Evaluation of the role of maternal serum high-sensitivity C-reactive protein in predicting early pregnancy failure

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.

The Clinical Value of 3D Ultrasonic Measurement of the Ratio of Gestational Sac Volume to Embryo Volume in IoT-Based Prediction of Pregnancy Outcome

The objective of the research study is to investigate the use of three-dimensional ultrasonic measurement technology, to determine the size of gestational sac and embryo volume, and to use the ratio of gestational sac volume to embryo volume in IoT-based prediction of pregnancy outcome. The abnormal and normal pregnancy identifiers are there, which assists in prediction of pregnancy outcomes: whether the pregnancy is normal or may suffer pregnancy loss during first trimester. For the observational study, 500 singleton pregnant women who made an appointment for delivery in Qiqihar Hospital from January 2015 to June 2019 were considered. The 500 pregnant women received transvaginal ultrasound at 6+0 ∼ 8+0 weeks of gestational age to measure gestational sac volume (GSV), yolk sac volume (YSV), and germ volume (GV). According to pregnancy outcome, they were divided into fine group (n = 435) and abortion group (n = 65). Among the 500 cases, 435 had normal delivery and 65 had abortions. According to the results of gestational age (GA) analysis, the pregnancy success rates at 6 (n = 268), 7 (n = 184), and 8 weeks (n = 48) were 85.8%, 87.5%, and 91.7%, respectively. Comparison of pregnancy failure rate among the three groups shows statistically significant difference. The morphology of germ, yolk sac, and gestational sac cannot be used as a predictor of pregnancy outcome in various degrees. The results of multivariate Cox proportional regression analysis show the following: the ratio of germ volume (GV) to gestational sac volume (GSV) (P=0.008) has an impact on the prediction of spontaneous abortion prognosis, showing statistically significant difference; yolk sac volume (YSV), germ volume (GV), and gestational sac volume (GSV) have no effect on the prediction of spontaneous abortion prognosis (P > 0.05). The ratio of GSV to germ volume has a strong prognostic value for pregnancy results. To a certain extent, the ratio of gestational sac volume to germ volume can predict spontaneous pregnancy abortion at 6th week of gestation, providing a theoretical basis for clinical ultrasound pregnancy examination indicators.

Findings from a multicentre, observational study on reproductive outcomes in women with unexplained recurrent pregnancy loss: the OTTILIA registry

STUDY QUESTION

What evaluation and care is offered to women after unexplained recurrent pregnancy loss (RPL) or intra-uterine foetal death (IUFD) and what are the reproductive outcomes?

SUMMARY ANSWER

Women are assessed for thrombophilia and often treated with low-molecular weight heparin (LMWH) and/or low-dose aspirin (ASA).

WHAT IS KNOWN ALREADY

Randomized controlled trials (RCTs) on possible efficacy of heparins and/or aspirin have been inconclusive due to limited power to detect a difference and patient heterogeneity.

STUDY DESIGN, SIZE, DURATION

Prospective multicentre cohort study performed in 12 hospitals in three countries between 2012 and 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All consecutive pregnant women with recurrent PL (≥3 losses or 2 losses in the presence of at least one euploid foetal karyotype) or at least one IUFD. Eligible women may have undergone thrombophilia testing before conception, at the discretion of local providers. The possible assignment of women to treatments (such as LMWH) was not decided a priori but was determined based on the responsible provider's current practice. Aims of the study were: (i) to evaluate factors associated with pregnancy outcome; (ii) to compare clinical management strategies in women with and without a subsequent successful pregnancy; and (iii) to evaluate characteristics of women who may benefit from antithrombotic therapy. A propensity score matching method was used to balance the differences in baseline characteristics.

MAIN RESULTS AND THE ROLE OF CHANCE

A matched sample of 265 pregnant women was analysed, with all undergoing thrombophilia screening; 103 out of 119 (86.6%) with and 98/146 (67.1%) without thrombophilia were prescribed with LMWH and/or ASA. Overall, live-births were recorded in 204 cases (77%), PL or IUFD in 61 (23%) pregnancies. Logistic regression showed a significant interaction between thrombophilia and treatment with LMWH (P = 0.03). Findings from sensitivity analysis showed odds ratio (OR) for pregnancy loss in women with inherited or acquired thrombophilia in absence of any treatment was 2.9 (95% CI, 1.4-6.1); the administration of LMWH (with or without ASA) was associated with higher odds of live-birth (OR, 10.6; 95% CI, 5.0-22.3). Furthermore, in women without thrombophilia, the odds of live-birth was significantly and independently associated with LMWH prophylaxis (alone or in association with ASA) (OR, 3.6; 95% CI, 1.7-7.9).

LIMITATIONS, REASONS FOR CAUTION

While the propensity score matching allows us to balance the differences in baseline characteristics, it does not eliminate all confounding.

WIDER IMPLICATIONS OF THE FINDINGS

Antithrombotic prophylaxis during pregnancy may be effective in women with otherwise unexplained PL or IUFD, and even more useful in those with thrombophilia.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by Italian Ministry of Health (Ricerca Corrente 2018-2020). Dr G.P. has received research grant support from Bristol Myers Squibb/Pfizer Alliance, Janssen, Boston Scientific Corporation, Bayer, and Portola and consultant fees from Amgen and Agile Therapeutics. Dr E.G. has received consultant fees from Italfarmaco and Sanofi. All other authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

NCT02385461.

Thrombophilia, Inflammation, and Recurrent Pregnancy Loss: A Case-Based Review

Recurrent pregnancy loss (RPL) is defined as the loss of two or more pregnancies and is often multifactorial with the majority of miscarriages being due to aneuploidy and anatomic or physiological abnormalities. However, inherited or acquired thrombophilias have also been associated with RPL, albeit inconsistently. While inherited thrombophilias, such as factor V Leiden and prothrombin gene mutation, are relatively prevalent in women with RPL compared with the general population, a causal link has yet to be definitively established. Recently, systemic inflammation, as measured by high-sensitivity C-reactive protein, has also been hypothesized to play a role in infertility. Based on limited prospective trial data, antithrombotic therapy and antiplatelet agents have been proposed as possible tools for the prevention of RPL. Because of the multifactorial nature of RPL and infertility, various clinicians, as obstetricians and gynecologists, endocrinologists, hematologists, or vascular medicine specialists, may be requested to counsel these women. This, together with evidence gaps, frequently leads to distinctly different diagnostic and therapeutic recommendations, especially regarding thrombophilia testing and treatment. Using four case vignettes in this review, we critically appraise the literature and highlight how two clinicians from different subspecialties approach the relationship between RPL, inflammation, and thrombophilia.

Evaluation of maternal serum biomarkers in predicting outcome of successful expectant management of tubal ectopic pregnancies

OBJECTIVE

To assess the value of multiple serum biomarkers for the prediction of successful outcome of expectant management in women with tubal ectopic pregnancy (TEP).

STUDY DESIGN

Women with a conclusive ultrasound diagnosis of TEP had a blood test to measure β-human chorionic gonadotropin (β-hCG), progesterone, inhibin A, activin A and high sensitivity C-reactive protein (hsCRP) at the initial visit. Women presenting with pain, serum β-hCG ≥ 1500 IU, evidence of a live ectopic pregnancy or a significant haemoperitoneum were advised to have emergency surgery. Women eligible for expectant management were followed-up prospectively until serum β-hCG declined to non-pregnant level or surgical treatment was required.

RESULTS

A total of 93 women with a TEP were included in the final cohort. Emergency surgery was carried out in 42/93 (45 %) of women whilst 51/93 (55 %) were managed expectantly. Of the latter group, 42/51 (82 %) had successful expectant management and 9/51(18 %) required surgical procedure after a period of follow up. On multi-variable analysis, only higher values of serum β-hCG and progesterone at the initial visit were associated with a lower chance of successful expectant management of TEP. A one-unit increase in either variable on the log-scale was associated with an approximate 20-fold reduction in the odds of a successful outcome.

CONCLUSION(S)

Serum β-hCG and progesterone were significantly lower in women who had successful expectant management of TEP. Other biomarkers under consideration were not significantly different in women with successful and failed expectant management.

Soluble urokinase plasminogen activator receptor (suPAR) as a biomarker of early pregnancy location and viability compared with hCG, progesterone and estradiol

A circulating biomarker of early pregnancy outcome independent of ultrasonography and gestational age is a coveted goal. This study evaluated soluble urokinase plasminogen activator receptor (suPAR), a well-described marker of inflammation and immunological activation, for this purpose, and compared it with established early pregnancy biomarkers of the luteoplacental phase: progesterone, estradiol and hCG. We merged data from two prospective first trimester cohorts to conduct a case-control study comparing these analytes in women who had either a live birth, a miscarriage or an ectopic pregnancy. The ability to predict pregnancy location and viability was assessed by areas under the receiver operating characteristic curves (AUC). Comparing women irrespective of gestational age with a live birth, miscarriage or ectopic pregnancy showed significantly lower suPAR values in the latter group (2.4 vs. 2.4 vs. 2.0 μg/L, p = 0.032, respectively), as were all other analytes. Before 6 weeks' gestation, suPAR was significantly inferior to progesterone, estradiol and hCG in pregnancy location and viability prediction (in 124 pregnancies, suPAR AUC_location = 0.69 [CI: 0.54-0.83] and AUC_viability = 0.58 [CI: 0.48-0.69], while progesterone AUC_location = 0.95 [CI: 0.87-1.00] and AUC_viability = 0.84 [CI: 0.75-0.92]). After 6 weeks' gestation, suPAR prediction improved but was inferior to hCG, progesterone and estradiol (in 188 pregnanices, suPAR AUC_location = 0.71 [CI: 0.63-0.78] and AUC_viability = 0.70 [CI: 0.63-0.78] compared with hCG AUC_location = 0.96 [CI: 0.93-0.99] and AUC_viability = 0.96 [CI: 0.93-0.98]). Collectively, suPAR is less useful as a predictor of early pregnancy outcome than hCG, progesterone and estradol.

The role of omentin in early pregnancy losses

This prospective case-control study aimed to investigate the role of omentin, an anti-inflammatory adipokine in early pregnancy losses. The study comprised 47 women with spontaneous miscarriage at a gestational age of 8-12 weeks and 36 healthy pregnant women, matched for age, body mass index and gestational age, gravdity and parity. A significant negative correlation was determined between plasma omentin concentrations and body weight (r= -0.242, p = .027) and gestational age (r= -0.249, p = .023). Although not statistically, the women with spontaneous miscarriage had higher plasma concentrations of omentin compared to those with healthy pregnancies (7.798 ± 3.453 ng/ml vs. 7.200 ± 3.442 ng/ml, p = .435). This finding might support the hypothesis that increased inflammation plays a role in the etiopathogenesis of early pregnancy losses. These results revealed the potential use of omentin to predict unhealthy pregnancies.Impact statementWhat is already known on the subject of the paper? The exact mechanism of early pregnancy loss with euploid foetal karyotype has not been elucidated yet. An alteration in the physiological inflammatory response of pregnancy might be one of the mechanisms responsible for miscarriage.What does this study add? To the best of our knowledge, this is the first study to investigate the role of omentin in early pregnancy loss. The results obtained from this current study could be used to clarify the relationship between inflammatory processes and miscarriage.What are the implications for clinical practice and/or further research? Identification of the role of omentin in the process of early pregnancy losses would be helpful in order to design further studies to determine the feasibility of using omentin as a serum marker to predict the risk of miscarriage in early pregnancies. Additionally, understanding of the etiopathogenesis of early pregnancy losses with euploid karyotype will give a lead to further researches which could focus on exploring new interventions to detect and treat altered inflammation in early pregnancies.

EVALUATION OF SERUM HIGH-SENSITIVITY C-REACTIVE PROTEIN LEVELS DURING VARIOUS PERIODS OF PREGNANCY IN WOMAN, INFECTED WITH PARVOVIRUS - B19 INFECTION

The aim of the research was analyze of C-reactive protein levels in serum blood samples during various periods of pregnancy in women, infected with parvovirus B19 and in case of presence of clinical complications. 129 pregnant women, infected with parvovirus B19 infection and 16 women with physiological pregnancy during first, second and third trimesters of pregnancy were examined. Depending on the presence or absence of clinical complications each group of pregnant women (I, II, III) was divided into two subgroups. The concentration of C-reactive protein in blood serum was determined by the method of immunoassay analysis using diagnostic sets of reagents (ELISA kits, USA). Statistical processing of data was carried out using the package of applied programs Microsoft Office Excel 2010 and StatSoft Statistica 6.1. The mean age of pregnant woman in our study was 26±6 years. In the Iand II groups of infected B19 parvovirus pregnant women were identified a significant increasing of C-reactive protein levels compared to controls by 62.5 % and 50.0 % (p<0.05). The largest increasing of C-reactive protein level relative to control values was observed in women with clinical complications in different pregnancy periods (p<0.05). An increase levels of the marker of systemic inflammation the C-reactive protein in the blood testifies to its active participation in the launch of a complex mechanism for the development of labor activity and the occurrence of fetal disorders, which was confirmed in groups of pregnant women with clinical complications in different periods of pregnancy.

Role of serum biomarkers in the prediction of outcome in women with threatened miscarriage: a systematic review and diagnostic accuracy meta-analysis

BACKGROUND

Threatened miscarriage affects one in five women and is associated with significant emotional distress. The uncertainty around the prognosis of threatened miscarriage makes it equally challenging to the healthcare professionals. Various biochemical markers have been investigated in the past to predict the outcome of threatened miscarriage; however, the results have been conflicting. Therefore, we have conducted a systematic review and meta-analysis to determine the diagnostic accuracy of biochemical markers in predicting the outcome in women presenting with threatened miscarriage.

METHODS

This is a systematic review and meta-analysis of prospective studies that investigated biochemical markers to determine outcomes for women with threatened miscarriage at 5-23 weeks gestational age. Electronic databases were searched up to June 2015 and study quality assessment was performed using QUADAS-2 (Quality Assessment for Diagnostic Accuracy Studies-2: A Revised Tool) for evaluating the diagnostic accuracy studies. Statistical analysis was performed using the Cochrane systematic review software.

RESULTS

A total of 19 studies were included in the qualitative data synthesis of which 15 (including 1263 women) were eligible for the meta-analysis. The review highlights the role of biochemical markers serum progesterone, hCG, pregnancy associated plasma protein A, estradiol and cancer antigen 125 (CA 125) in the prediction of outcome in women with threatened miscarriage. Interestingly, serum CA 125 appears to be the most promising marker (n = 648 women in seven studies), whereas serum progesterone and hCG are less useful once fetal viability is established. The summary receiver operating characteristics for CA 125 showed a sensitivity of 90% (95% confidence interval (CI) 83-94%), specificity of 88% (95% CI 79-93%), positive likelihood ratio of 7.86 (95% CI 4.23-14.60) and negative likelihood ratio of 0.10 (95% CI 0.06-0.20). The inverse of negative likelihood ratio was 9.31 (95% CI 5-17.1) indicating that a negative test is likely to identify those who are likely to continue with the pregnancy. Serum estradiol was the next best marker with a sensitivity of 45% (95% CI 6-90%), a specificity of 87% (95% CI 81-92%), a positive likelihood ratio of 3.72 (95% CI 1.01-13.71) and a negative likelihood ratio of 0.62 (95% CI 0.20-1.84).

CONCLUSIONS

In women with threatened miscarriage, serum CA 125 has high predictive value in identifying pregnancies that are 'likely to continue', whereas the most commonly used biomarkers of serum hCG and progesterone are not useful in predicting outcome of a pregnancy with a viable fetus. Other markers such as inhibin A and a combination of markers need to be investigated to hopefully improve the prediction of outcome in women with threatened miscarriage.