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Warren BB, Moyer GC, Manco-Johnson MJ. Hemostasis in the Pregnant Woman, the Placenta, the Fetus, and the Newborn Infant. Semin Thromb Hemost 2023; 49:319-329. [PMID: 36750218 DOI: 10.1055/s-0042-1760332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The hemostasis system is composed of procoagulant, anticoagulant, and fibrinolytic proteins that interact with endothelial and blood cells and with each other in a complex system of checks and balances to maintain blood flow while preventing both hemorrhage and thrombosis. Pregnancy is a unique physiological state in which biological alterations predispose both mother and fetus to both bleeding and clotting. The placenta is a vascular interface for maternal and fetal blood exchange which predisposes the mother to hemorrhage. Maternal hemostasis presents a compensatory hypercoagulability including elevated factor VIII, von Willebrand factor, fibrinogen and thrombin generation, decreased thrombin regulation with resistance to activated protein C and decreased free protein S, and decreased fibrinolysis with increased plasminogen activator inhibitors. The placental vascular surface is of fetal trophoblastic origin that derives many characteristics of endothelium but differs in that tissue factor is constitutively expressed. Ontogeny of fetal hemostasis is characteristic. Platelets, von Willebrand factor, factor VIII, and fibrinogen are expressed and mature early in gestation, while vitamin K-dependent and contact factors exhibit delayed development. The fetal hemostatic system has a decreased capacity to generate or regulate thrombin, resulting in a fragile balance with little capacity to compensate under stress conditions, particularly in the infant born prematurely. Dysfunction of the maternal/placental/fetal unit gives rise to gestational disorders including preeclampsia, fetal growth restriction, placental abruption, and premature delivery. Knowledge of normal hemostasis levels and function are critical to evaluate bleeding or clotting syndromes in the pregnant woman and her fetus or newborn infant.
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Affiliation(s)
- Beth Boulden Warren
- University of Colorado Hemophilia and Thrombosis Center, Aurora, Colorado
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | - Genevieve C Moyer
- University of Colorado Hemophilia and Thrombosis Center, Aurora, Colorado
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | - Marilyn J Manco-Johnson
- University of Colorado Hemophilia and Thrombosis Center, Aurora, Colorado
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
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Guerra-Shinohara EM, Bertinato JF, Tosin Bueno C, Cordeiro da Silva K, Burlacchini de Carvalho MH, Pulcineli Vieira Francisco R, Zugaib M, Cerda A, Morelli VM. Polymorphisms in antithrombin and in tissue factor pathway inhibitor genes are associated with recurrent pregnancy loss. Thromb Haemost 2012; 108:693-700. [PMID: 22918506 DOI: 10.1160/th12-03-0177] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 07/28/2012] [Indexed: 12/18/2022]
Abstract
Recurrent pregnancy loss (RPL) is a multifactorial condition. The effect of antithrombin (SERPINC1), protein C (PROC), thrombomodulin (THBD) and tissue factor pathway inhibitor (TFPI) single nucleotide polymorphisms (SNPs) on the risk of RPL is thus far unknown. Our objective was to determine the association of SNPs in the above mentioned genes with RPL. We included 117 non-pregnant women with three or more consecutive losses prior to 20 weeks of pregnancy without a previous history of carrying a fetus to viability, and 264 healthy fertile non-pregnant women who had at least two term deliveries and no known pregnancy losses. The PROC (rs1799809 and rs1799808), SERPINC1 (rs2227589), THBD (rs1042579) and TFPI (rs10931292, rs8176592 and rs10153820) SNPs were analysed by Real Time PCR. Genotype frequencies for PROC 2418A>G, PROC 2405C>T, THBD 1418C>T, TFPI (T-33C and TFPI C-399T) SNPs were similar in cases and controls. The carriers of SERPINC1 786A allele (GA + AA genotypes) had an increased risk for RPL (odds ratio [OR]: 1.77, 95% confidence interval [CI]: 1.05-3.00, p= 0.034) while women carrying the TFPI -287C allele (TC + CC genotypes) had a protection effect on having RPL (OR: 0.46, 95% CI: 0.26-0.83, p= 0.009). The TCC haplotype for TFPI T-33C/ TFPI T-287C/ TFPI C-399T SNPs was less frequent in cases (5.7%) than in controls (11.6%) (OR: 0.45, 95% CI: 0.23-0.90, p= 0.025). In conclusion, our data indicate that SERPINC1 786G>A variant increases the risk for RPL, while TFPI T-287C variant is protective; however, further studies are required to confirm our findings.
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Affiliation(s)
- Elvira M Guerra-Shinohara
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, SP, Brasil.
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Dusse LM, Carvalho MG, Cooper AJ, Lwaleed BA. Plasma factor VII: a potential marker of pre-eclampsia. Thromb Res 2010; 127:e15-9. [PMID: 21094984 DOI: 10.1016/j.thromres.2010.10.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Revised: 10/13/2010] [Accepted: 10/20/2010] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Normal pregnancy is associated with a local hypercoagulable state that becomes more profound in certain obstetric complications such pre-eclampsia (P-EC). Current literature on the levels of individual haemostatic factors in women with P-EC is limited and results are inconsistent. In this study we provide detailed investigation on the tissue factor (TF)-dependent pathway in women with P-EC. MATERIALS AND METHODS Enzyme-linked immunosorbent assays (ELISA) were used to measure plasma factor (F) FVII, FVIIa, TF and tissue factor pathway inhibitor (TFPI) in healthy non-pregnant women (n = 22), normal pregnant women (n = 15), and women with P-EC (n = 20). All subjects were age matched. In addition, pregnant women were matched for gestational age, parity and were all at the third trimester. RESULTS Plasma FVII levels were significantly higher in women with P-EC compared to the healthy non-pregnant (P<0.001) or the normal pregnant groups (P<0.001). No such significant trends were observed for plasma FVIIa, TF or TFPI levels. Plasma FVII levels can distinguish women with P-EC from healthy non-pregnant women or normal pregnant women at the third trimester, with high sensitivity (90%), specificity (80%), positive and negative predictive values (86%). CONCLUSIONS Plasma FVII levels are significantly elevated in women with P-EC, in the absence of comparable changes in other TF-dependent pathway factors (FVIIa, TF and TFPI). We propose the use of plasma FVII as a marker for P-EC.
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Affiliation(s)
- Luci M Dusse
- Faculty of Pharmacy, Federal University of Minas Gerais, Brazil
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Tchaikovski SN, van Vlijmen BJM, Cleuren ACA, Thomassen MCLGD, Tchaikovski V, Tans G, Rosing J. Pregnancy-associated changes in the hemostatic system in wild-type and factor V Leiden mice. J Thromb Haemost 2009; 7:312-8. [PMID: 19036061 DOI: 10.1111/j.1538-7836.2008.03240.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pregnancy, oral contraceptive (OC)use and hormone replacement therapy (HRT) are established risk factors for venous thrombosis. Acquired resistance to activated protein C (APC) has been proposed to contribute to the increased thrombosis risk. Mouse models are often used for preclinical testing of newly developed hormone preparations. However, it is not known whether hormone-induced APC resistance is also observed in laboratory animals. OBJECTIVES To investigate whether hormonal changes modulate APC resistance in mice, we used pregnant mice as a model of hormone-induced APC resistance. The effect of pregnancy on APC resistance was studied in wild-type and factor (F)V Leiden mice. METHODS APC resistance was determined in mouse plasma using a thrombin generation-based APC resistance test. APC resistance determinants,i.e. prothrombin, FV, FX, antithrombin and protein S levels,and of tissue factor pathway inhibitor (TFPI) activity were evaluated in plasma from non-pregnant and pregnant mice. RESULTS In contrast to humans, pregnancy induced a decrease in APC resistance in wild-type and in FV Leiden mice.Pregnant mice had higher levels of prothrombin, FV, FX,protein S and TFPI activity as compared with non-pregnant mice. CONCLUSIONS Pregnancy causes a decrease in APC resistance in mice, which can be explained by the elevation of protein S levels and increased TFPI activity in plasma. Our findings show species specificity in the effects of pregnancy on the major determinants of the protein C system and suggest that protein S and TFPI play an important role in the development of pregnancy-induced APC resistance in humans.
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Affiliation(s)
- S N Tchaikovski
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
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Abdel Gader AM, Al-Mishari AA, Awadalla SA, Buyuomi NM, Khashoggi T, Al-Hakeem M. Total and free tissue factor pathway inhibitor in pregnancy hypertension. Int J Gynaecol Obstet 2006; 95:248-53. [PMID: 17070527 DOI: 10.1016/j.ijgo.2006.07.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2005] [Revised: 07/21/2006] [Accepted: 07/26/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To clarify the role played by tissue factor pathway inhibitor (TFPI) in pregnancy hypertension. METHODS Using enzyme-linked immunosorbent assays, hemostatic measurements were obtained for women with pre-eclampsia (n=51), nonproteinuric hypertension of pregnancy (n=62), postpartum pre-eclampsia 24 h after childbirth (n=31), and no hypertension (healthy pregnant controls, n=100). RESULTS There was a significant increase in circulating free TFPI levels in women with pre-eclampsia (9.7+/-6.2 ng/mL) or nonproteinuric hypertension of pregnancy (8.3+/-5.3 ng/mL) compared with healthy controls (5.3+/-2.1 ng/mL). In women with pre-eclampsia the levels remained elevated after placental delivery (10.6+/-4.0 ng/mL). Free protein S levels were significantly higher in women with pre-eclampsia (40.0%+/-10.7%), nonproteinuric hypertension of pregnancy (37.1%+/-12.5%), or postpartum pre-eclampsia (39.3%+/-9.1%) than in healthy pregnant controls (32.2%+/-8.5%). CONCLUSION Increased levels of the physiologically active free forms of TFPI and free protein S, 2 coagulation inhibitors, may protect women with pregnancy-induced hypertension from the risks of hemostatic activation.
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Affiliation(s)
- A M Abdel Gader
- The Coagulation Laboratory, Department of Physiology, College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia.
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Abstract
OBJECTIVES To review of the state of the art relating to congenital heparin cofactor II deficiency as a potential risk factor for thrombosis, as reflected by the medical literature and the consensus opinion of recognized experts in the field, and to make recommendations for the use of laboratory assays for assessing this thrombotic risk in individual patients. DATA SOURCES Review of the medical literature, primarily from the last 10 years. DATA EXTRACTION AND SYNTHESIS After an initial assessment of the literature, including review of clinical study design and laboratory methods, a draft manuscript was prepared and circulated to participants in the College of American Pathologists Conference XXXVI: Diagnostic Issues in Thrombophilia. Recommendations were accepted if a consensus of experts attending the conference was reached. The results of the discussion were used to revise the manuscript into its final form. CONCLUSIONS Consensus was reached that there is insufficient evidence to recommend testing for heparin cofactor II deficiency in patients with thromboembolic disease.
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Affiliation(s)
- Douglas M Tollefsen
- Hematology Division, Department of Medicine, Washington University School of Medicine, St Louis, Mo 63110, USA.
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Uszyński M, Zekanowska E, Uszyński W, Kuczyński J. Tissue factor (TF) and tissue factor pathway inhibitor (TFPI) in amniotic fluid and blood plasma: implications for the mechanism of amniotic fluid embolism. Eur J Obstet Gynecol Reprod Biol 2001; 95:163-6. [PMID: 11301162 DOI: 10.1016/s0301-2115(00)00448-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
UNLABELLED Tissue factor (TF) is known to be present in a high concentration in amniotic fluid. The main question of this study is whether tissue factor pathway inhibitor (TFPI), a natural inhibitor of TF, is present in amniotic fluid. The study group consisted of 28 women with normal pregnancy course, and at the first stage of termed labour. Fifteen non-pregnant women were the control group. TF and TFPI were studied by an immunoenzymatic method (ELISA). The level of TFPI in amniotic fluid was 38.7% of that in blood plasma (16.81+/-5.34ng/ml versus 43.41+/-18.70ng/ml, P<0.001), while the level of TF in amniotic fluid was 44.8 times higher than in blood plasma (9995.93+/-8533.11pg/ml versus 252.66+/-28.84pg/ml, P<0.001). CONCLUSIONS (i) It was found, for the first time, that amniotic fluid contains TFPI (ii) It is reasonable to assume that the intrusion of amniotic fluid into the blood-stream may influence the plasmatic TFPI-TF equilibrium resulting in intravascular blood coagulation.
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Affiliation(s)
- M Uszyński
- Department of Medical Propedeutics, Ludwik Rydygier Medical University, Bydgoszcz, Poland
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Marbet GA. Heparinkofaktor-II-Mangelerkrankungen: Pathophysiologie, Klinik, Diagnostik und Therapie. Hamostaseologie 1999. [DOI: 10.1007/978-3-662-07673-6_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Petersen LC, Valentin S, Hedner U. Regulation of the extrinsic pathway system in health and disease: the role of factor VIIa and tissue factor pathway inhibitor. Thromb Res 1995; 79:1-47. [PMID: 7495097 DOI: 10.1016/0049-3848(95)00069-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
In 1964, the events of haemostasis were organized into the intrinsic and extrinsic pathways by the cascade/waterfall hypothesis, with primary physiological importance being given to the intrinsic pathway. Recent experimental evidence, as well as information about the clinical course of patients with various coagulation factor deficiencies, indicates a more prominent role for tissue factor. Rediscovery of the plasma protease inhibitor, tissue factor pathway inhibitor, and new information about the activation of factor XI have supported a revised theory of coagulation.
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Affiliation(s)
- L Luchtman-Jones
- Department of Pediatrics/Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St Louis, MO, USA
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Porter JB, Young L, Mackie IJ, Marshall L, Machin SJ. Sickle cell disorders and chronic intravascular haemolysis are associated with low plasma heparin cofactor II. Br J Haematol 1993; 83:459-65. [PMID: 8485052 DOI: 10.1111/j.1365-2141.1993.tb04671.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Thrombotic events are known to be increased in patients with sickle cell syndromes and a variety of abnormalities of coagulation or endothelial function have been described, although the relevance of these findings either to the pathogenesis of vaso-occlusive phenomena or the risk of thrombosis are unclear. Heparin cofactor II (HCII) and antithrombin III are circulating inhibitors of thrombin and low plasma levels have been associated with an increased risk of thrombosis in otherwise healthy individuals. We describe for the first time abnormally low plasma levels of HCII in patients with sickle cell syndromes. 45 adult patients with sickle cell syndromes (31 SS, 10 SC, 4 S beta Thal) were compared with 61 age matched control patients for HCII in plasma. There was a highly significant reduction in HCII in SS patients irrespective of crisis or transfusion state 0.68 +/- 0.15 U/ml (mean +/- SD) compared with controls 1.00 +/- 0.19 U/ml (P < 0.001). HCII antigen was also significantly reduced (0.53 +/- 0.19 U/ml) compared with controls (1.02 +/- 0.23 U/ml, P < 0.0001). By contrast there was no reduction in antithrombin III in this group. HCII (0.63 +/- 0.13 U/ml, P < 0.001) and HCII antigen (0.54 +/- 0.08 U/ml, P < 0.001) are also significantly reduced in SC patients HCII levels increased towards control values during sickle cell crises, in patients taking the contraceptive pill, or with regular blood transfusion; however, plasma HCII concentrations were not increased acutely by exchange transfusion. HCII was also decreased in thalassaemia intermedia and pyruvate kinase deficiency, suggesting that intravascular haemolysis may be the cause of reduced HCII levels.
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Affiliation(s)
- J B Porter
- Department of Haematology, University College and Middlesex School of Medicine, London
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Sandset PM, Lund H, Norseth J, Abildgaard U, Ose L. Treatment with hydroxymethylglutaryl-coenzyme A reductase inhibitors in hypercholesterolemia induces changes in the components of the extrinsic coagulation system. ARTERIOSCLEROSIS AND THROMBOSIS : A JOURNAL OF VASCULAR BIOLOGY 1991; 11:138-45. [PMID: 1987991 DOI: 10.1161/01.atv.11.1.138] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The present study was performed to determine the influence of pharmaceutical intervention on parameters of blood coagulation and fibrinolysis in hypercholesterolemic patients. Eighteen otherwise-healthy individuals with heterozygous familial hypercholesterolemia were treated with a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (simvastatin, 40 mg daily) for 12-14 weeks followed by additional treatment with omega-3 fatty acids (equivalent to 4 g eicosapentaenoic acid/docosahexaenoic acid daily) for 6 more weeks. With simvastatin treatment, the mean decreases in total cholesterol, low density lipoprotein (LDL) cholesterol, and apolipoprotein B (apo B) were 39%, 46%, and 36%, respectively. Only minor changes in high density lipoprotein (HDL) cholesterol and apo A-1 were recorded. omega-3 fatty acids had minor additional effects. The most prominent effects on the blood coagulation system were the changes in extrinsic pathway inhibitor (EPI), which is the inhibitor of the factor VIIa-tissue thromboplastin complex. EPI activity decreased from a median of 153% to 111% (p less than 0.001) with simvastatin treatment and to 112% (p less than 0.001) on the combined regimen. EPI activity was significantly correlated with LDL cholesterol (r = 0.78), total cholesterol (r = 0.77), apo B (r = 0.65), and apo A-1 (r = 0.45). Multiple stepwise regression analysis showed that LDL cholesterol was the most important predictor of EPI activity, which suggests that a majority of EPI activity in plasma is associated with LDL. Moreover, the alteration in EPI activity was correlated closely with the corresponding alteration in LDL, which suggests a direct relation between a coagulation-inhibitor activity and a pharmaceutical lipid-related response.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- P M Sandset
- Department of Medicine, Aker University Hospital, Oslo, Norway
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