COMBINED FIRST TRIMESTER MATERNAL PLATELETS INDICES AND UTERINE ARTERY DOPPLER IN PREDICTION OF PRE-ECLAMPSIA IN PRIMIGRAVIDAE

Table 6: PLT indices in relation to PE

DISCUSSION

Many researches revealed that Doppler ultra-sonography is one of the finest prognosticators of PE. The assessment of platelet indices is simple, economical and fast technique that was suitable for monitoring and early prognostication of PE in addition to its significance in diagnosing and evaluating disorder severity. Reduction of PC with rise MPV and PDW were requested early PE markers ¹¹.

Anomalous UtA Doppler blood flowing and anomalous PI are both connected to the etiological path-ways of PE and combined might progress prognostication of  the disorder in comparison to separate usages ¹².

In this study we aimed to know if we can use the maternal platelets indices in combination with the Doppler assessment of the uterine artery as reliable screening tests to enhance the prognostication of Preeclampsia in primigravidae at the 1^st -trimester.

This prospective study was performed at the Obstetrics and Gynecology Department, Al-Hussein Hospital, Al-Azhar University on 30 pregnant women visiting antenatal clinics and/or admitted in motherhood wards.

A significant change was found among the two studied groups in regard to MPV, PDW and PCT. We found that RI and PI were significantly higher in pre-eclampsia-group than normotensive-group. Moreover, diastolic notch was significantly more frequent in preeclampsia group than normotensive-group.

A significant change was found among the study groups regarding GA only. While there’s no significant difference regarding birth mass, Apgar at 1 min and 5 min.

The UtA Doppler indices in prognostication of PE were: sensitivity 85.7%, specificity 91.3%, NPV 95.5% and PPV 75% with accuracy of 90%.

Abdel Razik et al., ¹³ reported an anomalous Doppler was exist in 80 gravid of whom 44 patients (55%) had anomalous PI whereas ordinary Doppler was exist in 190 gravid of whom 13 patients (6.8%) had anomalous PI. It showed a significant positive correlation amongst anomalous UtA Doppler and raised MPV and PDW (P- value<0.001).

Razavi et al., ¹⁴ reported that seven out of 37 women with PE had normal Doppler (7.7%) and 30 were those who had abnormal Doppler (50.8%). A significant change was found among the cases with ordinary and anomalous Doppler sonography (P- value=0.001). Chi-square testing give a non-significant variance among severity of pre- eclampsia in cases with ordinary and non- ordinary Doppler sonography (P-value=0.06). The sensitivity of Doppler ultra-sonography in detecting early, late onsets and severe pre- eclampsia was 73.3 %, 62.5 %, and 100%, respectively. The specificity of Doppler ultra- sonography in detecting early-, late-onsets and severe pre-eclampsia was 64.4%, 66.1%, and 74.3%, correspondingly.

Salem & Ammar, ¹⁵ reported that the mean PI of the uterine artery at 11–13-wks’ pregnancy revealed a high significant change among pre-eclamptic (2.4 ± 0.2) and ordinary controls (1.4 ± 0.4). The optimum cutoff value of PI from the ROC curve was ≥1.69, gave sensitivity of 100%, specificity of 70%, PPV of 27%, NPV of 100% and an accuracy of 73%. The PLT indices in prediction of PE sensitivity were 57.14%, specificity was 91.3%, NPV was 87.5% and PPV was 66.67% with accuracy of 83.3%.

Nooh & Abdeldayem, ¹⁶ showed comparing among variations in PC, MPV and PDW in the 3 studied groups. Excepting a few cases in the group of PE with severe characteristics who developed thrombocytopenia, contributors in all groups had an ordinary PC, but it revealed nonstop reduction over the course of gestation between 24 and 28-wks pregnancy forward. This alteration was more noticeable in PE with no severe characteristics than normotensive gestation and in PE with severe characteristics than PE with no severe characteristics (p = 0.00). Variations in PI were prognostic of PE developments with onset of PE diagnosing at 30 and 32-wks pregnancy. As these variations in cases with PE preceded development of disease by 2 to 8-wks, In comparison to baseline values, MPV and PDW in contributors in studied groups revealed unceasing rise over the gestation course between 24 and 28-wks pregnancy forwards. This alteration was more noticeable in PE with no severe characteristics than normotensive gestation and in PE with severe characteristics than PE with no severe characteristics (p-value = 0.00).

Nooh & Abdeldayem, ¹⁶ reported that ROC curve analysis of variations of PDW value at 24 and 28-wks pregnancy give a PDW> 19.9 as optimum cutoff for the prognostication of PE development. This cut-off level had an AUC of 0.980 (95% CI: 0.964 - 1.000), a sensitivity of 96.3% and a specificity of 91.3% for prognostication of PE progress. Women with PDW > 19.9 at 24 and 28-wks pregnancy were more than 13-fold at risk of PE progress (RR: 13.36; 95% CI: 3.5 - 50.96).

As well, in females with PE, PDW was found to have a positive association with MAP, and PDW rise was proportional to the rise in MAP (r = −0.902; p-value = 0.000); making PDW the finest possible biomarker for predicting severity of high blood pressure. However, Yang et al., ¹⁷ recognized a PDW value of >13.5 as the optimum cutoff level for the prognostication of PE severity. They found that this value had an AUC of 0.74, a sensitivity of 72% and a specificity of 71%. As well, they concluded that only PDW had a significant association with MAP (r = 0.231, p-value = 0.011) and, consequently, they reported that PDW was the best PE biomarker.

Similarly, Freitas et al., ¹⁸ found a PDW value of >18.3 as the best cutoff level for the predicting PE. They found that this value has an AUC of 0.77 (95% CI: 0.66 - 0.85), a sensitivity of 55.17% and a specificity of 86.21%. As well, they concluded that only PDW had a significant association with MAP (r = 0.231, p = 0.011).

The combined uterine artery Doppler study and PLT indices in prognostication of PE were sensitivity 85.7%, specificity 100%, NPV 95.8% and PPV 100% with accuracy of 96.7%.

Abdel Razik et al., ¹³ showed that in accordance to the findings of Doppler US and PI gravid were separated into 4 groups: GI: anomalous Doppler + anomalous indices; GII: anomalous Doppler + ordinary indices; GIII: ordinary Doppler + anomalous indices and GIV: ordinary Doppler + ordinary indices (controls). It revealed that cases in GI (anomalous Doppler + anomalous indices) have significant high occurrence of severe PE (p-value < 0.001). In contrast, an ordinary Doppler study in most patients indicates normal gestation if accompanying with anomalous platelet (GIII, 84.6%) or ordinary platelet (GIV, 98.9%).

In Jain et al., ¹⁹ cases with PE were more expected to have significant reduction in platelets count, rise in PDW and MPV and that these variations could be detected at an early pregnancy age than significant increase in BP could be detected. They reported that approximation of PI could be taken in to consideration as an early, easy and economical method in the prognostication and evaluation of PE severity.

In Nooh & Abdeldayem, ¹⁶ the PC was lessening whereas MPV and PDW were growing as PE developed and these variations precede progress of PE by 2 – 8-wks making it the optimum biomarker for JUST ACCEPTED detecting PE.

Freitas et al., ¹⁸ aim was to study whether PC, MPV, PDW and plateletcrit (PCT) can expect sever form of PE. They studied the ROC curve for each variable and revealed that the parameters have steady diagnosing significance, excepting PCT that was regarded as bad for this aim.

Yang et al., ¹⁷ revealed that in the ROC curve analysis, the AUC of the PDW to expect severe PE was 0.74. Whereas Doğan et al., ¹² proposed that the growing platelet turnover in PE reasons a reduction in the PC, a rise of MPV values and particularly a reduction in PC/MPV ratio pointing that these features can has a significant function in expecting the risk of PE while they have no function on prediction of the PE severity.

AlSheeha et al., ²⁰ utilized the ROC curve to find validity of platelets indices in PE prediction and revealed that PC <248.010x10³/𝜇L and and PC to MPV ratio 31.2 are valid prognosticators of PE.

CONCLUSION

In our study we figured out that the maternal platelets indices in combination with the Doppler assessment of the UtA as reliable screening tests to enhance the prognostication of PE in primigravidae at the 1^st -trimester.