Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, and Routine Complete Blood Count Components in HELLP Syndrome: A Matched Case Control Study

Abstract

Background and objective: Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are new readily available inflammatory markers that have been analyzed in pregnancy-induced hypertensive disorders such as preeclampsia. Studies on the NLR/PLR ratio in hemolysis, elevated liver enzymes, low-platelet count (HELLP) syndrome are limited in the current literature. We compared NLR/PLR and other complete blood count (CBC) components between women with HELLP syndrome and women with healthy pregnancies. Methods: We conducted a retrospective matched case–control study at a tertiary care hospital in NY (USA) in the time frame between January 2016 and December 2018. The study compared pregnant women with HELLP syndrome (cases) to women with healthy pregnancies in the third trimester (controls), matched by age, body mass index (BMI), parity, and race. Patient with preeclampsia, infection, and fever were excluded. Venous blood samples were obtained as part of the routine work-up at admission for delivery, which included a CBC. The main outcomes were NLR and PLR. The secondary outcomes were hemoglobin, red cell distribution width (RDW), platelet count, mean platelet volume (MPV), neutrophils, lymphocytes. Results: There were 14 patients in each group. They were matched by age, race, BMI, and parity. NLR (5.8 vs. 3.6, p-value = 0.002) and neutrophil count (10.7 vs. 6.8, p-value = 0.001) were higher in women with HELLP compared to controls. PLR (34 vs. 130.2, p-value < 0.001) and platelet count (71 vs. 223, p-value < 0.001) were lower in the study group compared to controls. Conclusions: NLR was higher, and PLR was lower in women with HELLP syndrome. These inflammatory markers can be incorporated into the diagnostic algorithm for HELLP syndrome. Future studies are needed to evaluate their ability to predict HELLP syndrome.

Innate and Adaptive Immune Responses in HELLP Syndrome

“…In a study from Halim et al it was reported that liver tissue from HELLP patients was infiltrated with neutrophils in comparison to controls and liver tissue samples from acute fatty liver syndrome patients (35). Another study reported that neutrophils-to-lymphocyte ratio was higher in patients with HELLP syndrome majorly due to increased neutrophils in peripheral blood samples (13). This implicates that in HELLP patients, neutrophil counts are likely increased in the liver and in the peripheral circulation.…”

“…With the Mississippi Triple Class System further categorization of the disease is done based on the severity of thrombocytopenia (7,8). Although traditionally HELLP syndrome was considered to be a severe form of preeclampsia (a disorder characterized by development of hypertension and proteinuria in pregnancy), several research lines are counteracting to this notion mainly because HELLP is associated with hypertension and/or proteinuria only in 80% of the cases and shows different cytokine activation and aggravated placental vascular lesions (9)(10)(11)(12)(13)(14)(15). Furthermore, the etiopathogenesis of this syndrome is complex and still not completely understood thus, additional and more specific/sensitive laboratory criteria are needed for up-to-date HELLP screening, diagnosis and treatment.…”

Can neutrophil‐to‐lymphocyte and monocyte‐to‐lymphocyte ratios be useful markers for predicting missed abortion in the first trimester of pregnancy?

“…Recent studies have reported that routine complete blood count (CBC) components, neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR) could be used as novel markers of systemic inflammatory response in various medical conditions, including pregnancy complications, [19][20][21][22][23][24][25][26][27][28][29] cancers, 30,31 cerebral hemorrhage, 32,33 ischemic stroke, [34][35][36] major cardiac events, 37,38 sepsis and infectious pathologies 39,40 and other diseases, in which these inexpensive and readily available inflammatory markers can help to stratify patient risks and individualize treatment strategy during everyday clinical practice. In particular, increasing evidence indicates that these inflammatory markers, such as NLR, MLR and neutrophil count, may be useful in predicting the risk of developing preeclampsia and invasion of gestational trophoblastic disease, and diagnosing HELLP syndrome, gestational diabetes mellitus, intrahepatic cholestasis of pregnancy, as well as hyperemesis gravidarum.…”

“…In particular, increasing evidence indicates that these inflammatory markers, such as NLR, MLR and neutrophil count, may be useful in predicting the risk of developing preeclampsia and invasion of gestational trophoblastic disease, and diagnosing HELLP syndrome, gestational diabetes mellitus, intrahepatic cholestasis of pregnancy, as well as hyperemesis gravidarum. [19][20][21][22][23][24][25][26][27][28][29] Recently, it was found that raised NLR in early second trimester of pregnancy as predictors for development and severity of preeclampsia. 21 Wang et al also reported that NLR and MLR have better diagnostic accuracy in distinguishing preeclampsia from controls, suggesting they are effective indicators of clinical assessment, disease severity evaluation, and prognosis evaluation of preeclampsia.…”

“…21 Wang et al also reported that NLR and MLR have better diagnostic accuracy in distinguishing preeclampsia from controls, suggesting they are effective indicators of clinical assessment, disease severity evaluation, and prognosis evaluation of preeclampsia. 22 A retrospective matched case-control study reported that NLR and neutrophil count was higher, but platelet-to-lymphocyte ratio (PLR) and platelet count was lower in women with HELLP syndrome, 24 but these biomarkers in the first trimester did not predict HELLP syndrome. 25 Kan et al reported that NLR, PLR and C-reactive protein (CRP) levels in patients with hyperemesis gravidarum (<16 weeks gestation) admitted to emergency department were significantly higher than those in normal controls.…”