease Among Infants In Mosul City

Risk Factors for Congenital Heart Disease Among Infants In Mosul City

 Qusay Ahmed Attia⁽¹⁾                                                                             Riyadh Abdulatif Al-Obeidi⁽²⁾

Abstract :

Background: Congenital Heart Disease(CHD) is a problem of the heart's structure with its function at birth and it is the most common congenital anomaly . Etiology of congenital heart diseases are often unknown . However, many cases of CHD may result from genetic factors, environmental stimuli as well as chromosomal abnormalities  . Our study aimed to assess the degree of association of suggestive risk factors with the occurrence of congenital heart disease in infants at pediatric teaching hospitals ,in Mosul .

Materials and Methods  : A case-control prospective study  was carried out at pediatric teaching hospitals in Mosul city (Ibn Al Atheer and Al Khansaa Hospitals)on infant   ≤ 12 month of age with congenital heart diseases, who attended the pediatric cardiology units during 3 months from November 2019 to February 2020. To collect the data, a questionnaire was performed through interviews with parents of enrolled infant n= 557 (cases n= 272,controls n=285).

Results :   Residence of rural area , poverty , housewife mothers , parental low level of education ,  parental consanguinity, use of contraceptive measures, gestational diabetes, prematurity , low birth weight ,twins and caesarean section  have  significant associations with the occurrence of CHD .

Conclusions: Significant association were found between  prematurity ,low birth weight, twins, caesarian section,  positive family history for CHD, low parental education and poverty, and  the development of CHD.

Key words : Congenital heart disease, risk factors, infants, parents .

 1 M.Sc. Pediatrics Nursing ,College of Nursing, University of Mosul, Iraq

2 Assistant Professor, PhD. Pediatric Medicine, College of Medicine, University of Mosul, Iraq

1.1. Introduction

Congenital heart disease (CHD) is a problem of the heart`s structure with its function at birth , affect the heart and or adjacent blood vessels , detected at birth or later in life (Chelo et al,2016) . It is considered as the most common congenital anomaly (Garcia et al,2018 )which can be resulted from fetal event that occurs during the first 8weeks of gestation (Balat and Sahu, 2018) and it accounts for 28% of congenital anomalies in general (Quartermain et al,2015) .It is also considered as one of the most  common causes of death during the first year of life compared with other birth defects . It is an important cause of morbidity and mortality in infancy (Wong et al,2018).Mostly, the causes of congenital heart diseases are unknown. However, many cases of CHD may result from a contribution of genetic factor environmental stimuli as well as chromosomal abnormalities (Kliegman et al,2016).The genetic and environmental factors may affect the growth during pregnancy, that  influence the blood flow and oxygenation abnormalities (Steurer et al,2018).Multiple risk factors may contribute to CHD ; including the teratogenic effects of drugs during pregnancy such as the effect of warfarin (Kliegman et al,2020), maternal infection such as Rubella, diabetes (Karen,2019), and chromosomal abnormalities as well as familial predisposition (Kliegman et al,2020).Other risk factors includes; low birth weight, maternal co morbidity, family history of congenital heart defect, first born child, prolonged exposure to environmental pollutions (Nicoll, 2018), and age related maternal factors (Schulkey et al,2015).Lack of orientation about the risk factors , mostly modifiable environmental and behavioral factors add adverse effects on fetus cardiac development (Chou et al,2016); such  as maternal lifestyle factors  including; drinking strong tea or coffee cigarette smoker , smokeless tobacco and alcohol consumption have also been associated with risk of CHD (Zhu et al,2016) .As the problem of congenital heart defect, it may ultimately correlated with the increase in morbidity and mortality  rates  in early life or long term complications in  adolescents or even adulthood (Spector et al,2018) . Because of the adverse impact of CHD upon population level , a public health nearly is required to title the challenges of these common , critical and costly circumstances (Jenkins and Honein,2018) .To present an accurate picture the load of  congenital heart disease , we classified CHD as a major or minor . The major defects when the total structural complexity was of functional indication , e.g. atrioventricular septal defect (AVSD) , hypoplastic left heart syndrome (HLHS) , coarctation of the aorta (CoA) , large atrial septal defect (ASD) and large ventricular septal defect (VSD) , and surgical repair or catheter intervention may be required (Pei et al,2017) .Prevention can be achieved through many ways like a reduction in the occurrence of congenital infections, modification of risk factors  through  life style changes. (Garcia et al,2018). Also preventing and promotion of cardiac health can be achieved by: first: to recognize the economic and the social risk factors as well as educational health services,  second: implementation of a screening program for the social factors associated with  CHD (Kuo et al, 2016).Treatment may include : surgery, catheterization or medical conservative measures (lewis,  2018).

In our study, we aimed to evaluate the strength of associations of suggestive risk factors with the development of congenital heart diseases in infants of Mosul city.

Materials and Methods:

This    case – control  cohort study was conducted  in Ibn Al-Atheer Pediatric Hospital and Al-Khansaa Teaching Hospitals, in Mosul, Iraq, from November 2019 to February 2020,and was approved by the local ethical  medical research committee. Infants under the age of 12 months who visited the cardiology units and Echo units as well as those neonates admitted to the neonatal intensive unit complaining of congenital cardiac diseases were selected as a group of cases  . A questionnaire  interview was performed with the parents of the enrolled infants and data were collected  about infants and their parents including demographic factors, family history of CHD, parental consanguinity, abnormal events of pregnancy, genetic and family diseases ,prenatal status,  gestational age, delivery method, and other suggested factors that might have a role in the occurrence of CHD  . Another group with  age and sex matched infants and neonates under the age of 12 months , were attending the hospital  but without congenital heart diseases, were  considered as controls . To measure the statistical significance  for the possible risk factors associated with the CHD,  Odd  ratio(OR),was calculated in a case-control analysis using fourfold (2x2) tables ,The test of significance of OR was provided by Chi-square test with one degree of freedom, and 95% Confidence Interval .P value is considered significant when 

 Table 1.Demographic Variables of the infants and the Parents of cases vs. controls:

 The table (1)shows that CHD is found  more among  families from low socioeconomic status, low educational levels, un-employed mothers, familial consanguinity, and rural residence.

Table 2.Cases versus controls in the infants risk factors for CHD:

Table 2.reveals that  prematurity, low birth weight , developmental abnormalities ,twin pregnancy ,and familial predisposition for CHD ,having  significant associations with congenital heart diseases.

Table 3.Cases versus controls in the parents risk factors for CHD :

 Discussion:

1. Demographic Variables of the infants  cases vs. controls

1.1. Age :

In our study ,we did not find any significant role for age of the baby in the development of CHD, while Mecklin et al.,( 2017)reported more cases  among  infants younger  than 2 month .

1.2. Gender :

In this study the gender was not found to be of significance . This result was consistent with the study  conducted  by Mecklin et al., (2017)who found that no significant association between cases and controls .In addition, Zhange et al., (2019) , also showed the same outcome.

1.3. Residence :

The CHD appeared significantly more in infants from rural regions. This finding was in agreement with Liu and Yan, (2016) who stated that in the rural residence there was a significant difference between cases and controls group .In addition Yang et al., (2019) , also noted a similar finding.

2. Demographic Variables of the Parents of cases vs. controls :

2.1. Mother age (years) :

The study showed that there was no significant role for certain mother age .These result agreed  with the study of Zhange et al.,(2019) who indicated that the mothers age had no significant role .But Peng et al.,(2019) in his study found that most of his CHD cases were from mothers of ages 25-29.

2.2.Family income :

In our study ,we found a significant role for the family income with the occurrence of CHD . These result agreed with that of Liu and Yan, (2016) .

2.3. Mother occupation :

We found a significant role form others housewives in the occurrence of CHD .This finding was in agreement with Liu and Yan, (2016).

2.4. Parents educational level :

The study appeared that the frequency of CHD increased in families of  parents of primary school educational level with a significant association with the development of CHD . These result are consistent with other study that was conducted by Arjmandniaet al., (2018)and by(Liu and Yan, 2016) .

2.5.The parents consanguinity :

The  rate of infants with CHD was more among families of consanguineous parents than those from non-relative couples. This result was same with another study that was conducted by(Shoukriet al.,2017) .

3. Cases versus controls , in the infants risk factors for CHD :

3.1. Low infants weight at birth :

In this study, low infants weight ( < 2500gm ) shows a significant association with the development of CHD. This finding is in agreement with the study conducted by Zhange et al., (2019).

3.2. Premature baby :

The study noted a significant role for prematurity in the occurrence of CHD .This result was approximately in consistent with the study  conducted by Mecklin et al.,(2017).In addition, Zhange et al., (2019), showed the same outcome.

3.3. Developmental abnormality with CHD :

In the study, infants with Developmental abnormality showed CHD in  8.1% of cases compared with control group of 1.1%. This finding showed a significant association.

3.4. Twins :

Our study found that twin babies have a significant association with the development of CHD .  Study of Yang et al., (2019),similarly, reported that twins may play a role in CHD  .

3.5. Family history and CHD :

The study clarified  that the family history of CHD may play a role in the increment of CHD .incidence of

Similarly ,a study in hunan province by Li et al., (2017)  found that the family history with CHD showed a significant role .

4. Cases versus controls , in the parents risk factors for CHD :

4.1. Contraceptives :

We noticed that the frequency of CHD was increased among mothers who used contraception before the pregnancy of the affected gestation.

Zaqout et al., (2017) noticed the same outcome with the use of contraceptives .

 4.2. Parents smoking :

In our study ,we did not find any significant role for parental smoking in the development of CHD.

This finding is similar to that reported by were consistent with other study that was conducted in china by Liu and Yan ,( 2016) .

4.3. Previous miscarriages :

We found that the frequency of CHD increased among mothers known to have frequent previous abortions .The result is in contrast to the study done by Zhange et al., (2019) who found that the percentages of case and control groups of previous miscarriages were (28.1%,25.2%) ,and they concluded  no significant role.

4.4. Health problems during pregnancy :

The study showed that the mothers with health problems during pregnancy like gestational diabetes , Epilepsy, Migraine, Asthma ,and  Anemia may have a noted role in the increase of the frequency of CHD .

4.5. Mother with drugs :

The results appeared that the frequency of CHD increased among mothers who received drugs during pregnancy, these results have a significant association with the development of CHD . This finding is similar to that reported by other study that was conducted by Liu and Yan , ( 2016).In addition, Yang et al., (2019), showed the same outcome.

4.6. Birth methods :

The study  has noted a significant role for the caesarean section in the occurrence of CHD .This result  is consistent with the finding of  Behzad et al., (2013) who reported that the caesarean delivery may have a significant association with CHD.

Conclusions and Recommendations:

Conclusions :

Most of the cases with CHD were seen among infants less than 1 months of age . Majority  of these cases  were from rural areas  . Significant association between  poverty, low parental education ,consanguineous marriage and the development of CHD were noted.. Also that prematurity ,low birth weight babies, first born babies in the family, baby of twin, and positive family history , are  likely risk  factors. Related to parents of  infant with CHD , use of contraceptives ,maternal smoking, heavy mother  home work, familial diseases, pervious abortions, gestational diabetes ,anemia, use of drugs during pregnancy like; antiepileptic ,anti-migraine, and  delivery by caesarian section are probable risk for the occurrence of CHD..

Recommendations :

Based upon the findings and conclusions of the study , wean courage mother's good nutrition during pregnancy with light work, education of parents about anomalies and the risk factors that contributes to congenital heart disease ,encourage education  and schooling , avoid intake of drugs during pregnancy without   the prescription order of doctor.   Also avoidance as much as possible the    marriage between the relatives ,especially for these who have a history of congenital heart disease.

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