Biological Trace Element Research

, Volume 152, Issue 2, pp 174–179 | Cite as

A Prospective Study of Selenium Concentration and Risk of Preeclampsia in Pregnant Iranian Women: a Nested Case–Control Study

  • Seyede Zahra Ghaemi
  • Sedighe Forouhari
  • Mohammad Hossein Dabbaghmanesh
  • Mehrab Sayadi
  • Marzieh Bakhshayeshkaram
  • Faride Vaziri
  • Zohreh Tavana
Article

Abstract

Preeclampsia remains a leading cause of maternal and perinatal mortality and morbidity worldwide; however, its specific etiology still remains obscure. Some studies implicate poor maternal selenium status predisposing the mother to preeclampsia. This study was designed to determine changes in plasma selenium levels in women having preeclampsia as compared with those with normal pregnancy. In a nested case–control study, 650 normal primigravida in their first 24–28 weeks participated in the study. After 3 months of follow-up of all subjects, blood selenium levels were measured in 38 women presenting consecutively with preeclampsia and in 38 women having a normal pregnancy by atomic absorption spectrophotometry. Birth outcomes were recorded, such as gestational age at delivery, height, weight, birth head circumflex and 1-min Apgar score. Preeclampsia affects about 5.84 % of pregnancies, and in our study, there were no significant differences in age, anthropometric indices, and family history of preeclampsia between the preeclamptic and control groups. The selenium concentrations in plasma in women with preeclampsia were significantly lower as compared with those in women with normal pregnancy (70.63 ± 21.41 versus 82.03 ± 15.54 μg/L, p < 0.05). Being in the bottom tertile of selenium concentration (less than 62.2 μg/L) was associated with greater risk of preeclampsia in pregnant women. The reduced selenium in the maternal circulations observed in the preeclamptic mothers support the hypothesis that insufficient selenium concentration may be a contributing factor to the pathophysiological mechanisms associated with preeclampsia, and optimizing the dietary selenium intake through supplementation could produce demonstrable clinical benefits.

Keywords

Preeclampsia Plasma selenium levels Primigravida Birth outcomes 

Introduction

Pregnancy may be considered as a glimpse into a woman’s future health because gestation causes many challenges for various organ systems [1]. Preeclampsia, one of the complications in pregnancy, is recognized as the leading cause of morbidity and mortality in primigravida and their babies, and every year more than four million women worldwide develop this disorder [2]. Preeclampsia is a progressive, multi-systemic disorder characterized by triad of high-blood pressure, edema, and proteinuria, developing after 20 weeks of gestation [3]. Preeclampsia is an unknown disease with several conjectures and theories [4]. Despite identification of many risk factors in occurrence of preeclampsia, its specific etiology remains obscure [5]. Researchers have attempted to identify the etiology of dysfunction of the endothelial cells [5, 6]. An excessive maternal systemic inflammatory response has been proposed to be the driving force that contributes to endothelial cell dysfunction in preeclampsia [7]. These findings raise the potentially beneficial effects of antioxidants in the prevention of preeclampsia [8]. Some evidence suggests that antioxidant supplementation reduces the risk of preeclampsia. Antioxidants are a diverse family of components that act in order to prevent overproduction of and damage caused by noxious free radicals [9].

Selenium is an essential trace element vital for the proper functioning of selenoenzymes, such as the antioxidant glutathione peroxidase (GPx) [10]. Conflicting results have been found in investigations examining the serum concentrations of selenium in preeclamptic women. Some studies have observed a reduction in concentrations of selenium in plasma or serum [11], and others have been shown to increase selenium concentration in preeclamptic than normal pregnant women [12, 13]. In view of these contradictory results, and considering a possible protective role of selenium against preeclampsia development, the selenium concentrations in the plasma of preeclamptic women were determined in order to establish whether or not low plasma selenium levels concentrations were indicative of increased eclampsia risk in primigravida Iranian women.

Materials and Methods

Population Study

This prospective study was carried out in obstetric clinics of Shiraz University of Medical Sciences. According to the results of previous studies, to reach the objectives of our study, the sample size was calculated to be 38 subjects using the following formula \( n\prime =\frac{{{{{\left( {{z_{{1-\frac{\alpha }{2}}}}+{z_{{1-\beta }}}} \right)}}^2}}}{{{{{\left( {\frac{d}{{2\delta }}} \right)}}^2}}}\left( {\delta =0.093,\,d=0.06,\,\alpha =0.05,\,{z_{{1-\frac{a}{2}}}}=1.96,\,1-\beta =0.80, {z_{{1-\beta }}}=0.84} \right) \) In a prospective study design, to achieve the required sample size in the case group with a confidence level of 95 %, p = 7.5 %(incidence rate of preeclampsia), for the purpose of n numbers using the formula,\( n={{\left[ {A+\sqrt{{{A^2}+\frac{{n\prime }}{p}}}} \right]}^2} \); 650 was obtained. In this formula, \( A=\frac{{|{Z_{\alpha }}|}}{2}\sqrt{{\frac{1-p }{p}}} \).

Therefore, 650 eligible primigravida were invited to participate in this study during June and March 2011, with the following inclusion criteria: singleton pregnancy, gestational age between 24 and 28 weeks based on the first trimester ultrasound exam, no history of chronic hypertension, lack of use of any type of multivitamins containing selenium during the previous year, living in Shiraz during the previous 2 years, no history of recognized internal diseases during pregnancy, such as kidney disease, diabetes, thyroid, etc. All invited individuals accepted, and written informed consent was obtained from them. The study participants were asked to complete a questionnaire to obtain their demographic data, their method of contraception, and their history of cigarette or tobacco usage.

Anthropometric and Blood Pressure Measurements

Anthropometric parameters including weight, height, and body mass index were measured. Weight was measured using a standard scale, with the subjects dressed in light clothing. Body mass index was calculated as weight (in kilograms) divided by the squared height (in meters).The measurements of the maternal blood pressure were performed with a single standard mercury sphygmomanometer while the patients were seated and resting. Hypertension was defined as a systolic BP of at least 140 mm Hg and/or a diastolic BP of at least 90 mm Hg on two occasions within at least 6 h apart. None of the participants had high blood pressure at the beginning of the study.

Sample Collection and Analysis

Five milliliters venous blood was taken from each participant after overnight fasting in the early morning. The serum was separated within 1 h of sampling by centrifugation .Then, all the samples were coded, and the serum was frozen at −70 °C and remained intact in the site until the end of the second phase of sampling. All the participants were followed each, 2 weeks from 24 until 36 weeks, each week up to delivery, and until 2 days after the delivery.

In the follow-up, any individual with acceptable criteria for preeclampsia, according to the National High Blood Pressure Education Program including blood pressure equal to or greater than 90/140 mm Hg on two occasions with an interval of 6 h measured with a single standard machine by one of the researchers and proteinuria equal to or greater than 300 mg in 24 h urine that is equal or greater than +1 in the urine-stick test were categorized in the preeclampsia group [14]. For each preeclamptic patient in this group, five matched maternal and gestational age pregnant women were selected from those healthy pregnant women in the first turn of blood sampling. Then, the second stage of sampling was done in the preeclamptic and selected healthy individuals. They were followed up until 48 h after delivery. One out of these five healthy matched pregnant women who did not develop signs of preeclampsia was randomly selected and considered as a control case. Forty-eight were excluded from our study population due to preterm delivery before the second phase of the test, occurrence of any internal diseases at each stage of sampling, and lack of cooperation. After two stages of blood sampling, Varian AA240FS, USA atomic absorption spectrometer with the Graphite Tube Atomizer was used to determine Se concentrations, using palladium chloride as chemical modifier. The absorbance was measured at a wavelength of 196 nm, and serum selenium estimation was calculated on the basis of computer-determined calibration graphs.

For all the newborns, the required parameters including gestational age, weight, length, head circumference, and Apgar scores were determined in the first minute of birth.

Statistical Analysis

In this study, statistical analysis was performed using SPSS 16 software. Values were expressed as mean ± standard deviation. An independent-samples t test was used for comparison of the quantitative variables between the patient and control groups. Chi-square test was utilized for the quantitative variables. A p value < 0.05 was considered significant. Percentiles of 25, 50, and 75 based on the levels of selenium from the first phase of the two groups were determined. The odds ratio of having preeclampsia for women in the lowest selenium tertile compared with the rest. Binary logistic regression was used to calculate odds ratios.

Results

Demographic Data and Incidence of Preeclampsia

Six hundred fifty pregnant primigravida women were included in this study. Preeclampsia was shown in about 5.84 % (38 individuals) of pregnancies; there were no significant differences in maternal age, anthropometric indices, and family history (incidence of preeclampsia, diabetes, hypertension) between the preeclamptic and control groups at baseline (Table 1).
Table 1

Demographic and clinical characteristics of patients and control groups

Variables

Control (n = 38), mean ± SD

Preeclampsia(n = 38), mean ± SD

P value

Maternal age, years

28.2 ± 3.12

28.4 ± 3.13

NS

Weight, kg

63.70 ± 10.10

62.24 ± 6.55

NS

Height, cm

161.7 ± 3.5

161.2 ± 2.2

NS

Body mass index, kg/m2

23.9 ± 3.33

24.95 ± 2.76

NS

Systolic blood pressure, mm Hg

105.44 ± 18.15

156.52 ± 17.2

<0.0001

Diastolic blood pressure, mm Hg

74.07 ± 11.03

96.11 ± 12.19

<0.0001

Gestation in first sampling, weeks

24.52 ± 1.23

25.4 ± 1.34

NS

Gestation at delivery, weeks

39.5 ± 1.2

32.6 ± 1.4

<0.0001

Cigarette smoker, n (%)

1 (2.63)a

1 (2.63) a

NS

Family history of Preeclampsia, n (%)

Family history of hypertension, n (%)

2 (5.26) a

1 (2.63) a

NS

Family history of diabetes, n (%)

4 (10.52) a

3 (7.89) a

NS

Oral contraception

3 (7.89) a

1 (2.63) a

NS

NS not significant

aNumber (%)

Serum Selenium Concentrations

In this study, the mean maternal plasma selenium levels of both case and control groups at baseline showed that the average selenium levels in the case group was lower than controls (70.63 ± 21.41 versus 82.03 ± 15.54 μg/L). At the end of study, the mean serum selenium in plasma in women with preeclampsia was lower as compared with those in women with normal pregnancy (71.22 ± 16.95 versus 80.27 ± 17.12 μg/L).

The mean maternal plasma selenium levels of both case and control groups at baseline and the end of the study showed that the average selenium levels in the case group was significantly lower than those in the controls (Fig. 1).
Fig. 1

Mean selenium levels in both phases in women with preeclampsia and women of control group

The values for specific percentiles (25th, 50th, 75th) based on the levels of selenium from the first stage of the two groups were determined. Selenium concentration classified as low if <25th percentile, medium if between 25th and 75th, and high if >75th percentile .Selenium concentrations in 42.1 % of cases (preeclampsia) were low (less than 62.2 μg/L) while only 7.9 % of the controls had low levels. This difference was statistically significant (p < 0.002). Selenium concentration less than 62.2 μg/L was associated with a significantly increased risk of preeclampsia (odds ratio, 9.14 [95 % CI, 2. 25–37.01]) compared with the high level (>74.7 μg/L). Selenium concentration between 62.2 and 74.7 μg/L was more common in women with normal pregnancy than in pregnant women with preeclampsia (odds ratio, 7.33 [ 95 % CI, 1.58–33.96]). The odds ratio of having preeclampsia, if it was in the lowest tertile as compared with the middle or upper, was markedly higher (odds ratio, 8.48 [95 % CI, 2.21–32.51]).

Further analyses were done on the preeclampsia group to determine if the severity of the disease correlated with selenium status. We did not find any differences in the mean time of delivery between the two groups (low versus above 62.2 μg/L) in preeclamptic patients.

Effect of Selenium Concentration on the Incidence of Complications in Newborns

All neonates survived in both groups’ newborn parameters including gestational age, birth weight, birth length, head circumference, and Apgar scores at the first minute of birth differed significantly between the case and control groups (Table 2).
Table 2

Characteristics of neonates in the case and control groups

 

Case

Control

P value

Apgar at 1 min (n)

6.89 ± 0.89

9 ± 0.67

<0.0001

Birth weight, g

2400 ± 223

2770 ± 300

<0.0001

Birth length, cm

48.57 ± 3.24

50.95 ± 2.63

<0.0001

Birth head circumflex, cm

34.28 ± 1.19

35.55 ± 0.99

<0.0001

When 76 neonates were divided into two groups according to the maternal serum concentration in basal state, using cutoff point 62.2, there were significant differences in gestational age and Apgar scores between two groups (Table 3).
Table 3

Comparison between neonatal characteristics according to maternal serum selenium concentration

 

Selenium < 62.2 μg/l

Selenium > 62.2 μg/l

P value

Gestational age, weeks

34.0 ± 2.38

36.9 ± 3.67

<0.0001

Apgar at 1 min (n)

7.52 ± .90

8.11 ± 1.40

0.037

Birth weight, g

2514 ± 175

2614 ± 355

NS

Birth length, cm

49.61 ± 3.80

49.85 ± 3.16

NS

Birth head circumflex, cm

34.57 ± 1.12

35.05 ± 1.29

NS

A multivariate analysis of covariance was performed to determine if the differences remained after controlling gestational age; no significant differences were observed after contorting it.

Discussion

Preeclampsia is an important cause of premature delivery because the only known treatment is delivery of the placenta. This results in neonatal morbidity and substantial increases in the cost of health care [15]. It is estimated that 2 % to 7 % of all pregnant women experience preeclampsia during their gestation, corresponding to our results from this study [16, 17]. Despite the considerable morbidity and mortality, the exact nature of the etiological factors is not known [18]. Placental ischemia may induce elevated circulating levels of placental debris, and these microparticles have been shown to be associated with inflammation and vascular damage [19]. In preeclampsia, there is a demonstrable increased oxidative stress in the placenta and maternal circulation [20, 21]. Decreased antioxidant activities have also been reported in women with preeclampsia [22]. Impairment of the antioxidant activity results in oxidative stress of the tissues [23, 24]. Use of antioxidant supplementations as a preventive strategy against preeclampsia has attracted a great deal of attention in recent years. Unfortunately, antioxidant vitamins did not have a protective effect on prevention of pre-eclampsia [25, 26, 27, 28, 29]. Micro- and macro-nutrient deficiencies are a common global public health problem, particularly among the women of reproductive age [30, 31]. The changes in levels of various nutrients during pregnancy could affect pregnancy outcome through alterations in maternal and fetal metabolism [32]. The trace element selenium is an essential component of the antioxidant selenoproteins including GPx which are important antioxidant enzymes [33]. Compared with non-pregnant women, lower concentrations of selenium as well as lower glutathione peroxidase activities in the whole blood and plasma have been reported in pregnant women, and this decrease in serum selenium concentration is progressive as gestation proceeds [34, 35].

The selenium levels seen in this study indicate the selenium status of Iranian women to be inadequate when compared with other studies [36, 37]. This difference could be due to local or regional differences in nutritional habits.

Recent studies have been conducted on the possible role of selenium deficiency in pathogenesis of preeclampsia. However, the data from these studies are so equivocal. Several studies have reported that selenium levels of amniotic fluid and cord blood in preeclamptic patients were significantly lower than non-affected ones [38, 39]. Rayman et al. [40] found significantly lower levels of plasma selenium in preeclamptic women than in healthy pregnant women. On the other hand, Gromadzinska et al. reported that the plasma selenium levels in their preeclamptic women were significantly higher than in the controls [12].

Our study showed a significant reduction in maternal selenium concentrations in the preeclampsia samples compared with the normal pregnant controls, and the pregnant women with serum Se < 62.2 μg/L had a significantly increased risk of preeclampsia. This is in line with most of the other studies [11, 13, 41, 42].

There are several ways in which selenium in selenoproteins could reduce the risk and severity of preeclampsia. The reduced selenium concentrations might adversely affect the functional activities of the selenoproteins, leading to inability to protect against oxidative damages [43]. Selenoproteins, as functional components of the physiological antioxidant system, protect the endothelium by controlling the cytokine-induced adhesion molecule expression and by reducing inflammation [44].

Another way by which the glutathione peroxidases reduce the damage to the endothelium damage is through their ability to reduce hydrogen peroxide, lipid, and phospholipid hydroperoxides [45]. In view of the established link between oxidative stress and the development of systemic endothelial dysfunction, our study thus reaffirms that the observed low selenium status of our patients predisposes to preeclampsia development.

Conclusion

Our study shows that plasma selenium concentrations were significantly lower in women with preeclampsia as compared with those in normal pregnant women. The reduced selenium in the maternal circulations observed in the preeclamptic mothers support the hypothesis that insufficient selenium concentration may be a contributing factor to the pathophysiological mechanisms associated with preeclampsia, and optimal dietary selenium supplement may have a potential clinical benefit. However, further studies are required to investigate the role of selenium deficiency in preeclampsia.

Notes

Acknowledgments

Hereby, I would like to thank the vice chancellor for research of Shiraz University of Medical Sciences and Endocrine and Metabolism Research Center of Shiraz University of Medical Sciences for their financial support. The authors would like to thank Dr. Nasrin Shokrpour at Center for Development of Clinical Research of Nemazee Hospital for editorial assistance.

Conflict of Interest

The authors have no conflicts of interest to disclose.

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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Seyede Zahra Ghaemi
    • 1
  • Sedighe Forouhari
    • 2
  • Mohammad Hossein Dabbaghmanesh
    • 3
  • Mehrab Sayadi
    • 4
  • Marzieh Bakhshayeshkaram
    • 5
  • Faride Vaziri
    • 6
  • Zohreh Tavana
    • 7
  1. 1.Department of Midwifery, Estahban branchIslamic Azad UniversityEstahbanIran
  2. 2.Shiraz Infertility Research CenterShiraz University of Medical SciencesShirazIran
  3. 3.Shiraz Endocrinology and Metabolism Research CenterShiraz University of Medical SciencesShirazIran
  4. 4.Shiraz University of Medical SciencesShirazIran
  5. 5.Endocrine and Metabolism Research CenterShiraz University of Medical SciencesShirazIran
  6. 6.Department of Midwifery, School of Nursing and Midwifery Hazrat Fatemeh (P.B.U.H)Shiraz University of Medical SciencesShirazIran
  7. 7.Department of Obstetrics and GynecologyShiraz University of Medical SciencesShirazIran

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