Hearing Loss as a Complication of Pre-eclampsia?

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1 Hearing Loss as a Complication of Pre-eclampsia? Shatha Sami Hussein* FIBMS CABOC, Manal Madany Abdulqadar* FIBMS CABOC, Feryal Shakir Taher* FIBMS ABSTRACT Background: Pre-eclampsia is a systemic disorder, related to pregnancy, it is associated with increased blood pressure and proteinuria. Occurring after 20 weeks gestation, many complications occur due to preeclampsia for that many researchers try to study these complications to detect it early or prevent it. Objective: To detect if pre-eclampsia causing any complications on hearing ability. Methods: A prospective case-control study, carried out in Al-Yarmouk teaching hospital, department of Obstetrics and Gynecology, Baghdad, Iraq from February 2012 to February It included 30 women with pre-eclampsia and 30 normal healthy pregnant women as controls. Each patient submitted to otoscopic examinations pure tone audiometry and autoscopy during their last three months of pregnancy. We compared the result of auditory examination in both groups. Results: The statistic showed there was clear difference in both systolic and diastolic blood pressure p value less than since group a include patients with pre eclampsia. The mean of frequency in left ear in group A was 24.1±3.9 if compared with 18.1±2 the mean of frequency in left ear in group B which is statistically significant while the mean of frequency in right ear was 22.4±3.5 and 19.4±1.8 in group A, B, respectively. Conclusion: preeclampsia may cause hearing loss in patients as a complication. Keywords: Preeclampsia, Pure tone audiometry, Cochlear damage. Iraqi Medical Journal Vol. 63, No. 2, July 2017; p Preeclampsia (PET) is a multisystem disease that usually occurs in the second half of pregnancy. Pathophysiologic changes include vasospasm and damage of the endothelial. The organs which involved in pathophysiology of preeclampsia showed areas of endothelial edema, micro-infarctions and hemorrhages. The organs that affected by preeclampsia are the kidney, brain, liver, lungs (1,2). It is characterized by increased blood pressure and proteinuria. It usually presented after 20 weeks of gestation (3). Incidence was (3-5%) of pregnant women over the world is a major cause of maternal mortality, with about >60,000 maternal deaths per year (4). *Dept. of Obstetrics and Gynecology, Al-Yarmouk Teaching Hospital, Baghdad, Iraq. Preeclampsia originates in the placenta, where there was partial cytotrophoblast invasion to maternal endothelium and lead to endothelial dysfunction. Release of placental anti-antigenic factors, specifically soluble fms-related tyrosine kinase 1 and soluble endoglin, have been shown to be increased in preeclampsia (5). These factors are released into the maternal circulation; their actions lead to hypertension, proteinuria, and the other manifestations of preeclampsia. The exact bases for placental dysfunction of these factors were unknown. Hypoxia was the main important regulator. Changes in the renin angiotensin-aldosterone axis, immune adaptation, shedding of trophoblast debris, oxidative stress, and genetic basis play role in the pathogenesis of the abnormal placentation (5,6). Severe preeclampsia is associated with presence hypoperfusion of placenta and Iraqi Med J 2017 Vol. 63 (2) 141

2 infarction on histopathology other findings include acute thrombosis of vessels, diffuse vascular obstruction that includes fibrin accumulation, increased thickness of intima, necrosis and damaging of endothelium (7). Placental ischemia occurs due to occlusion of spiral arteries. Doppler ultrasound of uterine artery shows abnormality, goes with decreased uteroplacental perfusion, before the clinical appearance of preeclampsia (8). The severity of clinical disease correlated with the gross placental pathology, but these findings were not universal (6). The inner ear consists of the bony labyrinth, a system of passages include the two main functional parts the cochlea, which is responsible for hearing, and the vestibular system, which is responsible for balance (8,9). The inner ear is innervated by the eighth cranial nerve in all vertebrates (10). The cochlea is a bony, spiral-shaped compartment which contains the cochlear duct of the membranous labyrinth. The hearing sense is occurred by receptors within this duct. A pair of perilymphfilled chambers is found on each side of the duct. The entire system turns around a central bony hub (11). Pure tone audiometry is a subjective test aim to establish pure tone hearing threshold i.e. the quietest sound that can be perceived at different frequencies, the British Society of Audiology recommend the description of hearing threshold on audiogram as : 1. Normal hearing threshold are considered to be 20db, 2. Mild hearing loss between db, 3. Moderate loss db, 4. Severe loss db, 5. Marked loss worst than 95 db. Frequencies between Hz were defined as normal range of hearing (12). Methods This prospective control study was performed at Al-Yarmouk teaching hospital the department of obstetrics and gynecology and ENT department, Baghdad-Iraq. February 2013 to February Verbal consents were obtained from all patients before involving them in the study. It includes 60 pregnant women, in third trimester pregnancy subdivided into two groups as follows: Group A: Thirty pregnant patients presented with hypertension + proteinuria (PET), diagnosed by investigation. Group B: Thirty healthy pregnant women with no risk factors were selected as a control group, normotensive, no proteinuria. Full history was taken, including any hearing and neurological signs and symptoms. Gestational age was calculated from last menstrual period using Naegele s rule. Pre-eclampsia was defined as a blood pressure of 140 mmhg (systolic) or a blood pressure of 90 mmhg (diastolic) after 20 gestational weeks of pregnancy with proteinuria of at least 300 mg/24 h urine collection. The control group collected as pregnant who attend for check up to the hospital outpatient clinic. Exclusion criteria: Any history of disease or surgery of ears, upper respiratory tract infection at examination, using of medication that effect ears, age of patients >40 years, pregnancy induced hypertension, eclampsia, HELLP syndrome. Clinical examination done for all patients, and all audiometric assessment were done by the same ENT specialist and the same audiometry examiner. Verbal consent was taken from all participants and the result compared statistically. Data analyzed by Epi-Info ver. 7 Software. The data presented as mean and standard deviation. Independent t-test (two tailed) was used to compare the variables between study groups. Pearson correlation was calculated for the 142 Iraqi Med J 2017 Vol. 63 (2)

3 correlation between two quantitative variables with its t-test for testing the significance of correlation. The correlation coefficient value (r) either positive (direct correlation) or negative (inverse correlation) with value <0.3 represent no correlation, 0.3-<0.5 represent weak correlation, 0.5-<0.7 moderate strength, >0.7 strong correlation. In addition to correlation the r 2 was calculated (The coefficient of determination), i.e. when value of r=0.58, then r 2 =0.34, this means that 34% of the variation in the values of y may be accounted for by knowing values of x or vice versa. Statistical significance was considered whenever the P value was equal or less than Results Table 1 shows descriptive characteristic features for the study and control group revealed no statistical significance. Table 2 compares blood pressure (systolic and diastolic ), hearing thresholds between study and control group, it shows that there was significant difference in both systolic and diastolic blood pressure p value less than since group A include patients with pre eclampsia. The mean of frequency in left ear in group A was 24.1±3.9 if compared with 18.1±2 the mean of frequency in left ear in group B which is statistically significant while the mean of frequency in right ear was 22.4±3.5 and 19.4±1.8 in group A, B, respectively. Table 3 correlates hearing frequencies in left and right ear with respondents features and it revealed strong relation with proteinuria. Figure 1 shows there was a linear relationship between proteinuria and hearing frequency loss, when the level of protein in urine increased there was much loss in hearing. Figure 2 and 3 show there was a linear relationship between blood pressure (systolic and diastolic) and hearing frequency. Table 1: General features of the study groups. Cases (N=30) Variables Mean ±SD Control (N=30) Mean ±SD p-value Age (years) 26.3±7.1 27± Gravida 3.1± ± Para 1.8± ± Abortion 0.4± ± Gestational age (weeks) 35.4± ± SD= Standard deviation, Independent t-test Table 2: Comparison of blood pressure and hearing thresholds between the study groups. Cases (N=30) Control (N=30) Variables p-value Mean ±SD Mean ±SD Systolic blood pressure (mmhg) 156± ±10.8 <0.001* Diastolic blood pressure (mmhg) 103.7± ±6.6 <0.001* Frequency LT ear (db) 24.1± ±2 <0.001* Frequency RT ear (db) 22.4± ±1.8 <0.001* SD= Standard deviation, Independent t-test, * Significant at 0.05 level (2-tailed). Iraqi Med J 2017 Vol. 63 (2) 143

4 Table 3: The correlation coefficient (r). Frequency (db) Left ear Frequency (db) Right ear PET Control PET Control Systolic BP (mmhg) Diastolic BP (mmhg) Protienuria (g/dl) ** Gestational age (weeks) Gravidity * Parity Abortion Figure 1: The scatter diagram between proteinuria and frequency (db) of left (a) and right (b) ear in pregnant with PET. 40 Hearing frequency (db) Systolic BP (mmhg) Frequency LT ear (db) Linear (Frequency LT ear (db)) Frequency RT ear (db) Linear (Frequency RT ear (db)) Figure 2 Correlations between systolic blood pressure and hearing frequencies in both ears. 144 Iraqi Med J 2017 Vol. 63 (2)

5 Hearing frequency (db) Diastolic BP (mmhg) Frequency LT ear (db) Linear (Frequency LT ear (db)) Frequency RT ear (db) Linear (Frequency RT ear (db)) Figure 3 Correlations between diastolic blood pressure and hearing frequencies in both ears. Discussion Preeclampsia is one of common medical disease in pregnancy and one of major causes of maternal and fetal mortality and morbidity. Pre-eclampsia has a complex pathophysiology. Abnormal development of placental vessels early in pregnancy may lead to decreased placental blood flow/hypoxia/infarction, release of antiangiogenic factors into the maternal circulation that alter maternal systemic endothelial function and cause appearance of clinical presentation like hypertension and other manifestations of the disease, cochlear blood vessels is one of the vessels that may involved in this effect. Many researches done to detect complication of preeclampsia since it is a multi-organ syndrome of pregnancy. Bakhshaee et al study involved 75 pregnant women 37 of them were cases of preeclampsia the remaining was control,hearing test was done for each patient twice one before delivery second within two weeks after delivery and this revealed five from 37 patients had hearing impairment (13). The present study shows that 14 cases from 30 cases had mild hearing impairment of right ear by pure tone audiometry test this may be related to severity of preeclampsia which may influence the microcirculation or fluid balance of the cochlea, ischemia in the cochlear circulation, therefore, altering hearing levels. Baylan et al research studied 70 patients 40 were cases of preeclampsia undergone otoligical examination 8 of cases revealed to have hearing problem, 2 patients of control also had this problem, the study concluded that preeclampsia was a risk factor for permanent hearing loss (14). In a recent study which showed that there was significant correlation between both blood pressure (high systolic and diastolic) and proteinuria with hearing frequencies loss in both right and left ear p value < Altunta et al compared the ratio of hearing loss evaluated with transient evoked otoacoustic emission (TEOAEs) testing in normal and hypertensive pregnant women during the first week after delivery. Study group included 96 women with pregnancy induced hypertension, preeclampsia, eclampsia, or HELLP syndrome, 107 pregnant as control, its revealed that 7.3% of study group had Iraqi Med J 2017 Vol. 63 (2) 145

6 hearing loss versus 2.8% in control group (15). Cases in current study frequencies of hearing evaluated by pure tone audiometry and showed that both high blood pressure and proteinuria significantly correlated to hearing impairment. Terz et al studied 33 pregnant women with pre-eclampsia and 32 healthy women as controls. Otological examination done for all. Study revealed that hearing limit in the right ear at 1, 4, 8, and 10 khz and in the left ear at 8 and 10 khz were higher in the patients with pre-eclampsia compared to the control. The level of systolic blood pressure had deteriorating effect on hearing at 8, 10, and 12 khz in the right ear and at 10 khz in the left ear and the result comparable and agree with our study. References 1. Ananth CV, Savitz DA, Bowes WA, Luther ER. Influence of hypertensive disorders and cigarette smoking on placental abruption and uterine bleeding. British Journal Obstetrics Gynecology 1997;104: Ayala DE, Hermida RC, Mojon A, Fernanadez JR, Iglesias M. Circadian blood pressure variability during gestation in healthy and complicated pregnancies. Hypertension 1997; 30(2): Three Centres Collaboration Consensus Guideline Hypertension in Pregnancy, Preeclampsia and Eclampsia. March Altman D, Carroli G, Duley L, Farrell B, Moodley J, Neilson J, Smith D. Do women with preeclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomized placebo-controlled trial. Lancet 2002;359: Maynard SE, Min JY, Merchan J, Lim KH, Li J, Mondal S, Libermann TA, Morgan JP, Sellke FW, Stillman IE, Epstein FH, Sukhatme VP, Karumanchi SA. Excess placental soluble fmslike tyrosine kinase 1 (sflt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in preeclampsia. J Clin Invest 2003;111: Venkatesha S, Toporsian M, Lam C, Hanai J, Mammoto T, Kim YM, Bdolah Y, Lim KH, Yuan HT, Libermann TA, Stillman IE, Roberts D, D Amore PA, Epstein FH, Sellke FW, Romero R, Sukhatme VP, Letarte M, Karumanchi SA. Soluble endoglin contributes to the pathogenesis of preeclampsia. Nat Med 2006;12: Salafia CM, Pezzullo JC, Ghidini A, Lopez-Zeno JA, Whittington SS. Clinical correlations of patterns of placental pathology in preterm preeclampsia. Placenta 1998;19: North RA, Ferrier C, Long D, Townend K, Kincaid- Smith P. Uterine artery Doppler flow velocity waveforms in the second trimester for the prediction of preeclampsia and fetal growth retardation. Obstet Gynecol 1994; 83: Van De Water TR. Historical aspects of inner ear anatomy and biology that underlie the design of hearing and balance prosthetic devices. Anat Rec (Hoboken) 2012; 295(11): Presutti L, Nogueira JF, Alicandri-Ciufelli M, Marchioni D. Beyond the middle ear: endoscopic surgical anatomy and approaches to inner ear and lateral skull base. Otolaryngol Clin North Am 2013; 46(2): Maklad A, Fritzsch B. Development of vestibular afferent projections into the hindbrain and their central targets. Brain Res Bull 2003; 60: Martini FH. Fundamentals of Anatomy and Physiology. 7 th ed. Benjamin Cummings P Warner, Burgess, Patel et al. Otolaryngology Head and Neck Surgery. Oxford Specialist, 1 st ed. Oxford P M Bakhshaee, M Hassanzadeh, N Nourizadeh, E Karimi, T Moghiman, M Shakeri. Hearing impairment in pregnancy toxemia. Otolaryngology, Head and Neck Surgery 2008; 139(2): Baylan MY, Kuyumcuoglu U, Kale A, Celik Y, Topcu I. Is preeclampsia a new risk factor for cochlear damage and hearing loss? Otol Neurotol 2010; 31: Altuntas EE, Yenicesu AG, Mutlu AE, Muderris S, Cetin M, Cetin A. An evaluation of the effects of hypertension during pregnancy on postpartum hearing as measured by transient-evoked otoacoustic emissions. Acta Otorhinolaryngol Ital 2012; 32: Hasan Terzi, Ahmet Kale, Pinar Solmaz Hasdemir, Adin Selcuk, Arzu Yavuz, Selahattin Gen. Hearing loss: An unknown complication of pre-eclampsia. J Obstet Gynaecol Res 2015; 41(2): IMJ 2017;63(2): Iraqi Med J 2017 Vol. 63 (2)