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Preeclampsia and Preterm Premature Rupture of Membranes Impinge on the Sex

Ratio and Birth Weight of Preterm Neonates: A Study among North Indian
Women

Article · January 2016

DOI: 10.5958/0975-6884.2016.00008.6

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 The Asian Man
Vol. 10, Issue 1, January - June 2016 : 74-77
RESEARCH REPORT
Preeclampsia and Preterm Premature Rupture of Membranes Impinge on the
Sex Ratio and Birth Weight of Preterm Neonates: A Study among North Indian
Women
Jyoti Mishra1, Lovejeet Kaur1, Seerat Talwar1, Manju Puri2 and Kallur Nava Saraswathy3*
INTRODUCTION
Hypertensive disorders in pregnancy, especially
preeclampsia (PE), stay behind a major cause of maternal
and infant morbidity and mortality worldwide (Roberts and
Redman, 1993). Premature rupture of membranes (PROM)
consists in the rupture of foetal membranes before the
onset of the labour causing prematurity accounting for
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the 30–40% of preterm before 32 weeks (Cararach et al.,
2001). The root cause of low birth weight (LBW) is
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multifactorial and perhaps the single most important factor
that affects neonatal mortality, also a leading cause of post-
neonatal infant mortality and childhood mortality
(Mccormick, 1985). As per WHO, LBW is defined as a
birth weight less than 2,500 g, since below this value birth-
weight-specific infant mortality begins to rise rapidly
(Chase, 1967; 1969). In almost all high and middle income
countries, preterm birth (PTB) is the leading cause of child
death (Liu et al., 2012). As far as the sex of the newly born
is concerned, many studies suggest that the proportion
male of preterm neonates is higher than that of born at
term. Male babies are known to have a significantly higher
risk of being preterm than female babies in agreement with
previous reports (Hall and Carr-Hill, 1982 & Cooperstock
and Campbell, 1996). The present study is conducted to
comprehend the effect of preterm pregnancy complications
on foetal growth and how it influences the sex of the
neonate.
SUBJECTS AND METHODS
Study Population
The subjects recruited in the study were from the
Department of Obstetrics and Gynaecology, Lady Hardinge
Medical College and Sucheta Kriplani Hospital. Ethical
clearance was obtained from the Department of
1,3
Department of Anthropology, University of Delhi, Delhi, India
2
Department of Obstetrics and Gynaecology, Lady Hardinge Medical College, Delhi, India
*Corresponding author email id: knsaraswathy@yahoo.com
DOI: 10.5958/0975-6884.2016.00008.6
Anthropology, University of Delhi and Department of
Obstetrics and Gynaecology, Lady Hardinge Medical
College, New Delhi. The study definition for PE was the
presence of hypertension (blood pressure >140/90 mmHg)
associated with proteinuria (>0.3 g) (National High Blood
Pressure Education Program Working Group on High
Pressure in Pregnancy: Report of the National High Blood
Pressure Education Program Working Group on High Blood
Pressure in Pregnancy, 2000) and Preterm Premature
Rupture of Membranes PTPROM women, that is presenting
with rupture of membranes (Cararach et al., 2001). The
study groups were matched for age, gestation, geography,
social class, and ethnicity. The PE group included 113
women with gestation between 20 and 34 weeks matched
with 185 PTPROM group. Gestational age was based on
the date of the mother’s last menstrual period, and was
verified by first-trimester or early second-trimester
ultrasound. The data recorded includes age, gestation,
dietary patterns and any complications during pregnancy,
mode of delivery, neonatal sex and weight, and consumption
of drugs (smoking, alcohol and tobacco).
Analysis and Statistical Methods
We used frequencies to describe maternal
characteristics, and the neonatal outcome. t test was
performed to compare mean birth weights by gestational
week and age cohorts between women with PE and
normotensive PTPROM women. z score was calculated
for differences in the proportions of LBW.
RESULTS AND DISCUSSION
Both PE and PTPROM groups do not differ as regards
present age, dietary patterns and are non-smokers and
non-alcoholic. As regards, mode of delivery caesarean
sections as expected are significantly more (p<0.0001)
74
 Preeclampsia and Preterm Premature Rupture of Membranes Impinge on the Sex Ratio and Birth Weight of Preterm Neonates

among the PE subjects (62.04%) as compared to that of

PTPROM (4.42%). In the present study, mean birth weight

0.56 (0.57) NS

0.24 (0.81) NS

0.31 (0.75)NS
3.13 (0.001)
For LBW%

-2.1 (0.03)

1.72 (0.08)

2.30 (0.02)
2.49 (0.01)
in both the groups, as expected was found to be in the

z (p)

P value (Chi square)

LBW range (<2,500 g). Neonates born preterm to women
with PE weighed, on an average, 539.02 g less than those
born preterm to women with PTPROM. Also, birth weight

0.48 NS

0.72 NS
0.005
0.01
was significantly (p< 0.0001) low in PE subjects (1,358.10
g) as compared to PTPROM subjects (1,897.12 g). Further,
number of neonates with LBW was significantly higher

<0.0001

<0.0001

<0.0001
<0.0001
0.92 NS
p value
(t test)

0.0002
(p = 0.001) among PE subjects (94.7%) as compared to

0.002

0.01
PTPROM (81.08%). The average weight of the neonates in

PTPROM
different 5-year maternal age cohorts was also studied.

Female baby (%)

The mean weight was found to be significantly low in all
the age cohorts among PE group except for 33–37 years

LBW (%)
<2500g

89.70
82.67

66.67
81.08

85.71
85.48
74.47

46.11
cohort. Moreover, the percentage of LBW neonates in

54.8
51.7
39.3
75
different age cohorts didn’t show any particular trend with
increasing age in both PE and PTPROM women (Table 1).
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The percentage of LBW neonates is found to be relatively

higher among PE group in all the age cohorts except for
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1821.67±1028.60 (6)
1837.04±568.48 (68)

1995.71±656.46 (36)
Average weight (g)
Table 1: Sex and birth weight wise distribution of neonates in PE and PTPROM women

1930±594.82 (75)
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the youngest age cohort (18–22 years) where a

1897.12±615.72

1914.68±567.49
2020.83±508.95
Male baby (%) Female baby (%) Male baby (%)
1449.70±708.3
(Mean±SD)
significantly high frequency of LBW neonates was

45.2
48.3
60.7
53.8
observed in PTPROM women. It is indicative of the fact
that though universally an association of PE with LBW
has been reported still as per our study on North Indian
women, a higher risk for LBW in early age among PTPROM
women suggests that effect of PTPROM is more on the
foetal front, whereas effect of PE is more of a maternal
LBW (%)
<2500g

72.97
86.05
92.31
72.73

81.82

90.63

48.62
phenomenon specifically in the younger age groups where
94.7

36.4

62.1
100

25
a maladaptation between intrauterine environment and
semiallogeneic foetus is creating a unconductive
PE

environment for the foetal growth. According to Lockwood

NS: Non significant; p < 0.05 is considered as significant

1278.37±531.47 (43)
Average weight (g)

421.81±763.51 (26)
1781.25±636.92 (8)
1335±621.47 (30)

et al. (Lockwood et al., 2001), LBW babies are divided in

1538.73±596.29
1358.10±626

1105±465.17
(Mean±SD)

855±509.06

to four categories; Extreme preterm (<28 weeks), very

51.38
preterm (<32 weeks), moderately preterm (32–34 weeks)
63.6

37.9
75

and Late preterm (34–36 weeks). Out of these four, we have

targeted 20–34 weeks gestational groups. Gestation-wise
distribution shows expected LBW among PE in all the three
gestational groups, which is significantly low mean birth
weight as compared to PTPROM. However, the percentage
of LBW neonates for all gestational ages is found to be
Gestation groups (weeks)

32-34 Moderately Preterm

32-34 Moderately Preterm

very high in both the groups with no trend found among

PE subjects with increase in gestational age while a
<28 Extreme Preterm

<28 Extreme Preterm

Age groups (years)

decrease in the LBW percentage of the neonates was

<32 Very preterm

<32 Very preterm

observed with increase in the gestational ages among

PTPROM. Distribution of male and female babies on the
whole showed no significant difference between PE and
Overall
18-22
23-27
28-32
33-37

PTPROM subjects. In both extreme preterm and very

Total

preterm gestational groups, male babies are more frequent

The Asian Man 75

 Jyoti Mishra, Lovejeet Kaur, Seerat Talwar, Manju Puri and Kallur Nava Saraswathy
among PE mothers, though the difference was significant
only, with respect to the very preterm gestational age group.
The reverse trend that is significantly high frequency of
male neonates is found in PTPROM in the moderately
preterm category. Hence, it can be concluded that moderate
preterm (32–34 weeks) gestational period is a protected or
a safe gestational period especially among PTPROM
women due to lack of confounders associated with PE.
The chances of incompatibility in women with PE rise when
male foetus is in the womb due to the presence of Y
chromosome, not a part of female genome thus posing a
higher risk for maternal health as well the foetus. It can be
hypothesised that male foetus is posing a greater risk for
PE and vice versa presence of an incompatible genome in
male foetus is likely to increase the severity of PE causing
an unwarranted environment during pregnancy.This
hypothesis proposed in our study is in agreement with
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the study of Childs (Childs, 1965), where he put forwarded
that being heterogametic; males are necessarily the victims
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of whatever uncompensated dosage effects may exist. Our
study supports the ‘Evocative Principle’ proposed by
Gualtieri and Hicks (1985); where they hypothesised that
there is something about the male foetus that evokes an
inhospitable environment and this was related to the
relative antigenicity of the male foetus which may induce
a state of maternal immunoreactivity leading either directly
or indirectly to foetal damage. The earlier the gestation the
lower the birth weight elevating the risk for morbidity and
mortality of Preterm male babies as also reported by
Khoury et al. (1985), Verloove-Vanhorick et al. (1994), Smith
(1996) and Stevenson et al. (2000), where they say that
males have higher rates of foetal and neonatal mortality.
This interpretation was also supported by Zeitlin et al.
(2002), where they reported that the higher proportion of
PTB among males could contribute to an explanation for
their higher mortality in infancy. The present study points
towards a strong interrelationship between PE, PTB and
male sex. A high precision for individual estimates can be
made on evaluating a large number of sample size and also
a paradigm shift from managing PE cases and a safe
delivery, that is lowering the chances of caesarean section
in order to improve size at birth specifically when the foetus
is of male sex might provide fresh insight into the problem.
ACKNOWLEDGEMENTS
We are thankful to all the subjects who have
participated in the study.
76
CONTRIBUTION OF AUTHORS
All authors contributed extensively to the work
presented in this paper. Dr. K.N. Saraswathy has
conceptualised the proposed work. The recruitment of
subjects and the manuscript writing was done by Mrs.
Jyoti Mishra, Ms. Lovejeet Kaur, Mrs. Seerat Talwar
analysed the data and Prof. Manju Puri has contributed to
the interpretation of the data and integration of the
manuscript.
ETHICAL CLEARANCE
Ethical clearance was obtained from both the
departments, Department of Anthropology, University Of
Delhi (Dated: 29-04-2010, Ref No. Anthro/455-3), and Lady
Hardinge Medical College, Delhi (Dated: 23-12-2010, IEC-
69), from their respective departmental ethical committees
under the project entitled ‘A case control study of Global
and MTHFR gene specific methylation vis-à-vispregnancy
complications in north Indian population’.
FUNDING
Funded by Department of Biotechnology (DBT),
Ministry of Science and Technology, Government of India.
CONFLICT OF INTEREST STATEMENT
All authors declare no conflict of interest.
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