A CASE CONTROL STUDY OF RISK FACTORS INFLUENCING PREECLAMPSIA AMONGST WOMEN RECEIVING TREATMENT AT UNIVERSITI KEBANGSAAN MALAYSIA MEDICAL

CENTRE (UKMMC)
DR NORFAZILAH BINTI AHMAD P 36529

Norfazilah, A.1 Azmi, M.T.1 Shamsuddin, K.1 Mahdy, A.Z.2 Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia 2Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia Risk Factors of Pre-eclampsia
1

slide 1

INTRODUCTION
Hypertension in pregnancy important cause of maternal and perinatal morbidity and mortality Can be classified into: Gestational hypertension Preeclampsia and eclampsia Chronic hypertension Chronic hypertension with superimposed preeclampsia

(Brown et al.2001)

Risk Factors of Pre-eclampsia

slide 2

INTRODUCTION
Preeclampsia (PE): gestation with properly documented proteinuria Chronic hypertension with superimposed preeclampsia: Pregnant woman with chronic hypertension the appearance of de novo proteinuria after 20 weeks of gestation.
( magnitude of blood pressure, proteinuria, thrombocytopenia abnormal liver enzymes)

De novo hypertension after 20 weeks of

(Brown et al. 2001)

Risk Factors of Pre-eclampsia slide 3

JUSTIFICATION
Lack of published local studies regarding risk factors for preeclampsia Useful information in identifying women at risk of pre-eclampsia For screening and prophylaxis, as well as for recruitment into relevant clinical studies.

Risk Factors of Pre-eclampsia

slide 4

LITERATURE REVIEW
Certain risk factors have stronger association than others.. All play a role in identifying women at risk of preeclampsia Possessing a risk factor does not necessarily mean a woman will develop preeclampsia, neither does the absence of any risk factor guarantee safety
(Churchill & Beever 1999)

Risk Factors of Pre-eclampsia

slide 5

SOCIO-DEMOGRAPHIC FACTOR Ethnic Age

CONCURRENT MATERNAL MEDICAL HISTORY Type 2 diabetes mellitus

PREECLAMPSIA

Chronic hypertension Gestational diabetes

REPRODUCTIVE HISTORY Pre-pregnancy body mass index Obstetrics history MATERNAL AND PERINATAL MORTALITY/ MORBIDITY

FAMILY HEALTH HISTORY

Chronic hypertension
Type 2 diabetes mellitus

Risk Factors of Pre-eclampsia

OBJECTIVES
1. To determine the socio-demographic characteristics of preeclamptic cases 2. To determine the relationship between of the following risk factors and preeclampsia: i. ii. iii. iv. v. vi. Ethnic Age High pre-pregnancy body mass index Obstetrics history (parity) Concurrent maternal medical illness Family health history of chronic hypertension and type 2 diabetes mellitus (either alone or combined)
slide 7

Risk Factors of Pre-eclampsia

METHODOLOGY BACKGROUND
UKMMC Case-Mix system Medical record department

STUDY DESIGN
A hospital based unmatched case control study

Risk Factors of Pre-eclampsia

slide 8

METHODOLOGY SAMPLING METHOD

Cases (2002-2007)
Code: Hypertensive disorder in pregnancy Definition fulfilled Reached the sample size required (355) Control

Code: normotensive pregnant women Match by year to case Randomly selected from the database

Medical records: complete

Risk Factors of Pre-eclampsia slide 9

RESULT

Risk Factors of Pre-eclampsia

slide 10

RESULT (DESCRIPTIVE)
Ethnic: Malay (case 75.2%; control 68.7%)

Age

Risk Factors of Pre-eclampsia

slide 11

Table 1:ORs and 95% CI according to risk factors for preeclampsia

Risk factors Ethnic Non-Malay Malay Age (years)

Unadjusted OR (95% CI) 1.0 (referent) 0.79(0.99-1.92)

*Adjusted OR (95% CI)

< 35
35 Pre-pregnancy BMI Normal Underweight Overweight Obese
Risk Factors of Pre-eclampsia

1.0 (referent)
2.70 (175-4.17) 1.0 (referent) 0.56(0.35-0.88) 7.87(4.41-14.07) 14.54(6.40-33.04)

1.0 (referent)
2.10(1.19-3.70) 1.0 (referent) 0.60(0.37-0.97) 4.01(2.48-6.49) 6.40(2.92-14.00)
slide 12

Table 1:ORs and 95% CI according to risk factors for preeclampsia

Risk factors
Obstetrics history Others Primigravida Parity 2 Nulliparity Concurrent medical history

Unadjusted
OR (95% CI) 1.0 (referent) 1.24(0.84-1.840) 2.24(1.48-3.39) 2.47(1.39-4.39)

*Adjusted
OR (95% CI) 1.0 (referent) 2.25(1.43-3.56) 1.85(1.12-3.06) 3.15(1.63-6.08)

No
Yes

1.0 (referent)
7.22(3.21-16.24)

1.0 (referent)
4.83(1.74-13.42)

Risk Factors of Pre-eclampsia

slide 13

Risk factors Family history of chronic hypertension

Unadjusted OR (95% CI)

*Adjusted OR (95% CI)

No
Yes Family history of Type 2 diabetes mellitus No Yes Family history of chronic hypertension and type 2 diabetes mellitus No Yes

1.0 (referent)
3.12(2.30-4.25) 1.0 (referent) 1.96(1.39-2.75)

1.0 (referent)
2.18(1.55-3.09)

1.0 (referent) 3.18(2.34-4.33)

* Backward Stepwise (Likelihood Ratio) Multiple Logistic Regression applied

Model adequacy was checked by using Hosmer and Lemeshow test (p = 0.352), overall correctly classified percentage (69.5%) and area under the curve (0.77) No multicollinearity problem and interaction reported Nagelkerke R Square = 0.285 Final model equation: Preeclampsia = -1.43 + 0.74(aged 35 years) + 1.39(overweight) + 1.86(obese) + 0.81(being primigravida) 0.62(parity 2) + 1.15(nulliparity) + 1.58(having concurrent medical illness) Risk Factors of Pre-eclampsia slide 14 + 0.78(family history of chronic hypertension).

DISCUSSION
ETHNIC:
Hashimah et al. (2007) place design HKL & UKMMC case control 75 cases HKL (72) UKMMC (3) Non-Malay to Malay aOR 2.4 (0.7 - 8.2) Loi et al. (2007) Singapore cross-sectional

n=
comparison

93 cases
Malay to Chinese p = 0.001 Malay to Indian p = 0.170 Malay to Others p = 0.086 Malay=majority late booker

Risk Factors of Pre-eclampsia

slide 15

DISCUSSION
AGE:
place design 35 years Loi et al. (2007) Singapore cross-sectional p = 0.01 Ustun et al. (2005) Turkey retrospective cohort p = 0.001

PRE-PREGNANCY BMI: Increasing risk throughout the BMI distribution

Doherty et al. (2006) reference result normal BMI overweight (aOR 1.45 [0.72-2.90]) obese (aOR 3.74 [1.95-7.17]) Bhattacharya et al. (2007) normal BMI overweight (aOR 1.6 [1.2-1.8]) obese (aOR 3.1 [2.8-3.5]) morbidly obese (aOR 7.2 [4.7-11.2])
Risk Factors of Pre-eclampsia slide 16

DISCUSSION
OBSTETRICS HISTORY: nulliparity
Eskenazi et al. (1991) design n= reference parity case control 193 cases multiparous nulliparous aOR 5.4 (2.8-10.3) Anorlu et al. (2005) case control 128 cases >1 nulliparous aOR 4.77 (2.90-7.78) 1 nulliparous aRR 2.38 (2.28-2.49) Conde-Agudelo et al. (2000) cross-sectional

CONCURRENT MATERNAL MEDICAL HISTORY:

Risk Factors of Pre-eclampsia

Eskenazi et al. (1991); Stone et al. (1994); Anorlu et al. (2005) & Gaugler-Senden et al. (2005)
slide 17

DISCUSSION

FAMILY HEALTH HISTORY

Chronic hypertension agreement X Type 2 diabetes mellitus agreement X Combined agreement X

DISCUSSION

Ness et al.(2003)
cohort n=85/2211 (3.8%) 1: aRR 1.5 (0.1-2.5) 2: aRR 2.2 (1.1-4.5) Qiu et al. (2003) case control n = 190 aOR 2.0 (1.2-5.5)

Eskenazi et al.
(1991) aOR 1.7 (0.92-3.2) Stone et al. (1994)

Ness et al.
(2003) 1: aRR 1.3 (0.7-2.3) 2: aRR 1.1

Sanchez et al.
(2003) aOR 3.4 (1.4-8.4) -more aware of parental history of diabetes mellitus Qiu et al. (2003) aOR 1.8 (1.1-3.1)

Sanchez et al.
(2003) aOR 1.6 (0.9-2.7)

Qiu et al. (2003)

aOR 1.9 (1.3-2.9)

case control n = 70 cases 21% vs 19% Sanchez et al. (2003) case control n = 169 cases aOR 1.2 (0.7-2.2)

(0.5-5.0)

Risk Factors of Pre-eclampsia

slide 18

CONCLUSION
o Difficult to conduct epidemiological studies for preeclampsia in the absence of a database o UKMMC pioneered the case-mix system in Malaysia o The accessibility of which facilitated identification of specific disease cases, including pre-eclampsia

Risk Factors of Pre-eclampsia

slide 19

THANK YOU

Risk Factors of Pre-eclampsia

slide 20