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Plasma levels of thrombin activatable fibrinolysis inhibitor in normal and preeclamptic pregnant women
Thrombosis Research (2004) 114, 155--159
intl.elsevierhealth.com/journals/thre
Regular Article
Plasma levels of thrombin activatable fibrinolysis inhibitor in normal and preeclamptic pregnant women ¨ zcan *, Ahmet Alacacıog ˙Inci Alacacıog ˘lu, Mehmet Ali O ˘lu, Mesut Polat, ¨ ¨ ˘it Ozgencß, ¨ksel, Fatih Demirkan, Ozden Pisßkin, Yig Faize Yu ¨ ¨ner Ozsan, Bulent Undar Hayri Gu Division of Hematology, Institute of Oncology, Dokuz Eylul University, 35340 Izmir, Turkey Received 23 January 2004; received in revised form 21 May 2004; accepted 25 May 2004 Available online 13 July 2004
KEYWORDS Preeclampsia; Coagulation; Fibrinolysis; Thrombin activatable fibrinolysis inhibitor
ABSTRACT To explain the pathogenesis of preeclampsia with coagulation induction or a defective fibrinolysis, various hemostatic parameters were studied and different treatment modalities targeting these parameters were evaluated. Considering the role of TAFI in down-regulation of fibrinolysis, in our study we have investigated whether TAFI contributes to impaired fibrinolysis in patient with preeclampsia. Thirty patients with preeclampsia (mean age F SD 25.7 F 4.53; range 17--36) and 30 normal pregnant women as control group (mean age F SD 28 F 5.26; range 21--38) were included in our study. TAFI antigen was determined using an ELISA kit for quantitative measurement. The mean TAFI antigen levels were 12.55 F 1.88 Ag/ml in patients with preeclampsia and 12.29 F 3.0 Ag/ml in normal pregnant women. A statistically significant difference was not found between TAFI antigen levels of two groups ( p > 0.05). In order to clarify the role of TAFI in the pathogenesis of preeclampsia, in addition to plasma TAFI levels, its synthesis, activation and metabolism should also be evaluated. A 2004 Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Tel.: +90-2324123735; fax: +902322789495. ¨ zcan). E-mail address: [email protected] (M.A. O
Preeclampsia is a clinical condition induced by pregnancy after the 20th week of gestation which characterizes itself by the development of hypertension with proteinuria or edema. Pathogenesis of pre-
0049-3848/$ - see front matter A 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.thromres.2004.05.012
˙I. Alacacıog ˘lu et al.
156 eclampsia is not clearly understood. Uteroplacental circulation defect due to increased microthrombogenesis [1] or abnormal cytotrophoblast infiltration [2] may cause preeclampsia. To explain the pathogenesis with coagulation induction or a defective fibrinolysis, various hemostatic parameters were studied and different treatment modalities targeting these parameters were evaluated [3,4]. In previous studies, increased heterozygous factor V Leiden mutation, protein C deficiency, protein S deficiency, activated protein C resistance, plasma levels of plasminogen activator inhibitor type-I (PAII) and reduced antithrombin activity was shown in women with preeclampsia/eclampsia [5--9]. Thrombin activatable fibrinolysis inhibitor (TAFI) is a recently described glycoprotein that is synthesized in liver which suppresses fibrinolysis after activation by thrombin [10]. TAFI can be expected to play a role in various clinical conditions associated with thrombotic tendency. Increased plasma levels of TAFI antigen was found in obese type II DM women [11], and has been described as a mild risk factor for deep vein thrombosis [12] and increase in pro-TAFI has been observed in patients with symptomatic coronary artery disease [13]. Although some authors found no change in TAFI antigen levels during normal pregnancy [14], increased levels have been reported recently [15]. In our study, considering the role of TAFI in down-regulation of fibrinolysis, we have investigated whether TAFI contributes to impaired fibrinolysis in patients with preeclampsia.
Materials and methods Patients Thirty patients with preeclampsia (mean age F SD 25.7 F 4.53; range 17--36) and 30 normal pregnant women (mean age F SD 28 F 5.26; range 21--38) were included in our study. Blood samples were taken in the third trimester in control group and after the 20th week of gestation in preeclamptic group. None of the patients in both groups have received any medications like aspirin, non-steroid anti-inflammatory drugs, anticoagulants, antibiotics, vasodilators, steroids, anti-hypertensive drugs, lipid lowering drugs, and have none of the following illnesses: arterial or venous disease, acute infection, renal or liver disease, diabetes mellitus, coronary artery disease, chronic inflammatory disease. The study was approved by the local ethical committee of Dokuz Eylul University Hospital. Informed consent was obtained from every
patient. Patient data including age, proteinuria levels, intensity of edema, blood pressures, gestation week, and number of gestations were recorded. Patients were classified according to the Committee on Terminology of the American College of Obstetricians and Gynecologists (ACOG) criteria for determining the severity of preeclampsia [16].
Blood collection Blood samples were obtained from antecubital vein into citrated tubes (trisodium-citrate 0.129 mol/l, whole blood ratio 1:9) and centrifuged 2000 g for 15 min. Then, all plasma samples were divided into aliquots and frozen and preserved at 70j until test time. At the same time when blood samples were obtained whole blood count, liver function tests, renal function tests, coagulation parameters (PT, aPTT, D-dimer, INR) were also studied.
TAFI antigen assay TAFI antigen was determined using an ELISA kit VisuLisek for quantitative measurement (Affinity Biologicals, Ontario, Canada). Strip wells were precoated with polyclonal antibody to human TAFI. Plasma samples were thawed and diluted and applied to the wells. The TAFI present binds to the coated antibody. After washing away unbound material, peroxidase-labeled detecting antibody was applied. After washing, tetramethylbenzidine which is a peroxidase substrate was added to the wells. Then, color formed was measured spectrophotometrically in a microplate reader at 450 nm. The assay was calibrated using the reference plasma provided from manufacturer. All necessary buffers and reagents were prepared according to manufacturer’s instructions. Test plasma samples were diluted with a ratio of 1/200. All results were given as Ag/ml.
Statistics Statistics was performed by using SPSS 10.0 for Windows. For comparison of the means of two groups, Student’s t-test was used and a p-value < 0.05 was considered as significant.
Results The weeks of gestation were 31.9 F 5.09 (range 21-40) for patients with preeclampsia and 38.3 F 2.52 (range 32--41) for normal pregnant women. While two (6.6%) patients had severe disease, 28 (93.4%)
Plasma levels of thrombin activatable fibrinolysis inhibitor in normal and preeclamptic pregnant women 157 Table 1
Patient characteristics and laboratory findings Preeclampsia (n:30)
Systolic--diastolic blood pressures (mm Hg) Hemoglobin (g/dl) WBC ( 109/l) Platelet ( 109/l) BUN (mg/dl) Creatinin (mg/dl) AST (U/l) ALT (U/l) Total protein (g/dl) Albumin (g/dl) Urinary protein levels (mg/day)
157.6 F 12.7/98 F 9.6 11.15 F 1.71 11.06 F 2.32 220.26 F 64.52 20.66 F 6.0 0.61 F 0.18 20.5 F 7.20 22.66 F 6.67 5.45 F 0.60 2.28 F 0.42 1030 F 663.13
were mild type. The systolic--diastolic blood pressures and urinary protein levels were summarized in Table 1. The urinary protein levels were found as 1030 F 663.13 mg/day in the preeclamptic group (range 500--3000 mg/day). There was no statistically significant differences between two groups according to haemoglobin, white blood cell counts, platelet counts, BUN, AST, creatinin, total protein levels. But a statistically significant difference was found between ALT [22.66 F 6.67 (12--40) u/l in preeclamptic group, 18.1 F 6.13 (10--32) u/l in normal pregnant group; p = 0.008] and albumin (2.28 F 0.42 g/dl in preeclamptic group, 2.59 F 0.21 g/dl in normal pregnant group; p = 0.001) levels of two groups (Table 1). Although there was a statistically significant difference between two groups according to ALT levels, these values all were at normal range, so we evaluated this result as there were no hepatic dysfunction in two groups. In case of coagulation parameters, there were no statistically significant differences between PT, aPTT, INR values of two groups ( p>0.05). D-dimer levels were within normal ranges in all individuals (Table 2). The mean TAFI antigen levels were 12.55 F 1.88 Ag/ml in patients with preeclampsia a nd 12.29 F 3.0 Ag/ml in normal pregnant women. A statistically significant difference was not found
Table 2
PT (sn) APTT (sn) INR D-dimer (ng/ml)
Normal pregnancy (n:30)
P value
115 F 12.7/74.3 F 9.3 11.37 F 0.76 14.57 F 15.88 218.26 F 65.12 18.53 F 8.18 0.57 F 0.17 20.26 F 7.34 18.1 F 6.13 5.48 F 0.43 2.59 F 0.21 --
0.545 0.236 0.905 0.255 0.390 0.902 0.008 0.826 0.001
between TAFI antigen levels of two groups ( p>0.05) (Fig. 1).
Discussion In the pathogenesis of preeclampsia the earliest pathological change is thought to be uteroplacental circulation defect due to increased microthrombogenesis [2]. Association of coagulation activation or fibrinolysis impairment with the pathogenesis of preeclampsia has been investigated in various studies. Presence of Factor V Leiden mutation, protein C and protein S deficiency, resistance of activated protein C [3,5] and decrease in activation of antithrombin [6,7] have been described. Decreased fibrinolytic activity may be responsible from fibrin deposition at placenta. Maternal endothelial cell dysfunction has been proposed as the main factor underlying preeclampsia [17]. PAI-1 which is also secreted from endothelium has been found to be correlated with
Coagulation parameters of the patients Preeclampsia
Normal pregnancy
P value
12.25 F 4.05 29.84 F 4.17 0.981 F 0.36 0.5 F 0.1
12.29 F 0.95 28.70 F 2.81 0.981 F 0.33 0.5 F 0.1
0.958 0.220 0.999 >0.05
Fig. 1 Thrombin activitable fibrinolysis inhibitor antigen levels.
˙I. Alacacıog ˘lu et al.
158 severity of preeclampsia and PAI-1 has been thought to be a clinical marker of endothelial damage occurring in preeclampsia [8,9]. The role of TAFI in down-regulation of fibrinolysis [18,19] and in pathogenesis of thrombotic disease [12,13,20] have recently been described. One may speculate that TAFI may also be involved in the regulation of fibrinolysis in patients with preeclampsia. The first study about TAFI levels in pregnancy was made by Chetaille et al. [14]. The main aim of this study was to assess variations of TAFI antigen with respect to sex, age, racial origins and pregnancy. They evaluated TAFI variations in 249 healthy subjects and 12 normal pregnant women who were at third trimester. They found no significant difference between the pregnant women and age matched women control group. But it is possible that the number of women was not sufficient to reveal the difference expected. Another study including TAFI in pregnancy and targeting larger population compared to that of Chetaille et al. was made by Chabloz et al. [15]. They investigated TAFI antigen and D-dimer levels during pregnancy-delivery at 144 normal pregnant women. They observed TAFI increase in concordance with gestation weeks. But the concentration of TAFI antigen did not appear to increase to the same extent as that of PAI-I, factor VIII or fibrinogen levels during pregnancy. They also showed that in D-dimer levels gradually increased during the course of pregnancy there was no correlation between TAFI and D-dimer levels. In the light of all these literatures, we evaluated 30 preeclamptic and 30 uncomplicated pregnant women in terms of coagulation parameters. The weeks of gestation were 31.9 F 5.09 (range 21--40) for patients with preeclampsia and 38.3 F 2.52 (range 32--41) for normal pregnant women. There were no significant age difference between two groups ( p = 0.75). PT, aPTT, INR, Ddimer levels of all individuals were in the normal range. In contrast to findings of Patrick Chabloz et al., D-dimer levels of the individuals were the same (0.5 ng/ml) in our data. TAFI levels were studied in two groups. But there were no statistically significant difference between two groups (p = 0.709). Our D-dimer levels were within normal range in both groups. In the study of Schjetlein et al. it was shown that plasma D-dimer concentration was significantly higher in severe but not in mild preeclampsia [8]. As most of our preeclamptic patients were mild type, this may explain our normal D-dimer levels. The study of Antovic et al. was the only study about TAFI antigen levels in preeclampsia in the
literature [21]. This study included 46 complicated pregnant women (38 preeclamptic, eight pregnant with intra-uterine growth retardation) and 16 uncomplicated pregnant women. TAFI antigen levels were 48.89 F 26.83% in complicated pregnant women and 116.30 F 74.10% in uncomplicated pregnant women. They found a statistically significant difference in TAFI antigen levels between two groups and TAFI levels were found to be lower in preeclamptic group in their study. Regarding lower TAFI levels in their preeclamptic women, they speculated that TAFI levels was lower most probably as a consequence of decreased synthesis by liver and increased loss due to proteinuria as molecular mass of pro-TAFI (55 KD) is lower than albumin (64 KD). As our study group consisted of only two (% 6.6) severe preeclampsia patients and generally resembling a patient group with mild type preeclampsia, this may explain the contrast of our study in respect to the study of Antovic et al. The ALT and AST levels within the normal range may also be due to this difference. If the speculation of Antovic et al. regarding liver synthesis defect is accepted to be true, then this explains our similar TAFI antigen levels in our study groups. But if TAFI is also lost by proteinuria perhaps real TAFI levels would be higher than we found. In conclusion, levels of the hemostatic parameters including TAFI, could be effected from the severity of the preeclampsia. In order to clarify the role of TAFI in the pathogenesis of preeclampsia, in addition to plasma TAFI levels, its synthesis, activation and metabolism should also be evaluated in different severity groups of the disease.
References [1] Dizon-Townson D, Branch DW. Anticoagulant treatment during pregnancy: an update. Semin Thromb Hemost 1998; 24(Suppl. 1):55--62. [2] Roberts JM, Redman CW. Pre-eclampsia: more than pregnancy-induced hypertension. Lancet 1993;341:1447. [3] Heilmann L, von Tempelhoff FG, Gerhold S, Rath W. Effect of thrombophilic factors on thromboembolism and other pregnancy complications. Z Geburtshilfe Neonatol 2001; 205(4):128--36. [4] Maharaj R. Do acetysalicylic and other antiplatelet drugs prevent preeclampsia? Can Fam Physician 2001;47:2480--2. [5] Alfirevic Z, Roberts D, Martlew V. How strong is the association between maternal thrombophilia and adverse pregnancy outcome? A systematic review. Eur J Obstet Gynecol Reprod Biol 2002;101(1):6--14. [6] Ricci G, Cerneca F, Simeone R, Alberico S, et al. Coagulation and fibrinolytic parameters in normal and hypertensive pregnancies. J Matern.-Fetal Investig 1997;7:129--32. [7] Gammaro L, Lippi G, Bottini E, Valenti G, et al. Severe preeclampsia in antithrombin III deficiency with no his-
Plasma levels of thrombin activatable fibrinolysis inhibitor in normal and preeclamptic pregnant women 159
[8]
[9]
[10]
[11]
[12]
[13]
[14]
tory of venous thromboembolism. J Nephrol 2001;14(4): 312--5. Schjetlein R, Haugen G, Wisloff F. Markers of intravasculer coagulation and fibrinolysis in preeclampsia: association with intrauterine growth retardation. Circulation 1997; 96(2):569--74. Schjetlein R, Abdelnoor M, Haugen G, Husby H, et al. Hemostatic variables as independent predictors for fetal growth retardation in preeclampsia. Acta Obstet Gynecol Scand 1999;78(3):191--7. Mosnier LO, von dem Borne P, Meijers JC, Bouma BN. Plasma TAFI levels influence the clot lysis time in healthy individuals in the presence of an intact ıntrinsic pathway of coagulation. Thromb Haemost 1998;80:829--35. Hori Y, Gabazza E, Yano Y, Katsuki A, Insulin resistance is associated with increased circulating level of thrombin activatable fibrinolysis inhibitor in type 2 diabetic patients. J. Clin. Endocrinol Metab. Van Tilburg NH, Rosendaal FR, Bertina RM. Thrombin activatable fibrinolysis inhibitor and the risk for deep vein thrombosis. Blood 2000;95(9):2855--9. Silveira A, Schatteman K, Goossens F, Moor E, Scharpe S, et al. Plasma procarboxypeptidase U in men with symptomatic coronary artery disease. Thromb Haemost 2000;84: 364--8. Chetaille P, Alessi MC, Kouassi D, Morange I, Juhan-vague I. Plasma TAFI antigen variations in healthy subjects. Thromb Haemost 2000;83:902--5.
[15] Chabloz P, Reber G, Boehlen F, Hohfild P, et al. TAFI antigen and D-dimer levels during normal pregnancy and at delivery. Br J Haematol 2001;115:150--2. [16] Davey DA, MacGillivray I. The classification and definition of the hypertensive disorders of pregnancy. Am J Obstet Gynecol 1998;158:892--8. [17] Roberts JM, Taylor RN, Musci TJ, Rodgers GM, Hubel CA, McLaughlin MK. Preeclampsia: an endothelial cell disorder. Am J Obstet Gynecol 1989;161:1200--4. [18] Wang W, Boffa MB, Bajzar L, Walker JB. A study of the mechanism of inhibition of fibrinolysis by activated thrombin-activable fibrinolysis inhibitor. J Biol Chem 1998;273: 27176--81. [19] Sakharov DV, Plow EF, Rijken DC. On the mechanism of the antifibrinolytic activity of plasma carboxypeptidase B. J Biol Chem 1997;272:14477--82. [20] Hryszko T, Malyszko J, Malyszko JS, Brzosko S, et al. Patients on peritoneal dialysis but not on hemodialysis have elevated concentration and activity of thrombinactivatable fibrinolysis inhibitor. Thromb Res 2001;104: 233--8. [21] Antovic JP, Hamad RR, Antovic A, et al. Does thrombin activatable fibrinolysis inhibitor (TAFI) contribute to impairment of fibrinolysis in patients with preeclampsia and/or intrauterine fetal growth retardation? Thromb Haemost, 2002;88:644--7.
intl.elsevierhealth.com/journals/thre
Regular Article
Plasma levels of thrombin activatable fibrinolysis inhibitor in normal and preeclamptic pregnant women ¨ zcan *, Ahmet Alacacıog ˙Inci Alacacıog ˘lu, Mehmet Ali O ˘lu, Mesut Polat, ¨ ¨ ˘it Ozgencß, ¨ksel, Fatih Demirkan, Ozden Pisßkin, Yig Faize Yu ¨ ¨ner Ozsan, Bulent Undar Hayri Gu Division of Hematology, Institute of Oncology, Dokuz Eylul University, 35340 Izmir, Turkey Received 23 January 2004; received in revised form 21 May 2004; accepted 25 May 2004 Available online 13 July 2004
KEYWORDS Preeclampsia; Coagulation; Fibrinolysis; Thrombin activatable fibrinolysis inhibitor
ABSTRACT To explain the pathogenesis of preeclampsia with coagulation induction or a defective fibrinolysis, various hemostatic parameters were studied and different treatment modalities targeting these parameters were evaluated. Considering the role of TAFI in down-regulation of fibrinolysis, in our study we have investigated whether TAFI contributes to impaired fibrinolysis in patient with preeclampsia. Thirty patients with preeclampsia (mean age F SD 25.7 F 4.53; range 17--36) and 30 normal pregnant women as control group (mean age F SD 28 F 5.26; range 21--38) were included in our study. TAFI antigen was determined using an ELISA kit for quantitative measurement. The mean TAFI antigen levels were 12.55 F 1.88 Ag/ml in patients with preeclampsia and 12.29 F 3.0 Ag/ml in normal pregnant women. A statistically significant difference was not found between TAFI antigen levels of two groups ( p > 0.05). In order to clarify the role of TAFI in the pathogenesis of preeclampsia, in addition to plasma TAFI levels, its synthesis, activation and metabolism should also be evaluated. A 2004 Elsevier Ltd. All rights reserved.
Introduction
* Corresponding author. Tel.: +90-2324123735; fax: +902322789495. ¨ zcan). E-mail address: [email protected] (M.A. O
Preeclampsia is a clinical condition induced by pregnancy after the 20th week of gestation which characterizes itself by the development of hypertension with proteinuria or edema. Pathogenesis of pre-
0049-3848/$ - see front matter A 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.thromres.2004.05.012
˙I. Alacacıog ˘lu et al.
156 eclampsia is not clearly understood. Uteroplacental circulation defect due to increased microthrombogenesis [1] or abnormal cytotrophoblast infiltration [2] may cause preeclampsia. To explain the pathogenesis with coagulation induction or a defective fibrinolysis, various hemostatic parameters were studied and different treatment modalities targeting these parameters were evaluated [3,4]. In previous studies, increased heterozygous factor V Leiden mutation, protein C deficiency, protein S deficiency, activated protein C resistance, plasma levels of plasminogen activator inhibitor type-I (PAII) and reduced antithrombin activity was shown in women with preeclampsia/eclampsia [5--9]. Thrombin activatable fibrinolysis inhibitor (TAFI) is a recently described glycoprotein that is synthesized in liver which suppresses fibrinolysis after activation by thrombin [10]. TAFI can be expected to play a role in various clinical conditions associated with thrombotic tendency. Increased plasma levels of TAFI antigen was found in obese type II DM women [11], and has been described as a mild risk factor for deep vein thrombosis [12] and increase in pro-TAFI has been observed in patients with symptomatic coronary artery disease [13]. Although some authors found no change in TAFI antigen levels during normal pregnancy [14], increased levels have been reported recently [15]. In our study, considering the role of TAFI in down-regulation of fibrinolysis, we have investigated whether TAFI contributes to impaired fibrinolysis in patients with preeclampsia.
Materials and methods Patients Thirty patients with preeclampsia (mean age F SD 25.7 F 4.53; range 17--36) and 30 normal pregnant women (mean age F SD 28 F 5.26; range 21--38) were included in our study. Blood samples were taken in the third trimester in control group and after the 20th week of gestation in preeclamptic group. None of the patients in both groups have received any medications like aspirin, non-steroid anti-inflammatory drugs, anticoagulants, antibiotics, vasodilators, steroids, anti-hypertensive drugs, lipid lowering drugs, and have none of the following illnesses: arterial or venous disease, acute infection, renal or liver disease, diabetes mellitus, coronary artery disease, chronic inflammatory disease. The study was approved by the local ethical committee of Dokuz Eylul University Hospital. Informed consent was obtained from every
patient. Patient data including age, proteinuria levels, intensity of edema, blood pressures, gestation week, and number of gestations were recorded. Patients were classified according to the Committee on Terminology of the American College of Obstetricians and Gynecologists (ACOG) criteria for determining the severity of preeclampsia [16].
Blood collection Blood samples were obtained from antecubital vein into citrated tubes (trisodium-citrate 0.129 mol/l, whole blood ratio 1:9) and centrifuged 2000 g for 15 min. Then, all plasma samples were divided into aliquots and frozen and preserved at 70j until test time. At the same time when blood samples were obtained whole blood count, liver function tests, renal function tests, coagulation parameters (PT, aPTT, D-dimer, INR) were also studied.
TAFI antigen assay TAFI antigen was determined using an ELISA kit VisuLisek for quantitative measurement (Affinity Biologicals, Ontario, Canada). Strip wells were precoated with polyclonal antibody to human TAFI. Plasma samples were thawed and diluted and applied to the wells. The TAFI present binds to the coated antibody. After washing away unbound material, peroxidase-labeled detecting antibody was applied. After washing, tetramethylbenzidine which is a peroxidase substrate was added to the wells. Then, color formed was measured spectrophotometrically in a microplate reader at 450 nm. The assay was calibrated using the reference plasma provided from manufacturer. All necessary buffers and reagents were prepared according to manufacturer’s instructions. Test plasma samples were diluted with a ratio of 1/200. All results were given as Ag/ml.
Statistics Statistics was performed by using SPSS 10.0 for Windows. For comparison of the means of two groups, Student’s t-test was used and a p-value < 0.05 was considered as significant.
Results The weeks of gestation were 31.9 F 5.09 (range 21-40) for patients with preeclampsia and 38.3 F 2.52 (range 32--41) for normal pregnant women. While two (6.6%) patients had severe disease, 28 (93.4%)
Plasma levels of thrombin activatable fibrinolysis inhibitor in normal and preeclamptic pregnant women 157 Table 1
Patient characteristics and laboratory findings Preeclampsia (n:30)
Systolic--diastolic blood pressures (mm Hg) Hemoglobin (g/dl) WBC ( 109/l) Platelet ( 109/l) BUN (mg/dl) Creatinin (mg/dl) AST (U/l) ALT (U/l) Total protein (g/dl) Albumin (g/dl) Urinary protein levels (mg/day)
157.6 F 12.7/98 F 9.6 11.15 F 1.71 11.06 F 2.32 220.26 F 64.52 20.66 F 6.0 0.61 F 0.18 20.5 F 7.20 22.66 F 6.67 5.45 F 0.60 2.28 F 0.42 1030 F 663.13
were mild type. The systolic--diastolic blood pressures and urinary protein levels were summarized in Table 1. The urinary protein levels were found as 1030 F 663.13 mg/day in the preeclamptic group (range 500--3000 mg/day). There was no statistically significant differences between two groups according to haemoglobin, white blood cell counts, platelet counts, BUN, AST, creatinin, total protein levels. But a statistically significant difference was found between ALT [22.66 F 6.67 (12--40) u/l in preeclamptic group, 18.1 F 6.13 (10--32) u/l in normal pregnant group; p = 0.008] and albumin (2.28 F 0.42 g/dl in preeclamptic group, 2.59 F 0.21 g/dl in normal pregnant group; p = 0.001) levels of two groups (Table 1). Although there was a statistically significant difference between two groups according to ALT levels, these values all were at normal range, so we evaluated this result as there were no hepatic dysfunction in two groups. In case of coagulation parameters, there were no statistically significant differences between PT, aPTT, INR values of two groups ( p>0.05). D-dimer levels were within normal ranges in all individuals (Table 2). The mean TAFI antigen levels were 12.55 F 1.88 Ag/ml in patients with preeclampsia a nd 12.29 F 3.0 Ag/ml in normal pregnant women. A statistically significant difference was not found
Table 2
PT (sn) APTT (sn) INR D-dimer (ng/ml)
Normal pregnancy (n:30)
P value
115 F 12.7/74.3 F 9.3 11.37 F 0.76 14.57 F 15.88 218.26 F 65.12 18.53 F 8.18 0.57 F 0.17 20.26 F 7.34 18.1 F 6.13 5.48 F 0.43 2.59 F 0.21 --
0.545 0.236 0.905 0.255 0.390 0.902 0.008 0.826 0.001
between TAFI antigen levels of two groups ( p>0.05) (Fig. 1).
Discussion In the pathogenesis of preeclampsia the earliest pathological change is thought to be uteroplacental circulation defect due to increased microthrombogenesis [2]. Association of coagulation activation or fibrinolysis impairment with the pathogenesis of preeclampsia has been investigated in various studies. Presence of Factor V Leiden mutation, protein C and protein S deficiency, resistance of activated protein C [3,5] and decrease in activation of antithrombin [6,7] have been described. Decreased fibrinolytic activity may be responsible from fibrin deposition at placenta. Maternal endothelial cell dysfunction has been proposed as the main factor underlying preeclampsia [17]. PAI-1 which is also secreted from endothelium has been found to be correlated with
Coagulation parameters of the patients Preeclampsia
Normal pregnancy
P value
12.25 F 4.05 29.84 F 4.17 0.981 F 0.36 0.5 F 0.1
12.29 F 0.95 28.70 F 2.81 0.981 F 0.33 0.5 F 0.1
0.958 0.220 0.999 >0.05
Fig. 1 Thrombin activitable fibrinolysis inhibitor antigen levels.
˙I. Alacacıog ˘lu et al.
158 severity of preeclampsia and PAI-1 has been thought to be a clinical marker of endothelial damage occurring in preeclampsia [8,9]. The role of TAFI in down-regulation of fibrinolysis [18,19] and in pathogenesis of thrombotic disease [12,13,20] have recently been described. One may speculate that TAFI may also be involved in the regulation of fibrinolysis in patients with preeclampsia. The first study about TAFI levels in pregnancy was made by Chetaille et al. [14]. The main aim of this study was to assess variations of TAFI antigen with respect to sex, age, racial origins and pregnancy. They evaluated TAFI variations in 249 healthy subjects and 12 normal pregnant women who were at third trimester. They found no significant difference between the pregnant women and age matched women control group. But it is possible that the number of women was not sufficient to reveal the difference expected. Another study including TAFI in pregnancy and targeting larger population compared to that of Chetaille et al. was made by Chabloz et al. [15]. They investigated TAFI antigen and D-dimer levels during pregnancy-delivery at 144 normal pregnant women. They observed TAFI increase in concordance with gestation weeks. But the concentration of TAFI antigen did not appear to increase to the same extent as that of PAI-I, factor VIII or fibrinogen levels during pregnancy. They also showed that in D-dimer levels gradually increased during the course of pregnancy there was no correlation between TAFI and D-dimer levels. In the light of all these literatures, we evaluated 30 preeclamptic and 30 uncomplicated pregnant women in terms of coagulation parameters. The weeks of gestation were 31.9 F 5.09 (range 21--40) for patients with preeclampsia and 38.3 F 2.52 (range 32--41) for normal pregnant women. There were no significant age difference between two groups ( p = 0.75). PT, aPTT, INR, Ddimer levels of all individuals were in the normal range. In contrast to findings of Patrick Chabloz et al., D-dimer levels of the individuals were the same (0.5 ng/ml) in our data. TAFI levels were studied in two groups. But there were no statistically significant difference between two groups (p = 0.709). Our D-dimer levels were within normal range in both groups. In the study of Schjetlein et al. it was shown that plasma D-dimer concentration was significantly higher in severe but not in mild preeclampsia [8]. As most of our preeclamptic patients were mild type, this may explain our normal D-dimer levels. The study of Antovic et al. was the only study about TAFI antigen levels in preeclampsia in the
literature [21]. This study included 46 complicated pregnant women (38 preeclamptic, eight pregnant with intra-uterine growth retardation) and 16 uncomplicated pregnant women. TAFI antigen levels were 48.89 F 26.83% in complicated pregnant women and 116.30 F 74.10% in uncomplicated pregnant women. They found a statistically significant difference in TAFI antigen levels between two groups and TAFI levels were found to be lower in preeclamptic group in their study. Regarding lower TAFI levels in their preeclamptic women, they speculated that TAFI levels was lower most probably as a consequence of decreased synthesis by liver and increased loss due to proteinuria as molecular mass of pro-TAFI (55 KD) is lower than albumin (64 KD). As our study group consisted of only two (% 6.6) severe preeclampsia patients and generally resembling a patient group with mild type preeclampsia, this may explain the contrast of our study in respect to the study of Antovic et al. The ALT and AST levels within the normal range may also be due to this difference. If the speculation of Antovic et al. regarding liver synthesis defect is accepted to be true, then this explains our similar TAFI antigen levels in our study groups. But if TAFI is also lost by proteinuria perhaps real TAFI levels would be higher than we found. In conclusion, levels of the hemostatic parameters including TAFI, could be effected from the severity of the preeclampsia. In order to clarify the role of TAFI in the pathogenesis of preeclampsia, in addition to plasma TAFI levels, its synthesis, activation and metabolism should also be evaluated in different severity groups of the disease.
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Plasma levels of thrombin activatable fibrinolysis inhibitor in normal and preeclamptic pregnant women 159
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