The Journal of Maternal-Fetal and Neonatal Medicine, May 2010; 23(5): 425–430

Neonatal outcomes of premature infants born to preeclamptic mothers

MERIH ÇETINKAYA1, HILAL ÖZKAN1, NILGÜN KÖKSAL1, ZUHAL KARALI2, & TANER ÖZGÜR2
1
Department of Neonatology, and 2Department of Pediatrics, School of Medicine, Uludag University, Bursa, Turkey
(Received 21 October 2008; revised 12 July 2009; accepted 13 July 2009)
J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of California Irvine on 11/07/14

Abstract
Objective. Only limited studies with conflicting results are available on neonatal morbidity and mortality in infants born to
preeclamptic mothers. The objective of this study was to evaluate neonatal morbidity and mortality in premature infants born
to preeclamptic mothers.
Methods. Premature infants who were admitted to Uludag University, School of Medicine, Neonatal Intensive Care Unit
between June 2006 and December 2007 were included in this study. The infants were evaluated according to their
demographic characteristics and neonatal morbidities.
Results. Fifty-one infants born to preeclamptic mothers (study group) and 33 gestational age- and gender-matched infants
born to normotensive mothers (control group) were included in this study. No statistical difference was found between the
two groups in terms of demographic characteristics. However, frequency of neutropenia, duration of mechanical ventilation,
and neonatal sepsis rates were found to be significantly higher in the study group compared with those of the control group.
Although the rates of other neonatal morbidities such as bronchopulmonary dysplasia, retinopathy of prematurity,
intraventricular hemorrhage and necrotising enterocolitis were found to be higher in the study group, the difference was not
statistically significant. Mortality rates were also found to be similar in both groups.
For personal use only.

Conclusions. The infants born to preeclamptic mothers had significantly higher rates of neutropenia and sepsis. There were
no significant difference in terms of other neonatal morbidities and neonatal mortality between the study and the control
group.
Keywords: Preeclamptic mother, premature infant, neonatal outcome

Introduction mortality risk in premature infants born to preeclamptic

Preeclampsia, which is characterised by hypertension,
proteinuria and edema, is among the major causes of
fetomaternal morbidity and mortality [1]. Preeclampsia
complicates 2–8% of all pregnancies and progressively
deteriorates maternal general condition [2]. Although the
etiology and pathogenesis of preeclampsia is not fully
known, the placenta is thought to be involved in the
evolution of this disorder, and, therefore, delivery of the
fetus and placenta has been accepted as the only effective
treatment in preeclampsia [3]. Although delivery may be
beneficial for the mother, delivery before 34 gestational
weeks is associated with increased risk of neonatal
morbidity and mortality due to prematurity [4].
Neonatal outcomes in infants born to preeclamptic
mothers are primarily associated with severity of prema-
turity and small gestational age [5,6]. Gestational age at the
time of delivery was shown to be the main prognostic factor
for neonatal mortality and adverse neonatal outcomes in
severe preeclampsia [7]. Only limited studies have in-
vestigated neonatal outcomes of infants born to pree-
clamptic mothers; however, results are conflicting.
Preeclampsia was found to have a protective effect on
neonatal outcomes in some of these studies [8,9], whereas
some others reported higher neonatal morbidity and
mothers compared with other preterm infants [10].
The aim of this study was to evaluate the effect of maternal
preeclampsia on neonatal morbidity and mortality in
premature infants born to preeclamptic mothers in compar-
ison with preterm infants born to normotensive mothers.
Methods
A total of 51 premature infants born to preeclamptic
mothers less than 37 weeks of gestational age who were
admitted to Uludag University, School of Medicine,
Neonatal Intensive Care Unit between June 2006 and
December 2007 were included in this study. The control
group consisted of 33 gestational age-matched premature
infants born to normotensive mothers. All infants in the
control group were born prematurely due to acute fetal
distress. To eliminate the effects of maternal diseases on
neonatal outcomes, mothers with a history of maternal
chorioamnionitis, prolonged rupture of membranes, dia-
betes, or use of any medication during pregnancy were not
included in the study. In addition, infants with congenital
abnormalities or chromosomal anomalies were excluded
from the study. The study protocol was approved by the
Ethics Committee of Uludag University, School of

Correspondence: Merih Çetinkaya, Uludag Üniversitesi Tıp Fakültesi, Çocuk Saglıgı ve Hastalıkları ABD, Görükle, Bursa 16059, Turkey.
Tel: þ00-90-224-2950447. Fax: þ00-90-224-4428143. E-mail: drmerih@yahoo.com
ISSN 1476-7058 print/ISSN 1476-4954 online Ó 2010 Informa UK Ltd.
DOI: 10.3109/14767050903184173
 426 M. Çetinkaya et al.

Medicine. Informed parental consent was obtained for all
infants.
A detailed history from mothers including maternal age,
gravidity, antenatal steroid use, medications used in
pregnancy, route of delivery and premature rupture of
the membranes (PROM) was obtained and recorded.
Gestational history of infants including birth weight,
gestational age, gender, Apgar scores, small for gestational
age (SGA), intrauterine growth retardation (IUGR), need
for resuscitation, presence of respiratory distress syndrome
(RDS), neonatal sepsis, intraventricular hemorrhage
(IVH), bronchopulmonary dysplasia (BPD), necrotising
enterocolitis (NEC) and retinopathy of prematurity (ROP)
was obtained and recorded. Laboratory findings (leucocyte
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parameters were processed according to Manroe and
Rodwell scoring systems [18,19]. Leukopenia was defined
as leukocyte count 55000/mm3; leukocytosis was defined
as leucocyte count 425,000/mm3 at birth, 430,000/mm3
at 12–24 h and 421,000/mm3 after the second day.
Thrombocytopenia was defined as platelet count
5150,000/mm3. Normal absolute neutrophil count was
accepted as 7800–14,500/mm3 in the first 60 h and 1750–
5400/mm3 after 60 h. Gestational age was evaluated by
maternal dates and confirmed by the modified Ballard
examination [20]. SGA was defined as birth weight below
10th percentile according to the Lubchenco intrauterine
growth scale.
Statistical analyses were made using SPSS 13 for

count, platelet count, hemoglobin) and their follow-up
values during hospitalisation were recorded. Data regarding
the ventilation characteristics, duration of ventilation,
duration of total supplemental oxygen, duration of hospital
stay and mortality rate of infants were also recorded.
Preeclampsia was defined as a blood pressure of 140/
90 mmHg together with albuminuria of at least 300 mg/
24 h after 20 weeks of gestation [11]. RDS was diagnosed
according to clinical findings (tachypnea, retractions, nasal
flaring and cyanosis) or radiological findings (reticular
granular pattern or air bronchograms) [12]. Infants were
diagnosed as neonatal sepsis according to the criteria
defined by Gitto et al. [13] (Table I). IVH was evaluated by
cranial ultrasound examinations that were performed by
the same pediatric radiologist and diagnosed using the
Papile classification system [14]. BPD was defined as
For personal use only.
Windows Packet Program. Mann–Whitney U-test, Krus-
kal–Wallis test, ANOVA test and t-test were used for
evaluation of the differences between the groups. Correla-
tions between quantitative data were analysed by Spearman
correlation test. Values of P 5 0.05 were considered
significant.
Results
Fifty-one infants born to preeclamptic mothers (study
group) and 33 gestational age- and gender-matched infants
born to normotensive mothers (control group) were
included in this study. Mean gestational age of the study
group and the control group were 31.2 + 2.6 weeks and
31.4 + 2.7 weeks, respectively. Mean birth weights of the

oxygen dependency at 36-weeks postconceptional age for study group and the control group were 1353 + 502 g and
532 gestational age or at 28 days of age for 432 1554 + 613 g, respectively, and the differences between
gestational age [15]. NEC was diagnosed using Bell the groups were not statistically different (P 4 0.05). Also,
criteria [16]. ROP was classified according to the Interna- there were no differences between the two groups in terms
tional Classification of ROP [17]. Changes in hematologic of gender, Apgar scores at minute 1 and 5 or antenatal
corticosteroid use. Although the rate of cesarean delivery
was higher in the study group (78% vs. 60%), the
Table I. Criteria employed for defining neonatal sepsis. difference was not statistically significant (P 4 0.05). The
number of infants with SGA was significantly higher in the
Groups Criteria study group and the difference was significant (P 5 0.05).
Table II shows the demographic features.
Group 1 At least three sepsis-related clinical signs* RDS was diagnosed in 23 infants (45%) in the study
High probable CRP 41 mg/dl group and in 15 infants (45%) in the control group, and
sepsis At least two other altered serum parameters
in addition to CRP**
Blood culture; positive or negative
Table II. Demographic features of study and control groups.
Group 2 Less than three sepsis-related clinical signs*
Probable sepsis CRP 41 mg/dl
Demographic Study group Control
At least two other altered serum parameters
features (n ¼ 51) group (n ¼ 33) P value
in addition to CRP
Blood culture; negative Gestational 31.2 + 2.6 31.4 + 2.7 40.05
Group 3 Less than three sepsis-related clinical signs* age (week)
Possible sepsis CRP 51 mg/dl Birth weight (g) 1353 + 502 1554 + 613 40.05
Less than two other altered serum Caesarean 40 (78) 20 (60) 40.05
parameters delivery, n (%)
Blood culture; negative Gender 21/30 12/21 40.05
Group 4 No sepsis-related clinical signs* (male/female)
No sepsis CRP 5 1 mg/dl Apgar score at 4.02 + 1.9 4.5 + 1.76 40.05
No altered serum parameters 1 minute
Blood culture; negative Apgar score 6.5 + 1.65 6.9 + 1.5 40.05
at 5 minutes
CRP, C-reactive protein. Antenatal 19 (37) 14 (42) 40.05
*Sepsis-related clinical signs: temperature instability, apnea, need corticosteroid,
for supplemented oxygen, need for ventilation, tachycardia/ n (%)
bradycardia, hypotension, feeding intolerance, abdominal dis- Small for 33 (65) 13 (39) 50.05
tension, necrotising enterocolitis. gestational age
**Serum parameters other than CRP: white blood cell count, (SGA), n (%)
absolute neutrophil count, platelet count.
 Neonatal outcomes of preeclamptic mother infants 427

this difference was not significant. Neonatal sepsis was Table III. Comparison of perinatal outcomes and laboratory
diagnosed in 25 infants (49%) and in 7 infants (21%) in the findings of study and control groups.
study and the control group, respectively; the difference in
neonatal sepsis rate was statistically significant (P ¼ 0.02). Study Control
There were no significant differences in terms of ROP, Perinatal outcomes group (n ¼ 51) group (n ¼ 33) P value
IVH, NEC, hypoglycemia and hyperbilirubinemia between
the study and control group (P 4 0.05). Sepsis, n (%) 25 (49) 7 (21) 0.02
Neutropenia was found in 27 infants (53%) and RDS, n (%) 23 (45) 15 (45) 0.57
10 infants (33%) in the study and the control IVH, n (%) 11 (21.6) 5 (15.2) 0.57
group, respectively; the difference in neutropenia was BPD, n (%) 13 (15.5) 6 (7.1) 0.6
statistically significant (P ¼ 0.03). Mean leukocyte counts ROP, n (%) 8 (15.7) 2 (6.1) 0.3
were 3200 + 1250/mm3 (range: 1200–4750/mm3) and NEC, n (%) 23 (45.1) 10 (30.3) 0.25
4100 + 450/mm3 (range: 3550–4950/mm3) in neutropenic Neutropenia, 27 (54) 10 (30) 0.03
infants in the study group and the control group, n (%)
Thrombocytopenia, 34 (66.7) 18 (54.5) 0.35
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respectively (P 5 0.05). Neutropenia developed at

2.29 + 1.03 days and 3.01 + 0.86 days of life in the study n (%)
group and the control group, respectively (P 4 0.05). Hypoglycemia, n (%) 19 (37.3) 11 (33) 0.44
Duration of neutropenia was 1.78 + 2.22 days and Hyperbilirubinemia, 46 (90) 28 (85) 0.5
1.03 + 1.77 days in the study group and the control group, n (%)
respectively; the difference was not significant (P ¼ 0.07). Duration of 12.9 + 19.7 4.9 + 5.7 0.009
Neutropenia was resolved in all infants in each group at mechanical
discharge. There was no significant difference in terms of ventilation (days)
neonatal sepsis development between neutropenic (n ¼ 27) Total oxygen duration 21.5 + 24.8 13 + 19.9 0.025
and non-neutropenic infants (n ¼ 24) born to preeclamptic (days)
mothers. There was also no significant difference between Primary hospital stay 45.5 + 17.7 40.3 + 15.4 0.45
the study group and the control group in terms of (days)
thrombocytopenia (P 4 0.05). Mortality rate was higher Neonatal mortality, 17 (34) 13 (39) 0.39
in the study group compared with the control group (39 vs. n (%)
34%), but the difference between the groups was not
significant (P 4 0.05). RDS, respiratory distress syndrome; IVH, intraventricular hemor-
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The duration of oxygen administration was 21.5 + 24.8
days and 13 + 19.9 days in the study group and control
group, respectively, and this difference was statistically
significant (P ¼ 0.025). Duration of mechanical ventilation
was 12.9 + 19.7 days and 4.9 + 2.7 days in the study
group and control group, respectively, and this difference
was statistically significant (P ¼ 0.009). Although duration
of oxygen therapy and mechanical ventilation were
significantly longer in the study group compared with the
control group, BPD was not significantly higher (15.5% vs.
7.1%) (P 4 0.05). Also, no difference was found between
the groups with regard to duration of hospital stay
(45.5 + 17.7 days vs. 40.3 + 15.4 days) (P 4 0.05). Table
III shows the comparison of rates of neonatal morbidity
and mortality, and laboratory findings between the two
groups.
To evaluate the effect of gestational age on neonatal
morbidity, mortality and laboratory findings, the study
and the control groups were also classified into three
subgroups according to the infants’ gestational ages as
Group 1 (528 weeks gestational age), Group 2 (28–32
weeks gestational age) and Group 3 (32–36 weeks
gestational age). Groups 1, 2 and 3 contained 15 infants
(8 from study group, 7 from control group), 41 infants
(28 from study group, 13 from control group) and 28
infants (15 from study group, 13 from control group),
respectively. Although there were no differences between
the study and the control group in terms of RDS,
neonatal sepsis, BPD, ROP, IVH, NEC and mortality
rates (P 4 0.05), duration of neutropenia was significantly
longer in the study group compared with the control
group (2.37 + 2.13 days vs. 0.28 + 75 days) (P ¼ 0.04) in
Group 1. The rate of neutropenia was also significantly
higher in the study group (75% vs. 14.3%) (P ¼ 0.02) in
Group 1. No significant difference was found between the
study group and the control group in terms of neonatal
morbidity, mortality and laboratory findings in Groups 2
and 3 (P 4 0.05).
rhage; BPD, bronchopulmonary dysplasia; ROP, retinopathy of
prematurity; NEC, necrotising enterocolitis.
The number of infants with SGA was significantly higher
in the study group (65%) compared with that in the control
group (39%). Also, mean birth weight of infants in the
study group were lower compared with that in the control
group (1353 + 502 g vs. 1554 + 613 g); however, the
difference was not statistically significant (P 4 0.05).
Infants in the study group were hospitalised longer than
those in the control group (45.5 + 17.7 days vs.
40.3 + 15.4 days) (P 4 0.05). Although all infants in study
and control groups gained weight (1950 + 445 g and
2350 + 530 g, respectively), increased in length
(39.2 + 2.9 cm to 42.1 + 3.5 cm, respectively) and had
an increased head circumference (32.2 + 1.4 cm to
33.4 + 1.6 cm, respectively) at discharge, improvements
in such growth parameters were smaller in infants with
SGA compared with others in either group.
The number of infants with IVH were higher in the study
group compared with those in the control group (21% vs.
15%); however, the difference was not significant
(P 4 0.05). A total of seven patients in the study group
had neonatal convulsion during hospital stay, whereas only
three patients in the control group had neonatal convul-
sion. Neonatal convulsions were mostly seen in infants
with Grade 2 or higher IVH. However, there were no
significant differences between two groups in terms of
abnormal neurological examination, abnormal cranial
imaging findings (e.g. IVH, periventricular leucomalacia,
cerebral atrophy and hydrocephaly) and abnormal hearing
test results at discharge.
Discussion
Spontaneous preterm delivery and hypertensive dysorders
are the most important determinants of perinatal death in
 428 M. Çetinkaya et al.
developing countries [21]. Although delivery is considered
the most efficient treatment of preeclampsia, the decision
for delivery is dependent on the severity of preeclampsia
and also the maturity of fetus, particularly the maturity
of the lungs. In some studies, expectant management
to prolong pregnancy in severe preeclampsia was found to
be associated with a significant prolongation of pregnancy
and improvement of perinatal outcome without any
deleterious maternal complications [22,23]. However,
there are limited number of studies about the prognosis
in infants born to preeclamptic mothers and the results of
these studies including the effect of preeclampsia on
neonatal morbidity and mortality are conflicting. There-
fore, we aimed to evaluate the effect of preeclampsia on
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neonatal morbidity and mortality in premature infants.
Neutropenia is present in 40–50% of infants at birth who
were born to preeclamptic mothers [24]. Neutropenic
infants are more likely to have mothers with severe
preeclampsia that is associated with preterm delivery
[25,26]. It was reported that preeclampsia-associated
neutropenia might be a risk factor for an increased
incidence of infections in preterm infants even after
recovery of neutropenia [25,27]. Gray and Rodwell [28]
stated that prolonged neutropenia might be responsible for
the increased incidence of nosocomial infections in infants
born to preeclamptic mothers. It was also reported that
preeclampsia-associated neutrophil dysfunction contribu-
ted to high infection incidence in neutropenic infants
[25,27]. In a recent study, Güner et al. [29] reported that
the levels of serum granulocyte colony stimulating factor
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(G-CSF) were higher in neutropenic infants born to
preeclamptic mothers and suggested that response to G-
CSF might be altered or decreased in these infants. In
contrast, Paul et al. [30] showed that very low birth weight
infants born to preeclamptic mothers were not at increased
risk of culture-proven sepsis despite a reduction in absolute
number of neutrophils. Neutropenia and neonatal sepsis
were found to be significantly higher in infants born to
preeclamptic mothers in this study. When the infants were
classified according to their gestational ages, infants born
to preeclamptic mothers whose gestational age was smaller
than 28 weeks were found to be more frequently
neutropenic and the duration of neutropenia was signifi-
cantly longer in these infants.
Early studies reported a positive effect of maternal
hypertension on fetal lung maturation [31,32]. However,
a recent study suggested that fetal lung maturity was not
accelerated in pregnancies complicated by preeclampsia
[5]. Baud et al. [33] reported increased RDS severity and
chronic lung disease in infants born to preeclamptic
mothers. But, recently, Cheng et al. [6] reported no
differences between preeclamptic and control infants in
terms of respiratory outcome. In agreement, our study
showed no difference between preeclamptic and control
infants in terms of RDS. Paul et al. [34] stated that there
was no difference between preeclamptic mothers’ infants
and control infants in terms of the requirement for
mechanical ventilation. However, in a recent study, Hiett
et al. [35] reported that infants of preeclamptic women
required a significantly longer period of mechanical
ventilation. In this study, duration of mechanical ventilation
and oxygen therapy were significantly higher in the study
group and this was similar to the results of Hiett et al. [35].
Although durations of mechanical ventilation and oxygen
therapy were longer in the preeclamptic group, BPD did
not increase significantly. In the study group, the number of
infants who developed BPD was twofold that of infants
born to normotensive mothers (15.5% vs. 7%) although the
difference was not statistically significant. This might be
associated with the small number of infants in this study
and also with the complex pathophysiology of BPD [36].
IVH is another complication of premature delivery and
its frequency increases with decreasing gestational age.
Cheng et al. [6] reported IVH rate of 50% for infants born
to preeclamptic mothers and 26% for control group.
However, a study by Friedman et al. [37] that included 446
infants reported no increase in IVH incidence in infants
born to preeclamptic mothers, confirming data presented
in another study by Banias et al. [38]. In good agreement
with the aforementioned findings, the difference in IVH
incidence was not statistically significant in infants born to
preeclamptic mothers compared with the control group in
our study.
NEC incidence also was similar in infants born to
preeclamptic mothers and control patients according to
several studies [35,37,38]. Concordant with the literature,
although the NEC incidence was higher in infants born to
preeclamptic mothers, the difference was not statistically
significant in our study.
A small number of studies compared neonatal mortality
rates between premature infants born to preeclamptic or
normotensive mothers. Although Banias et al. [38]
reported increased perinatal mortality rates in infants born
to preeclamptic mothers compared with control infants,
some of the other studies reported similar mortality rates
for both groups of infants [35,37]. In our study, in
agreement with the latter, mortality rate showed no
significant difference between the two groups.
Maternal preeclampsia has been suggested to be
neuroprotective [39]. In our study, although greater
number of infants in the study group had IVH and
neonatal convulsion compared with the control group, no
significant differences were found between two group of
infants in terms of neurological examination, cranial
imaging findings and hearing tests.
One limitation of this study is that only short-term
neonatal outcomes of infants were evaluated until dis-
charge. Therefore, further studies investigating long-term
growth and neorological outcomes of infants born to
preeclamptic mothers are warranted. Another limitation of
this retrospective study is the constitution of the control
group. Because the number of SGA infants born to
preeclamptic mothers were statistically higher than those
born to normotensive mothers, such differences as high
neutropenia and enhanced secondary neonatal sepsis inci-
dence in the study group could also be attributable to the
effect of intrauterine growth restriction. Therefore, pre-
eclampsia and/or IUGR can induce low white blood cells
counts and possibly favour neonatal secondary sepsis.
In conclusion, the incidence of neonatal sepsis is
significantly higher in infants born to preeclamptic mothers
compared with those born to normotensive mothers
probably due to increased rate of neutropenia. Differences
in terms of rate of neutropenia and duration of neutropenia
are significant in infants born to preeclamptic mothers who
are smaller than 28 weeks of gestational age suggesting that
gestational age has an influence on development of neu-
tropenia followed by neonatal sepsis. However, there are
no differences in terms of other neonatal morbidities such
as IVH, ROP, NEC, BPD and neonatal mortality between
the two groups of infants. Although our sample size is
small, we conclude that preeclampsia is associated with
increased rate of neonatal sepsis because of increased rate
of neutropenia. Future studies with larger number of
patients are warranted for determining the effect of
preeclampsia on neonatal outcomes.

Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the
content and writing of the paper.
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