Home Print this page Email this page Small font size Default font size Increase font size
Users Online: 3389
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents 
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 1621-1627  

Prevalence of hypertension in pregnancy and its associated factors among women attending antenatal clinics in Bengaluru


1 ICMR-National Centre for Disease Informatics and Research, Bangalore, India
2 Indian Institute of Public Health Hyderabad, Bangalore Campus, Public Health of Foundation of India, Bangalore, India
3 Department of Community Medicine, J.N. Medical College, Belgavi, Karnataka, India

Date of Submission25-Jul-2020
Date of Decision17-Sep-2020
Date of Acceptance05-Jan-2021
Date of Web Publication29-Apr-2021

Correspondence Address:
Anita Nath
ICMR-National Centre for Disease Informatics and Research, Bangalore - 562 110, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_1520_20

Rights and Permissions
  Abstract 

Background: Hypertension in pregnancy is a major challenge in antenatal practice due to its impact on obstetric and foetal outcomes. Objective: To assess the prevalence of hypertension during pregnancy and its associated risk factors among pregnant women availing of antenatal care at public sector hospitals in Bengaluru, Southern India. Methods: The sample frame included pregnant women who were attending the antenatal clinic at three public sector hospitals. The data were analyzed for 783 pregnant women who had completed their baseline visit over a period of 18 months (September 2017 to March 2019). The blood pressure was categorized based on the American College of Cardiology/American Heart Association 2017 guidelines. Results: Out of the 783 respondents who were examined, 13.9% were found to be hypertensive. The adjusted Odd's ratio was significantly higher for those who were employed outside the house and obese respondents. Other factors such as higher maternal age, lower socioeconomic status, pregnancy-related anxiety, prenatal depression, nulliparity appeared to increase the risk. Conclusion: Hypertension during pregnancy continues to be a matter of concern. Risk factor profiling of pregnant women is of utmost importance to identify those who may be likely to develop hypertensive disorders during pregnancy.

Keywords: Hypertension, pregnancy, prevalence, risk factors


How to cite this article:
Nath A, Sheeba B, Raj S, Metgud CS. Prevalence of hypertension in pregnancy and its associated factors among women attending antenatal clinics in Bengaluru. J Family Med Prim Care 2021;10:1621-7

How to cite this URL:
Nath A, Sheeba B, Raj S, Metgud CS. Prevalence of hypertension in pregnancy and its associated factors among women attending antenatal clinics in Bengaluru. J Family Med Prim Care [serial online] 2021 [cited 2021 May 18];10:1621-7. Available from: https://www.jfmpc.com/text.asp?2021/10/4/1621/314894




  Introduction Top


Hypertension in pregnancy is a major challenge in antenatal practice due to its impact on obstetric and fetal outcomes. Hypertension plays a significant role in up to 15% of complications over the course of pregnancy and the postpartum period.[1] Hypertensive disorders of pregnancy encompass preexisting (or chronic) hypertension, gestational hypertension, preeclampsia, and eclampsia; accounting for an estimated prevalence of 5% to 10% in women belonging to the reproductive age group.[2],[3] These are a significant contributor to maternal and perinatal morbidity and mortality and account for 30,000 maternal deaths annually at the global level and 10% to 15% of maternal deaths in low- and middle-income countries.[4],[5] A multicenter study performed in four developing countries (India, Nigeria, Pakistan, and Mozambique) found that one out of every ten pregnant women had hypertension.[6]

Studies have found pregnancy-induced hypertension to be a significant independent risk factor for developing gestational diabetes mellitus.[7] The risk of developing cardiovascular diseases (CVD) in later life is reportedly higher among women with a history of raised blood pressure during pregnancy.[8],[9],[10] This has been attributed to the presence of common CVD risk factors such as type 2 diabetes, chronic hypertension, and raised blood lipids associated with rapid urbanization and changing lifestyles.[11],[12] The incidence of hypertension during pregnancy is on the rise and is associated with an increased risk of fetal growth retardation and adverse birth outcome.[13] Studies from India report that hypertension during pregnancy may contribute to up to one-third of maternal deaths.[14],[15] While blood pressure measurement is routinely monitored as a part of antenatal care, it is important to get a better understanding of the burden of hypertension during pregnancy and its associated risk factors. Primary care physicians are usually the first point of contact and it is essential for them to be sensitized concerning hypertension during pregnancy. Identification of modifiable risk factors would be vital for primary prevention of this condition and in avoiding adverse maternal and fetal outcomes.

Given this background, the present study aims to assess the prevalence of hypertension during pregnancy and its associated risk factors among pregnant women availing antenatal care at public sector hospitals in Bengaluru, Southern India.


  Methods Top


Study setting and participants

The present study is part of a cohort study to assess the effect of prenatal exposure to maternal cortisol and psychological distress on infant development in Bengaluru.[16] The sample frame included pregnant women who were attending the antenatal clinic at three public sector hospitals: Jayanagar General Hospital, Kempu Cheluvarajamanni (KC) General Hospital, and H Siddaiah Referral Hospital. While Jayanagar General Hospital and K.C General Hospital are state government sub-district hospitals, H Siddaiah Referral Hospital is managed by the city's municipal corporation. The eligibility criteria for being selected for this study included pregnant women (i) who were between 18 to 40 years of age, (ii) having a gestational age of fewer than or equal to 24 weeks, and (iii) without any reported obstetric complication. Pregnant women who met the inclusion criteria and volunteered to participate in the study were recruited into the study. The data were analyzed for 783 pregnant women who had completed their baseline visit over a period of 18 months (September 2017 to March 2019).

Data collection and measurements

The participants were explained about the nature of the study, and a participant information sheet was given to them for further reference after which a written informed consent was obtained. The study questionnaire was digitally recorded through an App (CASCADE version 2.1.3) installed on an Android tablet. The questionnaire captured detailed information on socio-demographic data, social support, domestic violence, marital discord, medical history, obstetric history, and measures of depression and anxiety. Edinburg Postnatal Depression Scale was used to screen for depression in pregnant women. It is a 10-item self-report scale widely used for screening of prenatal depression.[17] Screening for anxiety during pregnancy was performed using the 10-item Pregnancy-Related Anxiety (PRA) Scale.[18] Social support was captured using the Multidimensional Scale of Perceived Social Support (MSPSS). It has 12 items to assess the subjective perceptions of support from family, friends, and “significant others” with scores ranging from 1 to 7.[19] The revised Kuppuswamy Scale was used to measure socioeconomic status.[20] Domestic violence and marital discord were identified using the Modified Conflict Tactics Scale and the Revised Dyadic Adjustment Scale, respectively.[21] The anthropometric measurements were recorded at the final stage of the interview using a standardized calibrated weighing scale for weight and a stadiometer for height for subsequent estimation of body mass index (BMI), expressed as weight in kilograms divided by height in meter square (kg/m[2]).

Blood pressure was recorded using the Omron HEM 7130 ®blood pressure monitor during each antenatal visit. The participant was asked to sit quietly and rest for 15 min with their legs uncrossed. The measurements were taken with the participant sitting upright with proper back support, and with the arm supported on a table or a surface at the level of the heart. Three readings were taken at an interval of 5 min, and the average of the three readings was taken as the final blood pressure reading. The blood pressure was categorized based on the American College of Cardiology/American Heart Association 2017 guidelines.[22] Blood Pressure in adults was categorized into four: 1) Normal (systolic blood pressure <120 mm Hg and diastolic <80 mm Hg); 2) Elevated (120–129 mm Hg systolic and <80 mm Hg diastolic); 3) Hypertension stage 1 (129–139 mm Hg systolic and 80–89 mm Hg diastolic); and 4) Hypertension stage 2 (≥140 mm Hg systolic and ≥90 mm Hg diastolic). The guidelines have recently been adopted by the American College of Obstetricians and Gynecologists (ACOG) for the treatment of chronic hypertension in pregnant women.[23]

Statistical analysis

The data wereretrieved from the App in Microsoft excel sheet format, cleaned, and exported to SPSS version 22. The exposure variables were categorized according to the data type and included. (i) Socio-demographic data: age, religion, educational status, socioeconomic status, occupation. (ii) Psychosocial variables: social support, marital discord, domestic violence, depression, anxiety, and unplanned pregnancy. (iii) Obstetric and medical variables: parity, history of hypertension, body mass index. Tobacco use was reported by only five women; hence, it was not included for analysis.

Descriptive statistics were used to present the socio-demographic characteristics of the study population. Bivariate analysis was performed to explore the association between independent and dependent variables and was expressed in terms of crude odds ratio with 95% confidence interval. The variables were dichotomized, and those which were found to be associated at a significance level (P < 0.2) in the bivariate analysis were entered into a multivariate logistic regression model to calculate the adjusted odd's ratio and to eliminate the effects of confounding. Variables with a P value of < 0.05 in the multivariate analysis were considered to be significant in the study.

Ethical considerations

Ethical clearance was obtained from the Ethics Committee of the Indian Institute of Public Health Bangalore campus (IIPHHB/TRCIEC/118/2017) dated 15/3/2019. Participants were briefed about the study purpose, objectives, risk, and voluntary decision to decide their participation, and a written informed consent was obtained. Privacy and confidentiality of the individuals were strictly ensured throughout the study. Personal identification was masked using participant ID.


  Results Top


Socio-demographic characteristics of the study participants

The mean age of the study population was 23.6 ± 4.47 years, and the mean gestational age was 16.7 ± 4.4 weeks. The socio-demographic characteristics are shown in [Table 1]. The majority (88.8%) of the study participants were of or less than 28 years of age and more than half of them were of Islamic faith and were parous. About 90 percent of the respondents were homemakers and over one-third of them had received education up to high school. Almost 43.9 percent of them belonged to the upper lower class and more than 50 percent were receiving high social support from family, friends, and significant others.
Table 1: Socio-demographic characteristics of the study participants (n=783)

Click here to view


Prevalence of hypertension

Out of the 783 respondents who were examined, 13.9% were found to be hypertensive [Figure 1].
Figure 1: Prevalence of hypertension among the pregnant women (n = 783)

Click here to view


Association of socio-demographic variables with hypertension

Among the socio-demographic variables, the risk of hypertension in pregnancy was observed to be 1.7 times higher among women above the age of 28 years. This finding was significant on bivariate analysis but not after adjustment of confounders. The women who were employed outside the home were twice as likely to suffer from hypertension when compared to the homemakers; this being significantly higher on multivariate analysis (COR = 2.000; 95% CI: 1.01–2.28, AOR = 1.481; 95% CI: 0.97–2.24) [Table 2].
Table 2: Bivariate and multivariate analysis of risk factor variables

Click here to view


Association of psychosocial variables with hypertension

The odds of hypertension was 1.3 times higher among women with moderate to low social support although this was significant only on bivariate analysis. Pregnancy-related anxiety was found to be a positive predictor of hypertension (COR = 1.519; 95% CI: 1.01–2.28, AOR = 1.481; 95% CI: 0.97–2.24). Women who were depressed were 1.2 times more likely to be hypertensive, but this likelihood was not significant [Table 2].

Association of physiologic parameters with hypertension

While no significant association could be demonstrated between a history of hypertension, gravidity, and hypertension in the present pregnancy, it was observed that obese pregnant women were twice as likely to be hypertensive than nonobese women, with an AOR of 2.036 (95% CI 1.328–3.122) [Table 2].


  Discussion Top


The present study examined the prevalence of hypertension in pregnancy and its associated factors using the American College of Cardiology/American Heart Association 2017 guidelines. The prevalence of hypertension in the present study was observed to be 13.9 percent. This happens to be exactly equal to the observed rate of 13.9% demonstrated by Ganguly and Begum in a hospital-based study in Dhaka, Bangladesh.[24] There appears to be a striking geographic variation in the prevalence of hypertension across different states of India. The prevalence found in our study is slightly lesser than the reported prevalence rate of 15.5% from a hospital-based study conducted in Kolkata[25] but much higher than that elicited from other similar settings: 7.49% in Indore,[26] 5.38% in Varanasi,[27] and 10.4% in Salem.[28] This could be attributed to the use of JNC VII report for classification of hypertension in other studies, which used higher cut off values of BP ≥140/90 mm Hg. Lower values of prevalence have also been recorded in community-based studies such as reported rates of 6.9% and 5.8% in rural settings of Haryana and Punjab,[29],[30] respectively. The use of an expanded definition for hypertension as used in the present study may help to identify more women who would benefit from timely management.

The odds of hypertension were higher among women more than28 years of age although this was not statistically significant. Hypertension in pregnancy is known to be associated with advancing maternal age. This could be attributed to high levels of oxidative stress and low levels of nitric oxide that are associated with aging, which exerts an adverse influence on the relaxation of the endothelium.[31] Illiteracy has been reported to be an important risk factor for hypertension in pregnancy due to its relationship with early marriage and care-seeking behavior; however, no such observation was seen in the present study. We found that women who were employed outside the house were at a higher risk for hypertension. Other studies have also reported a similar association,[32],[33],[34] whereas some studies report that the risk is higher among homemakers.[35] Further research would be required to explain these differences as it may be determined by the nature and duration of work, whether done at home or outside.

Among the psychosocial variables, we could not establish any increase in risk with lower social support, unplanned pregnancy, and domestic violence. However, pregnancy-related anxiety appeared to be a positive predictor of hypertension. A plausible explanation is that stress during pregnancy is frequently associated with dysregulation of the hypothalamo pituitary adrenal (HPA) axis, resulting in a high endogenous cortisol level, which causes endothelial dysfunction.[36],[37] Similarly, pregnant women who were depressed appeared to be at a higher risk of hypertension although this was statistically not significant. Thombre et al. in their study confirmed that pregnancy-related anxiety increased the risk of hypertension during pregnancy by 1.2 times even after adjusting for confounding variables.[38]

Although primi parity is implicated to be a risk factor for gestational hypertension,[39],[40],[41] we could not identify any such association on multivariate analysis. The association between primi parity and hypertension has been ascribed to an array of physiologic and immunologic pathways.[42] The risk of hypertension appeared to be more than twice as higher among obese pregnant women than nonobese and was significantly associated even after adjusting for confounders. This is synonymous with results from other studies from different countries.[43],[44],[45] The pathophysiologic mechanism, which accounts for the relationship between obesity and hypertension is the state of hyperinsulinemia induced by high body mass index, which causes endothelial dysfunction.[46] The risk of pre-eclampsia is also stated to be increased due to high levels of triglyceride and free fatty acids that are associated with obesity.[47]

The present study has helped to identify a few modifiable risk factors of hypertension during pregnancy, such as obesity, which conforms to those observed in other similar study settings. The adjusted odds ratio was significantly higher for those who were employed outside the house and obese respondents. Other factors such as higher maternal age, lower socioeconomic status, pregnancy-related anxiety, prenatal depression, nulliparity appeared to increase the risk. Risk factor profiling of pregnant women is of utmost importance to identify those who may be likely to develop hypertensive disorders during pregnancy. Many of these factors could be addressed during early pregnancy, which would go a long way in preventing morbid obstetric and fetal outcomes and also reduce the future risk of cardiovascular complications among women.

Study limitations

The settings for this study comprised urban public sector hospitals wherein antenatal care is mostly availed by pregnant women belonging to the lower- and middle-income groups. Therefore, the findings from this study cannot be extrapolated to pregnant women belonging to a higher socio-economic group due to differences in psychosocial factors and standard of living. As this study was conducted as a part of an ongoing cohort study, it was not possible to capture data and identify factors such as a family history of hypertension, hypertension in previous pregnancies, prepregnancy weight for measuring weight gain, diet, physical activity, and history of diabetes; as observed in other studies. By excluding respondents who had obstetric complications, we have focused on the nonobstetric risk factors of hypertension during pregnancy.

The results were generated out of an analysis of data recorded in the baseline visit done around 24 weeks of the cohort study; hence, the reported hypertension could not be segregated into categories of chronic hypertension, gestational hypertension, and preeclampsia/eclampsia.


  Conclusion Top


The present study reports that hypertension during pregnancy is emerging as a major concern from a clinical and public health viewpoint, given that it could have serious short- and long-term consequences for maternal and offspring health. A substantial proportion of more than one-tenth of the pregnant women were found to be hypertensive in the present study. Primary care physicians have a critical role to play in the early identification and management of hypertension during early antenatal care.

Acknowledgements

The authors would like to extend thanks to the staff of the study hospitals and the women for participating and supporting them during data collection.

Financial support and sponsorship

This project is funded by Welcome Trust DBT India Alliance (Clinical and Public Health Research Fellowship); grant number IA/CPHI/16/1/502634.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
World Health Organisation. Health topics. Maternal Health. Available from: http://www.who.int/topics/maternal_health/en/. [Last accessed 2020 Feb 19].  Back to cited text no. 1
    
2.
Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, Blomstrom-Lundqvist C, Cifkova R, De Bonis M, et al. ESC Scientific Document Group. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018;39:3165-241.  Back to cited text no. 2
    
3.
Umesawa M, Kobashi G. Epidemiology of hypertensive disorders in pregnancy: Prevalence, risk factors, predictors and prognosis. Hypertens Res 2017;40:213-20.  Back to cited text no. 3
    
4.
Hafez SK, Dorgham LS, Sayed SA. Profile of high risk pregnancy among Saudi women in Taif-KSA. World J Medical Sci 2014;11:90-7.  Back to cited text no. 4
    
5.
Wu P, Haththotuwa R, Kwok CS, Babu A, Kotronias RA, Rushton C, et al. Preeclampsia and future cardiovascular health: A systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2017;10:e003497.  Back to cited text no. 5
    
6.
Magee LA, Sharma S, Nathan HL, Adetoro OO, Bellad MB, Goudar S, et al. The incidence of pregnancy hypertension in India, Pakistan, Mozambique, and Nigeria: A prospective population-level analysis. PLoS Med 2019;16:e1002783.  Back to cited text no. 6
    
7.
Aburezq M, AlAlban F, Alabdulrazzaq M, Badr H. Risk factors associated with gestational diabetes mellitus: The role of pregnancy-induced hypertension and physical inactivity. Pregnancy Hypertens 2020;22:64-70.  Back to cited text no. 7
    
8.
McDonald SD, Malinowski A, Zhou Q, Yusuf S, Devereaux PJ. Cardiovascular sequelae of preeclampsia/eclampsia: A systematic review and meta-analyses. Am Heart J 2008;156:918-30.  Back to cited text no. 8
    
9.
Bellamy L, Casas JP, Hingorani AD, Williams DJ. Pre-eclampsia and risk of cardiovascular disease and cancer in later life: Systematic review and meta-analysis. BMJ 2007;335:974.  Back to cited text no. 9
    
10.
Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990-–2013: A systematic analysis for the Global burden of disease study 2013. Lancet 2014;384:980-1004.  Back to cited text no. 10
    
11.
Stuart JJ, Tanz LJ, Missmer SA, Rimm EB, Spiegelman D, James-Todd TM, et al. Hypertensive disorders of pregnancy and maternal cardiovascular disease risk factor development: An observational cohort study. Ann Intern Med 2018;169:224-32.  Back to cited text no. 11
    
12.
Fraser A, Nelson SM, Macdonald-Wallis C, Cherry L, Butler E, Sattar N, et al. Associations of pregnancy complications with calculated cardiovascular disease risk and cardiovascular risk factors in middle age: The Avon longitudinal study of parents and children. Circulation 2012;125:1367-80.  Back to cited text no. 12
    
13.
Bakker R, Steegers EA, Hofman A, Jaddoe VW. Blood pressure in different gestational trimesters, fetal growth, and the risk of adverse birth outcomes: The generation R study. Am J Epidemiol 2011;174:797-806.  Back to cited text no. 13
    
14.
Konar H, Chakraborty AB. Maternal mortality: A FOGSI study (Based on institutional data). J Obst Gynecol 2013;63:88-95.  Back to cited text no. 14
    
15.
Doke G, Kamda J. Maternal mortality and its causes in a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol 2019;8:3471-4.  Back to cited text no. 15
    
16.
Nath A, Murthy GV, Babu GR, Di Renzo GC. Effect of prenatal exposure to maternal cortisol and psychological distress on infant development in Bengaluru, southern India: A prospective cohort study. BMC Psychiatry 2017;17:255.  Back to cited text no. 16
    
17.
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: Development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry. 1987;150:782-6.  Back to cited text no. 17
    
18.
Huizink AC, Delforterie MJ, Scheinin NM, Tolvanen M, Karlsson L, Karlsson H. Adaption of pregnancy anxiety questionnaire-revised for all pregnant women regardless of parity: PRAQ-R2. Arch Womens Ment Health 2016;19:125-32.  Back to cited text no. 18
    
19.
Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Assess 1988;52:30-41.  Back to cited text no. 19
    
20.
Shaikh Z, Pathak R. Revised Kuppuswamy and B G Prasad socio-economic scales for 2016. Int J Community Med Public Health. 2017;4:997-9.  Back to cited text no. 20
    
21.
Busby DM, Christensen C, Crane DR, Larson JH. A revision of the dyadic adjustment scale for use with distressed and non-distressed couples: Construct hierarchy and multidimensional scales. J Marital Fam Ther 1995;21:289-308.  Back to cited text no. 21
    
22.
Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 A guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American college of cardiology/American heart association task force on clinical practice guidelines. J Am Coll Cardiol 2018;71:e127-248.  Back to cited text no. 22
    
23.
American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin No. 203: Chronic hypertension in pregnancy. Obstet Gynecol 2019;133:e26-e50.  Back to cited text no. 23
    
24.
Ganguly S, Begum A. Rate of caesarean operation and complications in hypertensive disorders of pregnancy. ORION Med J 2007;27:463-6.  Back to cited text no. 24
    
25.
Mohan BS. Pregnancy induced hypertension and prior trophoblastic exposure. J Obstet Gynecol Ind 2004;54:568-70.  Back to cited text no. 25
    
26.
Nadkarni J, Bahl J, Parekh P. Perinatal outcome in pregnancy associated hypertension. Indian Pediatr 2001;38:174-8.  Back to cited text no. 26
    
27.
Prakash J, Pandey LK, Singh AK, Kar B. Hypertension in pregnancy: Hospital based study. J Assoc Physicians India 2006;54:273-8.  Back to cited text no. 27
    
28.
Sengodan S, Sreeprathi N. Prevalence of hypertensive disorders of pregnancy and its maternal outcome in a tertiary care hospital, Salem, Tamil Nadu, India. Int J Reprod Contracept Obstet Gynecol 2020;9:236-9.  Back to cited text no. 28
    
29.
Kuldip R, Aditya P, Kritika B, Priyanka D, Utkarsh P. Incidence of gestational hypertension among pregnant women in the rural population of District Amritsar-A community based study. Indian J Public Health Res Dev 2018;9:42-7.  Back to cited text no. 29
    
30.
Mehta B, Kumar V, Chawla S, Sachdeva S, Mahopatra D. Hypertension in pregnancy: A community-based study. Indian J Community Med 2015;40:273-8.  Back to cited text no. 30
[PUBMED]  [Full text]  
31.
Taddei S, Virdis A, Ghiadoni L, Versari D, Salvetti A. Endothelium, aging, and hypertension. Curr Hypertens Rep 2006;8:84-9.  Back to cited text no. 31
    
32.
Guduri GB, Bhimarasetty DM, Sreegiri S, B TN. Socio-demographic determinants for hypertension in pregnancy a case-control study in a tertiary care hospital of Visakhapatnam, Andhra Pradesh. Int J Res Health Sci 2015;3:93-8.  Back to cited text no. 32
    
33.
Jansen PW, Tiemeier H, Verhulst FC, Burdorf A, Jaddoe VW, Hofman A, et al. Employment status and the risk of pregnancy complications: The generation R study. Occup Environ Med 2010;67:387-94.  Back to cited text no. 33
    
34.
Bao Y, Hu Y, Fu S, Zhang J, Zhang F, Wang X. Studies on relationship between occupation and pregnancy outcome] Zhonghua Yu Fang Yi Xue Za Zhi 1999;33:30-3.  Back to cited text no. 34
    
35.
Tebeu PM, Foumane P, Mbu R, Fosso G, Biyaga PT, Fomulu JN. Risk factors for hypertensive disorders in pregnancy: A report from the Maroua regional hospital, Cameroon. J Reprod Infertil 2011;12:227-34.  Back to cited text no. 35
    
36.
Bertram CE, Hanson MA. Prenatal programming of postnatal endocrine responses by glucocorticoids. Reproduction 2002;124:459-67.  Back to cited text no. 36
    
37.
Vianna P, Bauer ME, Dornfeld D, Chies JA. Distress conditions during pregnancy may lead to pre-eclampsia by increasing cortisol levels and altering lymphocyte sensitivity to glucocorticoids. Med Hypotheses 2011;77:188-91.  Back to cited text no. 37
    
38.
Thombre MK, Talge NM, Holzman C. Association between pre-pregnancy depression/anxiety symptoms and hypertensive disorders of pregnancy. J Womens Health (Larchmt) 2015;24:228-36.  Back to cited text no. 38
    
39.
Assis TR, Viana FP, Rassi S. Study on the major maternal risk factors in hypertensive syndromes. Arq Bras Cardiol 2008;91:11-7.  Back to cited text no. 39
    
40.
Eskenazi BL, Fenster L, Sidney S. A multivariate analysis of risk factors for preeclampsia. JAMA 1991;266:237-41.  Back to cited text no. 40
    
41.
Meazaw MW, Chojenta C, Muluneh MD, Loxton D. Factors associated with hypertensive disorders of pregnancy in sub-Saharan Africa: A systematic and meta-analysis. PLoS One 2020;15:e0237476.  Back to cited text no. 41
    
42.
Mustafa R, Ahmed S, Gupta A, Rocco CV. A comprehensive review of hypertension in pregnancy. J Pregnancy 2012;2012:105918.  Back to cited text no. 42
    
43.
Kahsay HB, Gashe FE, Ayele WM. Risk factors for hypertensive disorders of pregnancy among mothers in Tigray region, Ethiopia: Matched case-control study. BMC Pregnancy Childbirth 2018;18:482.  Back to cited text no. 43
    
44.
Hutcheon JA, Stephansson O, Cnattingius S, Bodnar L, Johansson K. Pregnancy weight gain before diagnosis and risk of preeclampsia: A population-based cohort study in nulliparous women. Hypertension 2018;72:433-41.  Back to cited text no. 44
    
45.
Wagata M, Ishikuro M, Obara T, Nagai M, Mizuno S, Nakaya N, et al. Low birth weight and abnormal pre-pregnancy body mass index were at higher risk for hypertensive disorders of pregnancy. Pregnancy Hypertens 2020;22:119-25.  Back to cited text no. 45
    
46.
Lopez-Jaramillo P, Barajas J, Rueda-Quijano SM, Lopez-Lopez C, Felix C. Obesity and preeclampsia: Common pathophysiological mechanisms. Front Physiol 2018;9:1838.  Back to cited text no. 46
    
47.
Hubel CA, McLaughlin MK, Evans RW, Hauth BA, Sims CJ, Roberts JM. Fasting serum triglycerides, free fatty acids, and malondialdehyde are increased in preeclampsia, are positively correlated, and decrease within 48 hours post partum. Am J Obstet Gynecol 1996;174:975-82.  Back to cited text no. 47
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
   
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   Abstract
  Introduction
  Methods
  Results
  Discussion
  Conclusion
   References
   Article Figures
   Article Tables

 Article Access Statistics
    Viewed116    
    Printed0    
    Emailed0    
    PDF Downloaded25    
    Comments [Add]    

Recommend this journal