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

Background: 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. Objective: 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. Methods: 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. Results: 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). Conclusions: 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.