document: preeclampsia ( pe ) is a leading cause of maternal and neonatal mortality and morbidity , complicating 25% of all the pregnancies . 
   classically , the presence of proteinuria in women with gestational hypertension is clinically diagnosed as pe and is associated with increased maternal or neonatal morbidity and mortality compared with gestational hypertension . 
   however , several studies have shown that proteinuria is not a significant predictor of adverse maternal and neonatal outcomes . 
   the incidence of the disease increased in china , as the opening of the two - child policy , but there was not an indicator of the severe pe . 
   severe pe is often combined with hypoalbuminemia ; we hypothesize that hypoalbuminemia may serve as an indicator of the severity of pe . 
   hypoalbuminemia occurs mainly due to systemic small vessel spasm , increased secretion of angiotensin and damaged and increased permeability of vascular endothelial cells , thereby leading to a large number of proteins and liquid leaking in tissue clearance and a loss of a large number of plasma proteins ( especially serum albumin ) , causing intravascular dehydration . 
   this intravascular dehydration may accelerate the appearance of intravascular lesions , which is thought to be a predisposing factor of the hemolysis , elevated liver enzymes and low platelet ( hellp ) syndrome and acute fatty liver of pregnancy . 
   in addition , the reduction of hepatic blood flow due to the production of albumin is decreased . in two recent studies , hypoproteinemia during pregnancy 
   was observed in the pe group in the second trimester before the onset of clinical symptoms , and the authors suggest the possibility of preventing pe by maintaining adequate blood protein levels during early pregnancy . in the present study 
   , we asked whether hypoproteinemia was effective at predicting perinatal risk in women with pe . 
   the aim of our study was to evaluate maternal and perinatal outcomes in women with pe , according to the different value of albumin ( 25 g / l and < 25 
   in this retrospective cohort study , 299 women from the maternal and child health hospital of anhui province were enrolled between january 2014 and june 2015 . 
   the anhui medical university ethics committee provided ethics approval , and written informed consent was obtained from all participants . 
   g / l ( mild hypoproteinemia [ mhp ] , n = 220 ) , pe with an albumin value of 25 
   g / l ( severe hypoproteinemia [ shp ] , n = 79 ) . for the study 
   serum albumin was measured at the laboratory of the maternal and child health hospital of anhui province , using the unicel dxc800 of beckman coulter ( the united states ) . 
   pe was defined according to the guidelines of the international society for the study of hypertension in pregnancy : ( 1 ) hypertension : blood pressure 140/90 mmhg on at least two occasions and at least 46 h apart ; ( 2 ) the severe features , such as severe hypertension , platelet count below 100,000/l , serum creatinine concentration of 1.1 mg / dl , or doubling of the serum creatinine concentration in the absence of other renal disease , levels of liver transaminases elevated to twice the normal concentration , pulmonary edema , new - onset cerebral or visual disturbance ; ( 3 ) proteinuria : more than 300 mg protein in a 24-h urine collection , or a urinary protein - to - creatinine ratio of 0.3 , or a urine dipstick protein grade of 1 + or greater if other methods are unavailable . 
   pe was defined by ( 1 ) + ( 2 ) or ( 1 ) + ( 3 ) . 
   moreover , exclusion criteria were : kidney diseases , preexisting proteinuria , essential hypertension or other maternal chronic conditions ( autoimmune diseases , diabetes , etc . ) , and twin pregnancies . 
   maternal outcomes were evaluated : delivery mode ( spontaneous vaginal , instrumental vaginal , cesarean section [ cs ] ) , eclampsia , hellp syndrome , hypertension , abnormal liver function , abnormal renal function , ascites , oligohydramnios , thrombocytopenia , and abruptio placenta . for these complex cases , 
   the trial management team reviewed the case and a diagnosis was made by two senior deputy chief physicians or chief physicians , acting independently . 
   neonatal outcomes included : perinatal deaths , preterm birth ( < 37 and 28 weeks gestation , spontaneous or iatrogenic ) , neonatal asphyxia , and fetal growth restriction ( fgr , defined as actual birth weight below 10% for gestational age ) . in the meantime , birth weight was also assessed . 
   the comparisons of the continuous variables between the two groups were estimated using the t - test or mann  whitney test . 
   the comparisons of the categorical variables between the groups were estimated using the chi - square test or fisher s exact test . 
   a univariate logistic regression was used to analyze the associations between shp pe with poor maternal and neonatal outcomes . 
   pe was defined according to the guidelines of the international society for the study of hypertension in pregnancy : ( 1 ) hypertension : blood pressure 140/90 mmhg on at least two occasions and at least 46 h apart ; ( 2 ) the severe features , such as severe hypertension , platelet count below 100,000/l , serum creatinine concentration of 1.1 mg / dl , or doubling of the serum creatinine concentration in the absence of other renal disease , levels of liver transaminases elevated to twice the normal concentration , pulmonary edema , new - onset cerebral or visual disturbance ; ( 3 ) proteinuria : more than 300 mg protein in a 24-h urine collection , or a urinary protein - to - creatinine ratio of 0.3 , or a urine dipstick protein grade of 1 + or greater if other methods are unavailable . 
   pe was defined by ( 1 ) + ( 2 ) or ( 1 ) + ( 3 ) . 
   moreover , exclusion criteria were : kidney diseases , preexisting proteinuria , essential hypertension or other maternal chronic conditions ( autoimmune diseases , diabetes , etc . ) , and twin pregnancies . 
   maternal outcomes were evaluated : delivery mode ( spontaneous vaginal , instrumental vaginal , cesarean section [ cs ] ) , eclampsia , hellp syndrome , hypertension , abnormal liver function , abnormal renal function , ascites , oligohydramnios , thrombocytopenia , and abruptio placenta . 
   for these complex cases , the trial management team reviewed the case and a diagnosis was made by two senior deputy chief physicians or chief physicians , acting independently . 
   neonatal outcomes included : perinatal deaths , preterm birth ( < 37 and 28 weeks gestation , spontaneous or iatrogenic ) , neonatal asphyxia , and fetal growth restriction ( fgr , defined as actual birth weight below 10% for gestational age ) . in the meantime , birth weight was also assessed . 
   the comparisons of the continuous variables between the two groups were estimated using the t - test or mann  whitney test . 
   the comparisons of the categorical variables between the groups were estimated using the chi - square test or fisher s exact test . 
   a univariate logistic regression was used to analyze the associations between shp pe with poor maternal and neonatal outcomes . 
   a total of 309 women with singleton pregnancies were identified ; ten women were excluded due to incomplete outcome data . 
   there was no significant difference in age and body mass index between the two groups of pregnant women ( p = 0.17 and 0.23 , respectively ) , shown in table 1 . maternal characteristics in mild hypoproteinemia and severe hypoproteinemia preeclampsia the analysis shows that women with shp were delivered almost 1.5 weeks earlier than the mhp group ( p  0.01 ) . in the shp group , 
   the percentage of cs was higher , and the rate of spontaneous delivery was lower ( p = 0.04 and 0.04 , respectively ) . 
   severe hypertension was more frequent in the shp group than in the mhp group ( p = 0.01 and < 0.01 , respectively ) . 
   women with shp were more likely to present with abnormal liver or renal function , ascites , and abruptio placenta than women in the mhp group ( p < 0.05 ) . 
   pregnancy outcome in mild hypoproteinemia and severe hypoproteinemia preeclampsia neonatal outcomes are presented in table 3 ; the short - term neonatal outcome was worse in the shp group . 
   the average birth weight was significantly lighter ( 2498.1  866.5 g ) in the shp group than in the mhp group ( 2940.1  768.0 g ) . 
   neonates of the women in the shp group were more likely to have fgr , neonatal intensive care unit admission , and preterm deliveries ( p < 0.01 ) . 
   short - term neonatal outcome in mild hypoproteinemia and severe hypoproteinemia preeclampsia to further clarify the associations between shp pe with cs , poor maternal and neonatal outcomes , a univariate logistic regression was performed to analysis . 
   the results show that shp was a significant risk factor for cs ( odds ratio [ or ] 2.99 , 95% confidence interval [ ci ] 1.137.91 ) , poor maternal outcomes ( or 5.83 , 95% ci 3.3210.24 ) , and poor neonatal outcomes ( or 4.43 , 95% ci 2.577.62 ) in pe women [ table 4 ] . 
   a total of 309 women with singleton pregnancies were identified ; ten women were excluded due to incomplete outcome data . 
   there was no significant difference in age and body mass index between the two groups of pregnant women ( p = 0.17 and 0.23 , respectively ) , shown in table 1 . maternal characteristics in mild hypoproteinemia and severe hypoproteinemia preeclampsia 
   the analysis shows that women with shp were delivered almost 1.5 weeks earlier than the mhp group ( p  0.01 ) . in the shp group , 
   the percentage of cs was higher , and the rate of spontaneous delivery was lower ( p = 0.04 and 0.04 , respectively ) . 
   severe hypertension was more frequent in the shp group than in the mhp group ( p = 0.01 and < 0.01 , respectively ) . 
   women with shp were more likely to present with abnormal liver or renal function , ascites , and abruptio placenta than women in the mhp group ( p < 0.05 ) . 
   neonatal outcomes are presented in table 3 ; the short - term neonatal outcome was worse in the shp group . 
   the average birth weight was significantly lighter ( 2498.1  866.5 g ) in the shp group than in the mhp group ( 2940.1  768.0 g ) . 
   neonates of the women in the shp group were more likely to have fgr , neonatal intensive care unit admission , and preterm deliveries ( p < 0.01 ) . 
   short - term neonatal outcome in mild hypoproteinemia and severe hypoproteinemia preeclampsia to further clarify the associations between shp pe with cs , poor maternal and neonatal outcomes , a univariate logistic regression was performed to analysis . 
   the results show that shp was a significant risk factor for cs ( odds ratio [ or ] 2.99 , 95% confidence interval [ ci ] 1.137.91 ) , poor maternal outcomes ( or 5.83 , 95% ci 3.3210.24 ) , and poor neonatal outcomes ( or 4.43 , 95% ci 2.577.62 ) in pe women [ table 4 ] . the associations between severe hypoproteinemia preeclampsia with cesarean section , poor maternal and neonatal outcomes 
   the pathophysiologic mechanisms of pe are unclear ; the leading theory is that defects in placental implantation and function ultimately display as the development of pe . 
   scholars believe that gestational hypertension and preeclampsia are isolate disease processes with different mechanisms , research evidence includes the differential risk factors between hypertension and pe , specific histologic changes in the placenta and kidneys in pe only , the levels of antiangiogenic peptides of placental origin are elevated in pe but not in gestational hypertension , and a far lower irculating volume in pe compared with gestational hypertension . 
   pe patients often complicated with multiple organ hypoperfusion , the reduction of hepatic blood flow due to the production of albumin is decreased , thus lead to the gradual development of hypoproteinemia . in the prognosis , 
   women with chronic and gestational hypertension usually have good outcomes . however , pe represents one - third of cases of severe obstetric morbidity ; the mortality associated with pe and eclampsia was about 0.83 per 100,000 maternities . 
   simultaneously , pe is also strongly related with intrauterine growth restriction , neonatal asphyxia , low birth weight , preterm delivery , and neonatal respiratory distress syndrome . however , a common robust biomarker has not been detected . in this study , we evaluate maternal and perinatal outcomes in women with pe according to the different value of albumin ( 25 g / l and < 25 
   hypoalbuminemia is considered a factor of poor maternal and neonatal outcomes . in this study , 
   shp was a significant risk factor for cs ( or 2.99 , 95% ci 1.137.91 ) , poor maternal outcomes ( or 5.83 , 95% ci 3.3210.24 ) , and poor neonatal outcomes ( or 4.43 , 95% ci 2.577.62 ) in pe women . 
   the systemic small artery of women with pe was in spasm ; protein absorption and utilization in the gastrointestinal tract were affected , often causing the emergence of hypoproteinemia . 
   hypoalbuminemia indicates that the conditions are further exacerbated in pe and further affects the function of various organs , such as retinal damage , white matter lesions , pericardial effusion , ascites , and liver and kidney dysfunction . in our study , the presence of shp has been associated with increased risk of cs , severe hypertension , abnormal liver or renal function , ascites , and abruptio placenta . 
   the percentage of cs in shp was 93.7% , higher than in the mhp group . 
   the incidence of abnormal liver or renal function in shp ( 13.9% ) was significantly higher than in mhp ( 5.5% and 1.8% , respectively ) , and the difference was statistically significant ( p = 0.03 and < 0.01 , respectively ) . 
   placental vascular spasm in pe increases blood flow resistance from mother to the fetus , resulting in chronic fetal hypoxia . with 
   a high number of the mother s protein lost and protein and other nutrient deficiencies , these factors can lead to intrauterine growth restriction and low birth weight . 
   women with shp pe were more likely to deliver preterm infants ( 41 , 51.9% , p < 0.01 ) , lower average birth weight ( 2498.1  866.5 vs. 2940.1  768.0 g , p < 0.01 ) , fgr ( 15 , 19.0% , p < 0.01 ) than those with mhp pe . 
   it seems likely that many unknown risk factors may be present in women with pe , and it is unclear whether this finding occurred as a pathophysiology of latent pe or was responsible for it . 
   however , we show here that shp is a risk factor for women with pe . 
   shp pe is associated with a higher risk of adverse maternal and neonatal outcomes than mhp pe , deserving closer surveillance during pregnancy . 
    
    
   hbc and xtw performed the design and coordinated the study , data collecting , agreed for all aspects of the work , and prepared the manuscript . 
   ft provided assistance in the design , data collecting , analysis , and interpretation of data of the study and participated in manuscript preparation .
summary: background : the aim of this study was to evaluate maternal and perinatal outcomes in preeclampsia ( pe ) , according to the value of albumin.materials and methods : preeclamptic women were retrospectively divided into mild hypoproteinemia ( mhp , n = 220 ) and severe hypoproteinemia ( shp , n = 79 ) pe according to the value of albumin . 
   the maternal and perinatal outcomes were evaluated in both groups.results:two hundred and ninety - nine single pregnancies complicated by pe were included in this study . 
   gestational age at delivery was earlier in shp than mhp ( p < 0.01 ) . 
   severe hypertension , abnormal liver function , abnormal renal function , ascites , and abruption occurred more frequently in shp than in mhp ( p < 0.01 , 0.03 , < 0.01 , 0.01 , and 0.04 , respectively ) . 
   women in shp had a higher rate of cesarean section than those in mhp ( p = 0.04 ) . 
   fetal growth restriction infants were more frequent in shp than in mhp ( p < 0.01 ) . 
   the occupancy rate of the neonatal intensive care unit was higher in shp than in mhp ( p < 0.01).conclusion : shp pe is associated with a higher risk of adverse pregnancy outcome than mhp pe , deserving closer surveillance during pregnancy .