Research ajog.

org

OBSTETRICS
Early-pregnancy percent body fat in relation
to preeclampsia risk in obese women
Lindsay K. Sween, MD; Andrew D. Althouse, PhD; James M. Roberts, MD

OBJECTIVE: The purpose of this study was to identify differences of
early-pregnancy body fat percentage and body mass index (BMI)
between obese women that experienced preeclampsia and those
who did not.
STUDY DESIGN: We performed an analysis of the Prenatal
Exposures and Preeclampsia Prevention 3 longitudinal cohort
study of preeclampsia mechanisms in obese and overweight
women. Women completed questionnaires regarding their health
behaviors; had hematocrit level, weight and height, and waist and
hip circumferences measured, and had resistance and reactance
measured by bioelectric impedance analysis machine during the
first, second, and third trimesters. Total body water, fat mass, and
percent body fat were calculated with the use of pregnancy-
specific formulas. Preeclampsia was assessed with the clinical
definition and a research definition (clinical preeclampsia
plus hyperuricemia). Logistic regression models were constructed
to analyze early-pregnancy BMI and body fat percentage
(measured at 10.2
3.0 weeks of gestation) as predictors of
preeclampsia outcomes.
RESULTS: Three hundred seventy-three women were included in the
analysis: 30 women had preeclampsia by clinical definition (8.0%),
and 14 women had preeclampsia by the research definition (3.8%).
There was no relationship between BMI and preeclampsia risk in
obese women; however, body fat percentage was associated signifi-
cantly with increased risk of both the clinical definition of preeclampsia
and the research definition. In 239 obese women, a 1% increase in
body fat was associated with approximately 12% increased odds of
clinical preeclampsia and 24% increased risk of preeclampsia by the
research definition.
CONCLUSION: Early-pregnancy body fat appears to be important in the
pathophysiologic condition of preeclampsia in obese women.
Key words: bioelectric impedance analysis, body fat percentage, body
mass index, obesity, preeclampsia

Cite this article as: Sween LK, Althouse AD, Roberts JM. Early-pregnancy percent body fat in relation to preeclampsia risk in obese women. Am J Obstet Gynecol
2015;212:84.e1-7.

P reeclampsia is a serious pregnancy

complication that occurs in 5-8%
of pregnancies in the United States1 and
In this study, we hypothesized that the
amount of body fat may help to deter-
mine which obese women will experi-
recommended as an approach to the
assessment of this variable in pregnant
women.5,6 In this study, we used BIA to
accounts for approximately 15% of all ence preeclampsia. Prepregnancy BMI measure body fat in a large population
preterm births.2 Maternal prepregnancy has been used to dene obesity, but BMI of pregnant obese women and examined
obesity is one of the strongest potentially is not an optimal indicator of percent the relationship of rst-trimester
modiable risk factors for preeclamp- body fat in general and is even less reli- percent body fat to preeclampsia in
sia.3 There is a dose-response relation- able in pregnancy.5 Bioelectric imped- obese women.
ship between prepregnancy body mass ance analysis (BIA) is an alternative
index (BMI) and the risk of a woman evaluation of obesity. This approach
M ATERIALS AND M ETHODS
experiencing either mild or severe allows the estimation of body fat in large
Study population
preeclampsia.3,4 populations noninvasively and has been
Samples were collected as part of the
Prenatal Exposures and Preeclampsia
Prevention 3 Study, a longitudinal
From the Departments of Obstetrics, Gynecology, and Reproductive Sciences (Drs Althouse and
Roberts), Epidemiology (Dr Roberts), and Clinical and Translational Research (Dr Roberts), University cohort study of preeclampsia mecha-
of Pittsburgh School of Medicine (Dr Sween), and Magee-Womens Research Institute (Drs Althouse nisms in obese and overweight women
and Roberts), Pittsburgh, PA. that was approved by the University of
Received May 14, 2014; revised July 14, 2014; accepted July 30, 2014. Pittsburgh institutional review board; all
Supported by National Institutes of Health grant number P01 HD030367. women gave informed consent. Lean
The contents of this report represent the views of the authors and not necessarily those of the women were recruited in smaller
National Institutes of Health. numbers to compare any ndings in
The authors report no conict of interest. overweight and obese women with and
Corresponding author: James M. Roberts, MD. jroberts@mwri.magee.edu without preeclampsia to ndings in
0002-9378/$36.00  2015 Published by Elsevier Inc.  http://dx.doi.org/10.1016/j.ajog.2014.07.055 normal weight women. Women
with preexisting hypertension, diabetes

84.e1 American Journal of Obstetrics & Gynecology JANUARY 2015

ajog.org
mellitus, renal disease, other medical
complications, or multiple gestations
were excluded. Women were recruited in
early pregnancy from the outpatient
clinics of Magee-Womens Hospital in
Pittsburgh, PA, and had body composi-
tion assessed by bioelectrical impedance
in the rst, second, and third trimesters
(at approximately 10, 20, and 35 weeks
of gestation). The outpatient clinics
serve primarily low-income, uninsured,
unmarried, black, or biracial women;
373 women had complete early-
pregnancy (rst trimester) data and
were eligible for inclusion in this study.
Measurements
Women completed a questionnaire
regarding their health behaviors, repro-
ductive history, and demographic char-
acteristics. Standing height and waist
and hip circumferences were measured
twice for accuracy, and the mean of the 2
values was used. Waist circumference
was measured at the natural waist with
the center of the navel as a physical
landmark. Hip circumference was
measured just below the bony promi-
nence of the anterior superior iliac spine.
Early pregnancy BMI was calculated
from weight and height measurements at
the rst visit (at 10.3
2.9 weeks of
gestation).
Resistance and reactance were
measured with a Quantum IV Bioelec-
trical Impedance Analyzer (RJL Systems,
Clinton Township, MI). Measurements
were taken with the patient lying supine
with arms at a 30-degree angle from the
body and with the legs not touching so as
not to disrupt the electrical circuit.
Electrodes were attached in a tetrapolar
arrangement, with 2 electrodes on the
dorsal surface of the right foot and 2
electrodes on the dorsal surface of the
right hand, 1 proximally and 1 distally.
The distal electrodes act as the gener-
ating electrodes that transmit a small,
painless electrical current; the proximal
electrodes receive the electric current
and measure the voltage drop between
the right hand and right foot.5
Body composition calculations
BIA theory estimates total body water
(TBW) based on the resistance and
reactance measured by a BIA machine
and the patients height, weight,
abdominal circumference, and hemat-
ocrit level. TBW during pregnancy was
calculated with the equation deter-
mined by Lukaski et al7 (Table 1). TBW
was then used to estimate the weight of
body fat. We derived an equation for
weight of fat mass at any gestational age
based on the equations provided by van
Raaij et al.8 Water content of fat free
mass was calculated using two separate
equations, one for 0 to 10 weeks of
gestation and one for 10 to 40 weeks of
gestation, that were derived from
Figure 1 of van Raaij et al.8 These
equations were validated against
deuterium dilution spaces7 and under-
water weighing.8
Hematocrit level was measured in
blood samples that were obtained by
venipuncture.
Preeclampsia definition
We used 2 denitions of preeclampsia.
The rst matches the current American
College of Obstetrics and Gynecology
denition when we began the study, in
which a woman with previously normal
blood pressure has a blood pressure
140 and/or 90 mm Hg after 20
weeks of gestation and proteinuria;
we will refer to this as the clinical
TABLE 1
Body composition equations
Variable
Total body water, L 7
Weight of fat mass, kg8
10 wk
20 wk
30 wk
40 wk
Water content of fat-free mass, %
0-10 wk
0-40 wk
GA, gestational age; TBW, total body water; WB, bodyweight.
Sween. Percent body fat and preeclampsia risk. Am J Obstet Gynecol 2015.
JANUARY 2015 American Journal of Obstetrics & Gynecology
Obstetrics Research
denition of preeclampsia in the re-
sults.1 In previous studies, we found
that a research denition (adds to the
American College of Obstetricians and
Gynecologists clinical denition an in-
crease of >30 systolic and/or >15 dia-
stolic above blood pressure at <20
weeks of gestation and hyperuricemia
that is dened as 1 standard deviation
of uric acid concentration above the
mean for gestational age) denes a
more severe and homogeneous pre-
eclampsia population.9-11 Thirty wo-
men in the study cohort met the
American College of Obstetricians and
Gynecologists criteria for clinical pre-
eclampsia that was dened earlier; 14
of these women also met the more
restrictive research denition.
Blood pressure was determined by the
average of 5 pressures taken after hos-
pital admission for delivery and before
the administration of any medications
that would alter blood pressure. Pro-
teinuria was dened as >0.3 g of protein
in a 24-hour urine collection, 2 protein
measured by dipstick in a random urine
sample, a catheterized urine sample with
1 protein, or a protein-creatinine ratio
>0.3. A jury reviewed the abstracted
medical records to determine that
criteria for preeclampsia had been
satised.
Equation
TBW 0.7*(height [cm]2/resistance)
0.051*(abdominal circumference [cm]) 
0.069*(weight [kg])  0.029*(reactance) 
0.043*(hematocrit) 2.833
WFM WB  TBW/0.725
WFM WB  TBW/0.732
WFM WB  TBW/0.740
WFM WB  TBW/0.750
8
y 0.724 0.0001*GA
y 0.00000666*GA2 0.0005*GA 0.719
84.e2
Research Obstetrics
Statistical methods
Baseline data were described with the
mean
standard deviation for contin-
uous variables and percentages for cate-
goric variables in the total population
and separately by preeclampsia status.
Potential differences between women
with normal pregnancies or with pre-
eclampsia were evaluated with the use of
t tests for continuous variables (equal
variances unless otherwise called for;
unequal variances test used where
appropriate) and c2 tests for categoric
differences (Fisher exact test in cases
where expected cell counts were <5).
This study focused on early pregnancy
BMI and body fat percentage as pre-
dictors of preeclampsia outcomes;
therefore, rst-trimester measurements
of BMI and body fat were used in all
primary analyses. Body fat percentage
was examined as a function of BMI; the
Pearson correlation coefcient is pre-
sented to assess the linear relationship.
Lacking sufcient sample size to test
appropriately for interaction between
BMI and percent body fat, we instead
assessed the relationship between body
fat and preeclampsia by testing for dif-
ferences in percent body fat between
women with preeclampsia and healthy
control subjects within each of the World
Health Organization BMI classications
using t tests (a test with unequal variance
where appropriate). Logistic regression
models were constructed to analyze BMI
and body fat percentage as continuous
variables and allow adjustment for a
limited selection of potential con-
founders. Because the Prenatal Expo-
sures and Preeclampsia Prevention 3
study was designed to compare obese
women who did or did not experience
preeclampsia, we initially limited our
logistic regression models only to obese
women. We also performed a secondary
analysis that included all participants
because of the surprisingly high rates
of preeclampsia in the lean and over-
weight women (by the clinical deni-
tion, 7.69% of lean women and 6.31% of
overweight women experienced pre-
eclampsia). All statistical analyses were
performed with SAS software (version
9.4; SAS Institute, Cary, NC); probability
84.e3 American Journal of Obstetrics & Gynecology JANUARY 2015
values < .05 were considered statistically
signicant.
R ESULTS
Study participants were aged 23.7
4.1
years; 63% of them were black, and
20% of them were smokers (Table 2).
The average BMI was 33.1
7.8 kg/m2;
by study design, most participants were
overweight (22.0%) or obese (64.1%).
Gestational diabetes mellitus was
more common in women in the both
clinical (6.9%) and research-denitions
of preeclampsia (14.3%) than in those
with no preeclampsia (3.5%). Mean
gestational age at delivery was 39.5

1.3 weeks (39.0
1.3 weeks for the 30
women with clinical preeclampsia and
38.1
1.7 weeks for the 14 women
with research preeclampsia). There
were no signicant differences in the
distribution of obesity metrics (BMI,
waist circumference, waist-hip ratio,
or body fat percentage) in the 30
women with clinical or the 14 women
with research preeclampsia compared
with the 343 normal pregnancies
(Table 2).
There was a moderate linear correla-
tion between early-pregnancy body fat
percentage and BMI (R2 0.66; Figure),
but it was not a perfect linear correlation,
which suggests that body fat percentage
may offer independent information
about preeclampsia risk.
When we analyzed the mean body fat
percentage in women within World
Health Organization BMI classications,
only in the highest category of obese
women (BMI >40 kg/m2) was the body
fat percentage signicantly higher in
women who experienced preeclampsia
compared with those women who did
not (Table 3).
We compared BMI and percent
body fat as predictors of preeclampsia
in obese women (BMI 30 kg/m2;
Table 4). Higher BMI was associated
signicantly with higher risk for the
research denition of preeclampsia, but
not the clinical denition. The effect was
no longer signicant after adjustment
for age, race, and smoking status. In
contrast, there was a signicant rela-
tionship between percent body fat and
ajog.org
preeclampsia risk by both the research
and clinical denition. For each 1% in-
crease in body fat, the risk of clinical
preeclampsia increased 12% (odds ratio
[OR], 1.124; 95% condence interval
[CI], 1.018e1.240), and the risk of
preeclampsia by the research denition
increased 24% (OR, 1.239; 95% CI,
1.054e1.455). These relationships were
strengthened slightly when we adjusted
the model for age, race, and smoking
status (Table 4). We considered models
that included both BMI and percent
body fat together; in most of these
models, percent body fat showed a
stronger relationship than did BMI.
However, with the small number
of cases, including 2 highly correlated
variables in a single model, resulted in
model instability that was caused by
variance ination. Similarly, we asked
whether the relationships between body
fat/BMI and preeclampsia might be
dependent on central obesity as indi-
cated by waist circumference or waist/
hip ratio, but there was no interaction
with either of these variables in the
model (P > .05 for all).
In models that were stratied by race,
the ORs were generally similar for white
and black women. For clinical pre-
eclampsia, the OR was 1.15 (95% CI,
0.98e1.36) for white women, compared
with of the OR of 1.02 (95% CI,
0.95e1.11) for black women. By the
research denition, the OR for white
women was 1.15 (95% CI, 0.95e1.39)
compared with 1.29 (95% CI,
1.04e1.61) for black women. We did not
have a sufciently large sample to
formally test interaction by race.
When we examined these relation-
ships in all women (including the lean
and overweight women), neither BMI
nor body fat percentage was associated
signicantly with increased risk of pre-
eclampsia by the clinical denition or
the research denition (Table 5), which
suggested that the relationship between
percent body fat and preeclampsia
was present only in the obese women.
These relationships did not vary signi-
cantly when we adjusted for gestational
diabetes mellitus, waist circumference,
or waist/hip ratio.
 ajog.org
TABLE 2
Baseline characteristics of study participants
All No preeclampsia Clinical preeclampsia Research preeclampsia
Characteristic (n [ 373) (n [ 343) (n [ 30) P valuea (n [ 14) P valueb
Age, y 23.7
4.1 23.7
4.1 23.3
4.8 .62 24.9
6.3 .30
Race, %
White 35.2 35.1 36.7 .76 50.0 .65
Black 63.2 63.2 63.3 50.0
Other 1.6 1.8 0 0
Smoking, % 20.1 21.3 6.7 .05 0 .08
Gestational age at enrollment, wk 10.2
3.0 10.3
2.9 9.6
3.1 .22 9.0
2.8 .10
Gestational age at delivery, wk 39.5
1.4 39.5
1.3 39.0
1.6 .05 38.1
1.7 .01
Gestational diabetes mellitus, % 3.8 3.5 6.9 .35 14.3 .02
Body mass index
At enrollment, kg/m2 33.1
7.8 33.0
7.7 33.4
8.5 .79 34.8
11.2 .40
JANUARY 2015 American Journal of Obstetrics & Gynecology

Classification, %
Lean 13.9 14.0 13.3 .89 14.3 .35
Overweight 22.0 21.9 23.3 28.6
Obese 1 29.8 30.3 23.3 14.3
Obese 2 15.8 15.5 20.0 7.1
Obese 3 18.5 18.4 20.0 35.7

Obstetrics
Waist circumference, mm 1003
168 1002
168 1011
175 .78 1028
206 .57
Waist-hip ratio 0.86
0.07 0.86
0.07 0.87
0.08 .68 0.88
0.07 .30
Body fat percentage 45.9
10.2 45.8
10.1 46.9
11.3 .57 48.6
12.5 .31
a
Derived from comparison of 30 participants with clinical preeclampsia vs 343 participants with no preeclampsia; b Derived from comparison of 14 participants with research preeclampsia vs 343 participants with no preeclampsia.

Research
Sween. Percent body fat and preeclampsia risk. Am J Obstet Gynecol 2015.
84.e4
Research Obstetrics ajog.org

might directly impair implantation.4,12

FIGURE Potential covariants with obesity include
The relationship between BMI and percentage of body fat diet, exercise, and fat distribution. We
No preeclampsia
did not account for the diet or exercise
habits of the women in our study. Fat
Preeclampsia distribution, as approximated by waist
80 circumference and waist-hip ratio,
was not associated signicantly with
70 R = 0.663
increased preeclampsia risk nor did it
60
increase the impact of higher body fat
percentage.
50 This study used BIA as a more direct
% Body Fat

way than BMI to measure fat mass dur-

40
30
20
10
0 compartment and the changes in he-
0 10
The plus sign indicates no preeclampsia; the open circle indicates preeclampsia (clinical definition).
BMI, body mass index.
Sween. Percent body fat and preeclampsia risk. Am J Obstet Gynecol 2015.
C OMMENT
Our results demonstrate that, among
obese participants, increasing body fat
percentage predicts increased risk of
preeclampsia by both the clinical and
research denitions. Although the exact
mechanisms underlying this connection
remain unidentied, the nding that
body fat content more accurately pre-
dicts preeclampsia than does BMI sug-
gests adipose tissue itself may be involved
in the pathophysiologic condition of
preeclampsia. Preeclampsia is proposed
20 30 40 50 60
BMI (kg/m2)
to include fetal/placental and maternal
contributions.13 The maternal contri-
bution is posited to include predisposing
environmental, genetic, and behavior-
al responses to factors produced by
the insufciently perfused placenta.2
Obesity is one such risk factor that is
associated with inammation and
oxidative stress that are proposed to be
components in the pathophysiologic
condition of preeclampsia.2,4 A high
degree of maternal adiposity and asso-
ciated metabolic abnormalities also
ing pregnancy. The BIA analyzer com-
putes resistance and reactance, which
can be used to calculate TBW with the
use of algorithms largely developed
for nonpregnant women. Volume cal-
culations can be affected signicantly by
the expansion of the extracellular uid
70
matocrit level during pregnancy.5 To
nd a standard by which to compare BIA
measurements in pregnancy, pregnancy-
specic formulas can be used to calculate
TBW and then to convert it to body fat
mass.8 We did not validate BIA with
deuterium dilution spaces; however,
previous studies have shown that BIA
gives TBW estimates similar to dilution
values.6,7 Van Loan et al6 found that
TBW by dilution spaces in 10 healthy
pregnant women was 33.1
5.1 L at 8-
10 weeks of gestation, 36.1
4.1 L at 24-
26 weeks, and 38.7
3.9 L at 34-36
weeks.6 Our results for TBW in the
healthy women without preeclampsia
were in agreement with these deuterium
dilution spaces values: 34.4
7.4 L at
10.3
2.9 weeks of gestation, 35.8

5.8 L at 20.0
1.6 weeks, and 39.5
7.0 L

TABLE 3
Distribution of body fat percentages
No preeclampsia Preeclampsia
Body mass index classification n Mean body fat, % SD n Mean body fat, % SD P value
Lean 48 31.5
8.1 4 34.1
10.1 .54
Overweight 75 42.1
7.6 7 38.2
7.3 .20
Obese class 1 104 47.2
6.5 7 46.3
7.2 .73
Obese class 2 53 49.2
7.9 6 52.0
5.4 .40
Obese class 3 63 56.0
5.7 6 61.2
2.6 .03
Sween. Percent body fat and preeclampsia risk. Am J Obstet Gynecol 2015.

84.e5 American Journal of Obstetrics & Gynecology JANUARY 2015

ajog.org Obstetrics Research

TABLE 4
Relationships between body fat percentage and risk of preeclampsia: obese participants only
Odds ratio
Predictor Outcome Unadjusted 95% confidence interval Adjusteda 95% confidence interval
Body mass index Clinical preeclampsia (n 19) 1.017 0.947e1.092 1.011 0.939e1.088
Research preeclampsia (n 8) 1.099 1.008e1.198 1.082 0.989e1.184
Body fat Clinical preeclampsia (n 19) 1.124 1.018e1.240 1.127 1.009e1.257
Research preeclampsia (n 8) 1.239 1.054e1.455 1.294 1.060e1.581
a
Adjusted for age, race, and smoking status.
Sween. Percent body fat and preeclampsia risk. Am J Obstet Gynecol 2015.

at 35.2
0.9 weeks. Body fat percentage
as calculated by pregnancy-specic BIA
models also seems to agree with ndings
in studies that used hydrostatic weigh-
ing. Previous studies that used this
technique have found body fat percent-
age to be 29.6
6.15% in healthy, lean
women at 30 weeks of gestation.8,14 The
average body fat percentage among the
lean women in our study at 35 weeks of
gestation (n 13) was similar (29.6

7.3%). With all women in our study
cohort included, the average body fat
percentage at 35 weeks of gestation was
45.3
8.9%, because of the large num-
ber of overweight and obese women.
The relationship between body fat
percentage and preeclampsia risk was not
signicant when lean and overweight
women were included in the analysis, nor
was the usual relationship between
increasing BMI and increasing pre-
eclampsia risk seen in this cohort. Both
increasing body fat percentage and BMI
trended towards increased preeclampsia
risk with all women included, but the
values were not signicant. Because of
study design, our sample had low
numbers of lean and overweight women
(total 35.9%), which may not result in a
dispersal of data sufcient to demon-
strate a relationship. Alternatively, there
may truly not be a relationship between
body fat percentage and preeclampsia
risk in women with a low amount of body
fat. There was also a surprisingly high
incidence of preeclampsia in lean and
overweight women and a relatively low
incidence in obese women in this study
cohort (7.69% of lean women and 6.31%
of overweight women, compared with
7.95% of obese women by the clinical
denition), which may blunt the re-
lationships between BMI, body fat per-
centage, and preeclampsia risk. Another
reason the expected relationship between
prepregnancy BMI and the incidence of
preeclampsia was not seen could be
the predominance of obese black women
in the cohort. Several studies have
determined that obese black women
have a lower risk of the development of
preeclampsia than do obese white
women.3,15 Furthermore, this study was
designed to recruit women with BMI
>30 kg/m2, and most studies that have
investigated the relationship between
prepregnancy BMI and preeclampsia
have had small sample sizes of women
with BMI >35 kg/m2. Bodnar et al4
found that the ORs of preeclampsia
began trending downward after BMI 35
kg/m2, although they remained >1.0
compared with BMI 21 kg/m2. Rela-
tionship between BMI and preeclampsia
may become more ill-dened at very
high BMIs, given the varying percent
body fat and body fat distributions (eg,
central, abdominal, peripheral, or
visceral) between obese individuals.
Despite these possible explanations, both
the deviation from the well-established
association between increasing BMI and
elevated preeclampsia risk and the un-
usually high incidence of preeclampsia
among the lean and overweight women
do raise questions about the representa-
tive nature of this cohort.

TABLE 5
Relationships between obesity metrics and risk of preeclampsia: all patients
Odds ratio
Predictor Outcome Unadjusted 95% confidence interval Adjusteda 95% confidence interval
Body mass index Clinical preeclampsia (n 30) 1.006 0.960e1.055 1.008 0.961e1.057
Research preeclampsia (n 14) 1.028 0.964e1.096 1.025 0.963e1.091
Body fat Clinical preeclampsia (n 30) 1.011 0.973e1.050 1.009 0.971e1.048
Research preeclampsia (n 14) 1.030 0.973e1.092 1.034 0.977e1.094
a
Adjusted for age, race, and smoking status.
Sween. Percent body fat and preeclampsia risk. Am J Obstet Gynecol 2015.

JANUARY 2015 American Journal of Obstetrics & Gynecology 84.e6

Research Obstetrics
Another challenge encountered in this
study was the unusually high rates of
preeclampsia in the lean and overweight
women. The overall rate of preeclampsia
has not changed dramatically in our
Pittsburgh population, which suggests
that the high incidence of preeclampsia
may be an aberrant nding that is related
to the intentionally small numbers of
lean and overweight women. Alterna-
tively, the cohort is 63% black women,
for whom the literature is mixed with
regards to preeclampsia risk.3,16,17 In one
study, lean black women were more
likely to experience preeclampsia than
lean white women, but the trend
reversed at BMI >25 kg/m2.3 Thus, the
large number of black women in the lean
cohort may explain the high levels of
preeclampsia in this group. In our study,
when we dichotomized by race, there
was no signicant relationship between
body fat percentage in white obese
women and preeclampsia risk, probably
because of a smaller number of cases in
this subset. In obese black women, there
was a signicant relationship between
increasing body fat percentage and risk
of preeclampsia by the research, but not
by the clinical denition. This nding is
also probably because of a small sample
size in the research denition subgroup
and not a true racial interaction. It was
an unfortunate limitation of this study
that the sample of women who experi-
enced preeclampsia was not large
enough to assess adequately the impact
of body fat percentage by race.
There were additional limitations in
this study. This cohort had a small
number of cases (30 cases by the clinical
denition, of which 14 cases also t the
research denition), which led to wide
condence intervals for some BMI and
84.e7 American Journal of Obstetrics & Gynecology JANUARY 2015
body fat percentage values. Further, we
did not adjust for multiple comparisons
in our regression modeling, which
allowed the possibility of a spurious
result being interpreted as positive;
however, we believed that the application
of a particularly harsh adjustment of the
signicance level would have made it
impossible to detect any effect in a
cohort with relatively few cases. We
adjusted the logistic regression model for
age, race, and smoking during pregnancy
but could not account for other potential
covariates, such as prepregnancy and
pregnancy diet and exercise habits.
This study supports the relationship
of fat to preeclampsia. Subsequent lon-
gitudinal, multicenter trials with larger
case numbers are needed to further
assess the utility of BIA-determined body
fat percentage in the prediction of pre-
eclampsia onset. - fetal risk in women with gestational hyperten-
REFERENCES
1. American College of Obstetricians and Gy-
necologists. Diagnosis and management of
preeclampsia and eclampsia. ACOG Committee
on Practice Bulletins: Obstetrics. ACOG practice
bulletin no. 33. Obstet Gynecol 2002;99:
159-67.
2. Roberts JM, Gammill HS. Preeclampsia
recent insights. Hypertension 2005;46:1-7.
3. Bodnar LM, Catov JM, Klebanoff MA,
Ness RB, Roberts JM. Prepregnancy body
mass index and the occurrence of severe hy-
pertensive disorders of pregnancy. Epidemi-
ology 2007;18:234-9.
4. Bodnar LM, Ness RB, Markovic N,
Roberts JM. The risk of preeclampsia rises with
increasing prepregnancy body mass index. Ann
Epidemiol 2005;15:475-82.
5. McCarthy EA, Strauss BJG, Walker SP,
Permezel M. Determination of maternal body
composition in pregnancy and its relevance to
perinatal outcomes. Obstet Gynecol Surv
2004;59:731-42.
ajog.org
6. Van Loan MD, Kopp LE, King JC, Wong WW,
Mayclin PL. Fluid changes during pregnancy:
use of bioimpedance spectroscopy. J Appl
Physiol 1995;78:1037-42.
7. Lukaski HC, Siders WA, Nielsen EJ, Hall CB.
Total body water in pregnancy: assessment by
using bioelectrical impedance. Am J Clin Nutr
1994;59:578-85.
8. van Raaij JMA, Peek MEM, Vermaat-
Miedema SH, Schonk CM, Hautvast JGAJ. New
equations for estimating body fat mass in preg-
nancy from body density or total body water. Am
J Clin Nutr 1988;48:24-9.
9. NHBPEPW Group. Report of the National
High Blood Pressure Education Program
Working Group on High Blood Pressure in
Pregnancy. Am J Obstet Gynecol
2000;183(suppl):S1-22.
10. Hawkins TLA, Roberts J, Mangos GJ,
Davis GK, Roberts LM, Brown MA. Plasma uric
acid remains a marker of poor outcome in hy-
pertensive pregnancy: a retrospective cohort
study. BJOG 2012;119:484-92.
11. Roberts JM, Bodnar LM, Lain KY, et al. Uric
acid is as important as proteinuria in identifying
sion. Hypertension 2005;46:1263-9.
12. Roberts JM, Hubel CA. The two stage
model of preeclampsia: variations on the theme.
Placenta 2009;23(suppl):S32-7.
13. Burton GJ, Woods AW, Jauniaux E,
Kingdom JCP. Rheological and physiological
consequences of conversion of the maternal
spiral arteries for uteroplacental blood ow dur-
ing human pregnancy. Placenta 2009;30:
473-82.
14. Jaque-Fortunato SV, Khodiguian N, Artal R,
Wiswell RA. Body composition in pregnancy.
Semin Perinatol 1996;20:340-2.
15. Marshall NE, Guild C, Cheng YW,
Caughey AB, Halloran DR. Racial disparities in
pregnancy outcomes in obese women. J Matern
Fetal Neonatal Med 2014;27:122-6.
16. Sibai BM, Gordon T, Thom E, et al. Risk
factors for preeclampsia in healthy nulliparous
women: a prospective multicenter study. Am J
Obstet Gynecol 1995;172:642-8.
17. Knuist M, Bonsel GJ, Zondervan HA,
Treffers PE. Risk factors for preeclampsia in
nulliparous women in distinct ethnic groups: a
prospective cohort study. Obstet Gynecol
1998;92:174-8.