Article by: Jyotsna Gaikwad, MD (Gynac). M.Sc Health Sciences. BAMS
Preeclampsia is the hypertensive disorders of pregnancy which is one of leading causes of maternal and perinatal morbidity and mortality worldwide. Around the world, about 10% of all pregnancies are affected by hypertensive disorders. Preeclampsia affects 5% – 7% of all pregnancies and responsible for 12% maternal mortality, globally. Worldwide incidence of preeclampsia is estimated to be 3-10%. In Asia and Africa, pregnancy specific hypertensive disorders contribute to nearly one tenth of all maternal deaths.
Preeclampsia is responsible for approximately 12 to 25% of IUGR and small for gestational age infants as well as 15 to 20% of all preterm births (1). HELLP syndrome occurs in approximately 20% of women with severe preeclampsia. In terms of long-term consequences, preeclampsia is responsible for increase of cardiovascular events by 2- to 3fold; the risk increases with severity of disease Preeclampsia is the complication of pregnancy usually develops after 20th week of the gestation, characterized by a complex of symptoms including maternal hypertension and proteinuria with or without pathological oedema. It can last for 4-6 weeks postpartum. Symptoms of preeclampsia may range between mild and severe.
Pre-eclampsia is a result of imbalance between factors produced by the placenta and maternal adaptation to these factors. Abnormal placentation with impaired trophoblastic invasion at the beginning of pregnancy (weeks 8– 18) followed by inadequate remodelling of the uterine spiral arteries leading to hyper activation of maternal immunological response and progressive endothelial damage. Pre-eclampsia has pre-clinical (symptomless) and clinical stages, only the latter phase can be detected by clinical screening and is outcome of placental dysfunction secondary to maternal inflammatory reaction. It is probable that pre-eclampsia results from abnormal trophoblastic growth and differentiation, develops at any time after the earliest stages of implantation. The primary dysfunction may be immunologic response to fetal alloantigens, as first pregnancy preponderance of pre-eclampsia. Immunological response leads to activation of platelets, activation of neutrophils, secretion of pro-inflammatory cytokines and autoantibodies by leukocyte. These activated leukocytes like neutrophils, lymphocytes infiltrate in maternal systemic circulation precipitate vasoconstriction which is the background pathophysiology of preeclampsia. Neutrophil-lymphocyte ratio (NLR) and plateletlymphocyte ratio (PLR) are indicators of systemic subclinical inflammatory markers. Recent publications have generated interest in studying changes in systemic inflammatory markers in relation to various clinical conditions like cardiovascular diseases, malignancies, ulcerative colitis, systemic lupus erythromatosis.
Ali et al compared the changes in the values of systemic inflammatory response (SIR) markers (neutrophil-lymphocyte ratio/platelet-lymphocyte ratio) in severe preeclampsia (PE), healthy pregnant and non-pregnant women. NLR and PLR values did not have any significance in diagnosis of preeclampsia. A case-control study by Mustafa et al. and prospective study by Ozlem et al. showed the significant association of NLR with preeclampsia but the blood samples were collected after diagnosis of preeclampsia. Likewise, Emel et al. assessed the complete blood count retrospectively for NLR demonstrated its significance in presence of preeclampsia but severity and onset of disease was not evaluated. Prasmusinto et al. investigated NLR values just before delivery, found significantly higher NLR in preeclamptic patients; the test did not diagnose the onset of the disease. Next in order, Salih et al. at the time of childbirth determined positive correlation of higher NLR values with preeclampsia and its degree of severity. Results of the study by Mehmet et al. reflected existence of preeclampsia by higher values of NLR while lower PLR values in severe preeclampsia seen when compared with mild PE; however, tests were done immediately after delivery. On the other hand, Burak et al. investigated NLR and PLR values before the childbirth, found no diagnostic value for NLR while severe PE had lower PLR compared to control but not significant in detecting severity of PE. Kirbas et al. evaluated significance of NLR and PLR in early prediction and severity of disease. NLR could accurately predict PE whereas PLR predicted the severity of the preeclampsia whereas the prediction of preeclampsia was demonstrated by first trimester higher values of NLR and PLR by Cenk et al.
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