original contributions

nature publishing group

Maternal Body Mass Index, Height, and Risks of

Preeclampsia
Sara Sohlberg1, Olof Stephansson2,3, Sven Cnattingius2 and Anna-Karin Wikstrm1,2
Background
There is an association between maternal body mass index (BMI) and
preeclampsia, but if BMI has an effect on preeclampsia of all severities
is debated. If there is an association between maternal height and
preeclampsia of all severities is unknown.
Methods
In this population-based cohort study including 503,179 nulliparous
women, we estimated risks of preeclampsia of different severity in
short (<164cm) and tall (172cm) women, using women of average
height (164171cm) as reference, and in underweight (BMI: 18.4kg/
m2), overweight (BMI: 25.029.9kg/m2), obese class I (BMI: 30.0
34.9kg/m2) and obese class IIIII (BMI: 35.0kg/m2) women, using
women with normal weight (BMI: 18.524.9kg/m2) as reference.
Severity of preeclampsia was classified as early (<32 weeks),
moderately early (3236 weeks), and late (37 weeks) preeclampsia,
or severe preeclampsia and mild to moderate preeclampsia, as
defined by diagnostic codes.

Preeclampsia is commonly defined as hypertension after 20 gestational weeks combined with proteinuria. Maternal metabolic
risk factors are known to increase the risk of both early- and
late-onset preeclampsia, but there are also differences between
the two subgroups. Early-onset preeclampsia is believed tobe
more of a placental disease and thus more dependent on under
lying abnormal placentation,1,2 while late-onset preeclampsia is thought to be a mainly maternal metabolic disease.14
Especially, early-onset preeclampsia is a leading cause of morbidity and mortality among mothers and infants,5,6 due to
increased risks of maternal cardiovascular complications, intrauterine growth restriction and preterm birth.4
Cardiovascular disease and preeclampsia share constitutional risk factors, such as obesity, hyperlipidemia, hypertension, and increased blood glucose levels.7 Women who have
had preeclampsia are at increased risk of developing cardiovascular disease later in life.810 Long-term risk of cardiovascular
1Department of Womens and Childrens Health at Uppsala University, Uppsala,
Sweden; 2Department of Medicine, Clinical Epidemiology Unit at Karolinska
Institutet, Stockholm, Sweden; 3Department of Woman and Child Health,
Division of Obstetrics and Gynecology, Karolinska University Hospital and
Institutet, Stockholm, Sweden. Correspondence:Sara Sohlberg
(sara.sohlberg@kbh.uu.se)

Received 14 April 2011; first decision 22 May 2011; accepted 4 August 2011.
2012 American Journal of Hypertension, Ltd.
120

Results
Short women had increased risks of all types of preeclampsia,
but especially of early disease (adjusted odds ratio (OR) 1.3; 95%
confidence interval (CI) 1.21.5). The risks of all preeclampsia types
increased with BMI, but seemed higher for milder than more severe
types of preeclampsia. Obesity class IIIII was associated with a fourfold increased risk of mild to moderate preeclampsia (adjusted OR
4.0; 95% CI 3.74.4).
Conclusion
A short maternal stature and a high BMI increase risks of
preeclampsia of all severities. The associations seem especially strong
between short stature and severe types of preeclampsia, and high
BMI and mild types of preeclampsia.
Keywords: blood pressure; body height; body mass index; hypertension;
preeclampsia; risk factors
American Journal of Hypertension, advance online publication 06 October 2011;
doi:10.1038/ajh.2011.175

disease has been shown to be especially high if a woman had

recurrent preeclampsia, early preeclampsia or if the disease
appeared for the first time in a multiparous woman.11
High body mass index (BMI) is an important risk factor for
both preeclampsia12,13 and cardiovascular disease.14,15 Obesity
prevalence is increasing at an alarming rate in both high- and
low-income countries.16 The prevalence of obesity in European
women ranges from 1025%.16 The risk of preeclampsia has
been shown to increase with an increasing BMI, with the lowest
prevalence among underweight women.17 In a recent British
study, extremely obese women were shown to have a fourfold
increased risk of developing preeclampsia, compared to women
of normal weight.18 Studies have shown that the incidence of
preeclampsia is increasing in the United States,19,20 which may
be attributed to an increase in underlying risk factors, such as
obesity, diabetes, and chronic hypertension.19,21
Few have investigated the effects of maternal BMI on risks of
early and late preeclampsia separately.2225 These studies show
diverging results, with some showing that obesity and overweight are risk factors for late, but not early, preeclampsia.24,25
It has shown that the risk of severe preeclampsia is increased
in women with a high pre-pregnancy BMI.17,26,27
Women of short stature are supposed to have an increased
risk of cardiovascular disease.28 Only a few studies have investigated if short stature also is a risk factor for preeclampsia,29,30

January 2012 | VOLUME 25 NUMBER 1 | 120-125 | AMERICAN JOURNAL OF HYPERTENSION

Maternal BMI, Height, and Risks of Preeclampsia

and only one study has been able to show a correlation between
height and preeclampsia,30 with only an increased risk of severe
preeclampsia in short, compared to tall, multiparous women.
Based on the hypotheses of differences in underlying pathophysiology in early and late preeclampsia, we hypothesized
that a high BMI and short stature are associated with both subsets of disease, but with a stronger association between high
BMI and late preeclampsia and between short stature and early
preeclampsia.
In the present nationwide Swedish study, we included more
than 500,000 women with first births between 1992 and 2006.
Using this data set, we estimated the effects of a high BMI and
short stature on risk of preeclampsia of different severity.
Methods

We used information from the population-based Swedish

Medical Birth Register to define the study population. To increase
the homogeneity of the study population, we only included primiparous women born in the Nordic countries (Sweden, Norway,
Denmark, Finland, or Iceland) who delivered a singleton infant
in gestational week 22 or later, without congenital malformation,
during the years 19922006 (n = 503,179). We excluded women
with gestational hypertension (n = 6,182). The Birth Register
contains data on more than 98% of all births in Sweden31 and
includes prospectively collected demographic data, information on reproductive history and complications that occur during pregnancy, delivery, and the neonatal period. By means of
each individuals unique national registration number, the Birth
Register can be linked with other Swedish data sources.
At the time of registration for antenatal care, which occurs
before the 15th week of gestation in more than 95% of the
pregnancies,31 information about demographic data, BMI,
height, and smoking habits are collected by midwifes. We used
data on maternal height and divided our population into quartiles and stated the shortest quartile as short and the highest
quartile as tall. The upper cutoff for the lowest quartile was
between 163 and 164cm in our cohort, and the lower cutoff
for the highest quartile was between 171 and 172cm. We chose
164171cm as normal height in our model.
BMI (weight (kg)/height (m)2) was calculated and categorized into underweight (18.4); normal (18.524.9); overweight (25.029.9); obese class I (30.034.9); and obese class
IIIII (35.0) according to the definitions of the World Health
Organization.32 Information on maternal height was missing
in 8% (n = 39,489) of the study population, and we were not
able to calculate BMI in 16% (n = 81,337) of the women.
Complications during pregnancy and delivery were classified
according to the International Classification of Diseases, ninth
and tenth versions (ICD-9 and ICD-10), as noted by the responsible doctor at discharge from hospital. Mild to moderate preeclampsia was identified by the ICD-9 and ICD-10 codes 642 E,
O140, and O149; and severe preeclampsia, including eclampsia, by the ICD-9 and ICD-10 codes 642G-F, O141-2, and O15.
The clinical definition of preeclampsia is a rise in blood pressure (140/90) combined with proteinuria (0.3g/24h), and
the disease is defined as severe if the diastolic blood pressure
AMERICAN JOURNAL OF HYPERTENSION | VOLUME 25 NUMBER 1 | january 2012

original contributions
rises above 110mm Hg and/or the proteinuria exceeds 5g/24h.
We classified women with preeclampsia by severity of disease. First, we categorized pregnancies with preeclampsia into
three groups based on gestational length at birth. The following categories were used: term preeclampsia, including women
with preeclampsia who gave birth after 37 gestational weeks
or more; moderate early preeclampsia, including women with
preeclampsia who gave birth after 3236 weeks; and very early
preeclampsia, including women with preeclampsia who gave
birth before gestational week 32. In Sweden, gestational age is
assessed by ultrasound scans in 95% of women, usually around
the 17th week of gestation.33 If no early second trimester ultrasound scan was available, the last menstrual period was used
to calculate gestational age at delivery. Second, we categorized
pregnancies with preeclampsia as either mild/moderate or
severe preeclampsia according to the ICD codes. The quality
of the diagnose preeclampsia has previously been validated: of
148 pregnancies coded as preeclampsia in the birth registry, 137
(93%) had the disease according to the individual records.31
We used information on family situation, smoking habits,
and chronic diseases from the first antenatal visit. This information is recorded in a standardized manner, with check boxes.
Family situation is categorized into living or not living with
the infants father, and smoking habits into nonsmoker, light
smoker (19 cigarette/day) and heavy smoker (10 cigarettes/
day). Women with chronic disease were identified either by the
check boxes from the first antenatal visit and/or by diagnoses
registered at hospital discharge after delivery by use of the following ICD-9 and ICD-10 codes: hypertension 642A-C; 642H;
O10; O11; diabetes mellitus 250; 648A; O240; O241; O243;
chronic renal disease 581; 582; N03; N04; and systemic lupus
erythematosus 710A; M32. Information about maternal age
was collected when the woman was discharged from the hospital and categorized into 19 years or younger, 2024 years, 2529
years, 3034 years, and 35 years or older. The years of formal
education (categorized into up to 9 years, 1012 years, and 13
years or more) and mothers country of birth were obtained
by linking the Birth Register to the Education Register and the
Register of Total Population, respectively, both held by Statistics
Sweden. The study was approved by the research ethics committee at Karolinska Institutet, Stockholm, Sweden.
Statistical analysis. We examined the effects of maternal height
and BMI on the risk of developing preeclampsia of different
severity. Odds ratios (OR) with 95% confidence intervals (CI)
were estimated using multiple logistic regression, and normal
height (164171cm) and BMI (18.524.9) were used as reference. We adjusted the analysis for maternal age, years of formal
education, smoking habits and presence of chronic hypertension, diabetes mellitus (pregestational or gestational), chronic
renal disease, and systemic lupus erythematosus. When calculating effect of maternal height, we adjusted for maternal BMI
and vice versa. We also calculated the effect on risks for different types of preeclampsia per increasing BMI unit and per
decreasing height in cm by using BMI and height as continuous variables in the model, adjusting for the other variables as
121

original contributions
categorized variables. Further, within women with preeclampsia,
we also calculated if risks related to maternal stature or maternal BMI were more associated with mild/moderate than severe
preeclampsia, also adjusting for the other variables categorized
variables. All analyses were performed using the Statistical
Analysis Software version 9.2 (SAS Institute, Cary, NC).
Results

Preeclampsia affected 4.8%. Of the women who developed

preeclampsia, 3.7% developed term preeclampsia, 0.9% moderate early preeclampsia, and 0.2% early preeclampsia. The
corresponding rates for mild/moderate and severe preeclampsia were 3.2% and 1.6%, respectively.
Every fourth woman in the study had a BMI above normal
(i.e., 25.0); 17.7% were overweight (BMI 25.029.9), 4.8%
obese class I (BMI 30.034.9), and 1.7% obese class IIIII
(BMI 35.0) (Table1).
Table1 presents the associations between maternal characteristics and term preeclampsia, moderate early preeclampsia,
and early preeclampsia. The rates of preeclampsia of different gestational lengths increased with increasing maternal
age and BMI. Increasing maternal height was associated with
decreasing rates of preeclampsia. Compared with women with
12 years education or less, women with more years of formal
education had lower rates of preeclampsia. Smokers had lower
rates of preeclampsia, although smokers seemed less protected
from early than late preeclampsia. Women with pregestational
and gestational diabetes, chronic renal disease, and systemic
lupus erythematosus had increased rates of preeclampsia.
Women with chronic hypertension had especially increased
rates of early preeclampsia.
Table 2 presents maternal height and BMI and risks of
preeclampsia of different gestational lengths. Compared with
women of normal height, women of short stature had higher
risks and women of tall stature had lower risks of term, moderate early, and early preeclampsia. The association was especially strong between maternal height and early preeclampsia.
The risks of term, moderate early, and early preeclampsia
increased with increasing BMI. Compared with women with
normal BMI, women with obesity class IIIII faced a threefold
to a fourfold higher risk of developing term, moderate early,
and early preeclampsia.
Table3 presents maternal height and BMI and risks of mild/
moderate and severe preeclampsia. Compared with women of
normal stature, women of short stature had higher risks and
women of tall stature had lower risks of both mild and severe
preeclampsia. These associations were slightly stronger for
severe than for mild to moderate preeclampsia. The risks of
both mild and severe preeclampsia increased with increasing
BMI. The associations between increasing BMI and preeclampsia risks seemed stronger for mild to moderate than for
severe preeclampsia. Specifically, obesity class IIIII (BMI
35.0) was associated with a fourfold increased risk of mild to
moderate preeclampsia (adjusted OR 4.04; 95% CI 3.744.36)
and a threefold increased risk of severe preeclampsia (adjusted
OR 2.99; 95% CI 2.663.35).
122

Maternal BMI, Height, and Risks of Preeclampsia

Table 1| Rates of term (37 weeks), moderate early (3236

weeks), and early preeclampsia (<32 weeks) by maternal
characteristics
Early
Moderate early
Term
preeclampsia preeclampsia preeclampsia
(N = 1,215)
(N = 4,312)
(N = 18,594)
Numbers
Overall

Rates (%)

Rates (%)

Rates (%)

3.70

0.86

0.24

Age (years)
1319

19,250

3.49

0.84

0.25

2024

114,355

3.78

0.87

0.20

2529

198,527

3.58

0.80

0.21

3034

128,498

3.59

0.86

0.27

42,549

4.41

1.12

0.42

130162

100,977

4.14

1.03

0.31

163171

252,609

3.69

0.85

0.22

172

110,104

3.38

0.66

0.16

39,489

3.52

1.03

0.44

35
Height (cm)

Missing

Body mass index (kg/m2)a

18.4

10,771

2.22

0.69

0.10

289,515

2.85

0.69

0.18

25.029.9

88,849

5.03

1.02

0.28

30.034.9

23,921

7.45

1.55

0.47

8,786

10.52

2.33

0.68

81,337

3.60

0.94

0.33

18.524.9

35.0
Missing
Education (years)
9

34,242

3.54

0.91

0.29

1012

321,002

3.93

0.90

0.25

>12

146,921

3.23

0.75

0.21

1,014

4.04

0.59

0.20

Missing
Smoking

409,174

3.88

0.87

0.23

19 cigarettes
/day

No

46,124

2.81

0.61

0.21

10 cigarettes/
day

17,828

2.40

0.61

0.18

Missing

30,051

3.37

1.18

0.47

Diabetes
497,651

3.63

0.82

0.24

Gestational

No

2,861

8.35

2.06

0.52

Pregestational

2,667

10.72

7.20

0.82

Chronic hypertension
No

500,293

3.66

0.84

0.23

Yes

2,886

10.53

4.26

2.08

Chronic kidney disease

No

501,000

3.69

0.85

0.24

Yes

2,179

4.82

1.97

0.69

Systemic lupus erythematosus

No

502,637

3.69

0.86

0.24

Yes

542

4.98

1.66

1.85

aAt the time of registration for antenatal care, which occurs before the 15th week of
gestation in more than 95% of the pregnancies.

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original contributions

Maternal BMI, Height, and Risks of Preeclampsia

Table 2| Risks of term, moderate early, and early preeclampsia based on maternal height or BMI
Term preeclampsia
(>37 weeks) (N = 15,894)

Moderate early preeclampsia

(3236 weeks) (N = 3,598)

Early preeclampsia
(<32 weeks) (N = 962)

Crude OR (95% CI) Adjusted ORa (95% CI) Crude OR (95% CI) Adjusted ORa (95% CI) Crude OR (95% CI) Adjusted ORa (95% CI)
Height (cm)
130163

1.14 (1.101.19)

163171
172

1.11 (1.061.15)

1.13 (1.081.17)

Reference

1.17 (1.081.27)

1.43 (1.241.65)

Reference

1.34 (1.161.55)

Reference

0.90 (0.870.94)

0.92 (0.880.96)

0.91 (0.880.95)

0.78 (0.710.85)

0.70 (0.580.83)

0.69 (0.570.82)

0.78 (0.690.89)

0.79 (0.700.91)

0.77 (0.680.88)

1.06 (0.841.35)

0.57 (0.321.04)

0.63 (0.351.14)

BMI (kg/m2)b
18.4
18.524.9

Reference

Reference

Reference

25.029.9

1.82 (1.761.89)

1.79 (1.721.86)

1.81 (1.741.88)

1.42 (1.311.54)

1.59 (1.371.85)

1.49 (1.271.73)

30.034.9

2.81 (2.672.97)

2.74 (2.592.88)

2.76 (2.612.91)

2.08 (1.862.34)

2.66 (2.173.26)

2.40 (1.942.95)

35.0

4.20 (3.904.51)

4.03 (3.754.35)

4.05 (3.774.35)

3.04 (2.613.54)

3.87 (2.965.06)

3.40 (2.594.48)

BMI, body mass index; CI, confidence interval; OR, odds ratio.
aAdjustments for maternal age, body mass index, height, years of formal education, smoking habits, diabetes mellitus (pregestational or gestational), and presence of chronic
hypertension, chronic renal disease, systemic lupus erythematosus. bAt the time of registration for antenatal care, which occurs before the 15th week of gestation in more than 95% of
the pregnancies.

Table 3| Risks of mild to moderate preeclampsia and severe preeclampsia based on maternal height and body mass index
Mild to moderate preeclampsia (N = 13,734)

Severe preeclampsia (N = 6,720)

Crude OR (95% CI)

Adjusted ORa (95% CI)

Crude OR (95% CI)

Adjusted ORa (95% CI)

1.11 (1.061.15)

1.07 (1.021.11)

1.25 (1.181.32)

1.22 (1.151.30)

0.92 (0.880.96)

0.84 (0.790.89)

0.78 (0.670.90)

0.87 (0.731.05)

Height (cm)
130163
164171
172

Reference
0.90 (0.860.94)

Reference
0.85 (0.790.90)

Body mass index (kg/m2)b

18.4

0.77 (0.670.88)

18.524.9

Reference

0.92 (0.771.11)
Reference

25.029.9

1.86 (1.791.94)

1.82 (1.751.89)

1.49 (1.401.57)

1.44 (1.361.53)

30.034.9

2.84 (2.683.00)

2.72 (2.572.88)

2.27 (2.092.47)

2.18 (2.002.37)

35.0

4.26 (3.954.59)

4.04 (3.744.36)

3.16 (2.833.53)

2.99 (2.663.35)

CI, confidence interval; OR, odds ratio.

aAdjustments for maternal age, body mass index, height, years of formal education, smoking habits, diabetes mellitus (pregestational or gestational), and presence of chronic
hypertension, chronic renal disease, and systemic lupus erythematosus. bAt the time of registration for antenatal care, which occurs before the 15th week of gestation in more than 95%
of the pregnancies.

The risk of mild to moderate preeclampsia decreased 0.8%

(95% CI 0.61.1) per cm and increased 9.5% (95% CI 9.1
9.8) per BMI unit, whereas the risk of severe preeclampsia
decreased 2.2% (95% CI 1.82.6) per cm and increased 7.0%
(95% CI 6.57.5) per BMI unit.
Among women with preeclampsia, risk of severe preeclampsia increased with decreasing maternal height, while risk of
mild/moderate preeclampsia increased with increasing maternal BMI (P < 0.001 and P < 0.001, respectively). There was no
statistically significant interaction between maternal height
and BMI with respect to risk of preeclampsia (P = 0.21).
Discussion

We found that not only maternal BMI, but also maternal

height is associated with preeclampsia of all severities. A short
AMERICAN JOURNAL OF HYPERTENSION | VOLUME 25 NUMBER 1 | january 2012

maternal stature was foremost associated with increased risks

of the more severe types of preeclampsia, while overweight
and obesity were closer associated with the milder forms of
preeclampsia.
This is to our knowledge the first study showing an association between maternal height and preeclampsia of all severity. One previous study has shown an association between
maternal height and the risk of severe preeclampsia, but only
in multiparous and not in primiparous women.30 Since the
association both in our and in their study is not that strong,
the difference in cohort size (60,000 vs. 500,000) might at least
in part explain why we in our study were able to show correlation between maternal height and all types of preeclampsia
in primiparous women. Infants born small for gestational age
have an increased risk of short final stature, although most of
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Maternal BMI, Height, and Risks of Preeclampsia

them catch up in height during childhood.34 According to the

hypothesis of Developmental Origins of Health and Disease,
a poor nutrition in utero can result in fetal adaptation which
leads to survival gains in utero and in infancy, but also to longterm increased risks of metabolic and cardiovascular diseases,
including pregnancy complications such as preeclampsia in
adulthood.3537 This can be a reason why both short women
and women with preeclampsia have an increased risk of future
cardiovascular disease.9,10,28 In a recent study by Zhang et al.,
it has been shown that infants born by short statured women
have an increased risk of perinatal mortality which is partly
mediated through small for gestational age birth.38 Both small
for gestational age birth and early preeclampsia are associated
with abnormal placentation and therefore, the study by Zhang
et al. and our study both support an association between short
maternal stature and abnormal placentation.
Being overweight or obese is a well-known risk factor for
preeclampsia12,13,17,18,23,29 and the risk increases with increasing BMI.13,17,23,29 The associations between overweight and
obesity and preeclampsia of different severity are less studied.17,22,23,26,27 We found positive associations between
increasing BMI and risks of preeclampsia of different severity
and gestational lengths, and risks related to a high BMI were
slightly higher for the milder forms of preeclampsia. This is in
agreement with two recent reports,22,23 while two other reports
found that a high BMI was only a risk factor for late24,25 or
mild preeclampsia.24 Another study found a stronger association between increasing BMI and severe than mild preeclampsia.13 Limited sample sizes24,25 or a broader definition of severe
preeclampsia24 may have contributed to these findings. Our
finding, that BMI seems to have a stronger association to late
or mild preeclampsia, is compatible with the two stage model
of preeclampsia, in which early and or severe preeclampsia is
thought to originate to a larger extent in abnormal placentation, and less by maternal metabolic factors such as BMI, while
late/mildmoderate preeclampsia is thought to be more of a
maternal, metabolic disease.2,29
The strengths and limitations of the present study are constituted in the registry-based design. The included variables
from the Swedish Medical Birth Register have been validated
and have been shown to be reliable.31 To increase the homogeneity of the study population (and reduce the risks of residual
confounding), we restricted the study to primiparous women
born in Nordic countries. The large nationwide cohort enabled
us to look at preeclampsia of different gestational lengths and
different severity. Since maternal care is provided free of charge
for all women in Sweden and home deliveries are very rare,
selection bias is unlikely. Further, since data were collected
prospectively, recall bias is precluded. In contrast to previous
studies, our data are relatively recent,13 and the gestational
length was based on a routine ultrasound examination in early
second trimester and not the last menstrual period.13,23 A limitation of the study is that the diagnoses of mild/moderate and
severe preeclampsia have not been validated in the Swedish
Medical Birth Register, though the diagnosis of preeclampsia
has, with high accuracy. Further, adult height is influenced by

environmental and socioeconomic factors. We adjusted for

smoking and years of education, but an effect of unmeasured
factors cannot be excluded.
In conclusion, we found an association between short
maternal stature and preeclampsia, especially early preeclampsia. We further found an association between a high BMI and
preeclampsia of all severities, but especially with the milder
forms of preeclampsia. These findings correspond well with
the hypothesis of two subsets of preeclampsia, the early-onset
disease with a predominantly placental and genetic origin and
the late-onset disease with a stronger metabolic origin.

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Acknowledgments: This study was funded by Gillbergska foundation,

Regional Research Council in the Uppsala-rebro region (project No.
25531), Swedish Society of Medicine (project No. 101291 and 97321).
The study was approved by one of the Regional Ethical Review Boards in
Stockholm, Sweden. Reference number: 2008/1182. Date of approval: 3
September 2008.
Disclosure: The authors declared no conflict of interset.
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