Detection of Platelet Desensitization in Pregnancy-Induced Hypertension Is Dependent on the Agonist Used

Low Dose Aspirin in high-risk pregnancies: The volatile effect of acetylsalicylic acid on the inhibition of platelets uncovered by G. Born's light transmission aggregometry

Preeclampsia still represents a life-threatening pregnancy complication, associated with severe maternal and neonatal morbidity and mortality. Low-dose Aspirin is advised to avoid preeclampsia in high-risk pregnancies worldwide. As Aspirin does not cover all women at risk, the prescription raises questions concerning optimal target population, dosage, and onset of therapy. The aim of this study was to test platelet responsiveness on Aspirin by optical aggegrometry, to gain robust biochemically assessment data of Aspirin in an obstetric cohort. 248 women at high risk for development of preeclampsia were included in the study. Aspirin-prophylaxis was administered either in 100 mg (n = 229) or 150 mg (n = 90) daily. Dosing of 100 mg Aspirin was maintained if testing revealed a sufficient platelet inhibition. If platelet inhibition was insufficient, dosage was increased to 150 mg Aspirin and re-testing was advised. 91 patients (91/229 = 39.7%) presented a sufficient inhibitory Aspirin effect at a dosage of 100 mg, but in 138 patients LTA showed an inadequate Aspirin response (138/229 = 60.3%). In 19 women 150 mg Aspirin was administered as starting dose due to new recommendations. Of all women at 150 mg Aspirin 64 did not properly respond (35.4%). The overall rate of sufficient responding women regardless the Aspirin dose was 64.6%. This study demonstrates still an insufficient inhibition of platelet aggregation in about 1/3 of women even with a dosage of 150 mg Aspirin daily, who might potentially benefit from further increase. These data show, that there is a need for further research to allow a personalized approach for individualized Aspirin therapy, maximizing the preventive benefit for mother and child.

Physiologic and pathologic changes of platelets in pregnancy

Platelets are key players in haemostasis and thrombus formation. Defects affecting platelets during pregnancy can lead to heterogeneous complications, such as thrombosis, first trimester miscarriage and postpartum haemorrhage. The incidence of complications is increased in women who have heritable platelet function disorders. Modifications of platelet count or platelet functions during normal pregnancy and preeclampsia will be summarized and the management of pregnant women with heritable platelet function disorders will be discussed.

Platelet activation in the hypertensive disorders of pregnancy

OBJECTIVE

The purpose of this study was to determine whether platelet activation occurs only in preeclampsia or also in normal pregnancy.

STUDY DESIGN

Thirty women with preeclampsia, 30 women with gestational hypertension, 20 women with essential hypertension, 30 pregnant women with normotension, and 30 nonpregnant women were recruited at St George Hospital, Sydney, Australia. Platelet activation was determined by flow cytometry on whole blood samples.

RESULTS

Platelet activation was similar in all groups, except the group with preeclampsia. Compared with normal pregnant women, women with preeclampsia had significantly greater CD62 expression (1.35% vs 0.61%; P =.002), CD63 expression (1.73% vs 0.95%; P <.0001) and annexin V binding (1.03% vs 0.66%;P =.03) and significantly fewer circulating platelet microparticles (33 vs 49 x10(9)/L; P =.001). This was unrelated to other parameters that included platelet counts. Women with gestational hypertension in whom preeclampsia developed did not have enhanced platelet activation profiles.

CONCLUSION

Platelet activation is increased in preeclampsia but not in other hypertensive disorders or in normal pregnancy. This may be part of the pathophysiologic factors of preeclampsia complications but is not predictable by the platelet count and is not apparent in all women with preeclampsia.

Changes in platelet ATP secretion and aggregation during pregnancy and in preeclampsia

BACKGROUND

Platelet secretion plays an important role in the aggregation of platelets. However, the quantitative relationship between platelet aggregation and secretion of ATP during pregnancy and in pre-eclampsia has yet to be clarified. This study is designed to determine whether platelet count, volume, aggregation, and the amount of secreted ATP change in healthy, nonpregnant women, nonpreeclamptic pregnant women, and preeclamptic pregnant women and whether beta-thromboglobulin (BTG) and platelet factor 4 (PF-4) concentrations alter in nonpreeclamptic and pre-eclamptic women.

METHODS

Peripheral blood was collected from 114 women. Nonpreeclamptic pregnant women were divided into four groups (gestational weeks 10, 20, 30, and 35). Platelet aggregation and ATP secretion were investigated with the use of a lumi-aggregometer. BTG and PF-4 concentrations in peripheral blood were determined in 12 pregnant and 11 preeclamptic women.

RESULTS

The amount of secreted ATP upon induction by 5 microM ADP increased significantly (P < 0.05-0.01) with gestational age. On the other hand, the amount of secreted ATP induced by 5 microg/mL collagen reached the maximal value from gestational weeks 20 to 35 in nonpreeclamptic women. Significantly more platelet aggregation was induced by the ADP and collagen in nonpreeclamptic women in gestational weeks 20 and 30 than in the gestational weeks 10 or 35 (P < 0.05-0.005). The amount of secreted ATP and platelet count were significantly lower (P < 0.05) in preeclampsia than in normal pregnancy. The BTG and PF-4 concentrations were significantly higher (P < 0.05) in preeclampsia than in normal pregnancy.

CONCLUSIONS

The sensitivity of platelets for ATP secretion may intensify with progression of pregnancy. In normal pregnancy, around gestational week 35, the platelets may exhibit weaker ability to aggregate but maintain the capacity to secrete ATP. In preeclampsia, secreted ATP decreased because platelets may be stimulated to undergo a partial secretion.

Platelets from eclampsia patients have reduced membrane microviscosity and lower activities of the signalling enzymes

It has been shown that platelets from patients suffering from eclampsia are hyporesponsive to stimulation by agonists like thrombin and ADP. Although platelet hyporeactivity contributes to the pathogenesis of the disease process, the cause for this is still not known. Platelet aggregation and secretion are membrane-based phenomena initiated by the processes of cell signalling. Hence, to understand the mechanisms underlying platelet hyporeactivity in eclampsia, membrane microviscosity and activities of the signalling enzymes were measured in human platelets stimulated with thrombin. Membrane fluidity was determined from the steady-state fluorescence anisotropy of diphenylhexatriene incorporated in cell membranes. Activities of phospholipase C and protein kinase C in stimulated platelets were assessed from the extents of phosphatidic acid generation and pleckstrin phosphorylation, respectively. Platelet membrane microviscosity in eclampsia (2.3 +/- 0.2 SEM, n = 5) was significantly lower (P < 0.05) than that in the matched gravid control subjects (3.1 +/- 0.2, n = 4). In eclampsia, generation of phosphatidic acid and phosphorylation of pleckstrin were decreased by 25% (P < 0.05, n = 3) and 35% (P < 0.05, n = 3), respectively, after 60 sec of platelet stimulation. It was concluded that the hyporeactive platelets obtained from eclampsia have more fluid membranes and diminished activities of phospholipase C and protein kinase C. In summary, this study shows that alterations in membrane fluidity and activities of the signalling enzymes (phospholipase C and protein kinase C) may contribute to the diminished platelet responsiveness observed in the eclamptic condition.

Platelet intracellular free calcium response to arginine vasopressin is similar in preeclampsia and normal pregnancy

OBJECTIVE

Our purpose was to compare the effect of arginine vasopressin stimulation on platelet free intracellular calcium levels in normal pregnancy, incipient preeclampsia, and established preeclampsia.

STUDY DESIGN

Cross-sectional and prospective observational study designs were used. Platelet free intracellular calcium was measured by flow cytometry in 10 nonpregnant female volunteers, 10 women with established preeclampsia and their normal pregnant matched controls, and 64 normal pregnant women at 28 weeks' gestation. All pregnant women were nulliparous.

RESULTS

Increased response to arginine vasopressin stimulation was observed in nonpregnant compared with pregnant women (p < 0.001). No differences were observed between women with normal pregnancy, incipient preeclampsia, or established preeclampsia.

CONCLUSION

The platelet intracellular free calcium response to arginine vasopressin is not a feature of incipient or established preeclampsia. Therefore, in contrast to a previous report, it does not appear to have value as a predictive test for preeclampsia.

Effects of a thromboxane synthetase inhibitor on platelet function; possible risks of use in pregnancy

It has been proposed that thromboxane synthetase inhibitors may be of use in the treatment of hypertensive disorders of pregnancy. A patient in whom aspirin did not prevent the development of pre-eclampsia in a previous pregnancy was treated with a thromboxane synthetase inhibitor (dazmegrel, Pfizer) in addition to low-dose aspirin. Increased urinary levels of 6-keto-prostaglandin F1 alpha were found throughout pregnancy, which is consistent with the mode of action. At 17-18 weeks of gestation urinary prostaglandin E2 and F2 alpha levels were increased compared with control pregnancies. These increases in PGE2 and PGF2 alpha production were associated with mid-trimester abortion. In vitro studies were carried out to determine the effects of dazmegrel on platelet eicosanoid production. In whole blood from non-pregnant female volunteers this compound inhibited thromboxane B2 production and significantly enhanced prostaglandin E2 production and slightly increased prostacyclin production, demonstrating a redirection of prostaglandin endoperoxides. This suggested that similar changes in arachidonic acid metabolite production may occur in vivo and in vitro, and that thromboxane synthetase inhibitors should not be used during early pregnancy, since increased production of prostaglandins E2 and F2 alpha may result in preterm labour or abortion.

Whole blood platelet aggregation in moderate and severe pre-eclampsia

OBJECTIVE

To compare whole blood platelet aggregation in moderate and severe pre-eclampsia with normal pregnancy.

DESIGN

Whole blood platelet aggregation in response to collagen, ADP, PAF, adrenalin and arachidonic acid was measured in the pre-eclampsia group at 36 weeks gestation and at 1, 24 and 48 h and at five days and six weeks post delivery. The normal pregnancy group were studied serially at 12, 20, 28, 32, and 36 weeks gestation and at 1, 24, 48 h and six weeks post delivery.

SETTING

Trinity College Medical School, St James's Hospital, Dublin.

SUBJECTS

Thirty women with diagnosed pre-eclampsia were recruited for the study. Fifteen of these women had severe pre-eclampsia and the remaining 15 had moderate disease. The pre-eclampsia group were compared with 20 healthy primigravid women with uncomplicated pregnancies and deliveries.

RESULTS

In women with severe pre-eclampsia, platelet aggregation in response to collagen, ADP, adrenalin and arachidonic acid was significantly lower at 36 weeks gestation compared with normal pregnancy. Lower levels of collagen induced aggregation were also found at 1 h post delivery when compared with normal pregnancy. Women with moderate pre-eclampsia showed a decreased response to aggregating agents at 36 weeks gestation but this was not significant. ADP, collagen and PAF induced aggregation was higher in women with moderate pre-eclampsia at 36 weeks gestation and during the early puerperium compared with severe pre-eclampsia.

CONCLUSIONS

The clinical signs of pre-eclampsia are accompanied by a reduction in platelet responsiveness, the extent of which is related to the severity of the disease. This suggests that an abnormal platelet activation occurs early in pregnancies destined to be complicated by pre-eclampsia. This activation may be involved in the pathogenesis of pre-eclampsia since its inhibition using low dose aspirin has been shown to modify the disease in high risk pregnancies.

Changes in platelet reactivity following aspirin treatment for pre-eclampsia

OBJECTIVE

To determine whether aspirin therapy in women at risk of pre-eclampsia alters in vitro platelet aggregation.

DESIGN

Longitudinal observational study.

SETTING

RPMS Institute of Obstetrics and Gynaecology, Hammersmith Hospital, London.

SUBJECTS

Six pregnant women at-risk or with pre-eclampsia.

METHODS

Women considered to be at risk of pre-eclampsia or with the disorder were treated with aspirin. In vitro platelet aggregation in response to platelet-activating factor (PAF) and adenosine diphosphate (ADP) before and after aspirin therapy were analysed.

RESULTS

Prior to aspirin therapy platelet aggregation was decreased compared with normal pregnant women. After aspirin therapy platelet aggregation in response to PAF and ADP was greater, but did not return to levels associated with normal pregnancy.

CONCLUSIONS

In women with pre-existing decreased platelet aggregation suggestive of platelet exhaustion, aspirin increased aggregation. This suggests that aspirin decreases in vivo platelet activation and thereby decreases the platelet exhaustion revealed by the in vitro studies.

Changes in platelet function in pregnancies complicated by fetal growth retardation

Platelet function was investigated in three patients with severely decreased fetal growth rates detected by ultrasound scanning. Only one patient had hypertension, which was mild and developed after decreased fetal growth and altered platelet responses had been detected. Much higher concentrations of platelet-activating factor (PAF) (20-500 nM) were required to stimulate maximal platelet aggregation in all three patients compared with the concentrations of PAF (5-10 nM) required in control pregnancies of similar gestational age. In a fourth patient, platelet desensitisation was observed 5 weeks before the detection of decreased fetal growth. These results are similar to those observed in women with hypertensive disorders of pregnancy, and indicate that there may be a similar change in platelet function in gestational hypertension and in fetal growth retardation, although the clinical manifestations are different.