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OBSTETRICS
1.22 to 1.55) for each one standard deviation increase in Figure 1. Representation of the method for sonographic
ultrasound-measured VAT.5 measurement of visceral adipose tissue depth. Shown is a
cross-sectional representation of the patient in a supine
As the measurement of VAT in pregnancy can be limited position.
by the fact that using CT or MRI introduces either radia-
tion or high complexity and cost, little is known about the
relationship between VAT and adverse outcomes. Ultra-
sound measurement of intra-abdominal adipose tissue
correlates quite well with the amount of intra-abdominal
adipose tissue on CT,6 with correlation coefcients of
0.68 to 0.74.7 A simple straight-line vertical measurement
of VAT depth on ultrasound, from the anterior abdominal
wall to the aorta also, correlates well with CT and serves as
a proxy measure of visceral fat and other measures of the
metabolic syndrome.7 Thus, since VAT can be efciently
measured by ultrasound in early pregnancy, we evaluated its
relation to preeclampsia and PTB.
METHODS
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Preeclampsia and Preterm Birth Associated With Visceral Adiposity in Early Pregnancy
years, and mean (SD) BMI was 24.0 (4.9) kg/m2, ranging middle), as was the risk of preeclampsia with PTB
from 16.7 to 49.0 kg/m2. The median (interquartile range) (adjusted RR 16.91; 95% CI 1.24 to 231.07) (Figure 2,
parity was 0 (0 to 1), and the rate of ASA use was 4.8%. Of bottom).
all women, 236 (51.0%) were Caucasian, 39 (8.4%) were
South Asian, 74 (16.0%) East Asian, 35 (7.6%) Black, 53 DISCUSSION
(11.4%) Hispanic, and 26 (5.6%) belonged to other ethnic
groups. The mean (SD) VAT depth was 4.1 (1.7) cm, with Women with preeclampsia exhibit endothelial dysfunction.
a 10th percentile value of 2.2 cm and a 90th percentile value Omental adipose tissue, the largest component of the VAT
of 6.3 cm. The Pearson R2 between VAT depth and pre- compartment, produces angiogenic factors through endo-
pregnancy BMI was 0.35 (P < 0.001). glin gene expression and secretion of soluble fms-like
tyrosine kinase-1 (sFlt-1 or sVEGFR-1).11 Thus, it is
Preeclampsia developed in 15 of 463 participants (3.2%), conceivable that higher VAT may play a direct role in the
and the incidence was much higher at Q5 of VAT depth of pathogenesis of preeclampsia, including early onset pre-
5.2 cm (9.8%) than at Q1 to Q4 below that cut-point eclampsia necessitating preterm delivery.3 Studies of the
(1.6%) but not signicantly so in the adjusted model association between pre-pregnancy BMI and spontaneous
(Figure 2, top). Eight women (1.7%) had chronic hyper- PTB have largely shown a J-shaped relationship, further
tension; ve of these (5.4%) were in the Q5 VAT depth modied by the timing of the PTB, as well as maternal
group, and three (0.8%) were in the Q1-4 VAT group. parity and ethnicity.12e14 To the best of our knowledge, no
prior study has examined associations between VAT and
The risk of PTB was signicantly elevated at Q5 VAT PTB. It is clear that the pathogenesis related to sponta-
depth (adjusted RR 6.53; 95% CI 1.47 to 6.53) (Figure 2, neous PTB must be elucidated.
Figure 2. Crude (black circles) and adjusted (red diamonds) relative risk for preeclampsia (upper),
PTB before 37 weeks gestation (middle), and preeclampsia with PTB (lower), each in relation to
maternal VAT depth measured at 11 to 14 weeks gestation (black squares). Relative risks are
adjusted for age (continuous in years), parity (0 or 1), chronic hypertension, pre-pregnancy BMI
(continuous in kg/m2) and ASA use in pregnancy.
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factors differs between women with preterm and term 6. Armellini F, Zamboni M, Rigo L, Todesco T, Bergamo-Andreis IA,
preeclampsia. Additionally, rst-trimester measurement of Procacci C, et al. The contribution of sonography to the measurement of
intra-abdominal fat. J Clin Ultrasound 1990;18:563e7.
angiogenic factors such as the plasma sFlt-1:PlGF ratio16
7. Shuster A, Patlas M, Pinthus JH, Mourtzakis M. The clinical importance of
could be correlated with rst-trimester VAT and then visceral adiposity: a critical review of methods for visceral adipose tissue
assessed together for predicting preeclampsia. analysis. Br J Radiol 2012;85:1e10.
8. De Souza LR, Berger H, Retnakaran R, Maguire JL, Nathens AB,
Connelly PW, et al. First-trimester maternal abdominal adiposity predicts
dysglycemia and gestational diabetes mellitus in midpregnancy. Diabetes
CONCLUSION Care 2016;39:61e4.
9. Martin AM, Berger H, Nisenbaum R, Lausman AY, MacGarvie S, Crerar C,
Higher VAT may play a direct role in the pathogenesis of et al. Abdominal visceral adiposity in the rst trimester predicts glucose
preeclampsia and preterm delivery. More research is intolerance in later pregnancy. Diabetes Care 2009;32:1308e10.
needed to determine if this can be used in routine clinical 10. Magee LA, Helewa M, Moutquin JM, von Dadelszen P. Hypertension
practice, above and beyond current methods used to pre- Guideline Committee; Strategic Training Initiative in Research in the
Reproductive Health Sciences (STIRRHS) Scholars. Diagnosis, evaluation,
dict the risk of preeclampsia. and management of the hypertensive disorders of pregnancy. J Obstet
Gynaecol Can 2008;30(3 Suppl):S1e48.
11. Lappas M. Markers of endothelial cell dysfunction are increased in human
omental adipose tissue from women with pre-existing maternal obesity and
ACKNOWLEDGEMENTS gestational diabetes. Metabolism 2014;63:860e73.
This work was supported by the Canadian Institutes of 12. Shaw GM, Wise PH, Mayo J, Carmichael SL, Ley C, Lyell DJ, et al. March
of Dimes Prematurity Research Center at Stanford University School of
Health Research (CIHR Funding Reference Number Medicine. Maternal prepregnancy body mass index and risk of spontaneous
126080). Dr Ray is also supported by an Applied Research preterm birth. Paediatr Perinat Epidemiol 2014;28:302e11.
Chair in Reproductive and Child Health Services and 13. Wise LA, Palmer JR, Heffner LJ, Rosenberg L. Prepregnancy body size,
Policy Research from CIHR. The funders had no role in gestational weight gain, and risk of preterm birth in African-American
women. Epidemiology 2010;21:243e52.
the design and conduct of the study; collection, manage-
ment, analysis, or interpretation of the data; or preparation, 14. Cnattingius S, Villamor E, Johansson S, Edstedt Bonamy AK, Persson M,
Wikstrm AK, et al. Maternal obesity and risk of preterm delivery. JAMA
review, or approval of the manuscript. 2013;309:2362e70.
We gratefully thank our ultrasonographers who carried out 15. Sattar N, Clark P, Holmes A, Lean ME, Walker I, Greer IA. Antenatal waist
the measurements in this study (Sharon MacGarvie, Carrie circumference and hypertension risk. Obstet Gynecol 2001;97:268e71.
Crerar, Louisa Loizides, and Meredith Hood), and our 16. Verlohren S, Stepan H, Dechend R. Angiogenic growth factors in the
research assistants (Meagan Lacroix and Loralei DeGuia). diagnosis and prediction of pre-eclampsia. Clin Sci (Lond) 2012;122:43e52.
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