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Serum vitamin K1 concentration and vitamin K-dependent clotting factor activity in maternal and fetal cord blood
Serum vitamin K 1 concentration and vitamin K-dependent clotting factor activity in maternal and fetal cord blood Leon Sann, M.D., Michel Leclercq, B.Sc., Jacques Troncy, M.D., Marc Guillaumond, B.Sc., Marcel Berland, M.D., and Pierre Coeur, M.D. Lyon and Oullins, France The serum concentration of phylloquinone (vitamin K,) was measured in 34 healthy mothers and in the arterial cord blood of their newborn infants. In addition, the activities of factor II and of factors VII plus X were determined simultaneously in 16 paired maternal and fetal bloods. The serum vitamin K, concentration was similar to that of control subjects in 27 mothers: 9.03 ± 4.9 µg/L (mean and SD), with a simultaneous concentration of 10.4 ± 5.3 µg/L in cord blood. Six mothers exhibited high serum vitamin K, concentrations from 40 to 240 µg/L (median, 82) and the concentration in cord blood ranged from 25 to 115 µg/L (median, 71 ). One mother had a normal concentration of vitamin K,: 9 µg/L while no vitamin K, was detectable in the serum of her infant. The activity of factor II and factors VII plus X was 7% and 7%, respectively, in this infant and 100% in the mother. All other mothers showed normal factor II and factors VII plus X activity, while the median activity was 47% (28%-56%) for factor II and 65% (35%-100%) for factors VII plus X in cord blood. These data suggest that vitamin K, can cross the placental barrier but not in every case. Therefore the systematic administration of vitamin K, to the newborn infant seems to be required to prevent the occurrence of the hemorrhagic disease. (AM J OssTET GYNECOL 1985;153:771-4.)
Key words: Vitamin K,, neonate, placenta, hemorrhagic disease
The activity of the vitamin K-dependent clotting factors is low at birth in comparison to adults. The clotting factors decrease over the first few days of life especially in breast-fed neonates.'·" However, a systematic supplement of vitamin K to newborn infants remains controversial, since it is not known whether the neonates are deficient in vitamin K at birth. Early studies suggested a deficiency in vitamin K,'" but later investigations could not detect the protein induced by vitamin K absence in cord blood." 7 Thus the solution to this enigma can be found only by measuring the concentration of vitamin K in cord blood. This was carried out by Shearer et al.," who did not detect vitamin K in cord blood. These results suggest a deficiency of vitamin K in all neonates, which is contradicted by the recent findings of blood coagulation in neonates.·· Therefore in the present investigation we measured the serum concentration of vitamin K, (phylloquinone) and the activity of some vitamin K-dependent clotting factors (II and VII plus X) in maternal and fetal bloods.
Patients and methods Patients. Thirty-four healthy mothers and their newborn infants were included in this study, which was From the Department of Neonatology, Hopital Debrousse, Cemip, Imtitut Pasteur, and Laboratoire d'Hematologi.e, Hopital de la Croix-Rousse, Lyon, and Matemite Claude Bernard, Oullim. Received for publication June 19, 1985; accepted August 30, 1985. Reprint request~: Uon Sann, M.D., Department of Neonatology, Hopital Debrousse, 29 Rue Soeur Bouvier, 69322 Lyon, France.
carried out between April and September, 1982. Each mother gave her consent to the study, which had been approved by the Hospital's Ethic Committee. Pregnancies were followed up regularly in the same department and were uneventful in all cases. All deliveries occurred at term without any complication. Procedure. Within 120 seconds after birth, a IO cm section of umbilical cord was clamped and 5 ml of blood was drawn by puncture of the umbilical artery to avoid contamination with maternal or placental blood. Within the next minute a 10 ml sample of the mother's venous blood was drawn. For the determination of vitamin K,, 2.5 ml of umbilical blood and 5.0 ml of maternal blood were collected into polystyrene tubes protected from light. The serum was separated and frozen at - 20° C; 2.5 ml of umbilical blood was mixed with 0.25 ml sodium citrate, and 5 ml of maternal blood was mixed with 0.5 ml sodium citrate. After centrifugation the plasma was pipetted off and frozen at - 20° C. Assay of vitamin K 1• The determination of vitamin K, was carried out at room temperature and in subdued light with a slightly modified version of the method originally described.'' The internal standard was vitamin K,. 15 an analogue of phylloquinone but with 15 atoms of carbons in the phytyl chain instead of 20 as in phylloquinone. It was provided by HoffmannLaRoche, Basel, Switzerland. First, 500 µI of serum was deproteinized by 500 µI of a solution of 1% pyrogallol ethanol. Then 500 µI of distilled water was added; after the mixture was shaken for 5 minutes, the extraction 771
772
Sann et al.
December I, 1985 Am .J Obste! Gynecol
25tl
tion by a further 12 and 37 µg/L; thus 90% to 95% of the added vitamin K 1 was recovered. Mass spectrometry at the Centre National de Recherche Scientifique in Solaise, France, verified vitamin K with fractions corresponding to elution volume after pooling and concentration. The spectrum of vitamin K, in blood was similar to that in the control. In 19 healthy fasting control adults the normal concentration was 6.76 ± 1.4 µg/L (mean± 1 SD). The activity of factor II and factors VII plus X was determined by standard methods ' 0 with a Dade coagulometer and Dade reagents.
200
150
-
100
-
~
50
:.:
z
-
:I!
20
...<
-
:I!
"
" 10
..;.
MOTHER
FETUS
( UMRILICAL ARTERY )
Fig. I. Serum vitamin K concentration in the mother and the fetus.
was performed in 3 ml of hexane containing 20 ng of internal standard. The mixture was centrifuged at 200 g for 10 minutes, and 2.5 ml of the organic phase was evaporated by air stream without heating. The residue was dissolved in 250 µI n-heptane. The extracts were assayed by high-performance liquid chromatography. Columns packed with beads 5 µm in diameter were used for the successive chromatographies. The fractionation steps consisted of ( 1) semiquantitative highperformance liquid chromatography with use of normal-phase Waters silica columns and n-heptane and ethyl acetate (99: 1) for elution; (2) analytical high-performance liquid chromatography with use of a reversed-phase Waters octo-decysilane Resolve column with elution in pure acetonitrile. The ultraviolet photometric detection was made at 254 and 280 nm to prevent interference, with use of a Waters M440 ultraviolet detector. The linearity of the response was ascertained for natural phylloquinone and for the internal standard vitamin K,_,,, at a concentration range of 1 to 500 µg/L. The quantitation was based on the measurement of the ratio of the peak height of vitamin K, and vitamin K1_,.,. The sensitivity of the assay was 1 µg/L. The coefficient of variation was 5'}( at a concentration of 7 µg/L. The recovery and accuracy of the assay were assessed by the addition of a known amount of vitamin K, to raise the concentra-
Results The paired maternal and cord concentrations of serum vitamin K, are shown in Fig. 1. Twenty-seven mothers had concentrations similar to the controls with a mean (±SD) of 9.03 ± 4.9 µg/L. The corresponding concentrations in cord blood were similar: 10.4 ± 5.3 µg/L. Six mothers exhibited high serum vitamin K, concentrations between 40 and 240 µg/L (median, 82). The respective serum vitamin K, concentrations in cord blood were in the range of 25 to 115 µg/L (median, 71 ). The concentrations in cord blood represented 37% to 110% (median, 87%) of the maternal concentration. One mother had a normal serum vitamin K, concentration of 9.0 µg/L. No vitamin K, was detectable in the cord blood of her baby. The simultaneous determination of serum vitamin K, and the activity of the vitamin K-dependent clotting factors was carried out in 16 paired maternal and fetal blood samples. The results are shown in Table I. A normal activity of factor II and factors VII plus X was detected in the mothers whose serum vitamin K, concentrations ranged from 1 to 240 µg/L. In all cord blood but one, the mean (±SD) activity of factor I I and factors VII plus X was 47% ± 9% and 65% ± 19%, respectively, whereas the serum vitamin K, concentrations were between 1 and 88 µg/L (mean, 25 µg/L). No statistical difference of the activity of the vitamin Kdependent clotting factors was observed when the results were considered in the patients with serum vitamin K, concentrations between 1 and 14 µg/L or between 20 and 88 µg/L. In one newborn with no detectable vitamin K, in cord blood, the activities of factor II and factors VII plus X were markedly reduced, whereas the mother with a 9.0 µg/L serum vitamin K1 concentration exhibited a normal activity of the clotting factors. Comment When the serum vitamin K 1 levels of the mothers were within the normal range indicated by the controls, the vitamin K, levels proved similar in cord bloods of all infants but one. The present results are at variance
Vitamin K-dependent clotting factor activity
Volume 153
773
l'\umbcr 7
Table I. Serum vitamin K, concentrations and factors II, VII, and X activity in maternal and fetal cord bloods Serum vitamin K, concentration ( µ,g! L) No. of samples
Arterial cord blood I 10 5
Maternal blood 16
Median
ND 11 63 12
I
Range
Factor II activit)' ('lc) Median
I
Range
7 1-14 20-88 1-140
Factors VII plus X activit)' (%) Median
I
Range
7
48.:i 44
'.H-66 28-:)5
58 66
46-86 55-100
99.6
87-100
100
95-100
ND = Not detectable.
with the findings of Shearer et al." The discrepancy could be explained by different procedures: in Shearer et al.'s study, the amount of blood collected from cord blood was very large; their procedure for the assay of vitamin K, concentration required an additional step for extraction with heating; they used vitamin K epoxide as the internal standard. The concentrations in the controls were also much lower than in the present study. We followed the procedures of Lefevre et al.''- '" and found concentrations in the controls similar to their results. In the present study, as was done in Shearer's investigations, we measured the serum concentration of vitamin K, in the arterial cord blood so as to avoid the contamination of blood by the placenta. When the mother exhibited high concentrations of vitamin K,, the concentrations in cord blood amounted to 37% to 110% of the maternal concentration. Therefore the present results suggest that vitamin K1 usually can cross the placental barrier. Shearer et al. observed no change in serum vitamin K, concentration in cord bloods I I to 47 minutes after administration of l mg of phylloquinone to the mother." However, this period of time is rather short and may represent the time required for mixing in the plasma and for hepatic captation of the vitamin in the mother. Preliminary investigations in the rat performed in our laboratory have shown a delay of the passage of vitamin K1 to the fetus and an equilibration of the concentrations of serum vitamin K, in the mother and the fetus 6 to 12 hours after the injection of vitamin K1 to the mother. In man it has been shown that the administration of phylloquinone to the mother could prevent the postnatal decrease of the vitamin K-dependent factors,'"· 11 and recently it has been reported that the administration of vitamin K, for 2 weeks before delivery prevented the recurrence of hypoprothrombinemia and hemorrhages in the neonates of epileptic mothers treated with anticonvulsivant drugs. 1' However, Wefring" pointed out that this effect
could not be observed when the administration took place 4 hours before delivery. The reason(s) for the higher serum vitamin K, concentrations in some mothers is not known. It could be related to dietary factors: in neonates a greater incidence of coagulation disturbances and bleeding disorders has been reported during the winter months when the dietary intake of vitamin K, was low'- '" whereas the present study was carried out during the summer months. However, when high concentrations were detected in the mothers, high concentrations were also found in cord blood, again suggesting that vitamin K, can cross the placental barrier. In the cases of normal or elevated serum vitamin K, concentrations in cord blood, the activity of factor II and factors VII plus X did not exceed about 50% of the activity found in adults. These results are similar to previous investigations.'- 1 This finding supports the concept of deficient production of the protein prothrombin, proconvertin, and factor X in the fetus and neonate, since the concentration of serum vitamin K, was normal. In addition, in neonates we detected a urinary excretion of gamma carboxyglutamic acid similar to the excretion in adults." By contrast, in one neonate with no detectable vitamin K, in cord blood, the activity of factor I I and factors VII plus X was very low; the reason(s) for a reduced placental transfer of vitamin K, in this case is not known. However, this result is in agreement with the findings of Corrigan and Kryc 1" which showed that at term the normal coagulant activity/antigen ratio of factor II is not suggestive of vitamin K deficiency with the exception of some neonates with a decreased ratio resulting from reduced activity of factor II. In conclusion, the present results of serum vitamin K 1 determination in the mother and their newborn infants suggest that vitamin K can cross the placenta. However, this transfer can be disturbed in some cases, particularly if complications of labor and delivery oc-
774
Sann et al.
cur. Therefore it seems careful to administer vitamin K prophylactically, especially to high-risk infants, since the hemorrhagic disease is not easy to predict and may result in a disastrous clinical condition. REFERENCES 1. Dam H, Dyggve H, Larson H, Plum P. The relation of vitamin K deficiency to hemorrhagic disease of the newborn. Acta Pediatr 1952;5: 159-63. 2. Aballi A.J. The action of vitamin Kin the neonatal period. South Med J l 965;58:48-60. 3. Hathaway WE. Coagulation problems in the newborn infant. Pediatr Clin North Am 1979; 17:929-42. 4. Oski FA, Naiman JL. Hematologic problems in the newborn. Philadelphia: WB Saunders, 1972:236-50. 5. Yoshioka K, Kimoshita S, Takamiya 0, Fujimura Y, Mimura Y. Abnormal antigens of factors II, VII and IX in newborns and breast fed infants with vitamin K deficiency. Acta Haematol Jpn 1982;45:860-6. 6. Van Doorm JM, Muller AD, Hemker HG. Heparin-like inhibitor, not vitamin K deficiency in the newborn [Letter]. Lancet 1977;1:852-3. 7. Malia RG, Presborn FE, ~litchell VE. Evidence against vitamin K deficiency in normal neonates. Thromb Haemost 1980;44: 159-6.0. 8. Shearer M.J, Rahim S, Barkhan P, Stimmler L. Plasma vitamin K, in mothers and their newborn babies. Lancet l 982;2:460-3. 9. Leclercq M, Crozet M, Durand J, Bourgeay-Causse M, Sann L. Determination of phvlloquinone (vitamin K,) in
December I, 1985 Am J Obstet Gynecol
10. 11.
12.
13. 14.
15. 16.
17. 18.
sera of newborn infants and adults by high performance liquid chromatography. In: Frigerio A, ed. Chromatography in biochemistry, medicine and environmental research. Amsterdam: Elsevier Scientific, 1983:235-47. Caen J, Larrien MJ, Samama M. L'hemostase: methodes d'exploration et diagnostics pratiques. Paris: Expansion Scientifique, 1975. Lefevere MF, De Leenheer AP, Claeys AE. High performance liquid chromatographic assay of vitamin K in human serum.J Chromatogr 1979;186:749-62. Lefevere MF, De Leenheer AP, Clayes AE, Clayes IV, Steyaert H. Multidimensional liquid chromatography: a breakthrough in the assessment of physiological vitamin K levels.J Lipid Res 1982;23:1068-72. Wefring KW. Hemorrhage in the newborn and vitamin K prophylaxis. J Pediatr 1962;6 l :686-92. Owen GM, Nelsen CE, Baker GL, Connor WG,JacobsJP. Use of vitamin K, in pregnancy: effect on serum bilirubin and plasma prothrombin in the newborn. AM J 0BSTET Gna:c.o1. 1967 ;99:368-73. Deblay MF, Vert P, Andre M, Marchal F. Transplacental vitamin K prevents haemorrhage disease of infant of epileptic mother [Letter]. Lancet 1982;1:1247. Kerpel-Fronius E, Vargar F, Katai Pal E. Cause and significance of seasonal variation in the haemorrhagic tendency in the newborn. Arch Dis Child l 948;23:87-9. Sann L, Leclercq M, Fouillet M, Chappuis MC, Bruyere A. Gamma-carboxyglutamic acid in urine of newborn infants. Clin Chim Acta 1984;142:31-7. Corrigan JJ Jr, Kryc J.J. Factor II (prothrombin) levels in cord blood: correlation of coagulant activity with immunoreactive protein. J Pediatr l 980;97:979-83.
Erratum In the June 15, 1985, issue of the JOURNAL, in the article by Gazi Abdulhay, M.D., Philip J. DiSaia, M.D., John A. Blessing, Ph.D., and William T. Creasman, M.D., entitled "Human lymphoblastoid interferon in the treatment of advanced epithelial ovarian malignancies: A Gynecologic Oncology Group study," on page 422, first column, beginning in line 8 of the second paragraph, "(2) hematologic conditions (leukopenia was moderate and thrombocytopenia was mild overall, except in one patient in whom it was life-threatening);" "life-threatening" should have been "severe."
Key words: Vitamin K,, neonate, placenta, hemorrhagic disease
The activity of the vitamin K-dependent clotting factors is low at birth in comparison to adults. The clotting factors decrease over the first few days of life especially in breast-fed neonates.'·" However, a systematic supplement of vitamin K to newborn infants remains controversial, since it is not known whether the neonates are deficient in vitamin K at birth. Early studies suggested a deficiency in vitamin K,'" but later investigations could not detect the protein induced by vitamin K absence in cord blood." 7 Thus the solution to this enigma can be found only by measuring the concentration of vitamin K in cord blood. This was carried out by Shearer et al.," who did not detect vitamin K in cord blood. These results suggest a deficiency of vitamin K in all neonates, which is contradicted by the recent findings of blood coagulation in neonates.·· Therefore in the present investigation we measured the serum concentration of vitamin K, (phylloquinone) and the activity of some vitamin K-dependent clotting factors (II and VII plus X) in maternal and fetal bloods.
Patients and methods Patients. Thirty-four healthy mothers and their newborn infants were included in this study, which was From the Department of Neonatology, Hopital Debrousse, Cemip, Imtitut Pasteur, and Laboratoire d'Hematologi.e, Hopital de la Croix-Rousse, Lyon, and Matemite Claude Bernard, Oullim. Received for publication June 19, 1985; accepted August 30, 1985. Reprint request~: Uon Sann, M.D., Department of Neonatology, Hopital Debrousse, 29 Rue Soeur Bouvier, 69322 Lyon, France.
carried out between April and September, 1982. Each mother gave her consent to the study, which had been approved by the Hospital's Ethic Committee. Pregnancies were followed up regularly in the same department and were uneventful in all cases. All deliveries occurred at term without any complication. Procedure. Within 120 seconds after birth, a IO cm section of umbilical cord was clamped and 5 ml of blood was drawn by puncture of the umbilical artery to avoid contamination with maternal or placental blood. Within the next minute a 10 ml sample of the mother's venous blood was drawn. For the determination of vitamin K,, 2.5 ml of umbilical blood and 5.0 ml of maternal blood were collected into polystyrene tubes protected from light. The serum was separated and frozen at - 20° C; 2.5 ml of umbilical blood was mixed with 0.25 ml sodium citrate, and 5 ml of maternal blood was mixed with 0.5 ml sodium citrate. After centrifugation the plasma was pipetted off and frozen at - 20° C. Assay of vitamin K 1• The determination of vitamin K, was carried out at room temperature and in subdued light with a slightly modified version of the method originally described.'' The internal standard was vitamin K,. 15 an analogue of phylloquinone but with 15 atoms of carbons in the phytyl chain instead of 20 as in phylloquinone. It was provided by HoffmannLaRoche, Basel, Switzerland. First, 500 µI of serum was deproteinized by 500 µI of a solution of 1% pyrogallol ethanol. Then 500 µI of distilled water was added; after the mixture was shaken for 5 minutes, the extraction 771
772
Sann et al.
December I, 1985 Am .J Obste! Gynecol
25tl
tion by a further 12 and 37 µg/L; thus 90% to 95% of the added vitamin K 1 was recovered. Mass spectrometry at the Centre National de Recherche Scientifique in Solaise, France, verified vitamin K with fractions corresponding to elution volume after pooling and concentration. The spectrum of vitamin K, in blood was similar to that in the control. In 19 healthy fasting control adults the normal concentration was 6.76 ± 1.4 µg/L (mean± 1 SD). The activity of factor II and factors VII plus X was determined by standard methods ' 0 with a Dade coagulometer and Dade reagents.
200
150
-
100
-
~
50
:.:
z
-
:I!
20
...<
-
:I!
"
" 10
..;.
MOTHER
FETUS
( UMRILICAL ARTERY )
Fig. I. Serum vitamin K concentration in the mother and the fetus.
was performed in 3 ml of hexane containing 20 ng of internal standard. The mixture was centrifuged at 200 g for 10 minutes, and 2.5 ml of the organic phase was evaporated by air stream without heating. The residue was dissolved in 250 µI n-heptane. The extracts were assayed by high-performance liquid chromatography. Columns packed with beads 5 µm in diameter were used for the successive chromatographies. The fractionation steps consisted of ( 1) semiquantitative highperformance liquid chromatography with use of normal-phase Waters silica columns and n-heptane and ethyl acetate (99: 1) for elution; (2) analytical high-performance liquid chromatography with use of a reversed-phase Waters octo-decysilane Resolve column with elution in pure acetonitrile. The ultraviolet photometric detection was made at 254 and 280 nm to prevent interference, with use of a Waters M440 ultraviolet detector. The linearity of the response was ascertained for natural phylloquinone and for the internal standard vitamin K,_,,, at a concentration range of 1 to 500 µg/L. The quantitation was based on the measurement of the ratio of the peak height of vitamin K, and vitamin K1_,.,. The sensitivity of the assay was 1 µg/L. The coefficient of variation was 5'}( at a concentration of 7 µg/L. The recovery and accuracy of the assay were assessed by the addition of a known amount of vitamin K, to raise the concentra-
Results The paired maternal and cord concentrations of serum vitamin K, are shown in Fig. 1. Twenty-seven mothers had concentrations similar to the controls with a mean (±SD) of 9.03 ± 4.9 µg/L. The corresponding concentrations in cord blood were similar: 10.4 ± 5.3 µg/L. Six mothers exhibited high serum vitamin K, concentrations between 40 and 240 µg/L (median, 82). The respective serum vitamin K, concentrations in cord blood were in the range of 25 to 115 µg/L (median, 71 ). The concentrations in cord blood represented 37% to 110% (median, 87%) of the maternal concentration. One mother had a normal serum vitamin K, concentration of 9.0 µg/L. No vitamin K, was detectable in the cord blood of her baby. The simultaneous determination of serum vitamin K, and the activity of the vitamin K-dependent clotting factors was carried out in 16 paired maternal and fetal blood samples. The results are shown in Table I. A normal activity of factor II and factors VII plus X was detected in the mothers whose serum vitamin K, concentrations ranged from 1 to 240 µg/L. In all cord blood but one, the mean (±SD) activity of factor I I and factors VII plus X was 47% ± 9% and 65% ± 19%, respectively, whereas the serum vitamin K, concentrations were between 1 and 88 µg/L (mean, 25 µg/L). No statistical difference of the activity of the vitamin Kdependent clotting factors was observed when the results were considered in the patients with serum vitamin K, concentrations between 1 and 14 µg/L or between 20 and 88 µg/L. In one newborn with no detectable vitamin K, in cord blood, the activities of factor II and factors VII plus X were markedly reduced, whereas the mother with a 9.0 µg/L serum vitamin K1 concentration exhibited a normal activity of the clotting factors. Comment When the serum vitamin K 1 levels of the mothers were within the normal range indicated by the controls, the vitamin K, levels proved similar in cord bloods of all infants but one. The present results are at variance
Vitamin K-dependent clotting factor activity
Volume 153
773
l'\umbcr 7
Table I. Serum vitamin K, concentrations and factors II, VII, and X activity in maternal and fetal cord bloods Serum vitamin K, concentration ( µ,g! L) No. of samples
Arterial cord blood I 10 5
Maternal blood 16
Median
ND 11 63 12
I
Range
Factor II activit)' ('lc) Median
I
Range
7 1-14 20-88 1-140
Factors VII plus X activit)' (%) Median
I
Range
7
48.:i 44
'.H-66 28-:)5
58 66
46-86 55-100
99.6
87-100
100
95-100
ND = Not detectable.
with the findings of Shearer et al." The discrepancy could be explained by different procedures: in Shearer et al.'s study, the amount of blood collected from cord blood was very large; their procedure for the assay of vitamin K, concentration required an additional step for extraction with heating; they used vitamin K epoxide as the internal standard. The concentrations in the controls were also much lower than in the present study. We followed the procedures of Lefevre et al.''- '" and found concentrations in the controls similar to their results. In the present study, as was done in Shearer's investigations, we measured the serum concentration of vitamin K, in the arterial cord blood so as to avoid the contamination of blood by the placenta. When the mother exhibited high concentrations of vitamin K,, the concentrations in cord blood amounted to 37% to 110% of the maternal concentration. Therefore the present results suggest that vitamin K1 usually can cross the placental barrier. Shearer et al. observed no change in serum vitamin K, concentration in cord bloods I I to 47 minutes after administration of l mg of phylloquinone to the mother." However, this period of time is rather short and may represent the time required for mixing in the plasma and for hepatic captation of the vitamin in the mother. Preliminary investigations in the rat performed in our laboratory have shown a delay of the passage of vitamin K1 to the fetus and an equilibration of the concentrations of serum vitamin K, in the mother and the fetus 6 to 12 hours after the injection of vitamin K1 to the mother. In man it has been shown that the administration of phylloquinone to the mother could prevent the postnatal decrease of the vitamin K-dependent factors,'"· 11 and recently it has been reported that the administration of vitamin K, for 2 weeks before delivery prevented the recurrence of hypoprothrombinemia and hemorrhages in the neonates of epileptic mothers treated with anticonvulsivant drugs. 1' However, Wefring" pointed out that this effect
could not be observed when the administration took place 4 hours before delivery. The reason(s) for the higher serum vitamin K, concentrations in some mothers is not known. It could be related to dietary factors: in neonates a greater incidence of coagulation disturbances and bleeding disorders has been reported during the winter months when the dietary intake of vitamin K, was low'- '" whereas the present study was carried out during the summer months. However, when high concentrations were detected in the mothers, high concentrations were also found in cord blood, again suggesting that vitamin K, can cross the placental barrier. In the cases of normal or elevated serum vitamin K, concentrations in cord blood, the activity of factor II and factors VII plus X did not exceed about 50% of the activity found in adults. These results are similar to previous investigations.'- 1 This finding supports the concept of deficient production of the protein prothrombin, proconvertin, and factor X in the fetus and neonate, since the concentration of serum vitamin K, was normal. In addition, in neonates we detected a urinary excretion of gamma carboxyglutamic acid similar to the excretion in adults." By contrast, in one neonate with no detectable vitamin K, in cord blood, the activity of factor I I and factors VII plus X was very low; the reason(s) for a reduced placental transfer of vitamin K, in this case is not known. However, this result is in agreement with the findings of Corrigan and Kryc 1" which showed that at term the normal coagulant activity/antigen ratio of factor II is not suggestive of vitamin K deficiency with the exception of some neonates with a decreased ratio resulting from reduced activity of factor II. In conclusion, the present results of serum vitamin K 1 determination in the mother and their newborn infants suggest that vitamin K can cross the placenta. However, this transfer can be disturbed in some cases, particularly if complications of labor and delivery oc-
774
Sann et al.
cur. Therefore it seems careful to administer vitamin K prophylactically, especially to high-risk infants, since the hemorrhagic disease is not easy to predict and may result in a disastrous clinical condition. REFERENCES 1. Dam H, Dyggve H, Larson H, Plum P. The relation of vitamin K deficiency to hemorrhagic disease of the newborn. Acta Pediatr 1952;5: 159-63. 2. Aballi A.J. The action of vitamin Kin the neonatal period. South Med J l 965;58:48-60. 3. Hathaway WE. Coagulation problems in the newborn infant. Pediatr Clin North Am 1979; 17:929-42. 4. Oski FA, Naiman JL. Hematologic problems in the newborn. Philadelphia: WB Saunders, 1972:236-50. 5. Yoshioka K, Kimoshita S, Takamiya 0, Fujimura Y, Mimura Y. Abnormal antigens of factors II, VII and IX in newborns and breast fed infants with vitamin K deficiency. Acta Haematol Jpn 1982;45:860-6. 6. Van Doorm JM, Muller AD, Hemker HG. Heparin-like inhibitor, not vitamin K deficiency in the newborn [Letter]. Lancet 1977;1:852-3. 7. Malia RG, Presborn FE, ~litchell VE. Evidence against vitamin K deficiency in normal neonates. Thromb Haemost 1980;44: 159-6.0. 8. Shearer M.J, Rahim S, Barkhan P, Stimmler L. Plasma vitamin K, in mothers and their newborn babies. Lancet l 982;2:460-3. 9. Leclercq M, Crozet M, Durand J, Bourgeay-Causse M, Sann L. Determination of phvlloquinone (vitamin K,) in
December I, 1985 Am J Obstet Gynecol
10. 11.
12.
13. 14.
15. 16.
17. 18.
sera of newborn infants and adults by high performance liquid chromatography. In: Frigerio A, ed. Chromatography in biochemistry, medicine and environmental research. Amsterdam: Elsevier Scientific, 1983:235-47. Caen J, Larrien MJ, Samama M. L'hemostase: methodes d'exploration et diagnostics pratiques. Paris: Expansion Scientifique, 1975. Lefevere MF, De Leenheer AP, Claeys AE. High performance liquid chromatographic assay of vitamin K in human serum.J Chromatogr 1979;186:749-62. Lefevere MF, De Leenheer AP, Clayes AE, Clayes IV, Steyaert H. Multidimensional liquid chromatography: a breakthrough in the assessment of physiological vitamin K levels.J Lipid Res 1982;23:1068-72. Wefring KW. Hemorrhage in the newborn and vitamin K prophylaxis. J Pediatr 1962;6 l :686-92. Owen GM, Nelsen CE, Baker GL, Connor WG,JacobsJP. Use of vitamin K, in pregnancy: effect on serum bilirubin and plasma prothrombin in the newborn. AM J 0BSTET Gna:c.o1. 1967 ;99:368-73. Deblay MF, Vert P, Andre M, Marchal F. Transplacental vitamin K prevents haemorrhage disease of infant of epileptic mother [Letter]. Lancet 1982;1:1247. Kerpel-Fronius E, Vargar F, Katai Pal E. Cause and significance of seasonal variation in the haemorrhagic tendency in the newborn. Arch Dis Child l 948;23:87-9. Sann L, Leclercq M, Fouillet M, Chappuis MC, Bruyere A. Gamma-carboxyglutamic acid in urine of newborn infants. Clin Chim Acta 1984;142:31-7. Corrigan JJ Jr, Kryc J.J. Factor II (prothrombin) levels in cord blood: correlation of coagulant activity with immunoreactive protein. J Pediatr l 980;97:979-83.
Erratum In the June 15, 1985, issue of the JOURNAL, in the article by Gazi Abdulhay, M.D., Philip J. DiSaia, M.D., John A. Blessing, Ph.D., and William T. Creasman, M.D., entitled "Human lymphoblastoid interferon in the treatment of advanced epithelial ovarian malignancies: A Gynecologic Oncology Group study," on page 422, first column, beginning in line 8 of the second paragraph, "(2) hematologic conditions (leukopenia was moderate and thrombocytopenia was mild overall, except in one patient in whom it was life-threatening);" "life-threatening" should have been "severe."