Circulating levels of inflammatory cytokines (IL-1β and TNF-α), resistance to activated protein C, thrombin and fibrin generation in uncomplicated pregnancies

De-Hui W. Ku; Yale S. Arkel; Michael P. Paidas; Charles J. Lockwood

doi:10.1160/TH03-02-0119

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2003; 90(06): 1074-1079
DOI: 10.1160/TH03-02-0119

Blood Coagulation, Fibrinolysis and Cellular Haemostasis

Schattauer GmbH

Circulating levels of inflammatory cytokines (IL-1β and TNF-α), resistance to activated protein C, thrombin and fibrin generation in uncomplicated pregnancies

De-Hui W. Ku

¹The Center for Thrombosis in Women Health, Obstetrics and Gynecology Department, Yale University, New Haven, Connecticut, USA

,

Yale S. Arkel

¹The Center for Thrombosis in Women Health, Obstetrics and Gynecology Department, Yale University, New Haven, Connecticut, USA

,

Michael P. Paidas

¹The Center for Thrombosis in Women Health, Obstetrics and Gynecology Department, Yale University, New Haven, Connecticut, USA

,

Charles J. Lockwood

¹The Center for Thrombosis in Women Health, Obstetrics and Gynecology Department, Yale University, New Haven, Connecticut, USA

› Author Affiliations

Abstract

Summary

We studied 33 women during normal uneventful pregnancies and with no history of previous adverse pregnancy events for markers of activated coagulation and thrombin activity including prothrombin fragment 1.2(PF1.2), thrombin- antithrombin (TAT), and soluble fibrin polymer (SFP). In addition, we measured potential thrombin generation through the addition of thromboplastin to patient plasma in the presence of a throm-bin-specific chromogenic substrate determined serially over a period of time - Endogenous Thrombin Potential assay (ETP). This assay was performed with plasma treated and untreated with activated protein C (APC). The fibrinolytic system was assessed by measurement of thrombin activatable fibrinolysis inhibitor (TAFI). These findings were correlated with the levels of pro-inflammatory cytokines, interleukine-1β and tumor necrosis factor-α. Our data supports previous reports that indicate that resistance to activated protein C and coagulation activation markers are commonly increased in the later 2/3rds of pregnancy. There are no differences in thrombin generation potential, as determined by the ETP assay without the addition of APC, in the three trimesters. However, the thrombin reserve (TR), the ETP result without APC divided by the ETP result with the addition of APC, is increased above the reference range in the 2^nd and 3^rd trimesters. Patients with increased TR and resistance to APC had increased levels of TNF-α. Increased proinflammatory cytokines are reportedly associated with changes in the APC system with a decrease in the ability to generate APC. A sub-group of pregnancies with APC resistance had increased levels of TNF-α and may be important in the risk for adverse pregnancy outcomes.

Keywords

ETP - activation markers - pro-inflammatory cytokines - TAFI

Full Text

References

References
1 Stirling Y, Woolf L, North WR. et al. Haemostasis in normal pregnancy. Thromb Haemost 1984; 52: 176-82.
2 Comp PC, Thurnau GR, Welsh J. et al. Functional and immunologic protein S levels are decreased during pregnancy. Blood 1986; 68: 881-5.
3 Clark P, Brennand J, Conkie JA. et al. Activated protein C sensitivity, protein C, protein S and coagulation in normal pregnancy. Thromb Haemost 1998; 79: 1166-70.
4 Cumming AM, Tait RC, Fildes S. et al. Development of resistance to activated protein C during pregnancy. Br J Haematol 1995; 90: 725-7.
5 Kjellberg U, Anderson NE, Rosen S. et al. APC resistance and other haemostatic vari- ables during pregnancy and pueperium. Thromb Haemost 1999; 81: 527-31.
6 Rai R, Shlebak A, Cohen H. et al. Factor V Leiden and acquired activated protein C resistance among 1000 women with recurrent miscarriage. Hum Reprod 2001; 16: 961-5.
7 Brenner B, Mandel H, Lanir N. et al. Activated protein C resistance can be associated with recurrent fetal loss. Br J Haematol 1997; 97: 551-4.
8 Dizon TD, Meline L, Nelson LM. et al. Fetal carriers of the factor V Leiden mutation are prone to miscarriage and placenta infarction. Am J Obstet Gynecol 1997; 177: 402-5.
9 Preston FE, Rosendaal FR, Walker ID. et al. Increased fetal loss in women with heritable thrombophilia. Lancet 1996; 348: 913-6.
10 Kupferminc MJ, Eldor A, Steinman N. et al. Increased frequency of genetic thrombophilia in women with complications of pregnancy. N Engl J Med 1999; 340: 9-13.
11 Kupferminc MJ, Fait G, Many A. et al. Severe preeclampsia and high frequency of genetic thrombophilic mutations. Obstet Gynecol 2000; 96: 45-9.
12 Brenner B, Sarig G, Weiner Z. et al. Thrombophilic polymorphisms are common in women with fetal loss without apparent cause. Thromb Haemost 1999; 82: 6-9.
13 Comeglio P, Fedi S, Liotta AA. et al. Blood clotting activation during normal pregnancy. Thromb Res 1996; 84: 199-202.
14 Rosen T, Kuczynski E, O’Neill LM. et al. Plasma levels of thrombin-antithrombin complexes predict preterm premature rupture of the fetal membranes. J Matern Fetal Med 2001; 10: 297-300.
15 Eichinger S, Weltermann A, Philipp K. et al. Prospective evaluation of haemostatic system activation and thrombin potential in healthy pregnant women with and without factor V Leiden. Thromb Haemost 1999; 82: 1232-6.
16 Hemker HC, Beguin S. The generation of thrombin in whole plasma. Biochemical possibilities and physiological realities. Verh K Acad Geneeskd Belg 1985; 47: 321-39.
17 Rotteveel RC, Roozendaal KJ, Eijsman L. et al. The influence of oral contraceptives on the time-integral of thrombin generation (throm-bin potential). Thromb Haemost 1993; 70: 959-62.
18 Curvers J, Thomassen MC, Nicolaes GA. et al. Acquired APC resistance and oral contraceptives: differences between two functional tests. Br J Haematol 1999; 105: 88-94.
19 Nicolaes GA, Thomassen MC, Tans G. et al. Effect of activated protein C on thrombin generation and on the thrombin potential in plasma of normal and APC-resistant individuals. Blood Coagul Fibrinolysis 1997; 8: 28-38.
20 Bajzar L, Manuel R, Neshe im ME. Purification and characterization of TAFI, a thrombin-activable fibrinolysis inhibitor. J Biol Chem 1995; 270: 14477-84.
21 Esmon CT. Role of coagulation inhibitors in inflammation. Thromb Haemost 2001; 86: 51-6.
22 Rinehart BK, Terrone DA, Lagoo-Deenadayalan S. et al. Expression of the placenta cytokines tumor necrosis factor-alpha, interleukin 1 beta, and interleukin 10 is increased in preeclampsia. Am J Obstet Gynecol 1999; 181: 915-20.
23 Schatz F, Soderland C, Hendricks-Munoz KD. et al. Human endometrial endothelial cells: isolation, characterization, and inflammatory-mediated expression of tissue factor and type 1 plasminogen activator inhibitor. Biol Reprod 2000; 62: 691-7.
24 Esmon CT. Does inflammation contribute to thrombotic events?. Haemostasis 2000; 30 (02) suppl 34-40.
25 Mezzano D, Espana F, Panes O. et al. Increased activation of protein C, but lower plasma levels of free, activated protein C in uraemic patients: relationship with systemic inflammation and haemostatic activation. Br J Haematol 2001; 113: 905-10.
26 Taylor Jr FB, Stearns-Kurosawa DJ, Kurosawa S. et al. The endothelial cell protein C receptor aids in host defense against Escherichia coli sepsis. Blood 2000; 95: 1680-6.
27 Taylor Jr FB, Stern DM, Nawroth PP. et al. Activated protein C prevents E. coli induced coagulopathy and shock in the primate. Circulation 1986; 74: 65a abstr
28 Murakami K, Okajima K, Uchiba M. et al. Activated protein C prevents LPS-induced pulmonary vascular injury by inhibiting cytokine production. Am J Physiol 1997; 272: L197-202.
29 Dahlback B, Carlsson M, Svensson PJ. Familial thrombophilia due to a previously unrecognized mechanism characterized by poor anticoagulant response to activated protein C: prediction of a cofactor to activated protein C. Proc Natl Acad Sci USA 1993; 90: 1004-8.
30 Favaloro EJ, Mirochnik O, McDonald D. Functional activated protein C resistance assays: correlation with factor V DNA analysis is better with RVVT-than APTT-based assays. Br J Biomed Sci 1999; 56: 23-33.
31 Hooper WC, Phillips DJ, Renshaw MA. et al. The up-regulation of IL-6 and IL-8 in human endothelial cells by activated protein C. J Immunol 1998; 161: 2567-73.
32 Rijkers DTS, Wielders SJH, Beguin S, Hemker HC. Prevention of the influence of fibrin and _-macroglobulin in the continuous measurement of the thrombin potential: implications for an endpoint determination of the optical density. Thromb Res 1998; 89: 161-9.
33 Duncan RJS, Weston PD, Wrigglesworth R. A new reagent which may be used to introduce sulfhydryl groups into proteins, and its use in the preparation of conjugates for immunoassay. Anal Biochem 1983; 132: 68-73.
34 Lambin P, Pochon F, Fine JM. et al. The α₂-macroglobulin/thrombin interaction in the presence of hydroxylamine. Thromb Res 1983; 32: 123-32.
35 Hemker HC, Willems GM, Beguin S. A computer assisted method to obtain the pro-thrombin activation velocity in whole plasma independent of thrombin decay processes. Thromb Haemost 1986; 56: 9-17.
36 Arkel YS, Ku DH, Kamiyama M. et al. A highly specific functional test for factor V Leiden: a modified tissue factor assay for activated protein C resistance. Haemostasis 1997; 27: 290-304.
37 Mosnier LO, von den Borne PAK, Meijers JCM. et al. Plasma TAFI levels influence the clot lysis time in healthy individuals in the presence of an intact intrinsic pathway of coagulation. Thromb Haemost 1998; 80: 829-35.
38 Pelzer H, Schwarz A, Stuber W. Determination of human prothrombin activation fragment 1+2 in [plasma with an antibody against a synthetic peptide. Thromb Haemost 1991; 65: 153-9.
39 Pelzer H, Schwarz A, Heimburger N. Determination of human thrombin-antithrom-bin III complex in plasma with an enzyme-linked immunosorbent assay. Thromb Haemost 1988; 59: 101-6.
40 Gargan PE, Gaffney PJ, Pleasants JR. et al. A monoclonal antibody which recognizes an epitopic region unique to the intact fibrin polymeric structure. Fibrinolysis 1993; 7: 275-83.
41 Kim HK, Lee KR, Yang JH. et al. Plasma levels of D-dimer and soluble fibrin polymer in patients with hepatocellular carcinoma: a possible predictor of tumor thrombosis. Thromb Res 2003; 109: 125-9.
42 Bartels PC, Schoorl M, Schoorl M. et al. Activation of coagulation during treatment with haemodialysis. Scand J Clin Lab Invest 2000; 60: 283-90.
43 Kjellberg U, Andersson NE, Rosen S. et al. APC resistance and other haemostatic variables during pregnancy and puerperium. Thromb Haemost 1999; 81: 527-31.
44 Esmon CT, Taylor Jr FB, Snow TR. Inflammation and coagulation: linked process potentially regulated through a common pathway mediated by protein C. Thromb Haemost 1991; 66: 160-5.
45 Hooper WC, Phillips DJ, Renshaw MA. et al. The up-regulation of IL-6 and IL-8 in human endothelial cells by activated protein C. J Immunol 1998; 161: 2567-73.
46 Nawroth PP, Stern DM. Modulation of endothelial cell hemostatic properties by tumor necrosis factor. J Exp Med 1986; 163: 740-5.
47 Raghupathy R. Pregnancy: success and failure within the Th1/Th2/Th3 paradigm. Semin Immunol 2001; 13: 219-27.
48 Ju Z, Fan L, Lu L. Study on normal pregnancy and recurrent spontaneous abortions from helper T cell 1/helper T cell 2 cytokines balance. Zhonghua Fu Chan Ke Za Zhi 2000; 35: 473-5.
49 Marin V, Montero-Julian FA, Gres S. et al. The IL-6-soluble IL-6Ralpha autocrine loop of rndothelial activation as an intermediate between acute and chronic inflammation: an experimental model involving thrombin. J Immunol 2001; 167: 3435-42.
50 Ueno A, Murakami K, Yamanouchi K. et al. Thrombin stimulates production of interleu-kine-8 in human umbilical vein endothelial cells. Immunology 1996; 88: 76-81.