International Journal of Clinical Obstetrics and Gynaecology 2020; 4(4): 04-07

ISSN (P): 2522-6614

ISSN (E): 2522-6622
© Gynaecology Journal
Comparison of maternal CRP with WBC count in
www.gynaecologyjournal.com
2020; 4(4): 04-07
predicting intra-amniotic infection in premature rupture
Received: 04-05-2020 of membranes
Accepted: 06-06-2020

Dr. Parul Garg

Department of Obstetrics &
Dr. Parul Garg
Gynaecology, K.D. Medical
College, Hospital & Research DOI: https://doi.org/10.33545/gynae.2020.v4.i4a.611
Center, Mathura, Uttar Pradesh,
India Abstract
Background: To evaluate the usefulness of maternal CRP and WBC count in diagnosing intra-amniontic
infection in the preclinical stage in women with prelabor rupture of membranes.
Methods: This prospective study was conducted in the department of obstetrics & gynaecology at CSSH,
Meerut over a period of two years (2014-2016). 100 women were included in the study as subjects, of
which 50 had ruptured membranes before labor and 50 were gestational age matched controls with intact
membranes. After informed consent, maternal blood and serum for White blood cells (WBC) Count and
CRP evaluation was obtained in subjects with evident leaking of amniotic fluid vaginally and also in
subjects acting as control group. Intra-amniotic infection was confirmed by obtaining amniotic fluid
vaginally and subjecting it for aerobic and anaerobic culture.
Results: The sensitivity and specificity of maternal CRP was 83.33% and 80.76% respectively. The
sensitivity and specificity of WBC count in predicting intra-amniotic infection was 64.86% and 58.73%
respectively.
Conclusion: Present study concluded that CRP is a reliable diagnostic marker than WBC count for
predicting intra-amniotic infection in pregnancies complicated with rupture of membranes.

Keywords: C reactive protein, Preterm premature rupture of membranes, premature rupture of membranes,
white blood cell count

Introduction
Spontaneous membrane rupture that occurs before the onset of labor is termed as premature
rupture of membranes (PROM). Prelabor rupture of membranes before the 37th week of
gestation, termed preterm premature rupture of membranes (PPROM), is a common obstetric
complication which occurs in approximately 3-4.5% of all pregnancies [1]. PPROM is associated
with 30% of neonatal morbidities and mortalities in preterm delivery and remains a challenge
for the obstetrician [2, 3].
Acute inflammation of the membranes (amnion and chorion), chorioamnionitis, indicates high
risk of adverse neonatal outcomes [4-8]. Chorioamnionitis is typically the result of microbial
invasion in patients with PPROM and PROM, but can also be caused by genital mycoplasmas,
such as Ureaplasma and Mycoplasma hominis or systemic infection inspite of intact membranes
[9]
. Clinical chorioamnionitis is diagnosed in patients presenting with two or more of the
following criteria: high temperature, maternal tachycardia, fetal tachycardia, uterine tenderness,
foul smelling amniotic fluid, maternal leukocytosis with bands, and positive C reactive protein
(CRP) [10]. Maternal serum C-reactive protein (CRP) has been studied as an adjunct in the
diagnosis of subclinical infection among pregnant women with preterm labor or preterm rupture
of membranes. CRP is an acute-phase protein produced in the hepatocytes of the liver, and is
normally present as a trace constituent in the serum. A significant rise in the concentration is
seen following injury and inflammation [11]. Once released, CRP is bound to altered or necrotic
Corresponding Author: membrane structures, and its biological effects include enhancement of phagocytosis,
Dr. Parul Garg stimulation of leucocyte motility and opsonic effects, suggesting a specific role in tissue
Department of Obstetrics & regeneration and repair [12]. Possible humoral mediators are the macrophages of the endothelial
Gynaecology, K.D. Medical system, the endogene pyrogens and the prostaglandins [13]. Maximal concentrations are seen 24-
College, Hospital & Research
Center, Mathura, Uttar Pradesh,
48 h after the inducing stimulus. The half-time is 8-9. CRP is not transferred across the placenta
[14]
India . Various non-invasive markers have been studied to diagnose chorioamnionitis in the

~4~
International Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com

preclinical stage. The laboratory indicators most often used to ruptured membranes.
predict intra-amniotic infection are total leucocyte count (TLC), 2. Singleton pregnancy.
differential leucocyte count (DLC), urine culture, vaginal
culture. The present study was conducted with the aim to Exclusion criteria
compare maternal CRP and WBC count in predicting intra- 1. Pregnant women with congenital anomalies, antepartum
amniotic infection in pregnancies complicated with rupture of haemorrhage, pre-eclampsia.
membranes. 2. Pregnant women with medical disorders like diabetes,
hypertension, cardiac disease and renal disease.
Material & Methods 3. Intrauterine death
This study was conducted in department of obstetrics & 4. Clinical features of chorioamnionitis including maternal
gynaecology at Chhatrapati Shivaji Subharti Hospital, Meerut tachycardia (>100 beats/min), fetal tachycardia (>160
for a period of two years (November’ 2014-2016). After beats/min), uterine tenderness and foul smelling amniotic
obtaining informed consent, 100 women were included as fluid.
subjects in this prospective study, out of which 50 had ruptured 5. Pregnant women with multiple pregnancy.
membranes and 50 were gestational age matched controls with
intact membranes. Result
History taking, general, systemic and obstetrical examination of Socio-demographic characteristics: A total of 100 antenatal
subjects was done. Diagnosis of rupture of membranes was women were enrolled in the study. The distribution of cases into
made by gush of fluid seen coming through the cervical os on preterm premature rupture of membranes (pPROM) and
coughing on sterile per speculum examination. On admission, premature rupture of membranes (PROM) was 31 and 19
investigation like CBC & C-reactive protein levels estimation respectively. Fifty gestational age matched controls were equally
were done in both study and control group. Markers of distributed between pPROM and PROM. Out of 31, 17 cases of
intrauterine infection were maternal WBC count more than pPROM were in age group of 16-25 and 14 cases were in 26-35
15,000 cells/cu.mm with positive C-reactive protein levels. CRP years. In PROM, 8 cases belonged to 16-25 years and 11 cases
determination was done using latex agglutination method with between 26-35 years. Regarding gravid status, 9 cases in
the help of CRP reagent kit. CRP values were considered pPROM and 10 cases in PROM were primigravida and 22 out of
abnormal (positive), when the values exceeded 6 mg/l. In 31 and 9 out of 19 were multigravida in pPROM and PROM
subjects with leaking per vaginum on speculum examination, cases respectively. Rupture of membranes was more commonly
vaginally obtained amniotic fluid was sent for aerobic and found in women belonging to low socio-economic status in both
anaerobic culture to confirm presence of intraamniotic infection. pPROM and PROM group. The mean gestational age of rupture
of membranes in pPROM and PROM subjects was 33±1 weeks
Inclusion Criteria and 38±1 weeks respectively. (Table 1)
1. Pregnant women with gestational age > 28 weeks and with
Table 1: Showing distribution according to age, parity and socio-economic status.
Characteristic pPROM (31) Gestational age - matched controls (25) PROM (19) Control (25) n=100
Age in years
15-25 17 15 8 12 52
26-35 14 10 11 13 48
Gravidity
Primigravida 9 13 10 8 40
Multigravida 22 12 9 17 60
Socio-ecomonic status
Low 8 25 12 16 61
Middle 21 0 5 9 35
High 2 0 2 0 4

Table 2 shows the results of two markers of intra-amniotic had maternal WBC count > 15,000 cells/cu.mm. Only 13 in
infection. In pPROM, 26 cases were positive for maternal CRP control group had WBC count > 15,000 cells/cu.mm. 26 out of
while 14 out of 19 were positive in PROM group. Maternal CRP 50 showed growth on aerobic culture of amniotic fluid of which
was also found positive in 8 gestational age matched controls. 18 belonged to pPROM group and 8 were from PROM group.
Regarding WBC count more than 15,000 cells/cu.mm. taken as Seven subjects had streptococcus species and 3 had
cut off for intra-amniotic infection, 11 pPROM cases out of 31 acinetobacter baumanii on aerobic culture of amniotic fluid.
indicated presence of infection. Among PROM group, 13 cases

Table 2: Showing Markers of intra-amniotic infection

Marker pPROM (31) Gestational age - matched controls (25) PROM (19) Control (25) n=100
Maternal CRP
Positive 26 3 14 5 49
Negative 5 22 5 20 51
WBC count
>15,000 / cu.mm 11 8 13 5 37
≤15,000 / cu.mm 20 17 6 20 63
Amniotic fluid culture
Growth present 18 6 8 5 37
Growth absent 13 19 11 20 63

~5~
International Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com

In 31 cases of pPROM, 17 CRP positive patients had growth count > 15,000 cells/cu.mm, 7 cases had positive amniotic fluid
present in amniotic fluid culture while all 3 cases in control culture report in pPROM group while 4 were positive in control
group who were CRP positive had positive cultures. For WBC group. (Table 3)

Table 3: Amniotic fluid culture results in pPROM and controls

pPROM(31) Controls(25)
Culture(+ve) Culture(-ve) Culture(+ve) Culture(-ve)
CRP Positive 17 9 3 0
CRP Negative 1 4 3 19
WBC Count / cu.mm.
>15,000 cells 7 4 4 4
≤15,000 cells 11 9 2 15

Amniotic fluid cultures were positive in 6 CRP positive cases of fluid culture results were positive in 5 PROM patients in whom
PROM and 2 CRP negative cases of PROM. Two CRP positive WBC count > 15,000 cells/cu.mm. whereas 3 culture positive
cases also had growth in culture from control group. Amniotic patients had WBC count < 15,000 cells/cu.mm. (Table 4)

Table 4: Amniotic fluid culture results in PROM and controls

PROM (19) Controls (25)
Culture(+ve) Culture(-ve) Culture(+ve) Culture(-ve)
CRP Positive 6 8 2 3
CRP Negative 2 3 3 17
WBC Count / cu.mm.
>15,000 cells 5 8 1 4
≤15,000 cells 3 3 4 16

The sensitivity and specificity of maternal CRP was 83.33% and count in predicting intra-amniotic infection was 64.86% and
80.76% respectively. The sensitivity and specificity of WBC 58.73% respectively. (Table 5)

Table 5: Comparision of maternal CRP and WBC count in present study

Marker Sensitivity Specificity PPV* NPV*
Maternal CRP 83.33% 80.76% 80% 84%
WBC Count 64.86% 58.73% 48% 74%
*PPV - Positive predictive value
*NPV - Negative predictive value

Discussion Aggarwal A et al., wherein they concluded that CRP was the
Chorioamnionitis or intra-amniotic infection is an acute earliest and most reliable diagnostic marker of clinical as well as
inflammation of the membranes and chorion of the placenta, histological chorioamnionitis in patients with preterm premature
typically due to ascending polymicrobial bacterial infection in rupture of membranes.17 Ismail MA et al. in their study
the setting of membrane rupture. Expectant management for concluded that C-reactive protein level is a very sensitive
preterm premature rupture of membranes is now an accepted predictor of infectious morbidity in premature rupture of
modality of treatment. Nevertheless, the main clinical concern is membranes, its specificity is not high.18 In study done by Kurki
still the danger to the mother of acquiring chorioamnionitis. T et al. concluded that use of serial CRP measurements
Early detection of infection is of utmost importance during the increases the test performance and the high negative predictive
conservative management of premature rupture of membranes value suggested that CRP was useful in predicting the absence
(PROM). of chorioamnionitis [19].
In the present study, the sensitivity of maternal CRP in
predicting intra-amniotic infection in premature rupture of Conclusion
membranes was 83.33%, specificity 80.76%, positive predictive It is concluded from the present study that CRP is a reliable
value was 80% and negative predictive value was 84%. The diagnostic marker than WBC count for predicting intra-amniotic
sensitivity of WBC count in predicting intra-amniotic infection infection in pregnancies complicated with rupture of
was 64.86%, specificity 58.73%, positive predictive value 48% membranes. If CRP is found positive (>6 mg/l) on admission,
and negative predictive value was 74% with amniotic fluid pregnancy should be terminated as soon as possible to salvage
culture as the reference standard. The study is comparable to the baby as well as the mother.
study done by Saini S et al., in which sensitivity and specificity
of CRP determination was found to be 80% each as an early Acknowledgments
predictor of subclinical chorioamnionitis [15]. TLC had a low The author would like to thank all pregnant women who agreed
sensitivity of 20% and specificity of 60% in detecting to participate in this study.
subclinical chorioamnionitis. Study done by Ibarra V et al.
showed CRP as an early detector of amniotic infection with a References
sensitivity of 94.12% and a specificity of 100%, positive 1. Lee T, Silver H. Etiology and epidemiology of preterm
predictive value of 100% and a negative predictive value of premature rupture of the membranes. Clin Perinatol. 2001;
98.86% [16]. Our study also co-relates with study done by 28:721-34.

~6~
International Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com

2. Gopalani S, Krohn M, Meyn L et al.: Contemporary

management of preterm premature rupture of membranes:
determinants of latency and neonatal outcome. Am J
Perinatol. 2004; 21:183-90.
3. Garite TJ. Management of premature rupture of membranes.
Clin Perinatol. 2001; 28:837-47.
4. Ecevit A, Anuk-Ince D, Yapakci E et al.: Association of
respiratory distress syndrome and perinatal hypoxia with
histologic chorioamnionitis in preterm infants. Turk J
Pediatr. 2014; 56:56-61.
5. Dempsey E, Chen MF, Kokottis T et al. Outcome of
neonates less than 30 weeks gestation with histologic
chorioamnionitis. Am J Perinatol. 2005; 22:155-59.
6. De Felice C, Toti P, Laurini RN et al.: Early neonatal brain
injury in histologic chorioamnionitis. J Pediatr. 2001;
138:101-4.
7. Wu YW. Systematic review of chorioamnionitis and
cerebral palsy. Ment Retard Dev Disabil Res Rev. 2002;
8:25-29.
8. Nelson KB, Grether JK, Dambrosia JM et al. Neonatal
cytokines and cerebral palsy in very preterm infants. Pediatr
Res. 2003; 53:600-7.
9. Edwards RK. Chorioamnionitis and labor. Obstet Gynecol
Clin North Am. 2005; 32:287-96.
10. Gibbs RS, Blanco JD, St Clair PJ, Castaneda YS.
Quantitative bacteriology of amniotic fluid from women
with clinical intraamniotic infection at term. J Infect Dis.
1982; 145:1-8.
11. Morley JJ, Kushner I. Serum C-reactive protein levels in
disease. Ann NY Acad Sci. 1982; 389:406-17.
12. Gewurz H, Mold C, Siegel J, Fiedel B. C-reactive protein
and the acute-phase response. Year Book Medical
Publishers, 1982, 345-371.
13. Macintyre SS, Schultz D, Kushner I. Biosynthesis of C-
reactive protein. Ann NY Acad Sci. 1982; 389:76-87.
14. Shine B, Gould J, Campbell C, Hindocha P, Wilmot RP,
Wood CBS. Serum C-reactive protein in normal and
infected neonates. Clin Chim Acta. 1985; 148:97-103.
15. Saini S, God N, Sharma M, Arora B, Garg N. C-reactive
proteins as an indicator of sub-clinical infection in cases of
premature rupture of membranes. Indian J Pathol Microbiol.
2003; 46(3):515-6.
16. Ibarra CV, Sanhueza SP, Mota GM, Del RPG, Karchmer S.
CRP as early marker of chorioamnionitis in PROM (span).
Gynaecologia Y Obstetrica de Mexico. 1989; 57:203-8.
17. Aggarwal A, Pahwa S. Evaluation of the role of CRP as an
early predictor of chorioamnionitis in PPROM. Int J Reprod
Contracept Obstet Gynecol, 2018; 7:1351-6.
18. Ismail MA, Zinaman MJ, Lowensohn RI, Moawad AH. The
significance of C-Reactive protein levels in women with
premature rupture of membranes. Am J Obstet Gynecol.
1985; 151(4):541-544.
19. Kurki T, Teramo K, Ylikorkala O et al. C-reactive protein
in preterm premature rupture of the membranes. Arch
Gynecol Obstet. 1990; 247:31-37.
https://doi.org/10.1007/BF02390652

~7~