Determinants of pre-eclampsia: A

case-control study in a district hospital

in South India

Presenter Dr.Sachin
Shekde (Assistant DHO)
Guide Dr.Yogesh Mane
 Introduction
• Pre-eclampsia is pregnancy-induced
hypertension (PIH) of unknown etiology.
Pre-eclampsia can be quite serious as it
can lead to various complications both for
the mother and the baby. In fact, pre-
eclampsia and eclampsia, severe forms of
PIH, are the leading cause of infant and
maternal death in the United States.
• Hypertension complicates an estimated
6–8% of all pregnancies. There are
genuine differences in the incidence of
hypertensive disorders of pregnancy in
the populations of Southeast Asia and the
fact that these are not caused by
underlying differences in the baseline
blood pressures in these populations.(1)
• Though the cause for pre-eclampsia is
unknown, there does appear to be certain
risk factors associated with the condition.
The factors that have been postulated to
influence the risk of pre-eclampsia among
the mothers include diabetes, renal disease,
obesity, multiple pregnancy, primiparity, age
above 30 years, personal or family history
of pre-eclampsia, and chronic hypertension.
• In developing countries, evidence on the
association between these factors and pre-
eclampsia is scarce. There are many studies
in developed and some developing countries
to assess the association between these
factors and pre-eclampsia.(2-5) Those that
have been conducted have often had an
inadequate control and lack of statistical
power, resulting in inconclusive evidence for
determinants of pre-eclampsia in developing
countries.
• Very few studies have been conducted in
India to assess the determinants of pre-
eclampsia. Studies of such nature will be
a useful tool to take appropriate
interventional measures. In this context, a
case–control study was conducted to
elucidate some of the major risk factors
for pre-eclampsia.
 Objective
• The objective was to study the
determinants of pre-eclampsia among
pregnant women admitted for delivery in a
district hospital.
 Materials and Methods
• This unmatched case–control study was conducted
in the district government hospital attached to a
medical institution in South India. This is a tertiary
care hospital and its maternity service is a referral in
the care of highrisk pregnant women throughout the
district. The district covers a population of about 4.1
lakhs with 5 taluks in the coastal belt of Karnataka in
South India. A total of 100 cases and 100 controls
were selected for the year 2006. This is calculated
by taking power at 80%, odds ratio of 3, two-sided
significant level as 0.05, and proportion of controls
with exposure as 0.1.
• The group of pregnant women with pre-
eclampsia comprised those with
hypertension after the 20th week of gestation
with associated proteinuria, and controls
were pregnant women not diagnosed with
pre-eclampsia. After the selection of each
case as defined above, the next available
pregnant women who had fulfilled the criteria
for controls given above were selected and
included in the control group. This ensured a
case and control ratio of 1:1
• Antenatal records of the mothers who
delivered in the hospital from January to
December 2006 were scrutinized for
completeness of history and case write-up.
In the first step, the records with pre-
eclampsia were scrutinized and separated.
Then cases were selected from the
separated pre-eclampsia records by simple
random technique. Controls were selected
in the same manner.
• Information relating to maternal and
obstetric factors was obtained from the
case records, which included age, parity,
body mass index (BMI), multiple
pregnancy, history of chronic hypertension,
history of diabetes, history of renal
disease, family history of hypertension,
and history of PIH in earlier pregnancy.
• Data were analyzed by the use of SPSS
version 12. Crude and adjusted odds
ratios with 95% confidence intervals were
calculated. Since PIH is a multifactorial
condition, we used a multiple logistic
regression analysis to assess
independent effects of each variable.
 Results
• Majority of the cases and controls belonged
to the 20–29- year age group (76% and 85%,
respectively). BMI was normal among the
majority of the cases and controls (82% and
84%, respectively). Around 15% of cases
and 2% of controls had history of chronic
hypertension. The proportion of
multigravida was high among cases as
compared to controls but the difference
was not statistically significant.
Table 1: Univariate analysis showing the
determinants for pre-eclampsia
• On univariate analysis it was found that BMI
≥25) (OR = 11.27), history of chronic
hypertension (OR = 8.65), history of diabetes
(OR = 11.0), history of renal disease (OR =
7.98), family history of hypertension (OR = 5.4)
, history of PIH in earlier pregnancy (9.63),
and multiple pregnancy (OR = 4.85) were
significantly associated with pre-eclampsia.
But age group was not found to be
significantly associated with pre-eclampsia
[Table 1].
Table 2: Correlates of pre-eclampsia:
Multiple logistic regression analysis
• Six variables were significantly associated with
pre-eclampsia in multivariate logistic regression
analysis after adjustment for confounding
variables. The significant determinants identified
for pre-eclampsia were prepregnancy BMI of ≥25
(OR = 7.56), history of chronic hypertension (OR =
6.69), history of diabetes (OR = 8.66), history of
renal disease (OR = 5.6), family history of
hypertension (OR = 5.48), and multiple pregnancy
(OR = 5.73). The analysis revealed that BMI,
diabetes, and history of chronic hypertension are
the most dominating associated factors in the
occurrence of pre-eclampsia [Table 2].
 Discussion
• This study has been conducted in a district
government hospital attached to a medical
institution. Majority of the deliveries in the
district are institutional deliveries conducted in
private hospital/clinics. There is no proper
system that can record the history at home,
majority of private hospital/clinics, and public
sectors like primary health centers and
community health centers. Due to the
nonavailability of databases, this study has been
conducted in a district hospital attached to a
medical institution. This necessarily excludes
births in private hospitals, clinics, and at home.
• Our study demonstrated that the
prepregnancy BMI of ≥25, history of chronic
hypertension, history of diabetes, history of
renal disease, family history of hypertension,
and multiple pregnancy were significant
independent determinants of pre-eclampsia.
Well-documented studies to assess the
determinants of pre-eclampsia are few in
India.(6) Various studies found that
prepregnancy BMI is an important
determinant of pre-eclampsia.(2,3,6,7)
• Chronic hypertension is a common problem
in developing countries in nonpregnant
women and increases the incidence of pre-
eclampsia. We found that chronic
hypertension is one of the main determinants
of preeclampsia in this area. It is also found
to be a risk factor for pre-eclampsia in other
studies.(5,8) Family history of hypertension
was also independently associated with pre-
eclampsia in comparison to other studies.(9,
10)
• Diabetes and renal disease are well-known
for adverse pregnancy outcomes. However,
in this study both of these factors were
independently associated with pre-
eclampsia. The likelihood of pre-eclampsia
nearly increases by 8.7 times if diabetes is
present before pregnancy. The predicted
probability of pre-eclampsia was estimated
to be < 0.05 for those with a history of
diabetic mothers. Other studies also
showed similar findings.(5,9,11)
• The presence of renal disease is found to
be a risk factor for pre-eclampsia in other
studies.(5,12) Our study found that
multiple pregnancy increases the risk of
pre-eclampsia by 5.7 times. But other
studies showed the risk to increase by 3.5
times.(2,13)
• In the present study, age and parity were not found to
be associated with pre-eclampsia in contrast to other
studies.(3,5,14) A study done in Saudi Arabia showed
that women at extremes of maternal age, the
nulliparous women, and high-parity women are at an
increased risk of developing pre-eclampsia.(14) The
variation in the present study and other studies could
be due to the differences in the population-based and
hospital-based study. Another reason could be the
inclusion of mothers from the lower and middle
socioeconomic status group who came to this
hospital. These mothers were found to be at lower risk
compared to mothers from the higher socioeconomic
status group.
• This study provides baseline information
and a start to a debate on pre-eclampsia,
from a district hospital in a region, which
could help with possible early intervention
measures regarding pre-eclampsia in the
future. We could not take more information
because of lack of available data from the
records. Since this was a hospital-based
unmatched case control study, it can be
biased to a certain extent.
• Majority of cases and controls admitted will be from the
lower and middle socioeconomic group. But in other
private hospitals, selection bias may be more where
more affluent urban population comes for delivery. In
spite of the constraints, the study provides interesting
information, which can be helpful in planning maternal
health services at a district level in order to prevent the
complications both for the mother and the baby during
antenatal and postnatal period. In view of the above
findings, it is concluded that pregnant women at risk of
pre-eclampsia should be identified and high-quality
antenatal care should be given in order to minimize the
complications of pre-eclampsia both for the mother and
the fetus.
• We recommend the health authorities to
strengthen the maternal health programs
focusing on the prevention and control of
the risk factors during the prepregnancy
period. Also, corrective therapeutic
interventions are advised for the mothers
at risk by means of the practice of
physical activity and nutrition modification
for the reduction of body weight.
Limitations
 Conclusion
• Pregnant women at risk of pre-eclampsia
should be identified and high-quality
antenatal care should be given in order to
minimize the complications of pre-
eclampsia both for the mother and the
fetus.
 References
1. Geographic variation in the incidence of hypertension in pregnancy.
World Health Organization International Collaborative Study of
Hypertensive Disorders of Pregnancy. Am J Obstet Gynecol 1988;
158:80-3.

2. Lee CJ, Hsieh TT, Chiu TH, Chen KC, Lo LM, Hung TH. Risk
factors for pre- eclampsia in an Asian population. Int J Gynaecol
Obstet 2000;70:327-33.

3. Eskenazi B, Fenster L, Sidney S. A multivariate analysis of risk

factors for preeclampsia. JAMA 1991;266:237-41.

4. Mahomed K, Williams MA, Woelk GB, Jenkins-Woelk L, Mudzamiri

S, Madzime S, et al. Risk factors for preeclampsiaeclampsia among
Zimbabwean women: Recurrence risk and familial tendency
towards hypertension. J Obstet Gynaecol 1998;18:218-22.
5. Duckitt K, Harringt D. Risk factors for pre-eclampsia
at antenatal booking: Systematic review of
controlled studies. BMJ 2005;330:565.
6. Amir A, Mohd Y, Islam HM. Clinico epidemiological
study of factors associated with pregnancy induced
hypertension. Indian J community Med 1998;23:
25-9.
7. Thadhani R, Stampfer MJ, Hynter DJ, Manson JE,
Solomon CG, Curhan GC. High body mass index and
hypercholesterolaemia: Risk of hypertensive
disorders of pregnancy. Obstet Gynecol 1999;94:
543-50.
8. Davies AM, Czaczkes JW, Sadovsky E, Prywes R,
Weiskopf P, SterkVV. Toxemia of pregnancy in
Jerusalem I. Epidemiological studies of a total
community. Isr J Med Sci 1970;6:253-66.
9. Qiu C, Williams MA, Leisenring WM, Sorensen TK,
Frederick IO, Dempsey JC, et al. Family History of
Hypertension and Type 2 Diabetes in Relation to
Preeclampsia Risk. Hypertension 2003;41:408-13.
10. Ness RB, Markovic N, Bass D, Harger G, Roberts
JM. Family History of Hypertension, Heart
Disease, and Stroke among Women Who Develop
Hypertension in Pregnancy. Obstet Gynecol 2003;
102:1366-71.
11. Bryson CL, Loannov GN, Rulyak SJ, Critchlow C.
Association between gestational diabetes and
pregnancy induced hypertension. Am J Epidemiol 2003;
158:1148-53.
12. Davies AM, Czaczkes JW, Sadovsky E, Prywes R,
Weiskopf P, SterkVV. Toxemia of pregnancy in Jerusalem
I. Epidemiological studies of a total community. Isr J
Med Sci 1970;6:253-66.
13. Coonrod DV, Hickok DE, Zhu K, Easterling TR, Daling JR.
Risk factors for preeclampsia in twin pregnancies: A
population-based cohort study. Obstet Gynecol 1995;85:
645-50.
14. Lawoyn TO, Ani F. Epidemiologic aspects of pre-
eclampsia in Saudi Arabia. East Afr Med J. 1996;73:404-6.
Critical appraisal of article:

Step 1: Deciding whether I should read this article

a) Title : Is it interesting?- Yes /No

b) Abstract :
Whether conclusions useful for clinical practice? Yes /No

c) Assess material and method:

Whether settings are similar to our own settings of practice?(may be
dissimilar because of different facilities, different technological
availability, grossly different demographic profile of patients) Yes /
No
Step 2 : Assess the research question of the authors

a) Is there a well defined, clear cut and specific research question?

Yes /No

b) Was it feasible for the authors to study this question, given their
technical expertise, available facilities?
Yes /No

c) Whether the research question likely to add knowledge rather than

reconfirming the already well established facts?
Yes /No
Step 3 :Assess the issues of internal /external validity , bias
and methodology in the study

a) Is the actual population from which sample was taken is likely to be

representative of the population? Yes /No

b) Calculated the sample size? Yes /No

c) Described the method of sampling? Yes /No

d) Have the authors described

e) Questionnaire Yes /No
f) Any other scales Yes /No
Step 4 : Analysis

a) Has the presented in a simple form? Yes /No

b) Are the statistical tests correct for the type of variables being
analysed?
Yes /No
c) Have the author worked on 95 % confidence interval of the various
estimate?
Yes /No

Step 5 : Conclusions

a) Is the findings are statistically significant? Yes /No

b) If the findings are statistically not significant
Is it possible that real effect may have been missed as a consequences
of low sample size?
THANK YOU