Levels of thrombin activatable fibrinolysis inhibitor in gestational diabetes mellitus

Rotational thromboelastometry (ROTEM® ) in gestational diabetes mellitus and coagulation in healthy term pregnancy: A prospective observational study in Australia

BACKGROUND

Rotational thromboelastometry (ROTEM^® ) is a point-of-care test of coagulation. ROTEM^® -defined hypercoagulability has been identified in pregnant women and in non-pregnant patients with diabetes mellitus. Pregnancy is known to be a hypercoagulable state, but the influence of gestational diabetes mellitus (GDM) on coagulation is unknown.

AIM

The aim of this study was to assess the combined effect of pregnancy and GDM on coagulation using ROTEM^® and to compare this to healthy pregnant women presenting for elective caesarean delivery.

MATERIALS AND METHODS

Ethics approval was granted for recruitment of women presenting for elective caesarean delivery. Women with pre-existing conditions affecting coagulation were excluded. Group N included health pregnant women at term and Group G included pregnant women at term with GDM. Data regarding GDM management and glycaemic control were collected. Poor glycaemic control was defined by markers of accelerated fetal growth and elevated fasting or postprandial blood glucose levels. The ROTEM^® parameters (extrinsically activated thromboelastometric test (EXTEM) / fibrin polymerisation test (FIBTEM) amplitude at five minutes, coagulation time, maximum clot firmness and clot formation time) were compared between the two groups using Student's t-test.

RESULTS

There were 75 women in Group N and 21 women in Group G. Mean age and median body mass index values were comparable for both groups. There were no statistical differences found between the EXTEM and FIBTEM parameters analysed for the two groups.

CONCLUSIONS

There was no association between GDM and increased hypercoagulability as demonstrated by ROTEM^® parameters in healthy pregnant women presenting for elective caesarean delivery at term.

Gestational diabetes mellitus is associated with antenatal hypercoagulability and hyperfibrinolysis: a case control study of Chinese women

BACKGROUND

To determine the relationship between gestational diabetes mellitus (GDM) and coagulation/fibrinolysis abnormality in antenatal Chinese women.

METHODS

Case control study: 50 women had GDM and 132 did not (the NGDM group) grouping by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. Maternal plasma biochemistry and previous medical history were collected from perinatal health records. Antenatal coagulation/fibrinolysis activity (CFA) parameters were assessed using thromboelastography and routine CFA parameters, respectively. Univariate and multiple regression analyses were used to evaluate the associations between GDM and CFA parameters. Maternal age, platelet, ALT, ALP, urea nitrogen, and previous history of abortion were taken as the covariables.

RESULTS

The women with GDM were significantly older than those without GDM (30.3 vs. 28.6 years, p = .012). Compared with the NGDM group, the GDM group had a significantly higher prevalence of cesarean delivery (56.0 vs. 37.9%, p = .027) and higher values of fibrinogen (FIB; 4.7 vs. 4.3 g/L, p = .001), activated partial thromboplastin time (APTT; 30.9 vs. 29.5 s, p = .010).There were no significant differences in the prevalence of maternal thrombotic events or neonatal events. GDM was significantly associated with higher APTT (β =1.41 s, 95% CI: 0.29-2.53), higher FIB (β = 0.38 g/L, 95% CI: 0.14-0.61), and higher percentage reduction in clot lysis after 30 min (LY30; β = 1.14%, 95% CI: 0.15-2.13) after adjustment for potential confounding factors.

CONCLUSIONS

GDM is significantly associated with hypercoagulability and hyperfibrinolysis in these antenatal Chinese women.

Thrombin/PAR-1 activation induces endothelial damages via NLRP1 inflammasome in gestational diabetes

Gestational diabetes mellitus (GDM) is associated with an increased risk of progressing to type 2 DM and cardiovascular disease; however, the pathogenesis is still poorly understood. This study was to investigate roles of thrombin and its receptor protease-activated receptor 1 (PAR-1) and NLRP1 inflammasome in endothelial injury in GDM condition. Umbilical cord and plasma of GDM patients and high glucose (HG) cultured human umbilical vein endothelial cells (HUVECs) were used to examine the pathological changes of these pathways. Meanwhile, ameliorative effects and potential mechanisms of a natural product sarsasapogenin (Sar) were investigated in HUVECs. Thrombin/PAR-1 pathway, advanced glycation endproducts (AGEs) and their receptor (RAGE) axis, and the nucleotide-binding domain and leucine-rich repeat containing protein 1 (NLRP1) inflammasome were activated in GDM condition and HG-cultured HUVECs, accompanied by endothelial injury (decreased cell viability and increased lactate dehydrogenase release). Nevertheless, thrombin inhibition or PAR-1 antagonism caused decreases in AGEs formation and RAGE expression in HG-cultured HUVECs, while AGEs inhibition or RAGE antagonism declined PAR-1 expression not thrombin activity. Furthermore, thrombin inhibition or PAR-1 antagonism restrained NLRP1 inflammasome activation in HG-cultured HUVECs; meanwhile, NLRP1 expression and interleukin 18 levels were remarkably reduced in HG-cultured HUVECs after PAR-1 knockdown. Interestingly, Sar co-treatment could suppress thrombin/PAR-1 pathway, NLRP1 inflammasome, and AGEs/RAGE axis. Together, endothelial damages in GDM were likely due to enhanced interaction between AGEs/RAGE axis and thrombin/PAR-1 pathway, followed by NLRP1 inflammasome activation. Moreover, Sar may act as a protective agent against endothelial injury in chronic HG condition.

The variation degree of coagulation function is not responsible for extra risk of hemorrhage in gestational diabetes mellitus

BACKGROUND

Gestational diabetes mellitus (GDM) is characterized as glucose intolerance of any degree that begins or first diagnosed during pregnancy. It possesses a higher risk of haemorrhage, which may be caused by the coagulation dysfunction. However, there has been no study focus on how coagulation state changes in the progress of GDM pregnancy. Our study is aimed to assess the association of coagulation function and haemorrhage in GDM.

METHODS

A total of 662 subjects (273 from a population-based study and 389 from a prospective cohort study) were selected to measure mean platelet volume (MPV), platelet distribution width (PDW), platelet (PLT), thrombocytocrit (PCT), prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and fibrinogen (FIB). All pregnant individuals were divided into normal glucose tolerance (NGT) controls and GDM patients diagnosed between the 24th and 28th weeks of gestation.

RESULTS

Compared with NGT controls, GDM females showed shortened PT, shortened APTT, and increased blood FIB levels, while the platelet parameters MPV, PDW, PLT, and PCT remained unchanged in mid-pregnancy. By late pregnancy, the platelet parameters MPV, PDW, and PCT were increased in the GDM group compared with the NGT group, while PT and APTT were unchanged.

CONCLUSIONS

The GDM group was hypercoagulable compared with the NGT group rather than hypocoagulable as predicted, but still within the normal range. Therefore, our findings demonstrate that the variation degree of coagulation function is not responsible for extra risk of hemorrhage in GDM, and prevention of hemorrhage should focus on other causes.

Is There a Tendency for Thrombosis in Gestational Diabetes Mellitus?

Context:

Impact of gestational diabetes mellitus (GDM) on the coagulation system, dynamics involved at a pathophysiological level and the exact mechanism remain unclear.

Aims:

To evaluate the association between diabetes-related parameters and hemostatic factors to search for a tendency of thrombosis in GDM.

Settings and Design:

Nineteen pregnant women who had GDM, 16 healthy pregnant and 13 healthy nonpregnant controls admitted to the Endocrinology outpatient clinics were enrolled in the study.

Subjects and Methods:

Fasting and postprandial glucose, hemoglobin A1c and insulin levels, and insulin resistance; fructosamine, thrombin activatable fibrinolysis inhibitor (TAFI), tissue factor pathway inhibitor (TFPI), plasminogen activator inhibitor Type-1 (PAI-1), tissue-type plasminogen activator (t-PA), fibrinogen, plasminogen and hemoglobin levels, platelet counts, prothrombin time (PT), and activated partial thromboplastin time (aPTT) were studied.

Statistical Analysis Used:

One-way analysis of variance, Kruskal–Wallis, and post hoc Tukey honestly significant difference or Conover's nonparametric multiple comparison tests for comparison of the study groups.

Results:

PT and aPTT were significantly lower in GDM patients compared to controls (P < 0.05), whereas fibrinogen and plasminogen levels were significantly higher in this group compared to both nonpregnant and healthy pregnant controls (P < 0.05 for each). TAFI, TFPI, PAI-1, and tissue t-PA levels were not significantly different among groups.

Conclusions:

Our findings indicate tendency to develop thrombosis in GDM similar to diabetes mellitus; but more comprehensive studies with larger sample size are needed to determine the relationship between GDM and hemostasis.