02_risk factors influencing preeclampsia amongst women receiving treatment at ukmmc
TRANSCRIPT
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Risk Factors of Pre-eclampsia slide 1
A CASE CONTROL STUDY OF
RISK FACTORS INFLUENCING
PREECLAMPSIA AMONGST WOMENRECEIVING 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
1 Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia2Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia
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INTRODUCTION
Hypertension in pregnancy importantcause of maternal and perinatal morbidityand mortality
Can be classified into:
Gestational hypertension Preeclampsia and eclampsia
Chronic hypertension Chronic hypertension with
superimposed preeclampsia(Brown et al.2001)
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INTRODUCTION
Preeclampsia (PE):
De novohypertension after 20 weeks ofgestation with properly documented proteinuria
Chronic hypertension with superimposedpreeclampsia:
Pregnant woman with chronic hypertensionthe appearance ofde novoproteinuria after 20weeks of gestation.( magnitude of blood pressure, proteinuria, thrombocytopenia abnormal liver enzymes)
(Brown et al. 2001)
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JUSTIFICATION
Lack of published local studies regarding riskfactors for preeclampsia
Useful information in identifying women at risk ofpre-eclampsia
For screening and prophylaxis, as well as forrecruitment into relevant clinical studies.
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LITERATURE REVIEW
Certain risk factors have stronger association thanothers..
All play a role in identifying women at risk of
preeclampsia
Possessing a risk factor does not necessarily
mean a woman will develop preeclampsia, neitherdoes the absence of any risk factor guarantee safety(Churchill & Beever 1999)
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Risk Factors of Pre-eclampsia
Obstetrics history
Pre-pregnancy body
mass index
REPRODUCTIVE HISTORY
Ethnic
SOCIO-DEMOGRAPHIC FACTOR
Chronic hypertension
FAMILY HEALTH
HISTORY
CONCURRENT
MATERNAL
MEDICAL HISTORY
Type 2 diabetes mellitus
Gestational diabetes
Type 2 diabetes mellitus
Chronic hypertension
Age
MATERNAL AND
PERINATAL
MORTALITY/MORBIDITY
PREECLAMPSIA
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OBJECTIVES
1. To determine the socio-demographic characteristics
of preeclamptic cases2. To determine the relationship between of the
following risk factors and preeclampsia:
i. Ethnicii. Ageiii. High pre-pregnancy body mass index
iv. Obstetrics history (parity)v. Concurrent maternal medical illnessvi. Family health history of chronic hypertension and
type 2 diabetes mellitus (either alone or combined)
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METHODOLOGY
BACKGROUNDUKMMC
Case-Mix system
Medical record department
STUDY DESIGNA hospital based unmatched case control study
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METHODOLOGY
SAMPLING METHOD
Cases (2002-2007)
Code: Hypertensivedisorder in pregnancyDefinition fulfilledReached the sample
size required (355)
Control
Code: normotensivepregnant women
Match by year to caseRandomly selected
from the database
Medical records: complete
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RESULT
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RESULT (DESCRIPTIVE)
Ethnic: Malay (case 75.2%; control 68.7%)
Age
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Table 1:ORs and 95% CI according to riskfactors for preeclampsia
Risk factors Unadjusted *Adjusted
OR (95% CI) OR (95% CI)
Ethnic
Non-Malay 1.0 (referent)
Malay 0.79(0.99-1.92)
Age (years)
< 35 1.0 (referent) 1.0 (referent)
35 2.70 (175-4.17) 2.10(1.19-3.70)
Pre-pregnancy BMI Normal 1.0 (referent) 1.0 (referent)
Underweight 0.56(0.35-0.88) 0.60(0.37-0.97)
Overweight 7.87(4.41-14.07) 4.01(2.48-6.49)
Obese 14.54(6.40-33.04) 6.40(2.92-14.00)
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Table 1:ORs and 95% CI according to riskfactors for preeclampsia
Risk factors Unadjusted *Adjusted
OR (95% CI) OR (95% CI)
Obstetrics history
Others 1.0 (referent) 1.0 (referent) Primigravida 1.24(0.84-1.840) 2.25(1.43-3.56)
Parity 2 2.24(1.48-3.39) 1.85(1.12-3.06)
Nulliparity 2.47(1.39-4.39) 3.15(1.63-6.08)
Concurrent medical history
No 1.0 (referent) 1.0 (referent)
Yes 7.22(3.21-16.24) 4.83(1.74-13.42)
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* Backward Stepwise (Likelihood Ratio) Multiple Logistic Regression appliedModel adequacy was checked by using Hosmer and Lemeshow test (p = 0.352), overall correctly classifiedpercentage (69.5%) and area under the curve (0.77)No multicollinearity problem and interaction reportedNagelkerke 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)+ 0.78(family history of chronic hypertension).
Risk factors Unadjusted *Adjusted
OR (95% CI) OR (95% CI)
Family history of chronic hypertension
No 1.0 (referent) 1.0 (referent) Yes 3.12(2.30-4.25) 2.18(1.55-3.09)
Family history of Type 2 diabetes mellitus
No 1.0 (referent)
Yes 1.96(1.39-2.75)
Family history of chronic hypertension andtype 2 diabetes mellitus
No 1.0 (referent)
Yes 3.18(2.34-4.33)
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DISCUSSION
ETHNIC:
Hashimah et al. (2007) Loi et al. (2007)
place HKL & UKMMC Singapore
design case control cross-sectional
n=75 cases
HKL (72) UKMMC (3) 93 cases
comparison Non-Malay to Malay Malay to Chinese
aOR 2.4 (0.7 - 8.2) p = 0.001
Malay to Indian
p = 0.170Malay to Others
p = 0.086
Malay=majority late booker
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DISCUSSION
AGE: Loi et al. (2007) Ustun et al. (2005)place Singapore Turkey
design cross-sectional retrospective cohort
35 years p = 0.01 p = 0.001
Doherty et al. (2006) Bhattacharya et al. (2007)
reference normal BMI normal BMI
result overweight (aOR 1.45 [0.72-2.90]) overweight (aOR 1.6 [1.2-1.8])
obese (aOR 3.74 [1.95-7.17]) obese (aOR 3.1 [2.8-3.5])
morbidly obese (aOR 7.2 [4.7-11.2])
PRE-PREGNANCY BMI: Increasing risk throughoutthe BMI distribution
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DISCUSSION
OBSTETRICS HISTORY: nulliparityEskenazi et al.
(1991)
Anorlu et al.
(2005) Conde-Agudelo et al. (2000)
design case control case control cross-sectional
n= 193 cases 128 casesreference multiparous > 1 1
parity nulliparous nulliparous nulliparous
aOR 5.4 (2.8-10.3)
aOR 4.77
(2.90-7.78) aRR 2.38 (2.28-2.49)
CONCURRENT MATERNAL MEDICAL HISTORY:Eskenazi et al. (1991); Stone et al. (1994); Anorlu et al. (2005) &
Gaugler-Senden et al. (2005)
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DISCUSSIONFAMILY HEALTH HISTORY
DISCUSSION
Chronic hypertension Type 2 diabetes mellitus Combinedagreement X agreement X agreement X
Ness et al.(2003) Eskenazi et al. Ness et al. Sanchez et al. Sanchez et al. Qiu et al. (2003)
cohort (1991) (2003) (2003) (2003) aOR 1.9
n=85/2211 (3.8%) aOR 1.7 (0.92-3.2) 1: aRR 1.3 aOR 3.4 (1.4-8.4) aOR 1.6 (1.3-2.9)
1: aRR 1.5 (0.7-2.3) -more aware of (0.9-2.7)
(0.1-2.5) Stone et al. (1994) parental history
2: aRR 1.1 of diabetes
2: aRR 2.2 case control (0.5-5.0) mellitus
(1.1-4.5) n = 70 cases
21% vs 19% Qiu et al. (2003)
Qiu et al. (2003) aOR 1.8 (1.1-3.1)
case control Sanchez et al.
n = 190 (2003)
aOR 2.0 (1.2-5.5) case control
n = 169 cases
aOR 1.2 (0.7-2.2)
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CONCLUSION
o Difficult to conduct epidemiologicalstudies for preeclampsia in the absence of adatabase
o UKMMC pioneered the case-mix systemin Malaysia
o The accessibility of which facilitatedidentification of specific disease cases,including pre-eclampsia
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THANK YOU