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Varrias D, Spanos M, Kokkinidis DG, Zoumpourlis P, Kalaitzopoulos DR. Venous Thromboembolism in Pregnancy: Challenges and Solutions. Vasc Health Risk Manag 2023; 19:469-484. [PMID: 37492280 PMCID: PMC10364824 DOI: 10.2147/vhrm.s404537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/13/2023] [Indexed: 07/27/2023] Open
Abstract
Venous thromboembolism (VTE) is a serious medical condition that can lead to severe morbidity and mortality, making it a significant public health concern. VTE is a multifactorial condition that results from the interaction of genetic, acquired, and environmental factors. Physiological changes during pregnancy increase the risk of VTE as they express Virchow's triad (increased coagulation factors, decreased fibrinolysis, trauma, and venous stasis). Moreover, pregnancy-related risk factors, such as advanced maternal age, obesity, multiple gestations, and cesarean delivery, further increase the risk of VTE. Managing VTE in pregnancy is challenging due to the complexity of balancing the risks and benefits of anticoagulant therapy for both the mother and the fetus. A multidisciplinary approach involving obstetricians, hematologists, and neonatologists, is necessary to ensure optimal outcomes for both the mother and baby. This review aims to discuss the current challenges associated with VTE in pregnancy and identify potential solutions for improving outcomes for pregnant women at risk for VTE.
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Affiliation(s)
- Dimitrios Varrias
- Department of Medicine, Jacobi Medical Center, Bronx, NY, 10461, USA
- Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Michail Spanos
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Panagiotis Zoumpourlis
- Department of Medicine, Jacobi Medical Center, Bronx, NY, 10461, USA
- Albert Einstein College of Medicine, Bronx, NY, 10461, USA
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Stafford IA, Moaddab A, Dildy GA, Klassen M, Berra A, Watters C, Belfort MA, Romero R, Clark SL. Amniotic fluid embolism syndrome: analysis of the Unites States International Registry. Am J Obstet Gynecol MFM 2020; 2:100083. [PMID: 33345954 PMCID: PMC8500673 DOI: 10.1016/j.ajogmf.2019.100083] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Incidence, risk factors, and perinatal morbidity and mortality rates related to amniotic fluid embolism remain a challenge to evaluate, given the presence of differing international diagnostic criteria, the lack of a gold standard diagnostic test, and a significant overlap with other causes of obstetric morbidity and mortality. OBJECTIVE The aims of this study were (1) to analyze the clinical features and outcomes of women using the largest United States-based contemporary international amniotic fluid embolism registry, and (2) to investigate differences in demographic and obstetric variables, clinical presentation, and outcomes between women with typical versus atypical amniotic fluid embolism, using previously published and validated criteria for the research reporting of amniotic fluid embolism. MATERIALS AND METHODS The AFE Registry is an international database established at Baylor College of Medicine (Houston, TX) in partnership with the Amniotic Fluid Embolism Foundation (Vista, CA) and the Perinatology Research Branch of the Division of Intramural Research of the NICHD/NIH/DHHS (Detroit, MI). Charts submitted to the registry between August 2013 and September 2017 were reviewed, and cases were categorized into typical, atypical, non-amniotic fluid embolism, and indeterminate, using the previously published and validated criteria for the research reporting of AFE. Demographic and clinical variables, as well as outcomes for patients with typical and atypical AFE, were recorded and compared. Student t tests, χ2 tests, and analysis of variance tables were used to compare the groups, as appropriate, using SAS/STAT software, version 9.4. RESULTS A total of 129 charts were available for review. Of these, 46% (59/129) represented typical amniotic fluid embolism and 12% (15/129) atypical amniotic fluid embolism, 21% (27/129) were non-amniotic fluid embolism cases with a clear alternative diagnosis, and 22% (28/129) had an uncertain diagnosis. Of the 27 women misclassified as an amniotic fluid embolism with an alternative diagnosis, the most common actual diagnosis was hypovolemic shock secondary to postpartum hemorrhage. Ten percent (6/59) of the women with typical amniotic fluid embolism had a pregnancy complicated by placenta previa, and 8% (5/61) had undergone in vitro fertilization to achieve pregnancy. In all, 66% (49/74) of the women with amniotic fluid embolism reported a history of atopy or latex, medication, or food allergy, compared to 34% of the obstetric population delivered at our hospital over the study period (P < .05). CONCLUSION Our data represent a series of women with amniotic fluid embolism whose diagnosis has been validated by detailed chart review, using recently published and validated criteria for research reporting of amniotic fluid embolism. Although no definitive risk factors were identified, a high rate of placenta previa, reported allergy, and conceptions achieved through in vitro fertilization was observed.
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Affiliation(s)
- Irene A Stafford
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX.
| | - Amirhossein Moaddab
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX
| | - Gary A Dildy
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX
| | | | - Alexandra Berra
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX
| | - Christine Watters
- Biostatistics Program, School of Public Health, LSU Health, New Orleans, LA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX
| | - Roberto Romero
- Perinatology Research Branch, Program for Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, and Detroit, MI; Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, MI; Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI; Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI; Detroit Medical Center, Detroit, MI; Department of Obstetrics and Gynecology, Florida International University, Miami, FL
| | - Steven L Clark
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX
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Tanaka H, Katsuragi S, Osato K, Hasegawa J, Nakata M, Murakoshi T, Yoshimatsu J, Sekizawa A, Kanayama N, Ishiwata I, Ikeda T. Value of fibrinogen in cases of maternal death related to amniotic fluid embolism. J Matern Fetal Neonatal Med 2017; 30:2940-2943. [DOI: 10.1080/14767058.2016.1269166] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Shinji Katsuragi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Tokyo, Japan
| | - Kazuhiro Osato
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Takeshi Murakoshi
- Division of Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Jun Yoshimatsu
- Division of Maternal Fetal Medicine and Gynecology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Akihiko Sekizawa
- Department of Obstetrics and Gynecology, Showa University School of Medicine, Tokyo, Japan
| | - Naohiro Kanayama
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Isamu Ishiwata
- Ishiwata Obstetrics and Gynecology Hospital, Ibaraki, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
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von Tempelhoff GF, Schelkunov O, Demirhan A, Tsikouras P, Rath W, Velten E, Csorba R. Thrombelastometric results and platelet function during pregnancy in women receiving low molecular weight heparin with a history of recurrent/late abortion – A retrospective analysis. Clin Hemorheol Microcirc 2015; 61:99-110. [DOI: 10.3233/ch-151949] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Georg-Friedrich von Tempelhoff
- Department of Obstetrics and Gynaecology, St. Vinzenz Hospital, Hanau, Germany
- Institute of Coagulation Disorders in Obstetrics and Gynaecology, Hausen, Germany
| | - Olga Schelkunov
- Department of Obstetrics and Gynaecology, St. Vinzenz Hospital, Hanau, Germany
- Institute of Coagulation Disorders in Obstetrics and Gynaecology, Hausen, Germany
| | - Attila Demirhan
- Department of Obstetrics and Gynaecology, St. Vinzenz Hospital, Hanau, Germany
- Institute of Coagulation Disorders in Obstetrics and Gynaecology, Hausen, Germany
| | - Panagiotis Tsikouras
- Institute of Coagulation Disorders in Obstetrics and Gynaecology, Hausen, Germany
- Democritus University of Thrace, Department of Obstetrics and Gynecology, Alexandroupolis, Greece
| | - Werner Rath
- Department of Obstetrics and Gynaecology, RWTH University of Aachen, Germany
| | - Eva Velten
- Department of Obstetrics and Gynaecology, City Hospital of Aschaffenburg, Aschaffenburg, Germany
- Institute of Coagulation Disorders in Obstetrics and Gynaecology, Hausen, Germany
| | - Roland Csorba
- Department of Obstetrics and Gynaecology, City Hospital of Aschaffenburg, Aschaffenburg, Germany
- Institute of Coagulation Disorders in Obstetrics and Gynaecology, Hausen, Germany
- Department of Obstetrics and Gynaecology, University of Debrecen, Hungary
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Rath WH, Hofer S, Sinicina I. Amniotic fluid embolism: an interdisciplinary challenge: epidemiology, diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:126-32. [PMID: 24622759 PMCID: PMC3959223 DOI: 10.3238/arztebl.2014.0126] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 11/27/2013] [Accepted: 11/27/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Amniotic fluid embolism (AFE) is a life-threatening obstetric complication that arises in 2 to 8 of every 100 000 deliveries. With a mortality of 11% to 44%, it is among the leading direct causes of maternal death. This entity is an interdisciplinary challenge because of its presentation with sudden cardiac arrest without any immediately obvious cause, the lack of specific diagnostic tests, the difficulty of establishing the diagnosis and excluding competing diagnoses, and the complex treatment required, including cardio - pulmonary resuscitation. METHOD We selectively reviewed pertinent literature published from 2000 to May 2013 that was retrieved by a PubMed search. RESULTS The identified risk factors for AFE are maternal age 35 and above (odds ratio [OR] 1.86), Cesarean section (OR 12.4), placenta previa (OR 10.5), and multiple pregnancy (OR 8.5). AFE is diagnosed on clinical grounds after the exclusion of other causes of acute cardiovascular decompensation during delivery, such as pulmonary thromboembolism or myocardial infarction. Its main clinical features are severe hypotension, arrhythmia, cardiac arrest, pulmonary and neurological manifestations, and profuse bleeding because of disseminated intravascular coagulation and/or hyperfibrinolysis. Its treatment requires immediate, optimal interdisciplinary cooperation. Low-level evidence favors treating women suffering from AFE by securing the airway, adequate oxygenation, circulatory support, and correction of hemostatic disturbances. The sudden, unexplained death of a pregnant woman necessitates a forensic autopsy. The histological or immunohistochemical demonstration of formed amniotic fluid components in the pulmonary bloodflow establishes the diagnosis of AFE. CONCLUSION AFE has become more common in recent years, for unclear reasons. Rapid diagnosis and immediate interdisciplinary treatment are essential for a good outcome. Establishing evidence-based recommendations for intervention is an important goal for the near future.
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Affiliation(s)
- Werner H Rath
- Faculty of Medicine, Gynecology and Obstetrics, University Hospital RWTH Aachen
| | - Stefan Hofer
- Department of Anesthesiology, University of Heidelberg
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McDonnell N, Percival V, Paech M. Amniotic fluid embolism: a leading cause of maternal death yet still a medical conundrum. Int J Obstet Anesth 2013; 22:329-36. [DOI: 10.1016/j.ijoa.2013.08.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 08/06/2013] [Indexed: 10/26/2022]
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Collins N, Bloor M, McDonnell N. Hyperfibrinolysis diagnosed by rotational thromboelastometry in a case of suspected amniotic fluid embolism. Int J Obstet Anesth 2013; 22:71-6. [DOI: 10.1016/j.ijoa.2012.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 09/11/2012] [Accepted: 09/22/2012] [Indexed: 10/27/2022]
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Cesari M, Pahor M, Incalzi RA. Plasminogen activator inhibitor-1 (PAI-1): a key factor linking fibrinolysis and age-related subclinical and clinical conditions. Cardiovasc Ther 2010; 28:e72-91. [PMID: 20626406 PMCID: PMC2958211 DOI: 10.1111/j.1755-5922.2010.00171.x] [Citation(s) in RCA: 292] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION The close relationship existing between aging and thrombosis has growingly been studied in this last decade. The age-related development of a prothrombotic imbalance in the fibrinolysis homeostasis has been hypothesized as the basis of this increased cardiovascular and cerebrovascular risk. Fibrinolysis is the result of the interactions among multiple plasminogen activators and inhibitors constituting the enzymatic cascade, and ultimately leading to the degradation of fibrin. The plasminogen activator system plays a key role in a wide range of physiological and pathological processes. METHODS Narrative review. RESULTS Plasminogen activator inhibitor-1 (PAI-1) is a member of the superfamily of serine-protease inhibitors (or serpins), and the principal inhibitor of both the tissue-type and the urokinase-type plasminogen activator, the two plasminogen activators able to activate plasminogen. Current evidence describing the central role played by PAI-1 in a number of age-related subclinical (i.e., inflammation, atherosclerosis, insulin resistance) and clinical (i.e., obesity, comorbidities, Werner syndrome) conditions is presented. CONCLUSIONS Despite some controversial and unclear issues, PAI-1 represents an extremely promising marker that may become a biological parameter to be progressively considered in the prognostic evaluation, in the disease monitoring, and as treatment target of age-related conditions in the future.
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Affiliation(s)
- Matteo Cesari
- Area di Geriatria, Università Campus Bio-Medico, Rome, Italy.
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Conde-Agudelo A, Romero R. Amniotic fluid embolism: an evidence-based review. Am J Obstet Gynecol 2009; 201:445.e1-13. [PMID: 19879393 PMCID: PMC3401570 DOI: 10.1016/j.ajog.2009.04.052] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 04/10/2009] [Accepted: 04/23/2009] [Indexed: 10/20/2022]
Abstract
We conducted an evidence-based review of information about [corrected] amniotic fluid embolism (AFE). The estimated incidence of AFE is 1:15,200 and 1:53,800 deliveries in North America and Europe, respectively. The case fatality rate and perinatal mortality associated with AFE are 13-30% and 9-44%, respectively. Risk factors associated with an [corrected] increased risk of AFE include advanced maternal age, placental abnormalities, operative deliveries, eclampsia, polyhydramnios, cervical lacerations, [corrected] and uterine rupture. The hemodynamic response in [corrected] AFE is biphasic, with initial pulmonary hypertension and right ventricular failure, followed by left ventricular failure. Promising therapies include selective pulmonary vasodilators and recombinant activated factor VIIa. Important topics for future research are presented.
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Affiliation(s)
- Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD and Detroit, MI
| | - Roberto Romero
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD and Detroit, MI
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI
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Abstract
Amniotic fluid embolism (AFE), an uncommon disorder with a high fatality rate, is an obstetric emergency that requires swift recognition and intervention to save both the mother's life and that of her child.The high mortality rate and varying theories as to its cause make it difficult to diagnose AFE, which can occur at any point during labor and delivery, including during cesarean birth. These factors make it important for perioperative nurses to understand and recognize AFE when it occurs in the OR. Rapid delivery of the fetus is imperative for the survival of both mother and child. Monitoring and aggressively providing respiratory and circulatory support interventions are required if the mother is to survive AFE.
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Lewi L, Liekens D, Heyns L, Poliard E, Beutels E, Deprest J, Hoylaerts MF. In vitro evaluation of the ability of platelet-rich plasma to seal an iatrogenic fetal membrane defect. Prenat Diagn 2009; 29:620-5. [PMID: 19340818 DOI: 10.1002/pd.2249] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES The purpose of the study is to evaluate the ability of platelet-rich plasma (PRP) to seal an iatrogenic fetal membrane defect. METHODS First, we evaluated the stability of a PRP plug in an amniotic fluid environment. Further, we evaluated the sealing capability of PRP plugs in an in vitro model that mimics a fetoscopic membrane defect. Finally, we examined its influence on membrane repair and cell proliferation in monolayer cell cultures and amnion-chorion tissue explants. RESULTS PRP plugs persisted in an amniotic fluid for a median time of 7 weeks. PRP plugs also provided waterproof sealing of a fetoscopic membrane defect. Finally, PRP stimulated cell proliferation in a monolayer cell culture and provided a good matrix for cell proliferation and migration in amnion-chorion tissue explants. CONCLUSION Our in vitro experiments suggest that PRP plugs may provide a long-lasting, waterproof sealing of fetal membrane defects and stimulate fetal membrane repair.
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Affiliation(s)
- L Lewi
- Department of Woman and Child, Division Woman, Laboratory Experimental Gynecology, Faculty of Medicine, K.U.Leuven, Belgium
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12
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Abstract
Amniotic fluid embolism is one of the most catastrophic complications of pregnancy. First described in 1941, the condition is exceedingly rare and the exact pathophysiology is still unknown. The etiology was thought to be embolic in nature, but more recent evidence suggests an immunologic basis. Common presenting symptoms include dyspnea, nonreassuring fetal status, hypotension, seizures, and disseminated intravascular coagulation. Early recognition of amniotic fluid embolism is critical to a successful outcome. However, despite intensive resuscitation, outcomes are frequently poor for both infant and mother. Recently, aggressive and successful management of amniotic fluid embolism with recombinant factor VIIa and a ventricular assist device, inhaled nitric oxide, cardiopulmonary bypass and intraaortic balloon pump with extracorporeal membrane oxygenation have been reported and should be considered in select cases.
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Affiliation(s)
- Richard S Gist
- Department of Anesthesiology, The Mount Sinai Medical Center, One Gustave L Levy Place, New York City, NY 10029-6574, USA
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Peitsidou A, Peitsidis P, Tsekoura V, Spathi A, Tzaneti A, Samanta E, Siampalioti G, Kioses E. Amniotic fluid embolism managed with success during labour: report of a severe clinical case and review of literature. Arch Gynecol Obstet 2007; 277:271-5. [PMID: 18026975 DOI: 10.1007/s00404-007-0489-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2007] [Accepted: 10/04/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND AFE (amniotic fluid embolism) is widely known as a disastrous rapid-progressing clinical entity. The incident ranges from 1:800 to 1:8,000. The mortality rate reaches 61-86%. Neonatal survival is reported at 70%. METHODS We describe the case of a healthy 29-year old primigravida developing amniotic fluid embolism during labour. Acute respiratory failure and hypotension combined with seizures were the initial symptoms. The patient under went an urgent caesarean section with extreme blood loss, complicated by disseminated coagulopathy. RESULTS A total hysterectomy was performed due to profuse bleeding. Aggressive management was practiced with continuous transfusion of blood products and administration of vasocopressors. CONCLUSION Amniotic fluid embolism or anaphylactoid syndrome of pregnancy is a life-threatening condition. Diagnosis is one of the exclusion. Its management is very difficult and requires quick management and cooperation of physicians from different specialties.
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Affiliation(s)
- A Peitsidou
- Obstetrics and Gynecology Department, Alexandra General Hospital, Athens, Greece
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15
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Affiliation(s)
- Aidan O'Shea
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School Boston, Massachusetts 02115, USA
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Verkleij-Hagoort AC, Ursem NT, Hop WC, Geurts-Moespot A, Steegers EA, Sweep FC, Steegers-Theunissen RP. Complex congenital malformations and the impact of the plasminogen activator system and beta-hCG in amniotic fluid. Eur J Obstet Gynecol Reprod Biol 2006; 135:47-52. [PMID: 17141398 DOI: 10.1016/j.ejogrb.2006.10.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Revised: 08/30/2006] [Accepted: 10/30/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The plasminogen activator system and beta-hCG may affect neural crest cells and angiogenesis, and thereby embryogenesis. Therefore, we investigated these parameters in amniotic fluids of pregnancies with a complex congenital malformation. STUDY DESIGN In a case-control study amniotic fluid samples were collected from 62 pregnancies with a complex congenital malformation and from 110 healthy control pregnancies at an obstetric department of a large university hospital in the Netherlands. We determined concentrations of tissue-type plasminogen activator (tPA), urokinase-type plasminogen activator (uPA), plasminogen activator inhibitors (PAI-1, PAI-2), tPA approximately PAI-1 and uPA approximately PAI-1 complexes, and beta-hCG with enzyme-linked immunosorbent assays. Mann-Whitney U-tests and analysis of covariance, adjusting for gestational and maternal age, were performed for data comparisons. RESULTS Compared with controls, cases demonstrated significantly lower adjusted geometric mean levels of uPA (24%), tPA (> or =19%) and tPA approximately PAI-1 (35%). Cases showed significantly higher adjusted mean levels of beta-hCG (> or =48%) and PAI-2 (10 ng/mL) than controls. Mean PAI-1 and uPA approximately PAI-1 levels were comparable between both groups. CONCLUSIONS Disturbances in the plasminogen activator system and beta-hCG levels are suggested to be involved in the pathogenesis of complex congenital malformations by affecting neural crest cell migration and angiogenesis.
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Affiliation(s)
- Anna C Verkleij-Hagoort
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
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Harnett MJP, Hepner DL, Datta S, Kodali BS. Effect of amniotic fluid on coagulation and platelet function in pregnancy: an evaluation using thromboelastography. Anaesthesia 2005; 60:1068-72. [PMID: 16229690 DOI: 10.1111/j.1365-2044.2005.04373.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Amniotic fluid embolism is a rare obstetric complication. The exact pathogenesis of this syndrome remains unknown and significant controversy exists whether coagulopathy should always be present. We used thromboelastography to assess the effect of amniotic fluid on coagulation and platelet function in pregnant women. Different volumes of amniotic fluid (10-60 microl) were added to blood (330 microl) from pregnant women and thromboelastography variables determined. There were three important findings. R time, reflecting time to first clot formation, was significantly decreased with the addition of 10 microl amniotic fluid; platelet function, as determined by Reopro-TEG technique, was increased with the addition of 30 microl of amniotic fluid; and there was no evidence of fibrinolysis in any samples studied. In conclusion, our study substantiates the hypothesis that coagulation profile changes are invariable accompaniments of amniotic fluid embolism.
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Affiliation(s)
- M J P Harnett
- Staff Anaesthetist, Department of Anaesthesia, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Plomgaard P, Keller P, Keller C, Pedersen BK. TNF-alpha, but not IL-6, stimulates plasminogen activator inhibitor-1 expression in human subcutaneous adipose tissue. J Appl Physiol (1985) 2005; 98:2019-23. [PMID: 15677734 DOI: 10.1152/japplphysiol.01220.2004] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Plasminogen activator inhibitor-1 (PAI-1) is produced by adipose tissue, and elevated PAI-1 levels in plasma are a risk factor in the metabolic syndrome. We investigated the regulatory effects of TNF-alpha and IL-6 on PAI-1 gene induction in human adipose tissue. Twenty healthy men underwent a 3-h infusion of either recombinant human TNF-alpha (n = 8), recombinant human IL-6 (n = 6), or vehicle (n = 6). Biopsies were obtained from the subcutaneous abdominal adipose tissue at preinfusion, at 1, 2, and 3 h during the infusion, and at 2 h after the infusion. The mRNA expression of PAI-1 in the adipose tissue was measured using real-time PCR. The plasma levels of TNF-alpha and IL-6 reached 18 and 99 pg/ml, respectively, during the infusions. During the TNF-alpha infusion, adipose PAI-1 mRNA expression increased 2.5-fold at 1 h, 6-fold at 2 h, 9-fold at 3 h, and declined to 2-fold 2 h after the infusion stopped but did not change during IL-6 infusion and vehicle. These data demonstrate that TNF-alpha rather than IL-6 stimulates an increase in PAI-1 mRNA in the subcutaneous adipose tissue, suggesting that TNF-alpha may be involved in the pathogenesis of related metabolic disorders.
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Affiliation(s)
- Peter Plomgaard
- Copenhagen Muscle Research Centre, Rigshospitalet, Section 7641, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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Uszyński M, Perlik M, Uszyński W, Zekanowska E. Urokinase plasminogen activator (uPA) and its receptor (uPAR) in gestational tissues; Measurements and clinical implications. Eur J Obstet Gynecol Reprod Biol 2004; 114:54-8. [PMID: 15099871 DOI: 10.1016/j.ejogrb.2003.12.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2003] [Revised: 10/09/2003] [Accepted: 12/05/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Urokinase plasminogen activator (uPA) and urokinase plasminogen activator receptor (uPAR) are central molecules for uPA/uPAR/plasmin-dependent proteolysis, which is thought to play a significant role in the development of pregnancy, as well as its many complications. OBJECTIVE To measure the levels of uPA and uPAR in the placenta and myometrium, as well as in the foetal membranes and amniotic fluid. STUDY DESIGN The study group consisted of 35 women with normal course of pregnancy, but with complications arising during delivery, which led to Caesarean section. Samples of placenta, myometrium, foetal membranes, amniotic fluid and blood were obtained at the time of operation. Tissue extracts were prepared. Measurements were made by the ELISA method. RESULTS uPA and uPAR concentration in gestational tissues, including amniotic fluid, is 100-200 times higher than in plasma. Among tissues, the highest uPA level was found in placenta ( 1.32 +/- 0.48 ng/mg of protein), and the highest uPAR level in foetal membranes (3.33 +/- 1.20 ng/mg of protein). CONCLUSIONS uPA and uPAR are present in all gestational tissues, in some in relatively high concentrations. Our results support the modern clinical hypothesis that fibrinolytic system can participate in mechanisms of such obstetric complications as pre-term pre-mature rupture of foetal membranes and placental abruption.
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Affiliation(s)
- Mieczysław Uszyński
- Department of Propedeutics of Medicine, Ludwik Rydygier Medical University, Bydgoszcz, Poland
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Sánchez MC, Chiabrando GA, Vides MA. Pregnancy zone protein-tissue-type plasminogen activator complexes bind to low-density lipoprotein receptor-related protein (LRP). Arch Biochem Biophys 2001; 389:218-22. [PMID: 11339811 DOI: 10.1006/abbi.2001.2329] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Tissue-type plasminogen activator (t-PA), is a serine proteinase that catalyzes the initial and rate-limiting step in the fibrinolytic cascade. Its plasma activity is determined by the rate of release into the bloodstream, the rate of inhibition by plasminogen-activator inhibitor type 1 (PAI-1) and the rate of hepatic clearance. Two receptor systems contribute to the clearance of t-PA: the mannose receptor and the low-density lipoprotein receptor-related protein (LRP) that removes free t-PA as well as t-PA-PAI-1 complexes from the blood. During pregnancy a significant rise in the plasma levels of pregnancy zone protein (PZP) is observed, while alpha(2)-macroglobulin (alpha(2)-M) remains constant. Interestingly, the fibrinolytic activity is decreased during this period. In this context, we have recently demonstrated the in vitro formation of PZP-t-PA complexes. Here, we purified LRP from human placenta by affinity chromatography and then analyzed the binding specificity and affinity of PZP-proteinase complexes to the receptor by enzyme immunoassay (EIA). Our results clearly established that the binding of PZP-t-PA complexes to LRP was specific, saturable, and with K(d) = 337 +/- 31 nM. Moreover, by using the same EIA, we further observed that this binding was inhibited by receptor-associated protein. These data suggest that PZP, by binding to t-PA and promoting its clearance via LRP, might contribute in vivo to the downregulation of the fibrinolytic activity during pregnancy.
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Affiliation(s)
- M C Sánchez
- Departamento de Bioquímica Clínica, Universidad Nacional de Córdoba, 5000 Córdoba, Argentina.
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Uszynski M, Klyszejko A, Zekanowska E. Plasminogen, alpha(2)-antiplasmin and complexes of plasmin-alpha(2)-antiplasmin (PAP) in amniotic fluid and blood plasma of parturient women. Eur J Obstet Gynecol Reprod Biol 2000; 93:167-71. [PMID: 11074138 DOI: 10.1016/s0301-2115(00)00283-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of the present study was to determine whether the following components of the fibrinolytic system are present in amniotic fluid: plasminogen, plasmin and alpha(2)-antiplasmin, and plasmin-alpha(2)-antiplasmin (PAP) complexes. The study group consisted of 30 healthy women giving birth at term; 10 nonpregnant women constituted a control group. Plasminogen and alpha(2)-antiplasmin were studied by using an amidolytic method, and PAP by an ELISA method. The levels of plasminogen and alpha(2)-antiplasmin in amniotic fluid are low, 1.57+/-0.82 and 6.80+/-3.09%, respectively, of the values in blood plasma. The PAP concentration in amniotic fluid (70.61+/-14.28 microg/l) was also lower than in blood plasma (247.19+/-111.39 microg/l). We concluded that in amniotic fluid plasminogen and alpha(2)-antiplasmin are present, but at a concentration lower than in plasma. The presence of PAP in amniotic fluid is an evidence of two processes in the amniotic cavity: (i) plasmin generation, and (ii) plasmin inactivation by alpha(2)-antiplasmin.
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Affiliation(s)
- M Uszynski
- Department of Medical Propedeutics, Ludwik Rydygier Medical University ul. M. Curie-Sklodowskiej 9, 85 067 Bydgoszcz, Poland
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Uszyński M, Uszyński W, Zekanowska E, Garbacz J, Kielkowski A, Marcinkowski Z. Tissue plasminogen activator and plasminogen activator inhibitors of type 1 and type 2 in the plasma of parturient women. J Perinat Med 1996; 24:339-45. [PMID: 8880631 DOI: 10.1515/jpme.1996.24.4.339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Changes in the fibrinolytic system of parturient women have so far been only partially documented. Our main questions were whether and how the concentration of tissue plasminogen activator (tPA) and plasminogen activator inhibitors of type 1 (PAI-1) and type 2 (PAI-2) change in the plasma throughout normal labor. The study group consisted of 38 women with normal pregnancy, delivering at term. The concentration of antigens tPA, PAI-1 and PAI-2 in plasma was tested by enzyme-linked immuno-sorbent assay method, and the activity of PAI-1 by plasmin method. Results were analysed statistically. During labor the level of tPA antigen increases over two times: from 9.3 +/- 4.3 ng/ml before labor, to 23.3 +/- 9.6 ng/ml in the second stage of labor. Changes of PAI-1 antigen as well as its activity though noticeable, were not statistically significant. PAI-2 antigen level increased significantly in the third stage (146.3 +/- 58.7 ng/ml before labor, and 212.2 +/- 75.0 ng/ml after placenta expulsion). In summary the more significant change in the fibrinolytic system during labor is an increase of the level of tPA and PAI-2 antigens, but their peaks appear in different stages of labor. The predominance of PAIs over tPA is maintained throughout the whole labor, though on a lower level as can be inferred from the tPA/PAIs ratio.
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Affiliation(s)
- M Uszyński
- Department of Propedeutics of Medicine, University School of Medical Sciences, Bydgoszcz, Poland
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23
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Dear A, Medcalf R. The cellular and molecular biology of plasminogen activator inhibitor type-2. ACTA ACUST UNITED AC 1995. [DOI: 10.1016/s0268-9499(95)80079-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Watanabe T, Araki M, Mimuro J, Tamada T, Sakata Y. Fibrinolytic components in fetal membranes and amniotic fluid. Am J Obstet Gynecol 1993; 168:1283-9. [PMID: 7682753 DOI: 10.1016/0002-9378(93)90381-r] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE We evaluated fibrinolytic components in plasma and amniotic fluid of pregnant women and in postpartum fetal membranes. STUDY DESIGN Fibrinolytic parameters in amniotic fluid and plasma were measured by means of enzyme-linked immunosorbent assays. Fetal membranes collected after spontaneous labor at term were analyzed by immunohistochemical methods with immunospecific antibodies against fibrinolytic components. RESULTS Amniotic fluid contained high plasminogen activator inhibitor-1 concentrations but had low activity. Strong staining for plasminogen activator inhibitor-1 and vitronectin was observed in chorionic trophoblasts and moderate staining in decidual connective tissue. Strong staining for plasminogen activator inhibitor-2 was seen in decidual cells. Although prominent staining of plasminogen activators and plasminogen were observed in the amniotic epithelium, virtually no plasminogen activator inhibitor-1, plasminogen activator inhibitor-2, or alpha 2-plasmin inhibitor staining was detected. CONCLUSION The delicate balance of fibrinolytic activators and inhibitors in fetal membranes and amniotic fluid may contribute to the triggering of membrane rupture at term.
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Affiliation(s)
- T Watanabe
- Department of Obstetrics and Gynecology, Jichi Medical School, Tochigi-ken, Japan
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Takahashi K, Kiguchi T, Sawasaki Y, Karikusa F, Nemoto N, Matsuoka T, Yamamoto M. Lung capillary endothelial cells produce and secrete urokinase-type plasminogen activator. Am J Respir Cell Mol Biol 1992; 7:90-4. [PMID: 1378288 DOI: 10.1165/ajrcmb/7.1.90] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Bovine lung capillary endothelial cells (BLuEC) were isolated, and their ability to produce plasminogen activator (PA) in vitro was demonstrated. BLuEC secreted more than 10 times as much as urokinase-type PA (u-PA) as did bovine aortic, hepatic capillary and adrenal capillary endothelial cells, and lung fibroblasts. BLuEC secreted u-PA on both sides of the cell layer, the luminal surface, and the basic surface attached to the basement membrane. u-PA mRNA was detected in BLuEC by Northern blotting, but not in endothelial cells from other tissues and fibroblasts. These results suggest that BLuEC may contribute not only to the patency of lung vessels but also to the maintenance of alveolar functions through the production and secretion of u-PA.
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Affiliation(s)
- K Takahashi
- Department of Biochemistry, National Defense Medical College, Saitama, Japan
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España F, Gilabert J, Estellés A, Romeu A, Aznar J, Cabo A. Functionally active protein C inhibitor/plasminogen activator inhibitor-3 (PCI/PAI-3) is secreted in seminal vesicles, occurs at high concentrations in human seminal plasma and complexes with prostate-specific antigen. Thromb Res 1991; 64:309-20. [PMID: 1725227 DOI: 10.1016/0049-3848(91)90002-e] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Protein C inhibitor (PCI) is a heparin-dependent serpin present in a native form in plasma at concentrations of 5 micrograms/mL. In vitro, PCI inhibits activated protein C (APC), thrombin, plasma kallikrein (KK) and urokinase-(uPA) and tissue-type plasminogen activator (tPA), and we have shown in vivo inhibition of APC, uPA and KK by PCI. In order to further characterize the physiological role of PCI, we have measured the level of PCI in several biological fluids. PCI antigen was assayed by ELISA and PCI activity was measured by its capability to form complexes with APC in the presence of heparin. Seminal plasma from voluntary donors had PCI levels (160 +/- 20 micrograms/mL, mean +/- SD) about 30 or 40 times higher than those found in blood plasma. Patients under a fertilization program had significantly reduced PCI seminal levels (110 +/- 35 micrograms/mL). Seminal plasma PCI retained about 45% of its activity immediately after ejaculation, and the activity rapidly decreased following incubation of seminal plasma at 37 degrees C, in parallel with the appearance of complexes of PCI with prostate-specific antigen (PSA). PCI was present in seminal vesicle secretion, obtained by autopsy, at concentration similar to that observed in semen, was mostly active and was not inactivated by incubation of secretion at 37 degrees C. The mean functional and antigen levels of PCI in urine from normal donors were 0.58 and 0.25 micrograms/mL, respectively, whereas in saliva these levels were 20 and 0.8 ng/mL, respectively. Amniotic fluid contained PCI antigen levels of 2.1 +/- 0.2 microgram/mL. These results show that PCI is secreted in the seminal vesicles in a functional form, and suggest that PSA, a major secretory component of the prostate, is responsible for its inactivation. They also suggest a physiological role of PCI in reproduction, and show that PCI is present in various biological fluids.
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Affiliation(s)
- F España
- Research Center, Hospital Universitario La Fe, Valencia, Spain
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Estellés A, Gilabert J, España F, Aznar J, Galbis M. Fibrinolytic parameters in normotensive pregnancy with intrauterine fetal growth retardation and in severe preeclampsia. Am J Obstet Gynecol 1991; 165:138-42. [PMID: 1906680 DOI: 10.1016/0002-9378(91)90242-j] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In pregnancy a decrease in fibrinolytic activity, which is due to an increase in plasminogen activator inhibitor activity and plasminogen activator inhibitor type 1 and type 2, has been described. Because the placenta is a source of both type 1 and type 2 plasminogen activator inhibitor, we have studied them and other fibrinolytic parameters in a group of normotensive pregnant women with intrauterine fetal growth retardation and in two groups of women with preeclampsia, with or without intrauterine growth retardation. A significant increase in plasminogen activator inhibitor type 1 antigen and plasminogen activator inhibitor activity was observed in preeclampsia, with or without intrauterine growth retardation, but not in normotensive pregnancy with intrauterine growth retardation, when compared with normal pregnancy. Plasminogen activator inhibitor type 2 antigen levels showed a significant decrease in both groups of pregnant women (normotensive or preeclamptic) with intrauterine growth retardation when compared with pregnancies without intrauterine growth retardation. A significant correlation between plasminogen activator inhibitor type 2 levels and fetal weight has been observed in the clinical groups.
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Affiliation(s)
- A Estellés
- Research Center Hospital La Fe, Valencia, Spain
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