Evaluation of the Fibrinogen/CRP Ratio as A Diagnostic test for Disseminated Intravascular Coagulation in Patients with HELLP Syndrome

Abstract

Every woman wishes to have a healthy pregnancy which culminates in ahealthy baby and a healthy mother. Unfortunately, some women develop dreadedcomplications that may result in adverse obstetric outcomes. These includehypertensive disorders of pregnancy, pre-eclampsia, eclampsia and HELLPsyndrome. Disseminated intravascular coagulation (DIC) is characterized by the widespread activation of the coagulation process, which results in the intravascular fibrin formation.The International Society of Thrombosis and Haemostasis (ISTH) Subcommittee on DIC have proposed laboratory criteria for overt DIC. These laboratory criteria for calculating the overt DIC score included a platelet count, a fibrin-related marker, prothrombin time (PT), and fibrinogen. A recent study showed that the DIC scoring system was sufficiently accurate to make or reject a diagnosis of DIC (Taylor et al., 2001).

The central pathophysiological trigger of DIC in severe eclampsia and the HELLP syndrome is probably the endothelial damage induced by cytokines produced by activated placental leukocytes and macrophages, accompanied by microangiopathic hemolytic anemia (MHA) as well as platelet adhesion and activation facilitating fibrin formation and deposition(Kramer et al.,2002).

Most studies in pre-eclampsia have shown increased levels of FDPs in serum and urine. Plasma levels of soluble fibrinogen±fibrin complexes are also raised in pre- eclampsia compared with normal pregnancies. Fibrinogen is correlated positively and significantly with the severity of disease in preeclampsia(Bick RL, 2000). C-reactive proteins levels in normal pregnancies appear to be higher than standardized values for non pregnant individuals and CRP values are further elevated in Labour.Evidence of a possible exaggerated inflammatory response in preeclampsia especially in severe preeclampsia was confirmed by study which evaluates serum procalcitonin, CRP levels in mild and severe preeclampsia, showed that higher CRP found to be risk factor significantly associated with preeclampsia(Kucukgoz et al., 2012). Even though hypofibrinogenemia is believed to reflect the consumption of coagulation factor during intravascularfibrin formation, most of the DIC patients have not shown decreased levels of fibrinogen. Fibrinogen is considered to be an acute phase reactant, and it is almost always elevated in the patients with infection and/or inflammation. Because low plasma fibrinogen levels were seen in 5.4% of DIC patients, it was hypothesized that the exclusion of all the fibrinogen levels from the calculation of the ISTH DIC score would not affect the accuracy of the scoring system(Bakhtiari K et al., 2004). If the plasma level of fibrinogen is adjusted for acute phase response, the fibrinogen can be used as a useful marker of DIC. A ratio of fibrinogen to the other acute phase reactants such as C-reactive protein (CRP) can be applied as one of the laboratory markers for the DIC score. Kim et al succeeded in demonstrating that this new fibrinogen/C-reactive protein (CRP) ratio is able to improve the sensitivity of the DIC score for identifying those patients with active coagulation factor consumption in 1056 patients with underlyind disorders.Thus; Kim et al suggested replacing the parameter fibrinogen by their new fibrinogen/CRP ratio to gain both, more diagnostic and prognostic power for DIC(Kim et al., 2007).