Introduction
The prevalence of overweight and obesity among women
of reproductive age is increasing [13]. It is well known
that obesity in pregnancy increases the risk for both
adverse maternal and neonatal outcomes [14]. Obesity
has been associated with emergency caesarean section,
large size for gestational age at birth, neonatal hypoglycaemia and childhood obesity [58]. Maternal obesity
seems also to be associated with increased risks of hypertensive disorders. A study among 24 241 nulliparous
women observed an increased risk of gestational hypertension and preeclampsia for the morbidly obese
category, defined as a prepregnancy BMI of more than
35 kg/m2, as compared to normal weight women [6].
Furthermore, it has been suggested that maternal weight
gain might be associated with the risks of gestational
hypertension and preeclampsia [1,2,9]. It is not known
whether similar associations with gestational hypertensive disorders are present in the lower ranges of
0263-6352 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
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2011, Vol 29 No 5
Fig. 1
Participants enrolled during
pregnancy
N = 8880
Blood pressure was measured with the Omron 907 automated digital oscillometric sphygmomanometer, which
was validated in adults (OMRON Healthcare Europe
B.V., Hoofddorp, the Netherlands) [15]. All participants
were seated in upright position with back support and
were asked to relax for 5 min. A cuff was placed around
the nondominant upper arm, which was supported at the
level of the heart, with the bladder midline over the
brachial artery pulsation. In case of an upper arm exceeding 33 cm, a larger cuff (3242 cm) was used. The mean
value of two blood pressure readings over a 60-s interval
was documented for each participant. In total, blood
pressure was measured in 5295 women in first trimester
(median 13.2 weeks of gestation, 95% range 9.817.5), in
6500 women in second trimester (median 20.4 weeks of
gestation, 95% range 18.523.6) and in 6570 women in
third trimester (median 30.2 weeks of gestation, 95%
range 28.532.9). For the analyses, 18 365 blood pressure
measurements were available. Three, two and one blood
pressure measurements were available for 4894, 1675 and
333 women, respectively.
Pregnancy-induced hypertension and preeclampsia
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Covariates
Results
Participant characteristics
Statistical analysis
As compared to normal weight women, those with overweight, obesity and morbid obesity had a higher risk of
pregnancy-induced hypertension [odds ratio, OR 2.12
(95% CI: 1.542.91), OR 4.67 (95% CI: 3.077.09) and
OR 11.34 (95% CI: 6.8018.86), respectively] and preeclampsia [OR 1.82 (95% CI: 1.162.83), OR 2.49 (95%
CI: 1.294.78) and OR 3.40 (95% CI: 1.398.28), respectively] (Table 3). A positive trend was observed for each
model (P < 0.001). Gestational weight gain was associated with an increased risk of pregnancy-induced hypertension. As compared to the reference group (gestational
weight gain <7 kg), women who gained 711.9 kg and
women who gained at least 12 kg had a higher risk of
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Table 1
BMI
Height (cm)
Prepregnancy weight (kg)
Weight gain (kg)
Age (years)
Parity
Nulliparous
Multiparous
Gestational age at intake (weeks)b
Highest completed education (%)
Primary school
Secondary school
Higher education
Ethnicity (%)
European
Non-European
Maternal stress indexb
Alcohol consumption (%)
None
First trimester only
Continued
Smoking habits (%)
None
First trimester only
Continued
Folic acid supplement use (%)
Preconceptional use
First 10 weeks of use
No use
Caffeine intake (%)
None
<2 units per day
25.9 units per day
6 units per day
Pregnancy complications (%)
Preeclampsia
Pregnancy-induced hypertension
a
2011, Vol 29 No 5
Lean
(<20 kg/m2)
n 1122
168.4
53.6
11.2
29.1
(7.1)
(5.3)
(5.1)
(5.4)
Normal
(2024.9 kg/m2)
n 3873
167.8
62.7
11.0
30.0
(7.3)
(6.4)
(4.5)
(5.3)
Overweight
(2529.9 kg/m2)
n 1319
166.3
74.7
9.7
29.8
(7.5)
(7.5)
(5.4)
(5.2)
Obese
(3034.9 kg/m2)
n 425
165.8
88.2
7.7
29.5
(7.3)
(8.8)
(6.9)
(5.2)
Morbidly obese
(35 kg/m2)
n 163
165.1
105.6
5.4
28.9
(7.8)
(13.4)
(7.1)
(5.1)
<0.001
<0.001
<0.001
<0.001
63.4
36.6
14.5 (10.228.9)
60.5
39.5
14.2 (10.424.9)
47.3
52.7
14.4 (10.224.8)
40.0
60.0
14.8 (10.528.8)
50.3
49.7
14.5 (10.123.6)
<0.001
9.2
45.8
45.0
9.0
43.0
48.0
15.8
50.2
34.0
19.5
61.7
18.8
13.8
69.7
16.4
<0.001
61.3
38.7
0.17 (0.001.51)
62.2
37.8
0.15 (0.001.37)
48.7
51.3
0.19 (0.001.56)
42.4
57.6
0.17 (0.001.46)
40.8
59.2
0.25 (0.001.60)
<0.001
45.1
14.2
40.7
45.2
14.2
40.6
59.0
10.5
30.5
65.0
13.0
22.0
69.7
5.8
24.5
<0.001
71.1
8.7
20.2
74.9
8.9
16.3
76.4
7.2
16.4
75.9
6.5
17.6
70.1
8.4
21.5
0.03
38.3
35.2
26.5
41.6
32.9
25.5
37.2
28.0
34.7
29.4
28.2
42.4
24.3
28.7
47.1
<0.001
4.3
56.9
37.7
1.1
4.1
55.5
39.0
1.4
5.0
53.9
39.5
1.6
5.0
62.5
30.5
2.0
7.7
59.4
32.3
0.6
0.06
2.1
2.1
1.6
3.2
2.6
5.1
3.2
8.7
4.7
17.1
0.02
<0.001
0.07
<0.001
Discussion
Results from this prospective cohort study showed that
higher prepregnancy BMI is associated with both higher
SBP and DBP in all trimesters. The difference in blood
pressure between BMI groups is already present from
first trimester onwards and remains stable throughout
pregnancy. Overweight, obesity and morbid obesity are
also associated with increased risks of gestational hypertensive disorders. Higher gestational weight gain was
associated with a higher risk of pregnancy-induced hypertension, but not with preeclampsia.
Some methodological issues need to be considered. One
of the strengths of this study was the prospective data
collection from early pregnancy onwards. We had a large
sample size of 6902 participants with 18 365 blood pressure measurements. The response rate at baseline for
participation in the Generation R Study cohort was 61%.
The nonresponse would lead to biased effect estimates if
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Fig. 2
130
S
B
P
120
110
100
90
80
D
B
P
70
60
11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
BMI 20 24.9
BMI 25 29.9
BMI 30 34.9
BMI 35
Blood pressure patterns in different prepregnancy BMI categories. Change in SBP and DBP in mmHg for lean, overweight, obese and morbidly
obese women, compared to women with a normal BMI based on repeated measurement analysis. SBP 0 1 BMI 2 gestational
age 3 gestational age2 4 BMI gestational age. DBP 0 1 BMI 2 gestational age 3 gestational
age0.5 4 BMI gestational age. In these models, 0 1 BMI reflects the intercept and 2 gestational age 3 gestational
age2reflects the slope of change in blood pressure per week for SBP, and 2 gestational age 3 gestational age0.5reflects the slope of
change in blood pressure per week for DBP. Our term of interest is 4, which reflects the difference in change in blood pressure per week per
BMI category, as compared to women with a normal BMI, 2024.9 kg/m2. Estimates and P values are given in Supplementary Table S1,
http://links.lww.com/HJH/A80.
hypertensive complications might also indicate a selection towards a relatively healthy, low-risk population.
Overweight and obesity are a major public health concern
and have been associated with adverse pregnancy-related
outcomes for mother and offspring. Within the Generation R study, it has already been shown that maternal
prepregnancy BMI is positively associated with foetal
growth from second trimester onwards [5]. Furthermore,
women within the highest quintile of prepregnancy BMI
and gestational weight gain were at increased risk of
delivering large size for gestational age infants. Gestational weight gain modified the effect of prepregnancy
BMI. Women with the highest prepregnancy BMI and
the highest gestational weight gain had the highest risk of
large size for gestational age infants [5].
In this present study, we have shown that prepregnancy
BMI influences SBP and DBP levels during pregnancy,
already from first trimester onwards. We observed significant differences in SBP and DBP between the several
BMI categories in each trimester. This is in line with
observations in previous studies [4,10,20]. A study among
1733 women observed a positive association of prepregnancy BMI with SBP and DBP in each trimester [10].
Another study among 166 women suggested that the
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Table 2
2011, Vol 29 No 5
BMI
Lean (<20 kg/m2)
Normal (2024.9 kg/m2)
Overweight (2529.9 kg/m2)
Obese (3034.9 kg/m2)
Morbidly obese (35 kg/m2)
Trendc
Second trimesterb
n 6500
Third trimesterb
n 6570
BMI
Lean (<20 kg/m2)
Normal (2024.9 kg/m2)
Overweight (2529.9 kg/m2)
Obese (3034.9 kg/m2)
Morbidly obese (35 kg/m2)
Trendc
Second trimesterb
n 6500
Third trimesterb
n 6570
a
Values are regression coefficients (95% confidence interval) that reflect the difference in blood pressure in mmHg per BMI group compared to women with a normal
BMI, 2024.9 kg/m2. Estimates are from multiple imputed data. b Models are adjusted for gestational age at visit, maternal age, gestational weight gain, educational level,
ethnicity, parity, folic acid supplement use, smoking habits, alcohol consumption, caffeine intake and maternal stress. c Tests for trend were based on multiple linear
regression models with BMI as a continuous variable. M P value <0.001.
observed a protective effect of underweight against pregnancy-induced hypertension but not against preeclampsia [1]. We did not observe a protective effect of underweight, defined as a BMI below 20 kg/m2, against
Prepregnancy BMI, gestational weight gain and risk of pregnancy-induced hypertension and preeclampsia (N U 6902)a
Prepregnancy BMI
Preeclampsiab,c (n 131)
Trendd
0.66 (0.421.03)
ncases 23
Reference
ncases 117
2.12 (1.542.91)y
ncases 64
4.67 (3.077.09)y
ncases 35
11.34 (6.8018.86)y
ncases 25
1.16 (1.131.19)y
1.22 (0.742.00)
ncases 22
Reference
ncases 60
1.82 (1.162.83)M
ncases 31
2.49 (1.294.78)M
ncases 12
3.40 (1.398.28)M
ncases 6
1.08 (1.041.12)y
Preeclampsiab,e (n 121)
<7 kg
Reference
ncases 55
1.50 (1.042.16)M
ncases 103
1.86 (1.272.70)M
ncases 94
1.06 (1.131.19)y
Reference
ncases 36
0.78 (0.481.25)
ncases 42
1.08 (0.671.74)
ncases 43
1.02 (0.991.05)
711.9 kg
12 kg
Trendd
a
Values are odds ratios (95% confidence interval) that reflect the difference in risks of pregnancy-induced hypertension and preeclampsia in different BMI groups compared
to women with a normal BMI, 2024.9 kg/m2 and in different gestational weight gain groups compared to women with a gestational weight gain less than 7 kg. Estimates
are from multiple imputed data. b Model is adjusted for educational level, maternal age, ethnicity, parity, folic acid supplement use, smoking habits, alcohol consumption,
caffeine intake, maternal stress. c Model is also adjusted for gestational weight gain. d Tests for trend were based on multiple logistic regression models with BMI and
gestational weight gain as a continuous variable. e Model is also adjusted for prepregnancy BMI. M P < 0.05. y P < 0.001.
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Rotterdam. The authors gratefully acknowledge the contribution of children and parents, general practitioners,
hospitals, midwives and pharmacies in Rotterdam.
The general design of Generation R Study is made
possible by financial support from the Erasmus Medical
Center, Rotterdam, the Erasmus University Rotterdam,
the Netherlands Organization for Health Research and
Development (ZonMw), the Netherlands Organisation
for Scientific Research (NWO), the Ministry of Health,
Welfare and Sport and the Ministry of Youth and
Families. V.W.V.J. received additional grants from the
Netherlands Organization for Health Research and
Development (ZonMw 90700303, 916.10159).
There are no conflicts of interest.
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Acknowledgements
The Generation R Study is conducted by the Erasmus
Medical Center in close collaboration with the School of
Law and Faculty of Social Sciences of the Erasmus
University Rotterdam, the Municipal Health Service
Rotterdam area, Rotterdam, the Rotterdam Homecare
Foundation, Rotterdam and the Stichting Trombosedienst & Artsenlaboratorium Rijnmond (STAR-MDC),
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