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Overview

The field of obstetrics and gynecology focuses on the etiology, pathology, diagnosis and treatment of female genital disease. It also looks at the physiological and potential pathological changes in pregnancy and childbirth, especially the prevention and treatment of high risk pregnancy and dystocia. Due to the anatomical, biochemical and physiological changes in pregnancy and post-partum, obstetric patients are more prone to serious infections. Clinical complications are also more serious and the patient’s condition is more volatile. For example, multiple organ dysfunction and maternal sepsis are one of the leading causes of mortality in obstetrics. Pre-eclampsia is a disease unique to pregnancy. It is mainly characterized by high blood pressure, oedema and proteinuria. In severe cases, convulsions (in which case it becomes eclampsia) can occur leading to coma, with heart and kidney failure to follow. It is one of the four main causes of maternal mortality. Incidence rates are around 9.4-10.4%, maternal mortality rate of 46.9 per 100,000 and perinatal mortality rates of 16.6%.

1. Risk

Due to its anatomy and physiology, female genitalia are more prone to bacterial infections. The bacteria can spread through blood. The resulting inflammation can spread to adjacent organs, such as the ovaries via the fallopian tubes. Pre-eclampsia is commonly associated with genetics, immunocompromised, placental ischemia and oxidative stress. Pregnant women are also more prone to increased thrombus formation due to decreased levels of anticoagulants, decreased fibrinolysis and increase in the level of clotting factors.

2. Clinical manifestations

Gynecological inflammation usually manifests as dysuria, increased urgency and frequency, genital itching, redness, vaginal papules, increased vaginal discharge with or without blood/fou odor, backache, abdominal pain and anxiety.
Patients with pre-eclampsia present with elevated blood pressure, eclampsia, proteinuria and systemic oedema.
Note: Serious clinical symptoms – Hypercoagulability during pregnancy can lead to thrombosis, such as heart failure, renal failure, pulmonary embolism and other critical clinical manifestations

Investigations and diagnosis

ReLIA’s Biomarker Guide

1. Procalcitonin (PCT)

Procalcitonin is a biomarker for identifying bacterial infections and other inflammatory response states; determining the severity and prognosis of the disease and monitoring the effectiveness of antibiotics. Note that if procalcitonin levels continue increasing or maintain a high level, prognosis is poor.

2. C-Reactive Protein (CRP)

C-reactive protein is a protein and inflammatory marker that increases sharply in infection or tissue damage. It is helpful in the investigation of infection in gynecological patients. However, CRP levels remain essentially unchanged in most viral infections.

3. D-Dimer

D-dimer is a fibrin degradation product present after fibrinolysis. It is therefore an indicator for determining thrombosis and secondary fibrinolysis. Changes in D-dimer levels are markers for hypercoagulability. The use of D-dimer levels in this field is to focus on eliminating differential thrombotic diseases such as deep vein thrombosis (DVT) and pulmonary embolism (PE). The use of D-dimer levels should be done in conjunction with clinical assessment to maximize its relevance. In general, the higher the results, the greater the risk. If so, further investigations such as compressed ultrasound image, CT or venography are recommended.

4. N terminal – pro-brain natriuretic peptide

NT-proBNP is recognized as a good biochemical marker that reflects cardiac function. It can be used to diagnose symptomatic heart failure, estimate the prognosis of patients with heart failure and acute coronary syndrome and to monitor treatment. NT-proBNP levels is related to the grading of cardiac function (New York Heart Association) and the left ventricular ejection fraction (LVEF). The more severe the classification of cardiac function, the lower the LVEF, the higher the levels of NT-proBNP will be.

5. Neutrophil gelatinase-associated lipocalin (NGAL)

NGAL levels in blood and urine would increase rapidly in acute kidney injury (AKI), especially from causes such as postoperative cardiac surgery, kidney transplantation, renal ischemia and nephrotoxicity. Levels peak in 2 hours following injury whilst other traditional indicators such as serum creatinine and urine enzymes increase after 24-72 hours. Therefore, NGAL levels is a strong and early predictor of AKI. Note its reference value to be below 150 ng/mL. Note that urinary levels of NGAL have a higher sensitivity/specificity than serum NGAL for AKI.