Sleep Disruption, Psychological Stress, and Preeclampsia in High-Risk Pregnancies During the COVID-19 Era

Sleep disturbance and psychosocial stress are emerging contributors to hypertensive disorders of pregnancy. The present cohort was recruited during the COVID-19 period, a time marked by substantial changes in prenatal care delivery, social support, and daily routines, which may have influenced maternal sleep and stress burden.

This study aimed to evaluate the independent and integrated associations between maternal sleep quality, psychological stress, and pregnancy outcomes in women at moderate to high risk for preeclampsia.

In a single-center observational cohort of 170 pregnant women enrolled at 16 weeks' gestation, sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Fitbit Sense 2™ wearable data, while stress was measured through the Perceived Stress Scale (PSS-10), Generalized Anxiety Disorder-7 (GAD-7), and morning salivary cortisol. Associations with preeclampsia, birth weight, gestational age, and NICU admission were analyzed using multivariate regression and receiver operating characteristic (ROC) models. The COVID-19 period was treated as the contextual background of recruitment rather than as a directly compared exposure.

Poorer subjective sleep quality (higher PSQI) correlated negatively with birth weight (r = -0.34, p = 0.008) and gestational age (r = -0.28, p = 0.04). Elevated morning cortisol was significantly associated with NICU admission (r = 0.28, p = 0.002). The combined sleep + stress model predicted birth weight (R² = 0.26, p = 0.003) and preeclampsia (pseudo R² = 0.15, p = 0.015) more accurately than individual domains, achieving an ROC-AUC of 0.86 (95% CI: 0.78-0.92).

In high-risk pregnancies, integrated evaluation of sleep and stress parameters may improve the prediction of fetal growth impairment and preeclampsia beyond single-domain models. These findings support the incorporation of psychosocial and behavioral markers into antenatal risk stratification. Because no pre-pandemic or post-pandemic comparator group was included, the COVID-19 period should be interpreted as the contextual background of the study rather than as an independently tested exposure.