The Compounded Risk of Maternal Anemia and Preeclampsia: Neonatal Outcomes and Predictive Modeling in a Low-Resource Tertiary Center

<b>Background</b>: Anemia and preeclampsia are common and independently associated with adverse neonatal outcomes. Their combined effect, however, remains insufficiently explored. This study aims to evaluate the impact of second-trimester maternal anemia on neonatal outcomes in pregnancies complicated by preeclampsia, and to assess its predictive value for preterm birth and NICU admission. <b>Methods</b>: We conducted a retrospective cohort study including 3517 singleton births from a Romanian tertiary maternity hospital between October 2023 and December 2024. A total of 295 preeclamptic pregnancies were stratified by anemia severity (none, mild, moderate-to-severe) and compared with 428 matched non-preeclamptic anemic pregnancies matched by closest-neighbor selection. Neonatal outcomes included birthweight, gestational age, anthropometric parameters, Apgar score, preterm birth, and NICU admission. Logistic regression and ROC curve analysis were performed using anemia severity as a predictor. <b>Results</b>: Moderate-to-severe anemia in preeclamptic pregnancies was associated with significantly lower birthweight (2618 ± 461 g), shorter gestational age (36.6 ± 2.0 weeks), and higher preterm birth (41.1%) and NICU admission rates (40.0%) were compared to non-anemic counterparts. Each increase in anemia severity conferred 84% higher odds of preterm delivery (OR = 1.84; AUC = 0.63) and a 49% increase in NICU admission (OR = 1.49; AUC = 0.58). Youden's indices were 0.25 and 0.14, respectively. <b>Conclusions</b>: Maternal anemia is associated with increased neonatal morbidity in preeclamptic pregnancies, with moderate predictive value for preterm birth. These findings support the integration of early anemia screening and risk stratification into hypertensive pregnancy protocols to improve perinatal outcomes.