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Sokou R, Parastatidou S, Konstantinidi A, Tsantes AG, Iacovidou N, Piovani D, Bonovas S, Tsantes AE. Contemporary tools for evaluation of hemostasis in neonates. Where are we and where are we headed? Blood Rev 2024; 64:101157. [PMID: 38016836 DOI: 10.1016/j.blre.2023.101157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023]
Abstract
The assessment of hemostatic disorders in neonates is crucial, but remains challenging for clinicians. Although the concept of developmental hemostasis is widely accepted among hemostasis specialists globally, it is probably under-recognized by clinicians and laboratory practitioners. In parallel with age-dependent hemostatic status maturation, comprehension of the differences between normal values is crucial for the accurate diagnosis of potential hemorrhagic and thrombotic disorders of the vulnerable neonatal population. This review outlines the basics of developmental hemostasis and the features of the available coagulation testing methods, with a focus on novel tools for evaluating the neonatal hemostatic profile. Common errors, issues, and pitfalls during the assessment of neonatal hemostasis are discussed, along with their impact on patient management. Current knowledge gaps and research areas are addressed. Further studying to improve our understanding of developmental hemostasis and its reflection on everyday clinical practice is warranted.
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Affiliation(s)
- Rozeta Sokou
- Neonatal Intensive Care Unit, "Agios Panteleimon" General Hospital of Nikea, Piraeus, Greece.
| | | | | | - Andreas G Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Nicoletta Iacovidou
- Neonatal Department, National and Kapodistrian University of Athens, Aretaieio Hospital, Athens, Greece
| | - Daniele Piovani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Stefanos Bonovas
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; IRCCS Humanitas Research Hospital, Milan, Italy
| | - Argirios E Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
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Khizroeva J, Makatsariya A, Vorobev A, Bitsadze V, Elalamy I, Lazarchuk A, Salnikova P, Einullaeva S, Solopova A, Tretykova M, Antonova A, Mashkova T, Grigoreva K, Kvaratskheliia M, Yakubova F, Degtyareva N, Tsibizova V, Gashimova N, Blbulyan D. The Hemostatic System in Newborns and the Risk of Neonatal Thrombosis. Int J Mol Sci 2023; 24:13864. [PMID: 37762167 PMCID: PMC10530883 DOI: 10.3390/ijms241813864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/04/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Newborns are the most vulnerable patients for thrombosis development among all children, with critically ill and premature infants being in the highest risk group. The upward trend in the rate of neonatal thrombosis could be attributed to progress in the treatment of severe neonatal conditions and the increased survival in premature babies. There are physiological differences in the hemostatic system between neonates and adults. Neonates differ in concentrations and rate of synthesis of most coagulation factors, turnover rates, the ability to regulate thrombin and plasmin, and in greater variability compared to adults. Natural inhibitors of coagulation (protein C, protein S, antithrombin, heparin cofactor II) and vitamin K-dependent coagulation factors (factors II, VII, IX, X) are low, but factor VIII and von Willebrand factor are elevated. Newborns have decreased fibrinolytic activity. In the healthy neonate, the balance is maintained but appears more easily converted into thrombosis. Neonatal hemostasis has less buffer capacity, and almost 95% of thrombosis is provoked. Different triggering risk factors are responsible for thrombosis in neonates, but the most important risk factors for thrombosis are central catheters, fluid fluctuations, liver dysfunction, and septic and inflammatory conditions. Low-molecular-weight heparins are the agents of choice for anticoagulation.
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Affiliation(s)
- Jamilya Khizroeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Alexander Makatsariya
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Alexander Vorobev
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Victoria Bitsadze
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Ismail Elalamy
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
- Hematology and Thrombosis Center, Tenon Hospital, Sorbonne University, 4 Rue de la Chine, 75020 Paris, France
| | - Arina Lazarchuk
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Polina Salnikova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Sabina Einullaeva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Antonina Solopova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Maria Tretykova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Alexandra Antonova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Tamara Mashkova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Kristina Grigoreva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Margaret Kvaratskheliia
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Fidan Yakubova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Natalia Degtyareva
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - Valentina Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, 2 Akkuratova Str., 197341 Saint Petersburg, Russia;
| | - Nilufar Gashimova
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
| | - David Blbulyan
- Department of Obstetrics, Gynecology and Perinatal Medicine, N.F. Filatov Clinical Institute of Children’s Health, I.M. Sechenov First Moscow State Medical University (Sechenov University), Trubetskaya Str. 8-2, 119991 Moscow, Russia; (A.M.); (A.V.); (V.B.); (I.E.); (A.L.); (P.S.); (S.E.); (A.S.); (M.T.); (A.A.); (T.M.); (K.G.); (M.K.); (F.Y.); (N.D.); (N.G.); (D.B.)
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Assessment of haemostatic function in paediatric surgical patients: 'if you prick us, do we not bleed?'. Br J Anaesth 2023; 130:119-121. [PMID: 36529575 DOI: 10.1016/j.bja.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 12/23/2022] Open
Abstract
Healthy babies have ∼50% of adult procoagulant factor levels, but without an increased risk of bruising or bleeding. The preoperative clotting tests, prothrombin time and partial thromboplastin time, are frequently performed in infants and children. However, the clinical usefulness of screening coagulation tests remains controversial. Viscoelastic coagulation tests are increasingly used to guide perioperative haemostatic interventions. Enhanced coagulability was previously demonstrated on some viscoelastic testing devices using blood from younger infants. This editorial focuses on several key findings from the paediatric reference range study using a new whole blood viscoelastic coagulation test system, ClotPro® (Haemonetics, Boston, MA, USA). Altered clotting patterns in younger infants, underlying mechanisms of coagulation, and potential clinical implications are discussed.
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Schlagenhauf A, Bohler S, Kunze M, Strini T, Haidl H, Erlacher M, Zieger B. Neonatal Platelets: Lower G12/13 Expression Contributes to Reduced Secretion of Dense Granules. Cells 2022; 11:cells11162563. [PMID: 36010639 PMCID: PMC9406762 DOI: 10.3390/cells11162563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 12/03/2022] Open
Abstract
Despite fully functional primary hemostasis, platelets of healthy neonates exhibit hypoaggregability and secretion defects, which may be adaptations to specific requirements in this developmental stage. The etiologies for reduced signal transduction vary with the type of agonist. The discovered peculiarities are lower receptor densities, reduced calcium mobilization, and functional impairments of G proteins. Reduced secretion of dense granules has been attributed to lower numbers of granules. Signaling studies with adult platelets have shown a regulating effect of the G12/13 signaling pathway on dense granule secretion via RhoA. We comparatively analyzed secretion profiles using flow cytometry and expression levels of Gq, Gi, and G12/13 using Western blot analysis in platelets from cord blood and adults. Furthermore, we evaluated Rho activation after in vitro platelet stimulation with thrombin using a pulldown assay. We observed a markedly reduced expression of the dense granule marker CD63 on neonatal platelets after thrombin stimulation. Gα12/13 expression was significantly decreased in neonatal platelets and correlated with lower Rho activation after thrombin stimulation. We conclude that lower expression of G12/13 in neonatal platelets results in attenuated activation of Rho and may contribute to reduced secretion of dense granules after exposure to thrombin.
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Affiliation(s)
- Axel Schlagenhauf
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Sheila Bohler
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center-University of Freiburg, 79098 Freiburg im Breisgau, Germany
| | - Mirjam Kunze
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Freiburg, 79110 Freiburg im Breisgau, Germany
| | - Tanja Strini
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Harald Haidl
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Miriam Erlacher
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center-University of Freiburg, 79098 Freiburg im Breisgau, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center-University of Freiburg, 79098 Freiburg im Breisgau, Germany
- Correspondence: ; Tel.: +49-761-270-43000
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de Laat-Kremers R, Di Castelnuovo A, van der Vorm L, Costanzo S, Ninivaggi M, Cerletti C, Huskens D, De Curtis A, Gialluisi A, Bai C, de Gaetano G, Yin D, Donati MB, de Laat B, Iacoviello L. Increased BMI and Blood Lipids Are Associated With a Hypercoagulable State in the Moli-sani Cohort. Front Cardiovasc Med 2022; 9:897733. [PMID: 35783839 PMCID: PMC9243635 DOI: 10.3389/fcvm.2022.897733] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
The coagulation system can be assessed by the thrombin generation (TG) assay, and increased TG peak height, endogenous thrombin potential (ETP), and velocity index are associated with an increased risk of thrombosis. Obesity had been reported to increase TG and is associated with dyslipidemia, which also predisposes to atherosclerotic cardiovascular disease (CVD). However, the effect of the blood lipid profile on TG has not been studied extensively. To gain more insight into the associations of TG, body mass index (BMI) and lipid profile, we studied TG in relation to these parameters in a large Italian population cohort, the Moli-sani study (N = 22,546; age ≥ 35 years; 48% men). TG was measured in plasma samples collected at the enrollment of subjects in the Moli-sani study. TG was triggered with 1 or 5 pM tissue factor, and TG parameters lag time, peak, ETP, time-to-peak (TTP) and velocity index (VI). Additionally, thrombomodulin was added to assess the function of the activated protein C system during TG. In both women and men, overweight (BMI 25–30 kg/m2) and obesity (BMI > 30 kg/m2) were significantly associated with higher ETP, peak and VI (all p < 0.001). High total cholesterol, triglycerides and LDL-cholesterol levels were significantly associated with increased ETP and peak (all p < 0.001). Linear regression analysis revealed that the ETP is positively associated with both plasma LDL and HDL cholesterol levels, whereas the velocity index is positively associated with HDL cholesterol. Additionally, ETP, peak and VI were significantly associated with the plasma triglycerides content. In conclusion, our study shows significant associations of high BMI and blood lipid levels with increased TG parameters, and this hypercoagulability may partly explain the increased risk of CVD in individuals with obesity and/or dyslipidemia.
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Affiliation(s)
- Romy de Laat-Kremers
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
- *Correspondence: Romy de Laat-Kremers
| | | | - Lisa van der Vorm
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
| | - Simona Costanzo
- Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy
| | - Marisa Ninivaggi
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
| | - Chiara Cerletti
- Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy
| | - Dana Huskens
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, Netherlands
| | - Amalia De Curtis
- Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy
| | - Alessandro Gialluisi
- Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy
- Research Center in Epidemiology and Preventive Medicine (EPIMED), Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Cuicui Bai
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Protein Engineering, Synapse Research Institute, Maastricht, Netherlands
| | | | - Dongmei Yin
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
| | | | - Bas de Laat
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Protein Engineering, Synapse Research Institute, Maastricht, Netherlands
| | - Licia Iacoviello
- Department of Epidemiology and Prevention, IRCCS Neuromed, Pozzilli, Italy
- Research Center in Epidemiology and Preventive Medicine (EPIMED), Department of Medicine and Surgery, University of Insubria, Varese, Italy
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The role of the calibrated automated thrombogram in neonates: describing mechanisms of neonatal haemostasis and evaluating haemostatic drugs. Eur J Pediatr 2022; 181:23-33. [PMID: 34283272 PMCID: PMC8760221 DOI: 10.1007/s00431-021-04196-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 06/11/2021] [Accepted: 07/01/2021] [Indexed: 12/04/2022]
Abstract
Premature infants are at high risk of haemorrhage and thrombosis. Our understanding of the differences between the neonatal and adult haemostatic system is evolving. There are several limitations to the standard coagulation tests used in clinical practice, and there is currently a lack of evidence to support many of the transfusion practices in neonatal medicine. The evaluation of haemostasis is particularly challenging in neonates due to their limited blood volume. The calibrated automated thrombogram (CAT) is a global coagulation assay, first described in 2002, which evaluates both pro- and anti-coagulant pathways in platelet-rich or platelet-poor plasma. In this review, the current applications and limitations of CAT in the neonatal population are discussed.Conclusion: CAT has successfully elucidated several differences between haemostatic mechanisms in premature and term neonates compared with adults. Moreover, it has been used to evaluate the effect of a number of haemostatic drugs in a pre-clinical model. However, the lack of evidence of CAT as an accurate predictor of neonatal bleeding, blood volume required and the absence of an evidence-based treatment algorithm for abnormal CAT results limit its current application as a bedside clinical tool for the evaluation of sick neonates. What is Known: • The Calibrated automated thrombogram (CAT) is a global coagulation assay which evaluates pro- and anti-coagulant pathways. • CAT provides greater information than standard clotting tests and has been used in adults to evaluate bleeding risk. What is New: • This review summarises the physiological differences in haemostasis between neonates and adults described using CAT. • The haemostatic effect of several drugs has been evaluated in neonatal plasma using CAT.
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How I manage pregnancy in carriers of hemophilia and patients with von Willebrand disease. Blood 2021; 136:2143-2150. [PMID: 32797211 DOI: 10.1182/blood.2019000964] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 06/15/2020] [Indexed: 12/11/2022] Open
Abstract
Women with inherited bleeding disorders, including carriers of hemophilia A and B, or with von Willebrand disease, have an increased risk of bleeding during pregnancy and delivery. The unborn child may also be affected by the bleeding disorder for which specific measures have to be considered. This requires a multidisciplinary approach, with a team that includes a hematologist, a pediatric hematologist, a clinical geneticist, an obstetrician-perinatologist, and an anesthesiologist. An optimal approach includes prepregnancy genetic counseling, prenatal diagnostic procedures, and a treatment plan for delivery for both the mother and child. Recent retrospective studies show that even if strict guidelines are followed, these women are still at risk of postpartum bleeding. This occurs even if coagulation factor levels are normalized, either due to the pregnancy-induced rise of factor levels or by infusion of coagulation factor concentrates at the time of delivery. In this article, we describe our current diagnostic and clinical management of pregnancy and delivery in women with inherited bleeding disorders. We also briefly discuss possible interventions to improve the outcome of current strategies by increasing target factor levels during and after delivery.
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Schlagenhauf A, Zieger B, Muntean W. Contact activation and acquired von Willebrand syndrome during neonatal extracorporeal circulation. J Thromb Haemost 2020; 18:3119-3121. [PMID: 33463037 DOI: 10.1111/jth.15058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 06/25/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Axel Schlagenhauf
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Wolfgang Muntean
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
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Achey MA, Nag UP, Robinson VL, Reed CR, Arepally GM, Levy JH, Tracy ET. The Developing Balance of Thrombosis and Hemorrhage in Pediatric Surgery: Clinical Implications of Age-Related Changes in Hemostasis. Clin Appl Thromb Hemost 2020; 26:1076029620929092. [PMID: 32584601 PMCID: PMC7427005 DOI: 10.1177/1076029620929092] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/14/2020] [Accepted: 04/30/2020] [Indexed: 12/17/2022] Open
Abstract
Bleeding and thrombosis in critically ill infants and children is a vexing clinical problem. Despite the relatively low incidence of bleeding and thrombosis in the overall pediatric population relative to adults, these critically ill children face unique challenges to hemostasis due to extreme physiologic derangements, exposure of blood to foreign surfaces and membranes, and major vascular endothelial injury or disruption. Caring for pediatric patients on extracorporeal support, recovering from solid organ transplant or invasive surgery, and after major trauma is often complicated by major bleeding or clotting events. As our ability to care for the youngest and sickest of these children increases, the gaps in our understanding of the clinical implications of developmental hemostasis have become increasingly important. We review the current understanding of the development and function of the hemostatic system, including the complex and overlapping interactions of coagulation proteins, platelets, fibrinolysis, and immune mediators from the neonatal period through early childhood and to young adulthood. We then examine scenarios in which our ability to effectively measure and treat coagulation derangements in pediatric patients is limited. In these clinical situations, adult therapies are often extrapolated for use in children without taking age-related differences in pediatric hemostasis into account, leaving clinicians confused and impacting patient outcomes. We discuss the limitations of current coagulation testing in pediatric patients before turning to emerging ideas in the measurement and management of pediatric bleeding and thrombosis. Finally, we highlight opportunities for future research which take into account this developing balance of bleeding and thrombosis in our youngest patients.
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Affiliation(s)
| | - Uttara P. Nag
- Department of Surgery, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Gowthami M. Arepally
- Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jerrold H. Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Elisabeth T. Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA
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Haidl H, Zöhrer E, Pohl S, Leschnik B, Weiss EC, Gallistl S, Muntean W, Schlagenhauf A. New insights into neonatal coagulation: normal clot formation despite lower intra-clot thrombin levels. Pediatr Res 2019; 86:719-724. [PMID: 31404918 DOI: 10.1038/s41390-019-0531-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Healthy neonates exhibit no bleeding tendencies, but exhibit longer partial thromboplastin times than adults. Lower clotting factor levels may be balanced by lower inhibitor levels, which is not reflected in routine coagulation assays, but could result in normal clot formation in vivo. The novel thrombodynamics assay simulates a damaged vessel with tissue factor immobilized to a surface. We hypothesized that intra-clot thrombin levels and spatial fibrin clot formation with this assay are comparable in neonates and adults. METHODS Coagulation was tested in plasma from venous neonatal blood (N = 12), cord blood (N = 30), and adult blood (N = 20) using thrombodynamics and calibrated automated thrombography. RESULTS Neonates exhibited a higher initial rate of clot formation than adults (adult: 60.7 ± 3.9 µm/min; neonatal: 66.8 ± 3.9 µm/min; cord: 68.1 ± 3.3 µm/min; P < 0.001) and a comparable stationary rate of clot formation (adult: 35.8 ± 8.5 µm/min; neonatal: 37.0 ± 4.6 µm/min; cord: 36.0 ± 5.2 µm/min; P = 0.834). Intra-clot thrombin levels were lower in neonates (adult: 41.9 ± 11.2 AU/l; neonatal: 22.6 ± 10.2 AU/l; cord: 23.6 ± 9.7 AU/l; P < 0.001), but the longitudinal rate of thrombin propagation was comparable (adult: 27.2 ± 4.2 µm/min neonatal; 27.9 ± 2.9 µm/min; cord: 27.6 ± 3.4 µm/min; P = 0.862). CONCLUSIONS Despite lower intra-clot thrombin levels, neonates exhibit normal spatial fibrin clot growth, which concurs with clinically well-functioning hemostasis in healthy neonates.
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Affiliation(s)
- Harald Haidl
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Evelyn Zöhrer
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Sina Pohl
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bettina Leschnik
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Eva-Christine Weiss
- Department of Obstetrics and Gynaecology, Medical University of Graz, Graz, Austria
| | - Siegfried Gallistl
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Wolfgang Muntean
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Axel Schlagenhauf
- Department of General Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.
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11
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Krogh AKH, Brunse A, Thymann T, Bochsen L, Kristensen AT. Staphylococcus epidermidis sepsis induces hypercoagulability in preterm pigs. Res Vet Sci 2019; 127:122-129. [PMID: 31704497 DOI: 10.1016/j.rvsc.2019.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 11/30/2022]
Abstract
Gram positive bacteria are a cause of sepsis in human preterm infants, and associates with high mortality and hemostatic dysfunction. It is unknown whether bovine colostrum may protect against sepsis and prevent hemostatic dysfunction. The current study was part of an overall sepsis study investigating Staphylococcus epidermidis (SE) induced sepsis in premature pigs including investigation of the effect of feeding bovine colostrum. The specific hypothesis of this study was that the hemostatic response would be hypercoagulable in septic pigs compared to non-infected controls, and that feeding bovine colostrum would increase the hypercoagulant response. Thromboelastography, activated partial thromboplastin time, prothrombin time and fibrinogen concentration were characterized in SE infected pigs, SE infected pigs fed bovine colostrum, and uninfected controls. All pigs were followed for 24 h. In addition, the same parameters were evaluated in a group of premature pigs and a group of full born pigs all followed for 11 days. SE septic premature pigs were characterized by increased clot strength and decreased fibrinolysis, significantly low platelet count and high fibrinogen concentration. Feeding bovine colostrum did not affect the hemostatic response. Compared to full born pigs, preterm newborn pigs demonstrated reduced clot strength, prolonged prothrombin time and low fibrinogen concentration. In all pigs, the fibrinogen concentration increased 11 days post-partum. To conclude, SE induced sepsis in premature pigs resulted in hypercoagulability. Bovine colostrum did not mitigate the hemostatic response. A hypocoagulable hemostatic response was present in healthy preterm pigs compared to full born pigs, similar to previous reports in infants.
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Affiliation(s)
- Anne Kirstine Havnsøe Krogh
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Anders Brunse
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Thomas Thymann
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Louise Bochsen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Annemarie T Kristensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
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Schmidt AE, Israel AK, Refaai MA. The Utility of Thromboelastography to Guide Blood Product Transfusion. Am J Clin Pathol 2019; 152:407-422. [PMID: 31263903 DOI: 10.1093/ajcp/aqz074] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To provide an overview of the clot viscoelastic testing technology and to describe its utility in guiding blood product transfusions. METHODS A case scenario will be discussed as well as interpretation of thromboelastography (TEG) tracings. In addition, literature examining the utility of viscoelastic testing in guiding patient management and blood product transfusions will be reviewed. RESULTS TEG/rotational thromboelastometry (ROTEM) is useful in evaluating clot kinetics in trauma and acutely bleeding patients. TEG/ROTEM parameters are reflective of values measured using standard coagulation assays; however, TEG/ROTEM parameters are more rapidly available and more costly. TEG and ROTEM are used in three main settings: cardiac surgery, liver transplantation, and trauma to assess global hemostasis and administration of blood products. CONCLUSIONS TEG/ROTEM can be helpful in guiding resuscitation and blood product transfusion. Several studies have demonstrated a reduction in transfusion of blood components with TEG/ROTEM; however, other studies have suggested that TEG/ROTEM is not clinically effective in guiding transfusion.
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Affiliation(s)
- Amy E Schmidt
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Anna Karolina Israel
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
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Haidl H, Pohl S, Leschnik B, Gallistl S, Muntean W, Schlagenhauf A. Neonatal thrombocytopenia: Thrombin generation in presence of reduced platelet counts and effects of rFVIIa in cord blood. Sci Rep 2019; 9:8014. [PMID: 31142810 PMCID: PMC6541708 DOI: 10.1038/s41598-019-44199-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 05/07/2019] [Indexed: 11/12/2022] Open
Abstract
Healthy neonates exhibit a well-functioning haemostatic system despite peculiarities regarding composition of clotting factors and inhibitors as well as impaired platelet aggregation. Thrombocytopenia and severe bleeding events are feared in sick infants. Recombinant factor VIIa (rFVIIa) is a haemostatic agent used as a last resort in neonates with refractory bleedings. Aim of this study was to investigate in-vitro (i) changes in thrombin generation with different platelet counts, (ii) effects of rFVIIa under conditions of thrombocytopenia and (iii) potentially differing dose-response of rFVIIa in cord blood as a surrogate for neonatal blood compared to adult blood. Thrombin generation parameters were observed in cord blood plasma and adult plasma with various platelet counts, with or without addition of rFVIIa, respectively. Low platelet counts did not influence thrombin generation in cord blood in contrast to adult blood. RFVIIa primarily affected lag time throughout all platelet concentrations. Interestingly, peak height was reduced exclusively in cord blood plasma after addition of rFVIIa. No significant differences regarding dose-response were observed between cord blood and adult blood. In contrast to adult blood, thrombocytopenia in cord blood does not significantly influence thrombin generation. Even at very low platelet counts there is enough negatively charged surface to support rFVIIa action in plasma from cord blood and adult blood in-vitro.
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Affiliation(s)
- Harald Haidl
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Sina Pohl
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bettina Leschnik
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Siegfried Gallistl
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Wolfgang Muntean
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Axel Schlagenhauf
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.
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Hasan S, Abuelkasem E, Williams B, Henderson R, Mazzeffi M, Tanaka K. Factor IX from prothrombin complex concentrate augments low dose tissue factor-triggered thrombin generation in vitro. Br J Anaesth 2018; 121:936-943. [DOI: 10.1016/j.bja.2018.05.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/14/2018] [Accepted: 06/02/2018] [Indexed: 11/17/2022] Open
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Adding to the complexity of fetal and neonatal alloimmune thrombocytopenia: Reduced fibrinogen binding in the presence of anti-HPA-1a antibody and hypo-responsive neonatal platelets. Thromb Res 2017; 162:69-76. [PMID: 29306729 DOI: 10.1016/j.thromres.2017.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 11/30/2017] [Accepted: 12/27/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND In fetal and neonatal alloimmune thrombocytopenia (FNAIT), maternal alloantibodies directed against paternally-derived platelet antigens are transported across the placenta to the fetus, where they may cause thrombocytopenia. The most serious complication of FNAIT is an intracranial hemorrhage (ICH), which may cause death or life-long disability of the child. Apart from alloantibody-mediated platelet destruction, the clinical outcome in FNAIT may be affected by properties of neonatal platelets and possible functional effects on platelets caused by maternal alloantibodies. METHODS AND RESULTS The function of umbilical cord blood platelets was compared with adult platelets in two assays, impedance aggregometry (Multiplate) and rotational thromboelastometry (Rotem). Both revealed a decreased in vitro neonatal platelet function compared to adult platelets. Consistent with this finding, activation using TRAP revealed less pronounced changes in the expression of CD62P, PAC-1, CD41 and CD42a in umbilical cord blood platelets compared to adult platelets. Furthermore, a monoclonal anti-HPA-1a antibody, derived from an immunized mother of two children with FNAIT, blocked fibrinogen binding to resting and activated umbilical cord blood and adult HPA-1aa and HPA-1ab platelets, interfered with platelet activation by TRAP, and impaired the function of umbilical cord blood HPA-1aa platelets in rotational thromboelastometry. DISCUSSION AND CONCLUSIONS Reduced fibrinogen binding in the presence of anti-HPA-1a antibodies may disturb the neonatal hemostatic balance, characterized by poorly responsive platelets. This effect may operate in parallel to platelet destruction and contribute to the clinical outcome in FNAIT.
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16
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Reference intervals of citrated-native whole blood thromboelastography in premature neonates. Early Hum Dev 2017; 115:60-63. [PMID: 28923772 DOI: 10.1016/j.earlhumdev.2017.09.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 08/21/2017] [Accepted: 09/09/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Bleeding due to acquired coagulation disorders is a common complication in premature neonates. In this clinical setting, standard coagulation laboratory tests might be unsuitable to investigate the hemostatic function as they reflect the concentration of pro-coagulant proteins but not of anti-coagulant proteins. Thromboelastography (TEG), providing a more complete assessment of hemostasis, may be able to overcome some of these limitations. Unfortunately, experience on the use of TEG in premature neonates is very limited and, in particular in this population, reference ranges of TEG parameters have not been yet evaluated. AIMS To evaluate TEG in preterm neonates, and to assess their reference ranges. METHODS One hundred and eighteen preterm neonates were analyzed for TEG in a retrospective cohort study. Double-sided 95% reference intervals were calculated using a bootstrap method after Box-Cox transformation. TEG parameters were compared between early-preterm and moderate-/late-preterm neonates and between bleeding and non-bleeding preterm neonates. RESULTS Comparing early-preterm with moderate-/late-preterm neonates, TEG parameters were not statistically different, except for fibrinolysis which was significantly higher in early preterm neonates. Platelet count significantly correlated with α angle and MA parameters. Bleeding and non-bleeding neonates had similar TEG values. CONCLUSIONS These results reinforce the concept that in stable preterm neonates, in spite of lower concentration of pro- and anti-coagulants proteins, the hemostasis is normally balanced and well functioning.
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17
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Schlagenhauf A, Haidl H, Pohl S, Weiss EC, Leschnik B, Gallistl S, Muntean W. Polyphosphate in Neonates: Less Shedding from Platelets and Divergent Prothrombotic Capacity Due to Lower TFPI Levels. Front Physiol 2017; 8:586. [PMID: 28970801 PMCID: PMC5609555 DOI: 10.3389/fphys.2017.00586] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/31/2017] [Indexed: 12/28/2022] Open
Abstract
Background: The neonatal hemostatic system exhibits a fragile balance featuring lower levels of clotting factors as well as inhibitors. Neonatal platelets show in-vitro hypoaggregability, but neonates exhibit well-functioning primary and secondary hemostasis despite this impairment. Recently, polyphosphate shed by activated platelets has been shown to induce a prothrombotic shift on the plasmatic coagulation system of adults. The impact of platelet derived polyphosphate might differ in neonates due to aforementioned peculiarities. Aims: We aimed to comparatively determine polyphosphate content and release from adult and neonatal platelets and to determine its impact on thrombin generation in plasma from adult and cord blood. Methods: Polyphosphate was extracted from adult and neonatal platelet lysates and releasates using silica spin-columns and quantified with a DAPI based fluorescence assay. The impact of exogenous polyphosphate in various concentrations (208–0.026 μg/ml) on thrombin generation was evaluated in plasma from adult and cord blood as well as in adult plasma with reduced tissue factor pathway inhibitor (TFPI) levels using calibrated automated thrombography. Results: Polyphosphate content was comparable in both groups, but the fraction of released polyphosphate upon stimulation with thrombin receptor activating peptide was lower in neonatal samples (adult: 84.1 ± 12.9%; cord: 58.8 ± 11.2%). Relative impact of polyphosphate on lag time of thrombin generation was higher in adult samples compared to samples from cord blood (adult: 41.0% [IQR: 35.2–71.8%] of vehicle; cord: 73.4% [IQR: 70.2–91.4%] of vehicle). However, in samples from cord blood, lower concentrations of polyphosphate were required to obtain maximal impact on thrombin generation (adult: 26 μg/ml; cord: 0.814 μg/ml). PolyP affected thrombin generation in adult plasma similarly to cord plasma, when the TFPI concentration was reduced to neonatal levels. Conclusion: Differences in the impact of polyphosphate on adult and neonatal coagulation are largely caused by differences in TFPI levels. Lower polyphosphate release from neonatal platelets, but lower optimum concentration to drive neonatal plasmatic hemostasis emphasizes the well-matched, but fragile interplay between platelets and coagulation in newborns. A potential developmental mismatch should be considered when transfusing adult platelets into neonates.
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Affiliation(s)
- Axel Schlagenhauf
- Department of General Pediatrics and Adolescent Medicine, Medical University of GrazGraz, Austria
| | - Harald Haidl
- Department of General Pediatrics and Adolescent Medicine, Medical University of GrazGraz, Austria
| | - Sina Pohl
- Department of General Pediatrics and Adolescent Medicine, Medical University of GrazGraz, Austria
| | - Eva-Christine Weiss
- Department of Obstetrics and Gynecology, Medical University of GrazGraz, Austria
| | - Bettina Leschnik
- Department of General Pediatrics and Adolescent Medicine, Medical University of GrazGraz, Austria
| | - Siegfried Gallistl
- Department of General Pediatrics and Adolescent Medicine, Medical University of GrazGraz, Austria
| | - Wolfgang Muntean
- Department of General Pediatrics and Adolescent Medicine, Medical University of GrazGraz, Austria
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Paar M, Rossmann C, Nusshold C, Wagner T, Schlagenhauf A, Leschnik B, Oettl K, Koestenberger M, Cvirn G, Hallström S. Anticoagulant action of low, physiologic, and high albumin levels in whole blood. PLoS One 2017; 12:e0182997. [PMID: 28800610 PMCID: PMC5553770 DOI: 10.1371/journal.pone.0182997] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/27/2017] [Indexed: 01/01/2023] Open
Abstract
Albumin is the most abundant plasma protein. Critical illness is often associated with altered, predominately decreased, serum albumin levels. This hypoalbuminaemia is usually corrected by administration of exogenous albumin. This study aimed to track the concentration-dependent influence of albumin on blood coagulation in vitro. Whole blood (WB) samples from 25 volunteers were prepared to contain low (19.3 ± 7.7 g/L), physiological (45.2 ± 7.8 g/L), and high (67.5 ± 18.1 g/L) levels of albumin. Haemostatic profiling was performed using a platelet function analyzer (PFA) 200, impedance aggregometry, a Cone and Platelet analyzer (CPA), calibrated automated thrombogram, and thrombelastometry (TEM). Platelet aggregation-associated ATP release was assessed via HPLC analysis. In the low albumin group, when compared to the physiological albumin group, we found: i) shortened PFA 200-derived closure times indicating increased primary haemostasis; ii) increased impedance aggregometry-derived amplitudes, slopes, ATP release, as well as CPA-derived average size indicating improved platelet aggregation; iii) increased TEM-derived maximum clot firmness and alpha angles indicating enhanced clot formation. TEM measurements indicated impaired clot formation in the high albumin group compared with the physiological albumin group. Thus, albumin exerted significant anticoagulant action. Therefore, low albumin levels, often present in cancer or critically ill patients, might contribute to the frequently occurring venous thromboembolism.
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Affiliation(s)
- Margret Paar
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Christine Rossmann
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Christoph Nusshold
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Thomas Wagner
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Graz, Graz, Austria
| | | | - Bettina Leschnik
- Department of Pediatrics, Medical University of Graz, Graz, Austria
| | - Karl Oettl
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | | | - Gerhard Cvirn
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
- * E-mail:
| | - Seth Hallström
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
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Abuelkasem E, Hasan S, Mazzeffi MA, Planinsic RM, Sakai T, Tanaka KA. Reduced Requirement for Prothrombin Complex Concentrate for the Restoration of Thrombin Generation in Plasma From Liver Transplant Recipients. Anesth Analg 2017; 125:609-615. [DOI: 10.1213/ane.0000000000002106] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Zeng L, Choonara I, Zhang L, Li Y, Shi J. Effectiveness of prothrombin complex concentrate (PCC) in neonates and infants with bleeding or risk of bleeding: a systematic review and meta-analysis. Eur J Pediatr 2017; 176:581-589. [PMID: 28281092 DOI: 10.1007/s00431-017-2877-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 02/07/2017] [Accepted: 02/09/2017] [Indexed: 02/05/2023]
Abstract
UNLABELLED To systematically evaluate the effectiveness of prothrombin complex concentrate (PCC) in neonates and infants, we performed a systematic review and meta-analysis based on current evidence. Quality of studies was assessed by Cochrane Collaboration's risk of bias tool and Newcastle-Ottawa quality assessment scale. For dichotomous data, we obtained the number of events and total number and calculated the relative risk (RR) with 95% confidence intervals (CI). For continuous variables, we obtained mean and standard deviation (SD) values and calculated mean difference (MD) with 95% CI. We identified six trials and two cohort studies. For trials, selection bias and performance bias were high, while detection bias, attrition bias, and reporting bias were relatively low. For cohort studies, selection bias was low. Both individual studies and meta-analysis failed to find any benefit of PCC on mortality. Meta-analysis also failed to show any benefit in reducing intracranial hemorrhage. The effectiveness of PCC on the correction of hemostatic defects was inconsistent among studies. In addition, PCC was not more effective than fresh frozen plasma (FFP) in correcting hemostatic defects. CONCLUSION There is insufficient evidence to allow a recommendation for use of PCC in neonates and infants. What is Known: • Prothrombin Complex Concentrate is becoming increasingly used off-label for treatment of neonates and infants with severe bleeding or risk of severe bleeding. • Some case reports showed PCC seemed to be effective for infants and children with coagulation factor deficiency, but evidence about the effectiveness of PCC to reverse serious Vitamin K Deficiency Bleeding is limited. What is New: • As far as we know, this is the first systematic review that evaluates the effectiveness of PPC in neonates with bleeding or risk of bleeding. • There is insufficient evidence to allow a recommendation for use of PCCs in neonates and infants.
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Affiliation(s)
- Linan Zeng
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Imti Choonara
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby, UK
| | - Lingli Zhang
- Department of Pharmacy/Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China.
| | - Youping Li
- Chinese Evidence-Based Medicine Centre/Chinese Cochrane Center, West China Hospital, Sichuan University, Chengdu, China.
| | - Jing Shi
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, China
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Tanjung MT, Siddik HD, Hariman H, Koh SCL. Coagulation and Fibrinolysis in Preeclampsia and Neonates. Clin Appl Thromb Hemost 2016; 11:467-73. [PMID: 16244774 DOI: 10.1177/107602960501100415] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Coagulation and fibrinolysis were determined in 67 Indonesian women admitted to the University Hospitals for delivery in Medan. They were diagnosed to be at term gestation (mean 39.3 ± 1.1 weeks) with moderate and severe preeclampsia (n=32) and in labor, and 8 had preterm labor (gestation mean 33.5 ± 2.6 weeks). Twenty-seven normal pregnant women in labor (gestation mean 39.7 ± 1.0 weeks) served as controls. Cord blood from 23 neonates from normal pregnancy and 31 neonates from preeclampsia was also evaluated. Preeclamptic women in labor showed further enhanced coagulation activation (F1+2) with raised urokinase-like plasminogen activator (u-PA) activity and reduced plasminogen activator inhibitor-2 (PAI-2) levels. In preterm preeclampsia, significantly reduced antithrombin III (ATIII) and PAI-2 levels with further elevated tissue-type PA (t-PA) antigen and plasminogen activator inhibitor-1 (PAI-1) antigen were seen compared to normal pregnancy. These would suggest a state of enhanced thrombin generation with elevated fibrinolytic/inhibitor proteins in preterm preeclampsia. The reduced PAI-2 levels seen in preeclampsia have been suggested to be associated with reduced placental function. Neonates born to mothers of either normal pregnancy or preeclampsia at term showed similar hemostatic changes with reduced fibrinogen, ATIII, t-PA, u-PA antigen, PAI-1 levels, and coagulation activation compared to their respective maternal plasma levels. No significant differences in hemostatic parameters studied between the neonates of both cohorts were seen, and this would suggest that the neonates were protected from the adverse effects of preeclampsia and their hemostatic system was physiologically balanced.
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Affiliation(s)
- M Thamrin Tanjung
- Department of Obstetrics and Gynaecology, University of North Sumatra, Faculty of Medicine, Medan, Indonesia
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Rice NT, Szlam F, Varner JD, Bernstein PS, Szlam AD, Tanaka KA. Differential Contributions of Intrinsic and Extrinsic Pathways to Thrombin Generation in Adult, Maternal and Cord Plasma Samples. PLoS One 2016; 11:e0154127. [PMID: 27196067 PMCID: PMC4873248 DOI: 10.1371/journal.pone.0154127] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 04/09/2016] [Indexed: 11/18/2022] Open
Abstract
Background Thrombin generation (TG) is a pivotal process in achieving hemostasis. Coagulation profiles during pregnancy and early neonatal period are different from that of normal (non-pregnant) adults. In this ex vivo study, the differences in TG in maternal and cord plasma relative to normal adult plasma were studied. Methods Twenty consented pregnant women and ten consented healthy adults were included in the study. Maternal and cord blood samples were collected at the time of delivery. Platelet-poor plasma was isolated for the measurement of TG. In some samples, anti-FIXa aptamer, RB006, or a TFPI inhibitor, BAX499 were added to elucidate the contribution of intrinsic and extrinsic pathway to TG. Additionally, procoagulant and inhibitor levels were measured in maternal and cord plasma, and these values were used to mathematically simulate TG. Results Peak TG was increased in maternal plasma (393.6±57.9 nM) compared to adult and cord samples (323.2±38.9 nM and 209.9±29.5 nM, respectively). Inhibitory effects of RB006 on TG were less robust in maternal or cord plasma (52% vs. 12% respectively) than in adult plasma (81%). Likewise the effectiveness of BAX499 as represented by the increase in peak TG was much greater in adult (21%) than in maternal (10%) or cord plasma (12%). Further, BAX499 was more effective in reversing RB006 in adult plasma than in maternal or cord plasma. Ex vivo data were reproducible with the results of the mathematical simulation of TG. Conclusion Normal parturient plasma shows a large intrinsic pathway reserve for TG compared to adult and cord plasma, while TG in cord plasma is sustained by extrinsic pathway, and low levels of TFPI and AT.
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Affiliation(s)
- Nicklaus T. Rice
- Department of Obstetric and Gynecology, Vanderbilt Medical Center, Nashville, Tennessee, United States of America
| | - Fania Szlam
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Jeffrey D. Varner
- School of Chemical Engineering, Purdue University, West Lafayette, Indiana, United States of America
| | - Peter S. Bernstein
- Department of Clinical Obstetric & Gynecology and Women’s Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, United States of America
| | - Arthur D. Szlam
- Department of Mathematics, CCNY, New York, United States of America
| | - Kenichi A. Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
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Tanaka KA, Mazzeffi MA, Strauss ER, Szlam F, Guzzetta NA. Computational simulation and comparison of prothrombin complex concentrate dosing schemes for warfarin reversal in cardiac surgery. J Anesth 2016; 30:369-76. [DOI: 10.1007/s00540-015-2128-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 12/19/2015] [Indexed: 10/22/2022]
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Uszyński M, Kuczyński J, Żekanowska E, Uszyński W. The Contact Activation System (CAS) in cord blood: Measurement of CAS components and comparison with mother's blood. A pilot study. Thromb Res 2015; 136:1018-21. [PMID: 26384441 DOI: 10.1016/j.thromres.2015.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 06/19/2015] [Accepted: 07/22/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Classical reference data concerning the coagulation system and fibrinolysis in fetuses and newborns date back to the 1990 s. Since that time a number of methodological or other improvements have been implemented, which may cast some doubt on timeliness of the data. The study objective was to measure the levels of Contact Activation System (CAS) components by antigen, i.e. factors XII and XI (FXII, FXI), prekallikrein (PK) and high molecular weight kininogen (HMWK) in cord blood and maternal blood. MATERIAL AND METHODS The study group consisted of 35 healthy parturient women with an uneventful pregnancy and birth. The samples of cord blood and maternal blood were obtained immediately after delivery, before clumping the umbilical cord. The CAS components were measured by immunoenzymatic method (ELISA). RESULTS The median concentrations of CAS components in cord blood plasma and mother's plasma were as follow: FXII: 1.02 (0.60- 2.58) ng/mg protein vs. 0.94 (0.66-1.86) ng/mg protein (p>0.05); FXI: 2.71(0.03-8.0) ng/mg protein vs. 0.92 (0.03-10.44) ng/mg protein (p>0.05); PK: 168.78 (104.28-261.16) pg/mg protein vs. 113.44 (79.94-146.70) pg/mg protein (p>0.05); HMWK: 2169.45 (1530.64- 2539.83) ng/mg protein vs. 2857.96 (2541.52-3161.04) ng/mg protein (p<0.001). CONCLUSIONS 1. The antigen levels of the three contact factors, i.e. FXII, FXI and PK in the cord blood of full-term and healthy fetuses were similar to those observed in mother's blood immediately after delivery. Only high molecular weight kininogen was found to be lower (accounting for 84% of the values noted in mothers). 2. Based on our measurements, we claim that the cited reference data concerning the contact factors in full-term and healthy newborns are underestimated; hence, new reference values need to be determined for each antigen and activity contact factor level.
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Affiliation(s)
- Mieczysław Uszyński
- Department of Propedeutics of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland.
| | | | - Ewa Żekanowska
- Department of Pathophysiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland
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Pal S, Curley A, Stanworth SJ. Interpretation of clotting tests in the neonate. Arch Dis Child Fetal Neonatal Ed 2015; 100:F270-4. [PMID: 25414486 DOI: 10.1136/archdischild-2014-306196] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 11/05/2014] [Indexed: 01/01/2023]
Abstract
There are significant differences between the coagulation system in neonates compared with children and adults. Abnormalities of standard coagulation tests are common within the neonatal population. The laboratory tests of activated partial thromboplastin time (aPTT) and prothrombin time (PT) were developed to investigate coagulation factor deficiencies in patients with a known bleeding history, and their significance and applied clinical value in predicting bleeding (or thrombotic) risk in critically ill patients is weak. Routine screening of coagulation on admission to the neonatal intensive care unit leads to increased use of plasma for transfusion. Fresh frozen plasma (FFP) is a human donor plasma frozen within a short specified time period after collection (often 8 h) and then stored at -30°C. FFP has little effect on correcting abnormal coagulation tests when mild and moderate abnormalities of PT are documented in neonates. There is little evidence of effectiveness of FFP in neonates. A large trial by the Northern Neonatal Nursing Initiative assessed the use of prophylactic FFP in preterm infants and reported no improvement in clinical outcomes in terms of mortality or severe disability. An appropriate FFP transfusion strategy in neonates should be one that emphasises the therapeutic use in the face of bleeding rather than prophylactic use in association with abnormalities of standard coagulation tests that have very limited predictive value for bleeding.
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Affiliation(s)
- Sanchita Pal
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anna Curley
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Simon J Stanworth
- Department of Haematology, National Health Service Blood and Transplant/Oxford University Hospitals Trust, Headington, Oxford, UK
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Abstract
Two detailed reviews of the management of neonatal thrombosis were published in 2012; one was an up-dated version of guidance first issued in 2004 and the other was a comprehensive review. Both of these publications gave very similar advice regarding the practical aspects of the indications, dosage and management of antithrombotic therapy. The authors stated that the evidence supporting most of their recommendations for anti-thrombotic therapy in neonates remained weak and so the therapy for a neonate with a thrombosis has to be based on an individualized assessment of estimated risk versus potential benefit. The aim of this present review is to give the treating physician an outline of the unique physiology of neonatal coagulation and how this affects the monitoring, dosing and even the choice of therapeutic strategy for the management of thrombosis in the neonate.
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Affiliation(s)
- Andrew Will
- Department of Paediatric Haematology, Royal Manchester Children's Hospital, Manchester, UK
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Cvirn G, Waha JE, Ledinski G, Schlagenhauf A, Leschnik B, Koestenberger M, Tafeit E, Hinghofer-Szalkay H, Goswami N. Bed rest does not induce hypercoagulability. Eur J Clin Invest 2015; 45:63-9. [PMID: 25413567 DOI: 10.1111/eci.12383] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 11/19/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although there is no direct evidence, it is generally believed that bed rest shifts the haemostatic system towards hypercoagulability; thus, immobilized patients are commonly treated with anticoagulants. We therefore aimed to investigate whether long-term bed rest actually leads to an elevated risk for thromboembolic events. MATERIALS AND METHODS Eleven healthy men were enrolled in our study (bed rest campaign in MEDES Clinique d'Investigation, Toulouse, France). Besides various standard laboratory methods, we used calibrated automated thrombography (CAT) and thrombelastometry (TEM). Activation of samples with minute amounts of relipidated tissue factor allowed sensitive detection of hyper- or hypocoagulable states. RESULTS CAT and TEM values were not indicative of bed rest-induced hypercoagulability. On the contrary, several parameters were indicative of a tendency towards a hypocoagulable state. Peak and thrombin formation velocity (VELINDEX) were significantly decreased during bed rest compared to baseline. Coagulation times were significantly increased and alpha angles were significantly decreased, indicating attenuated clot formation. Moreover, F1 + 2 and thrombin/antithrombin complex (TAT) values were significantly decreased during bed rest, indicating suppressed coagulation activation. FVII plasma levels were also significantly decreased during the first week of bed rest. CONCLUSIONS Our data indicate that the re-ambulation period is associated with a tendency towards hypercoagulability: ttPeak and StartTail were significantly shorter, Peak and VELINDEX were significantly higher compared to baseline. Moreover, plasma levels of F1 + 2, TAT, FVII and FVIII were significantly higher compared to baseline. The results from our study suggest that bed rest by itself is not associated with hypercoagulable states in healthy subjects.
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Affiliation(s)
- Gerhard Cvirn
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
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Koutroumpi S, Spiezia L, Albiger N, Barbot M, Bon M, Maggiolo S, Gavasso S, Simioni P, Frigo A, Mantero F, Scaroni C. Thrombin generation in Cushing's Syndrome: do the conventional clotting indices tell the whole truth? Pituitary 2014; 17:68-75. [PMID: 23408210 DOI: 10.1007/s11102-013-0467-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cushing's Syndrome (CS) is associated with an increased mortality, where hypercoagulability seems to have a crucial role in both arterial and venous thrombosis. Parameters of in vitro thrombin generation (TG) such as lag time, peak thrombin and endogenous thrombin potential (ETP), that describe the time until thrombin burst, the peak amount of TG and the total amount of thrombin generated, respectively as well as classical clotting markers were evaluated in 33 CS patients compared to both a group of 28 patients matched for the features of Metabolic Syndrome (MetS) and 31 healthy individuals. CS and MetS patients had shorter lag time (p < 0.0001), higher peak and ETP (p < 0.0001) than healthy controls, though lag time was less shortened in CS (p < 0.0001) respect to MetS group. Prothrombin time (PT) was increased (p < 0.0001) in both CS and MetS patients, while partial thromboplastin time (PTT) was shorter (p < 0.0001) in CS compared to both MetS and healthy group (p < 0.0001). Factor VIII (FVIII), Antithrombin (AT), protein C and S were increased only in CS patients (p < 0.0001). lag time, AT and FVIII correlated to night salivary cortisol (r = + 0.59; p = 0.0005, r = + 0.40; p = 0.003, r = + 0.40; p = 0.04, respectively); PTT correlated inversely to urinary free cortisol (r = -0.45; p = 0.009). BMI correlated negatively to lag time (r = -0.40; p = 0.0001) and positively to peak and ETP (r = + 0.34; p = 0.001, r = + 0.28; p = 0.008, respectively). Obese and diabetic patients had shorter lag time (p = 0.0005; p = 0.0002, respectively), higher ETP (p = 0.0006; p = 0.007, respectively) and peak (p = 0.0003; p = 0.0005, respectively) as well as a more prolonged PT (p = 0.04; p = 0.009, respectively). Hypertensive individuals had higher ETP (p = 0.004), peak (p = 0.0008) and FVIII (p = 0.001). Our findings confirm a prothrombotic state in both CS and MetS patients, though lag time was less shortened in CS. The high levels of endogenous physiological anticoagulants, could possibly represent a protective mechanism against hypercoagulability seen in CS patients.
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Affiliation(s)
- S Koutroumpi
- Endocrinology Unit, Department of Medicine-DIMED, University of Padua, Via Ospedale, 105, 35128, Padua, Italy
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Abstract
The coagulation system involves a dynamic group of procoagulation and anticoagulation proteins that appear early in fetal life and whose levels change throughout childhood and into the teenage years. This process is called developmental hemostasis. Developmental hemostasis creates unique challenges for clinicians affecting the diagnosis and treatment of coagulation disorders during early childhood. The objective of this review is to assist pediatricians in understanding the coagulation system in fetal life and childhood and to provide guidance for interpreting basic coagulation testing, which will result in an improved ability to diagnose and treat patients with hemostatic and thrombotic disorders.
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Affiliation(s)
- Julie Jaffray
- Department of Hematology/Oncology, Children's Hospital of Los Angeles, University of Southern California Keck School of Medicine, 4650 Sunset Boulevard, Mail Stop #54, Los Angeles, CA 90027, USA
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Kuperman AA, Brenner B, Kenet G. Intraventricular haemorrhage in preterm infants – Can we improve outcome by addressing coagulation? J Matern Fetal Neonatal Med 2013; 28 Suppl 1:2265-7. [DOI: 10.3109/14767058.2013.796165] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lamprecht M, Moussalli H, Ledinski G, Leschnik B, Schlagenhauf A, Koestenberger M, Polt G, Cvirn G. Effects of a single bout of walking exercise on blood coagulation parameters in obese women. J Appl Physiol (1985) 2013; 115:57-63. [DOI: 10.1152/japplphysiol.00187.2013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Obesity is associated with increased prevalence of thromboembolic events. We aimed to investigate whether obese women might benefit from vigorous aerobic exercise. Forty-two overweight and obese women performed a 30-min walking exercise test (treadmill ergometer) at an intensity of 70% of individual peak oxygen uptake. Blood samples were collected before and immediately after exercise. Thrombelastometry and platelet function measurements were performed on whole blood. Standard coagulation times, thrombin generation curves, markers of thrombin generation, fibrinolytic parameters, plasma levels of pro- and anticoagulatory factors, and microparticle procoagulant activity were determined in platelet-poor plasma samples. Thrombelastometry revealed a significant prolongation of clot formation time ( P = 0.037) and a significant deceleration of fibrin build up (alpha angle, P = 0.034) after exercise. Calibrated automated thrombography revealed a significant exercise-induced decrease in endogenous thrombin potential ( P = 0.039). Moreover, thrombin formation stopped earlier postexercise, reflected in shortened StartTail ( P = 0.046). Significantly elevated tissue-plasminogen activator levels ( P = 0.001) indicate an exercise-induced activation of the fibrinolytic system. White blood cell count increased significantly from pre- to postexercise ( P = 0.045), indicating a mild exercise-induced leukocytosis. The results of this study demonstrate that vigorous aerobic exercise might be a suitable tool to protect obese women from thrombotic events. We show that a single bout of vigorous aerobic exercise is clearly associated with an activation of the fibrinolytic system and a decreased readiness of the postexercise samples to form a clot and to generate thrombin, the pivotal enzyme of hemostasis.
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Affiliation(s)
- Manfred Lamprecht
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
- Green Beat-Institute of Nutrient Research and Sport Nutrition, Graz, Austria; and
| | - Herve Moussalli
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Gerhard Ledinski
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Bettina Leschnik
- Department of Pediatrics, Medical University of Graz, Graz, Austria
| | | | | | - Guenter Polt
- Green Beat-Institute of Nutrient Research and Sport Nutrition, Graz, Austria; and
| | - Gerhard Cvirn
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
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Palojärvi A, Andersson S, Långström S, Petäjä J. Coordinated release of tissue factor and tissue factor pathway inhibitor in VLBW infants. Acta Paediatr 2013; 102:584-9. [PMID: 23458419 DOI: 10.1111/apa.12220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 01/28/2013] [Accepted: 02/26/2013] [Indexed: 11/28/2022]
Abstract
AIM Tissue factor (TF), a mediator between coagulation and inflammation, is upregulated in alveolar compartment and circulation in very low birthweight (VLBW) infants. We investigated the contribution of TF to systemic regulation of coagulation in VLBW infants. METHODS We measured TF, total and free tissue factor pathway inhibitor (TFPIt, TFPIf), prothrombin fragment (F1 + 2), and thrombin-antithrombin complexes (TAT) in plasma from 51 VLBW infants during their first week of life. RESULTS F1 + 2 in cord plasma was high (1385 pmol/mL) and decreased postnatally to 17% (p = 0.002). TAT decreased from a high cord concentration to 3% postnatally (p < 0.001). Plasma TF increased and peaked on day 3, showing no correlation with F1 + 2 or TAT. TFPIt and TFPIf increased postnatally, correlating with TF (day 1 TFPIf: R = 0.595, p < 0.001, day 3 TFPIf: R = 0.582, p < 0.001). Based on the TF/TFPIf ratio, a relative excess of plasma TF over TFPIf probably prevailed on day 3. CONCLUSIONS In VLBW infants plasma TF fails to associate with thrombin formation. This is partly explained by release of TFPI. Despite TFPI, the newborn VLBW infant is subjected to a substantial circulating pool of TF with potential proinflammatory effects.
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Affiliation(s)
- Anniina Palojärvi
- Children's Hospital, University of Helsinki, and Helsinki University Central Hospital, Helsinki, Finland.
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Cimenti C, Schlagenhauf A, Leschnik B, Schretter M, Tschakert G, Gröschl W, Seibert FJ, Hofmann P, Muntean WE. Low endogenous thrombin potential in trained subjects. Thromb Res 2013; 131:e281-5. [PMID: 23628230 DOI: 10.1016/j.thromres.2013.04.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/19/2013] [Accepted: 04/08/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION A paradox seems to exist: exercising leads to clotting activation in conventional clotting tests, but exercising persons have a low risk of thrombosis. In this study we tried to evaluate the effect of exercise performance status on in vitro plasma thrombin generation, which represents an overall function test of hemostasis. MATERIALS AND METHODS We compared 56 trained subjects to 98 healthy age matched sedentary volunteers. Blood samples were analyzed for thrombin generation using calibrated automated thrombography. Microparticles were quantified using ELISA. Additionally prothrombin fragments 1 + 2, thrombin-antithrombin complex, tissue factor pathway inhibitor, antithrombin and prothrombin were measured. The group of the trained subjects performed an incremental cycle-ergometer exercise test after taking the blood sample. RESULTS A significantly lower endogenous thrombin potential was observed in the group of the trained subjects compared to the sedentary individuals (p = 0.007). Microparticles (ELISA) were significantly lower in the trained subjects compared to the sedentary subjects (p = 0.001). Prothrombin fragments 1 + 2 (p < 0.001) and thrombin-antithrombin complex (p = 0.01) were significant higher in the trained subjects and antithrombin (p = 0.02) as well as prothrombin (p < 0.0001) were significantly lower in this group, whereas tissue factor pathway inhibitor values did not show significant differences. Both maximal and submaximal power output was significantly negatively related to endogenous thrombin potential (r = -0.43, r = -0.45) and thrombin peak (r = -0.44, r = -0.42). CONCLUSIONS Trained subjects have a lower endogenous thrombin potential than sedentary subjects possibly explaining the lower incidence of thrombosis in this group despite a higher acute clotting activation during strenuous exercise.
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Affiliation(s)
- Christina Cimenti
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Austria
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Increased procoagulant function of microparticles in pediatric inflammatory bowel disease: role in increased thrombin generation. J Pediatr Gastroenterol Nutr 2013; 56:401-7. [PMID: 23164759 DOI: 10.1097/mpg.0b013e31827daf72] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Patients with inflammatory bowel disease (IBD) have a higher risk for venous thromboembolism compared with non-IBD subjects. The pathogenic mechanisms of the thrombotic events are not fully understood. We investigated levels of circulating microparticles and their influence on thrombin generation in pediatric patients with IBD during active and quiescent disease compared with healthy controls. METHODS Plasma samples were collected from 33 pediatric patients with Crohn disease (CD), 20 pediatric patients with ulcerative colitis (UC), and 60 healthy controls. Microparticles' procoagulant activity was measured by enzyme-linked immunosorbent assay, and the dependency of thrombin generation on microparticles-derived tissue factor was determined by means of calibrated automated thrombography. RESULTS The procoagulant function of microparticles was significantly increased in patients with active and inactive CD, and active UC compared with controls. Endogenous thrombin potential was significantly higher in patients with CD and UC compared with controls. A minor influence of microparticles on thrombin generation was only observed for patients with active UC. CONCLUSIONS Our study shows increased procoagulant function of microparticles in pediatric patients with active and quiescent CD and active UC compared with controls, but demonstrates that they are not a major cause for the higher thrombin generation in pediatric patients with IBD.
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Kuperman AA, Brenner B, Kenet G. Intraventricular hemorrhage in preterm infants and coagulation – Ambivalent perspectives? Thromb Res 2013; 131 Suppl 1:S35-8. [DOI: 10.1016/s0049-3848(13)70018-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Effect of rivaroxaban, in contrast to heparin, is similar in neonatal and adult plasma. Blood Coagul Fibrinolysis 2012; 22:588-92. [PMID: 21799400 DOI: 10.1097/mbc.0b013e328349f190] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Neonates have lower levels of clotting factors as well as inhibitors. Effects of heparin in neonatal plasma differ from those in adult plasma, and dosage recommendations cannot be extrapolated from adult trials. Riveroxaban is an oral direct factor Xa inhibitor that can achieve an anticoagulant effect without dependence on anti-thrombin. We performed comparative thrombin generation measurements in neonatal cord and adult plasma with different concentrations of unfractionated heparin and rivaroxaban to evaluate the potential of rivaroxaban in neonatal anticoagulation. The impact of heparin or rivaroxaban on the neonatal and adult hemostatic system was determined measuring calibrated automated thrombin generation and activated partial thromboplastin time in platelet-poor plasma pools of 15 adult samples or 15 neonatal cord samples and addition of seven increasing concentrations of heparin or rivaroxaban, respectively, to the pooled samples. Lag time, time to peak and peak height of thrombin generation in neonatal cord samples were significantly less affected by different heparin concentrations than in adult samples, whereas the impact on reduction of endogenous thrombin potential was higher in neonatal cord samples. The impact of rivaroxaban on thrombin generation parameters showed better comparability between neonatal cord and adult samples. Both anticoagulants showed the same differences in activated partial thromboplastin time between adult and neonatal plasma at each concentration. Rivaroxaban shows a very similar pattern in neonatal cord and adult plasma in suppressing thrombin generation and prolonging activated partial thromboplastin time values, suggesting that dose finding may be easier with rivaroxaban in neonates.
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Bolliger D, Seeberger MD, Tanaka KA. Principles and Practice of Thromboelastography in Clinical Coagulation Management and Transfusion Practice. Transfus Med Rev 2012; 26:1-13. [DOI: 10.1016/j.tmrv.2011.07.005] [Citation(s) in RCA: 288] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Microparticles (MPs), tissue factor (TF) and tissue factor inhibitor (TFPI) in cord blood plasma. A preliminary study and literature survey of procoagulant properties of MPs. Eur J Obstet Gynecol Reprod Biol 2011; 158:37-41. [DOI: 10.1016/j.ejogrb.2011.04.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 04/20/2011] [Accepted: 04/30/2011] [Indexed: 11/23/2022]
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Microparticles in newborn cord blood: Slight elevation after normal delivery. Thromb Res 2011; 128:62-7. [DOI: 10.1016/j.thromres.2011.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 12/28/2010] [Accepted: 01/31/2011] [Indexed: 11/18/2022]
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Ferrer-Marin F, Chavda C, Lampa M, Michelson AD, Frelinger AL, Sola-Visner M. Effects of in vitro adult platelet transfusions on neonatal hemostasis. J Thromb Haemost 2011; 9:1020-8. [PMID: 21320282 PMCID: PMC3130591 DOI: 10.1111/j.1538-7836.2011.04233.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Thrombocytopenia is frequent among neonates, and 20-25% of affected infants are treated with platelet transfusions. These are frequently given for mild thrombocytopenia (platelets: 50-100 × 10(9) L(-1)), largely because of the known hyporeactivity of neonatal platelets. In tests of primary hemostasis, however, neonates have shorter bleeding and closure times (CTs) than adults. This has been attributed to their higher hematocrits, higher von Willebrand factor (VWF) concentrations, and predominance of longer VWF polymers. OBJECTIVE To determine whether the 'transfusion' of adult (relatively hyperreactive) platelets into neonatal blood results in a hypercoagulable profile. METHODS Cord blood (CB) and adult peripheral blood (PB) were separated (with a modified buffy coat method) to generate miniaturized platelet concentrates (PCs) and thrombocytopenic blood. PB-derived and CB-derived PCs (n = 7 per group) were then 'transfused'in vitro into thrombocytopenic CB and PB. The effects of autologous vs. allogeneic (developmentally mismatched) 'transfusions' were evaluated with whole blood aggregometry, a platelet function analyzer (PFA-100), and thromboelastography (TEG). RESULTS Adult platelets aggregated significantly better than neonatal platelets in response to thrombin receptor-activating peptide, ADP, and collagen, regardless of the blood into which they were transfused. The 'transfusion' of adult platelets into thrombocytopenic CB resulted in shorter CTs-EPI (PFA-100) and higher clot strength and firmness (TEG) than 'transfusion' of neonatal autologous platelets. CONCLUSIONS In vitro'transfusion' of adult platelets into neonatal blood results in shorter CTs than 'transfusion' with neonatal platelets. Our findings should raise awareness of the differences between the neonatal and adult hemostatic system and the potential 'developmental mismatch' associated with platelet transfusions for neonatal hemostasis.
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Affiliation(s)
- Francisca Ferrer-Marin
- Division of Newborn Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Chaitanya Chavda
- Division of Newborn Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Michael Lampa
- Division of Hematology/Oncology and Center for Platelet Research Studies, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Alan D. Michelson
- Division of Hematology/Oncology and Center for Platelet Research Studies, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Andrew L. Frelinger
- Division of Hematology/Oncology and Center for Platelet Research Studies, Children's Hospital Boston and Harvard Medical School, Boston, MA
| | - Martha Sola-Visner
- Division of Newborn Medicine, Children's Hospital Boston and Harvard Medical School, Boston, MA
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Abstract
Hemostasis is an active process regulating the formation and dissolution of fibrin clot to preserve vascular integrity. The different phases of hemostasis are coordinated so that effective clotting occurs only at the site of vascular injury while maintaining blood flow in other parts of the circulation. Procoagulant processes culminate in thrombin generation and fibrin clot formation to protect the vasculature against uncontrolled bleeding after injury. Conversely, anticoagulant processes limit clot extension to unaffected portions of the vasculature. Lastly, fibrinolysis is responsible for clot dissolution once tissue repair and regeneration permit the return of normal blood flow. A precise and delicate interplay exists among these processes to ensure normal hemostasis. The hemostatic system is incompletely developed at birth and matures throughout infancy. Both full-term and preterm neonates are born with low levels of most procoagulant proteins including all the contact activation factors and vitamin K-dependent factors. Similarly, levels of the major anticoagulant proteins are low at birth. Although often characterized as 'immature', the neonatal hemostatic system is nevertheless functionally balanced with no tendency toward coagulopathy or thrombosis. In this article, we will review the current models of hemostasis and the maturation of the hemostatic system. Our goal is to help clinicians gain a better understanding of the actions of procoagulant agents and of the disruptive effects of serious systemic illnesses on the precarious hemostatic balance of infants.
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Affiliation(s)
- Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia 30322, USA.
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43
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Schlagenhauf A, Schweintzger S, Birner-Gruenberger R, Leschnik B, Muntean W. Newborn platelets: lower levels of protease-activated receptors cause hypoaggregability to thrombin. Platelets 2010; 21:641-7. [PMID: 20807173 DOI: 10.3109/09537104.2010.504869] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Newborn platelets show in vitro hypoaggregability to thrombin. Sensitivity of platelets to such a potent agonist is crucial for a functional clot formation. Nevertheless, newborns have an excellent hemostasis. We wanted to investigate the reason for this impairment by comparatively analysing levels of receptors known to be involved in thrombin signaling in newborn and adult platelets. Platelets of adult and cord blood were isolated, washed, and lysed. Resulting protein samples were separated by SDS-PAGE and blotted on nitrocellulose membranes. Receptors were visualized using immunodetection and evaluated densitometrically. Thrombin receptor activating peptide induced platelet aggregation was measured in citrated whole blood on a Multiplate analyzer. Statistical analysis was performed using SPSS 16.0. Significantly lower levels of protease-activated receptors (PAR1, PAR4) and higher levels of glycoprotein Ibα (GPIbα) were found in newborn platelets as compared to adult platelets. Platelet aggregation was lower in newborn samples than in adult controls and values correlated with the corresponding PAR levels. Our results suggest that lower levels of protease-activated receptors contribute to the poor thrombin induced aggregation observed with newborn platelets, which can not be compensated by higher levels of GPIbα.
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Affiliation(s)
- A Schlagenhauf
- Department of Pediatrics, Medical University of Graz, Austria
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44
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Juutistenaho S, Vahtera E, Aranko K, Kekomäki R. Prothrombin activation fragment 1 + 2 as a marker of coagulation activation in cord blood collection for banking. Transfus Med 2010; 20:250-7. [PMID: 20345383 DOI: 10.1111/j.1365-3148.2010.01004.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There have been efforts to increase the quality of cord blood (CB) collections aimed at banking and transplantation. Yet, the effect of CB collection techniques on haemostatic activation is scarcely studied, despite the unique nature of the neonatal haemostatic system. The aim of this study was to explore coagulation system and platelet (PLT) activation during CB collection at a national CB bank. At three time points over a 9-year period (in 1998, 2000 and 2006), CB collections were assessed to evaluate the collection process during bank setup and changes in procedures. Thrombin generation and PLT activation were assessed with prothrombin activation fragment 1 + 2 (F1 + 2) and PLT factor 4 (PF4), respectively. The median F1 + 2 level was 2.8 nmol L(-1) in 1998 (n = 11), 0.7 nmol L(-1) in 2000 (n = 10) and 0.7 nmol L(-1) in 2006 (n = 6), the decrease being statistically significant (1998 vs 2000, P < 0.001; 1998 vs 2006, P = 0.01). The median PF4 level was 117 IU mL(-1) in 1998 and 104 IU mL(-1) in 2000. PF4 was not measured in 2006. The level of F1 + 2 correlated with that of PF4 (n = 21; Spearman's Rho = 0.59, P = 0.006). Haemostatic activation, assessed as a part of CB bank process control, decreased from the first to the subsequent sample series. F1 + 2 may be a candidate for quality control in CB banking; however, further studies are needed to optimise the analyses and to assess the effect of haemostatic activation on CB quality.
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Affiliation(s)
- S Juutistenaho
- Finnish Red Cross Blood Service, 00310 Helsinki, Finland.
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45
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Piotrowski A, Dabrowska-Wojciak I, Mikinka M, Fendler W, Walas W, Sobala W, Kuczkowski KM. Coagulation abnormalities and severe intraventricular hemorrhage in extremely low birth weight infants. J Matern Fetal Neonatal Med 2010. [DOI: 10.3109/14767050903229614] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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46
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Zieger B. Hämorrhagische Diathesen im Kindesalter. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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47
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Tripodi A, Chantarangkul V, Mannucci PM. Acquired coagulation disorders: revisited using global coagulation/anticoagulation testing. Br J Haematol 2009; 147:77-82. [DOI: 10.1111/j.1365-2141.2009.07833.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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48
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Bernhard H, Rosenkranz A, Petritsch M, Köfeler H, Rehak T, Novak M, Muntean W. Phospholipid content, expression and support of thrombin generation of neonatal platelets. Acta Paediatr 2009; 98:251-5. [PMID: 18976372 DOI: 10.1111/j.1651-2227.2008.01075.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Newborns have, despite low clotting factors and poor in vitro platelet function, a well functioning haemostasis. We investigated whether phospholipids (PL) in neonatal platelets differ from those in adult platelets in their exposure on the platelet surface, and their effect on thrombin generation. METHODS The effect of newborn and adult platelets on thrombin generation (TG) was measured by means of calibrated automated thrombography (CAT), and in a purified system. In addition, clotting times were measured. Phosphatidylserine (PS)-exposure was measured by flow cytometry. The amount of PL was determined by means of mass-spectrometry (Materials and Methods section in Supporting Information online). RESULTS In comparison with adults the clotting times in platelet-rich plasma of newborns were less shortened by adding calciumionophore. No differences in the support of TG between neonatal and adult platelets were found by means of CAT. In the purified system, TG was increased by ionophor-stimulated platelets but no difference was evident between newborn and adult platelets. Flow cytometric analysis showed no difference between adult and newborn platelets. Results of mass-spectrometry showed a very similar pattern of phospholipid-content of adult and newborn platelets. CONCLUSION Our results do not provide any evidence that a different phospholipid-expression of neonatal platelets may alter TG in neonates.
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Affiliation(s)
- Heike Bernhard
- Department of Pediatrics, Medical University of Graz, Austria
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49
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Procoagulants and anticoagulants in fetal blood. A literature survey. Folia Histochem Cytobiol 2009; 47:545-50. [PMID: 20430718 DOI: 10.2478/v10042-009-0094-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
In intrauterine life, hemostasis is maintained by the same components as in extrauterine life (blood platelets, coagulation and fibrinolysis systems, involvement of the vascular wall); in the fetus, however, these components show significant differences of a quantitative/qualitative nature. In the present study, we surveyed the literature on the coagulation system in the fetus. We focused on the velocity of development of the coagulation system, being reflected in the increased concentration of all procoagulants and anticoagulants (a rise from approximately 20% in the middle of pregnancy to about 60% or more in the period of labor; exceptions: factors V, VIII and XIII which in the labor period reach the adult level) and screening test results (prothrombin time, aPTT - activated prothrombin time, and thrombin time). Reference values were given for the 19-38 weeks of pregnancy and the labor term. Biochemical features of fetal fibrinogen and PIVKA factors were also discussed. The role of activated protein C (APC) in the maintenance of balance between procoagulants and anticoagulants was postulated as well as the role of APC in the formation of thrombin activatable fibrinolysis inhibitor (TAFI).
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50
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Effects of nadroparin, enoxaparin, and unfractionated heparin on endogenous factor Xa and IIa formation and on thrombelastometry profiles. Blood Coagul Fibrinolysis 2009; 20:71-7. [DOI: 10.1097/mbc.0b013e32831d0f80] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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