Influence of so far neglected psychosomatic factors, BMI and smoking on pregnancy-induced hypertension (PIH)

Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 2 (2012) 93–100

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Original Article

Influence of so far neglected psychosomatic factors, BMI and smoking on pregnancy-induced hypertension (PIH) M. Rauchfuss a,⇑, T. Fischer b, G. Bogner b, B. Maier b a b

Centre of Internal Medicine and Dermatology, Clinic for Internal Medicine and Psychosomatics, Charité - University Medicine Berlin, Germany Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria

a r t i c l e

i n f o

Article history: Received 7 November 2011 Accepted 28 November 2011 Available online 11 December 2011 Keywords: Pregnancy-induced hypertension (PIH) Psychosocial predictors Logistic regression Pregnancy- and birth-giving-related anxieties Smoking Body mass index (BMI)

a b s t r a c t Objective: Correlation of descriptive psychosomatic factors and birth parameters for pregnancy-induced hypertension (PIH). Study design: For this prospective study 508 pregnant (singleton) women from 16th-22nd gestational week (GW) were investigated by means of a semi-standardized questionnaire. Complete data concerning delivery were obtained from medical records. In addition to medical and sociodemographic risk factors, so far neglected parameters such as biographical information, personality factors, social environment, stress coping strategies and pregnancy-related anxieties were examined. A factor analysis was performed using a principal component method with subsequent varimax rotation. Main outcome measures: Main outcome measures were imminent preterm delivery, PIH, factual preterm delivery before 37GW and birth weight <10th percentile. Results: Four hundred and eighty-eight qualified for evaluation and got included in the univariate logistic regression – 12.6% of them had PIH. The development of PIH showed a significant correlation with age (OR, 95% CI). Very young and older women were more likely to develop PIH. Results: Development of PIH is significantly more frequent in women, whose parents adhered to an authoritarian educational style, had no emotional support of female friends, and a higher BMI. Results: Women who always had been non-smokers and women who did not give up smoking during pregnancy, but only reduced the amount of cigarettes had the least probability of developing PIH, whereas total abandoning of smoking before and especially during pregnancy was associated with a significantly increased risk for the development of PIH. Conclusions: This study suggests psychosomatic factors, BMI and smoking behavior to be relevant for the development of PIH. Ó 2011 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.

Introduction Abbreviations: GW, week of gestation; PIH, pregnancy-induced hypertension; SGA, small for gestational age; PFB, Partner-Relationship Questionnaire; BMI, body mass index. ⇑ Corresponding author. Centre of Internal Medicine and Dermatology, Clinic for Internal Medicine and Psychosomatics, Charité - University Medicine Berlin, Luisenstraße 13a, D-10117 Berlin, Germany. Tel.: +49 (0)30 450553002. E-mail addresses: [email protected] (M. Rauchfuss), [email protected] (B. Maier).

Hypertensive disorders represent significant complications of pregnancy and are the main causes for preterm deliveries [1] and perinatal mortality [2,3]. The most important clinical manifestation is pre-eclampsia which is defined by hypertension and proteinuria (P0.3 g/24 h) [4,5].

2210-7789/$ - see front matter Ó 2011 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.preghy.2011.11.003

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A retrospective study showed that hypertensive disorders accounted for 15.6% of preterm deliveries before the 37th week of gestation (GW) [6]. Severe pre-eclampsia accounts for intrauterine growth retardation and for SGA (small for gestational age) babies [7,8]. Etiology is multicausal [9]. The scientific literature describes several predisposing and stimulating factors. The clinical symptoms appear in the second part of pregnancy, whereas the underlying pathophysiological alterations develop at the beginning in the trophoblast. Treatment after the occurrence of symptoms does not cure the disease but only reduce negative effects. Also, an eventual psychosomatic impact on origin and development of the disease deserves attention, especially stress proves to be a predisposing factor [10,11]. Recent research refers to immunological factors [12,13] as well as to Leptin [14]. In animal trials a correlation was observed between stress caused by coldness and a reduced trophoblast invasion [15]. Evidently, the autonomous nerval system has influence on the development of PIH during early placentation. Also, stress associated with starvation creates a biochemical situation similar to human preeclampsia. The activation of the sympathetic nervous system was higher when rats were molested with starvation and coldness. Several stress stimuli have a synergistic effect on the activation of the sympathetic nervous system [16,17]. Nevertheless, it was shown that the sympathetic nervous system is especially activated with pre-eclampsia [18]. Further studies refer to the relations between symptoms of depression, elevated levels of pro-inflammatory cytokines and preterm delivery as well as pre-eclampsia [19]. On the background of the somatic findings pointing to a multicausal etiology the aim of this study was to identify relevant psychosomatic factors in the development of PIH.

Material and methods For this prospective study 589 pregnant women from 16th to 22nd gestational week (GW) were approached as consecutive cases. For 519 women complete information about obstetrical and neonatal outcome collected from obstetric charts was available. Five hundred and eight women met the precondition of singleton pregnancy. A semi-standardized questionnaire was administered to women in medical practices in Berlin containing items related to social variables relevant for the course of pregnancy (age, family status, education, vocational qualifications, employment status, and income). The questionnaire contained data about medical history, specific pregnancy-related factors as well as biographic parameters, and furthermore, information about family of origin, significant others, circumstances of leaving the parental home, family emotions and family functioning. A factor analysis was performed in order to create comprehensive variables. Coping strategies and personality variables which are the most relevant in stress management were obtained by the analysis of 10 personality areas containing 68 items (control, frustration, tolerance, autonomy, health attitudes,

flexibility, attribution, anxiety, specific disorders of bodily functions, specific mental disorders, unspecific health complaints). In order to operationalize findings scales were produced after factor analysis. Anxiety is a main stress inducing factor, therefore 18 questions were chosen dealing with anxieties related to pregnancy and delivery. They were adapted from the questionnaire of attitudes toward sexuality, pregnancy and delivery (S-S-G) by Lukesch and Lukesch [20]. The respective total scores were determined after factor analysis. Also, helpful stress reducing factors were evaluated. General as well as pregnancy-related possibilities of getting support by close and extended family and friends got examined in detail, e.g. the quality of the partner relationship was assessed by Hahlweg’s Partner-Relationship Questionnaire (PFB) which already had been used in the preliminary studies [21]. Health attitudes playing an important role for disorders as well as coping strategies, got assessed on the basis of 47 items including smoking and body mass index (BMI). Continuous vocational activity, job security, physical health-endangering stress and mental occupational stress were investigated to draw a picture of stress inducing/ reducing factors. A survey sheet was compiled with regard to medical parameters of pregnancy and delivery, specific characteristics of pregnancy (such as infertility treatment), smoking, alcohol, and drug abuse as well as medication. Of further interest were pregnancy related as well as general ailments, sick leaves, in- and out-patient treatment, number of days spent in the hospital, number of appointments during pregnancy, and participation in birth-giving preparation courses. Data about delivery included: level of the maternity unit, presence of significant others during labor, week of gestation at delivery, mode of delivery, duration of giving birth, problems during delivery, e.g. pathological cardiotocography, medication, blood loss, and postpartum complications. Data about the newborn were collected with regard to size, weight, sex, condition, signs of immaturity, un/adequate percentile growth, Apgar score, umbilical cord blood pH, problems of the newborn, and eventual transfer to a neonatal intensive care unit. In order to achieve a reduction of data, a factor analysis with the principal component method and subsequent varimax rotation was performed using information from 508 participants of which 488 had complete sets of data in the areas ‘‘biographical data’’, ‘‘coping strategies and personality variables’’, ‘‘pregnancy-related attitudes and anxieties’’ and ‘‘partner-relationship’’. The factors determined were subjected to a reliability analysis with regard to their internal consistency. The factor ‘‘general anxiety’’ (aCr = 0.89) covered four items and its mean value in the study population was 2.5 ± 1.0. Pregnant women with a high anxiety level tended to describe themselves as anxious, worried by situations unfamiliar to them, easily overcome by feelings of anxiety for no reason and captivated by them to the extent of becoming unable to think clearly. After factor analysis of the original five items on ‘‘pregnancy-related anxieties’’ (aCr = 0.75), the mean value of the

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three items included was 3.7 ± 1.3. Extreme anxieties concerning pregnancy were characterized by fears of injury of the child, and of bleeding with loss of the fetus as well as by worries that the fetus could be harmed by an unhealthy lifestyle. Groups were formed around the items on ‘‘subjective satisfaction with the partner-relationship’’, on ‘‘happiness in the relationship’’ and on ‘‘thoughts of separation’’. The first group was built around the category ‘‘ideal partnership‘‘ containing 115 women who never had considered separation in their relationship, who lived with the child’s father in a common household, who described themselves (very) happy with their partnership and who never had experienced distress due to their partner’s behavior. In the second group 27 women who defined their relationship as (very) unhappy were classified in two categories of being unhappy or very unhappy in their partnership. The third group of 51 women had at least once seriously considered separating from their partner. For statistical analysis logistic regression was employed. Statistical significance was defined with p < 0.05. The variables, which were considered to be relevant in the univariate calculations, were included in the multivariate logistic regression model whenever they were outcomerelated. This procedure complies with the recommendations of Hosmer and Lemeshow for the reduction of variables and model construction which assess the clinically relevant variables with a p-value <0.25 as candidates for the multivariate model [22]. On the basis of the results of the univariate evaluation 18 variables were included into the building of the predictive model. Four variables were obtained from sociodemographic fields, three from healthbehavior and three from pregnancy-related anxieties and attitudes, two from social support, two from the professional situation and two from medical biographical data, one from the social network and one from partnership evaluation (Fig. 1).

Sociodemographic variables age-related risk training qualification graduation partner training qualification partner

A predictor model for preterm birth before the 37th GW, calculated by multivariate logistic regression, is presented. Results Four hundred and eighty-eight women with complete data of the questionnaires were included in the univariate logistic regression – n = 59/12.6% of them had PIH. There was a significant correlation with age. A third of very young (<18 years) and a third of older women (>35 years) developed PIH – but only 11.3% between 18 and 35 years (p = 0.032) (Table 1). Concerning professional qualifications there were more distinct associations with the partners’ professional qualifications than with women’s own. As expected, lower degrees were associated with higher incidence of PIH and vice versa. However, in this study differences were not statistically significant. The incidence of PIH was lowest for secundiparous women (9.3%). The difference between primiparous (13.7%) and multiparous women (14.3%) was not statistically significant. Neither pregnancy-related burdens nor patientrelated risk factors in clinical reports were significantly correlated with PIH occurrence. Women who had experienced an authoritarian educational parental style developed PIH more often, but not significantly. Surprisingly, stress related coping mechanisms did not show any associations with developing PIH. Sleeping well should be a stabilizing factor, therefore correlations of PIH with sleeping disorders were investigated. There was a trend for women with a medium sleeping problem toward the lowest PIH rate (n = 293/9.6%), for women with serious sleeping disorders toward a higher incidence for PIH (n = 99/18.2%). The differences were above the significance level (p = 0.072) (Table 1).

Biographical data authoritarian educational style

Coping with stress/Personality. Sleeping disorders

Pregnancy-related attitudes Pregnancy-related anxieties Birth-giving related anxieties Pregnancy related attitudes

Medical anamnestic data medical risks

Vocational situation security of being able to return to job professional changes

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PregnancyInduced Hypertension (PIH)

Social network Emotional understanding for pregnancy by female friends Acceptance by partner

Partnership PFB conflict behavior Health behaviour Pre-pregnancy BMI Smoking behavior Smoking according to clinical records

Fig. 1. Variables, which went down into the multivariate logistic regression for pregnancy-induced hypertension (PIH) grouped according to evaluation fields (significant variables in the final model are marked bold).

Variable Socio-demographic data Age-related risk

Social network Emotional support by female friends Acceptance of pregnancy by partner Health behavior Pre-pregnancy BMI

Smoking according to clinical records

Smoking behavior

Smoker during pregnancy Non-smoker versus smoker Vocational situation Vocational changes

Means (M) Variable

Pre-pregnancy BMI M ± SD Educational style M ± SD Pregnancy-related anxieties M ± SD Birth-giving-related anxieties M ± SD

n

Characteristic

PIH (%)

OR

95% CI

p1

470 3 15

18–35 y <18 y >35 y

11.3 33.3 33.3

1.00 3.93 3.93

0.35–44.13 1.23–11.95

0.725 0.016

89 293 99

Marginal (<1.3) Medium High (>3.99)

13.5 9.6 18.2

1.00 0.68 1.43

0.33–1.40 0.64–3.16

0.292 0.381

270 218 445 43

Yes No Yes No

9.3 15.6 13.0 2.3

1.00 1.81 1.00 0.16

290 52 94 18 274 136 48 10 270 44 85 63 20 314 168 270 212

19–24 <19 >24–30 >30 No smoking No record Smoking Abuse Always non-smoker Non-smoker before pregnancy Non-smoker during pregnancy Reduced smoking during pregnancy Unchanged smoking habit during pregnancy Non-smoker/before pregnancy non-smoker Smoker during pregnancy Non-smoker Smoker

9.3 0.0 18.1 38.9 9.5 16.2 16.7 0.0 9.6 15.9 18.8 11.1 15.0 10.0 15.5 9.6 15.6

1.00 Not calculable

249 104 135

No changes Positive changes Negative changes

10.4 8.7 17.8

PIH in pregnancy Yes

No

25.43 ± 4.87 6.84 ± 2.25 4.03 ± 1.29 3.11 ± 1.15

21.99 ± 3.16 6.31 ± 2.05 3.67 ± 1.33 2.84 ± 1.07

1.00 1.84 1.91 1.00 1.78 2.18 1.17 1.66 1.00

p2 0.032

0.072

0.035 1.04–3.14 0.072 0.02–1.18 0.002 0.616 2.15 6.20

1.11–4.15 2.22-17.31

1.00–3.39 0.81–4.51 Not calculable

0.050 0.141 0.670

0.72–4.38 1.11–4.29 0.49–2.84 0.46–6.03

0.213 0.025 0.723 0.444

1.56

0.90–2.71

0.023 <0.001 0.181

0.219

0.115

1.00 1.73

1.00–3.00

0.050

1.00 0.81 1.85

0.37–1.80 1.02–3.38

0.057 0.609 0.044

OR

95% CI

p

1.24 1.12 1.23 1.25

1.51–1.34 0.98–1.28 1.00–1.52 0.98–1.60

<0.001 0.092 0.051 0.077

p1 = statistical significance for differences in OR of different parameter values of variables, p2 = statistical significance oft he correlation between the variable and imminent preterm labor

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Coping with stress Sleeping disorders

96

Table 1 Univariate logistic regression – hypertensive disorders in pregnancy (n = 488, PIH 12.6%).

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Pregnancy related as well as birth-giving-related anxieties correlate with the occurrence of PIH. The average values of PIH of anxious women in comparison with non-anxious women reached almost significance level (pregnancy-related anxiety, p = 0.051, birth-giving-related anxiety, p = 0.077). Women with medium values on the scale of pregnancy anxieties developed PIH only in 9.8%, whereas women with high levels indicating a rather anxious attitude in 19.3%. Pregnant women with a very positive attitude toward pregnancy were treated for PIH in 13.2%. However, the differences between different attitudes were again barely above the significance level (p = 0.060). Women without emotional understanding from female friends for their pregnancy had significantly more frequently PIH and significantly higher blood pressure (0.035) (Table 1). Highly significant correlations were found between the BMI before pregnancy and the occurrence of PIH. Women below BMI 19 did not develop PIH, women with BMI above 30 did in 38.9% (p = 0.002) (Table 1). A significant higher PIH rate was found in women who had experienced negative professional changes during the last 12 months (p = 0.044). A higher incidence of PIH was associated with one illness (OR 5.62; 95% CI 1.31–17.74) and, even more significantly, with more illnesses in the medical history (medical risk 1: cardiac arrhythmia, asthma, diabetes, preexisting hypertension), birth-giving anxieties, emotional (non-) understanding of female friends, conflict behavior (PFB), BMI before pregnancy, smoking (as well as medical record of smoking) (OR 17.32; 95% CI 19.09–3633.6). Furthermore, a higher pre-pregnancy BMI (OR 1.28; 95% CI

1.12–1.45), an authoritarian educational style in the family of origin (OR 1.32; 95% CI 1.04–1.68), more intense birthrelated anxieties (OR 2.86; 95% CI 1.70–4.80), a deranged conflict behavior (OR 0.19; 95% CI 0.05–0.71), and the lack of emotional support for pregnancy by female friends (OR 2.63; 95% CI 0.91–7.61) were associated with a higher incidence of PIH. Also, smoking was significantly correlated with the development of PIH. The lowest incidence was observed in women who had never smoked in their life (9.6%). Women who had smoked before or were smoking during pregnancy developed PIH in 15.6% (p = 0.050). Women who had abandoned smoking before pregnancy (OR 2.17; 95% CI 0.43–10.93) or during pregnancy (OR 6.50; 95% CI 1.70–6.42) had a higher risk for PIH than women who had never smoked (OR 1.00) and women who only had reduced smoking during pregnancy (OR 0.64; 95% CI 0.06–6.42). Women for whom no data about smoking were available in the patient reports (OR 4.08; 95% CI 1.29– 12.97) or those who were registered smoking up to five cigarettes per day (OR 4.71; 95% CI 0.64–34.49) had a higher risk for PIH (Table 2). The validity of the model was positively assessed by the Log-Likelihood-Function and the Chi-square values (Table 2). In the multivariate logistic regression for PIH including 331 women for which data about childhood and parental educational style were provided n = 28 were diagnosed with PIH and included according to the selection of variables. Between the variables there was only a very low or low correlation (Spearman-Rho). The occurrence of PIH was significantly predicted by a medical history of nongynecological diseases (medical risks 1), age, BMI, lack of emotional understanding for their pregnancy by female

Table 2 Results of the multivariate logistic regression for PIH (bio-psycho-social final model; variables with significant influence). Variable

n

Characteristic

OR

95% CI

p1

Medical risks 1

294 31 6

No risk 1 risk >1 risk

1.00 5.62 17.32

1.31–17.74 19.09–3633.6

0.018 <0.001

56 215 60

Marginal (<1.3) Medium High (>3.99)

1.00 1.35 0.26

0.33–5.64 0.04–1.50

Sleeping disorders

B

p2 <0.001

0.119 0.678 0.130

Authoritarian educational style

331

0.28

1.32

1.04–1.68

0.021

Birth-giving-related anxieties

331

1.05

2.86

1.70–4.80

<0.001

Emotional understanding by female friends

186 145

1.00 2.63

0.91–7.61

Yes No

0.075

PFB conflict behavior

331

1.59

0.19

0.05–0.71

0.013

Pre-pregnancy BMI

331

0.26

1.28

1.12–1.45

0.001

Smoking

208 86 33 4

No smoking No record Smoking Abuse

1.00 4.08 4.71 Not calculable

1.29–12.97 0.64–34.49 0.900

0.017 0.127

189 32 60 43 7

Non-smoker Non-smoker before pregnancy Non-smoker during pregnancy Reduced smoking during pregnancy Smoker during pregnancy

1.00 2.17 6.50 0.64 Not calculable

0.43–10.93 1.70–24.86 0.06–6.42 0.855

0.347 0.006 0.707

Smoking behavior

0.088

0.047

p1 = statistical significance for differences in OR of different parameter values of variables, p2 = statistical significance of the correlation between the variable and imminent preterm labor.

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friends, negative professional changes during the last year, birth-giving anxieties, and smoking.

Discussion The frequency of PIH ranges between 6-7% according to the German Perinatal Statistics, the incidence of chronic hypertension diseases in pregnancy between 1% and 5% [23]. In the study population 12.6% of women had documented PIH. These, in comparison to the perinatal statistics, slightly elevated findings may be caused by an overrepresentation of primiparous women who have a higher risk for PIH [24]. Potential bias e.g. due to specialized university setting or course of recruitment process (e.g. willingness for participation in this study) could not get eliminated. Causes for PIH had been mostly investigated on a somatic level alone whereas psychosomatic studies are left out. This is surprising because hypertension is a common medical field for psychosomatic investigation [25–27]. The limitations of the study are also due to the qualitative self-ratings by the women themselves. In this study the factor medical risks 1 was integrated in the explanatory model. Cardiac arrhythmia, asthma, diabetes and rheumatism are the classical medical risk factors for clinical problems associated with hypertension during pregnancy [28]. They are assumed to be the psychosomatic expression of an intense vegetative stress reaction [29–32]. And that leads to the assumption that women with hypertension in pregnancy may also develop hypertensive diseases without being pregnant on the basis of similar psychophysical reaction patterns. As an indication for an increased psychophysical (psychosomatic) reactivity, Teixeira [33] found a significant correlation between State and Trait anxieties of pregnant women with an increased resistance in the uterine arterial blood flow. In women who developed pre-eclampsia, Sikkema could neither detect higher cortisol levels nor higher trait anxieties or pregnancy-related anxieties than in women with an uncomplicated course of pregnancy [34]. In the present study no significant correlation between hypertensive pregnancy disorders, general anxiety or pregnancy-related anxieties was found whereas birth-giving anxieties were significant predictors for PIH. Birth-giving anxieties do not occur in the first half of pregnancy during which the investigation of Sikkema was performed [34]. High values on the birth-giving-anxiety scale, which was developed for this study reveal a distinct fear of physical pain during labor but also of complications and, especially of losing control or being abandoned. Fear of loss of control is also associated with two other variables which were integrated into the final model of the multivariate logistic regression for PIH. Pregnant women, whose parents adhered to a more authoritarian style of education focusing on following rules and on punishment, developed hypertension significantly more frequently. Surprisingly, PIH was associated with pronouncedly balanced conflict behavior in partnership. This means the partners did not scold each other in an argument. This for harmony striving behavior is only understandable against the psychodynamic background

which was psychoanalytically described by Berger-Oser and Richter [35] as ‘‘malignant symbiosis’’ of the pregnant woman with her mother. The mother was emotionally ‘‘cold’’ and ‘‘ignorant’’, presenting herself to her daughter as ideal and self-sacrificing – an image which the daughter had internalized. On the basis of such a misguided mother– daughter relationship, these daughters experienced problems as caused only by themselves and consecutively developed feelings of guilt. Their anger against the ignorance of their mothers had to be denied. However, such conflicts tend to exacerbate, especially in first pregnancies. Hypertension could be seen as the physical correlate of fighting aggressive impulses. The predictive variables of the model constructed for this study (authoritarian educational style, birth-giving anxieties and conflict behavior) support this hypothesis. The emotional support of female friends was the only parameter from the social network variables that could get integrated into the predictor model for PIH. Pregnant women without such support have a higher risk for developing PIH. According to the hypotheses of Berger-Oser and Richter [35] these patients are locked into close and symbiotic relationships with their mothers and unable to develop own female identities. This unfortunate symbiosis never got broken down by a third person, e.g. by the father. Fathers were described by the patients as rather weak. Their actual partners fit into the same category. This could explain the need for support by a female person and the pathogenic consequences if not available. In contrast to women endangered of preterm birth-giving, the relationship with the partner is of minor importance for the development of hypertension. An increased pre-pregnancy BMI is connected with a higher risk for PIH [36,37]. In the predictor model developed for this study, the pre-pregnancy BMI was integrated as a significant factor and turned out to be positively correlated with the development of hypertension, presumably due to the increased BMI itself or the emotional process of getting overweight. The higher the BMI, the higher was the incidence of PIH. Recent research findings indicate a connection between Leptin and hypertension during pregnancy [38]. Higher Leptin concentrations were found in the cord blood of newborns whose mothers had developed pre-eclampsia. The differences compared with children without maternal pre-eclampsia remained significant, also after adjustment concerning gestational age, sex, and the Ponderal Index (relating body weight to volume) [38]. Fat cells generate the protein Leptin which inhibits the ingestion of food. The neuroendocrine effects are mediated by receptors located in the hypothalamus where emotional processes are regulated as well [39,40]. Leptin is assumed to be involved in emotional processes as well as into the induction of the serotonine metabolism [41]. Furthermore, Leptin seems important for the induction of menarche [42] and the regulation of the menstrual cycle [43]. During pregnancy Leptin is released in high concentration by the placenta [44]. However, the preliminary results are inconsistent. The interrelations are far from being well understood, but promising for the understanding of PIH. Preparation for further investigations seems a holistic psychophysiological approach involving emotions.

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Smoking is known as a risk factor for pregnancy complications like intrauterine fetal growth reduction, low fetal birth weight and perinatal mortality. The paradoxical findings of Castles with regard to smoking suggest an apparently protective effect on pre-eclampsia. This should be balanced against the harmful effects [45]. However, the radical abandoning of smoking before, and especially during pregnancy, was associated with a significantly increased risk for the development of PIH. Several cohort as well as case-control studies showed a lower risk for hypertension for smokers during pregnancy [45,46]. A final explanation of this ‘‘protective’’ effect of ‘‘moderate smoking’’ is missing. Debates focus on the lower plasma-volume of smokers and on the hypotensive effect of Thiocyanat as well as on the inhibition of fetal Thromboxan A2 [45]. However, a recommendation in favor of smoking should not be given considering the harmful effects. Taking a psychosomatic perspective on PIH the influence of the variable of sleeping disorders on pregnancy complications seems surprising. In the study population a serious sleeping disorder was associated with a low incidence of hypertension. In contrast with these results, Berger-Oser and Richter [30] found sleeping problems in most of their 10 in-patients with severe pre-eclampsia between the 29th and 39th GW. The data of the present study were obtained between the 16th and 22nd GW, definitely before an eventual clinical manifestation of hypertension. With regard to sleeping disorders a tilting over of symptoms from over-compensation to decompensation could be a reason for the paradoxical findings. Sleeping disorders are associated with an activation of the sympathetic nervous system. As pre-eclampsia is associated with an activation of the sympathetic nervous system it is to expect that these women suffer from sleeping disorders [17,18]. In the multivariate model the occurence of PIH could be seen as a somatic decompensation of a dysfunction developed early in pregnancy – or even before – or a dysfunction compensated over a long time. The physical starting point can be set at the beginning of pregnancy. PIH is, among other factors, caused by a deranged trophoblast invasion. The clinical symptoms emerge in the second half of pregnancy [47,48]. Pregnant women seem to develop hypertension on the basis of increased psychovegetative reactivity to stress, which in non-pregnant women may lead to diseases like asthma, cardiac arrhythmia, or hypertension. The imbalance of angiogenic and anti-angiogenic factors may contribute to the pathophysiology of pre-eclampsia. Further investigations deal with them [49,50]. The results of this study point at psychosomatic factors for the development and course of PIH. At the same time PIH leads to psychosocial problems which are insufficiently integrated into obstetric care concepts although e.g. in the field of cardiology effective psychosomatic therapies are already established. Women with PIH seem not easily prepared to accept psychosocial treatment according to the predictor constellation provided in this study. An explanation may well be the increased anxiety of loosing control and the overwhelming difficulty to face conflicts which may lead to avoid group therapies. Women with imminent preterm delivery are better motivated to accept psychosocial help because of the acute

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coercive situation they are in [51]. A confiding relationship, in which anxieties and aggressive impulses are addressed, needs a more individual approach for a longer time period. Additionally, developing better conflict management structures calls for the cooperation of the partner. Therefore body-related relaxation therapies turn out to have positive effects and are immediately operationable and more easily acceptable. Conclusions The predictor model for preterm birth and PIH shows: Women with PIH significantly more often suffer from birth-giving-related anxieties. Grown up in an authoritarian parental relationship they do not seem to have learned how to handle conflicts and presumably had and still have to oppress aggressive impulses. PIH incidence is higher when emotionally supportive pregnancy related female network is lacking. With regard to smoking the harm should be considered against a presumably existing protective effect on preeclampsia. Conflict of interest There is no conflict of interests for any of the authors involved. Author’s contributions All authors participated actively in the study by creating and following the study concept, analysis of the data, and production of the manuscript. Acknowledgments The project was conducted by the Berlin Public Health Research Association and located at the Charité University Clinic Berlin. At this point we would like to express our thanks to all of the colleagues who participated in the project work. References [1] Omu AE, Al Othman S, Mohamed AS, Al-Kaluwby NW, Fernandez S. A comparative study of obstetric outcome of patients with PIH: economic considerations. Acta Obstet Gynecol Scand 1996;75:443–8. [2] Steegers EA, von Dadelszen P, Duvekot JJ, Pijnenborg R. Preeclampsia. Lancet 2010;376(9741):631–44. [3] Duley L. The global impact of pre-eclampsia and eclampsia. Semin Perinatol 2009;33(3):130–7. [4] Jim B, Sharma S, Kebede T, Acharya A. Hypertension in pregnancy: a comprehensive update. Cardiol Rev 2010;18(4):178–89. [5] ACOG Practice Bulletin No. 33. Diagnosis and management of preeclampsia and eclampsia. Obstet Gynecol 2002;99:159–67. [6] Schneider H, Naiem A, Malek A, Hanggi W. Etiologic classification of premature labor and its importance for prevention. Geburtsh Frauenheilkd 1994;54:12–9. [7] Xiong X, Mayes D, Demianczuk N, Olson DM, Davidge ST, NewburnCool C, et al. Impact of pregnancy induced hypertension on fetal growth. Am J Obstet Gynecol 1999;180:207–13. [8] Maynard SE, Karumanchi SA. Angiogenic factors and preeclampsia. Semin Nephrol 2011;31(1):33–46. [9] Frey L. Gestose und HELLP-Syndrom. Anaesthesist 1997;46:732–47.

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