A Comparative Study of Serum C-reactive Protein Level Between Pre-eclampsia and Normal Pregnancy in Tertiary Level Hospital
Perivascular epithelioid cell tumors (PEComas) represent a rare family of mesenchymal neoplasms with distinctive morphological and immunophenotypic features. Gastrointestinal PEComas constitute an uncommon subset with variable clinical behavior, ranging from benign localized lesions to malignant and metastatic neoplasms. Accurate diagnosis requires integration of histologic features, immunohistochemical analysis demonstrating myomelanocytic differentiation, and exclusion of mimics such as gastrointestinal stromal tumors, metastatic melanoma, and epithelioid smooth muscle tumors. Central to the pathogenesis of PEComas is dysregulation of the mTOR signaling pathway. TSC1 and TSC2 alterations underlie mTOR activation in a significant proportion of conventional PEComas, whereas a subset of cases harbor TFE3 gene rearrangements that define a biologically and clinically distinct subgroup. These molecular features not only clarify pathogenetic mechanisms but also support targeted therapeutic strategies, most notably mTOR inhibitors, which have demonstrated meaningful clinical activity in advanced or unresectable disease. Risk stratification remains challenging, as existing criteria—particularly those proposed by Folpe and colleagues—were developed from heterogeneous cohorts and incompletely predict behavior in gastrointestinal sites. Emerging evidence suggests the incorporation of additional features such as Ki-67 index, necrosis, mitotic activity, and molecular alterations may improve prognostic accuracy. Comprehensive surgical excision remains the primary treatment for localized tumors, while systemic therapy, particularly mTOR pathway inhibition, is reserved for recurrent, unresectable, or metastatic disease. Continued multidisciplinary collaboration, expanded molecular profiling, and development of prospective registries are essential to refine risk prediction, therapeutic selection, and long-term management of gastrointestinal PEComas.
Jannat S¹, Islam A¹, Yesmin S²*, Shanta FI³, Jabin AM³, Sanjida S⁴ and Trishna D⁵
Keywords: Serum C-reactive Protein; Pre-eclampsia; Normal Pregnancy; Pathophysiology
Abbreviations
CRP: C-Reactive Protein; IMCH: International Medical College and Hospital; SBP: Systolic Blood Pressure; DBP: Diastolic Blood Pressure; SPSS: Statistical Package for Social Science.
Introduction
Pre-eclampsia is most common medical complication during pregnancy. It is a multisystem disorder of pregnancy which is characterized by new onset of hypertension. It is recorded as one of the top five causes of maternal death in the world. Here hypertension (SBP and DBP is ≥140 and 90 mm of Hg respectively) on two occasions, at least two hours apart and proteinuria (protein excretion of ≥ 300 mg in a 2 hours’ urine collection, or a dipstick of ≥ 2+), that develop after 20 weeks of gestation in previously normotensive woman [1]. The pathophysiology of pre-eclampsia remain is uncertain despite of a failure of the trophoblastic invasion of the uterine blood vessels. Immunological intolerance leading to maladaptation of maternal spiral arterioles which may be associated with a vascular resistance of the uterine artery and decrease perfusion of the placenta [2, 3].
Pre-eclampsia is characterized by the development of hypertension, proteinuria and oedema at 20th week of gestation. Placenta into maternal plasma plays a central role in the ensuring endothelial dysfunction that is the prominent feature of this disease. Here the exact aetiology of eclampsia is still unknown.
This is a transient and serious complication of pregnancy that approximately affect 2-4% of all pregnancies. It is a major cause of maternal & perinatal morbidity & mortality worldwide particularly in developing countries. All over the world pre- eclampsia is in the third position for maternal mortality and in 7th position of the perinatal mortality. On average 50,000 to 60,000 woman dies in each year and it is now a global leading cause out of which 9% of maternal death is in Asia [4, 5]. In spite of various attempts to understand the primary aetiology behind this vascular endothelial dysfunction and inflammation are considered to have a crucial role in pre-eclampsia. Pre- eclampsia developed in 4-5% of human pregnancies. Pre- eclampsia is characterized by elevated blood pressure and proteinuria which developed after 20 weeks of gestational age [3, 5]. Pre-eclampsia can result in eclampsia when convulsions develop or other manifestations as haemolysis and increased liver enzymes & low platelet count which all together known as HELLP syndrome. Endothelial dysfunction and inflammation are considered to have a crucial role in a pathophysiological mechanism of pre-eclampsia [3]. CRP is an acute phase protein which is synthesized in hepatocytes. CRP is an important marker of systemic inflammation and it has been shown that CRP is elevated in woman with pre-eclampsia [4, 5].
It is therefore important to identify woman who are in high risk of developing the disease early in pregnancy. This is because very early identification of CRP level as a biochemical marker of the disease would not only facilitate selective recruiting of those at increased risk for pre-eclampsia but also help in determining those patients who were more likely to get benefit from interventional measures. This study will also help to get idea about the level of serum CRP in pre-eclampsia and its relationship with the severity of the disease.
Material and Methods
A cross-sectional study was conducted in the clinical pathology department of IMCH, Gazipur from January 2018 to December 2018. Total number of 150 pregnant women in third trimester of pregnancy attending in Obstetrics’ and gynaecology department of IMCH and Digital Diagnostic and Hospital were selected as study subjects.
Among them 75 patients were diagnosed as case of pre- eclampsia were selected as group I with age range 18-36 years and 75 age matched normal healthy woman as group II. Pregnant woman with pre-existing hypertension, diabetes mellitus and renal disease were excluded from the study by history, clinical examination and relevant laboratory investigations. After obtaining informed written consent from all the study subjects relevant data were documented in a predefined data sheet. With maintaining all aseptic precautions, blood samples were collected from all the study subjects for estimation of serum CRP level. Serum CRP level was measured by ELISA method.
Statistical analysis was performed by using computer- based software, Statistical package for social science (SPSS) for windows version 20. Mean values of differences between two groups by using students unpaired “t” test. Chi-square test was performed to find out the statistical difference regarding qualitative variables between two group. For all statistical analysis “p” value <0.05 was considered as a level of significant.
Results
The study included parameters in terms such as anti- natal checkup, Blood pressure (BP), BMI are shown in Table 1-3. There are 75 pregnant women with pre-eclampsia (severe pre-eclampsia) and 75 normal pregnant women. In this study, it was observed that anti-natal check-up of group I was significant compared to group II and on the other hand regular antenatal checkup more in group II (75.0%) than group I (52.0%). The difference was statistically significant (P<0.05) between two groups (Table 1).
In case of BP this study showed that the percentage of high SBP/DBP in group I was more compared to group II and the difference was statistically significant (P<0.05) between two groups (Table 3).
In this study it was observed that BMI of group I was significantly high compared to group II shown in (Table 2).
Table 4 shows the comparison of mean serum CRP level between group I and group II. Majority of the subjects 70 (92%) in group I having increased serum CRP level >6 mg/L compared to group II (3 mg/L). The results was statistically significant (p<0.05) between two groups. Here CRP level <6 mg/L in group I (8%) and group II (97%). The results was statistically significant (P<0.05) between two groups.
| ANC | Group I (n=75) | Group II (n=75) | p value | ||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Regular | 39 | 52 | 55 | 75 | 0.021S |
| Irregular | 36 | 48 | 20 | 25 |
Table 2: Distribution of the study subjects by BMI.
Table I: Distribution of study subjects by Antenatal check up.
| BMI (Kg/m2) | Group I (n=75) | Group II (n=75) | p value | ||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Normal weight (18.5-24.9) | 7 | 10 | 29 | 39 | 0.043S |
| Over weight (25.5-29.9) | 68 | 90 | 46 | 61 |
Table 3: Distribution of the study subjects by BMI.
| BP (mm of Hg) | Group I (n=75) | Group II (n=75) | p value | ||
|---|---|---|---|---|---|
| Systolic BP | n | % | n | % | |
| 100-119 | 0 | 0 | 64 | 85 | |
| 120-139 | 8 | 10 | 11 | 15 | |
| 140-159 | 62 | 82 | 0 | 0 | |
| 160-180 | 5 | 8 | 0 | 0 | |
| Mean + SD | 149.6 + 8.52 | 113 + 7.18 | 0.001S | ||
| Range (min-max) | (143-158) | (105 - 120) | |||
| Diastolic BP | n | % | n | % | |
| 60-69 | 0 | 0 | 8 | 10 | |
| 70-79 | 0 | 0 | 64 | 85 | |
| 80-89 | 5 | 8 | 3 | 5 | |
| 90-100 | 70 | 92 | 0 | 0 | |
| Mean + SD | 94.2 + 2.72 | 84.5 + 3.86 | 0.001S | ||
| Range (min-max) | (91 - 97) | (80 - 88) |
Table 4: Distribution of the study subjects by BP.
| CRP (mg/L) | Group I (n=75) | Group II (n=75) | p value | ||
|---|---|---|---|---|---|
| n | % | n | % | ||
| >6 (mg/L) | 70 | 92 | 2 | 3 | |
| <6 (mg/L) | 5 | 8 | 73 | 97 | |
| Mean ± SD | 1.3 ± 0.23 | 2.03 ± 0.15 | 0.001S | ||
| Range (min-max) | (1.04 – 1.50) | (1.8 – 2.2) | |||
| Mean ± SD | 3.52 ± 0.75 | 4.34 ± 0.47 | 0.001S | ||
| Range (min-max) | (2.77 – 4.27) | (3.87 – 4.81) |
Table 1: Distribution of serum CRP in study subjects.
Discussion
Pre-eclampsia is not merely hypertension unmasked by pregnancy. It is a significant cause of maternal and perinatal mortality and morbidity. Hypertension seems to be a marker of the disorder rather than a causal factor. Thus success in treating pre-eclampsia is not merely reducing BP rather ameliorating the syndrome itself including improved perinatal outcome, the major complication of the management strategy of early delivery.
This cross sectional study was carried out with an aim to compare CRP level in pre-eclampsia woman and normal pregnant woman. Frequency of regular antenatal check up was more in normal pregnant group compared to pre- eclampsia group. The difference was statistically significant (p<0.5) between two groups which was similar with one previous study [6].
In measurement of BP, SBP (140 mm of Hg) was significantly more (p= 0.001) observed in group I than group II. Similarly, there was significantly high in DBP (> 90 mm of Hg) in group I (100%) compared to group II (8%) (Table 3). Another previous study showed the mean SBP and DBP were high in pre-eclampsia group compared to normal pregnant group. The difference was statistically significant (p<0.05%) between two groups [3, 7]. In this current study it was observed that majority 90.0% subjects had over weight (25 – 29.9 kg/m2) in group I and 61.0% in group II (Table 2). The difference was statistically significant (p<0.05%) between two groups. This observation was consistent with another study [4].
In this study mean serum CRP level was found 1.3 ± 0.23 mg/Lin group I and 2.03 ± 0.15 mg/L in group II. The difference was statistically significant (p<0.05%) between two groups (Table 4). This result was consistent with the result of a previous study that showed serum CRP level was higher in pre-eclampsia group compared to normal pregnant group [8, 9].
Another few studies showed that there was significant difference in serum CRP among normal pregnant and both mild and severe pre-eclampsia and they concluded that measurement of this elements may be used for the early diagnosis of pre-eclampsia condition [1, 3]. Another study reported an increase in serum CRP level in pregnant woman with pre-eclampsia [10].
Other study showed serum CRP level was significantly increased in pre-eclampsia women compared to the healthy group. This study also revealed that the level of CRP in pre- eclampsia women was not only significantly high when the diagnosis was confirmed but also the initial level from early in the pregnancy was higher than the healthy pregnant group. Their observation suggested that raised CRP level may be one of the etiology of pre-eclampsia [5, 11]. A study suggested that the increased level of CRP since the beginning of pregnancy may reduce the rate of pre-eclampsia among pregnant women [8].
CRP monitoring during pregnancy may be able to reduce intrauterine growth retardation and pre-eclampsia and safe the birth weight of baby. There are also few studies concerning CRP level due to severity of pre-eclampsia. It has been shown that level of CRP was positively related to the degree of blood pressure elevation [12].
Regarding this study and other previous established study can make a conclusion that increased CRP might have an important role in the etiology of pre-eclampsia. So early diagnosis of this parameter may reduce the incidence of pre- eclampsia and increase the maternal and perinatal outcomes.
Conclusion
The findings of this study showed that higher CRP level was associated with pre-eclampsia. This supports the hypothesis that alteration of this serum marker CRP may take a role in the etiology of pre-eclampsia. So far early diagnosis and prevention of pre-eclampsia, regular antenatal checkup and routine investigation of CRP should be advocated. As well as further trials are needed regarding the role of early detection of CRP in reduction of systemic complications and maternal death due to pre-eclampsia.
References
-
Sibai B, Baha M, Dekker G (2003) Diagnosis and management of gestational hypertension and pre- eclampsia, Obstetrics and Gynaecology. Journal of Dental and Medical sciences 102(1): 181-192.
-
Luis B, Alice S, Murlel C, Irene R (2003) Neutrophil activation and c reactive protein concentration in pre-eclampsia. American journal of Obstetrics and Gynaecology 22(2): 129-141.
-
Anil B, Jayashree A, Ganu J, Nitin N (2011) Serum Hs-CRP and uric acid as indication of severity in Pre-eclampsia. International Journal of Pharmacology and Bio-sciences 2(3): 340-345.
-
Kameswaramma K, Lim K, Jeffery L, Cher E (2014) Estimation of C-reactive Protein, Magnesium and uric acid levels in pre-eclampsia patients in comparison with noemal pregnant woman. Scientific Journal of Applied Medical Sciences 2(23): 628-632.
-
Power R, Bodnar L, Ness R, Cooper K (2006) CRP concentrations in early pregnancy among pre-eclampsic women and normal pregnant women. American journal of Obstetrics and Gynaecology 28(6): 160-172.
-
Mandal K, Premchandra Y, Arpita D, Gyaneshwar W (2015) Serum uric acid and CRP in pre-eclampsia. International Journal of Clinical Biochemistry 14(2): 116-123.
-
Ayatollah H, Hasanzade N, Farzadnia Mahdi, Rahmanian A (2007) Serum level of HS-Creactive Protein in normal and Pre-eclampsic Pregnancies. Iranian Journal of Pathology 2(3): 100-104.
-
Guvan M, Coskun A, Ertas E, Aral M (2009) Association of maternal serum CRP, IL-6, TNF α, Vit B12 levels with the severity of Pre-eclampsia and fetal birth weight, Hypertersion in pregnancy. International Journal of Clinical Biochemistry 28(3): 190-200.
-
Qin C, Luthy D, Zhang C, Walash S (2004) A progressive study of maternal serum C-reactive Protein concentration and risk of Pre-eclampsia. American journal of Obstetrics and Gynaecology 17(2): 154- 160.
-
Yu H, Rafai N, Leveno K, Gant N (2000) High sensitivity C-reactive Protein in pre-eclampsia and Normal Pregnant women. British journal of Obstetrics and Gynaecology 33(8): 601-610.
-
Kupfermine M, Aderka D, Sokal M, Wallach D (2009) Soluble tumour necrosis factor receptors and Interleukin-6 and CRP levels in patients with Severe Pre-eclampsia. International Journal of Obstetrics and Gynaecology 88(3): 420-427.
-
Belo L, Caslake M, Sritos S, Cooney J (2003) Neutrophil activation and C-reactive protein Concentration in Pre- eclampsia. European Journal of Obstetrics. Gynaecology and Reproductive Biology 22(2): 121-125.
- Establishment of Baseline Haematological Values for Canine Population in North-Central Nigeria: A Cross-Sectional Study in the Federal Capital Territory
- Biochemical Assessment of Uroliths Extracted in Patients with Urolithiasis in a Tertiary Health Institution
- Update on Gastrointestinal Pecomas: Molecular Pathogenesis and Risk Stratification
- From Deformity to Alignment: Clinical Outcomes of the Schnepp Osteotomy in Hallux Valgus in 47 Feet
- Pediatric Sinonasal Ewing Sarcoma
- Knee Bone Measurements for Forensic Anthropological Age and Sex Assessment: Uses in Identification and Medicolegal Cases