Original Article

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Medical Journal of the Islamic Republic of Iran (MJIRI)
Med J Islam Repub Iran. 2018(28 Oct);32.104. https://doi.org/10.14196/mjiri.32.104

Role of obesity in gestational hypertension in primigravidae

women: A case control study in Shadegan, Iran
Leila Moftakhar1, Masoud Solaymani-Dodaran*2, Bahman Cheraghian3

Received: 31 Aug 2017 Published: 28 Oct 2018

Abstract
Background: Gestational hypertension is a serious problem among pregnant women in Shadegan. This study was conducted to
estimate the prevalence and risk factors of gestational hypertension in these women.
Methods: In this study, the prevalence of gestational hypertension was estimated. Then, a case-control study was performed on 310
pregnant women with gestational hypertension and 930 healthy pregnant women in 2014. Multiple logistic regression was used to
explore the possible risk factors. The analysis was repeated in a subgroup of primigravidae women to identify the risk factors that led
to gestational hypertension.
Results: The prevalence of gestational hypertension among pregnant women in Shadegan was 9.6%. Moreover, multiple logistic
regression of all pregnant women showed that obese pregnant women were 1.79 times (OR = 1.79; 95%CI= 1.19-2.71; p<0.005) more
likely to have gestational hypertension. Overweight and obese primigravidae women were 2.13 (OR= 2.1; 95%CI= 1.031-4.34;
p<0.041) and 4.8 (OR= 2.4; 95%CI= 1.13-5.16; p<0.022) times more likely to have gestational hypertension than women with normal
BMI, respectively. Age, education, history of gestational hypertension, and type of residential area of the primigravidae women were
also significant factors.
Conclusion: BMI is the most important risk factor for gestational hypertension. More focus needs to be laid on this issue to raise
awareness on the preservation of proper BMI before pregnancy, which can help decrease gestational hypertension.

Keywords: Gestational hypertension, Pregnancy, Risk factor, Shadegan, Iran

Conflicts of Interest: None declared
Funding: None

*This work has been published under CC BY-NC-SA 1.0 license.

Copyright© Iran University of Medical Sciences

Cite this article as: Moftakhar L, Solaymani-Dodaran M, Cheraghian B. Role of obesity in gestational hypertension in primigravidae women: A case
control study in Shadegan, Iran. Med J Islam Repub Iran. 2018 (28 Oct);32:104. https://doi.org/10.14196/mjiri.32.104

Introduction
Hypertension is one of the most important and that of eclampsia is 2% to 5%. Hypertensive disorders
complications that may occur during pregnancy. of pregnancy occur in 5% to 10% of all pregnancies and
Hypertensive disorders during pregnancy are classified as contribute to a major proportion of maternal morbidities
chronic hypertension, preeclampsia, eclampsia, and and mortalities (2). The pre valence of this disorder has
preeclampsia superimposed on chronic hypertension (1). been estimated at around 3% in the United States, 7.8% in
Chronic hypertension in pregnancy is defined (2) as a Tizhchi (3), 6.9% in Haryana (4), 6/1% in Ghana (1), and
minimum of 140 mmHg systolic or 90 mmHg diastolic 1.9% South Asia (5). However, in Iran, it has a prevalence
blood pressure after the 20th week of pregnancy or the of 3.4% in Iranshahr (6) and 6.4% in Tehran (7).
first 24 hours after delivery. If it is associated with Despite decades of extensive research, it is yet unclear
proteinuria higher than 300 mm, it is called preeclampsia how pregnancy can aggravate hypertension (2). While
(2).The incidence of preeclampsia in pregnancies is 6% preeclampsia has been accepted as a preventable and
______________________________
Corresponding author: Dr Masoud Solaymani-Dodaran, [email protected]
↑What is “already known” in this topic:
1. Department of Epidemiology, School of Health, Iran University of Medical Hypertension is one of the most important complications that
Sciences, Tehran, Iran may occur during pregnancy. It is defined as a minimum of
2. Minimally Invasive Surgery Research Center, Iran University of Medical 140 mmHg systolic or 90 mmHg diastolic blood pressure after
3.
Sciences, Tehran, Iran the 20th week of pregnancy or the first 24 hours after
Research Center for Infectious Diseases of Digestive System, Department of
Biostatistics and Epidemiology, School of Public Health, Ahvaz Jundishapur
delivery.
University of Medical Sciences, Ahvaz, Iran
→What this article adds:
This study revealed that obesity was the main cause of gesta-
tional hypertension in primigravidae women.
Obesity is the main cause of gestational hypertension

controllable disease (8), identified risk factors for analysis was repeated for a subgroup of primigravidae
gestational hypertension are obesity, multiple pregnancies, women to identify the variables that led to gestational
maternal age over 35 years, race and ethnicity, hypertension.
environmental factors, poverty, and chronic hypertension Chi-square test was used to evaluate the association
(6), having a history of preeclampsia (9), low education between qualitative variables and compare them in the 2
level, having a sister with a history of preeclampsia, groups. In addition, independent t test was used to
exposure to diethylstilbestrol, interval between current and compare quantitative variables between the 2 groups.
previous pregnancy, history of preterm delivery, and Univariate logistic regression analysis was used to find the
inadequate prenatal care (6). probable risk factors for gestational hypertension.
Gestational hypertension is one of the most common Multiple logistic regression analysis (backward stepwise
causes of hospitalization among pregnant women, and if method with maximum likelihood ratio approximation)
other symptoms of preeclampsia also occur, it can be life- was used to identify the potential risk factors that cause
threatening in both the mother and the fetus. Moreover, gestational hypertension. Then, variables that were
this disorder imposes high costs on the health care system significant in the univariate logistic regression model were
and causes stress in patients. This study was conducted to entered in the multiple logistic regression model. The
determine the prevalence and the most important risk results of univariate and multiple logistic regression
factors of gestational hypertension in primigravidae and analyses were presented with odds ratio and 95%
pregnant women in Shadegan, Iran. confidence interval.

Methods Results
Data Among the total 4015 pregnant women, 387 had
This unmatched case-control study was conducted gestational hypertension and the prevalence of gestational
among pregnant women receiving prenatal care in hypertension was estimated to be 9.6% (95%CI: 8.74-
Shadegan in 2014. The research council and ethics 10.59) among pregnant women in Shadegan. The mean
committee of Iran University of Medical Sciences BMI among pregnant women with gestational
approved the study’s proposal. The researcher visited hypertension was significantly higher than those without
Shadegan’s health centers to estimate the prevalence of gestational hypertention (28.28±5.88 vs. 25.87±4.77,
gestational hypertension among pregnant women by p<0.0001). The mean BMI among primigravidae women
collecting data on the total number of pregnant women with and without gestational hypertension was 27.53±5.16
and the number of pregnant women with gestational and 24.42±4.38, respectively, and it was statistically
hypertension in 2014. significant (p<0.0001). Pregnant women with gestational
All eligible pregnant women with gestational hypertension were older (mean±SD age: 28.95±5.88
hypertension (310) were selected as the case group and a years) than those without hypertension (mean±SD age:
random sample of healthy pregnant women (930 27.36±5.84 years; p<0.0001) Also, pregnant women with
participants) from Shadegan were selected as the control gestational hypertension had the gravidity and parity
group. higher than those in the control group (Table 1).
Women who had a minimum of 140 mmHg systolic or On examining the relationship between gestational
90 mmHg diastolic blood pressure after the 20th week of hypertension and various factors without controlling the
pregnancy or during the first 24 hours after delivery were confounding factors in pregnant women, we found
included in the study. Inclusion criterion for the control statistically significant associations between the risk of
group was not having gestational hypertension (2). Those gestational hypertension and pregnant women’s age,
with heart disease were excluded from the study. education, parity, BMI, gravidity, and history of
After selecting the case and control groups, the hypertension in a previous pregnancy (Table 2).
researchers visited urban and rural health centers in Finally, after controlling for the potential confounding
Shadegan to collect data and complete the checklist by variables in all pregnant women, we observed that with
extracting health information from the existing health care each year increase in age, the risk of gestational
file filled during pregnancy. hypertension increased by 1.037 times (OR = 1.037; 95%
A predesigned checklist was used that consisted of CI = 1-1.069; p<0.002). Moreover, pregnant women with
demographic information such as, age, type of residential BMI in the obese range were 1.79 times more likely to
area, education level, and occupation. Furthermore, the have gestational hypertension than those with normal BMI
following information about pregnancy was also (OR = 1.79; 95% CI = 1.19-2.71; p<0.005). The risk of
collected: history of previous pregnancies, gestational age, gestational hypertension in women with a history of
parity, body mass index, gravidity, gestational hypertension in a previous pregnancy was about 10 times
hypertension, abortion, multiple pregnancies, interval higher than those without a history of gestational
between previous and current pregnancy, and latest hypertension (OR= 9.87; 95% CI= 5.88-16.55; p<0.0001).
method of contraception used. Moreover, women with high school education were 2.4
times (OR= 2.4; 95% CI=1.13-5.16; p<0.022) and those
Statistical analysis with secondary school education were 2.1 times more
Data were analyzed using SPSS v. 22. After examining likely than women with academic education (OR= 2.1;
all pregnant women to identify the risk factors, the 95% CI=1.031-4.34; p= 0.041) to have gestational

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2 Med J Islam Repub Iran. 2018 (28 Oct); 32:104.
 L. Moftakhar, et al.

Table 1. The relationship between quantitative and qualitative variables in the 2 groups of pregnant women: Those with gestational hypertension
and those without gestational hypertenson in Shadegan in 2014
Variable Category Case (n=310) Control (n=930) p***

Age (year) - 28.95േ5.88* 27.36േ5.84 0.0001

BMI - 28.28േ5.88 25.87േ4.77 0.0001
Gravidity - 2.91േ1.61 2.65േ1.47 0.012
Parity - 1.65േ1.46 1.44േ1.32 0.015
Interval between previous and current - 36.78േ26.36 35.74േ25.36 0.598
pregnancy
Body mass index - - 0.0001
=<18.49 4(1.3)** 25(2.7) -
18.5-24.9 91(29.4) 409(44) -
25-29.99 102(32.9) 331(35.6) -
>=30 113(36.5) 165(17.7) -
History of - - 0.0001
hypertension in pregnancy
No 168(54.2) 684(14.6) -
Yes 65(21) 27(2.9) -
Education - - 0.0001
Illiterate 60(19.4) 136(14.6) -
Primary school 125(40.3) 2993(31.5) -
Secondary school 55(17.7) 166(17.8) -
High school 47(15.2) 246(26.5) -
Academic 23(7.4) 89(9.6) -
Type of residential area - - 0.008
Urban 185(59.7) 555(59.7) -
Rural 125(40.3) 375(40.6) -
History of abortion - - 0.183
No 199(64.5) 632(68) -
Yes 34(11) 79 (8.5) -
Occupation - - 0373
Housewife 299(96.5) 890(95.7) -
Self-employed 4(1.3) 7(0.7) -
Employee 7(2.3) 33(3.5) -
Latest method of contraception used - - 0.378
Combined pill 82(26.5) 282(30.3) -
Minipills 2(0.6) 13(1.04) -
Condom 31(10) 100(10.8) -
Injection 4(1.3) 7(0.8) -
Natural Methods 71(22.9) 220(23.7) -
None 120(38.7) 308(33.1) -
Multiple pregnancy - - 0.745
No 302(97.2) 909(97.7)
Yes 8(2.6) 21(2.3)
*Mean±SD, **n (%), *** Student t–test for continuous variables and Chi-Square for categorical variables

Table 2. Results of univariate and multivariate regression analyses of risk factors in all the pregnant women of Shadegan in 2014
Variable OR (95% CI) OR adj* (95% CI)
Age 1.04(1.02-1.06) 1.03(1.006-1.06)
- -
Academic 1 1
Education High school 1.7(0.98-2.96) 2.42(1.13-5.16)
Secondary school 1.65(0.99-2.73) 2.11(1.03-4.34)
Primary school 1.28(0.73-2.22) 2.03(0.93-4.39)
Illiterate 0.73(0.42-1.28) 0.92(0.42-2.04)
History of hypertension in previous pregnancy 9.8(6.06-15.83) 9.87(5.88-16.55)
- -
18.5-25 1 1
Body mass index =<18.5 0.71(0.24-2.11) 0.83(0.23-2.99)
25-29.99 1.38(1-1.93) 0.86(0.57-1.28)
>=30 3.07(2.21-4.28) 1.79(1.19-2.71)
*Adjusted for BMI, age, history of hypertension in previous pregnancy, parity, and education

hypertension. There was no statistically significant hypertension was 2 times more in women who lived in
association between other variables entered in the multiple urban areas than in those who lived in rural areas
logistic regression and the risk of gestational hypertension (OR=1.99; 95% CI= 1.05-3.61; p<0.022). Furthermore,
(Table 2). compared to women with normal BMI, the risk of
Primigravidae women were analyzed separately to gestational hypertension was 5 times greater in
identify the variables that led to gestational hypertension primigravidae women with BMI in the obese range
in the first pregnancy. Multiple logistic regression analysis (OR=4.88; 95% CI= 2.35-10.12; p<0.0001) and 2.1 times
of these women revealed that the risk of gestational greater in those with BMI in the overweight range
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Med J Islam Repub Iran. 2018 (28 Oct); 32.104. 3
Obesity is the main cause of gestational hypertension

Table 3. Results of univariate and multivariate regression analyses of risk factors in the primigravidae women of Shadegan in 2014
Variable OR (95% CI) OR adj* (95% CI)
Type of residential area
Rural 1 1
Urban 2.16(1.22-3.81) 1.93(1.07-3.5)
- -
18.5-25 1 1
Body mass index =<18.5 0.76(0.08-6.42) 0.81(0.4-77.05)
25-29.99 2.25(1.19-4.24) 2.1(1.1-4.02)
>=30 5.73(2.83-11.61) 4.91(2.36-1.1)
*Adjusted for BMI, age and type of residential area (Education was not significant in univariate regression analyses and did not enter the final model.)

Iranshahr 3.4
Kerman 5
Gorgan 5.2
Yasouj 5.4
Shadegan 9.6

0 2 4 6 8 10 12
Fig. 1. The prevalence of gestational hypertension in percent different cities of Iran

(OR=2.1; 95% CI= 1.12-4.05; p<0.021) (Table 3). pregnancy.

The risk factors for gestational hypertension identified
Discussion in various studies are obesity, multiple pregnancies,
The prevalence of gestational hypertension was 9.6% in maternal age over 35 years, race and ethnicity,
pregnant women in Shadegan. This figure is much higher environmental factors, poverty, and chronic hypertension
than the results reported by the many studies conducted in (6). Elsewhere, other factors have been identified as risk
Iran and around the world (3, 6) (Fig. 1), and it may be factors for gestational hypertension as well, such as
attributed to the women’s lifestyle or nutrition. having a history of preeclampsia, low education level,
In this study, after controlling for possible confounding having a sister with a history of preeclampsia, exposure to
factors, we found that only BMI and residential area diethylstilbestrol, interval between current and previous
remained significant factors in the final model in pregnancy, history of preterm delivery, and inadequate
primigravidae women. Obese primigravidae pregnant prenatal care (6).
women were 5 times more likely to develop gestational In our study, age was also recognized as a risk factor for
hypertention compared to those with normal weight gestational hypertension. The risk of having gestational
(Table 3). BMI, age, history of hypertension in a previous hypertension increased by 1.034 times for each year
pregnancy and education level were risk factors for increase in age. These findings are consistent with those
gestational hypertension. When we examined all pregnant of other studies (3,7, 15-16). This may be explained by the
women in the study, we found that the risk of gestational high rate of fertility in Shadegan’s women and the fact
hypertension in obese pregnant women was reduced from that they continue to reproduce until older age.
3 to 1.8 times after adjusting for confounding factors. This There was a significant association between a history of
decrease was due to the confounding effect of history of gestational hypertension and the risk of gestational
hypertension in the previous pregnancy. After performing hypertension in the current pregnancy. Women with a
the analysis without the confounding factor of history of previous history of gestational hypertension were 10 times
hypertension in the previous pregnancy, we found no more likely to have gestational hypertension than women
changes in other variables. without any history. This correlation has been observed in
BMI was identified as the most important factor many other studies (6, 11, 17). Given that there is an
causing gestational hypertension in primigravidae. Before increased risk of recurrence of gestational hypertension in
controlling for BMI and residential area, the strength of women who have experienced it before, they should
association was close to 6 times for women with normal receive more intensive prenatal and pregnancy care.
BMI, but it was reduced to 5 after adjustment, indicating We also observed a statistically significant association
the presence of confounding by age and residential area. between pregnant women’s education and risk of
This correlation has been observed in many other studies gestational hypertension. Women with high and
as well (5, 10-14). According to our results, obesity and Secondary school education level had a higher risk of
overweight in pregnant women are alarming conditions gestational hypertension than women with academic
for gestational hypertension. Hence, women who are education. However, in studies conducted in Tehran, low
planning for pregnancy should consider reducing their maternal education was recognized as a risk factor (6).
weight. Furthermore, women should acquire knowledge Zhang et al. found that the risk of hypertension in
about the complications of overweightness and obesity in pregnancy is higher in illiterate and uneducated women

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4 Med J Islam Repub Iran. 2018 (28 Oct); 32:104.
 L. Moftakhar, et al.

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Our study had certain limitations. Firstly, it was a case- 12. Luealon P, Phupong V. Risk factors of preeclampsia in Thai women.
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gestational hypertension. Moreover, women should adopt
a healthy lifestyle and consume healthy foods.

Acknowledgment
The researchers would like to thank Dr. A Doosti Irani
and the officials of Shadegan’s health centers.

Conflict of Interests
The authors declare that they have no competing interests.

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