1
ABSTRACT
mortality. Hypertensive disorders are the second most common obstetric cause
defined as systolic blood pressure (BP) level of 140mmHg or higher and diastolic
hour urine collection but efforts have been done to shorten the period required for
as well as for decreasing hospital cost and patient inconvenience. The goal of
this study is to determine the correlation between 12- and 24-hour urine total
protein values to examine whether the 12-hour urine samples could be used for
2
CHAPTER I
INTRODUCTION
broad spectrum of conditions which are associated with substantial maternal and
O., & Ige, O. K., 2011). In developing countries, the incidence of the preeclampsia
common obstetric cause of stillbirths and early neonatal deaths in these countries
(Ngoc, N.T. et. al, 2006). In the Philippines, maternal mortality ratio in 2015
remains high at 114 per 100,000 livebirths (CIA, 2015) Furthermore, hypertension
300 mg protein in 24-hour urine specimen, a urine protein: creatinine ratio 0.3;
preeclampsia can also occur in the absence of proteinuria if there is a new onset
3
of signs and symptoms including thrombocytopenia, renal insufficiency, impaired
liver function, pulmonary edema and cerebral or visual symptoms (ACOG, 2013).
hour urine collection (Singhal, S. R.,2014). The rationale behind 24-hour collection
significantly over a 24-hour period and collection of less than this duration may not
accurately reflect the actual amount of daily protein loss (Evans, W.,2000).
Adelberg, et. al in 2001 however noted the drawbacks of these method including
too much time for collection that may lead to incorrect estimation due to improper
collection, improper mixing or spillage which may result in a delay in the diagnosis
the period required for the diagnosis of preeclampsia would be valuable for
inconvenience (Rinehart, B.K et. al.,1999). Efforts are going on to find the shortest
and most reliable time period for urine collection, and few studies have been
carried out in this regard (Rabiee, S., 2007; Amirabi A., 2011). Therefore, the aim
of this study was to determine whether 12-hour urine protein values correlate with
4
SIGNIFICANCE OF THE STUDY
standard for its diagnosis is the 24-hour period collection of urine protein which is
part of the standard antenatal care. However, a 24-hour period required for the
collection of urine may result in the delay of diagnosis and treatment hence result
The goal of this study is to determine the correlation between 12- and 24-
hour urine total protein values to examine whether the 12-hour urine samples could
well as clinical factors such as the patients gravidity and parity. With this
a good prognosis in patients with preeclampsia. This can also be a basis for health
5
promotion policies to accomplish the millennium development goal of improving
maternal health and the most recent sustainable development goal of achieving
RESEARCH OBJECTIVES
General Objective
To determine if 12-hour urine total protein values correlate with the 24- hour value
Specific Objectives
Medical Center Department of Obstetrics and Gynecology who was found to have
features of preeclampsia. And from this population, 12 hour and 24-hour urine
6
in the diagnosis of preeclampsia. Hence, generalizing the results beyond the
Prospective studies are less prone to selection bias since the outcome is
including recall bias and social desirability bias were generally avoided. In the
study, general data as well as socioeconomic and clinical factors were determined.
To avoid response bias, the form was explained in detail with adequate instruction
in filling up the forms of the respondents. The proponent is also present if in case
for correct urine volume determination and a stirring rod for adequate mixing of the
7
CHAPTER II
Preeclampsia
persistent 30 mg/dL (1+ dipstick) protein in random urine samples (ACOG, 2013).
In the absence of proteinuria, preeclampsia can still be present with the following
signs and symptoms accompanying the new onset of hypertension. This includes
8
Preeclampsia with severe features is defined as any of these features
four hours apart in a woman on bed rest, thrombocytopenia with platelet count less
concentration in the absence of other renal diseases, impaired liver function with
(ACOG, 2013).
N., Farrel, T., & Galimberti, A., 2003; Wagner, L. K.,2004). A recent
random spot urine protein/creatinine ratio of 30 mg/mmol and presumes that there
is no evidence of a urinary tract infection (Brown, M., et. Al., 2001). Although
9
the methods of recording its presence or extent are poorly described or
standardized.
The dipstick estimation of spot urine samples is the most commonly used
and recorded method. However, several studies showed that the accuracy of
poor and therefore of limited usefulness to the clinician (Brown, M. A., & Buddie,
al., 2004).
al,,2013) These are widely studied however with contradicting results. Several
studies had showed random UPCR as a valid correlation with 24-hour urine
collection (Price C.P., Newall, R.G, & Boyd JC, 2005; Wikstrom, A.K, 2006) and
preeclampsia (Wongkitisophon, K. et. al, 2003; Justesen, T.I et. al, 2006).
Conversely, other studies have reported weaker correlation which showed that the
random protein/creatinine ratio did not reflect the protein/creatinine ratio from 24-
10
hour urine collection accurately, which suggested that the random protein/
creatinine ratio does not adjust adequately for variation in protein excretion from
Many studies have been carried out to study the correlation of level of
two different studies, total protein values for 8- and 12-hour urine samples correlate
positively with values for 24-hour samples for patients with proteinuria (Adelberg,
Wongkitisophon, et. al. in 2003 and Amirabi and Danaii in 2011 both
showed that there was a correlation between 4-hour and 24-hour urine proteins.
The finding indicates that a random 4-hour sample might be used for the initial
assessment of proteinuria.
Two studies suggested that two-hour urine sampling offers the same clinical
In a broader study conducted by Singhal, et. al, 2014, it was found out that
there was significant correlation (p value < 0.01) in two, four, eight and 12-hour
urine protein with 24-urine protein, with correlation coefficient of 0.97, 0.97, 0.96
11
and 0.97, respectively. When a cut off value of 25 mg, 50 mg. 100 mg, and 150
mg for urine protein were used for 2-hour, 4-hours, 8-hour and 12-hour urine
12
CHAPTER III
METHODOLOGY
A. RESEARCH DESIGN
A prospective analytical cross sectional study design was used for the
comparison of 12-hour urine albumin and 24-hour urine albumin in the diagnosis
preeclampsia who met the inclusion criteria were identified and written consents
were obtained. During the 1st 48 hours of the patient, urine sample for the 12-hour
albumin and the 24-hour albumin were collected and sent to the reference
laboratory. Results were obtained and analyzed for the comparison of the 2
B. RESEARCH SITE
13
C. OPERATIONAL DEFINITION OF VARIABLES
Independent Variable
protein in 12 hours
protein in 24 hours
Dependent Variable
Preeclampsia
In the absence of proteinuria, new onset hypertension with any of the following
14
impaired liver function with elevated transaminase
pulmonary edema
Confounders
a. Age refers to the length of time the respondent has lived (years) at
classified as follows:
consensually
education.
15
e. Financial Status refers to the self-reported monthly household
following categories:
15,000
ii. Middle income - those with monthly family income of Php 15,
001-30,000
iii. High income - those with monthly family income of Php 30,001
and above
D. SELECTION OF RESPONDENTS
Inclusion Criteria
Eligible respondents are those that are representative of the following criteria:
OMMC with elevated systolic and diastolic blood pressure of at least 140
16
- Over 20 weeks age of gestation
Exclusion Criteria
women with urinary tract infection, preexisting renal disease and chronic
hypertension
E. SAMPLING DESIGN
A letter approved by both the chief resident and the Chairman of the
Department of Obstetrics and Gynecology was sent to the Directors Office and
Chief of Clinics Center for approval before data collection. Identification of patients
Center (OMMC) with features of preeclampsia and met the inclusion criteria for the
17
study were obtained. Eligible participants were given a brief overview of the study
and a consent form was asked to be filled out for those that agree to participate in
the study. All those that declined are considered non-responders. All participants
who are enrolled are asked to fill out the sociodemographic data and patients 12
and 24-hour urine albumin samples were collected with the guidance of health
Sample size was computed using the Raosoft Sample Size Calculator.
distribution were made based from the findings from previous literature on the
preeclampsia done by Crisologo and Flores in 2009. The computed sample size is
18
G. DATA COLLECTION
hospital. Prior to urine collection, all women were carefully instructed regarding the
procedure. Ice boxes were provided for storage of the urine specimen throughout
the 24-hour urine collection. The samples were collected using a Foley catheter to
which signals the start of the collection period. The urine samples for each patient
were collected in two separate and clearly marked containers. One of the
containers was used to collect the first 12-hour urine sample (from 8 am to 8 pm)
and labelled Bottle #1, and the other one was used for the subsequent 12-hour
urine sample collected from 8 pm to 8 am the following day which was labelled
Bottle #2. After the 24-hour specimen collection, the sample in each bottle was
19
thoroughly mixed using a stirring rod to ensure sample homogeneity. The urine
volume of Bottle #1 was obtained using a graduated cylinder which was then
recorded. A 5-mL aliquot was collected and placed in a clean vial. This represents
the 12-hour sample. Bottle # 1 was then mixed to Bottle #2 with thorough mixing.
Total volume was determined and another 5-mL aliquot was obtained which
represented the 24-hour urine collection. Both samples are sent to the reference
laboratory for sample processing. Results are obtained after 2 working days.
Urine concentration of protein in the two samples were determined using dipstick
method. The total urinary protein (mg/day) was determined by multiplying the total
urine volume (dl) by the concentration of protein in the test sample (mg/dl).
The 24-hour urine protein was used as a gold standard to determine the sensitivity,
specificity, positive predictive value (PPV) and negative predictive value (NPV) of
12-hour urine sample. The receiver operating characteristic (ROC) curve was used
to determine the cut-off point for predicting proteinuria. Demographic data are
presented as descriptive graph and the variable age as meanSD. The results of
the 12-hour urine samples were compared to the 24-hour urine results by simple
Package for Social Sciences (SPSS, version 24). A p-value of < 0.05 was
20
RESULTS
A total of 20 patients were eligible and thus included in the study. The
findings indicate that the mean age of the study population is 31.9 7.22 years.
respondents. Majority of the respondents 9 (45%) have common law partners. Six
(30%) were married, 3 (15%) were single and 2 (10%) were common law.
reached college level, 5 (25%) were college graduates, 3 (15%) reached high
(60%) of patients were employed, 2 (10%) were self-employed and 6(30%) were
that they belong to the middle-class income earners. Eight (35%) came from a
high-income class household and 5 (25%) came from low-income class household.
religion. Majority of patients 16 (75%) were Catholics, 4 (20%) were Born Again
urinary protein concentrations and traditional 24-hour urine albumin values. PPV,
21
NPV, sensitivity and specificity for the gold standard 24-hour urine protein
collections were respectively all 100% The same indices for the 12-hour urine
protein collections were 100%, 92.9%%, 85.7% and 100% Accuracy for 12-hour
The area ROCof both 24 hour urine and 12 hour urine samples are shown
identified that a value of 176.240 mg/d in the 12-hour urine sample has the highest
The analyzed data revealed that 12-hour urine samples could be used to
measure proteinuria in women with preeclampsia, but 24- hour urine protein still
DISCUSSION
was 31.9 7.22 years. Most patients were Catholics (75%) and reached college
level (55%). Multiple studies suggest that the risk of preeclampsia is higher for very
young pregnant women as well as pregnant women older than 40. (Skjaeryen,
Wilcox and Lie, 2002; Catoy, Ness, Kip and Olsen, 2007). In the study, majority of
the pregnant patients were employed. Studies suggest that being employed
22
with a housewife. The working status of women increases the risk due to increased
preeclampsia and is a reliable factor in the prognosis of the disease. Currently the
24-hour urine is the gold standard for the evaluation of proteinuria. There are
multiple laboratory tests used in the detection of proteinuria. The most commonly
used is the dipstick method for random urine specimens however it has been
proven to have low sensitivity and specificity (Price, Newall and Boyd, 2005).
Currently, the gold standard is still the 24-hour urine albumin determination
however, it was found to be time consuming and inconvenient for both the patient
earlier hospital discharge rates and lower health care costs. Patient compliance
will improve since urine collection is shortened and simplified (Schubert and
Abernathy, 2006).
Many studies have been carried out to study the correlation of level of
a study using protein to creatinine ratio, it showed significant correlation with the
standard 24-hour urine albumin However, this only holds true for patients with
23
protein values of less than one gram in 24-hours. (Aggarwal, et. al, 2008).
However, there is also a study revealing that the random urine protein to creatinine
Several studies have been done for the evaluation of proteinuria in a shorter
period (2, 4, 6, 8 and 12 hours). A large-scale study revealed that there was
significant correlation (p value < 0.01) in two, four, eight and 12-hour urine protein
with 24-urine protein, with correlation coefficient of 0.97, 0.97, 0.96 and 0.97,
respectively. Furthermore, when a cut off value of 25 mg, 50 mg. 100 mg, and 150
mg for urine protein were used for 2-hour, 4-hours, 8-hour and 12-hour urine
of 68.42%, 94.74%, 84.21% and 84.21% were obtained, respectively (Singhal, et.
al, 2013). A study done by Adelberg et. al, in 2001, concluded that total protein
values for 8- and 12-hour urine samples correlate positively with values for 24-hour
concluded that a random 2-hour sample could be used for the initial assessment
24
In a study by Amirabi and Danaii in 2011, there was noted significant
4- hour urine protein value and the standard 24-hour urine protein.
similar setting, Kieler et al. in 2003 compared 12-hour urine samples with 24-hour
collection correlated well with 24-hour collection and they concluded that 24-hour
urine collection can be substituted with 12-hour collection. This study also yielded
similar results. It was found out that the positive predictive value, negative
predictive value, sensitivity and specificity of the 12-hour urine albumin were 100%,
92.9%%, 85.7% and 100% respectively. The 12-hour urine albumin was
The findings of this study indicate that the 12-hour values of urine protein
evidence to suggest the values of total urine protein of 12-hour samples might be
25
used for initial assessment of preeclampsia. The use of such samples for the
26
REFERENCES
Jul;23(4):378-80.
709-714.
Catov JM, Ness RB, Kip KE, Olsen J. Risk of early or severe pre-eclampsia
Skjaerven R, Wilcox AJ, Lie RT. The interval between pregnancies and the risk of
Epidemiol. 1998;147:106270.
Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: normal and problem pregnancies.
27
Jeyabalan, A. (2013). Epidemiology of preeclampsia: impact of obesity.Nutrition
Amirabi, A., & Danaii, S. (2011). A Comparison of 4-and 24-Hour Urine Samples
pregnancy, 2011.
Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in
six developing countries. Bull World Health Organ. 2006 Sep. 84(9):699-705.
The Philippine Health Statistics (2013). Retrieved September 16, 2016 from
http://www.doh.gov.ph/sites/default/files/publications/2013%20Philippine%20
Health%20Statistics.pdf.
Horsager, R., Roberts, S., Rogers, V., Santiago-Muoz, P., Worley, K., & Hoffman,
28
American College of Obstetricians and Gynecologists, Task Force on
urine collection for the determination of proteinuria. J Obstet Gynecol 2003; 23:
378-380.
protein measurements in 8-, 12-, and 24-hour urine samples for the diagnosis
Report of the National High Blood Pressure Education Program Working Group on
2001;20: IXXIV.
29
Rodriguez-Thompson, D., & Lieberman, E. S. (2001). Use of a random urinary
Waugh, J. J., Clark, T. J., Divakaran, T. G., Khan, K. S., & Kilby, M. D. (2004).
Sanchez-Ramos, L., Gillen, G., Zamora, J., Stenyakina, A. and Kaunitz, A.M.,
BJOG;113:930-4.
Price Cp, Newall RG, Boyd JC.(2005) Use of protein : creatinine ratio
;86:529-34.
Justesen TI, Damm P, Petersen JLA, Mathiesen ER, Ekbom P. (2006) Albumin-
to-creatinine ratio in random urine samples might replace 24-h urine collections
30
in screening for micro- and macroalbuminuria in pregnancy woman with type 1
J Obstet Gynecol;189:848852.
Singhal, S. R., Ghalaut, V., Lata, S., Madaan, H., Kadian, V., & Sachdeva, A.
(2014). Correlation of 2 hour, 4 hour, 8 hour and 12 hour urine protein with 24
Evans W, Lensmeyer JP, Kirby RS, Malnory ME, Broekhuizen FF.(2000) Two hour
urine collection for evaluating renal function correlates with 24- hour urine
Amirabi, Afsane, and Shahla Danaii. "A Comparison of 4-and 24-Hour Urine
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Rinehart BK, Terrone DA, Larmon JE, Perry KG Jr, Martin RW, Martin JN Jr. A 12
Gynecol. 2003;110:127.
protein measurements in 8-, 12-, and 24-hour urine samples for diagnosis of
Gynecol. 2003;23:37380
Evans W, Lensmeyer JP, Kirby RS, Malnory ME, Broekhuizen FF. Two hour urine
collection for evaluating renal function correlates with 24- hour urine collection
Crisologo, M.C.P and Flores, M.G.L (2009). Correlation of the 4 hour, 8 hour and
12 hour urine protein values with the 24 hour proteinuria in hospitalized patients
32
Price CP, Newall RG, Boyd JC. Use of protein:creatinine measurement on random
33
APPENDIX
10% 15%
Single
Married
Common law
30%
45% Separated
5%
College
Graduate
55%
34
Figure 3. Percent Distribution by Occupation of
Respondents
10%
30% Unemployed
Employed
Self-employed
60%
25%
35% Low income
Middle income
High income
40%
35
1
0.9
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0 0.2 0.4 0.6 0.8 1
False positive rate (1 - Specificity)
0.9
True positive rate (Sensitivity)
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0 0.2 0.4 0.6 0.8 1
False positive rate (1 - Specificity)
36
1
0.9
0.8
True positive rate (Sensitivity)
0.7
0.6
0.5
12 hour urine albumin
0.4 24 hour urine albumin
0.3
0.2
0.1
0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
False negative rate (1 - Specificity)
Figure 8. Correlation between the 12-hour urine protein and 24-hour urine
protein
37
Table 1. List of all Respondents with 12-Hour Urine Albumin and 24-hour Urine
Albumin Determination
Albumin Albumin
1 24 112.6 107.1
2 38 141.7 200.7
3 34 55.1 198.4
4 39 117.3 169.3
5 35 95.0 132.0
6 21 50.0 67.0
7 36 186.0 152.0
8 19 91.0 83.4
9 26 82.0 60.0
10 43 111.0 118.0
11 31 141.0 194.0
12 33 176.24 244.0
13 39 98.0 145.0
14 39 148.0 142.0
15 24 906.0 1346.0
16 42 26.0 80.0
17 35 365.0 210.0
38
18 25 451.0 487.9
19 26 637.0 671.0
20 29 755.0 799.5
Urine Albumin
Value (PPV)
Value (NPV)
Proteinuria
r 0.956 1.0
39
A Comparison of 12- and 24-Hour Urine Albumin Levels in the Confirmation
of Diagnosis of Preeclampsia Among Hypertensive Pregnant Patients
Consulting at a Tertiary Hospital in Manila from April May 2017
Principal investigator: Arlene P. Umali M.D.
Kung mayroon mang parte ng pag-aaral na ito na nalilito o may problema kayo,
maaari niyong kausapin ang pangunahing nagsasagawa ng pag-aaral. Wala man
kayong direktang benepisyo na makukuha sa pagsali niyo sa pag-aaral na ito,
40
makakatulong ang mga impormasyon na maibabahagi niyo upang mas malaman
kung makakatulong ang lebel ng ihi sa loob ng labindalawang (12) oras sa
pagkumpirma kung may Preeclampsia ang isang buntis. Bukod dito,
makakatulong rin kayo upang makagawa ng mga programa na mas
makakapagpaganda sa estado ng kalusugan ng mga nagbubuntis. Dahil dito,
lubos naming inaasam na kayo ay makakalahok sa pag-aaral na ito.
Deklarasyon
Nabasa at naintindihan ko ang mga nakasaad sa information sheet at ang layunin
ng pag-aaral na ito. Naiintindihan ko na:
Kung ako ay lalahok sa pag-aaral na ito, ito ay dahil personal ko itong
kagustuhan.
Ako ay pumapayag na sumailalim sa mga tests na kasama sa pag-aaral na
ito.
Maaari akong tumanggi na sagutin ang kahit anong katanungan kung ito
ang nais ko.
Naiintindihan ko na ang mga sagot ko sa questionnaire at ang resulta ng
mga ipapagawa sa aking tests ay mananatiling pribadong impormasyon.
Consent
Lagda: ___________________
Petsa: ____/____/____
41