J Infertil Reprod Biol, 2017, Volume 5, Issue 4, Pages: 20-25. https://doi.org/10.47277/JIRB/5(4)/20  
Maternal, Fetal and Placental Responses in the  
Early and Late Onset Preeclampsia  
1
*
2
3
Mona Sharma , Renu Dhingra , Neerja Bhatla  
1
Assistant Professor, Department of Reproductive Biology, All India Institute of Medical Sciences, New Delhi, India  
2
Professor, Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India  
3
Professor, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India  
.
Received: 17/09/2017  
Accepted: 20/11/2017  
Published: 20/12/2017  
Abstract  
Preeclampsia is the pregnancy induced disorder of hypertension and proteinuria manifesting after midgestation. Depending upon  
the onset of symptoms, it can be classified as early onset (≤34 wks) or late onset (≥34wks). The objectives of the present study were to  
compare the maternal responses (maternal age, gestational age, mode of delivery, blood pressure, proteinuria), the fetal responses  
(
birth weight, APGAR score) and placental responses (placental weight, placental morphology, trophoblastic and syncytial knot  
apoptotic rates) between the early and late onset preeclamptic women. The study group included early onset (20 placentas), late onset  
20 placentas) cases of preeclampsia and control group included 20 placentas from normotensive nonproteinuric pregnant women. For  
(
the placental pathological changes, hematoxylin and eosin staining and M30 immunostaining were used. The maternal, fetal and  
placental responses were compared between study and control groups. As compared to the control group, the maternal age, blood  
pressure and proteinuria were higher in both early and late onset preeclamptic groups. The early onset preeclamptic group was  
associated with low placental weight along with premature delivery of low birth weight babies with low APGAR scores as compared  
to control and late onset preeclamptic group. The mode of delivery in most of the cases of early onset preeclamptic group was  
caesarean section. The fetal and placental responses in late preeclamptic group were comparable to that of control group. The placental  
villous and vascular morphology along with apoptotic indices were severely altered in early onset preeclamptic group. Between the  
two types of preeclampsia, the early onset preeclamptic group showed poor maternal, fetal and placental responses suggesting its  
severity and bad prognosis.  
Keywords: Preeclampsia, Maternal age, Placentas, Premature delivery, APGAR Score  
Introduction  
maternal immune system and contributes to maternal vascular  
injury and endothelial dysfunction which centralises the  
pathogenetic events of this disorder (5). It can be assumed that  
maternal inflammatory response is the final pathway of this  
disorder but its initiative routes can vary greatly. Though the  
hypothesis pertaining to pathological changes of preeclampsia  
revolves around the abnormal trophoblastic apoptosis and  
syncytial shedding but the onset of symptoms in preeclampsia  
greatly differ. In early onset preeclampsia, the symptoms  
appear at ≤34 wks whereas in late onset preeclampsia, the  
symptoms appear at ≥34wks of gestation (6). The  
trophoblastic apoptosis can be estimated by using various  
cytoplasmic and nuclear apoptotic markers such as annexin v  
staining, TUNEL, M30 immunostaining. M30 antibody has  
been used to identify apoptotic changes specifically in the  
cytoplasm. This antibody identifies the cytokeratin breakdown  
occurring during apoptosis cascade and it has been used as  
apoptotic markers for trophoblastic cells (7, 8).  
The pregnancy associated hypertensive disorders are one  
of the causes of maternal mortality all over the world.  
A
thorough understanding of the current causes of maternal  
mortality is crucial for addressing the challenge of high rates  
of maternal mortality. The International Society for the study  
of Hypertension in Pregnancy (ISSHP) defines preeclampsia  
as the onset of sudden hypertension (systolic blood pressure  
140mmHg and diastolic blood pressure ≥90 mmHg) along  
with proteinuria ≥300 mg in a 24-hour collection of urine after  
th  
weeks of gestation in a previously normotensive,  
2
0
nonproteinuric pregnant woman. These identifying clinical  
features should disappear by the end of third month  
postpartum (1).  
The pathological features of this disorder have been correlated  
with the aberrant trophoblastic life cycle. The exaggerated rate  
of trophoblastic apoptosis in preeclamptic placentas leads to  
insufficient trophoblastic invasion causing abnormal  
implantation and placental vascular insufficiency (2).  
Apoptosis is the natural mechanism of trophoblast turnover  
process and it involves extrinsic and intrinsic mechanisms (3).  
Placental trophoblastic cells form abundant syncytial knots  
which get detach from the villous surface into maternal  
circulation (4). These syncytial aggregates stimulate the  
Preeclampsia remains the target of extensive research in recent  
years and more work needs to be conducted to unfold the  
underlying pathological events of the subsets of this disorder.  
Therefore, to circumvent the differences in the onset of  
cardinal symptoms, we hypothesise that the maternal, fetal and  
*
Corresponding author: Mona Sharma, Department of Reproductive Biology, 2 Floor, Teaching Block, AIIMS, New Delhi, India. E-  
mail: dr.mona18sharma@gmail.com  
20  
J Infertil Reprod Biol, 2017, Volume 5, Issue 4, Pages: 20-25. https://doi.org/10.47277/JIRB/5(4)/20  
placental responses may differ in the early and late onset  
preeclampsia.  
correction was applied. P value <0.05 was considered  
statistically significant. For multiple comparisons, fischer’s  
exact test was used with bonferroni correction and P <0.018  
was considered statistically significant.  
Methods  
A total of 60 placentas were collected from the labour  
room of Department of Obstetrics and Gynaecology, All India  
Institute of Medical Sciences, New Delhi. The ethical  
committee approved the protocol of the study. The consent  
was taken from each individual for the study groups. Out of  
the total samples, 20 placentas were from early onset  
preeclamptic pregnant women, 20 placentas were from late  
onset preeclamptic pregnant women and 20 placentas were  
taken from normotensive nonproteinuric pregnant women.  
Preeclampsia was diagnosed according to the ISSHP criteria.  
Patients with chronic hypertension, pregestational diabetes,  
chorioamnionitis, renal disease, cardiac disease, thyroid  
disease, pre-existing seizure disorder and HELLP syndrome  
were excluded from this study.  
The placental samples were collected immediately after  
delivery. The central part of the placental disc was chosen for  
taking the samples. The areas of visible infarcts, hematomas  
or calcification were excluded. The placental tissue samples  
were fixed in 10% formaldehyde and subsequently paraffin  
blocks and 5µm tissue sections were prepared. Subsequently,  
tissue sections were deparaffinised rehydrated and processed  
for hematoxylin and eosin staining and were examined under  
light microscope. Standard procedure for immunostaining was  
followed according to manufacturer’s protocol. For M30  
immunostaining (Roche Diagnostic, Germany), the  
subsequent steps were carried out at room temperature in a  
Results  
Maternal Responses  
The systolic blood pressure (SBP) [160±4.6(150-170)] as  
well as diastolic blood pressure (DBP) [108±6.5(100-118)]  
were more in early onset preeclamptic group as well as in late  
onset group [SBP-144±4.4(138-156), DBP-93.9±3.8(90-100)  
as compared to control group[SBP-112±8.6(100-124), DBP-  
79.7±6.1(70-90)]. The rate of proteinuria was also more in  
early onset preeclamptic group [4.1±0.6(3-5)] as well as in late  
onset preeclamptic group [1.7±0.6(1-2.9)] as compared to the  
control group [0.16±0.04(0.1-0.2)]. Maternal age was more in  
early [35±1.9(32-38)] as well as in late onset preeclamptic  
groups [34.2±2.2(30-38)] as compared to control group  
[27.6±3.6(20-34)]. The early onset preeclamptic group showed  
less gestational age [33.6±1.5(31-36)] as compared to the late  
onset preeclamptic group [37.7±1.2(36-40)] and control group  
[38.2±1.4(36-41)]. In the early onset preeclamptic group, 90%  
women were delivered by caesarean sections as compared to  
late onset preeclamptic (25%) and control group (10%).  
Amongst the two preeclamptic groups, the early onset group  
showed higher SBP, DBP and rate of proteinuria (Tables 1-3,  
6, 7).  
Fetal Responses  
The newborns in the early onset group were low weight  
2 2  
humidified chamber. The 3% H O prepared in methanol was  
[
2088±166(1800-2400)] as compared to late onset  
preeclamptic group [2825±226(2500-3500)] and control group  
2924±260(2500-3500)]. The newborns delivered from early  
used for 10 minutes to block peroxidase activity. The  
specimens were then incubated in 1-3 drops of serum block  
for 2 hours to prevent non-specific binding to collagen and  
connective tissue. Further, the specimens were incubated for  
[
onset preeclamptic women, 85% of them showed low APGAR  
scores as compared to late onset preeclamptic (25%) and  
control group (0%) (Tables 2, 4, 6, 7).  
2
4 hrs with M30 antibody (1:50) followed by 1-3 drops of  
biotinylated secondary antibody (anti mouse IgG) for 30  
minutes. Thereafter, the specimens were incubated in 1-3  
drops of HRP-streptavidin complex for 30 minutes. The slides  
were then counterstained with hematoxylin and dehydrated by  
passing through ascending grades of ethanol. The slides were  
then mounted with DPX and were observed under light  
microscope. The negative tissue control included eliminating  
the primary antiserum and replacing species-specific  
antiserum with normal horse serum. Sections of colon  
adenocarcinoma were taken as positive controls. Stained  
sections showing trophoblastic cells and syncytial knots with  
the brown cytoplasmic stain were considered M30  
immunostaining positive apoptotic cells. The trophoblastic  
and syncytial knot apoptotic indices were calculated (total  
number of apoptotic cells per total number of cells multiply by  
Placental Responses  
The placental weight in early onset preeclamptic group  
was less [376.5±67.7(240-490)] as compared to the late onset  
preeclamptic [504±50.5(400-600)] and control groups  
[524±45(440-630)].The early onset preeclamptic placentas  
showed gross areas of infarcts, hematomas and thrombi. On  
histological examination, the placental villi showed altered  
morphological patterns along with interstitial edema. These  
villi were of variable sizes and were lined by  
syncytiotrophoblastic cells and less of cytotrophoblastic cells.  
The villous core composed of mesenchyme and blood vessels.  
There was increased capillarisation seen in these villi which  
made their surface deformed. The intervillous space was more  
in these placentas. The fibrin deposits were seen on the  
trophoblastic surface. The nuclei of trophoblastic cells  
aggregated and formed excessive of syncytial knots (figures 1-  
1
00). The maternal responses (maternal age, gestational age,  
mode of delivery, blood pressure, urinary protein), fetal  
responses (birth weight, APGAR scores) and placental  
responses (placental weight, placental morphology by  
hematoxylin and eosin staining, trophoblastic and syncytial  
knot indices by M30 immunostaining) were compared among  
the study groups. Statistical analysis was done using Stata  
5
). The trophoblastic apoptotic index was more in these group  
of placentas [91.3±6.3(80-99)] as compared to late onset  
preeclamptic [62.3±13.8(38-85)] and control groups  
1.9±14.4(37.3-87.9)]. The syncytial knot apoptotic index was  
also more in early onset preeclamptic group [87.7±10.1(70-  
00)] as compared to late onset preeclamptic [43±16.2(10-70)]  
and control groups [36.9±20.2(0-66.6)]. There were no  
[
6
9
.0/Data analysis software (college station, Texas). Data were  
1
presented as in Mean ±SD (range). For comparison among the  
study groups, one way ANOVA test with bonferroni  
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J Infertil Reprod Biol, 2017, Volume 5, Issue 4, Pages: 20-25. https://doi.org/10.47277/JIRB/5(4)/20  
significant pathological changes observed in the placentas of  
Table 1: Comparison of Maternal responses in the study groups  
late onset preeclamptic group (Tables 2, 5-7).  
Parameters  
Early Onset Preeclampsia (n= 20)  
160±4.6(150-170)  
Late Onset Preeclampsia (n=20)  
144±4.4(138-156)  
P value  
<0.0001  
<0.0001  
<0.0001  
Systolic BP (mm Hg)  
Diastolic BP (mm Hg)  
Proteinuria (g/day)  
108±6.5(100-118)  
4.1±0.6(3-5)  
93.9±3.8(90-100)  
1.7±0.6(1-2.9)  
n = number of subjects, Data is presented in Mean ±SD (range), One way ANOVA test with bonferroni correction; P<0.05, statistically significant  
Table 2: Comparison of Maternal and fetal responses in the study groups  
Parameters  
Early Onset Preeclampsia (n= 20)  
35±1.9(32-38)  
Late Onset Preeclampsia (n=20)  
34.2±2.2(30-38)  
P value  
0.9  
<0.0001  
<0.0001  
<0.0001  
Maternal Age (yrs)  
Gestational Age (wks)  
Birth Wt (gms)  
33.6±1.5(31-36)  
2088±166(1800-2400)  
376.5±67.7(240-490)  
37.7±1.2(36-40)  
2825±226(2500-3500)  
504±50.5(400-600)  
Placental Wt (gms)  
n = number of subjects, Data is presented in Mean ±SD (range), One way ANOVA test with bonferroni correction; P<0.05, statistically significant  
Table 3: Comparison of Maternal parameters (mode of delivery) in study groups  
Study groups  
Percentage  
Overall  
p-value  
Multiple comparison (p value <0.018)  
Gp 1 Vs Gp 2  
<0.0001  
Gp 1 Vs Gp 3  
0.407  
Gp 2 Vs Gp 3  
<0.0001  
Control Group  
Gp1  
NV-18(90)  
CS-2(10)  
<0.0001  
Early Onset PE  
Gp2  
NV-2(10)  
CS-18(90)  
Late Onset PE  
Gp3  
NV-15(75)  
CS-5(25)  
Fischer’s exact test, statistical significance: P<0.05;  
Multiple comparison with bonferroni correction, statistical significance: P<0.018 (NV: normal vaginal delivery; CS: caesarean section)  
Table 4: Comparison of Fetal parameters (APGAR score) in study groups  
Study Groups  
Percentage  
Overall  
p-value  
Multiple comparison (p value <0.018)  
Gp 1 Vs Gp 2  
<0.0001  
Gp 1 Vs Gp 3  
0.047  
Gp 2 Vs Gp 3  
<0.0001  
Control Group  
Gp1  
≤7-0(0)  
≥7-20(100)  
<0.0001  
Early Onset PE  
Gp2  
≤7-17(85)  
≥7-3(15)  
Late Onset PE  
Gp3  
≤7-5(25)  
≥7-15(75)  
Fischer’s exact test, statistical significance: P<0.05  
Multiple comparison with bonferroni correction, statistical significance : P< 0.018  
Table 5: Comparison of Placental responses in the study groups  
Parameters  
Trophoblastic Index (%)  
Syncytial Knot Index (%)  
Early Onset Preeclampsia (n= 20)  
91.3±6.3(80-99)  
Late Onset Preeclampsia (n=20)  
62.3±13.8(38-85)  
P value  
<0.0001  
<0.0001  
87.7±10.1(70-100)  
43±16.2(10-70)  
n = number of subjects, Data is presented in Mean ±SD (range), One way ANOVA test with bonferroni correction; P<0.05, statistically significant  
22