Med. J. Cairo Univ., Vol. 83, No. 2, December: 159-163, 2015
www.medicaljournalofcairouniversity.net
Waist to Hip Circumference Ratio as a Predictor of Preeclampsia
SHAIMAA A. ZEDAN, M.Sc.; ASHRAF N. ALMANTAWY, M.D.; MOHAMMED A. MOHAMMED, M.D. and
MAHMOUD A. ABDULFATTAH, M.D.
The Department of Gynecology and Obstetrics, Faculty of Medicine, Banha University
Abstract
Hypertension, which is often associated with obesity, has been found to be more prevalent in women
with centrally distributed fat [1-6] . Therefore it is
plausible to predict that the development of preeclampsia is also associated with abnormal body fat
distribution. However, only limited data are available with regard to the relationship between abnormal body fat distribution and the development of
preeclampsia.
Objective: To assess whether waist to hip circumference
ratio at the first antenatal visit predicts risk of developing
preeclampsia later in pregnancy.
Methods: Prospective study on Pregnant women with
singleton pregnancies (n = 500, median age 29 years, interquartile range 21-37 years, all primigravidas) were recruited
at their first antenatal visits. Using standardized methods,
weights, heights determined (for calculation of body mass
index [BMI]), and waist circumferences of all women.
In the present study, we investigated whether
upper type of body fat distribution is associated
with the development of preeclampsia or not.
Results: 26 women developed preeclampsia (hypertension
with proteinuria). WHR, BMI, and BW early in pregnancy
were significantly higher in the preeclampsia group ( p<0.001).
WHR, BMI, and BW positively correlated with the development of preeclampsia on univariate regression analysis and
stepwise multiple regression analysis. When the WHR predictive of the development of preeclampsia was set at 0.85, the
sensitivity was 76.9% (20/26), which was significantly better
than that of 25 of BMI (57.7%, 15/26; p<0.05).
Material and Methods
This study was conducted on 500 Primigravidae
attending the obstetric clinic between March 2014
and March 2015 in Benha University Hospital,
Qaliobiya governorate and Kuwait ministry of
health obstetric clinics for antenatal care who were
less than 9 weeks pregnant (as shown by a sure
date of the last menstrual period), with no history
of medical disorders such as; cardio-vascular or
urinary disease or diabetes mellitus, singleton
pregnancy, blood pressure less than 140/90, urine
negative for proteins and willing to continue their
antenatal care in the clinic at scheduled visits, for
the study. All the women's blood pressures, Waist
to hip circumference ratio (WHR), body weight
(BW), and body mass index (BMI) were measured
by the same examiner early in pregnancy. Age,
height, parity, tobacco usage, education period,
gestational duration, onset of preeclampsia (in
preeclampsia group), and weight gain during pregnancy were recorded. Fully informed consent was
obtained from each subject. Waist and hip circumferences were measured by using standard nonstretch tape with the subjects wearing light clothes;
waist circumference (WC) was measured at the
midpoint, above the iliac crest and below the lowest
Conclusion: Higher WHR is a significant predictor of the
development of preeclampsia.
This relation is irrespective of overall adiposity.
Key Words: Body mass index (BMI) – Preeclampsia – Risk
factor – Waist to hip circumference ratio (WHR).
Introduction
THERE are many risk factors for the development
of preeclampsia. These include maternal obesity
and excessive weight gain during pregnancy.
However, preeclampsia often occurs despite
the absence of these risk factors. Recent evidence
indicates that body fat distribution rather than
overall adiposity might significantly influence the
risk for endocrine and metabolic diseases including
hypertension, diabetes mellitus, and athelosclerosis.
Correspondence to: Dr. Shaimaa A. Zedan, The Department
of Gynecology and Obstetrics, Faculty of Medicine,
Banha University
159
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Waist to Hip Circumference Ratio as a Predictor of Preeclampsia
rib margin, in the standing position with minimal
expiration. Hip circumference (HC) was measured
at the widest point over the buttocks [7] . The waist
to hip circumference ratio (WHR) was culculated
all data needed for the study, accurate assessment
of gestational age and recording of maternal weight
and height (before pregnancy weight gain and
earlier than in other studies, which mostly measured
these indices after the first trimester) to allow
comparison with the findings of previous studies.
Results
We studied 582 primigravidae women, less than
9 weeks pregnant for early prediction of preeclampsia using measurement of the waist, hip and
waist/hip ratio. 26 cases developed obtained by
dividing the values of the waist and hip circumferences, and their classification was based on a cutoff
point of 0.85 [8] . The strengths of this study is the
large number of subjects from a multiracial population, prospective collection of data which allowed
us to freely escaped the follow-up, 46 cases aborted,
2 cases died due to causes not related to pregnancy,
426 remained normotensive. In 18 normotensives,
the blood pressure was 140/90 in the second trimester, returned to normal during the following
antenatal visits. Preeclampsia was defined as "the
development of a blood pressure 140/90 mmHg,
after the 20 th gestation week, associated with > +1
proteinuria by dipstick test". It was evident in this
study that increase WHR early in pregnancy was
significantly higher in the preeclampsia group
compared to normotensive group.
Table (1): Baseline characteristics of the two groups.
No pre-eclampsia
(n=474)
Pre-eclampsia
(n=26)
t
p-value
4.61
3.04
<0.05
81.92
15.87
6.07
<0.05
6.55
159.27
7.31
0.9
>0.05
23.48
3.69
32.17
5.58
7.9
<0.001
Waist (cm)
82.96
9.54
104.04
10.84
10.9
<0.001
Hip (cm)
102.78
9.84
117.08
12.03
7.1
<0.001
WHR
0.80
0.06
0.88
0.04
6.9
<0.001
Baseline systole
110.78
11.27
114.12
9.67
1.5
>0.05
Baseline Diastole
69.97
7.77
72.81
7.41
1.8
>0.05
Mean
S.D
Mean
S.D
Age (yrs)
26.14
3.87
28.54
Weight in the 1 st visit (kg)
60.71
10.31
Height (cm)
160.46
BMI
Data are presented as mean, standard deviation (S.D). BMI: Body mass index. WHR: Waist to hip circumference ratio.
Table (2): Outcome of univariate regression analysis in both groups.
Pre-eclampsia
Pre-eclampsia
(n=26)
Regression
coefficient
p-value
No
Yes
Age
26.14±3.87
28.54±4.61
0.15
<0.001
BW
60.71 ± 10.31
81.92± 15.87
0.12
<0.001
Height
160.46±6.55
159.27±7.31
–0.02
>0.05
BMI
23.48±3.69
32.17±5.58
0.34
<0.001
Waist circumference
82.96±9.54
104.04± 10.84
0.19
<0.001
Hip circumference
102.78 ±9.84
117.08± 12.03
0.09
<0.001
WHR
0.80±0.06
0.88±0.04
30.9
<0.001
Weight gain during pregnancy
10.92± 1.31
10.54± 1.53
–0.22
>0.05
BW: Body weight. WHR: Waist to hip circumference ratio. BMI: Body mass index.
161
Shaimaa A. Zedan, et al.
Table (3): Outcome of stepwise multiple regression analvsis.
95% Confidence
Interval
Regression
Coefficients
Age (yrs)
Weight (kg)
Height (cm)
BMI
Waist (cm)
Hip (cm)
W/H Ratio
0.09
–0.01
–0.08
0.32
0.19
–0.002
0.14
Lower
Bound
Upper
Bound
0.001
–0.007
–0.007
0.000
0.000
–0.003
0.033
0.009
0.006
0.002
0.033
0.008
0.003
1.003
p
value
<0.05
>0.05
>0.05
<0.05
<0.05
>0.05
<0.05
BMI: Body mass index.
WHR: Waist to hip circumference ratio Weight gain during pregnancy
and gestational duration were excluded from the analysis.
Table (4): Relationship between WHR and preeclampsia risk.
WHR ≥ 0.85 WHR < 0.85
Development of preeclampsia
Absence of preeclampsia
20
124
6
302
Data are presented as n, WHR: Waist to hip circumference ratio.
Sensitivity = 76.9% (20/26).
Specificity = 70.8% (302/426).
Positive predictor value = 13.8% (20/144).
Negative predictive value = 98% (302/308).
Table (5): Relationship between BMI and preeclampsia risk.
BMI ≥ 25
BMI < 25
15
126
11
300
Development of preeclampsia
Absence of preeclampsia
Data are presented as n, BMI: Body mass index.
Sensitivity = 57.7% (23/26).
Specificity = 70.4% (300/426).
Positive predictive value = 10.6% (23/149).
Negative predictive value = 96.4% (300/303).
Table (6): Comparison of baseline characteristics and anthropometric variables between mild and severe preeclampsia.
n
Mild
Severe
preeclampsia preeclampsia
p
value
22
4
Age (y)
27.41 ± 3.78
29.45±4.16
>0.1
Height (cm)
161.64 ± 5.66
160.72 ± 6.13
>0.1
Body weight at first
antenatal visit
61.16±9.21
82.23 ± 12.72
>0.1
Body mass index
24.84 ± 3.96
33.72 ± 5.82
>0.1
Weight gain during
pregnancy (kg)
10.73 ± 1.73
8.45± 1.34
>0.1
Onset of preeclampsia
(weeks)
27.16±3.33
24.50±2.57
<0.1
WHR
0.82 ± 0.09
0.89±0.04
<0.1
Data are presented as mean ± standard deviation.
WHR: Waist to hip circumference ratio.
Discussion
Preeclampsia (PE) is a very serious and dangerous pregnancy complication that affects approximately 6-8% of all pregnancies. It is prevalent in
primigravidae, where it increases the risk of morbidity and mortality of the mother and the fetus.
It has long been recognized that maternal obesity
before pregnancy is associated with increased risks
of pregnancy complications. An increased incidence
of preeclampsia in the obese gravid women has
been reported [9,10] . Excessive maternal weight
gain during pregnancy has also been suggested to
tend to induce preeclampsia [11] .
In the present study, the association of maternal
obesity before pregnancy with the development of
preeclampsia was also confirmed. Weight gain was
less in preeclampsia group compared to non preeclampsia group, which may be explained by the
shorter gestational duration in the preeclampsia
group. The duration of pregnancy in weeks was
very highly significantly shorter in the preeclampsia
group, maternal age also was found to be significantly higher in the preeclampsia group.
Our results are in general agreement with those
of previous studies that examined the anthropometric measures and its relation to preeclampsia, as
Yamamoto, et al. [12] ; Sattar, et al. [13] and Taebi
et al. [14] who found that WHR is a good predictor
for development of preeclampsia.
The probable effects of maternal age on preeclampsia have been previously studied. Some studies
have shown that with the increasing ages of pregnant women, adverse obstetric complications and
preeclampsia have also been increasing [15,16] and
our study agreed with that, while others as Wang
et al. [17] , Taebi et al. [14] did not find a relationship
between women's ages and preeclampsia.
However, we consider that pregnancy exists in
an important position such a loading test to detect
occulted hypertension. Thus, it is likely that hypertension is prone to manifest in some women with
upper type of body fat distribution with advancing
pregnancy.
Based on these results, we conclude that women
with upper type of body fat distribution have a
potential risk for preeclampsia. This risk is irrespective of overall obesity. The ability to predict
increased risk of preeclampsia is most important
for selecting patients for preventive treatment.
Thus, we recommend measuring WHR in all
pregnant women early in pregnancy. We believe
that WHR might be useful in predicting the devel-
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Waist to Hip Circumference Ratio as a Predictor of Preeclampsia
opment of preeclampsia as well as the conventional
obesity indices including BMI.
References
1- KISSEBAH A.H., VYDELINGUM N., MURRAY R.,
EVANS D.J., HARTZ A.J., KALKHOFF R.K. and ADAMS P.W.: Relationof body-fat distribution to metabolic
complicationof obesity. J. Clin. Eizdocrinol. Metab., 54:
254-260, 1982.
2- KISSEBACH A.H. and PEIRIS A.N.: Biology of regionalbody-fat distribution: Relationship to non-insulin dependent diabetes mellitus. Diabetes Metab. Rev., 5: 83109, 1989.
3- LARSSON B., SVARSUDD K., WELIN S., WILHELMSEN L., BJORNTORP P. and TIBBLIN G.: Abdominal
adipose tissue distribution, obesity and risk of cardiovascular disease and death: 13 years follow-up of participants
in the study of men born in 1913. Br. Med. J., 288: 14011404, 1984.
4- BJORNTOP P.: Regional pattern of fat distribution. AJZTlIi lt Med., 103: 994-995, 1985.
5- DESPERS J.P., ALLARD B., TREMBLAY A. and BOUCHARD C.: Evidence for a regional component of fatness
in the association with serum lipids in men and women.
Metabolism, 34: 967-973, 1985.
6- DONAHUE R.P., ABOTT R.D., BLOOM E., REED D.M.
and YANO K.: Central obesity and coronary heart disease.
Lancet, 1: 821-824, 1987.
7- WANG F., WU S. and SONG Y.: Waist circumference,
body mass index and waist to hip ratio for prediction of
the metabolic syndrome in Chinese. Nutr. Metab. Cardiovasc. Dis., 19: 542-547, 2009.
8- FELDSTEIN C.A., AKOPIAN M. and OLIVIERI A.O.:
A comparison of body mass index and waist-to-hip ratio
as indicators of hypertension risk in an urban Argentine
population: A hospital-based study. Nutr. Metab. Cardiovasc. Dis., 15: 310-315, 2005.
9- TRACY T.A. and MILLER G.L.: Obstetric problem of
the massive obese. Obstet. Gyiiecol., 33: 204-208, 1969.
10- KLIEGMAN R.M. and GROSS T.: Perinatal problems of
the obese mother and her infant. Obstet. Gynecol., 66:
299-303, l985.
11- NAEYE R.L.: Weight gain and outcome of pregnancy.
Am. J. Obstet. Gyiiecol., 135: 3-9, 1979.
12- YAMAMOTO S., DOUCHI T., YOSHIMITSU N., et al.:
Waist to hip circumference ratio as a significant prediction
of preeclampsia, irrespective of overall adiposity. Obstet.
Gynaecol., 27: 27-31, 2001.
13- SATTAR N., CLARK P. and HOLMES A.: Antenatal
waist circumference and hypertension risk. Obstet. Gynecol., 97: 268-271, 2001.
14- MAHBOUBEH TAEBI, ZOHREH SADAT, FARZANEH
SABERI, et al.: Early pregnancy waist-to-hip ratio and
risk of preeclampsia: A prospective cohort study. Hypertension Research 38, 80-83 (January 2015) doi:10.1038
/hr.2014.133.
15- KHALIL A., SYNGELAKI A., MAIZ N., et al.: Maternal
age and adverse pregnancy outcome: A cohort study.
Ultrasound Obstet. Gynecol., 42: 634-643, 2013.
16- LAMMINPAA R., VEHVILAINEN-JULKUNEN K.,
GISSLER M., et al.: Preeclampsia complicated by advanced maternal age: A registry-based study on primiparous women in Finland 1997-2008. BMC Pregnancy
Childbirth, 12: 47, 2012.
17- WANG Y., TANBO T., ABYHOLM T., et al.: The impact
of advanced maternal age and parity on obstetric and
perinatal outcomes in singleton gestations. Arch. Gynecol.
Obstet., 284: 31-37, 2011.
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