{"paper_id":"96c6b702-fe96-45d4-9af4-f27906a16587","body_text":"1\nTitle: Timing matters: Unveiling the distinct effects of early vs late onset pre-\neclampsia on mothers and newborns in a tertiary hospital in Bangladesh \n \nAuthors: Taukir Tanjim\n1, Saleh Haider1, Hafsa Hossain2, Dilruba Zeba3 \n \nAuthor Affiliations: \n1. International Centre for Diarrhoeal Diseases Research, Bangladesh \n(icddr,b), Dhaka, Bangladesh. \n2. Diabetic Association Medical College, Faridpur, Bangladesh. \n3. Faridpur Medical College, Faridpur, Bangladesh. \n \nCorresponding author info: \nTaukir Tanjim, MBBS, MPH, Project Research Physician,  Infectious \nDiseases Division, International Centre for Diarrhoeal Diseases Research, \nBangladesh (icddr,b), Dhaka, Bangladesh. Phone: (+880) 1752-234465. \nEmail: taukir.tanjim@bsmmc.edu.bd, taukir.tanjim@icddrb.org.  \n \nABSTRACT \nBackground: Pre-eclampsia (PE) is a significant cause of maternal and \nperinatal morbidity and mortality worldwide. The clinical course and severity of PE \ncan vary depending on the gestational age at onset. However, limited data from \ndeveloping countries including Bangladesh stratify outcomes by onset timing, \nhindering context-specific management. This study aimed to differentiate maternal \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n 2\nand perinatal outcomes associated with early-onset PE (EO-PE, <34 weeks) \nversus late-onset PE (LO-PE, ≥ 34 weeks) in a tertiary care setting in Bangladesh. \nMethods: A cross-sectional study was conducted at Faridpur Medical College \nHospital, Faridpur, Bangladesh, from March to August 2023. Data were collected \nfrom hospital records and through pre-structured telephone questionnaires for 255 \nmothers diagnosed with PE (EO-PE: n=121; LO-PE: n=134). Maternal, fetal and \nneonatal outcomes were compared between the EO-PE and LO-PE groups. \nResults: The prevalence of PE among admitted pregnant women was 11.28%. \nEO-PE was associated with more adverse perinatal outcomes compared to LO-PE, \nincluding lower fetal survival (72% vs 97%), higher rates of prematurity (76% vs \n13%), low birth weight (74% vs 18%), and increased need for neonatal hospital \nadmission (54% vs 21%) (p<0.001). Maternal complications such as eclampsia \n(31% vs 19%, p=0.018) and placental abruption (20% vs 10%, p=0.022) were more \nfrequent in the EO-PE group. However, cesarean section rates were higher in the \nLO-PE group (p<0.001).  \nConclusions: Early-onset PE is associated with more severe adverse maternal \nand perinatal outcomes compared to late-onset PE. Early screening, health \neducation, and specialized management protocols for EO-PE group could be \neffective in mitigating associated complications. \n \nKeywords: Developing Countries, Perinatal Death, Pre-eclampsia, Pregnancy \nComplications, Pregnancy Outcome. \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 3\nMAIN TEXT  \n1. Introduction  \nPregnancy, while a transformative phase in a woman's life, can be complicated by \nconditions that pose significant risks to both mother and child 1. Hypertensive \ndisorders of pregnancy, particularly pre-eclampsia (PE), are major contributors to \nmaternal and perinatal morbidity and mortality globally 2. PE is typically \ncharacterized by new-onset hypertension after 20 weeks of gestation accompanied \nby proteinuria or other evidence of maternal end-organ or uteroplacental \ndysfunction 3. It affects an estimated 2% to 10% of pregnancies worldwide, with \n20% of the total global PE patients belong to the underdeveloped nations 2, 4. The \nburden of PE is disproportionately high in developing countries, which may range \nfrom 2% to 17% due to challenges in healthcare infrastructure and management of \ncomplications 5, 6. \nBangladesh has made significant progress in reducing overall maternal \nmortality in recent decades. However, the prevalence of PE is 14.4% in \nBangladesh which is much higher compared to the global percentage \n7. According \nto Bangladesh Maternal Mortality and Health Care Surveys (BMMSs) 2016, the \npreeclampsia/eclampsia-specific mortality ratio was 46 per 100,000 live births, 8. \nMoreover, 9% of stillbirths and 7% of early neonatal deaths in Bangladesh was \nattributed to eclampsia, the severe progression of PE \n9. PE remains a formidable \nchallenge, accounting for nearly one-fourth of all maternal deaths and ranking as \nthe second most common direct cause of maternal mortality in Bangladesh 8. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 4\nThe classification of PE into early-onset (EO-PE, typically occurring <34 weeks \nof gestation) and late-onset (LO-PE, occurring ≥ 34 weeks of gestation) has gained \nprominence due to its significant prognostic implications 10, 11. EO-PE is often \nassociated with more severe underlying placental pathology, leading to more \nsevere clinical manifestations and poorer outcomes for both mother and fetus \ncompared to LO-PE 12, 13. Understanding these distinctions is critical for risk \nstratification, targeted interventions, and optimizing resource allocation. \nDespite the recognized importance of this classification, there is a relative \nscarcity of studies directly comparing maternal and fetal outcomes between EO-PE \nand LO-PE groups within the context of Bangladesh and other developing \ncountries. Existing local data do not stratify by onset timing, limiting the ability to \ntailor management strategies effectively. A better understanding of PE, including its \nvarying clinical presentations and outcomes based on the timing of onset, is \nessential for improving maternal and perinatal health. Therefore, this study aimed \nto compare the maternal, fetal, and neonatal outcomes of early versus late-onset \nPE among women managed at a tertiary referral hospital in Faridpur, Bangladesh. \n \n2. Methods \n2.1 Study Design and Setting \nThis cross-sectional study was conducted at the Department of Obstetrics and \nGynecology, Faridpur Medical College Hospital (FMCH) in Faridpur, Bangladesh. \nFMCH is a tertiary level hospital serving as a major referral center for public and \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 5\nprivate hospitals in Faridpur and adjacent districts including Rajbari, Gopalganj, \nMagura, and Madaripur. \n \n2.2 Study Population and Sampling \nWe reviewed hospital admission records of all pregnant women admitted and \ndelivered at FMCH between March 2023 and August 2023. Women diagnosed with \nPE according to the American College of Obstetricians and Gynecologists (ACOG) \nguidelines were considered eligible \n3.  \nInclusion criteria for participants were: women of reproductive age ranging \nbetween 18-45 years, a complete hospital record (including pregnancy, delivery, \nand neonatal details) and availability of contact information for follow-up. Patients \nwhose pregnancy with PE was terminated before the age of fetal viability (defined \nas <28 weeks of gestation) and those without significant hospital record data or \nunavailable contact information were excluded. PE was categorized as early-onset \n(EO-PE) if diagnosed before 34 completed weeks of gestation and late-onset (LO-\nPE) if diagnosed at or after 34 completed weeks of gestation \n10. \n \n2.3 Data Collection \nSocio-demographic information (e.g., age, education, occupation, residence, \nreligion), and other clinical history were collected through telephone interviews. \nClinical information, including antenatal care (ANC) and obstetric history, \npregnancy complications, maternal outcome, were primarily extracted from hospital \nmedical records using a standardized data abstraction form. Fetal and neonatal \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 6\noutcomes such as prematurity, low birth weight (LBW), Intrauterine Growth \nRestriction (IUGR), congenital anomalies, Apgar scores, need for hospital \nadmission, respiratory support, neonatal death were also collected from the \nrecords. The data collection was conducted by two trained data collectors using a \npre-structured and pre-tested questionnaire.  \n \n2.4 Data Analysis \nCollected data were rechecked for errors and cleaned using Microsoft Excel \n(version 16.72). Statistical analysis was performed using STATA version 14.2 \n(StataCorp, College Station, Texas, USA). Descriptive statistics were used to \nsummarize participant characteristics. Categorical data were presented as \nfrequencies and percentages, and comparisons between EO-PE and LO-PE \ngroups were made using the Chi-square test or Fisher's exact test where \nappropriate. Continuous data were presented as mean ± standard deviation (SD), \nand comparisons were made using the independent samples t-test. A p-value \n<0.05 was considered statistically significant. \n \n2.5 Ethical Considerations \nEthical approval for this study was obtained from the Institutional Review Board \n(IRB) of Faridpur Medical College Hospital, Faridpur. Informed verbal consent was \nobtained from participants prior to conducting the telephone interviews. All data \ncollected were anonymized prior to analysis.  \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 7\n3. Results \n3.1 Participant Recruitment and Baseline Characteristics \nDuring the six-month study period (March to August 2023), a total of 3785 pregnant \nwomen were delivered at the Department of Gynaecology and Obstetrics, FMCH, \nFaridpur. Among them, 427 (11%) mothers were diagnosed with PE. 89 cases \nwere excluded due to the unavailability of significant clinical records, and an \nadditional 41 cases were excluded as our data collectors were unable to contact \nthem. From the eligible cases, 255 women with PE agreed to participate and \nprovide further information. This final sample comprised 121 women in the EO-PE \ngroup and 134 women in the LO-PE group. (Figure 1) \n \n \nFigure 1: Flowchart of participant selection from admitted pre-eclamptic patients \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 8\nThe mean age of the patients was 26.48 ± 6.02 years, with women in the EO-\nPE group being older in age compared to the LO-PE group (27.85 ± 5.63 years vs \n25.18 ± 6.10 years, p=0.003). While the majority of participants had attained only \nup to primary level education, the overall educational level was significantly higher \nin the LO-PE group (p=0.016). Approximately 80% of participants were \nhomemakers. However, being a student was significantly more common in the LO-\nPE group compared to the EO-PE group (15.67% vs. 8.26%, p=0.03). About 95% \nof participants were Muslim, and approximately two-thirds resided in rural areas, \nwith no significant difference between groups. A significantly higher percentage of \nwomen in the EO-PE group resided outside Faridpur district compared to the LO-\nPE group (62.81% vs. 44.03%, p=0.003). (Table 1) \n \nTable-1: Comparison of socio-demographic factors between EO-PE & LO-PE groups \nCharacteristics EO-PE (n=121) LO-PE (n=134) P-value \nFrequency Percentage Frequency Percentage \nAge (Mean ± SD) 27.85 ± 5.63 25.18 ± 6.10 0.003* \nEducation Level:     0.016* \n-  Illiterate 11 9.09 % 9 6.72 %  \n-  Able to read/write 18 14.88 % 6 4.48 %  \n-  Primary 45 37.19 % 44 32.84 %  \n-  Secondary 16 13.22 % 30 22.39 %  \n-  Undergraduate 23 19.01 % 27 20.15 %  \n-  Graduate & above 8 6.61 % 18 13.43 %  \nOccupation:     0.03* \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 9\n-  Homemaker 101 83.47 % 105 78.36 %  \n-  Business 8 6.61 % 2 1.49 %  \n-  Student 10 8.26 % 21 15.67 %  \n-  Service holder 2 1.65 % 6 4.48 %  \nReligion:     0.455 \n-  Islam 113 93.39 % 128 95.52 %  \n-  Hinduism 8 6.61 % 6 4.48 %  \nResidence:     0.003* \n-  In Faridpur district 45 37.19 % 75 55.97 %  \n-  Outside Faridpur 76 62.81 % 59 44.03 %  \nLiving Area:     0.731 \n-  Rural 88 72.73 % 100 74.63 %  \n-  Urban 33 27.27 % 34 26.27 %  \n* P-value <0.05 – statistically significant. \n \n3.2 Maternal Clinical History and ANC \nA significantly higher proportion of the EO-PE women were primigravid compared \nto the LO-PE group (76.03% vs. 47.76%, p<0.001). Pre-existing chronic \nhypertension (14.88% vs 5.97%, p=0.019) and hypothyroidism (14.05% vs. 1.49%, \np<0.001) had significantly higher prevalence in the EO-PE group as well. There \nwere no significant differences between groups in the prevalence of gestational \ndiabetes mellitus or a family history of hypertension. \nRegarding ANC, more than half of all participants did not complete the \nminimum recommended four ANC visits. There was no significant difference in \nachieving \n≥ 4 ANC visits between the LO-PE group and the EO-PE group (44.78% \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 10\nvs. 35.54%, p=0.277). Similarly, no significant difference was observed in the \nhistory of PE in previous pregnancies among multigravida women (17.39%  vs. \n12.50%, p=0.405). (Table 2) \n \nTable 2: Comparison of clinical characteristics between the EO-PE and LO-PE groups \nCharacteristics EO-PE (n=121) LO-PE (n=134) P-value \nFrequency Percentage Frequency Percentage \nPrimigravida 92 76.03 % 64 47.76 % <0.001* \nGestational Diabetes \nMellitus \n8 6.61 % 8 5.97 % 0.833 \nHypothyroidism 17 14.05 % 2 1.49 % <0.001* \nChronic Hypertension 18 14.88 % 8 5.97 % 0.019* \nHistory of PE in previous \npregnancies \n16 (n= 92) 17.39 % 8 (n=64) 12.50 % 0.405 \nFamily history of \nHypertension \n48 39.67 % 51 38.06 % 0.792 \nANC (Minimum 4 visits) 43 35.54 % 60 44.78 % 0.277 \n* P-value <0.05 – statistically significant. \n \n3.3 Maternal Outcomes and Complications \nMaternal mortality did not differ significantly between the groups (3.31% in EO-PE \nvs. 1.49% in LO-PE, p=0.340). However, specific maternal complications were \nmore frequent in the EO-PE group. PE progressed to eclampsia in 31.40% of EO-\nPE cases compared to 18.66% in LO-PE cases (p=0.018). Placental abruption was \nalso more common in the EO-PE group (19.83% vs 9.70%, p=0.022). The \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 11\noccurrence of other severe maternal complications such as HELLP syndrome, \npostpartum hemorrhage (PPH), acute kidney injury (AKI), cerebrovascular \naccidents or pulmonary edema had no significant differences between the groups. \nThe overall prevalence of adverse maternal outcome (defined as one or more \nmaternal complications or maternal death) was slightly higher in the EO-PE group \n(47.11%) compared to the LO-PE group (44.78%, p=0.709). Interestingly, women \nin the LO-PE group had a significantly higher rate of cesarean sections (C/S) \ncompared to those in the EO-PE group (84.33% vs 51.24%, p<0.001). (Table 3) \n \nTable 3: Comparison of maternal outcomes between the EO-PE and LO-PE groups \nCharacteristics EO-PE (n=121) LO-PE (n=134) p value \nFrequency Percentage Frequency Percentage \nMode of delivery:  \n-  NVD 59  48.76 % 21 15.67 % <0.001* \n-  C/S 62 51.24 % 113 84.33 % \nMaternal outcome:  \n-  Maternal death 4 3.31 % 2 1.49 % 0.340 \nComplications:  \nEclampsia 38 31.40 % 25 18.66 % 0.018* \nHELLP Syndrome 10 8.26 % 10 7.46 % 0.812 \nAbruptio Placenta 24 19.83 % 13 9.70 % 0.022* \nPostpartum hemorrhage 6 4.96 % 12 8.96 % 0.213 \nAcute Kidney Injury 4 3.31 % 2 1.49 % 0.340 \nCerebrovascular accidents 8 6.61 % 8 5.97 % 0.833 \nPulmonary edema 8 6.61 % 4 2.99 % 0.172 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 12\nMaternal adverse outcome \na \n57 47.11 % 60 44.78 % 0.709 \n* P-value <0.05 – statistically significant. \na Maternal adverse outcome was defined as occurrence of one or more maternal complications or \nmaternal death. \n \n \n3.4 Fetal and Neonatal Outcomes \nThe EO-PE group experienced significantly poorer fetal outcomes. Fetal survival \n(resulting in a livebirth) was markedly lower in the EO-PE group (72%; 87 livebirths \nout of 121 cases) compared to the LO-PE group (97%; 130 livebirths out of 134 \ncases, p<0.001). The sex distribution of infants did not differ significantly between \nthe groups. (Table 4) \n \nTable 4: Comparison of fetal outcomes between the EO-PE and LO-PE groups \nCharacteristics EO-PE (n=121) LO-PE (n=134) P-value \nFrequency Percentage Frequency Percentage \nFetal outcome:     <0.001* \n-  Livebirth 87 71.90 % 130 97.01 %  \n-  Stillbirth 34 28.10 % 4 2.99 %  \nBaby Sex:     0.200 \n-  Male 58 47.93 % 75 55.97 %  \n-  Female 63 52.07 % 59 44.03 %  \n* P-value <0.05 – statistically significant. \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 13\nIn terms of neonatal outcomes, those born to mothers with EO-PE had \nsubstantially worse outcomes. Women in the EO-PE group (75.86%) had five times \nmore premature (<37 weeks) deliveries compared to the LO-PE group (13.07%, \np<0.001). Similarly, low birth weight babies (<2500g) were about four times more \nfrequent in the EO-PE group (73.56%) than in the LO-PE group (17.69%, p<0.001). \nIUGR was also significantly more common in neonates from the EO-PE group \n(29.89% vs 14.62%, p=0.007). \nThe need for neonatal hospital admission was significantly higher for neonates \nin the EO-PE group compared to the LO-PE group (54.02% vs. 20.77%, p<0.001). \nNeonatal death occurred significantly more often in the EO-PE group (11 deaths, \n12.64%) compared to the LO-PE group (2 deaths, 1.54%, p=0.001). The difference \nin the proportion of neonates with a 5-minute Apgar score and the number of cases \nof congenital anomalies between the EO-PE and LO-PE groups was not \nsignificant. Overall, the neonatal adverse outcome (defined as the occurrence of at \nleast one or more neonatal complications or neonatal death) was alarmingly higher \nin the EO-PE group compared to the LO-PE group (89.66% vs. 25.38%, p<0.001). \n(Table 5) \n \nTable 5: Comparison of neonatal outcomes between the EO-PE and LO-PE groups \nCharacteristics EO-PE (n=87) LO-PE (n=130) P-value \nFrequency Percentage Frequency Percentage \nPrematurity (<37 weeks) 66 75.86 % 17 13.07 % <0.001* \nLBW (<2500 g) 64 73.56 % 23 17.69 % <0.001* \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 14\nIUGR 26 29.89 % 19 14.62 % 0.007* \nCongenital Anomaly 0 0.00 % 4 3.08 % 0.099 \nHospital Admission 47 54.02 % 27 20.77 % <0.001* \n5-minute APGAR Score \n<7 \n12 13.79 % 10 7.69 % 0.145 \nNeonatal Death 11 12.64 % 2 1.54 % 0.001* \nNeonatal adverse \noutcome a \n78 89.66 % 33 25.38 % <0.001* \n* P-value <0.05 – statistically significant. \na Neonatal adverse outcome was defined as the occurrence of one or more neonatal complications \nor neonatal death. \n \n4. Discussion  \nThis study showed that early-onset PE was associated with more severe maternal \ncomplications such as eclampsia and placental abruption, and substantially worse \nperinatal outcomes including higher rates of stillbirth, prematurity, low birth weight \nand neonatal mortality. Our findings align with previous research suggesting that \nearly-onset PE (EO-PE) represents a more severe form of the disorder \n12-15. \nThe observed prevalence of PE (11.28%) among admitted pregnant women in \nour study is consistent with reports from some other studies in the region. Recent \nfacility-based studies in Nepal and Bangladesh reported the prevalence of PE as \n12% and 14% respectively 16, 17. This high prevalence in tertiary centers is likely \nindicative of referral bias, where complicated cases are disproportionately \nrepresented. Such tertiary centers should be adequately resourced with \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 15\nspecialized personnel and infrastructure to handle the high volume of these \npatients. \nStudies have consistently shown that women with EO-PE have a higher \nincidence of severe maternal complications 18-20. In our study, EO-PE was \nassociated with significantly higher rates of eclampsia and placental abruption. \nSimilarly, a study in India found higher rates of eclampsia (43% vs. 28%) and \nabruptio placentae (14.4% vs. 12%) in the EO-PE group compared to the LO-PE \ngroup \n21 The underlying cause of these poor outcomes lies in the defective \nplacentation that occurs early in pregnancy, leading to inadequate spiral artery \nremodeling, uteroplacental ischemia, and a surge of anti-angiogenic factors into \nthe maternal bloodstream \n13, 22. These factors contribute to widespread endothelial \ndysfunction. Given its severity, EO-PE should be treated as a high-risk condition \nthat requires close monitoring and care in specialized settings. Improving early \nscreening and educating women about warning signs during pregnancy could help \nreduce serious maternal complications. \nInterestingly, our study found a significantly higher rate of Cesarean sections in \nthe LO-PE group. This contrasts with some studies that show no difference or \nhigher rates in EO-PE due to urgency [17,19].  The difference observed in our \nstudy may be influenced by local clinical practices and the specific thresholds used \nfor obstetric interventions, such as decisions around the mode and timing of \ndelivery. This highlights the need for clear institutional guidelines for the timing and \nmode of delivery in both PE phenotypes. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 16\nThis study reported that EO-PE was associated with poorer fetal survival and \nincreased rates of prematurity, low birth weight, IUGR and neonatal death. These \nadverse neonatal outcomes reflect the severe uteroplacental insufficiency \ncharacteristic of EO-PE, where the placenta fails to develop properly early in \npregnancy \n13. As a result, it cannot provide adequate oxygen and nutrients to the \nfetus 23. This dysfunctional placenta poses serious risks to both the baby and the \nmother. To protect the mother’s health, doctors often need to deliver the baby \nprematurely through iatrogenic preterm birth.  While this can be life-saving for the \nmother, it results in neonatal prematurity and its associated complications such as \nbreathing difficulties, feeding problems, and long-term disability \n24, 25. This \npathophysiology justifies the higher rate of hospitalization and neonatal mortality \namong children born to mothers with EO-PE, which was also observed in our \nstudy. Management of these cases must occur exclusively in integrated tertiary \ncenters with a Neonatal Intensive Care Unit (NICU). Additionally, specialized \ntraining should be facilitated for healthcare providers for a better maternal and \nneonatal outcome. \nTo the best of our knowledge, this is the first study from Bangladesh to \ncompare pregnancy outcomes based on the timing of pre-eclampsia onset. An \nadditional strength lies in the comprehensive evaluation of maternal, fetal, and \nneonatal outcomes, enabling a multidimensional understanding of the clinical \nburden associated with PE. However, several limitations must be acknowledged. \nFirst, being a single facility based study, the findings may be subject to referral bias \nand may not be generalizable to the broader pregnant population in Bangladesh. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint \n\n 17\nSecond, the sample size may have been insufficient to detect significant \ndifferences for less common maternal complications. Third, the collection of socio-\ndemographic and family history data via phone interview introduces potential for \nrecall bias, although a pre-structured questionnaire was used to standardize this \nprocess. Future research should include larger, multi-center prospective studies \nwith adjustment for confounders to further delineate these differences and explore \nunderlying pathophysiological mechanisms. Longitudinal studies are also needed \nto understand the long-term health consequences of EO-PE and LO-PE for both \nmothers and their children. \n \n5. Conclusion \nThis study showed that the timing of PE onset has distinct implications for both \nmaternal and perinatal outcomes in a tertiary level hospital setting in Bangladesh. \nEO-PE showed more adverse maternal and perinatal outcomes. This group is \nhighly vulnerable and requires close monitoring in well-equipped facilities. Focus \nshould be given on early screening, health education, and training of the \nhealthcare providers. 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(which was not certified by peer review)\nThe copyright holder for this preprint this version posted October 17, 2025. ; https://doi.org/10.1101/2025.10.15.25337483doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}