Description of Neutrophil-to-lymphocyte Ratio, C-reactive Protein, and Procalcitonin Levels in Pregnancy with COVID-19 at Sanglah General Hospital Period of April 2020–April 2021
Anak Agung Ngurah Jaya Kusuma, Made Bagus Dwi Aryana, I Nyoman Bayu Mahendra, Daniel Hadinata Susanto
COVID-19 in pregnancy, C-reactive protein, Neutrophil-to-lymphocyte ratio, Pregnancy
Citation Information :
Kusuma AA, Aryana MB, Mahendra IN, Susanto DH. Description of Neutrophil-to-lymphocyte Ratio, C-reactive Protein, and Procalcitonin Levels in Pregnancy with COVID-19 at Sanglah General Hospital Period of April 2020–April 2021. J South Asian Feder Obs Gynae 2022; 14 (4):445-452.
Background: Theoretically, pregnant women are more susceptible to infection of coronavirus disease 2019 (COVID-19) and severe pneumonia due to presentation of physiological changes adaptation and immunosuppression during pregnancy. Based on the immune clock theory, if pregnant women had COVID-19 in the first and third it can appearance of cytokine storm due to hyperinflammation state, and lead to poor maternal and neonatal outcomes. Hyperinflammation state is characterized by an increase in inflammatory biomarkers in the serum, including the neutrophil-to-lymphocyte ratio (NLR), C-reactive protein (CRP), and procalcitonin levels. This study aims to determine the characteristic of NLR, CRP, and procalcitonin in pregnancy with COVID-19 at Sanglah General Hospital, Denpasar, Bali, Indonesia.
Methods: This study is a cross-sectional descriptive study using secondary data from patient's medical records and is conducted in the delivery room and medical record department at Sanglah General Hospital, Denpasar from April 2020 to April 2021.
Result: Pregnancy cases with COVID-19 in this study were in the 26–30-year age group, as much as 26 cases (37.14%) with most common comorbidities found were preeclampsia and electrolyte imbalance, as much as nine cases each (12.86%). Most of the neonates born at term, with birth weight 2,500 gm, and vigorous baby. The highest median NLR value was found in pregnant women with COVID-19 in comorbid with obesity, 6.79 (2.88–9.14). In this study, the cases with a length of stay more than or 10 days had a median NLR value of 6.93 (2.57–20.69), CRP 59.83 (1.60–151.56), and procalcitonin 0.145 (0.03–2.56), which are all higher than those whose length of stay was less than 10 days.
Conclusion: NLR, CRP, and procalcitonin values are affected by the trimester of pregnancy, the maternal comorbidities, the commonly found chest X-ray features, the length of hospital stay, the prognostic value to be determined to find the disease severity, the needs of oxygen supplementation, and the intensive care treatment, and also they could be the predictors for neonatal outcome in pregnancy with COVID-19.
Vakili S, Savardashtaki A, Jamalnia S, et al. Laboratory findings of COVID-19 infection are conflicting in different age groups and pregnant women: a literature review. Arch Med Res Elsevier Inc, 2020;51(7):603–607. DOI: 10.1016/j.arcmed.2020.06.007.
Mor G, Aldo P, Alvero AB. The unique immunological and microbial aspects of pregnancy’, Nat Rev Immunol 2017;17(8):469–482. DOI: 10.1038/nri.2017.64.
Andrikopoulou M, Madden N, Wen T, et al. Symptoms and critical illness among obstetric patients with coronavirus disease 2019 (COVID-19) infection. Obstet Gynecol 2020;136(2):291–299. DOI 10.1097/AOG.0000000000003996.
Knight M, Bunch K, Vousden N, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population based cohort study. BMJ 2020;369:m2107. DOI: 10.1136/bmj.m2107.
Qiancheng X, Jian S, Lingling P, et al. Coronavirus disease 2019 in pregnancy. Int J Infect Dis 2020;95:376–383. DOI: 10.1016/j.ijid.2020.04.065.
Khalil A, Kalafat E, Benlioglu C, et al. SARS-CoV-2 infection in pregnancy: a systematic review and meta-analysis of clinical features and pregnancy outcomes. EClinicalMedicine 2020;25:100446. DOI: 10.1016/j.eclinm.2020.100446.
Yin MZ, Zhang LJ, Deng GT, et al. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy in China: a retrospective cohort study. MedRxiv 2020;2. DOI: 10.1101/2020.04.07.20053744.
Dap M, Morel O. Proteinuria in Covid-19 pregnant women: preeclampsia or severe infection? Eur J Obstet Gynecol Reprod Biol 2020;252:612. DOI: 10.1016/j.ejogrb.2020.07.005.
Akhtar H, Patel C, Abuelgasim E, et al. COVID-19 (SARS-CoV-2) infection in pregnancy: a systematic review. Gynecol Obstet Invest 2020;85(4):295–306. DOI: 10.1159/000509290.
Zambrano LD, Ellington S, Strid P, et al. Update: Characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status: United States, January 22–October 3, 2020. MMWR Morb Mortal Wkly Rep 2020; 69(44):1641–1647. DOI: 10.15585/mmwr.mm6944e3.
Papapanou M, Papaioannou M, Petta A, et al. Maternal and neonatal characteristics and outcomes of covid-19 in pregnancy: an overview of systematic reviews. Int J Environ Res Public Health 2021;18(2):1–20. DOI: 10.3390/ijerph18020596.
Sun G, Zhang Y, Liao Q, et al. Blood test results of pregnant COVID-19 patients: an updated case–control study. Front Cell Infect Microbiol 2020;10:560899. DOI: 10.3389/fcimb.2020.560899.
Cho JH, Cho HJ, Lee HY, et al. Neutrophil–lymphocyte ratio in patients with acute heart failure predicts in-hospital and long-term mortality. J Clin Med 2020;9(2):557. DOI: 10.3390/jcm9020557.
Singhal K, Pal AK, Tiwari S, et al. Neutrophil lymphocyte ratio (NLR) as a bio inflammatory marker in pre-eclampsia. Int J Contemp Med Res 2019;6(4):4–6. DOI: 10.21276/ijcmr.2019.6.4.17.
Mohaupt MG. C-reactive protein and its role in preeclampsia. Hypertension 2015;65(2)285–287. DOI: 10.1161/HYPERTENSIONAHA. 114.04531.
Mangogna A, Agostinis C, Ricci G, et al. Overview of procalcitonin in pregnancy and in pre-eclampsia. Clin Exp Immunol 2019;198(1):37–46. DOI: 10.1111/cei.13311.
Furuncuoğlu Y, Tulgar S, Dogan AN, et al. How obesity affects the neutrophil/lymphocyte and platelet/lymphocyte ratio, systemic immune-inflammatory index and platelet indices: a retrospective study. Eur Rev Med Pharmacol Sci 20(7):1300–1306. PMID: 27097950.
Visser M, Bouter LM, Mcquillan GM, et al. Elevated C-reactive protein levels in overweight and obese adults. 1999; 282(22):2131–2135. DOI: 10.1001/jama.282.22.2131.
Kassas GM El, Shehata MA, Wakeel MA, et al. Role of procalcitonin as an inflammatory marker in a sample of Egyptian children with simple obesity. Open Access Maced J Med Sci 2018;6(8):1349-1353. DOI: 10.3889/oamjms.2018.323.
Hu R, Han C, Pei S, et al. Procalcitonin levels in COVID-19 patients. Int J Antimicrob Agents 2020;56(2):106051. DOI: 10.1016/j.ijantimicag. 2020.106051.
Erdogan A, Can FE, Gonullu H. Evaluation of the prognostic role of NLR, LMR, PLR, and LCR ratio in COVID-19 patients. J Med Virol 2021;93(9):5555–5559. DOI: 10.1002/jmv.27097.
Huang J, Xu Y, Wang B, et al. Risk stratification scores for hospitalization duration and disease progression in moderate and severe patients with COVID - 19. BMC Pulm Med 2021;21(1):120. DOI: 10.1186/s12890-021-01487-6.
Parasher A. COVID-19: current understanding of its pathophysiology, clinical presentation and treatment. Postgrad Med J 2021;97(1147):312–320. DOI: 10.1136/postgradmedj-2020-138577.
Orsi MA, Oliva G, Toluian T, et al. Feasibility, reproducibility, and clinical validity of a quantitative chest X-ray assessment for COVID-19. Am J Trop Med Hyg 2020;103(2):822–827. DOI: 10.4269/ajtmh.20-0535.
Baratella E, Crivelli P, Marrocchio C, et al. Severity of lung involvement on chest X-rays in SARS-coronavirus-2 infected patients as a possible tool to predict clinical progression: an observational retrospective analysis of the relationship between radiological, clinical, and laboratory data. J Bras Pneumol 2020;46(5):e20200226. DOI: 10.36416/1806-3756/e20200226.
Markowicz S, Donat S, Glaude EL, et al. Level of CRP predicts need for respiratory support in hospitalized COVID-19 patients. Research Square Platform LLC 2020;1–12. DOI: 10.21203/rs.3.rs-36429/v1.
Liu H, Liu F, Li J. Clinical and CT imaging features of the COVID-19 pneumonia: Focus on pregnant women and children. J Infect 2020;80(5):e7–e13. DOI: 10.1016/j.jinf.2020.03.007.
Wang K, Wang X, Du J, et al. Relationship between changes in the course of COVID-19 and ratio of neutrophils-to-lymphocytes and related parameters in patients with severe vs. common disease. Epidemiol Infect 2021;149:e81. DOI: 10.1017/S0950268821000674.
Xu JB, Xu C, Zhang RB, et al. Associations of procalcitonin, C-reaction protein and neutrophil-to-lymphocyte ratio with mortality in hospitalized COVID-19 patients in China. Sci Rep 2020;10(1):15058. DOI: 10.1038/s41598-020-72164-7.
Liu J, Liu Y, Xiang P, et al. Neutrophil-to-lymphocyte ratio predicts critical illness patients with 2019 coronavirus disease in the early stage. J Transl Med 2020;18(1):206. DOI: 10.1186/s12967-020- 02374-0.
Yang AP, Liu JP, Tao WQ, et al. The diagnostic and predictive role of NLR, d-NLR, and PLR in COVID-19 patients. Int Immunopharmacol 2020;84:106504. DOI: 10.1016/j.intimp.2020.106504.
Sproston NR, Ashworth JJ. Role of C-reactive protein at sites of inflammation and infection. Front Immunol 2018;9:754. DOI: 10.3389/fimmu.2018.00754.
Tang Y, Liu J, Zhang D, et al. Cytokine storm in COVID-19: the current evidence and treatment strategies. Front Immunol 2020;11:1708. doi: 10.3389/fimmu.2020.01708.
Zeng F, Huang Y, Guo Y, et al. Association of inflammatory markers with the severity of COVID-19: a meta-analysis. Int J Infect Dis 2020;96:467–474. DOI: 10.1016/j.ijid.2020.05.055.
Pereira A, Cruz–Melguizo S, Adrien M, et al. Clinical course of coronavirus disease-2019 in pregnancy. Acta Obstet Gynecol Scand 2020;99(7):839–847. DOI: 10.1111/aogs.13921.
Lombardi A, Duiella S, Piani LL, et al. Inflammatory biomarkers in pregnant women with COVID-19: a retrospective cohort study. medRxiv 2020;(Ver. 1):0–2. DOI: https://doi.org/10.1101/2020.08.27.20183624.
Tatum D, Houghton A, Stover J, et al. Neutrophil-to-lymphocyte ratio and outcomes in Louisiana COVID-19 patients. 2020;54(5):652–658. DOI: 10.1097/SHK.0000000000001585.
Krause M, Douin DJ, Tran TT, et al. Association between procalcitonin levels and duration of mechanical ventilation in COVID-19 patients. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500634/2020;15(9):e0239174. DOI: 10.1371/journal.pone.0239174.
Eke RN, Taşkın S, Acar AB, et al. An easy parameter that can predict intensive care unit admission in patients with COVID-19 in the early stage: neutrophil to lymphocyte ratio. 2021;08(01):5185–5191. DOI: 10.18535/ijmsci/v8i01.01.
Sharifpour M, Rangaraju S, Liu M, et al. C-reactive protein as a prognostic indicator in hospitalized patients with COVID-19. PLoS One, 2020;15(11):e0242400. DOI: 10.1371/journal.pone.0242400.
Tanacan A, Yazihan N, Erol SA, et al. The impact of COVID-19 infection on the cytokine profile of pregnant women: a prospective case–control study. Cytokine 2021;140:155431. DOI: 10.1016/j.cyto.2021.155431.