The Impact of Hypertensive Disorders of Pregnancy on Neonatal Adverse Outcomes and Inflammatory Markers

doi:10.21203/rs.3.rs-4948317/v1

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The Impact of Hypertensive Disorders of Pregnancy on Neonatal Adverse Outcomes and Inflammatory Markers

https://doi.org/10.21203/rs.3.rs-4948317/v1

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Background

Hypertensive disorders of pregnancy (HDP), including pregnancy-induced hypertension (PIH), mild preeclampsia (MPE), and severe preeclampsia (SPE), significantly impact maternal and neonatal health [1]. These conditions are associated with increased risks of cesarean section, placental abruption, preterm birth, and neonatal inflammation [2]. The inflammatory state of neonates is closely linked to their development and can influence both short-term and long-term health outcomes [3, 4]. However, the specific relationships between HDP and neonatal inflammatory markers remain underexplored. This study aimed to assess inflammation levels in neonates born to mothers with HDP, providing scientific evidence for clinical intervention and management.

Methods

This study included pregnant women diagnosed with HDP and their neonates at the Zengcheng Branch of Nanfang Hospital from January 2021 to December 2023. Maternal and neonatal characteristics, along with inflammatory markers within the first day of birth, were compared among the PIH (n = 40), MPE (n = 35), and SPE (n = 50) groups. Neonatal development was tracked at 14 and 28 days post-birth.

Results

Compared with the other groups, the SPE group had a significantly higher incidence of preterm birth, low birth weight, and respiratory distress syndrome (P < 0.001). The white blood cell and neutrophil counts were significantly lower in the SPE group than in the PIH and MPE groups (P < 0.05). Inflammatory markers, including the neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and pan-immune-inflammation value (PIV), were also significantly reduced in the SPE group (P < 0.05). Compared with the PIH group, the MPE group presented greater neutrophil counts and PIV (P < 0.05). These differences persisted even after adjusting for preterm birth. Additionally, term neonates in the SPE group had significantly lower birth lengths and weights (P < 0.05), although no significant differences were observed among the groups at 28 days post-birth.

Conclusions

Severe preeclampsia significantly affects neonatal inflammatory states and growth, increasing the risk of adverse outcomes. While mild preeclampsia enhances the inflammatory response, severe preeclampsia appears to induce neonatal immunosuppression, potentially increasing the risk of infection and leading to short-term and long-term health complications.

hypertensive disorders of pregnancy

adverse pregnancy outcomes

inflammatory markers

development

maternal and neonatal health

Preeclampsia, characterized by the onset of hypertension and proteinuria after 20 weeks of gestation, can lead to multisystem dysfunction affecting both the mother and child [1, 5]. Hypertensive disorders of pregnancy, particularly preeclampsia, are associated with high rates of cesarean section [6], placental abruption [7], abnormal placental cord insertion [8], and other complications. Placental dysfunction is central to the pathogenesis of preeclampsia, and directly impairs fetal blood supply and nutrition, which can result in intrauterine growth restriction (IUGR) and preterm birth [9]. Maternal hypertension and placental insufficiency also cause significant alterations in neonatal hematological parameters, including leukopenia, neutropenia, and thrombocytopenia [10, 11]. These hematological abnormalities further compromise the neonatal immune response, especially in preterm infants who have an immature immune system, increasing their vulnerabilityto inflammation and infection [12, 13].

Neonatal inflammation is linked to adverse perinatal outcomes and developmental delays, potentially increasing the risk of chronic diseases in adulthood [14–16]. Therefore, assessing the inflammatory state of neonates born to mothers with hypertensive disorders of pregnancy is crucial for understanding the long-term health implications for these infants. Recently, systemic inflammatory markers derived from complete blood count, such as the neutrophil-to-lymphocyte ratio (NLR), systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and pan-immune-inflammation value (PIV), have gained attention. Research has increasingly focused on the relationship between these markers and maternal-fetal complications in obstetric care [17–20]. These markers provide a simple yet effective means of assessing systemic inflammation. This study investigated white blood cell count, neutrophil count, and these systemic inflammatory markers in neonates, and examined the impact of varying degrees of hypertensive disorders of pregnancy on neonatal inflammatory status, thereby offering clinicians scientific evidence to better manage high-risk pregnancies and neonatal care.

Study population

The study population comprised pregnant women diagnosed with hypertensive disorders of pregnancy and their neonates, and who were delivered at the Zengcheng Branch of Nanfang Hospital between January 2021 and December 2023. The inclusion criteria require pregnant women to meet the diagnostic criteria for hypertensive disorders of pregnancy [5], including pregnancy-induced hypertension (PIH), mild preeclampsia (MPE), and severe preeclampsia (SPE). The exclusion criteria included women with chronic hypertension, chronic hypertension complicated by preeclampsia, gestational diabetes, and infectious diseases.

Pregnancy-induced hypertension (PIH) is defined as hypertension (systolic blood pressure ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg) that develops after 20 weeks of gestation, without the presence of proteinuria or other signs of preeclampsia. Preeclampsia is characterized by new-onset hypertension after 20 weeks of gestation, accompanied by new, unexplained proteinuria (≥ 300 mg/24 hours or a dipstick urine protein level of 1+) and/or signs of end-organ dysfunction. Women presenting with severe-range blood pressures (systolic blood pressure ≥ 160 mm Hg and/or diastolic blood pressure ≥ 110 mm Hg) are diagnosed with severe preeclampsia.

Data collection

Clinical data, including maternal age, weight, body mass index (BMI), gestational weight gain, obstetric history, placental pathology results, and pregnancy complications, were obtained from the hospital’s electronic medical record system. The neonatal data encompassed gender, weight, length, and clinical diagnosis at discharge.

Within 24 hours of birth, 2 ml of peripheral venous blood was collected from the neonates, and a complete blood cell analysis was performed via the Mindray BC-6800/BC-6900 hematology analyzer. Pediatricians measured the length, weight, and neonatal behavioral neurological assessment (NBNA) scores at birth, 14 days, and 28 days for term neonates. The NBNA is a 20-item Chinese neonatal behavioral nerve score, with a score greater than 36 considered normal.Systemic inflammatory marker levels were calculated via complete blood count as follows:

NLR (neutrophil-to-lymphocyte ratio) = neutrophil count / lymphocyte count
SII (systemic immune-inflammation index) = platelet count × neutrophil count / lymphocyte count
SIRI (systemic inflammation response index) = neutrophil count × monocyte count / lymphocyte count
PIV (pan-immune-inflammation value) = platelet count × neutrophil count × monocyte count / lymphocyte count

Statistical analysis

The data were analyzed via SPSS 26.0 software, and graphs were generated via GraphPad Prism 9.0. Categorical variables were expressed as frequencies and percentages, with group comparisons performed via the chi-square test. Continuous variables were expressed as the mean ± standard deviation (Mean ± SD) for normally distributed data or as median (interquartile range) for non-normally distributed data. Group comparisons for continuous variables were conducted via one-way analysis of variance (ANOVA). A P-value of < 0.05 was considered to indicate to indicate statistical significance.

Clinical data of pregnant women with hypertensive disorders of pregnancy and their neonates

Weight gain during pregnancy was highest in the MPE group (18.33 ± 6.54 kg) compared to the other two groups (P < 0.05). The SPE group exhibited the highest incidence of placental abruption(P < 0.01) and abnormal placental cord insertion, including 7 cases of circumvallate placenta and 1 case of velamentous insertion (P < 0.05), as shown in Table 1. Additionally, there was 1 case of chorioamniotic hematoma in the MPE group and 1 case of a single umbilical artery in the SPE group.

Table 1

Comparison of maternal characteristics with hypertensive disorders of pregnancy
	PIH (n = 40)	MPE (n = 35)	SPE (n = 50)	F/χ2	P
Age (years, mean ± SD)	30.55 ± 5.1	29.09 ± 4.70	31.1 ± 4.92	1.721	0.175
BMI (kg/m², mean ± SD)	24.34 ± 7.33	22.42 ± 3.04	22.35 ± 3.63	0.923	0.133
Weight gain (kg, mean ± SD) Gestational age (weeks, mediansand interquartile ranges)	14.77 ± 5.52 [37,39]38	18.33 ± 6.54 [38,39]39	15.51 ± 5.29 [35,38]36	3.471 25.715	0.023 < 0.001
Cesarean section (n%) Umbilical cord twisting (n%) Abnormal placental cord insertion (n%) Amniotic fluid pollution(n%) Premature rupture of membranes(n%) Placental abruption (n%)	18(45.00) 4(10.00) 0(0.00) 6(15.00) 5(12.50) 0(0.00)	12(34.30) 2(5.70) 3(8.60) 7(20.00) 6(17.10) 0(0.00)	41(82.00) 7(14.00) 8(16.00) 6(12.00) 3(6.00) 6(12.00)	22.440 1.527 7.092 1.024 2.670 9.454	< 0.001 0.466 0.029 0.599 0.263 0.009

Compared with the other groups,neonates born to women in the SPE group had significantly lower birth weights and lengths (P < 0.001). The incidence of preterm birth, low birth weight, and respiratory distress syndrome was significantly higher in the SPE group (P < 0.001). The totaladverse outcome rate in the SPE group was 74%, including 26 cases of preterm birth, 29 cases of low birth weight, 1 case of neonatal asphyxia, 12 cases of respiratory distress syndrome, 3 cases of neonatal shock, and 12 cases of neonatal infection, as detailed in Table 2.

Table 2

Comparison of neonatal characteristics between mothers with hypertensive disorders of pregnancy
	PIH (n = 40)	MPE (n = 35)	SPE (n = 50)	F/χ2	P
Gender (male) (n%) Weight (g, mean ± SD) Length (cm, medians and interquartile ranges) Preterm birth (n%) Low birth weight(n%) Neonatal asphyxia (n%) Respiratorydistresssyndrome (n%) Neonatal shock (n%) Neonatal infection (n%) Adverse outcomes (n%)	27(67.50) 3079.88 ± 46 [49,50]50 3(7.50) 6(15.00) 4(10.00) 0(0.00) 0(0.00) 7(17.50) 16(40.00)	20(57.14) 3066.43 ± 49 [49,50]50 5(14.30) 4(11.40) 4(11.40) 0(0.00) 1(2.90) 4(11.40) 13(37.14)	23(46.00) 2374.40 ± 603. [44,49]48 26(52.00) 29(58.00) 1(2.00) 12(24.00) 3(6.00) 12(24.00) 37(74.00)	4.195 24.952 31.404 26.317 27.994 3.429 19.912 2.601 2.199 15.090	0.123 < 0.001 < 0.001 < 0.001 < 0.001 0.180 < 0.001 0.272 0.333 0.001

Levels of inflammatory markers in neonates

The white blood cell count, neutrophil count, and inflammatory markers were significantly lower in the SPE group than in the PIH and MPE groups (P < 0.05). Additionally, the neutrophil count and pan-immune-inflammation value (PIV) were higher in the MPE group than in the PIH group (P < 0.05), as illustrated in Fig. 1. After excluding data from preterm neonates, the differences in white blood cell count, neutrophil count, and inflammatory markers among term neonates in the three groups remained significant, as shown in Fig. 2. However, no significant differences were observed in the neutrophil count and inflammatory markers between term neonates in the SPE and PIH groups (P > 0.05).

Growth and development in term neonates

Term neonates in the SPE group had a significantly lower length at birth (47.71 ± 1.73 cm) compared to those in the PIH group (49.27 ± 1.47 cm) (P < 0.01) and the MPE group (49.53 ± 1.76 cm) (P < 0.001). This difference in length persisted on day 14, with the SPE group measuring 49.96 ± 1.89 cm, which was lower than the PIH group (51.24 ± 1.61 cm) (P < 0.05) and the MPE group (51.43 ± 1.85 cm) (P < 0.01), as shown in Fig. 3A. Birth weight was also significantly lower in the SPE group (2.84 ± 0.51 kg) than in the PIH group (3.22 ± 0.40 kg) (P < 0.01) and the MPE group (3.25 ± 0.51 kg) (P < 0.01). However, at 14 days and 28 days post-birth, there were no significant differences in weight among the three groups (P > 0.05), as shown in Fig. 3B. The neonatal behavioral neurological assessment (NBNA) scores were within the normal range at all three time points across all the groups, as shown in Fig. 3C.

This study compared neonatal outcomes and white blood cell, neutrophil, and inflammatory marker levels in neonates born to mothers with hypertensive disorders of pregnancy (PIH, MPE, and SPE). These findings highlight the impact of varying degrees of hypertensive disorders of pregnancy on neonatal growth, development, and immune-inflammatory status. Compared with those in the other groups,neonates in the SPE group had significantly lower birth weights and lengths, with higher rates of preterm birth, low birth weight, and respiratory distress syndrome. These results are consistent with previous research [2], indicating that SPE severely impacts fetal intrauterine growth, increasing the risk of growth restriction and preterm birth. This may be due to placental dysfunction caused by SPE, which affects fetal nutrition and the oxygen supply, thereby impacting growth and development [21–23]. Even after adjusting for preterm birth, term neonates in the SPE group still presented lower birth weights and lengths compared to those in the other groups. However, at 14 and 28 days post-birth, there were no significant differences in weight among the groups, suggesting that while SPE negatively affects early growth and development, this impact does not persist postnatally. Additionally, the NBNA scores were within the normal range across all groups, indicating that preeclampsia has minimal short-term impact on the neurobehavioral development of term neonates.

Maternal hypertension can alter neonatal neutrophil kinetics, with preeclampsia often leading to neonatal neutropenia [24, 25]. In this study, we observed significantly lower white blood cell and neutrophil counts in the SPE group than in the other groups. This reduction may be related to placental insufficiency and the resulting suppression of fetal bone marrow hematopoiesis [26]. Neutrophil counts were particularly low in preterm neonates within the SPE group, likely due to their immature immune systems, which lead to significant deficiencies in neutrophil production and function [27, 28]. These differences persisted even after adjusting for preterm birth, further demonstrating that SPE may impair neonatal immune function. Interestingly, the neutrophil count in the MPE group was higher than in the PIH group, suggesting that mild and severe preeclampsia differentially impact neonatal immune function.

Preeclampsia is known to create a pro-inflammatory immune environment in neonates [26]. In this study, the level of inflammatory markers in both term and preterm neonates born to mothers with hypertensive disorders of pregnancy were higher than those reported for normal term [29] and preterm neonates [19] within the first day of birth. These finding indicate that hypertensive disorders of pregnancy increase the inflammatory response in neonates. There are significant differences in the inflammatory state between term and preterm neonates, with preterm neonates experiencing poor regulation of inflammatory responses due to an immature immune system [30, 31]. After excluding preterm neonates, inflammatory markers in term neonates from the SPE group increased but remained lower than those in the MPE group. Additionally, PIV was higher in the MPE group than in the PIH group. These findings reinforce the association between the severity of preeclampsia and impaired neonatal immune function, where mild preeclampsia enhances inflammatory responses, whereas severe preeclampsia suppresses them.

Inflammation plays a critical role in neonatal development, and abnormal inflammatory states may be linked to impaired immune function, increasing the risk of infection and other complications [32, 33]. In this study, the level of inflammatory markers, such as the NLR, SII, SIRI, and PIV, were significantly lower in neonates from the SPE group than in those from the other groups. These markers are important for assessing systemic inflammatory states, and the results suggest that the systemic inflammatory response induced by SPE is weaker, potentially increasing the risk of infection. Although the SPE group had the highest proportion of neonatal infections, the infection rates did not significantly differ among the groups, likely due to medical interventions, sample size limitations, and other factors such as delivery mode and maternal health.

Hypertensive disorders of pregnancy, particularly severe preeclampsia, negatively impact neonatal immune function and early growth. While this study focused primarily on short-term inflammatory responses after birth, neonates exposed to preeclampsia may be at increased risk for chronic inflammation-related diseases in the future [34, 35]. This potential long-term health risk underscores the importance of early intervention and ongoing monitoring. The lower inflammatory markers observed in the SPE group may have led to more health issues during early development, including growth retardation and immune deficiency. Therefore, assessing and managing the inflammatory state of neonates born to mothers with SPE is crucial for improving long-term health outcomes.

This study provides valuable evidence for clinicians to identify and manage high-risk neonates. Early monitoring and interventions for SPE mothers, such as optimizing perinatal care, enhancing placental function monitoring, and timely cesarean delivery, can significantly improve maternal and neonatal health outcomes. Specifically, early interventions for neonatal inflammation, such as appropriate antibiotic therapy and immune support, should be implemented to reduce the risk of infection and improve long-term health. Despite its valuable findings, this study has everal limitations. The relatively small sample size may affect the generalizability of the results, and inflammatory markers were measured only within 24 hours of birth, which may not fully reflect the dynamic changes in the inflammatory state. Future studies should include large-scale, multicenter prospective studies to further validate and expand upon these findings.

Overall, severe preeclampsia significantly affects neonatal growth and inflammation, increasing the risk of adverse outcomes. Early identification and intervention in pregnant women with hypertensive disorders of pregnancy can effectively improve neonatal health outcomes. This study provides scientific evidence for clinical practice, emphasizing the importance of optimizing perinatal management and interventions to enhance long-term maternal and neonatal health.

HDP

Hypertensive disorders of pregnancy

PIH

Pregnancy-induced hypertension

MPE

Mild preeclampsia

SPE

Severe preeclampsia

NLR

Neutrophil-to-lymphocyte ratio

SII

Systemic immune-inflammation index

SIRI

Systemic inflammation response index

PIV

Pan-immune-inflammation value

IUGR

Intrauterine growth restriction

BMI

Body mass index

NBNA

Neonatal behavioral neurological assessment

Ethics approval and consent to participate

Approval for the study was obtained from the Ethics Committee of Nanfang Hospital of Southern Medical University (SMUL2022002), and informed consent was obtained from the participants.

Consent for publication

Not applicable.

Data availability statement

Data will be made available on request.

Declaration of Interest Statement

No potential conflict of interest was reported by theauthor(s).

Funding

The author(s) reported there is no funding associated withthe work featured in this article.

Author contribution statement

Conceptualization: Yumin Liang, Shafei Zou, Congrong Wang. Data curation: Yumin Liang, Shafei Zou, Caihong Qiu. Resources: Duoduo Liu. Software: Yumin Liang, Ying Liu. Supervision: Yongmei Wang. Writing – original draft: Yumin Liang. Writing – review & editing: Congrong Wang. The author(s) read and approved the final manuscript.

Acknowledgements

The authors acknowledge support from the Laboratory Department of Zengcheng Branch, Nanfang Hospital, Southern Medical University, as well as the Department of Pediatrics, Zengcheng Branch, Nanfang Hospital, Southern Medical University.

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You are reading this latest preprint version

The Impact of Hypertensive Disorders of Pregnancy on Neonatal Adverse Outcomes and Inflammatory Markers

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Materials and Methods

Study population

Data collection

Statistical analysis

Results

Clinical data of pregnant women with hypertensive disorders of pregnancy and their neonates

Levels of inflammatory markers in neonates

Growth and development in term neonates

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1