An Analysis of C-Reactive Protein, Procalcitonin, and D-Dimer in Pre-Eclamptic Patients

A mitochondrial regulator protein, MNRR1, is elevated in the maternal blood of women with preeclampsia

OBJECTIVE

Preeclampsia, one of the most serious obstetric complications, is a heterogenous disorder resulting from different pathologic processes. However, placental oxidative stress and an anti-angiogenic state play a crucial role. Mitochondria are a major source of cellular reactive oxygen species. Abnormalities in mitochondrial structures, proteins, and functions have been observed in the placentae of patients with preeclampsia, thus mitochondrial dysfunction has been implicated in the mechanism of the disease. Mitochondrial nuclear retrograde regulator 1 (MNRR1) is a newly characterized bi-organellar protein with pleiotropic functions. In the mitochondria, this protein regulates cytochrome c oxidase activity and reactive oxygen species production, whereas in the nucleus, it regulates the transcription of a number of genes including response to tissue hypoxia and inflammatory signals. Since MNRR1 expression changes in response to hypoxia and to an inflammatory signal, MNRR1 could be a part of mitochondrial dysfunction and involved in the pathologic process of preeclampsia. This study aimed to determine whether the plasma MNRR1 concentration of women with preeclampsia differed from that of normal pregnant women.

METHODS

This retrospective case-control study included 97 women with preeclampsia, stratified by gestational age at delivery into early (<34 weeks, n = 40) and late (≥34 weeks, n = 57) preeclampsia and by the presence or absence of placental lesions consistent with maternal vascular malperfusion (MVM), the histologic counterpart of an anti-angiogenic state. Women with an uncomplicated pregnancy at various gestational ages who delivered at term served as controls (n = 80) and were further stratified into early (n = 25) and late (n = 55) controls according to gestational age at venipuncture. Maternal plasma MNRR1 concentrations were determined by an enzyme-linked immunosorbent assay.

RESULTS

1) Women with preeclampsia at the time of diagnosis (either early or late disease) had a significantly higher median (interquartile range, IQR) plasma MNRR1 concentration than the controls [early preeclampsia: 1632 (924-2926) pg/mL vs. 630 (448-4002) pg/mL, p = .026, and late preeclampsia: 1833 (1441-5534) pg/mL vs. 910 (526-6178) pg/mL, p = .021]. Among women with early preeclampsia, those with MVM lesions in the placenta had the highest median (IQR) plasma MNRR1 concentration among the three groups [with MVM: 2066 (1070-3188) pg/mL vs. without MVM: 888 (812-1781) pg/mL, p = .03; and with MVM vs. control: 630 (448-4002) pg/mL, p = .04]. There was no significant difference in the median plasma MNRR1 concentration between women with early preeclampsia without MVM lesions and those with an uncomplicated pregnancy (p = .3). By contrast, women with late preeclampsia, regardless of MVM lesions, had a significantly higher median (IQR) plasma MNRR1 concentration than women in the control group [with MVM: 1609 (1392-3135) pg/mL vs. control: 910 (526-6178), p = .045; and without MVM: 2023 (1578-8936) pg/mL vs. control, p = .01].

CONCLUSIONS

MNRR1, a mitochondrial regulator protein, is elevated in the maternal plasma of women with preeclampsia (both early and late) at the time of diagnosis. These findings may reflect some degree of mitochondrial dysfunction, intravascular inflammation, or other unknown pathologic processes that characterize this obstetrical syndrome.

The association of antenatal D-dimer and fibrinogen with postpartum hemorrhage and intrauterine growth restriction in preeclampsia

BACKGROUND

D-dimer and fibrinogen were verified to be altered in preeclampsia. This study was to evaluate the associations of D-dimer and fibrinogen plasma levels with postpartum hemorrhage or intrauterine growth restriction in preeclamptic women.

METHODS

This was a retrospective study that recruited 278 preeclamptic women with singleton pregnancy from January 2016 to December 2019. Patients were allocated into five groups: mild preeclampsia (mPE) (n=68), mild preeclampsia with postpartum hemorrhage (mPE+PPH) (n=13), severe preeclampsia (sPE) (n=112), severe preeclampsia with postpartum hemorrhage (sPE+PPH) (n=17) and severe preeclampsia with intrauterine growth restriction (sPE+IUGR) (n=68). The antenatal D-dimer and fibrinogen plasma levels were analyzed among the groups. Logistic regression was used to determine the correlation between serum indexes and PPH or IUGR in preeclampsia.

RESULTS

The antenatal D-dimer plasma levels were significantly higher in the sPE+PPH group than that in the sPE group (2.02 μg/ml versus 1.37 μg/ml, P = 0.001), but there was no difference in fibrinogen. Elevated D-dimer was associated with PPH among severe preeclamptic women (adjusted odds ratio (aOR) [95% CI]: 3.093 [1.527-6.264], P = 0.002). No differences in D-dimer and fibrinogen were found between the mPE and mPE+PPH groups or between the sPE and sPE+IUGR groups.

CONCLUSIONS

Elevated antenatal plasma D-dimer level may be associated with postpartum hemorrhage in severe preeclampsia, but not with intrauterine growth restriction. Future prospective clinical trials are needed to investigate the predictive value of D-dimer in postpartum hemorrhage in severe preeclampsia.

Postpartum fibroid degeneration associated with elevated procalcitonin levels

Objectives

To describe a novel presentation of severely elevated procalcitonin (PCT) levels associated with postpartum fibroid degeneration.

Case presentation

We report a case of a 34-year-old woman with multiple large fibroids who was found to have fevers and a severely elevated PCT level of 34.03 ng/mL 2 days postpartum. MRI revealed carneous degeneration of her fibroids, and other etiologies such as infection were ruled out. She was successfully treated with the use of intravenous non-steroidal anti-inflammatory drugs and antibiotics, as a precaution. This report indicates procalcitonin may be elevated secondary to the inflammatory state caused by degenerating fibroids. Informed consent was obtained from all individuals included in this study.

Conclusions

Uterine leiomyomas, or fibroids, are tumors of the female reproductive tract affecting anywhere from 20–40% of women. One known complication of fibroids is degeneration, when the fibroid can infarct due to a decrease in blood supply. This can cause an inflammatory state with the release of multiple inflammatory markers. During pregnancy, routine markers such as white blood cell counts may be unreliable. Other markers such as procalcitonin are not well-studied in pregnancy. This case provides practitioners an example where the marker procalcitonin can be used to more accurately assess an inflammatory state during pregnancy. It also provides alterative diagnoses in the workup of postpartum fever.

Maternal and umbilical cord procalcitonin, high-sensitivity C-reactive protein, and interleukin-6 levels in preeclamptic and normotensive patients: A cross-sectional study

OBJECTIVES

To report maternal and umbilical vein levels of procalcitonin (PCT) in patients with preeclampsia (PE) compared to controls. As secondary aims, we measured high-sensitivity C-reactive protein (hs-CRP), and interleukin-6 (IL-6). Moreover, correlation analyses were performed between the inflammatory biomarkers and mean arterial pressure (MAP).

STUDY DESIGN

This was a single center, cross-sectional study.

MAIN OUTCOME MEASURES

After Institutional Review Board approval and written informed consent, patients with or without PE were enrolled. PCT, hs-CRP, and IL-6 levels were compared between groups using multiple linear regression models. We calculated the adjusted ratios of geometric means (aRGM) for the comparison of patients with and without PE. Correlation analysis between the inflammatory biomarkers and MAP was performed using Spearman's method.

RESULTS

A total of 156 participants were enrolled, yielding 156 venous blood samples and umbilical venous blood samples. Seventy-six patients were in the PE group, and 80 patients were in the control group. Maternal plasma and serum concentrations of PCT (aRGM 3.35 (95% confidence interval [CI]: 2.26, 4.95; p < 0.001)), hs-CRP (aRGM 1.85 (95% CI: 1.30, 2.63; p = 0.003)), and IL-6 (aRGM 1.49 (95% CI: 1.08, 2.04; p = 0.045)) were higher in the PE group. In umbilical venous samples, the concentrations of PCT (aRGM 2.54 (95% CI: 1.46, 4.44; p = 0.003)) and hs-CRP (aRGM 1.45 (95% CI: 1.13, 1.87; p = 0.012)) in the PE group were higher than the controls. No difference in umbilical venous IL-6 concentrations were detected between PE vs. control groups (aRGM 1.46; 95% CI: 1.07, 1.98; p = 0.051). There was positive correlation for both PCT and hs-CRP with MAP in maternal and umbilical venous samples. However, there was no correlation between IL and 6 and MAP in maternal or umbilical venous samples.

CONCLUSIONS

PCT levels were elevated in maternal and umbilical venous samples of patients with PE, and correlated with disease severity.

Maternal Serum and Fetal Cord Blood C-Reactive Protein Levels but not Procalcitonin Levels Are Increased in Idiopathic Intrauterine Growth Restriction

BACKGROUND The aim of the present study was to compare procalcitonin and CRP levels in maternal serum and fetal cord blood samples of patients with idiopathic intrauterine growth restriction (IUGR) vs. a control group of appropriate for gestational age (AGA) infants. MATERIAL AND METHODS The present prospective study included 43 patients: 27 patients with idiopathic IUGR (IUGR group) and 26 AGA infants at similar gestational ages (control group). Maternal serum and fetal cord blood samples were collected from the control group and IUGR group at time of delivery. Procalcitonin and CRP levels were analyzed in maternal blood. Procalcitonin and CRP levels were analyzed in fetal cord blood. RESULTS The median value of CRP levels in maternal blood was 47.5 mg/dl in the IUGR group and 15.255 mg/dl in the AGA group (p=0.001). The mdian CRP level in cord blood was 36.4 mg/dl (range, 17.3-47.2) in the IUGR group and 10.1 mg/dl (range, 4.07-16.5) in the control group, and the difference was statistically significant (p=0.001). The median maternal serum procalcitonin level was 0.05 µg/l in the IUGR group and 0.04 µg/l in the AGA group, and the difference was not statistically significant (p=0.435). The median procalcitonin value in fetal cord blood was 0.06 µg/l in the IUGR group and 0.04 µg/l in the AGA group, and the difference was not statistically significant (p=0.741). CONCLUSIONS Maternal serum and fetal cord CRP levels were higher in the IUGR group; however, there was no difference in procalcitonin, which is another inflammatory indicator, between the groups.

Overview of procalcitonin in pregnancy and in pre-eclampsia

Procalcitonin (PCT), a precursor for calcitonin, is a prohormone involved in the inflammatory processes, which has been poorly studied in the context of pregnancy. During severe inflammation, PCT derives from almost all cell types, including monocytes and parenchymal tissues, making it a good predictive and diagnostic marker of an inflammatory state with rapidly increased serum levels in inflammation or sepsis. In normal pregnancy, PCT is basally expressed at very low level by decidual cells, even if decidual macrophages, which in normal pregnancy are skewed to M2 macrophages, are resistant to lipopolysaccharide (LPS)-induced production of PCT. As PCT increase is associated with an inflammatory state, several research groups investigated whether PCT can be considered a marker of pre-eclampsia, a pregnancy disease characterized by systemic inflammation. The first aim of this review is to summarize what is already known about the tissues synthesizing PCT, about the stimuli that cause the increase of circulating PCT levels and how PCT acts as a proinflammatory stimulus by itself. Secondly, we will describe the role of this prohormone in normal pregnancy and in pregnancies complicated by pre-eclampsia, highlighting the involvement of the decidual macrophages and the proinflammatory cytokine tumor necrosis factor-α in the modulation of PCT expression in the decidual microenvironment.

Inflammatory Markers and Preeclampsia: A Systematic Review

BACKGROUND

Preeclampsia (PE), a serious and variable pregnancy complication affecting 5%-10% of the obstetric population, has an undetermined etiology, yet inflammation is concomitant with its development, particularly in relation to endothelial dysfunction.

OBJECTIVE

The purpose of this systematic review was to examine the published evidence concerning an association between PE and inflammatory markers for their usefulness in the prediction or early identification of women with PE in antepartum clinical settings.

METHODS

In this systematic review, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Cumulative Index for Nursing and Allied Health and MEDLINE/OVID were the electronic databases used for identifying published articles. We placed no time limit on the publication year.

RESULTS

The search generated 798 articles. After removing duplicates, screening abstracts, and conducting full-text reviews, we retained 73 articles and examined 57 unique markers. This review shows that C-reactive protein and the cytokines, specifically the proinflammatory markers IL-6, IL-8, and tumor necrosis factor alpha, garner the most support as potential inflammatory markers for clinical surveillance of PE, particularly during the second and third trimesters.

DISCUSSION

Based on this review, we cannot recommend any single inflammatory marker for routine clinical use to predict/identify PE onset or progression. Research is recommended to examine a combination panel of these four inflammatory markers both with and without clinical risk factors toward the goal of translation to practice.

Fibrinolytic proteins of normal pregnancy and pre-eclamptic patients in North West Nigeria

BACKGROUND

The hypercoagulability of pregnancy is exaggerated in pre-eclamptic state because of endothelial activation with resultant production of some endothelial derived proteins that are said to be inhibitors of fibrinolysis. This study compares these proteins like tPA, PAI-1 and D-dimers in normal pregnant women and the pre-eclamptic women.

METHODOLOGY

This was a comparative cross-sectional study. Eighty-five pre-eclamptic women were recruited as subjects and eighty five age, trimester and parity matched normotensive pregnant women as controls. Levels of PT, aPTT, tPA, PAI-1, D-dimer protein were determined in blood samples of subjects and controls. Urinalysis was performed with dipstick method on their urine samples. Data generated was analysed using the IBM®SPSS 20.0 (2011) soft ware packages and the level of significance was a p-value <0.05.

RESULTS

The mean age of the respondents was 29.9±5.2 years. The median(25th-75th percentile) values of D-dimer, tPA, and PAI-1 of subjects were 730 (305.000-1560.000ng/ml), 0.11 (0.065-0,300ng/ml) and 3.65 (2.970-4,400ng/ml) respectively which were significantly higher than the corresponding values in the controls of 520 (24.000-1030.000ng/ml), 0.05 (0.040-0.090ng/ml and 2.650 (2.125-3.400ng/ml) respectively, p<0.05 each.

CONCLUSION

The abnormal levels of PAI-1, D-dimer and tPA imply that they contribute to the exaggerated hypercoagulabilty state in pre-eclampsia thus, measuring their levels can help in the management of the condition.

Efficacy of serum procalcitonin to predict spontaneous preterm birth in women with threatened preterm labour: a prospective observational study

Background

A hypothesis of preterm parturition is that the pathogenesis of spontaneous preterm birth (sPTB) may be associated with an inflammatory process. Based on this theory, we have hypothesized that an inflammatory biomarker, procalcitonin (PCT), may be a good predictive marker of sPTB at the admission for threatened preterm labour (TPL). The present study was aimed to investigate the association between serum PCT and sPTB in women with TPL and to evaluate whether PCT levels may predict sPTB in women with TPL within 7 or 14 days.

Methods

In a prospective observational laboratory-based study, women with singleton pregnancies, TPL between 24 and 36 weeks and intact membranes, were enrolled between January 2014 and June 2016. Participants received routine medical management of TPL (tocolysis with atosiban, antenatal corticosteroids, and biological tests at admission (C-reactive protein, white blood cell count, and PCT measured on electrochemiluminescence immunoassay)). The primary endpoint was sPTB before 37 weeks of gestation. The value of serum PCT levels to predict sPTB within 7 or 14 days were evaluated using receiver-operating curves (ROC) analysis.

Results

A total of 124 women were included in our study. PCT levels did not statistically differ between women with sPTB (n = 30, 24.2%) and controls (n = 94) (median in ng/mL [interquartile range]: 0.043 [0.02–0.07] compared to 0.042 [0.02–0.13], respectively; P = 0.56). PCT levels did not also statistically differ between women with sPTB within 7 days (n = 7, 5.6%) or 14 days (n = 12, 9.7%) after testing and controls. Moreover, subgroup analysis revealed no difference among PCT levels at admission between 24 and 28 weeks, between 28 and 32 weeks and over 32 weeks, and controls. On the basis of the receiver-operating characteristic curve, the highest sensitivity and specificity corresponded to a PCT concentration of 0.038 ng/mL, with poor predictive values for sPTB within 7 or 14 days.

Conclusion

Serum PCT was not relevant to predict sPTB within 7 or 14 days in women admitted with TPL between 24 and 36 weeks, and thus it is not a suitable biological marker to confirm the hypothesis of an inflammatory process associated with preterm parturition.

Trial registration

Clinicaltrials.gov (NCT01977079), Registered 24 October 2013.

Pre-eclampsia affects procalcitonin production in placental tissue

PROBLEM

Procalcitonin (PCT) is the prohormone of calcitonin which is usually released from neuroendocrine cells of the thyroid gland (parafollicular) and the lungs (K cells). PCT is synthesized by almost all cell types and tissues, including monocytes and parenchymal tissue, upon LPS stimulation. To date, there is no evidence for PCT expression in the placenta both in physiological and pathological conditions.

METHOD

Circulating and placental PCT levels were analysed in pre-eclamptic (PE) and control patients. Placental cells and macrophages (PBDM), stimulated with PE sera, were analysed for PCT expression. The effect of anti-TNF-α antibody was analysed.

RESULTS

Higher PCT levels were detected in PE sera and in PE placentae compared to healthy women. PE trophoblasts showed increased PCT expression compared to those isolated from healthy placentae. PE sera induced an upregulation of PCT production in macrophages and placental cells. The treatment of PBDM with PE sera in the presence of anti-TNF-α completely abrogated the effect induced by pathologic sera.

CONCLUSION

Trophoblast cells are the main producer of PCT in PE placentae. TNF-α, in association with other circulating factors present in PE sera, upregulates PCT production in macrophages and normal placental cells, thus contributing to the observed increased in circulating PCT in PE sera.

Serum amyloid A, procalcitonin, highly sensitive C reactive protein and tumor necrosis factor alpha levels and acute inflammatory response in patients with hemolysis, elevated liver enzymes, low platelet count (HELLP) and eclampsia

AIM

The aim of this study was to determine the relationship between serum amyloid A (SAA), procalcitonin (ProC), highly sensitive C reactive protein (hsCRP) and tumor necrosis factor (TNF) alpha activity in patients with pre-eclampsia, eclampsia and hemolysis, elevated liver enzymes, low platelet count (HELLP), and the pathogenesis and severity of the disease.

METHOD

Ninety patients at ≥ 32 gestational weeks, according to the last date of menstruation and ultra-sonographic measurements, diagnosed with pre-eclampsia (30 patients), eclampsia (30 patients) or HELLP syndrome (30 patients) were included in the study. Thirty healthy pregnant women from the outpatient clinic during the same period were recruited as the control. The age, gravida, parity, gestational age, systolic and diastolic blood pressures, proteinuria, hemoglobin, thrombocyte count, liver function tests (aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, SAA, TNF alpha, ProC and hsCRP levels during pregnancy) were determined and recorded.

RESULTS

No statistically significant differences were detected between the four groups in terms of age, gravida, parity, gestational age and hemoglobin parameters (P > 0.05). When compared to the control, systolic and diastolic blood pressures, spot and 24 h urine protein levels, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, SAA, ProC, hsCRP and TNF alpha levels were significantly high and thrombocyte levels were low in the pre-eclamptic, eclamptic and HELLP groups (P < 0.05).

CONCLUSION

The investigated parameters were useful to gain an understanding of the maternal inflammatory profile of pre-eclampsia and might be beneficial as markers to predict complications such as HELLP and eclampsia and to provide the necessary preventive approach in these patients.

Level of High Sensitive C-reactive Protein and Procalcitonin in Pregnant Women with Mild and Severe Preeclampsia

Background:

In this study, we compare the level of two inflammatory markers, high sensitive C-reactive protein (hs-CRP) and procalcitonin (PCT), in pregnant women with mild and severe preeclampsia (PE) and women with normal pregnancy.

Materials and Methods:

In this case–control study, normal pregnant women and pregnant women with PE were enrolled. Pregnant women with diagnosed PE were selected as case group and classified into two groups with mild and severe PE. Serum samples for measurement of hs-CRP and PCT were obtained and compared in studied groups.

Results:

In this study, 50 normal pregnant women and 59 pregnant women with PE, 26 (44.1%) mild, and 33 (55.9%) severe were studied. Mean of hs-CRP and PCT was higher in pregnant women with PE than normal pregnant women (7.71 ± 6.19 vs. 5.44 ± 3.94, P = 0.02 for hs-CRP and 0.05 ± 0.03 vs. 0.04 ± 0.01, P = 0.001 for PCT). Area under curve for hs-CRP and PCT was 0.611 and 0.646, respectively. The optimal cut-off point for hs-CRP was 5.24 with a sensitivity of 62.7% and a specificity of 56%. The optimal cut-off point for PCT was 0.042 with a sensitivity of 71% and a specificity of 54%.

Conclusion:

The findings of this study indicated that higher level of hs-CRP and PCT in pregnant women with PE than those with normal pregnancy could potentially explain the exaggerated inflammation in PE. Regarding significantly increased level of hs-CRP in severe PE than mild PE, we could suggest that hs-CRP is more appropriate marker for investigating pregnant women with severe PE, and its clinical usefulness is superior to PCT in this regard.

Procalcitonin in amniotic fluid at the time of genetic amniocentesis and preterm delivery

PURPOSE

Procalcitonin (PCT) is an acute-phase protein that has been infrequently studied in amniotic fluid. We sought to determine if PCT levels measured in amniotic fluid samples at the time of genetic amniocentesis are predictive of preterm delivery.

MATERIALS AND METHODS

A retrospective cohort study was performed on all women presenting for genetic amniocentesis between 15-23 weeks of pregnancy at our institution from 2011 to 2013 with stored amniotic fluid samples. PCT protein levels were measured in the samples by enzyme-linked immunosorbent assay (ELISA). PCT levels in women who delivered less than 37 weeks versus those who delivered at or after 37 week were compared. Mann-Whitney test was used.

RESULTS

Eighty-seven samples were available for analysis and of these eight (9.2%) were from patients who delivered preterm. Sixty-two (70%) had PCT levels below the lower limit of quantification, which was 25 pg/mL. Median PCT levels did not differ between the preterm and term group [20.4 pg/mL (range 0-82.8) and 20.2 pg/mL (range 0-198.4), respectively, p = .95].

CONCLUSION

In asymptomatic women undergoing genetic amniocentesis in this cohort, procalcitonin levels were low to undetectable and did not correlate with risk of subsequent preterm birth.

Shared biomarkers between female diastolic heart failure and pre-eclampsia: a systematic review and meta-analysis

Evidence accumulates for associations between hypertensive pregnancy disorders and increased cardiovascular risk later. The main goal of this study was to explore shared biomarkers representing common pathogenic pathways between heart failure with preserved ejection fraction (HFpEF) and pre‐eclampsia where these biomarkers might be potentially eligible for cardiovascular risk stratification in women after hypertensive pregnancy disorders. We sought for blood markers in women with diastolic dysfunction in a first literature search, and through a second search, we investigated whether these same biochemical markers were present in pre‐eclampsia.This systematic review and meta‐analysis presents two subsequent systematic searches in PubMed and EMBASE. Search I yielded 3014 studies on biomarkers discriminating women with HFpEF from female controls, of which 13 studies on 11 biochemical markers were included. Cases had HFpEF, and controls had no heart failure. The second search was for studies discriminating women with pre‐eclampsia from women with non‐hypertensive pregnancies with at least one of the biomarkers found in Search I. Search II yielded 1869 studies, of which 51 studies on seven biomarkers were included in meta‐analyses and 79 studies on 12 biomarkers in systematic review.Eleven biological markers differentiated women with diastolic dysfunction from controls, of which the following 10 markers differentiated women with pre‐eclampsia from controls as well: C‐reactive protein, HDL, insulin, fatty acid‐binding protein 4, brain natriuretic peptide, N terminal pro brain natriuretic peptide, adrenomedullin, mid‐region pro adrenomedullin, cardiac troponin I, and cancer antigen 125.Our study supports the hypothesis that HFpEF in women shares a common pathogenic background with pre‐eclampsia. The biomarkers representing inflammatory state, disturbances in myocardial function/structure, and unfavourable lipid metabolism may possibly be eligible for future prognostic tools.

D-dimer as a potential biomarker for the progression of COPD

BACKGROUND

D-dimer is a manifestation of endogenous fibrinolytic activity and associated with inflammation process. Despite chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease characterized by a hypercoagulable state, D-dimer levels in COPD patients are still conflicting.

METHODS

Forty-three participants were investigated at admission for an acute exacerbation of COPD, and reassessed when stable. Forty-three controls were matched for age, gender, body mass index, smoking index, comorbidities and medication use. Participants underwent pulmonary function and laboratory testing, including the measurements of D-dimer and high-sensitivity C-reactive protein (hsCRP).

RESULTS

The median of D-dimer was 2839 μg/l (IQR: 2078-4389 μg/l) and 1799 μg/l (IQR: 1205-2196 μg/l) in exacerbated and stable COPD patients respectively. The median of D-dimer in the control subjects was 433 μg/l (IQR: 369-456 μg/l). D-dimer level was significantly increased in stable COPD patients compared with healthy controls, and further increased in those patients with an acute exacerbation (both P<0.001). D-dimer was positively correlated with the well-known inflammatory marker hsCRP both in the exacerbated and stable phases of COPD (r=0.392 P=0.009 and r=0.411 P=0.006, respectively), and negatively correlated with FEV1% predicted and FEV1/FVC in stable COPD (r=-0.409 P=0.006 and r=-0.343 P=0.024, respectively).

CONCLUSIONS

D-dimer is increased in COPD patients, and could be considered as an inflammatory marker for the assessment of inflammation in the progression of COPD.

D-dimer concentration outliers are not rare in at-term pregnant women

OBJECTIVES

To determine the D-dimer levels in pregnant women at term and the differences between pregnant women with different D-dimer levels.

DESIGN AND METHODS

The plasma D-dimer concentrations in pregnant women at term were identified in a cross-sectional study. The clinical indicators that are potentially relevant to D-dimer levels were compared between the pregnant women with different D-dimer levels (i.e., normal, mildly increased, and severely increased).

RESULTS

There were always some D-dimer concentration outliers in the pregnant women at term regardless of the presence or absence of complications, and there were no significant differences in maternal age, gestational age, gravidity, parity, blood count, blood coagulation, or liver function between the pregnant women with different D-dimer levels.

CONCLUSIONS

D-dimer levels may vary significantly during pregnancy for unknown reasons. This variation, particularly in pregnant women at term, might lead to questionable diagnostic information regarding coagulation.

A Dormant Microbial Component in the Development of Preeclampsia

Preeclampsia (PE) is a complex, multisystem disorder that remains a leading cause of morbidity and mortality in pregnancy. Four main classes of dysregulation accompany PE and are widely considered to contribute to its severity. These are abnormal trophoblast invasion of the placenta, anti-angiogenic responses, oxidative stress, and inflammation. What is lacking, however, is an explanation of how these themselves are caused. We here develop the unifying idea, and the considerable evidence for it, that the originating cause of PE (and of the four classes of dysregulation) is, in fact, microbial infection, that most such microbes are dormant and hence resist detection by conventional (replication-dependent) microbiology, and that by occasional resuscitation and growth it is they that are responsible for all the observable sequelae, including the continuing, chronic inflammation. In particular, bacterial products such as lipopolysaccharide (LPS), also known as endotoxin, are well known as highly inflammagenic and stimulate an innate (and possibly trained) immune response that exacerbates the inflammation further. The known need of microbes for free iron can explain the iron dysregulation that accompanies PE. We describe the main routes of infection (gut, oral, and urinary tract infection) and the regularly observed presence of microbes in placental and other tissues in PE. Every known proteomic biomarker of "preeclampsia" that we assessed has, in fact, also been shown to be raised in response to infection. An infectious component to PE fulfills the Bradford Hill criteria for ascribing a disease to an environmental cause and suggests a number of treatments, some of which have, in fact, been shown to be successful. PE was classically referred to as endotoxemia or toxemia of pregnancy, and it is ironic that it seems that LPS and other microbial endotoxins really are involved. Overall, the recognition of an infectious component in the etiology of PE mirrors that for ulcers and other diseases that were previously considered to lack one.

Endocan, a putative endothelial cell marker, is elevated in preeclampsia, decreased in acute pyelonephritis, and unchanged in other obstetrical syndromes

Objective: Endocan, a dermatan sulphate proteoglycan produced by endothelial cells, is considered a biomarker for endothelial cell activation/dysfunction. Preeclampsia is characterized by systemic vascular inflammation, and endothelial cell activation/dysfunction. Therefore, the objectives of this study were to determine whether: (1) plasma endocan concentrations in preeclampsia differ from those in uncomplicated pregnancies; (2) changes in plasma endocan concentration relate to the severity of preeclampsia, and whether these changes are specific or observed in other obstetrical syndromes such as small-for-gestational age (SGA), fetal death (FD), preterm labor (PTL) or preterm prelabor rupture of membranes (PROM); (3) a correlation exists between plasma concentration of endocan and angiogenic (placental growth factor or PlGF)/anti-angiogenic factors (soluble vascular endothelial growth factor receptor or sVEGFR-1, and soluble endoglin or sEng) among pregnancies complicated by preeclampsia; and (4) plasma endocan concentrations in patients with preeclampsia and acute pyelonephritis (both conditions in which there is endothelial cell activation) differ.

Method: This cross-sectional study included the following groups: (1) uncomplicated pregnancy (n = 130); (2) preeclampsia (n = 102); (3) pregnant women without preeclampsia who delivered an SGA neonate (n = 51); (4) FD (n = 49); (5) acute pyelonephritis (AP; n = 35); (6) spontaneous PTL (n = 75); and (7) preterm PROM (n = 64). Plasma endocan concentrations were determined in all groups, and PIGF, sEng and VEGFR-1 plasma concentrations were measured by ELISA in the preeclampsia group.

Results: (1) Women with preeclampsia had a significantly higher median plasma endocan concentration than those with uncomplicated pregnancies (p = 0.004); (2) among women with preeclampsia, the median plasma endocan concentration did not differ significantly according to disease severity (p = 0.1), abnormal uterine artery Doppler velocimetry (p = 0.7) or whether diagnosis was made before or after 34 weeks gestational age (p = 0.3); (3) plasma endocan concentration in women with preeclampsia correlated positively with plasma anti-angiogenic factor concentrations [sVEGFR-1: Spearman rho 0.34, p = 0.001 and sEng: Spearman rho 0.30, p = 0.003]; (4) pregnancies complicated by acute pyelonephritis with bacteremia had a lower median plasma endocan concentration than pregnancies complicated by acute pyelonephritis without bacteremia (p = 0.004), as well as uncomplicated pregnancies (p = 0.001); and (5) there was no significant difference in the median plasma endocan concentration between uncomplicated pregnancies and those complicated by FD, delivery of an SGA neonate, PTL or preterm PROM (other members of the “great obstetrical syndromes”; each p > 0.05).

Conclusion: Median maternal plasma endocan concentrations were higher preeclampsia and lower in acute pyelonephritis with bacteremia than in uncomplicated pregnancy. No significant difference was observed in the median plasma endocan concentration between other great obstetrical syndromes and uncomplicated pregnancies. The difference in the direction of change of endocan in preeclampsia and acute pyelonephritis with bacteremia may be consistent with the view that both disease entities differ in pathogenic mechanisms, despite their associations with systemic vascular inflammation and endothelial cell activation/dysfunction.

Complement activation and regulation in preeclamptic placenta

Preeclampsia (PE) is a common disorder of pregnancy originating in the placenta. We examined whether excessive activation or poor regulation of the complement system at the maternal–fetal interface could contribute to the development of PE. Location and occurrence of complement components and regulators in placentae were analyzed. Cryostat sections of placentae were processed from 7 early-onset PE (diagnosis <34 weeks of gestation), 5 late-onset PE, 10 control pregnancies, and immunostained for 6 complement activators and 6 inhibitors. Fluorescence was quantified and compared between PE and control placentae. Gene copy numbers of complement components C4A and C4B were assessed by a quantitative PCR method. Maternal C4 deficiencies (≥1 missing or non-functional C4) were most common in the early-onset PE group (71%), and more frequent in late-onset PE compared to healthy controls (60 vs. 38%). Complement C1q deposition differed significantly between control and patient groups: controls and early-onset PE patients had more C1q than late-onset PE patients (mean p = 0.01 and p = 0.005, respectively). C3 activation was analyzed by staining for C3b/iC3b and C3d. C3d was mostly specific to the basal syncytium and C3b/iC3b diffuse in other structures, but there were no clear differences between the study groups. Activated C4 and membrane-bound regulators CD55, CD46, and CD59 were observed abundantly in the syncytiotrophoblast. Syncytial knots, structures enriched in PE, stained specifically for the classical pathway inhibitor C4bp, whereas the key regulator alternative pathway, factor H (FH) showed a wider distribution in the placenta. Differences in C1q deposition between late- and early-onset PE groups may be indicative of the different etiology of PE symptoms in these patients. Irregular distribution of the complement regulators C4bp and FH in the PE placenta and a higher frequency of C4A deficiencies suggest a disturbed balance between complement activation and regulation in PE.

Increased serum procalcitonin levels in pregnant patients with asymptomatic bacteriuria

Background

Among the pregnancy urinary tract infections, asymptomatic bacteriuria (ASB) is the most common one. Untreated ASB can progress to pyelonephritis in 30-50% of the patients and can also result in prematurity in 27% of the pregnancy so it needs immediate diagnosis and treatment. In this study, we wanted to evaluate procalcitonin levels, compared to other inflammatory in pregnant women with ASB.

Methods

The study was designed between the period of January 2012 and February 2013 at Sakarya University School of Medicine, Department of Gynecology and Obstetrics. The study population included 30 pregnant patients with asymptomatic bacteriuria and 39 healthy pregnant controls.

Results

Mean age was 28 (SD, 5.5) of the study population; mean maternal weight was 70 (SD, 8) kilogram. There were no statically significant differences between the groups according to the routine biochemical parameters, but gestational age was significantly lower in the ASB group compared to the controls (20.4 vs 28.6, respectively; p < 0.001). Serum procalcitonin levels were negative in all of the controls. In ASB group, 9 (30%) patients had procalcitonin levels greater than >0.05 ng/ml and 21(70%) patients had negative procalcitonin levels (Chi-squrae, p < 0.001). The sensitivity and specificity of procalcitonin assay for ASB was calculated as 30% and 100%, respectively. The positive predictive value was 100% and the negative predictive value was 65%. The most frequent microorganisms in the urine culture were Escherichia coli (26 patients, 87%), Proteus mirabilis (3 patients, 10%) and Klebsiella (1 patient, 3%) in the ASB group. We experienced four (44%) recurrences among nine positive procalcitonin in ASB patients after completion of treatment of the first ASB diagnosis.

Discussion

Procalcitonin levels were significantly higher in ASB group than the control group and serum procalcitonin levels were higher in pregnant women with recurrent ASB. This finding is an important result revealed that high procalcitonin level can predict the further urinary tract infection risk. Finally, serum procalcitonin levels were normal in healthy pregnant women while other inflammatory markers such as WBC, ESR and CRP levels were higher.

Maternal plasma soluble TRAIL is decreased in preeclampsia

OBJECTIVE

Preeclampsia (PE) is characterized by systemic intravascular inflammation. Women who develop PE are at an increased risk for cardiovascular disease in later life. Tumor necrosis factor related apoptosis-inducing ligand (TRAIL) has anti-atherosclerotic effects in endothelial cells and can mediate neutrophil apoptosis. Low soluble TRAIL (sTRAIL) and high C-reactive protein (CRP) concentrations are associated with an increased risk of future cardiovascular disease in non-pregnant individuals. The aim of this study was to determine whether maternal plasma concentrations of sTRAIL and CRP differ between women with PE and those with uncomplicated pregnancies.

METHOD

This cross-sectional study included women with an uncomplicated pregnancy (n = 93) and those with PE (n = 52). Maternal plasma concentrations of sTRAIL and CRP concentrations were determined by ELISA.

RESULTS

1) The median plasma sTRAIL concentration (pg/mL) was significantly lower and the median plasma CRP concentration was significantly higher in women with PE than in those with an uncomplicated pregnancy (25.55 versus 29.17; p = 0.03 and 8.0 versus 4.1; p = 0.001, respectively); 2) the median plasma concentration sTRAIL/CRP ratio was two-fold lower in women with PE than in those with an uncomplicated pregnancy (p < 0.001); and 3) women with plasma sTRAIL and CRP ratio in the lowest quartile were 8 times more likely to have PE than women with concentrations in the upper three quartiles (OR 8.9; 95% CI: 2.8-27.8).

CONCLUSION

Maternal plasma sTRAIL concentrations are lower (while those of CRP are higher) in women with PE than in those with uncomplicated pregnancies. These findings are consistent with the evidence of intravascular inflammation in this disorder.

Two variants of the C-reactive protein gene are associated with risk of pre-eclampsia in an American Indian population

BACKGROUND

The etiology of pre-eclampsia (PE) is unknown; but it is accepted that normal pregnancy represents a distinctive challenge to the maternal immune system. C-reactive protein is a prominent component of the innate immune system; and we previously reported an association between PE and the CRP polymorphism, rs1205. Our aim was to explore the effects of additional CRP variants. The IBC (Cardiochip) genotyping microarray focuses on candidate genes and pathways related to the pathophysiology of cardiovascular disease.

METHODS

This study recruited 140 cases of PE and 270 matched controls, of which 95 cases met criteria as severe PE, from an American Indian community. IBC array genotypes from 10 suitable CRP SNPs were analyzed. A replication sample of 178 cases and 427 controls of European ancestry was also genotyped.

RESULTS

A nominally significant difference (p value <0.05) was seen in the distribution of discordant matched pairs for rs3093068; and Bonferroni corrected differences (P<0.005) were seen for rs876538, rs2794521, and rs3091244. Univariate conditional logistic regression odds ratios (OR) were nominally significant for rs3093068 and rs876538 models only. Multivariate logistic models with adjustment for mother's age, nulliparity and BMI attenuated the effect (OR 1.58, P = 0.066, 95% CI 0.97-2.58) for rs876538 and (OR 2.59, P = 0.050, 95% CI 1.00-6.68) for rs3093068. An additive risk score of the above two risk genotypes shows a multivariate adjusted OR of 2.04 (P = 0.013, 95% CI 1.16-3.56). The replication sample also demonstrated significant association between PE and the rs876538 allele (OR = 1.55, P = 0.01, 95% CI 2.16-1.10). We also show putative functionality for the rs876538 and rs3093068 CRP variants.

CONCLUSION

The CRP variants, rs876538 and rs3093068, previously associated with other cardiovascular disease phenotypes, show suggestive association with PE in this American Indian population, further supporting a possible role for CRP in PE.

Preeclampsia is a biomarker for vascular disease in both mother and child: the need for a medical alert system

This paper reviews the literature pertaining to the impact of preeclampsia not only on the mother but particularly on the children. The review points to the higher blood pressure in children born to preeclamptic mothers compared to controls, their increased tendency to suffer strokes, the reduction in their cognitive ability, and their vulnerability to depression. Mechanisms that may induce these changes are emphasized, particularly the placental vascular insufficiency and the resulting hypoxic and proinflammatory environments in which the fetus develops. The hypothesis proposed is that these changes in the fetal-placental environment result in epigenetic programming of the child towards a higher propensity for vascular disease. The review's main recommendation is that, within ethical boundaries, the medical records of individuals born to preeclamptic mothers should clearly indicate this event and should be made available to the affected individuals so that preventive measures against vascular complications and lifestyle changes that may mitigate the latter can be instituted.

Increased maternal cytokine production and congenital heart defects

Congenital heart defects (CHDs) are a major cause of infant mortality. Most CHDs are thought to result from genetic, lifestyle, and environmental factors that include maternal obesity, diabetes, toxicant exposure, and alterations in anti-oxidant capacity. Since these well-documented risk factors are also associated with immune dysregulation, we sought to compare the maternal immune response in mothers carrying a fetus with a CHD with those mothers whose pregnancies were not affected by any birth defect. We conducted a case-control study to examine the maternal cytokine profile using multiplex technology in pregnant mothers (subject mean=26 weeks' gestation). This investigation revealed that whole blood cultures derived from case mothers produced higher levels of certain cytokines and chemokines compared with cultures from control subjects when activated with mitogen. Cultures from case subjects produced higher levels of IL-10, IL-13, IL-4, IL-5, IL-17, and IL-6, when stimulated with mitogen compared with control subjects. Plasma levels of chemokine MIP-1α were higher in cases compared with controls. In contrast, C-reactive protein levels were not statistically different. These results demonstrate the need to further examine the maternal cytokine signature in CHD-affected pregnancies. This information could pave the way toward maternal immunotherapeutic intervention to prevent CHDs, and novel biomarker discovery to improve pre-natal diagnosis.