[Protein C, protein S and antithrombin III at normal delivery and during abruptio placentae]

Protein C, Protein S and Antithrombin III were screened in one hundred patients admitted for abruptio placentae and one hundred women who delivered normally in Dakar university hospital. We found a reduction of Protein S at normal delivery which is linked to hypercoagulation activity during this process. PC and PS were significantly decreased during abruptio placentae in relation with the disseminated intravascular coagulation which was found in our study. We recommend to include these tests to explore aetiologies of abruptio placentae and to confirm their congenital deficit two months after delivery.

Plasma total homocysteine, pregnancy complications, and adverse pregnancy outcomes: the Hordaland Homocysteine study

BACKGROUND

Total homocysteine (tHcy) measured in serum or plasma is a marker of folate status and a risk factor for cardiovascular disease.

OBJECTIVE

Our objective was to investigate associations between tHcy and complications and adverse outcomes of pregnancy.

DESIGN

Plasma tHcy values measured in 1992-1993 in 5883 women aged 40-42 y were compared with outcomes and complications of 14492 pregnancies in the same women that were reported to the Medical Birth Registry of Norway from 1967 to 1996.

RESULTS

When we compared the upper with the lower quartile of plasma tHcy, the adjusted risk for preeclampsia was 32% higher [odds ratio (OR): 1. 32; 95% CI: 0.98, 1.77; P for trend = 0.02], that for prematurity was 38% higher (OR: 1.38; 95% CI: 1.09, 1.75; P for trend = 0.005), and that for very low birth weight was 101% higher (OR: 2.01; 95% CI: 1.23, 3.27; P for trend = 0.003). These associations were stronger during the years closest to the tHcy determination (1980-1996), when there was also a significant relation between tHcy concentration and stillbirth (OR: 2.03; 95% CI: 0.98, 4.21; P for trend = 0.02). Neural tube defects and clubfoot had significant associations with plasma tHcy. Placental abruption had no relation with tHcy quartile, but the adjusted OR when tHcy concentrations >15 micromol/L were compared with lower values was 3.13 (95% CI: 1.63, 6. 03; P = 0.001).

CONCLUSION

Elevated tHcy concentration is associated with common pregnancy complications and adverse pregnancy outcomes.

Second-trimester maternal serum marker screening: maternal serum alpha-fetoprotein, beta-human chorionic gonadotropin, estriol, and their various combinations as predictors of pregnancy outcome

OBJECTIVE

We evaluated the value of all 3 common biochemical serum markers, maternal serum alpha-fetoprotein, beta-human chorionic gonadotropin, and unconjugated estriol, and combinations thereof as predictors of pregnancy outcome.

STUDY DESIGN

A total of 60,040 patients underwent maternal serum screening. All patients had maternal serum alpha-fetoprotein measurements; beta-human chorionic gonadotropin was measured in 45,565 patients, and 24,504 patients had determination of all 3 markers, including unconjugated estriol. The incidences of various pregnancy outcomes were evaluated according to the serum marker levels by using clinically applied cutoff points.

RESULTS

In confirmation of previous observations, increased maternal serum alpha-fetoprotein levels (>2.5 multiples of the median) were found to be significantly associated with pregnancy-induced hypertension, miscarriage, preterm delivery, intrauterine growth restriction, intrauterine fetal death, oligohydramnios, and abruptio placentae. Increased beta-human chorionic gonadotropin levels (>2.5 multiples of the median [MoM]) were significantly associated with pregnancy-induced hypertension, miscarriage, preterm delivery, and intrauterine fetal death. Finally, decreased unconjugated estriol levels (<0.5 MoM) were found to be significantly associated with pregnancy-induced hypertension, miscarriage, intrauterine growth restriction, and intrauterine fetal death. As with increased second-trimester maternal serum alpha-fetoprotein levels, increased serum beta-human chorionic gonadotropin and low unconjugated estriol levels are significantly associated with adverse pregnancy outcomes. These are most likely attributed to placental dysfunction.

CONCLUSION

Multiple-marker screening can be used not only for the detection of fetal anomalies and aneu-ploidy but also for detection of high-risk pregnancies.

Thrombomodulin: a new marker for placental abruption

Thrombomodulin (TM), a marker of endothelial cell damage, has been localized to the placental syncytiotrophoblast. A prospective cohort study of twenty-five pregnant women who were admitted with a clinical diagnosis of placental abruption was undertaken. Abruption was confirmed after delivery in eight cases (Group 1). Group 2 consisted of seventeen patients with no clinical or pathologic evidence of placental abruption after delivery. TM was significantly elevated in Group 1 (71.59+/-5.35 vs. 48.29+/-3.53 ng/ml, p = 0.001). The sensitivity and specificity of TM > or =60 ng/ml as a marker for abruption was 87.5 and 76.5%, respectively. In comparison, the sensitivity of an abnormal coagulation profile, maternal Kleihauer-Betke and ultrasound in patients with abruption was 0, 16.7 and 28.6%, respectively. TM is a highly sensitive and specific marker for acute placental abruption.

Simultaneous measurement of adenosine and hypoxanthine in human umbilical cord plasma using reversed-phase high-performance liquid chromatography with photodiode-array detection and on-line validation of peak purity

A new, robust and sensitive reversed-phase high-performance liquid chromatographic method was developed for concomitant measurement of plasma concentrations of the ATP catabolites adenosine and hypoxanthine in human umbilical cord blood. Deproteinized cord plasma was chromatographed on Hypersil C18 columns, using UV photodiode-array detection, spectral analysis of peaks and on-line confirmation of peak purity. Elution with a gradient of acetonitrile-tetrahydrofuran in ammonium dihydrogen phosphate buffer pH 4.7, yielded sharp, well-resolved peaks of adenosine and hypoxanthine within 16 min. Peak areas were quantified from external calibration curves and converted to plasma concentrations via cord blood hematocrits. In seven deliveries, gestational ages 32-40 weeks, adenosine (range, 0.1-2.1 microM) was less than hypoxanthine (range, 1.6-18.5 microM) in the same cord plasma sample. Arteriovenous levels of each purine were similar, except in an abruptio placenta delivery.

Plasma fibrin D-dimer in pregnancies complicated by partial placental abruption

OBJECTIVE

To evaluate the value of the plasma fibrin D-dimer test, a sensitive indicator of coagulation abnormalities, as a method of affirmation of partial placental abruption.

METHODS

Fibrin D-dimer studies were obtained on 25 healthy, normotensive gravidas with late second and third trimester uterine bleeding and a clinical diagnosis of partial placental abruption. The test was repeated 24 hours later if bleeding persisted. The results were compared with D-dimer tests done on 30 healthy, term gravidas. Postpartum, all placentas were evaluated for evidence of abruption, and those suspected of abruption were sent for pathologic evaluation.

RESULTS

Three of 34 D-dimer tests, performed on 25 women who had 28 bleeding episodes, were mildly elevated. At delivery, 12 of the 25 placentas showed evidence of abruption, and six had pathologic findings suggesting abruption. One of the 16 D-dimer tests done on these 12 women was mildly elevated, and 2 of the 18 tests done on the other 13 women, whose placentas appeared normal, were mildly elevated. All 30 D-dimer studies in the control group were normal. The difference between the study group and the controls' results was not significant (P = 0.3).

CONCLUSION

We did not find the fibrin D-dimer test to be of value in substantiating the diagnosis of partial placental abruption.

Interleukin-4, interleukin-10, and soluble tumor necrosis factor receptors in cord blood

OBJECTIVE

We assessed cord blood for levels of interleukin-4 (IL-4), interleukin-10 (IL-10), and p55 (sTNFR-I) and p75 (sTNFR-II) soluble tumor necrosis factor receptors.

STUDY DESIGN

Umbilical cord IL-4, IL-10, tumor necrosis factor alpha (TNF alpha), sTNFR-I, and sTNFR-II were measured in 21 normal appropriately grown newborns delivered vaginally (normal pregnancy), and 3 abnormal pregnancies (1 preterm delivery, 1 premature rupture of membranes with chorioamnionitis, and 1 abruptio placentae with fetal and neonatal distress). Umbilical cord arterial blood pH and PO2 were also measured.

RESULTS

The TNF alpha, sTNFR-I, and sTNFR-II were detectable in all cord blood samples in normal pregnancies. IL-4 was detected in 10 of 21 samples (47.6%), and IL-10 was undetectable in normal pregnancies. IL-10 could be detected in the cases with chorioamnionitis and abruptio placentae. Soluble tumor necrosis factor receptors in the case with preterm delivery and the case with abruptio placentae were elevated compared with the levels in control samples.

CONCLUSION

Both the p55 and p75 soluble tumor necrosis factor receptors are physiologic constituents of term cord blood. An immunosuppressive role of IL-10 and a protective role of soluble tumor necrosis factor receptors are suggested in abnormal pregnancies. However, in view of the small number of abnormal pregnancies, these observations must be considered preliminary.

Hyperhomocysteinemia: a risk factor for placental abruption or infarction

OBJECTIVE

To establish the prevalence of hyperhomocysteinemia in women with placental abruption or infarction.

DESIGN

Forty-six women with normal pregnancy outcome (controls) and 84 women with placental abruption or infarction (study group) were selected, and studied in the non-pregnant state. Homocysteine metabolism was investigated by a standardized oral methionine loading test. Hyperhomocysteinemia was defined as a concentration of fasting and/or postmethionine plasma homocysteine exceeding the estimated 97.5 percentile level of the controls. In the fasting state, the vitamin status was investigated by the measurement of serum and red cell folate, serum vitamin B12, and whole blood pyridoxal-5'-phosphate (PLP, an active form of vitamin B6).

RESULTS

Hyperhomocysteinemia was diagnosed in four controls (9%) and 26 women of the study group (31%, P < 0.05). The median concentrations of the vitamins studied were significantly lower in women of the study group as compared to the controls, except for red cell folate, where the median concentration was comparable in both groups. The median concentration of fasting plasma homocysteine, unlike post-methionine plasma homocysteine, was significantly higher in women who experienced placental abruption or infarction in their first pregnancy than in women who had the same event after one or more uncomplicated pregnancies.

CONCLUSION

Hyperhomocysteinemia is associated with placental abruption or infarction.

Activity alterations of chosen parameters of cord blood hemostasis in newborns from complicated pregnancies with premature ablation of placenta

The study was carried out on 20 newborns with diagnosed premature ablation of placenta of 0,I,II clinical degree. In comparison to healthy newborns (n = 30) statistically significant differences were proved in: ATIII activity-48% (65%), plasminogen concentration-50% (63%), alpha 2antyplasmin activity 53% (67%); euglobulin clot fibrinolysis time 70 (95) min., and fibrinogen concentration 1.4 (1.8) g/l. The presented differences prove increased coagulation system activation in newborns from mothers with symptoms of premature ablation of placenta. Activity changes of hemostasis system in cases of premature ablation of placenta have the features of disorders accompanying intrauterine fetal anoxia.

Maternal serum CA 125 levels in the diagnosis of abruptio placentae

OBJECTIVE

To evaluate measurements of maternal serum CA 125 for the diagnosis of abruptio placentae.

METHODS

This investigation was conducted at Swedish Medical Center/Seattle from December 1991 through April 1992. During the study period, we identified 21 consecutive patients with a clinical diagnosis of abruptio placentae. In addition, we enrolled two groups of patients whose pregnancies were not complicated by placental abruption (28 preterm controls and 53 term controls).

RESULTS

Mean maternal serum levels of CA 125 were significantly higher among women with abruptio placentae (40.6 +/- 29.6 U/mL) than among preterm controls (26.6 +/- 17.2 U/mL) or term controls (22.0 +/- 11.4 U/mL). Using a positive threshold of 35 U/mL, the sensitivity and specificity of maternal serum CA 125 for abruptio placentae were 42.9% (95% confidence interval [CI] 21.7-64.1) and 92.5% (95% CI 85.4-99.6), respectively.

CONCLUSIONS

These findings support an earlier report documenting higher mean maternal serum levels of CA 125 among women with pregnancies complicated by abruptio placentae than in control subjects. However, measurement of maternal serum CA 125 does not appear to be a useful marker for the diagnosis of abruptio placentae. At present, clinical diagnosis of abruptio placentae, with the aid of ultrasonography to rule out other causes of late gestational hemorrhage, should be considered the most sensitive and specific method of detecting this pregnancy complication.

A rapid test for abruptio placentae: evaluation of a D-dimer latex agglutination slide test

OBJECTIVE

Our purpose was to evaluate a rapid latex agglutination slide test for D-dimer, a byproduct of clot lysis, in the prediction of abruptio placentae.

STUDY DESIGN

Four groups were studied: (1) 15 patients with normal pregnancies at 40 weeks' gestation, (2) 17 participants with preeclamptic pregnancies, (3) 14 patients with preterm labor, and (4) 15 patients with confirmed abruptio placentae. The latex agglutination slide test was performed with positive and negative reference solutions and plasma dilutions of 1:1, 1:2, 1:4, and 1:8. A test was considered positive if, at 2 minutes, agglutination was present at dilutions of > or = 1:2 (> or = 1.0 micrograms/ml fibrin equivalent units). Test results were compared in patient groups with and without abruptio placentae by means of the chi 2 test.

RESULTS

The likelihood of a positive D-dimer test result was not significantly different among patients in the non-abruptio placentae groups (p = 0.454). Patients in the abruptio placentae group were significantly more likely to have a positive D-dimer slide test result than those in the non-abruptio placentae groups (p = 0.0001). The D-dimer test conferred sensitivity, specificity, positive predictive value, and negative predictive value of 67%, 93%, 91%, and 48%, respectively. In contrast, other laboratory measures of coagulation (e.g., platelet count, prothrombin time, partial thromboplastin time, and fibrinogen levels) yielded no better than a 20% sensitivity for abruptio placentae.

CONCLUSIONS

The D-dimer slide test may be a superior rapid method to improve early diagnosis of abruptio placentae.

The prevalence of antiphospholipid antibodies in women with reproductive failure or major abruptio placentae

The so-called antiphospholipid syndrome may be responsible for repeated spontaneous abortion and fetal loss. We examined the plasma of 61 women with either reproductive failure or abruptio placentae for the presence of lupus anticoagulant and anticardiolipin antibodies in an attempt to assess the prevalence of this condition. No patient had haematological abnormalities consistent with the presence of lupus anticoagulant. However, 6 women had anticardiolipin antibodies with normal coagulation tests. The clinical profile together with this laboratory finding allows us to diagnose the antiphospholipid syndrome in these patients. Our incidence is considerably lower than that reported in many other studies but does suggest a place for screening for this condition in patients with recurrent complications of pregnancy.

Maternal plasma D-dimer levels in normal and complicated pregnancies

OBJECTIVE

To evaluate D-dimer as a marker for fibrinolysis in normal and complicated pregnancies using an enzyme-linked immunosorbent assay (ELISA) technique.

METHODS

Four groups of pregnant women were enrolled: 17 normal women followed longitudinally from 28-40 weeks' gestation, 14 patients with preterm labor at 28-34 weeks, 17 patients with preeclampsia at term (37-40 weeks), and 14 patients with abruptio placentae (32-40 weeks). We assayed peripheral venous blood samples from each patient for D-dimer levels using a commercial ELISA kit. D-dimer values were calculated by regression analysis using internal standards and controls for each assay. Data were compared using Student t test or analysis of variance with repeated measures.

RESULTS

D-dimer values increased slightly with increasing gestational age. Patients with preterm labor, preeclampsia, and abruptio placentae had mean D-dimer values significantly greater than those of controls (P < .003). D-dimer values of the abruption group were approximately twice those of the control group (3393 +/- 2086 versus 1750 +/- 839 ng/dL).

CONCLUSION

An increase in fibrinolysis may be associated with the pregnancy complications studied, as reflected by alterations in maternal plasma D-dimer levels.

Conservative management of placental abruption complicated by severe clotting disorders

Placental abruption resulting in fetal death may seriously affect maternal health, especially when clotting disorders arise. The prevailing view is that the clotting system will only normalize after the uterus has been evacuated and therefore prompt delivery, often by induction of labor, is advocated. Over a 3-year period, 16 cases (0.35%) of intra-uterine fetal death due to placental abruption occurred at Leiden University Hospital. Five cases were complicated by severe clotting disorders. All women delivered vaginally. No maternal deaths occurred. In contrast to most authors, we present data showing that in four out of five cases the clotting system started to normalize before the uterus was emptied. We suggest that an expectant approach until recovery of the coagulopathy is safer than aiming at a quick delivery. After stabilization of the clotting disorder, one may then consider evacuation of the uterus, if need be by induction of labor.

Plasma fibronectin receptor levels during pregnancy complicated by preeclampsia and abruptio placentae

The level of human fibronectin receptor (FNR) in plasma was measured by enzyme-linked immunosorbent assay in samples from normal pregnant women in the 1st trimester (n = 5), 2nd trimester (n = 7), 3rd trimester (n = 23), normal postpartum women day 1 (n = 4), day 2 (n = 5), day 3 (n = 8), nonpregnant women (n = 18), 20 preeclamptic patients in the 3rd trimester, and 8 patients with abruptio placentae in the 3rd trimester. In normal pregnancy, the mean value of FNR was 1.4 +/- 0.4 micrograms/ml in the 1st, 1.4 +/- 0.2 micrograms/ml in the 2nd, and 1.9 +/- 0.3 micrograms/ml (p less than 0.05) in the 3rd trimester. FNR values increased with pregnancy. During the puerperium, its level decreased with time, being 1.4 +/- 0.5 micrograms/ml (p less than 0.01) on day 1, 1.0 +/- 0.3 micrograms/ml on day 2, and 0.8 +/- 0.2 micrograms/ml on day 3. The level in preeclamptic patients was 2.0 +/- 0.4 micrograms/ml, and that in abruptio placentae was 2.7 +/- 0.4 micrograms/ml. There were significant differences between the levels in abruptio placentae versus preeclampsia (p less than 0.05) and 3rd-trimester normal pregnant women (p less than 0.01). In the immunohistochemical study, the surface of normal decidual cells stained weakly for FNR, and the decidual cell membranes of the cases of preeclampsia stained moderately or strongly. Decidual cells and their extracellular matrix close to hematomas of abruptio placentae stained very strongly for FNR.(ABSTRACT TRUNCATED AT 250 WORDS)

Placental abruption in the preterm gestation: an association with chorioamnionitis

Thirty-seven women with acute severe preterm placental abruption were compared with a control group of 51 women requiring preterm delivery for a medical complication of pregnancy. Histologic chorioamnionitis and funisitis were present significantly more often in patients with abruption than in control patients (41 versus 4%; P less than .0001). No patient in either group had clinical evidence of chorioamnionitis. We conclude that a significant association exists between preterm placental abruption and histologic chorioamnionitis.

The rapid inhibition of urokinase by plasma from pregnant women at risk for abruptio placenta

Rapid inhibition of urokinase in plasma obtained from women in the third trimester of pregnancy was assessed by the addition of 75 IU urokinase per ml plasma, and measurement of residual urokinase activity with PyroGlu-Gly-Arg-pNA after 5 minutes incubation at 37 degrees C. The urokinase inhibitory capacity was markedly increased for the pregnant women compared to non-pregnant controls. Alpha 1-antitrypsin, alpha 2-macroglobulin and alpha 2-antiplasmin did not account for the activity. Inhibition was higher for women with multiple gestations or macrosomia (n = 11) compared to normal pregnant women (n = 35) suggesting that the placenta contributes significantly to the measured activity. Inhibition was lower for women with hypertension (n = 33) compared to the normal pregnant women. Although the etiology for this difference is unclear, the decreased inhibitory activity may contribute to the increased risk for placental abruption that is observed for this group of women.