Evaluation of the diagnostic value of the first-trimester maternal serum high-sensitivity C-reactive protein level for prediction of pre-eclampsia

Evaluation of serum level of C-reactive protein (CRP) and its correlation with fetal ultrasound parameters in the prediction of threatened miscarriage in the first trimester

BACKGROUND

Pregnancy loss occurring before 20 weeks gestation is referred to as miscarriage. Various clinical presentations of miscarriage include threatened, inevitable, incomplete, complete, septic, and missed miscarriage. Early-stage threatened miscarriage may manifest with symptoms such as abdominal discomfort and vaginal bleeding. Threatened miscarriage is clinically defined as the manifestation of positive fetal heart sounds in pregnancies occurring before the 20th week of gestation, concomitant with vaginal bleeding and a closed cervix.

OBJECTIVES

The primary aim of this study was to evaluate the association between serum C-reactive protein (CRP) levels and fetal ultrasound findings in the prediction of threatened miscarriage during the first trimester of pregnancy.

METHODS

In this prospective case-control study, a total of 100 pregnant women at 7-13 weeks of gestation were enrolled. All participants initially presented with a singleton embryo displaying cardiac activity on ultrasound. The study cohort was divided into two groups: Group 1 consisted of 50 women with uncomplicated pregnancies, while Group 2 comprised 50 women experiencing symptoms indicative of threatened miscarriage.

RESULTS

Notably, within Group 2, patients who eventually experienced miscarriage exhibited significantly elevated serum high-sensitivity CRP levels in comparison to those who maintained their pregnancies.

CONCLUSIONS

Threatened miscarriage cases demonstrated a substantial increase in serum high-sensitivity CRP levels compared to the control group. Furthermore, CRP levels exhibited a correlation with the risk of miscarriage, suggesting their potential utility in conjunction with ultrasound parameters for prognosticating threatened miscarriage during the first trimester.

Longitudinal profile of high-sensitivity C-reactive protein in women with pre-eclampsia

PROBLEM

C-reactive protein (CRP) is a marker for inflammation and its role as a possible biomarker for an early prediction of pre-eclampsia (PE) is unclear. The present study investigates the levels of high-sensitivity CRP (hs-CRP) longitudinally across pregnancy in women with PE and compares them to women without PE (non-PE).

METHOD OF STUDY

A total of 324 pregnant women [216 non-PE and 108 PE women] were included in this study. Maternal blood was taken at four different intervals (V1 = 11-14 weeks, V2 = 18-22 weeks, V3 = 26-28 weeks, and V4 = at delivery).

RESULTS

Maternal serum hs-CRP levels were higher at V1, V2, and V3 (p < .05 for all) in the PE group compared to the non-PE group. The hs-CRP levels were associated with maternal blood pressure throughout pregnancy. Maternal hs-CRP levels did not differ among early and late onset PE. Higher maternal hs-CRP levels were associated with the increased risk of PE in unadjusted model in early pregnancy. However, there was no significance after adjusting for confounding factors.

CONCLUSIONS

Our findings suggest although the levels of hs-CRP were higher in PE in early pregnancy, they are not associated with an increased risk of PE.

Association of D-Dimer, C-Reactive Protein, and Ferritin with COVID-19 Severity in Pregnant Women: Important Findings of a Cross-Sectional Study in Northern Brazil

BACKGROUND

The COVID-19 pandemic has had a great impact on pregnant women due to the broad clinical spectrum of the disease. The present study investigated the profile of three biomarkers during hospital admission of pregnant women-D-dimer, C-reactive protein (CRP), and ferritin-and their correlation with the severity and outcome of COVID-19.

METHODS

The cross-sectional study included 226 pregnant women hospitalized in the city of Belém, Pará, Northern Brazil, from April 2020 to July 2021. Epidemiological and laboratory data were obtained from medical records, and all pregnant women underwent RT-PCR molecular testing for the detection of SARS-CoV-2.

RESULTS

In total, 121 (53.5%) were positive and 105 (46.5%) were negative for SARS-CoV-2 using RT-PCR. Most pregnant women (49.5%) with COVID-19 were between 26 and 34 years old, were residing in the interior of the state of Pará (51.2%), and were in the third gestational trimester (71.9%). In addition, 71.1% of them were admitted to the ward and 28.9% were admitted to the intensive care unit (ICU), with 90.9% surviving COVID-19. The concentrations of D-dimer (p = 0.0122) and ferritin (p ≤ 0.0001) were significantly higher among pregnant women with COVID-19, especially among those hospitalized in the ICU.

CONCLUSION

Ferritin and D-dimer seem to serve as important biomarkers for the prognosis of COVID-19 in pregnant women, which was not observed for CRP.

Maternal Serum High-Sensitivity C-Reactive Protein (hsCRP) as a Prognostic Marker of Fetomaternal Outcome in Hypertensive Disorders of Pregnancy: A Novel Study

Introduction: Hypertensive disorders of pregnancy (HDP) are a group of obstetric disorders causing profound fetomaternal compromise, leading to adverse obstetric outcomes. High-sensitivity c-reactive protein (hsCRP), an inflammatory marker of systemic inflammation, is elevated in HDP and correlates with the severity of the disease. However, prediction and prevention of HDP and its associated fetomaternal complications remain elusive to most obstetricians. The present study aimed to evaluate the use of hsCRP as a prognostic marker of adverse fetomaternal outcome in HDP.

Methods: The study included 132 third-trimester pregnancies with HDP who underwent hsCRP quantification at the time of presentation to the out-patient department and followed up till delivery. HsCRP quantification was done using immunoturbidimetry method.

Results: Of the 132 cases studied, 72 had normal hsCRP levels while the remaining 60 had raised hsCRP levels. It was observed that patients with raised hsCRP levels had poorer fetomaternal outcomes at delivery as compared to those with normal hsCRP levels. 

Conclusion: The obstetric outcomes of patients with HDP worsened with increasing levels of hsCRP, as shown in our study, when compared to normotensive patients. Thus, hsCRP delivers promising results as a prognostic marker of adverse fetomaternal outcomes in patients of HDP.

C-Reactive Protein for Prediction or Early Detection of Pre-Eclampsia: A Systematic Review

OBJECTIVE

Pre-eclampsia (PE) is a serious disease of pregnancy and one of the major causes of morbidity and mortality for both the mother and baby. This systematic review aims to detect the role of high-sensitivity C-reactive protein (CRP) in the detection of PE.

METHODS

Thirty-four articles published between 2001 and 2019 were included in this review. The articles were extracted from OVID Medline and Embase. The study designs of these articles are randomized controlled, cohort, case-control, and cross-sectional studies evaluating CRP as a marker to predict or early diagnose PE. The quality assessment of these articles is made by the modified Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was not done because of clinical and statistical heterogeneity.

RESULTS

A positive association between CRP levels and the development of PE was confirmed in 18 studies. This positive effect was addressed in patients with normal BMI (<25 kg/m2) in 3 studies and in overweight patients in 2 studies. One study addressed this positive association in patients with a BMI ranging between 28 and 31 kg/m2. Three studies determined a cutoff level of CRP above which a significant risk of PE development should be suspected. These levels ranged between 7 and 15 mg/L.

CONCLUSION

CRP is a promising cost-effective biomarker that may be used in the prediction of PE. A CRP level higher than 15 mg/L may suggest initiation of low-dose aspirin in low-risk pregnancies.

Differential Dynamics of the Maternal Immune System in Healthy Pregnancy and Preeclampsia

Preeclampsia is one of the most severe pregnancy complications and a leading cause of maternal death. However, early diagnosis of preeclampsia remains a clinical challenge. Alterations in the normal immune adaptations necessary for the maintenance of a healthy pregnancy are central features of preeclampsia. However, prior analyses primarily focused on the static assessment of select immune cell subsets have provided limited information for the prediction of preeclampsia. Here, we used a high-dimensional mass cytometry immunoassay to characterize the dynamic changes of over 370 immune cell features (including cell distribution and functional responses) in maternal blood during healthy and preeclamptic pregnancies. We found a set of eight cell-specific immune features that accurately identified patients well before the clinical diagnosis of preeclampsia (median area under the curve (AUC) 0.91, interquartile range [0.82-0.92]). Several features recapitulated previously known immune dysfunctions in preeclampsia, such as elevated pro-inflammatory innate immune responses early in pregnancy and impaired regulatory T (Treg) cell signaling. The analysis revealed additional novel immune responses that were strongly associated with, and preceded the onset of preeclampsia, notably abnormal STAT5ab signaling dynamics in CD4⁺T cell subsets (AUC 0.92, p = 8.0E-5). These results provide a global readout of the dynamics of the maternal immune system early in pregnancy and lay the groundwork for identifying clinically-relevant immune dysfunctions for the prediction and prevention of preeclampsia.

Inflammation, depression and cardiovascular disease in women: the role of the immune system across critical reproductive events

Women are at increased risk for developing depression and cardiovascular disease (CVD) across the lifespan and their comorbidity is associated with adverse outcomes that contribute significantly to rates of morbidity and mortality in women worldwide. Immune-system activity has been implicated in the etiology of both depression and CVD, but it is unclear how inflammation contributes to sex differences in this comorbidity. This narrative review provides an updated synthesis of research examining the association of inflammation with depression and CVD, and their comorbidity in women. Recent research provides evidence of pro-inflammatory states and sex differences associated with alterations in the hypothalamic-pituitary-adrenal axis, the renin-angiotensin-aldosterone system and the serotonin/kynurenine pathway, that likely contribute to the development of depression and CVD. Changes to inflammatory cytokines in relation to reproductive periods of hormonal fluctuation (i.e. the menstrual cycle, perinatal period and menopause) are highlighted and provide a greater understanding of the unique vulnerability women experience in developing both depressed mood and adverse cardiovascular events. Inflammatory biomarkers hold substantial promise when combined with a patient's reproductive and mental health history to aid in the prediction, identification and treatment of the women most at risk for CVD and depression. However, more research is needed to improve our understanding of the mechanisms underlying inflammation in relation to their comorbidity, and how these findings can be translated to improve women's health.

Low-Dose Aspirin May Prevent Trophoblast Dysfunction in Women With Chlamydia Pneumoniae Infection

OBJECTIVE

Previously, we demonstrated that live Chlamydia pneumoniae (Cp) impaired extravillous trophoblast (EVT) viability and invasion and that Cp DNA was detected in placentas from cases with preeclampsia. We sought to elucidate whether (1) inactive forms of Cp also affect EVT function; (2) potential therapeutic interventions protect against the effects of Cp; and (3) anti-Cp antibodies are associated with preeclampsia.

METHODS

Human first-trimester EVTs were infected with ultraviolet light-inactivated Cp. Subgroups of EVTs were pretreated with low-dose acetyl-salicylic acid (ASA), dexamethasone, heparin, and indomethacin. We conducted functional assays after infection with inactivated Cp and measured interleukin 8 (IL8), C-reactive protein (CRP), heat shock protein 60 (HSP60), and tumor necrosis factor-α (TNFα) in culture media. We measured anti-Cp IgG serum levels from women who developed preeclampsia (N = 105) and controls (N = 121).

RESULTS

Inactivated Cp reduced EVT invasion when compared to noninfected cells (P < .00001) without adversely affecting cell viability. Increased levels of IL8, CRP, HSP60, and TNFα were detected in EVTs infected with inactivated Cp compared to noninfected cells (P < .0001). Only pretreatment with low-dose ASA prevented reduced EVT invasion and decreased release of inflammatory mediators (P < .01). Elevated anti-Cp IgG antibodies were more prevalent in serum from cases with preeclampsia compared to controls (67/105 vs 53/121; adjusted P = .013); elevated IgG correlated significantly with elevated serum CRP and elevated soluble fms-like tyrosine kinase-1-placental growth factor ratio.

CONCLUSION

Inactivated Cp induces decreased EVT invasion and a proinflammatory response; these effects were abrogated by pretreatment with low-dose ASA. Our results suggest an association between Cp infection, trophoblast dysfunction, and preeclampsia.

Maternal lipids, BMI and IL-17/IL-35 imbalance in concurrent gestational diabetes mellitus and preeclampsia

The objective of the present study was to investigate the role of blood glucose, lipid metabolism, body mass index (BMI), C-reactive protein (CRP) as well as an interleukin (IL)-17/IL-35 imbalance in the pathogenesis of concurrent gestational diabetes mellitus (GDM) and preeclampsia (PE) (DPE). The mRNA expression of forkhead box protein 3 (FoxP3), IL-35 [including Epstein-Barr virus-induced gene 3 (EBI3) and P35 subunits] and IL-17 in the peripheral blood mononuclear cells of patients with DPE (n=30), GDM (n=33), PE (n=33) and normal pregnancy (n=33) were determined by reverse transcription-quantitative polymerase chain reaction. The serum levels of IL-35, IL-17 and CRP were analyzed using ELISA. Serum total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL) and fasting blood glucose (FBG) were also detected. The levels of low-density lipoprotein (LDL) were calculated using the Friedewald formula. Body weight and height were determined in order to calculate the BMI. It was observed that the levels of FBG were markedly elevated in patients with GDM, PE and DPE. In addition, significantly higher serum TG, TC, LDL and very LDL were detected in patients with GDM, PE and DPE compared with those in subjects with normal pregnancies. By contrast, the concentration of HDL was lower in the patient groups. In addition, higher BMI values were identified in patients with GDM, PE and DPE. A decreased expression of FoxP3, P35 and EBI3 mRNA, and an elevated expression of IL-17 in PBMCs was detected in patients with GDM, PE and DPE. In addition, higher serum levels of IL-17 and CRP, as well as lower levels of IL-35, were observed. Furthermore, in patients with DPE, positive correlations of diastolic blood pressure with IL-17 levels, BMI and TG, as well as IL-17 levels with BMI and proteinuria were identified. In conclusion, the present study indicated that abnormal maternal lipids, hyperglycemia, high BMI, high CRP and IL-17/IL-35 imbalance may have a role in the pathophysiology of DPE. Therefore, pregnant women and clinicians should be made aware that maternal hyperlipidaemia, hyperglycemia, high BMI, high CRP levels and IL-17/IL-35 imbalance may lead to DPE.

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.

Reference Intervals for Non-Fasting CVD Lipids and Inflammation Markers in Pregnant Indigenous Australian Women

Indigenous Australians experience high rates of cardiovascular disease (CVD). The origins of CVD may commence during pregnancy, yet few serum reference values for CVD biomarkers exist specific to the pregnancy period. The Gomeroi gaaynggal research project is a program that undertakes research and provides some health services to pregnant Indigenous women. Three hundred and ninety-nine non-fasting samples provided by the study participants (206 pregnancies and 175 women) have been used to construct reference intervals for CVD biomarkers during this critical time. A pragmatic design was used, in that women were not excluded for the presence of chronic or acute health states. Percentile bands for non-linear relationships were constructed according to the methods of Wright and Royston (2008), using the xriml package in StataIC 13.1. Serum cholesterol, triglycerides, cystatin-C and alkaline phosphatase increased as gestational age progressed, with little change seen in high-sensitivity C-Reactive Protein and γ glutamyl transferase. Values provided in the reference intervals are consistent with findings from other research projects. These reference intervals will form a basis with which future CVD biomarkers for pregnant Indigenous Australian women can be compared.

Pregnancy outcomes in younger and older adolescent mothers with severe preeclampsia

Background

Adolescent mothers are at higher risk for preeclampsia, but the effect of their age on the outcome of the pregnancy complication is not clear.

Objective

To describe maternal and neonatal outcomes among singleton adolescent pregnancies complicated with severe preeclampsia in a low-income-setting hospital and compare results according to age.

Materials and methods

Maternal and neonatal outcomes of 213 adolescent mothers complicated with severe preeclampsia delivering at the Enrique C. Sotomayor Obstetrics and Gynecology Hospital (Guayaquil, Ecuador) were analyzed and compared according to their age (16 or less years, n=82 vs 17–19 years, n=131).

Results

Cesarean section rate was high in both studied groups; otherwise, obstetrical outcome did not differ and there were no maternal deaths or severe complications. Neonatal outcome was adverse in the two groups evidenced by high rates of preterm birth, small-for-gestational-age and low-birth-weight infants, low first-minute Apgar scores and admissions to neonatal intensive care; however, it was not significantly different between the analyzed groups. There were no neonatal deaths among mothers aged 16 or less and 4 in the group aged 17–19 years. This was, however, not significant (p=0.30).

Conclusion

Pregnancy outcome in this adolescent population with severe preeclampsia was similarly adverse, independent of maternal age.

Blood laboratory testing for early prediction of preeclampsia: chasing the finish line or at the starting blocks?

Preeclampsia (PE) affects 2-8% of pregnancies worldwide, thus representing an important cause of maternal and neonatal morbidity, up to death. Many studies have been designed to identify putative biomarkers for accurate and timely diagnosing PE, but only some of them were focused on specific and sensitive biomarkers for early prediction of this life-threatening condition. In particular, some prospective studies aimed to investigate the predictive role of circulating biomarkers before 20 weeks of gestation in the general pregnant population yielded conflicting results. This article is hence centered on results obtained in studies investigating the predictive performances of angiogenic, anti-angiogenic, inflammatory, endocrine, and epigenetic biomarkers. The available evidence suggests that angiogenic and anti-angiogenic molecules, in particular the sFlt1:PlGF ratio, may be considered the biomarkers with the best diagnostic performance in the second trimester. However, doubts remain about their use in clinical settings before the 20th gestational week. Even lower evidence is available for other biomarkers, due to the fact that some positive results have not been confirmed in ensuing investigations, whereas unresolved analytical issues still contribute to make their clinical reliability rather questionable. Differential expression of microRNAs seems also a promising evidence for early prediction of PE, but additional research and well-designed prospective studies are needed to identify and validate routine predictive tests. KEY MESSAGES Preeclampsia affects 2-8% of pregnant women worldwide, thus remaining one of the leading causes of maternal and neonatal morbidity and mortality. Several studies have investigated the predictive role of circulating biomarkers before 20th week of gestation with conflicting results. Additional research and well-designed prospective studies are needed to identify and validate predictive tests in clinical practice.

Genetic predisposition to elevated levels of C-reactive protein is associated with a decreased risk for preeclampsia

OBJECTIVE

To examine the association between genetic predisposition to elevated C-reactive protein (CRP)and risk for preeclampsia using validated genetic loci for C-reactive protein.

METHODS

Preeclampsia cases (n = 177) and normotensive controls (n = 116) were selected from live birth certificates to nulliparous Iowa women during the period August 2002-May 2005. Disease status was verified by the medical chart review. Genetic predisposition to CRP was estimated by a genetic risk score on the basis of established loci for CRP levels. Logistic regression analyses were used to evaluate the relationships between the genotype score and preeclampsia. Replication analyses were performed in an independent, US population of preeclampsia cases (n = 516) and controls (n = 1,097) of European ancestry.

RESULTS

The genetic risk score (GRS) related to higher levels of CRP demonstrated a significantly decreased risk of preeclampsia (OR 0.89, 95% CI 0.82-0.96). When the GRS was analyzed by quartile, an inverse linear trend was observed (p = 0.0006). The results were similar after adjustments for the body mass index (BMI), smoking, and leisure-time physical activity. In the independent replication population, the association with the CRP GRS was also marginally significant (OR 0.97, 95% CI 0.92, 1.02). Meta-analysis of the two studies was statistically significant (OR 0.95, 95% CI 0.90, 0.99).

CONCLUSION

Our data suggest an inverse, counterintuitive association between the genetic predisposition to elevated levels of CRP and a decreased risk of preeclampsia. This suggests that the blood CRP level is a marker of preeclampsia, but it does not appear to be a factor on the causal pathway.

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.

NF-κΒ and SOD expression in preeclamptic placentas

BACKGROUND/AIM

Preeclampsia is a leading cause of maternal death in the developing world. Our aim was to quantify and compare messenger (mRNA) expression of nuclear factor-kappa beta (NF-κΒ) and superoxide dismutase (SOD) in control patients with preeclampsia and without preeclampsia with or without familial hereditary background.

MATERIALS AND METHODS

Four groups of patients were formed depending on the presence or absence of preeclampsia and presence or absence of familial history for preeclampsia. NF-κΒ and SOD were measured in human placentas by real-time quantitative polymerase chain reaction. The 2-ΔΔct analysis method was used to measure the difference in the relative expression of the target genes in each group of patients.

RESULTS

In NF-κΒ expression, there was an increase of 23.35% in the group of women with preeclampsia versus women with preeclampsia without familial history. Regarding SOD, there was a reduction of about 33.33% in the expression in women with preeclampsia with familial history versus women with preeclampsia without familial history.

CONCLUSION

Familial presence of preeclampsia could predispose to altered expression in SOD and NF-κΒ.

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.

Formerly eclamptic women have lower nonpregnant blood pressure compared with formerly pre-eclamptic women: a retrospective cohort study

OBJECTIVE

To compare nonpregnant blood pressure and circulating metabolic factors between formerly pre-eclamptic women who did and did not deteriorate to eclampsia.

DESIGN

Retrospective observational cohort study.

SETTING

Tertiary referral centre.

POPULATION

Formerly pre-eclamptic women with (n = 88) and without (n = 698) superimposed eclampsia.

METHODS

Women who experienced pre-eclampsia with or without superimposed eclampsia during their pregnancy or puerperium were tested for possible underlying cardiovascular risk factors at least 6 months postpartum. We measured blood pressure and determined cardiovascular and metabolic risk markers in a fasting blood sample. Groups were compared using Mann-Whitney U test, Spearman's Rho test or Fisher's Exact test (odds ratios).

MAIN OUTCOME MEASURES

Differences in postpartum blood pressures and features of the metabolic syndrome between formerly pre-eclamptic and formerly eclamptic women.

RESULTS

Formerly pre-eclamptic women who developed eclampsia differed from their counterparts without eclampsia by a lower blood pressure (P < 0.01) with blood pressure correlating inversely with the likelihood of having experienced eclampsia (P < 0.001). In addition, formerly eclamptic women had higher circulating C-reactive protein levels than formerly pre-eclamptic women (P < 0.05). All other circulating metabolic factors were comparable. Finally, 40% of all eclamptic cases occurred in the puerperium.

CONCLUSIONS

Formerly pre-eclamptic women with superimposed eclampsia have lower nonpregnant blood pressure compared with their counterparts without neurological sequelae with blood pressure negatively correlated to the occurrence of eclampsia. As about 40% of all eclamptic cases occur postpartum, routine blood pressure monitoring postpartum should be intensified.

Evaluation of high-sensitivity C-reactive protein and serum lipid profile in southeastern Nigerian women with pre-eclampsia

OBJECTIVE

To evaluate the serum C-reactive protein (CRP) and lipid profile in women with pre-eclampsia.

MATERIALS AND METHODS

Thirty-five women with and 35 women without pre-eclampsia, who were in the 3rd trimester of pregnancy, were enrolled in this study. Weight in kilogrammes and height in metres were measured to calculate the mean body mass index (BMI) for each group. The diastolic and systolic blood pressures were measured. Lipid profile tests and serum CRP assay were done for all patients. Total cholesterol, triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C) were determined using enzymatic methods, while low-density lipoprotein cholesterol (LDL-C) was calculated using Friedewald's formula.

RESULTS

The mean values of the BMI were 29.47 ± 6.90 versus 26.14 ± 2.92, of the diastolic blood pressure 109.14 ± 15.41 versus 72.29 ± 9.42 mm Hg and of the systolic blood pressure 170.57 ± 19.55 versus 120.86 ± 17.72 mm Hg for women with and without pre-eclampsia, respectively, and the differences were statistically significant (p = 0.012, p = 0.001 and p = 0.001, respectively). The biochemical analysis also indicated that the women with pre-eclampsia had a significantly higher mean serum CRP (8.57 ± 2.68 vs. 6.46 ± 2.46 mg/l, p = 0.001), TG (2.84 ± 0.45 vs. 1.87 ± 0.38 mmol/l, p = 0.001) and total cholesterol (5.59 ± 0.92 vs. 4.63 ± 0.78 mmol/l, p = 0.001) level but a lower mean HDL-C (1.10 ± 0.12 vs. 1.26 ± 0.15 mmol/l, p = 0.001) level than the controls. There was no statistical difference in the mean LDL-C values between the 2 groups (1.58 ± 0.8 vs. 1.45 ± 0.78 mmol/l, p > 0.05).

CONCLUSION

Significant changes in CRP as well as TG, total cholesterol and HDL-C were associated with pre-eclampsia in these Southeastern Nigerian women.

Can maternal serum C-reactive protein levels predict successful labour induction with intravenous oxytocin in term pregnancies complicated with premature rupture of the membranes? A cross-sectional study

OBJECTIVE

High sensitive C-reactive protein (hs-CRP) is a serum marker for acute inflammation and/or infection. The diagnostic value of serum levels of this protein has been investigated among patients with preterm delivery, premature rupture of the membranes (PROM) and preeclampsia. In this study, the predictive value of hs-CRP for successful labour induction in patients with PROM has been evaluated.

MATERIAL AND METHODS

Eighty-six term pregnant patients who experienced pre-labour amniotic membrane rupture from 37-41 weeks of gestation were selected for the study. Maternal serum hs-CRP levels were determined upon admission to the delivery unit and low dose intravenous oxytocin infusion was started to induce labour. The mode of delivery and time interval from labour induction to delivery were the primary endpoints of the study.

RESULTS

Twenty-five (29%) out of 86 patients had delivered by caesarean section, while the remaining 61 (71%) had delivered vaginally. The receiver operator characteristic (ROC) curve for testing the significance of higher hs-CRP values and lower probability of vaginal delivery revealed that higher hs-CRP values were found to be insignificant for predicting the need for caesarean section. No statistically significant correlation between high serum hs-CRP levels and the probability of caesarean delivery has been established (Spearman rho:-.126; p=0.24). The mean maternal serum hs-CRP levels during PROM were found to be similar between vaginal and abdominal deliveries.

CONCLUSION

Hs-CRP, as an inflammatory marker, was found to be neither specific nor sensitive for the prediction of successful labour induction in term pregnancies with pre-labour rupture of the membranes.