|Year : 2020 | Volume
| Issue : 1 | Page : 16-20
Biomarkers for prediction of preterm delivery: A hospital-based study
Archana Dhok1, Ranjit Ambad2, Minal Kalambe3, Mrunal Nakade4
1 Department of Biochemistry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
2 Biochemistry, Datta Meghe Medical College, SMHRC (Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
3 Biochemistry; Department of OBGY, Datta Meghe Medical College, SMHRC (Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
4 Department of OBGY, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Submission||03-Feb-2020|
|Date of Decision||10-Feb-2020|
|Date of Acceptance||25-Feb-2020|
|Date of Web Publication||13-Oct-2020|
Dr. Ranjit Ambad
Department of Biochemistry, DMMC and SMHRC, Nagpur - 441 110, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Preterm delivery (PTD) is a significant determinant of morbidity and neonatal mortality. Preterm babies are prone to severe neonatal illness or death. PTD is one of the unresolved problems in clinical obstetrics and one of the greatest threats to the developing fetus; predictive biomarker needs to be identified for premature delivery. Therefore, the aim of this study was to assess the serum levels of hemoglobin, iron, alkaline ferritin phosphatase and ceruloplasmin in preterm and full-term delivery. Materials and Methods: The present study includes total 60 participants that comprise thirty women presenting with preterm onset of labor followed by delivery and thirty women who delivered at term served as controls. Blood samples from the patients were obtained for Iron, Ferritin, alkaline phosphatase and ceruloplasmin estimation, when patient was in labor. Results: Serum alkaline phosphatase levels were significantly increased (P ≤ 0.05) in PTD as compared to full-term delivery. Serum ceruloplasmin levels were significantly increased in PTD as compare to the full-term delivery (P ≤ 0.05). Serum ferritin levels were significantly increased (P < 0.001) in PTD as compared to full-term delivery. Serum iron levels were nonsignificantly increased in PTD as compare to the full-term delivery.(P ≤ 0.05). Conclusion: Significant rise in serum ceruloplasmin, ferritin and alkaline phosphatase in PTD as compared to full-term delivery indicate that these biomarkers can be used as predictive biomarker for PTD. Moreover, these parameters are cost effective, simple to perform and less time-consuming and indicative of subclinical infections of pregnancy which could be one of the reasons for PTD.
Keywords: neonatal mortality, preterm delivery (PTD), serum ceruloplasmin levels
|How to cite this article:|
Dhok A, Ambad R, Kalambe M, Nakade M. Biomarkers for prediction of preterm delivery: A hospital-based study. J Datta Meghe Inst Med Sci Univ 2020;15:16-20
|How to cite this URL:|
Dhok A, Ambad R, Kalambe M, Nakade M. Biomarkers for prediction of preterm delivery: A hospital-based study. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 17];15:16-20. Available from: http://www.journaldmims.com/text.asp?2020/15/1/16/297985
| Introduction|| |
Preterm birth is generally described as any birth before 37 weeks of gestation have ended. An estimated 15 million infants are born preterm globally, impacting the low- and middle-income countries overwhelmingly. A term birth has been described as between 37 and 42 weeks and used to describe the optimum timing for the mother and baby to get a good outcome. The international classification of diseases describes term pregnancy as a delivery of <42 completed weeks (259–293 days) of gestation from 37 completed weeks. Neonatal outcomes, however, vary within this wide gestational age range, with a 2012 international stakeholder working group recommending subcategorization of term birth to describe deliveries and their outcomes more accurately. Preterm birth is a major cause of death, and a major cause of long-term loss of the human potential of survivors throughout the world. Premature birth defects are the single largest direct cause of neonatal mortality, responsible for 35 percent of the world's 3.1 million deaths a year. Severely premature babies born before 28 weeks of pregnancy are assumed. The earlier an infant is born, the less likely it is to survive. Those who survive sometimes face severe, often long-term, health problems, and disabilities. Gestational age is the “age” of pregnancy, and is often counted in weeks and days.
About 45%–50% of premature births are idiopathic, 30% are linked to premature membrane rupture (PROM) and another 15%–20% are due to medically suggested or elective premature delivery. The risk factors associated with premature delivery consist of an earlier history of Premature Spontaneous Labor (PSL), cervical instability, infection, antepartum hemorrhage, and multifunctional care. However, more than 50% of women who have no known risk factors will have PTL and deliver prematurely afterwards.
Ceruloplasmine, an acute-phase serum protein, has been reported to increase in PROM cases, and during inflammation, ceruloplasmine is aα-2, copper carrying globulin synthesized in liver microsomes and has feroxidase activity. In serum, it acts as an antioxidant by oxidizing ferrous iron that could otherwise act as a catalyst in the production of toxic-free radicals.
Alkaline phosphates (ALP) are a group of isoenzymes produced by the liver (isoenzymes ALP1-1), bones (isoenzymes ALP2), kidneys, small intestine and placenta (isoenzymes ALP-3). Placenta ALP is physiologically produced by placenta at the brush border membranes of the syncytiotrophoblast, and its' major function is thought to aid in metabolism and facilitate transport across cell membranes. It appears in maternal serum between the 15th and 26th weeks and increases during the third trimester.
Ferritin, an intracellular iron storage protein, has been studied as a marker for the prediction of preterm labor. Ferritin is an acute-phase reactant and it increases during inflammation.
The requirement for iron is greater in rapidly growing and differentiating cells. Low iron status had been associated with increased risk of preterm and low birth weight. Iron deficiency is suggested to lead changes in stress hormones such as nor epinephrine, cortisol and corticotrophin-releasing hormone concentrations, and indexes of oxidative stress that may adversely affect gestation, fetal growth or both. Iron prophylaxis during pregnancy should be recommended as a general prophylaxis given to all women in developing countries with sparse health resources. Prophylaxis of general iron means that it is recommended that all pregnant women take iron supplements regardless of their iron status. Individual prophylaxis indicates the adjustment of iron supplements to the iron status of the woman.
There are several risk factors for preterm delivery (PTD) have been identified; the ability to specifically predict when labor will occur remains indefinable. The detection of novel biomarkers that could identify women who will consequently deliver preterm may allow for timely medical intervention and targeted therapeutic treatments aimed at improving maternal and fetal outcomes.
Most of the predictive biomarkers suggested for PTD need methods such as high-performance liquid chromatography, chemiluminescence, enzyme-linked immunosorbent assay, and immunoturbidometry. They are expensive and time-consuming. However, the estimation of serum ceruloplasmin, alkaline phosphatase, iron, and ferritin is the most affordable and widely available biomarkers. Therefore, the present study aimed to assess the levels of ceruloplasmin, alkaline phosphatase, iron, and ferritin in full-term delivery and PTD.
| Materials and Methods|| |
The present study was prospective study, carried out in the Department of Biochemistry and Department of Obstetrics and Gynecology at Datta Meghe Medical College, SMHRC, Nagpur in collaboration with Jawaharlal Nehru medical College (Datta Meghe Institute of Medical Sciences, Wardha). Ethical clearance was obtained for the present study. The participants for the present study were enrolled from the department of OBGY. The present study includes total 80 participants (women with regular prenatal care) ranging age 18–40 years, which were divided into two groups: Control Group-40 women with full term delivery Study Group-40 women with PTD (women presenting with preterm onset of labor followed by delivery (regular, uterine contractions resulting in progressive cervical effacement, and dilatation). Written consent has been taken from women with preterm and full-term delivery.
Five milliliter of venous blood sample in plain vial was collected from the patients when patient was in labor, before the administration of any medications. Serum was separated and used for the estimation of alkaline phosphatase and ceruloplasmin. The inclusion criteria for PTD were the pregnant women with <37 weeks of gestation. The inclusion criteria for full-term delivery were the pregnant women with 38–42 weeks of gestation. Pregnant women having maternal uterine anomalies, multi-fetal gestation, cervical cerclage, lethal fetal anomalies, preeclampsia, multiple pregnancies, and diabetes mellitus were excluded from the study.
- Serum ceruloplasmin was estimated by Herbert A Ravin and Revinet al. method
- Serum alkaline phosphatase was estimated by Kinetic p-NPP method
- Serum Iron was estimated by coral clinical kit method
- Serum ferritin was performed by electrochemiluminescence method.
| Observations and Results|| |
The result indicates that the mean levels of ceruloplasmin were significantly increased in the study group as compared to control group (P < 0.001). Mean levels of alkaline phosphatase were significantly increased in study group as compared to control group (P < 0.001). The result indicates that the mean levels of ferritin were significantly increased (P < 0.001) in the study group as compared to the control group. The result also indicates that iron levels were increased but not statistically significant in the study group as compared to the control group (P > 0.05).
| Discussion|| |
Premature birth is a major cause of death and a major cause of long-term loss of survivors' human potential worldwide. Premature birth complications are the single largest direct cause of neonatal deaths, responsible for 35% of the 3.1 million deaths a year in the world. Premature birth is the leading cause of child death in almost all the world's high- and middle-income countries. Being born premature also increases the risk of a baby dying due to other causes, particularly from premature birth infections estimated to be a risk factor in at least 50% of all neonatal deaths. More than one in ten of the world's babies in 2010 were born prematurely, resulting in an estimated 14.9 million premature births as a result, more than one million died as a direct result of their premature birth.
In this study, there was no significant difference between the two groups in the iron level. There was a statistically significant difference between two groups as regarding serum ceruloplasmin, alkaline phosphatase, and ferritin level. Our results showed that a marked correlation of elevated ceruloplasmin, alkaline phosphatase, and ferritin levels in women's with PTD was observed when compared to women without PTD.
Ogino et al. showed that ceruloplasmin in cervicovaginal secretions was significantly higher in PROM cases (P < 0.001) than non PROM cases and concluded that active ceruloplasmin in the cervicovaginal secretion might be a reliable clinical marker for term PROM. Kondhalkar et al. serum ceruloplasmin levels were significantly increased (P < 0.001) in PTD as compared to full-term delivery. Bhatia et al. found the higher ceruloplasmin level in the group who delivered before 34 weeks as compare to the group who delivered after 34 weeks.
We found high mean levels of ceruloplasmin in PTD as compared to full-term delivery may be due to subclinical infection generated oxidative stress and inflammatory pathology. Ceruloplasmin increased as an antioxidant defense mechanism against oxidative stress.
In the present study, we found alkaline phosphatase was significantly increased in preterm (study group) as compared to the full term (control) P < 0.001 [Table 1].
|Table 1: Comparison of mean levels of ceruloplasmin, alkaline phosphatase, iron, and ferritin in the control group and study group|
Click here to view
Our results are concurrent with Kondhalkar et al. and showed that alkaline phosphatase levels are significantly increased in PTD (P < 0.001) as compared to full-term delivery. Tripathi et al. demonstrated that the significant correlation between PTD and serum ALP levels at 24–28 weeks was observed (≤ 0.009). Moawad et al. reported association of alkaline phosphatase and alpha-fetoprotein levels with preterm birth. When alkaline phosphatase levels at 24 weeks were studied, the odds ratio for spontaneous PTD at <32 weeks was 6.8 and at <35 weeks was 5.1 they observed a significant elevation in ALP in pregnancies that ended in spontaneous preterm birth. Huras et al. were found that significantly higher levels ALP (above 300 IU/L) in patients from the study group with PTD compared to the control group women without PTD. Goldenberg et al. demonstrated that a high ALP level was associated with three fold increased risk for PTD.
The elevated ALP level in pregnancy is due to increase in number of cells synthesizing it. However, it is increased even more in PTD because of increased wear and tear of placental cells. It also gives an idea that there must have been some injury to the placenta due to hypoxia leading to infarction of the placenta and therefore increases in the level of alkaline phosphatase in the maternal serum.
We found a high level of alkaline phosphatase in preterm women's as compared to term women's due to the mild chronic subclinical infection which may be responsible for the markedly raised ALP level in PTD.
In the present study, we found the mean levels of ferritin were significantly increased in PTD (study group) as compared to the full-term delivery (control) (P < 0.001) [Table 1].
Our study is concurrent with a study of Tamura et al. reported that women with higher serum ferritin concentrations, compared with those women with lower concentrations experienced an almost threefold increased risk of delivering preterm. Movahedi et al. showed that, on 222 singleton pregnancies, 69 (31.1%) had PTD and 153 (68.9%) had term delivery). Women who delivered before 37 weeks had a higher mean serum ferritin concentration than those who delivered after 37 weeks of gestation (26.7 ± 5.5 ng/ml vs. 19.8 ± 3.6 ng/ml, (P < 0.001).
In pregnancy, there is change in vaginal pH which may result in vain cervical infection. This follows bacterial colonization and macrophage infiltration at the chorionic deciduas interface and ferritin is produced as part of acute-phase response. Brails ford proposed that the increased extracellular ferritin has an important role in host defence against bacteremia by stimulating oxidative metabolism. Thus, the high serum ferritin level in the study group is most likely a part of acute-phase reaction to a subclinical infection and not due to iron overload.
We found significantly high levels of ferritin in PTD as compared to full-term delivery might be due to subclinical infections. Ferritin is formed as a part of an acute-phase response and involved in the host defense mechanism.
In the present study, we found that the mean levels of iron were nonsignificantly increased in preterm (study group) as compared to the full term (control) (P > 0.05) [Table 1].
Our study is concurrent with a study of Allen and reported that there was no evidence to support a relationship between iron deficiency as cause of premature birth and low birth weight. Tripathi et al. showed that serum iron levels were less in women who delivered preterm as compared to the women who delivered at term, but the difference was not statistically significant (p≥ 0.053). Further, they reported that in developing countries such as India, the etiology of PTD might be more related to nutrition and specifically deficiency of micronutrients like iron. Kaneshige demonstrated that, the serum iron levels were higher in the study group (PROM) as compared to the control group (third trimester), although the difference was not statistically significant. The lack of statistical significance may be due to the wide range in serum iron levels. However, this mild increase in study groups could be due to a covert process of infection, which is known to raise serum iron as a result of tissue damage.
We found no statistical difference of iron in PTD as compared to full-term delivery may be due to the wide range in serum iron levels and day to day variations in serum iron. Serum iron values in an individual can vary within a single day or from day to day. However, this nonsignificant rise in study groups might be due to idiopathic infection, which leads to tissue damage and that could lead to slight increase in iron level.
| Conclusion|| |
The findings from this study have shown that the assessment of concentrations of ceruloplasmine, alkaline phosphatase, and ferritin can be used as appropriate markers to predict the risk of premature delivery. In addition, these parameters are cost-effective, simple to perform, and less time-consuming and indicative of subclinical pregnancy infections which could be one of the reasons for premature delivery. On the other hand, as its pilot study, our study has certain limitations that include the smaller sample size of preterm cases and controls. Since premature labor is multifactorial, various factors may have been uncounted. To order to overcome the drawbacks, a greater sample size study from early pregnancy is recommended at regular intervals.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Quinn JA, Munoz FM, Gonik B, Frau L, Cutland C, Mallett-Moore T, et al
. Preterm birth: Case definition & guidelines for data collection, analysis, and presentation of immunisation safety data. Vaccine 2016;34:6047-56.
World Health Organization. ICD-10: International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. World Health Organization; 2010.
van Zijl MD, Koullali B, Mol BW, Pajkrt E, Oudijk MA. Prevention of preterm delivery: Current challenges and future prospects. Int J Womens Health 2016;8:633-45.
Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard Score, expanded to include extremely premature infants. J Pediatr 1991;119:417-23.
Howson CP, Kinney MV, Lawn J. Born Too Soon: The Global Action Report on Preterm Birth. March of Dimes, PMNCH, Save the Children, WHO; 2012.
Conde-Agudelo A, Papageorghiou AT, Kennedy SH, Villar J. Novel biomarkers for the prediction of the spontaneous preterm birth phenotype: A systematic review and meta-analysis. BJOG 2011;118:1042-54.
Rathore S, Gupta A, Singh B, Rathore R. Comparative study of trace elements and serum ceruloplasmin level in normal and pre-eclamptic pregnancies with their cord. Blood Biomed Res 2011;22:209-12.
Ramsey PS, Tamura T, Goldenberg RL, Mercer BM, Iams JD, Meis PJ, et al
. The preterm prediction study: Elevated cervical ferritin levels at 22 to 24 weeks of gestation are associated with spontaneous preterm delivery in asymptomatic women. Am J Obstet Gynecol 2002;186:458-63.
American College of Obstetricians and Gynecologists, Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin no. 127: Management of preterm labor. Obstet Gynecol 2012;119:1308-17.
Milman N. Oral Iron prophylaxis in pregnancy: Not too little and not too much. Journal of Prgnancy; 2012;90:369-77.
Rosas JP, Regil LM, Dowswell T, Viteri FE. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev. 2012;11:1-14.
Sukrat B, Wilasrusmee C, Siribumrungwong B, McEvoy M, Okascharoen C, Attia J, Thakkinstian A, et al
. Hemoglobin concentration and pregnancy outcomes: A systematic review and meta-analysis. BioMed Res Int 2013;38:1-9.
Ozgu-Erdinc AS, Cavkaytar S, Aktulay A, Buyukkagnici U, Erkaya S, Danisman N. Mid-trimester maternal serum and amniotic fluid biomarkers for the prediction of preterm delivery and intrauterine growth retardation. J Obstet Gynaecol Res 2014;40:1540-6.
Ravin HA. An improved colorimetric enzymatic assay of ceruloplasmin. J Lab Clin Med 1961;58:161-8.
Norbert W. Tietz, ed. Carol A, Bell Md. Clinical Guide to Laboratory Tests. 3rd
ed.. W.B. Saunders, Co., Philadelphia: AACC; 1995. p. 22-3.
Siedel J, Wahlefeld AW, Ziegenhorn J. A new iron ferrozine reagent without deproteinization. Clin. Chem., 1984;30:975.
Laboratory Procedure Manual, NHANES 2015-2016, Nutritional Biomarkers Branch Division of Laboratory Sciences National Center for Environmental Health; 2017.
Zijl V, Koullali B, Mo B, Pajkrt E, Oudijk M. Prevention of preterm delivery: Current challenges and future prospects. Int J Women's Health 2016;8:633-45.
Mazaki-Tovi S, Romero R, Kusanovic J, Erez O, Pineles L, Gotsch T, et al
. Recurrent Preterm Birth semin perinanol. Recurrent Preterm Birth 2007;31:142-58.
Ogino M, Hiyamuta S, Takatsuji-Okawa M, Tomooka Y, Minoura S. Establishment of a prediction method for premature rupture of membranes in term pregnancy using active ceruloplasmin in cervicovaginal secretion as a clinical marker. J Obstet Gynaecol Res 2005;31:421-6.
Kondhalkar A, More K, Kumar S. Ceruloplasmin and alkaline phosphatase levels in preterm delivery. Int J Biochem Res Rev 2019;28:1-6.
Bhatia K, Mukherjee B, Ambade VN. Serum ceruloplasmin in predicting preterm labour. Int J Contemp Med Res 2016;3:3320-3.
Tripathi R, Tyagi S, Singh N, Mala YM, Singh C, Bhalla P, et al
. Can preterm labour be predicted in low risk pregnancies? Role of clinical, sonographic, and biochemical markers. J Pregnancy 2014;2014:623269.
Moawad AH, Goldenberg RL, Mercer B, Meis PJ, Iams JD, Das A, et al
. The preterm prediction study: The value of serum alkaline phosphatase, alphafeto-protein, plasma corticotropin-releasing hormone, and other serum markers for the prediction of spontaneous preterm birth. Am J Obstet Gynecol 2002;186:990-6.
Huras H, Ossowski P, Jach R, Reron A. Usefulness of marking alkaline phosphatase and C-reactive protein in monitoring the risk of preterm delivery. Med Sci Monit 2011;17:657.
Goldenberg RL, Iams JD, Mercer BM, Meis PJ, Moawad A, Das A, et al
. The preterm prediction study: Toward a multiple-marker test for spontaneous preterm birth. Am J Obstet Gynecol 2001;185:643-51.
Hurmale AK, Deshwali SK, Singh J. Study of serum iron, serum zinc and serum alkaline phosphatase in premature delivery. Int J Med Sci Educ 2019;6:26-30.
Tamura T, Goldenberg RL, Johnston KE, Cliver SP, Hickey CA. Serum ferritin: A predictor of early spontaneous preterm delivery. Obstet Gynecol 1996;87:360-5.
Movahedi M, Saiedi M, Gharipour M, Aghadavoudi O. Diagnostic performance of descriminative value of the serum ferritin level for predicting preterm labour. J Res Med Sci 2012;17:164-6.
Valappil SA, Varkey M, Areeckal B, Thankan K, Siva MD. Serum ferritin as a marker for preterm premature rupture of membranes –A study from a tertiary centre in central Kerala. J Clin Diagnostic Res 2015;9:09-12.
Allen LH. Biological mechanisms that might underlie Iron's effects on fetal growth and preterm birth. J Nutrit 2001;131:581S-9.
Kaneshige E. Serum ferritin as an assessment of iron stores and other hematologic parameters during pregnancy. Obstet Gynecol 1981;57:238-42.
Gaikwad KB, Joshi NG, Selkar SP. Study of Nitrosative Stress in Pregnancy Induced Hypertension. J Clin Diagn Res 2017;11:BC06–8. Available from: https://doi.org/10.7860/JCDR/2017/23960.9396
. [Last accessed on 2020 Jun 12].