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. 2025 Jul 30;8(8):e71114. doi: 10.1002/hsr2.71114

Comparison of Prooxidant Antioxidant Balance Between Neonates of Preeclamptic Mothers and Normal Pregnancies in Ghaem Hospital, Mashhad, From 2019 to 2022

Boskabadi Hassan 1, Zakerihamidi Maryam 2,✉, Amirkhani Samin 2
PMCID: PMC12308149  PMID: 40740285

ABSTRACT

Background and Aims

The current study has been carried out to compare PAB between neonates of preeclamptic mothers and mothers with normal pregnancies.

Methods

This cross‐sectional study has been carried out on 191 preterm neonates including 105 neonates with preeclamptic mothers (55%) and 86 neonates with non‐preeclamptic mothers (45%) in Ghaem hospital, Mashhad, from 2019 to 2022. Sampling has been done by available sampling method. After delivery, PAB was measured from the umbilical cord of newborns with preeclamptic mothers and those with healthy mothers. Complete neonatal characteristics including first and fifth minute Apgar score, gestational age, birth weight, incident of respiratory distress syndrome (RDS), need for mechanical ventilation, condition at the time of discharge, and death was surveyed. Afterwards, using statistical methods, PAB amount in the umbilical cord of neonates with preeclamptic mothers and those with healthy mothers was compared.

Results

In this study, mean amount of PAB in all neonates was 27.50 ± 36.70 HK. In neonates with preeclamptic mothers and those with healthy mothers, mean ± standard deviation (SD) of PAB was 36.89 ± 42.70 and 16.04 ± 23.21 HK, fifth minute Apgar score 8.1 ± 1.36 and 7.1 ± 1.46, and the birth weight 1328 ± 301.76 and 1443.61 ± 395.33, respectively. To identify neonates at risk of oxidative stress who were born to preeclamptic mothers (compared to healthy mothers' newborns), PAB > 11.2 HK had sensitivity of 88.2% and specificity of 75%.

Conclusion

PAB in neonates with preeclamptic mothers is disturbed, during preeclampsia its levels increase and also, this disturbance is associated with adverse neonatal outcomes such as low birth weight, increased incidence of RDS, and need for ventilation.

Keywords: mother, neonate, oxidative stress, preeclampsia, prooxidants‐antioxidants balance

Summary

  • Synopsis of 125 with structure of study question
    • ◦
      Considering the significant role of oxidative stress in occurrence of preeclampsia and the numerous neonatal complications it may cause; the current study was conducted aiming to compare PAB levels between newborns of preeclamptic mothers and those of mothers with normal pregnancies.
  • What's already known
    • ◦
      Preeclampsia is a particular clinical syndrome with multisystem involvement that appears in the second or third trimester of pregnancy. Its incidence depends on geographic region, season, nutrition, and race and affects approximately 3%–8% of women worldwide.
  • What this study adds
    • ◦
      PAB in neonates with preeclamptic mothers is disturbed, during preeclampsia its levels increase and also, this disturbance is associated with adverse neonatal outcomes such as low birth weight, increased incidence of RDS, and need for ventilation.

1. Introduction

Preeclampsia is a particular clinical syndrome with multisystem involvement that appears in the second or third trimester of pregnancy. Its incidence depends on geographic region, season, nutrition, and race and affects approximately 3%–8% of women worldwide [1, 2, 3]. Preeclampsia is defined by mother's elevated blood pressure (more than 140/90 mmHg) and proteinuria (more than 300 mg/24 h). The main treatment for preeclampsia is termination of the pregnancy which can lead to the birth of a premature neonate and prematurity complications will be forced on the neonate [4]. Early preeclampsia is associated with impaired vascular remodeling of spiral arteries and superficial trophoblast invasion [5]. The exact cause of preeclampsia is not quite clear but placental insufficiency plays a significant role in the development of this syndrome due to insufficient reconstruction of maternal vessels in the interplacental space [6]. During a normal pregnancy there is an increase in the production of prooxidants which is balanced by the synthesis of antioxidants [7]. Evidence depict that oxidative stress may be associated with preeclampsia [8]. An imbalance between prooxidant production and antioxidant defense has been considered as one of the causes of preeclampsia [9]. The most significant impact of increased prooxidant level in preeclampsia is endothelial damage, vasospasm and increased environmental resistance [10]. Due to the reason that most women with preeclampsia are diagnosed after the syndrome's development, it is unclear whether this imbalance between prooxidants and antioxidants (oxidative stress) occurs before or after preeclampsia [11].

Pregnancy is a phenomenon known to increase oxidative stress which is generally caused by natural systemic inflammatory responses that can lead to higher amounts of reactive oxygen species and reactive nitrogen species in circulation. These two species play a significant role as secondary messengers in intracellular signaling cascades. The main source of ROS during pregnancy is placenta. These two species and antioxidants create a balance that indicates the oxidation condition. When oxidative stress surpasses antioxidant defenses in the placenta, oxidative damage can spread to other tissues [12, 13]. The link between oxidative stress and hypertension has been proven in several animal models.

However, in humans, conflicting results have been reported in various studies. For example, in the study by Griendling et al., the relationship between high blood pressure in humans and oxidative stress has not been investigated [14]. While this relationship has been confirmed in the studies of Touyz et al. [15] and Rodrigo et al. [16]. Oxidative stress is described as a disturbance in pro‐oxidant/antioxidant balance (PAB) with an increase in prooxidants [17, 18]. The placenta is the main source for synthesis of endogenous antioxidants and its defect increases the placental production of oxidants, and excessive production of free radicals, causing oxidative damage to lipids, proteins, and DNA and it can cause consequences for the mother and fetus such as hypertension, preeclampsia, miscarriage, gestational diabetes, liver defects, edema, disseminated intravascular coagulation (DIC), eclampsia, cerebral edema, premature rupture of the membranes (PROM), cesarean delivery, intrauterine growth restriction (IUGR), low birth weight neonate, prematurity, fetal death, and retinopathy of prematurity (ROP) [4, 11, 19, 20, 21, 22, 23, 24, 25, 26]. Preeclampsia affects the prognosis of the neonates, therefore, in the neonates with preeclamptic mothers gestational age and first minute Apgar score are lower and the rate of cesarean delivery, ROP and PROM are higher [26]. PAB levels are significantly higher in pregnant woman compared to nonpregnant women. Oxidative stress increases during pregnancy and PAB levels raise with increase in gestational age [27]. Considering the significant role of oxidative stress in occurrence of preeclampsia and the numerous neonatal complications it may cause; the current study was conducted aiming to compare PAB levels between newborns of preeclamptic mothers and those of mothers with normal pregnancies.

2. Methods

This is a cross‐sectional study that has been carried out on 191 preterm neonates, including 105 neonates with preeclamptic mothers (55%) and 86 neonates with non‐preeclamptic mothers (45%) in Ghaem hospital, Mashhad, from 2019 until 2022. Sampling has been carried out via available sampling method. This project has been approved by Mashhad University of medical sciences (IR.MUMS.MEDICAL.REC.1401.705) and the mothers' consent was obtained before entering the study. In this research, neonates of preeclamptic mothers and neonates of healthy mothers were included. Neonates with other diseases during pregnancy (such as hypothyroidism, diabetes, and epilepsy), were excluded from this study and neonates with congenital anomalies and congenital infections were also excluded. At least 0.2 ml of serum was separated from the umbilical cord blood which is usually discarded, following the cold chain protocol, it was sent to Bu Ali research Institute for measuring PAB levels. The control group concluded of neonates whose 0.2 mL umbilical cord blood sample was sent to the laboratory for PAB level analysis after obtaining their parents' consent.

PAB assay: Antioxidant level was evaluated by TMB staining (3.3−3.5 tetramethylbenzidine), and the oxidation of colored cations was evaluated [28]. The solutions were prepared as described. Standard solutions were created by combining varying proportions (0%–100%) of 250 μM hydrogen peroxide with 3 mM uric acid in 10 mM NaOH. To produce the 3,3′,5,5′‐tetramethylbenzidine (TMB) cation, 60 mg of TMP powder was dissolved and thoroughly mixed with a ratio of 10−20 mL of the solution. This mixture was then left in a dark environment for 2 h. Subsequently, 25 units of peroxidase enzyme were introduced to 20 mL of the solution and kept at 20°C. For the preparation of the TMB solution, 200 mL of TMB was blended with 10 mL of acetate buffer (0.05 M buffer, pH 5.8); the working solution was established by merging 1 mL of TMB cation with 10 mL of TMB solution. Afterward, this solution was stored in a dark, dry place for 2 min. Following this, 10 μL of each sample was mixed with 200 μL of the working solution and positioned in a 96‐well plate in darkness at 37°C for 12 min. To conclude the procedure, 100 μL of 2 N Hall was added to each well and read in an ELISA plate reader at wavelengths of 450 and 620 nm. The PAB values were computed based on the standard curve reported previously [29, 30].

The complete neonatal characteristics including first and fifth minute Apgar score, gestational age, birth weight, condition at the time of discharge, need for ventilation, incidence of RDS and infections were evaluated and recorded. In the laboratory evaluation of the neonates, the amount of PAB was investigated. Preeclampsia was considered as new onset hypertension in addition to new onset proteinuria 300 mg in 24 h after 20 weeks of gestation [31].

Neonates who had tachypnea, grunting, and subcostal or intercostal retraction as well as respiratory support such as positive end expiratory pressure (PEEP) > 8 20 cm H with fractional inspired oxygen (Fio2) > 30%, administration of surfactant and endotracheal intubation, as well as radiographic findings of RDS, were deliberated to have RDS.

Data analysis has been achieved with T‐test, Chi‐square, and SPSS software version 23. First, we described the findings using tables and statistical charts, and then we compared two groups of neonates with preeclamptic mothers and those of healthy mothers by using Chi‐Square and T‐test. After delivery, by using T‐test, the amount of PAB in the umbilical cord of newborns with preeclamptic mothers and newborns with healthy mothers was compared. p < 0.05 was considered significant.

3. Results

In 60.3% of cases, delivery was by cesarean section and in 39.7%, it was normal vaginal delivery (NVD). Average PAB was 27.50 ± 36.70 HK, first minute Apgar score 6.00 ± 1.95, fifth minute Apgar score 8.30 ± 1.44, gestational age 31.88 ± 1.85 weeks, and the average birth weight was 1380.52 ± 350.77 g. The characteristics of neonates in both groups of newborns with preeclamptic and normal pregnancy mothers are listed in Table 1. Based on the results of the present study, there was a statistically significant difference in fifth minute Apgar score (p = 0.003), birth weight (p = 0.028), and neonatal PAB (p < 0.001) in both studied groups, which means in the group of neonates with preeclamptic mothers, the values of neonatal PAB and fifth minute Apgar score were higher and birth weight was lower.

Table 1.

Comparison of average characteristics of newborns in two groups of newborns with preeclamptic and normal pregnancy mothers.

Variable Neonates of mothers with normal pregnancy (number: 86) mean ± SD Neonates of preeclamptic mothers (number: 105) mean ± SD t df p value (T‐test)
First minute Apgar 6.1 ± 1.90 6.1 ± 1.98 0.636 88.024 0.526
Fifth minute Apgar 7.1 ± 1.46 8.1 ± 1.36 −3.090 124 0.002
Gestational age (week) 32.2 ± 2.31 31.1 ± 1.55 1.273 65.961 0.156
Birth weight (gram) 1443.61 ± 395.33 1328.85 ± 301.76 189 0.024 0.028
Neonatal PAB (HK) 16.04 ± 23.21 36.89 ± 42.70 −4.290 166.133 0.001
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Note: The t‐test for equality of means provides the results for the actual Independent Samples t‐test.

Abbreviations: Df, degree of freedom; HK, Hamidi−Koliakos; PAB, prooxidant antioxidant balance; SD, standard deviation; T, t is the computed test statistic, using the formula for the equal‐variances‐assumed test statistic or the formula for the equal‐variances‐not‐assumed test statistic.

RDS was significant in two groups of neonates with preeclamptic and normal pregnancy mothers, and short‐term prognostic variables, CPR in delivery room, neonatal outcomes, and infections were not significant (Table 2).

Table 2.

Comparison of neonatal variables in both groups of neonates with preeclamptic and normal pregnancy mothers.

Variables Groups
Neonates of mothers with normal pregnancy number (percentage) 86 (45) Neonates of preeclamptic mothers number (percentage) 105 (55) Significance level (Chi‐square)
CPR after delivery 0.139
Yes 0 (0) 18 (95.20)
No 86 (100) 5 (4.80)
Mechanical ventilation after delivery 0.016
Yes 6 (15.40) 27 (36.00)
No 33 (84.60) 48 (64.00)
Sepsis 0.720
Without 80 (100) 67 (95.70)
With 0 (0) 3 (4.30)
RDS 0.001
Not presented 69 (80.90) 39 (52.70)
Presented 17 (19.10) 35 (47.30)
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To identify neonates at risk of oxidative stress who were born to preeclamptic mothers (compared to healthy mothers' newborns), PAB > 11.2 HK had a sensitivity of 88.2% and a specificity of 75% (Figure 1).

Figure 1.

Figure 1

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Sensitivity and specificity of neonatal PAB to diagnose preeclampsia.

4. Discussion

Fetuses and neonates of mothers with preeclampsia are affected by maternal conditions. It is believed that preeclampsia, in addition to causing uteroplacental blood flow restrictions, is an endothelial disorder in maternal and fetal vessels, which can increase oxidative stress. Maternal vascular endothelial dysfunction and oxidative stress are associated with severity of neonatal complications and risk of future vascular disorders. In addition, maternal symptoms disappear immediately after delivery, which supports the importance of placenta in the pathophysiology of this disorder. Placenta can be the source of some endothelial dysfunction factors in both mothers with preeclampsia and their fetuses [32]. The increase in the incidence of ROP in neonates of preeclamptic mothers can be a sign of vascular disorders of the newborn's retina caused by preeclampsia [26]. A study shows, increase in the level of oxidative stress in the mother is related to increase in oxidative stress levels in the neonate's umbilical cord blood [33]. while transferring from embryonic to neonatal life, the fetus is conveyed from a hypoxic intrauterine environment with an oxygen pressure level of 20−25 mmHg to an extrauterine environment with an oxygen pressure level of 100 mmHg. This increase in oxygen pressure increases the production of ROS [34] and also RNS which is considered to be toxic and harmful for the fetal tissues [35]. Increased oxidative stress plays a role in the pathophysiology and complications of many neonatal diseases, including RDS, asphyxia, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), patent ductus arteriosus (PDA), hearing loss, and necrotizing enterocolitis [31, 36, 37, 38].

The results of Bharadwaj et al. study showed that maternal total antioxidant status (M‐TAS) in neonates born to preeclamptic mothers was lower than normal neonates. Furthermore, prematurity, IUGR, RDS, and early onset sepsis (EOS), were more common in neonates of preeclamptic mothers. Neonates who were born to preeclamptic mothers had weaker neuromotor outcomes, and lower motor age, motor score, and motor development quotient (MoDQ) [21]. In our study, among the neonates of preeclamptic mothers, RDS and need for ventilation were reported to be significantly higher than neonates of healthy mothers. To diagnose preeclampsia, neonatal PAB > 11.2HK, had a sensitivity of 88.2% and a specificity of 75% (AUC = 0.885). To the extent of the researchers' investigations, this is the only study that investigated the cutoff point of PAB in infants with preeclamptic mothers. The limitations of our study are the lack of control of PAB during pregnancy and lack of examination of preeclampsia predisposing factors.

5. Conclusion

The results of this study depicted disturbance of PAB in neonates with preeclamptic mothers and also increased PAB levels. These neonates are also exposed to oxidative stress and have adverse neonatal complications such as low birth weight, higher incidence of RDS, and the need for mechanical ventilation. Therefore, it may be possible to prevent complications caused by oxidative stress in neonates by proper control of preeclamptic mothers.

Author Contributions

Boskabadi Hassan: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, supervision, validation, visualization, writing – original draft, writing – review and editing. Zakerihamidi Maryam: conceptualization, investigation, methodology, project administration, resources, supervision, validation, visualization, writing – original draft, writing – review and editing. Amirkhani Samin: investigation, methodology, supervision, validation, visualization, writing – original draft, writing – review and editing.

Ethics Statement

This study was approved by the ethics committee of Mashhad University of Medical Sciences (IR.MUMS.MEDICAL.REC.1401.705).

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author, Zakerihamidi Maryam, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Acknowledgments

The current study is a result of the project approved by Mashhad University of Medical Science (IR.MUMS.MEDICAL.REC.1401.705). Hereby, the authors of this article express their gratitude to the research assistant of the university, the director of the research department and other officials or authorities, and they are grateful to all the people who assisted this project.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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