Value of maternal procalcitonin levels for predicting subclinical intra-amniotic infection in preterm premature rupture of membranes

Diagnostic tests for the prediction of histological chorioamnionitis and funisitis in pregnant women with preterm premature rupture of membranes: A systematic review

BACKGROUND

Infection of the amniotic cavity is an important driver and/or consequence of preterm prelabour rupture of membranes (PPROM). Prediction of infection is challenging, limiting guidance for interventions during the antenatal period. Infection typically triggers a host inflammatory response, and non-invasive indirect markers of the maternal or fetal inflammatory response have been reported in the context of PPROM and intra-amniotic infection. Some of these markers have also been tested in amniotic fluid (AF) samples.

AIMS

This study compared markers of the inflammatory response in women with PPROM against the outcome standard of histological chorioamnionitis (HCA) or funisitis (FUS).

METHODS

Searches were conducted for studies reporting diagnostic test sensitivity and specificity for proven HCA or FUS in pregnant women with PPROM after 20 weeks' gestation. Weighted mean pooled sensitivity (Se), specificity (Sp), positive predictive value, negative predictive value, diagnostic odds ratio and 95% confidence intervals were calculated for each of the selected diagnostic tests.

RESULTS

Except ultrasonographic detection of fetal thymic involution, almost all index tests analysed showed relatively low sensitivity. Maternal white cell count, interleukin-6 (IL-6) and AF IL-6 had credible specificity. Testing of AF markers, while more consistent than serum markers, showed no clear diagnostic accuracy improvement.

CONCLUSIONS

There is a clear lack of evidence for the reliability of any individual diagnostic test to assist in the detection of HCA or FUS in women with PPROM. Combining several markers into a predictive model for improved diagnosis may be worth investigating.

The adenosine deaminase family acting on RNA 1 can be a useful diagnostic biomarker in chorioamnionitis

INTRODUCTION

Chorioamnionitis (CAM) involves infection and inflammation of the chorion and amniotic membrane, but there are still no effective diagnostic biomarkers for CAM.

METHODS

We investigated the correlation between RNA editing enzyme Adenosine deaminase family acting on RNA 1 (ADAR1) and CAM in chorion and amniotic membrane specimens derived from premature rupture of the membrane (PROM), CAM (pathologically diagnosed), and clinical CAM (clinically diagnosed) patients using reverse transcription polymerase chain reaction (RT-PCR).

RESULTS

ADAR1 was upregulated in the chorion and amniotic membrane specimens of CAM and clinical CAM patients (p < 0.001 and p = 0.005). ADAR1 had a significantly higher area under the curve (AUC) (0.735 and 0.828) than markers of inflammation characteristics in diagnosing CAM and clinical CAM patients. ADAR1 also had significantly higher AUC (0.701 and 0.837) than clinical characteristics for CAM and clinical CAM patients.

DISCUSSION

ADAR1 can be a useful diagnostic biomarker in CAM patients.

The potential presence of infection may be indicated through non-invasive prediction of procalcitonin and C-reactive protein levels within the initial three days after cervical cerclage: a retrospective case-control study

PURPOSE

To identify which non-invasive infection indicators could better predict post-cervical cerclage (CC) infections, and on which days after CC infection indicators should be closely monitored.

METHODS

The retrospective, single-center study included 619 single-pregnancy patients from January 2021 to December 2022. Patients were categorized into infected and uninfected groups based on physicians' judgments of post-CC infections. Registered information included patient characteristics, cervical insufficiency history, gestational age at CC, surgical method (McDonald/Shirodkar), purpose of CC, mid-pregnancy miscarriage/preterm birth, infection history or risk factors, and infection indices on days 1, 3, 5, and 7 after CC. Propensity score matching (PSM) was applied to reduce patient characteristic bias. Statistical analysis of C-reactive protein (CRP), white blood cell (WBC), neutrophil count (NEU), percentage of neutrophil count (NEU_P), interleukin-6 (IL-6), and procalcitonin (PCT) in the infected group compared with the uninfected group was performed using chi-square tests and t-tests. Receiver operating characteristic (ROC) curves were used to further assess the diagnostic value of CRP, PCT, and CRP-PCT in combination.

RESULTS

Among the 619 included patients, 206 patients were matched using PSM and subsequently assessed. PCT values on day 1 and day 3 after CC exhibited significant differences between the two groups in two statistical ways (P < 0.01, P < 0.05). The CRP levels on day 1 were significantly higher in the infected group compared to the uninfected group in two statistical ways (P < 0.05). On day 3, the mean CRP value was significantly elevated in the infected group compared to the uninfected group (P < 0.05). Analyses of IL-6, WBC, NEU, and NEU_P did not yield clinically significant results. The area under the ROC curves for CRP, PCT, and CRP-PCT on day 1 and day 3 were all below 0.7. In the preventive CC group, the AUC values of CRP and CRP-PCT obtained on d1 were found to be higher than 0.7, indicating moderate diagnostic accuracy.

CONCLUSION

For women after CC surgery, especially of preventive aim, increased serum CRP and PCT levels from post-CC day 1 to day 3 may signal a potential postoperative infection, warranting close monitoring.

Association Analysis Between Maternal Neutrophil Ratio and the Risk of Histological Chorioamnionitis in Pregnant Women with Premature Rupture of Membranes in Late Pregnancy

Background

We aimed to investigate the association between maternal neutrophil ratio and histological chorioamnionitis (HCA) risk in pregnant women with premature rupture of membranes (PROM) in late pregnancy.

Methods

A retrospective analysis was conducted on 95 cases of women with PROM in their late pregnancy between March 2018 and August 2021. These women were divided into two groups based on the presence of HCA. General clinical data and laboratory indicators were compared between the two groups. A generalized additive model was used for curve fitting, and a segmented regression model was used to explain further the non-linear relationship between neutrophil ratio and HCA risk.

Results

After adjusting for confounding factors, the curve fitting showed a "U"-shaped curve relationship between the neutrophil ratio and the risk of HCA. When the neutrophil ratio was <76.3%, the risk of HCA exhibited a decreasing trend, but the difference was not statistically significant (adjusted OR = 0.884, 95% CI: 0.781-1.001, P = 0.053). However, when the neutrophil ratio was >76.3%, the HCA risk was significantly increased (adjusted OR = 1.339, 95% CI: 1.067-1.680, P = 0.012). Furthermore, we equally divided the neutrophil ratio into three groups. The risk of HCA was significantly increased in the low-ratio group (OR = 4.292, 95% CI: 1.247-14.706, P = 0.021) compared with the middle-ratio group, which was used as the reference group. Similarly, the HCA risk of the high-ratio group (OR = 13.145, 95% CI: 1.796-96.233, P = 0.011) was also significantly enhanced. However, there was no significant difference in HCA risk between the high-ratio and low-ratio groups (OR = 1.182, 95% CI: 0.357-3.909, P = 0.784).

Conclusion

There was a significant "U"-shaped relationship between maternal neutrophil ratio and HCA risk in women with PROM in late pregnancy.

Changes in serum inflammatory factors in group B streptococcal infection and their predictive value for premature rupture of membranes complicated by chorioamnionitis

Objective: The aim of this study as to unveil changes in serum inflammatory factors in pregnant women with genital tract group B Streptococcus (GBS) infection and their predictive value for premature rupture of membranes (PROM) complicated by chorioamnionitis (CS) and adverse pregnancy outcomes. Methods: The value of serum inflammatory factor levels in predicting PROM complicating CS and adverse pregnancy outcomes in GBS-infected pregnant women was evaluated by ELISA. Results: Serum IL-6, TNF-α, PCT and hs-CRP levels were higher in pregnant women with GBS infection. The combined diagnosis of these factors had excellent diagnostic value in PROM complicating CS and adverse pregnancy outcomes. Conclusion: Joint prediction of IL-6, TNF-α, PCT and hs-CRP has the best predictive value for PROM complicating CS and adverse pregnancy outcomes.

Procalcitonin levels in pregnancy: A systematic review and meta-analysis of observational studies

BACKGROUND

The utility of procalcitonin to identify obstetric sepsis is unknown.

OBJECTIVE

To calculate the mean (range) procalcitonin in pregnancy among healthy women not in labor (group 1), healthy women in labor (group 2), and women with preterm prelabor rupture of membranes (PPROM) without clinical chorioamnionitis (group 3).

SEARCH STRATEGY

NLM PubMed, Elsevier Embase, and Wiley Cochrane Central Register of Controlled Trials from inception to February 21, 2022.

SELECTION CRITERIA

Ten or more pregnant women with procalcitonin reported at more than 20 weeks of pregnancy, with information on labor, PPROM, and infection. Exclusions were major medical comorbidities.

DATA COLLECTION AND ANALYSIS

Each abstract and full-text review was independently reviewed by the same two authors. Quality was reviewed using the Newcastle-Ottawa Scale. A meta-analysis was performed using a random effects model.

MAIN RESULTS

The systematic review included 25 studies: 10 (40%) of good quality and 15 (60%) of poor quality. The meta-analysis included 21 studies. Mean procalcitonin in group 1 was 0.092 ng/mL (range 0.036-0.049 ng/mL), in group 2 it was 0.130 ng/mL (range 0.049-0.259 ng/mL), and in group 3 it was 0.345 ng/mL (range 0.005-1.292 ng/mL).

CONCLUSIONS

Among healthy pregnant women not in labor, procalcitonin levels are comparable to those in non-pregnant adults and may be useful in identifying infection. Procalcitonin levels in other groups overlap abnormal values of procalcitonin in non-pregnant adults, and may not discriminate infection among women in labor or with obstetric comorbidities.

PROSPERO

CRD42020157376, registered 4/28/2020.

Procalcitonin levels in maternal serum and cord blood as marker for diagnosis of early onset neonatal sepsis

Objectives

To assess the diagnostic accuracy of Procalcitonin in maternal serum and umbilical cord blood samples to predict Early onset neonatal sepsis (EONS).

Study Design

It was a Prospective analytical cohort study. Pregnant women ≥ 34 weeks gestation in active labour, with risk factors for EONS were included in the study. Maternal blood samples at recruitment and umbilical cord blood samples after delivery were taken for Total leucocyte count (TLC), high sensitivity C-Reactive Protein (hs-CRP) and Procalcitonin. Newborns were classified into non-infected, suspected and proven infection. Sensitivity, specificity and diagnostic accuracy of maternal and cord blood procalcitonin, TLC and hs-CRP were calculated.

Results

A total of 200 women were recruited. Maternal procalcitonin had a superior diagnostic accuracy of 99% compared to maternal TLC and maternal hs-CRP. Also, cord blood procalcitonin had a diagnostic accuracy of 95%.

Conclusion

Procalcitonin in both maternal as well as cord blood is a promising biomarker to detect EONS with high diagnostic accuracy.

The yield of procalcitonin and Interleukin-6 in predicting intraamniotic infection in the presence of intrapartum fever: A pilot study

Intrapartum fever (IF) accompanied by either maternal or foetal tachycardia, elevated WBC, or purulent discharge is classified as "suspected triple 1", the hallmark of intraamniotic infection (IAI). Poor specificity of the clinical diagnosis of IAI results, in retrospect, in the unnecessary treatment of most parturients and neonates. We studied the yield of specific acute phase reactants (APRs): procalcitonin, CRP, IL-6, in detecting bacterial IAI among parturients classified as "suspected triple 1" (cases) compared to afebrile parturients (controls). Procalcitonin, CRP, and IL-6 were all significantly elevated in the cases compared to the controls, yet this by itself was not sufficient for an additive effect in detecting a bacterial infection among parturients clinically diagnosed with "suspected triple 1", as demonstrated by the poor area under the receiver operating characteristic curve of all three APRs.

Non-invasive prediction of histologic chorioamnionitis using maternal serum markers in women with preterm prelabour rupture of membranes

PROBLEM

This study aimed to evaluate and compare the predictive accuracy of serum markers for histological chorioamnionitis (HCA) among women with preterm prelabour rupture of membranes (PPROM), and to develop a nomogram prediction model to minimize the damage of the disease.

METHOD OF STUDY

This case-control study included 153 pregnant women with PPROM with a gestational age of 20⁺⁰ ∼ 36⁺⁶ weeks. The subjects were assigned into two groups: PPROM with and without HCA. According to the results of Logistic regression analysis, the predictive equation and nomogram were generated using key parameters, and the discrimination and consistency of the model were evaluated by receiver operating characteristic (ROC) curves and calibration curves.

RESULTS

From 153 subjects with PPROM, 77 developed HCA. Compared with the PPROM without HCA group, the CRP, PCT and NLR were significantly higher in HCA group (P<0.001), and the CRP had the highest predictive value. The area under the curve (AUC) of the prediction model was 0.873, and the sensitivity and specificity of predicting HCA were 68.8% and 92.1%, respectively. And the calibration curves fitted well with the realistic situation.

CONCLUSION

Maternal serum CRP and NLR could be used as predictive biomarkers for HCA in women with PPROM, while PCT needs to be further explored due to its slightly lower predictive value. Our serum markers and gestational age at PPROM could be used as a non-invasive and convenient method to predict HCA in women with PPROM. This article is protected by copyright. All rights reserved.

Clinical Factors and Perinatal Outcomes Associated With Short Latency Period in Twin Pregnancies With Preterm Premature Rupture of Membranes Before 34 Weeks: A Retrospective Study

Background

There is a lack of literature on short latency period (SLP) in twin pregnancies with preterm premature rupture of membranes (PPROM). Thus, the aim of this study was to identify the clinical factors and perinatal outcomes associated with SLP in twin pregnancies with PPROM and to establish a predictive model to identify SLP.

Methods

Twin pregnancies with PPROM between 24 0/7 and 33 6/7 weeks were included and a retrospective analysis was performed. Patients were divided into two groups based on the latency period after PPROM: Group 1 ≤24 h (defined as SLP) and Group 2 >24 h (defined as long latency period, LLP), the clinical factors and perinatal outcomes were compared between the two groups. Binary logistic regression and receiver operating characteristic curve analyses were used to identify the independent clinical factors associated with latency period after PPROM and assess the predictive accuracy for SLP.

Results

98 and 92 pregnant women had short and long latency period, respectively. Prolonged latency significantly increased the occurrence of chorioamnionitis. Neonatal outcomes were not affected by latency duration after PPROM. Binary regression analysis revealed that higher gestational age (GA) at PPROM (P = 0.038), presence of uterine contractions (P < 0.001), Bishop score > 4 (P = 0.030), serum procalcitonin levels ≥0.05 ng/mL upon admission, and absence of use of tocolytic agents (P < 0.001) were significant independent predictors of a SLP. A predictive model developed using these predictors had an area under the curve (AUC) of 0.838, and the presence of uterine contractions alone had an AUC of = 0.711.

Conclusion

Uterine contraction was the most important prognosticator for a SLP. A latency period of >24 h was associated with chorioamnionitis, but adverse neonatal outcomes were not observed.

Diagnostic accuracy of procalcitonin in maternal plasma to detect early intra-amniotic infection in preterm premature rupture of the membranes with respect of highvaginal swab as gold standard

Objective:

To determine the diagnostic accuracy of procalcitonin in maternal plasma to detect early intra-amniotic infection in Preterm premature rupture of the membranes (PPROM) with respect of high vaginal swab as gold standard

Methods:

A cross-sectional study was conducted at Liaquat National Hospital, Karachi, from February to August 2017. The blood sample of women with PPROM were collected to measure procalcitonin level. PCT1 and PCT2 were run along with the sample for the accuracy of the results. Sensitivity, specificity, PPV, NPV, and diagnostic accuracy of procalcitonin were calculated taking HVS C/S as gold standard.

Results:

Out of total 150 women, mean age was 28.78±4.79 years. Mean gestational age was 30.79±3.07 weeks. Mean procalcitonin level was 0.13±0.24 ng/ml. Intra-amniotic infection was diagnosed in 48.7% cases through procalcitonin levels and 51.3% through HVS culture and sensitivity. Sensitivity, Specificity, PPV (Positive predictive value), NPV (Negative predictive value) and accuracy were 87%, 91.8%, 91.78%, 87%, and 89.3% respectively. For females with gestational age ≤32 weeks, sensitivity, specificity, and diagnostic accuracy were 83.9%, 90.4%, and 87.03% respectively. For females with gestational age >32 weeks, sensitivity, specificity, and diagnostic accuracy were 95.2%, 92.5%, and 95.23% respectively.

Conclusion:

Diagnostic accuracy of maternal blood procalcitonin levels were found satisfactory in detection of early intra-amniotic infection in PPROM.

White blood cells in pregnancy: reference intervals for before and after delivery

BACKGROUND

White blood cells (WBC) are commonly measured to investigate suspected infection and inflammation in pregnant women, but the pregnancy-specific reference interval is variably reported, increasing diagnostic uncertainty in this high-risk population. It is essential that clinicians can interpret WBC results in the context of normal pregnant physiology, given the huge global burden of infection on maternal mortality.

METHODS

We performed a longitudinal, repeated measures population study of 24,318 pregnant women in Oxford, UK, to map the trajectory of WBC between 8-40 weeks of gestation. We defined 95% reference intervals (RI) for total WBC, neutrophils, lymphocytes, eosinophils, basophils, and monocytes for the antenatal and postnatal periods.

FINDINGS

WBC were measured 80,637 times over five years. The upper reference limit for total WBC was elevated by 36% in pregnancy (RI 5.7-15.0×109/L), driven by a 55% increase in neutrophils (3.7-11.6×109/L) and 38% increase in monocytes (0.3-1.1×109/L), which remained stable between 8-40 weeks. Lymphocytes were reduced by 36% (1.0-2.9×109/L), while eosinophils and basophils were unchanged. Total WBC was elevated significantly further from the first day after birth (similar regardless of the mode of delivery), which resolved to pre-delivery levels by an average of seven days, and to pre-pregnancy levels by day 21.

INTERPRETATION

There are marked changes in WBC in pregnancy, with substantial differences between cell subtypes. WBC are measured frequently in pregnant women in obstetric and non-obstetric settings, and results should be interpreted using a pregnancy-specific RI until delivery, and between days 7-21 after childbirth.

FUNDING

None.

Vaginal microbiome as a tool for prediction of chorioamnionitis in preterm labor: a pilot study

Intra-amniotic infection (IAI) is a major cause of preterm birth with a poor perinatal prognosis. We aimed to determine whether analyzing vaginal microbiota can evaluate the risk of chorioamnionitis (CAM) in preterm labor cases. Vaginal discharge samples were collected from 83 pregnant women admitted for preterm labor. Based on Blanc's classification, the participants were divided into CAM (stage ≥ II; n = 46) and non-CAM (stage ≤ I; n = 37) groups. The 16S rDNA amplicons (V1-V2) from vaginal samples were sequenced and analyzed. Using a random forest algorithm, the bacterial species associated with CAM were identified, and a predictive CAM (PCAM) scoring method was developed. The α diversity was significantly higher in the CAM than in the non-CAM group (P < 0.001). The area under the curve was 0.849 (95% confidence interval 0.765-0.934) using the PCAM score. Among patients at < 35 weeks of gestation, the PCAM group (n = 22) had a significantly shorter extended gestational period than the non-PCAM group (n = 25; P = 0.022). Multivariate analysis revealed a significant difference in the frequency of developmental disorders in 3-year-old infants (PCAM, 28%, non-PCAM, 4%; P = 0.022). Analyzing vaginal microbiota can evaluate the risk of IAI. Future studies should establish appropriate interventions for IAI high-risk patients to improve perinatal prognosis.

Maternal serum procalcitonin levels in prediction of chorioamnionitis in women with preterm premature rupture of membranes

INTRODUCTION

Chorioamnionitis is one of the most important maternal complications in the expectant management of patients with preterm premature rupture of membranes (PPROM). Procalcitonin (proCT), the precursor of the hormone calcitonin, is used to differentiate bacterial infections from non-bacterial ones. The objective of the study was to determine the efficacy of maternal serum procalcitonin levels in the early prediction of chorioamnionitis in women with PPROM.

MATERIAL AND METHODS

The study was conducted in 76 pregnant women hospitalized due to PPROM at the maternal-fetal medicine unit of a tertiary center in Istanbul. Patients were followed up with white blood cell (WBC), C-reactive protein (CRP) and proCT levels every 2 days. The values of investigated parameters were recorded at the diagnosis of PPROM and at the time of delivery. The maximum values during the follow-up period were also recorded.

RESULTS

Out of the 76 patients with PPROM, 15 (19.73%) developed clinical chorioamnionitis. No significant difference could be detected in the gravidity, parity, duration of hospitalization and gestational week at diagnosis between those patients who developed clinical chorioamnionitis and those who did not. The WBC at the time of hospital admittance and before delivery, and CRP levels before delivery were statistically higher in the chorioamnionitis group (p < 0.05). No difference in the proCT levels could be detected either at the time of hospital admittance or before delivery between the two groups.

CONCLUSIONS

Maternal proCT was not found to be predictive of chorioamnionitis. However, since there are reports in the literature that contradict these results, further studies are warranted to determine the true efficacy of proCT in the prediction of clinical chorioamnionitis.

Procalcitonin in preterm rupture of membranes: a systematic review and meta-analysis

PURPOSE

Early detection of infection is of supreme importance in obstetrics; however, during pregnancy it is not reliably predicted by standard laboratory tests. We aimed to determine if procalcitonin (PCT) is a reliable predictor of chorioamnionitis (CA) in women with premature rupture of membranes (PPROM).

METHODS

An electronic search of Scopus, ISI, Medline, Embase, ClinicalTrials.gov and the Cochrane Library databases was performed using specified key words. We examined all English and French reports on PCT measurement after admission for PPROM and considered: human studies published between 1990 and 2019; observational studies; and randomized controlled trials. A protocol was determined previously, registered at PROSPERO as CRD42019145464. The eligibility was independently assessed by two researchers and literature search yielded 590 studies; after revision of the titles and abstracts, 46 articles were identified as potentially eligible; eight studies were included in the meta-analysis. Primary data synthesis was performed in Review Manager Version 5.3 and average sensitivity and specificity was calculated using Midas, Stata.

RESULTS

From the eight studies included, 335 participants with PPROM were enrolled. Our meta-analysis disclosed that PCT has a poor sensitivity (0.50; 95% CI 0.28-0.73) and a modest specificity (0.72; 95% CI 0.51-0.87) in diagnosing CA. C-reactive protein (CRP) not only has better sensitivity (0.71; 95% CI 0.53-0.84), but also better specificity (0.75; 95% CI 0.55-0.88), compared with the other inflammatory parameters analyzed. Procalcitonin does not seems to be better than CRP in preterm rupture of membranes for chorioamnionitis diagnosis.

Maternal inflammatory markers for chorioamnionitis in preterm prelabour rupture of membranes: a systematic review and meta-analysis of diagnostic test accuracy studies

BACKGROUND

There is no consensus on the role of inflammatory markers in identifying chorioamnionitis in preterm prelabour rupture of membranes (PPROM). We set out to evaluate the accuracy of maternal blood C-reactive protein (CRP), procalcitonin and interleukin 6 (IL6) in diagnosis of histological chorioamnionitis and/or funisitis (HCA/Funisitis) in PPROM.

METHODS

We searched MEDLINE, EMBASE and The Cochrane Library from inception to January 2020 for studies where maternal blood CRP, procalcitonin or IL6 was assessed against a reference standard of HCA/Funisitis in PPROM. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess methodological quality. Hierarchical summary receiver operating characteristic (SROC) models were used to construct summary curves. Bivariate models were used to obtain summary estimates for studies with the same cut-off.

RESULTS

We included 23 studies reporting HCA/Funisitis in 902 of 1717 women, median prevalence 50% (inter-quartile range 38-57). Of these studies, 20 were prospective cohort design and 3 were retrospective cohort. Eleven studies reported the index test against a reference standard of HCA and/or funisitis, 10 reported HCA alone and 2 reported funisitis alone. Many studies had high risk of bias scores on the QUADAS-2 assessment but low concerns for applicability. Sensitivity and specificity for CRP ≥ 20 mg/L (5 studies, 252 participants) was 59% (95% CI 48-69) and 83% (95% CI 74-89) respectively. SROC curves are provided for each index test. At selected specificity of 80%, the sensitivities for CRP (all cut-offs, 17 studies, 1404 participants), PCT ( all cut-offs, 6 studies, 231 participants) and IL6 (all cut-offs, 5 studies, 299 participants) were 59%(95% CI 52-68), 56%(95% CI 50-69) and 52% (95% CI 50-86) respectively.

CONCLUSIONS

There is insufficient evidence to support use of CRP, procalcitonin or IL6 in maternal blood for diagnosis of HCA/Funisitis in PPROM. This review followed recommended methodology and data analytic methods that made the most of the data regardless of the different cut-offs used. However, the evidence is based on few studies with generally small sample sizes, poor-quality scores and substantial heterogeneity. There is a need for good-quality diagnostic accuracy studies to better assess the role of these biomarkers in PPROM.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42015023899, registered on 8 October 2015.

Establishment of reference intervals for maternal blood and umbilical cord blood procalcitonin in healthy Chinese women in late pregnancy

AIM

To establish reference intervals (RIs) for maternal blood and umbilical cord blood procalcitonin (PCT) in healthy Chinese women in late pregnancy.

METHODS

One hundred and twenty-seven healthy Chinese women in late pregnancy, including 70 vaginal deliveries and 57 cesarean section deliveries, were retrospectively analyzed. These pregnant women gave birth to 58 male infants and 69 female infants. Another 127 age-matched healthy women who were not pregnant were enrolled as the control group. PCT levels in maternal blood, umbilical cord blood and control blood were determined using electrochemiluminescence immunoassay. The RIs of PCT were defined using an intermediate 95% interval.

RESULTS

The RIs for maternal blood and umbilical cord blood PCT were 0.020-0.075 ng/mL and 0.020-0.159 ng/mL, respectively. The cord blood PCT level was not significantly different between different delivery methods (P > 0.05). In contrast, the umbilical cord blood PCT in female newborns was higher than that in male newborns (0.088 ± 0.046 ng/mL vs 0.072 ± 0.030 ng/mL, P < 0.05).

CONCLUSION

Maternal blood and umbilical cord blood PCT of Chinese women in late pregnancy have different RIs, and umbilical cord blood PCT level is affected by the gender of newborns.

Predictive value of procalcitonin, C-reactive protein, and white blood cells for chorioamnionitis among women with preterm premature rupture of membranes

OBJECTIVE

To determine the predictive value of procalcitonin, C-reactive protein (CRP), and white blood cells (WBC) for chorioamnionitis among women with preterm premature rupture of membranes (PPROM).

METHODS

A prospective cross-sectional study of all women with singleton pregnancy and PPROM admitted to a referral hospital in Shiraz, Iran, from 2016 to 2018. All women were hospitalized until delivery. The incidence of chorioamnionitis was recorded. Maternal serum CRP, procalcitonin, and WBC were measured on the day of admission and the day before termination of pregnancy. The diagnostic accuracy of each test was evaluated by receiver operator characteristic (ROC) curve analysis.

RESULTS

Overall, 75 women with PPROM were included in the study. After termination of pregnancy, 34 (45.3%) were diagnosed with clinical chorioamnionitis. Those with chorioamnionitis had significantly higher serum levels of CRP both on admission (P=0.004) and before termination of pregnancy (P<0.001). The area under the curve for last CRP was 0.78 (95% confidence interval, 0.57-0.84), indicating moderate accuracy. Procalcitonin and WBC had low accuracy to predict chorioamnionitis.

CONCLUSION

Among CRP, procalcitonin, and WBC, maternal serum CRP was found to be the most accurate predictor of chorioamnionitis among women with PPROM.

Pretransplant ascites and encephalopathy and their influence on survival and liver graft rejection in alcoholic cirrhosis disease

INTRODUCTION

The Child-Pugh and model for end-stage liver disease (MELD) scores are widely used to predict the outcomes of liver transplant (LT). Both have similar prognostic values in most cases, although their benefits might differ in some specific conditions. The aim of our study was to analyze the influence of pre-transplant ascites and encephalopathy in post-transplant liver rejection development and survival in alcohol cirrhosis (AC) patients undergoing LT to determine the usefulness of the Child-Pugh score for the assessment of prognosis in such patients.

MATERIAL AND METHODS

Two hundred and eighty-one AC patients, classified according to viral infections and pre-transplant complications, were analyzed. Acute (AR) and chronic (CR) liver rejections and Child-Pugh, MELD and albumin-bilirubin (ALBI) scores were studied in all cases.

RESULTS

Similar AC rejection percentages were observed in ascites or encephalopathy groups (18.5% and 16.5%, p = 0.735), although a higher but not statistically significant AC rate was observed in patients with grade III ascites (p = 0.777) and with grade II encephalopathy (p = 0.089). Chronic rejection was only developed by 9.1% of AC patients, regardless of the presence of ascites (6.2%) or encephalopathy (5.5%). The presence of ascites and encephalopathy complications did not seem to influence post-transplant survival. Neither the Child-Pugh nor the ALBI score can be considered the best for predicting patient survival in the short or long term.

CONCLUSIONS

Ascites and encephalopathy do not seem to influence AC or CR in patient survival, regardless of the presence of viral infections, so in our study neither the Child-Pugh nor ALBI score seems to be the best score to predict the outcomes of these patients.

Metabolomics applied to maternal and perinatal health: a review of new frontiers with a translation potential

The prediction or early diagnosis of maternal complications is challenging mostly because the main conditions, such as preeclampsia, preterm birth, fetal growth restriction, and gestational diabetes mellitus, are complex syndromes with multiple underlying mechanisms related to their occurrence. Limited advances in maternal and perinatal health in recent decades with respect to preventing these disorders have led to new approaches, and "omics" sciences have emerged as a potential field to be explored. Metabolomics is the study of a set of metabolites in a given sample and can represent the metabolic functioning of a cell, tissue or organism. Metabolomics has some advantages over genomics, transcriptomics, and proteomics, as metabolites are the final result of the interactions of genes, RNAs and proteins. Considering the recent "boom" in metabolomic studies and their importance in the research agenda, we here review the topic, explaining the rationale and theory of the metabolomic approach in different areas of maternal and perinatal health research for clinical practitioners. We also demonstrate the main exploratory studies of these maternal complications, commenting on their promising findings. The potential translational application of metabolomic studies, especially for the identification of predictive biomarkers, is supported by the current findings, although they require external validation in larger datasets and with alternative methodologies.

Utility of CD64 on Neutrophils in Orthopedic Infection

Background

Musculoskeletal infections are often seen in the daily practice of orthopedics. Several markers [white blood cell (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT)] have been used for diagnosing these infections. However, these markers may be elevated due to surgery or trauma, and may not be infection-related. These markers also show drug-dependent dynamics during infection that differ from its usual dynamics. Such situations make diagnosis of infections difficult, and Cluster of Differentiation 64 (CD64) has been brought to attention. This study aimed to clarify the utility of CD64 on neutrophils by comparing it with conventional infection markers (CRP, PCT) in musculoskeletal infection.

Methods

Forty-four patients who were suspected of having musculoskeletal infection between May 2010 and November 2013 in our hospital were enrolled in this study. Patients were divided into subgroups according to their culture results, antibiotics administration, measurement timing, and if they were immunocompromised. The measurements of the infection markers were compared between each group. In addition, the positive rates of each infection marker were compared between groups.

Results

There was no difference in the infection marker measurements between several groups. There was no statistically significant difference between groups for the positive rates of CD64, CRP, and PCT.

Conclusion

We evaluated the utility of CD64 on neutrophils in musculoskeletal infection. CD64 showed the utility that was equivalent to conventional infection markers in diagnoses of various musculoskeletal infections.

Validation of diagnostic tests for histologic chorioamnionitis: Systematic review and meta-analysis

INTRODUCTION

The aim of this study was to determine the diagnostic performance of different diagnostic tests for histologic chorioamnionitis in patients at more than 20 weeks of gestation.

METHODS

A systematic search was carried out through MEDLINE, EMBASE, LILACS, CENTRAL and unpublished literature. Observational studies included with pregnant women (>20 weeks) with chorioamnionitis. The reference standard was the histopathological study of the placenta, umbilical cord and fetal membranes. Two independent researchers extracted data and performed a meta-analysis of diagnostic tests.

RESULTS

Twenty-nine articles were included. The studies provided evidence in the form of maternal clinical and serological tests; tests of vaginal fluid, amniotic fluid or the umbilical cord; fetal monitoring and ultrasound tests. To assess the performance of maternal serum CRP, 13 studies were included, showing a combined sensitivity of 68.7% (95%CI 58%-77%) and a combined specificity of 77.1% (95%CI 67%-84%). Maternal leukocytosis was evaluated in four publications, showing a combined sensitivity of 51% (95%CI 40%-62%) and a combined specificity of 65% (95%CI 50%-78%).

CONCLUSIONS

CRP and maternal leukocytosis, showed a low sensitivity and specificity. The sonographic evaluation of the fetal thymus is also more sensitive for the diagnosis of histologic chorioamnionitis than the fetal biophysical profile.

Prediction of histological chorioamnionitis and neonatal and infantile outcomes using procalcitonin in the umbilical cord blood and amniotic fluid at birth

Aim

We aimed to clarify the usefulness of procalcitonin (PCT) in the evaluation of histological chorioamnionitis (CAM) and in the prediction of neonatal and infantile outcomes as a reference of interleukin‐6 (IL‐6).

Methods

Subjects were 36 singleton pregnant women delivered at 22–37 weeks’ gestation due to threatened premature delivery and/or preterm premature rupture of membranes. Cases were classified into the CAM and non‐CAM groups, according to Blanc's criteria. Comparisons were made on umbilical venous and amniotic fluid PCT levels among the groups. The relations between umbilical venous PCT and IL‐6 levels and neonatal and infantile outcomes were also analyzed.

Results

The umbilical venous PCT level in the CAM group (240.2 pg/mL, 125.4–350.3 pg/mL: median, first quartile–third quartile) was higher than that in the non‐CAM group (105.1, 50.2–137.5 pg/mL; P = 0.0006). There were no differences in the amniotic fluid PCT levels between the groups. There was a strong correlation between umbilical venous PCT and IL‐6 levels (correlation coefficient: 0.793). Among 10 cases with an umbilical venous PCT level of ≥170.0 pg/mL and six cases with IL‐6 ≥ 11.0 pg/mL, six (60.0%) and five cases (83.3%), respectively, had adverse neonatal and infantile outcomes. Among seven cases with adverse neonatal and infantile outcomes, six (85.7%) and five (71.4%) cases showed umbilical venous PCT levels of ≥170.0 pg/mL and IL‐6 levels of ≥11.0 pg/mL, respectively.

Conclusion

Similar to IL‐6, the umbilical venous PCT level is a promising parameter for predicting histological CAM and adverse neonatal and infantile outcomes related to in utero inflammatory status.

Microbiome profile of the amniotic fluid as a predictive biomarker of perinatal outcome

Chorioamnionitis (CAM), an inflammation of the foetal membranes due to infection, is associated with preterm birth and poor perinatal prognosis. The present study aimed to determine whether CAM can be diagnosed prior to delivery based on the bacterial composition of the amniotic fluid (AF). AF samples from 79 patients were classified according to placental inflammation: Stage III (n = 32), CAM; Stage II (n = 27), chorionitis; Stage 0-I (n = 20), sub-chorionitis or no neutrophil infiltration; and normal AF in early pregnancy (n = 18). Absolute quantification and sequencing of 16S rDNA showed that in Stage III, the 16S rDNA copy number was significantly higher and the α-diversity index lower than those in the other groups. In principal coordinate analysis, Stage III formed a separate cluster from Stage 0-I, normal AF, and blank. Forty samples were classified as positive for microbiomic CAM (miCAM) defined by the presence of 11 bacterial species that were found to be significantly associated with CAM and some parameters of perinatal prognosis. The diagnostic accuracy for CAM according to miCAM was: sensitivity, approximately 94%, and specificity, 79-87%. Our findings indicate the possibility of predicting CAM prior to delivery based on the AF microbiome profile.

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.

Predictive value of procalcitonin or c-reactive protein for subclinical intrauterine infection in patients with premature rupture of membranes (PROM)

INTRODUCTION

to evaluate the diagnostic value of procalcitonin (PCT) and C-reactive protein (CRP) for the prediction of subclinical intrauterine infection in patients with premature rupture of membranes (PROM).

METHODS

a retrospective analysis was performed based on patients with PROM admitted into our hospital between January 2011 and January 2016. Using the pathological diagnosis of placenta as the gold standard, the sensitivities, specificities, positive predictive values, and negative predictive values of PCT and CRP for the diagnosis of subclinical intrauterine infection at different gestational weeks were analyzed. Further, the diagnostic accuracies were compared according to their receiver operating characteristic (ROC) curves.

RESULTS

276 cases were included. The area under the ROC curve of CRP is 0.632, and it is significantly better than PCT. The sensitivity, specificity, positive predictive value, and negative predictive value of CRP are 0.686, 0.958, 0.501, and 0.765, which are all better than those of PCT. The group analysis according to different gestational weeks demonstrated that for the group of 28-33+6 weeks pregnant women, the area under the ROC curve of CRP and PCT is 0.869, and 0.787. The both test have satisfactory accuracy. But the sensitivity and specificity of PCT is 0.830, and 0.950, respectively. That are significantly better than CRP.

CONCLUSION

both PCT and CRP have good application potential for the diagnostic prediction of subclinical intrauterine infection in <34 gestational weeks pregnant women with PROM, and PCT is more applicable to 28-33+6 gestational weeks pregnant women with PROM.

[Evaluation of the interest of procalcitonin in the diagnosis of chorioamnionitis in preterm premature rupture of membranes. An observational and prospective study]

INTRODUCTION

Diagnosis of chorioamnionitis (CA) is difficult because all clinical and biological signs are rarely concordant. According to recent literature, PCT could act as a specific marker of bacterial infection. Our main objective was to assess whether PCT could improve our management of patients with preterm premature rupture of membranes (pPROM), allowing earlier and more specific diagnosis for CA.

METHODS

Patients with pPROM from 24 and 34weeks of amenorrhea were included, from November 2013 to October 2014. PCT was collected twice a week, from pPROM until delivery. Obstetricians were blinded from PCT results, in order not to influence the management of the patients. PCT values were then compared to clinical and other biological diagnostic markers (CRP and white blood cells count [WBC]).

RESULTS

Thirty patients were included, with 11 cases of histological CA and 5 early-onset neonatal sepsis. With a cut-off value of 0.05ng/mL, the sensitivity of PCT to detect histological CA was 54%, the specificity was 79% and the positive and negative predictive value were respectively 60% and 75%. The positive likelihood ratio was 2.57 and the negative likelihood ratio was 0.58. Using PCT values, our medical decision of foetal extraction would have change in 5 cases (in a wrong way in 3 of them).

CONCLUSION

PCT in the diagnostic of CA is not useful in the management of patients.

Maternal serum concentrations of s-Endoglin and IL-6 in pregnancy complicated by preterm premature membrane rupture

OBJECTIVE

This study aimed to investigate maternal serum concentrations of s-Endoglin and compare s-Endoglin with other inflammatory markers in prediction of time to delivery, in pregnancies complicated by preterm premature rupture of membranes (PPROM).

MATERIALS AND METHODS

Fifty five patients complicated by PPROM whose gestational age were between 2433 weeks and 44 matched healthy pregnant women were included in present study. Maternal concentrations of s-Endoglin concentrations were measured by an enzyme-linked immunosorbent assay (ELISA) and compared with maternal inflammatory markers including interleukin-6 (IL-6), white blood cell (WBC) count and serum C-reactive protein (CRP). The best variable for prediction of preterm birth was computed.

RESULTS

Mean s-Endoglin levels in PPROM were lower than control groups (0.24 ± 0.12 pg/ml and 0.69 ± 0.25 pg/ml, respectively, p < 0.01). Besides IL-6 (p < 0.01), WBC (p = 0.016) and CRP (p = 0.010) levels were higher in PPROM group. In PPROM group, ROC analysis results of s-Endoglin for prediction of preterm delivery <48 h, <7 days, <32 weeks were not different (p > 0.05). For predicting preterm birth before 48 h and 7 days, only IL-6 at cut off value >0.70 (pg/ml) and >0.55 (pg/ml) had area under curve (AUC); 0.871 (0.7750.965), p < 0.01, AUC; 0.925 (0.8560.993), p < 0.001, respectively.

CONCLUSION

s-Endoglin as an anti-angiogenic marker seemed to have a role in pathogenesis but results of present study showed that, unlike IL-6, it was unsatisfactory for estimating time to delivery in PPROM.

Predictive factors for latency period in viable pregnancies complicated by preterm premature rupture of the membranes

Objective:

In this study, we aimed to evaluate some laboratory and clinical factors in the prediction of latency period for pregnant patients complicated with preterm premature rupture of the membranes.

Materials and Methods:

Sixty-five pregnant patients between 24 and 34 weeks of gestation, who were admitted to University of Çukurova School of Medicine Hospital with the diagnosis of preterm premature rupture of the membranes (PPROM) between January 01, 2013 and December 31, 2013, were included in this study. Serum CRP, procalcitonin, sedimentation rate, leukocyte count and cervical length (measured with transvaginal ultrasound) of patients were analyzed for the correlation with the latency period.

Results:

None of the parameters were found to be correlated with the latency period. However, patients with cervical length of <25 mm were found to have shorter duration of latency.

Conclusion:

Although preterm premature rupture of the membranes is thought to be either an infection-based disease or a disease increasing the risk of infectious complications, major infection markers are not found to be helpful criteria for the prediction of latency period. Patients with a cervical length of <25 mm can be expected to deliver earlier and, therefore, can be referred to a tertiary center earlier.