Acta Pzdiatr Scand 64: 327-336, 1975
ABNORMAL PROTEOLYSIS IN SICK NEWBORNS
PER HENRIKSSON and H A N S E K E L U N D From the Coagulation Laboruton und the Department of Paediatrics, Unit3ersiry o f l u n d , Mulmij General Hospital, Mulmo, SHeden
ABSTRACT. Henriksson, P. and Ekelund, H. (Department of Paediatrics, University of Lund, Allmanna Sjukhuset, Malmo, Sweden). Abnormal protenlysis in sick newborns. Acta Paediatr Scand, 64:327, 1 9 7 5 . 4 7 newborn infants were studied on their first day of life for defects in the coagulation and fibrinolytic systems. The infants were divided into two diagnostic groups, one with IRDS, the other with mixed neonatal disorders. Factor V, fibrinogen and fibrin/fibrinngen degradation products (FDP) were abnormal more often than any of the other factors examined. The presence or absence of “multiple defects’’ appeared to depend on the seierity of the illness acd its ultimate course.. Thus 28% of the surviving infants or 85% of those who died had “multiple defects”. The pattern of abnormalities did not differ between the infants with IRDS and those with mixed disorders. The “multiple defects” are ascribed to the following mechanisms: (1) impaired synthesis due to vitamin K deficiency and/or liver damage, (2) abnormal proteolytic activity stimulated by tissue damage and causing (a) an activation of the coagulation process ( b ) activation of the fibrinolytic system, or (c) of both the coagulation and the fibrinolytic systems. Differentiation between these pathways to defective haemostasis are important when -deciding upon therapeutic measures in addition to the basic treatment.
KEY WORDS: Abnormal protenlysis, coagulation, fibrinolysis, IRDS, newborn
Changes in the haemostatic mechanism in the pathogenesis of various disorders in newborns have received much space in the literature in the last few years ( I , 2, 8-12, 15, 25, 26, 29, 40, 42, 46, 47, 48, 54, 61, 63). Interest has been focused mainly on the possible role played by disseminated intravascular coagulation (DIC). The contributions to the debate have recently been reviewed by McMillan et al. (491, Oski & Naiman ( 5 5 ) and Karpatkin (33). This paper reports a comparison between a group of newborns with IRDS and a group of infants with mixed neonatal disorders for possible changes in haemostasis.
CLINICAL MATERIAL The material is summarised in Fig. 1. where all the 87 infants, 33 with IRDS and 54 with otliei neonatal diaorders, are grouped according to gestational age and diagnosis. The diagnosis of IRDS was based on Hutchison’s criteria (30). though chest x-ray was not always possible. The mixed group consisted of infants v i t h unspecified respiratory symptoms not consistent with IRDS. apnoea due to immaturity (RIS), postnatal asphyxia and haemolytic disease due to Rhesus immunisation. 12 infants in each group died in the neonatal period. 10 infants, 6 in the IRDS group and 4 in the mixed group, showed evidence of significant intracranial haemorrhage (ICH). One infant in each group survived. In these 2 ir.idnts the diagnosis of ICH was based on cytologic findings in the cerebrospinal fluid. All the infants received vitamin K,, I rng i.m. at birth, and they were all delivered at the same obstetrical Actu Pzdiurr Scand 64
P . Henriksson and H . Ekelund
328
. * . .,. 2L
25
26
27
28
. 29
30 31
32
*.w
A
3 3 3 4 35 36 3 7 W 3 1 W E E K OF G E S T A T I O N
Fig. I. Survey of material. Circles denote preterm infants: triangles, term infants. Unfilled symbols denote survivors; filled symbols, those who died. A vertical on a symbol denotes intracranial haemorrhage.
department and cared for in the same neonatal unit. One infant was given whole blood due to haemorrhagic shock. Blood sornpling Blood specimens were obtained 2 to 24 hours after delivery from an indwelling plastic catheter inserted in one of the umbilical arteries for therapeutic and diagnostic purposes. The blood was collected with the silicone technique, and citrated plasma was prepared as described previously (32). Owing to the general condition and smallness of the infants as well as technical difficulties it was not always possible to obtain sufficient blood for a complete set of determinations. The determinations made are given in Table I .
( 6 ) . Prothrombin, factor VII and factor X were measured by the P&P method of Owren & Aas (56). Factor V activity was determined according to Wolf ( 6 5 ) . and factor VlII according to Nilsson et al. (51). Fibrinogen was measured by an immunochemical method of Karaca et al. (31). Plasminogen was determined by an immunochemical method according to Ganrot & Nilkhn (22). Fibrinolytic activity of plasma was measured on unheated bovine fibrin plates described by Nilsson & Olow (52). Fibrin/fibrinogen degradation products (FDP) were determined with the immunochemical method of NilChn (50). The determinations of FDP were performed on serum obtained from blood collected in tubes containing thrombin and EACA. The ethanol gelation test described by Godal & Abildgaard (23) was used as a test for fibrin monomers. Statistictrl procedures The significance of differences between means was estimated with Student's t-test. Significances of differences between the factors in various diagnostic groups were studied with the X*-test.
RESULTS The normal ranges of the various factors are based on a survey given by Bleyer et al. ( 7 ) and on personal studies (28). The factor levels were compared between the IRDS P S
I
)IED
:D )IED
LABORATORY METHODS Pkatelet counts were made by the method of Bjorkman 60
Table I . Laboratory stitdies in entire material (87 infkzts)
k LO
Determination
**
Infants examined
-
Factor V l l l P&P Factor V Fibrinogen Platelet9 Fibrin/fibrinogen degradation products Plasminogen Fibrin plates Ethanol gelation
71 53 65 65 62
xi
18 10
.
-_.
....
1.. t
l0 o
82
.-
......
t
Fig. 2. Comparison of P&P in infants with IRDS and mixed disorders and in surviving and nun-surviving infants. Dashed and dotted lines denote lower limits in healthy term and preterm infants.
Abnormal proteolysis in sick newborns
-
hCT
:D
IF
SURV -
MIXED
!IED
320-
SURV.
DIE0
8
.A
I
329
0
h
220. 200 180-
0
A
0 0 0
5
0 0 0000
160-
oAo
140-
120.
. .
'O-
.
__ 1. 60-
3 8-4 - .-.L
0
OBO 0%
8 -O-
.*
0%
..
0.
:
...... ....
......
0-
Fig. 3. Comparison of F VIIl in infants with IRDS and mixed disorders and in surviving and non-surviving infants.
group and the mixed group and between the surviving and the dead. The IRDS group did not differ from the mixed group in maturity @'0.05). Those who had succumbed3 however, had had a lower gestational age than those who had survived @O.OS). F V (Fig. 4). I n the total IRDS group the factor V levels ranged between 5 % and 100% (mean S7%, S.D.?23%) and in the toial mixed group between 0% and 107% (mean SS%, S.D.+27%). There was no significant difference between the two groups @>O.OS). A difference was found between the infants who had survived (range 10-107%, mean 60%, S.D.+21%) and those who had died (range 0-loo%, mean 4496, S.D.+33%) (p
ABNORMAL PROTEOLYSIS IN SICK NEWBORNS
PER HENRIKSSON and H A N S E K E L U N D From the Coagulation Laboruton und the Department of Paediatrics, Unit3ersiry o f l u n d , Mulmij General Hospital, Mulmo, SHeden
ABSTRACT. Henriksson, P. and Ekelund, H. (Department of Paediatrics, University of Lund, Allmanna Sjukhuset, Malmo, Sweden). Abnormal protenlysis in sick newborns. Acta Paediatr Scand, 64:327, 1 9 7 5 . 4 7 newborn infants were studied on their first day of life for defects in the coagulation and fibrinolytic systems. The infants were divided into two diagnostic groups, one with IRDS, the other with mixed neonatal disorders. Factor V, fibrinogen and fibrin/fibrinngen degradation products (FDP) were abnormal more often than any of the other factors examined. The presence or absence of “multiple defects’’ appeared to depend on the seierity of the illness acd its ultimate course.. Thus 28% of the surviving infants or 85% of those who died had “multiple defects”. The pattern of abnormalities did not differ between the infants with IRDS and those with mixed disorders. The “multiple defects” are ascribed to the following mechanisms: (1) impaired synthesis due to vitamin K deficiency and/or liver damage, (2) abnormal proteolytic activity stimulated by tissue damage and causing (a) an activation of the coagulation process ( b ) activation of the fibrinolytic system, or (c) of both the coagulation and the fibrinolytic systems. Differentiation between these pathways to defective haemostasis are important when -deciding upon therapeutic measures in addition to the basic treatment.
KEY WORDS: Abnormal protenlysis, coagulation, fibrinolysis, IRDS, newborn
Changes in the haemostatic mechanism in the pathogenesis of various disorders in newborns have received much space in the literature in the last few years ( I , 2, 8-12, 15, 25, 26, 29, 40, 42, 46, 47, 48, 54, 61, 63). Interest has been focused mainly on the possible role played by disseminated intravascular coagulation (DIC). The contributions to the debate have recently been reviewed by McMillan et al. (491, Oski & Naiman ( 5 5 ) and Karpatkin (33). This paper reports a comparison between a group of newborns with IRDS and a group of infants with mixed neonatal disorders for possible changes in haemostasis.
CLINICAL MATERIAL The material is summarised in Fig. 1. where all the 87 infants, 33 with IRDS and 54 with otliei neonatal diaorders, are grouped according to gestational age and diagnosis. The diagnosis of IRDS was based on Hutchison’s criteria (30). though chest x-ray was not always possible. The mixed group consisted of infants v i t h unspecified respiratory symptoms not consistent with IRDS. apnoea due to immaturity (RIS), postnatal asphyxia and haemolytic disease due to Rhesus immunisation. 12 infants in each group died in the neonatal period. 10 infants, 6 in the IRDS group and 4 in the mixed group, showed evidence of significant intracranial haemorrhage (ICH). One infant in each group survived. In these 2 ir.idnts the diagnosis of ICH was based on cytologic findings in the cerebrospinal fluid. All the infants received vitamin K,, I rng i.m. at birth, and they were all delivered at the same obstetrical Actu Pzdiurr Scand 64
P . Henriksson and H . Ekelund
328
. * . .,. 2L
25
26
27
28
. 29
30 31
32
*.w
A
3 3 3 4 35 36 3 7 W 3 1 W E E K OF G E S T A T I O N
Fig. I. Survey of material. Circles denote preterm infants: triangles, term infants. Unfilled symbols denote survivors; filled symbols, those who died. A vertical on a symbol denotes intracranial haemorrhage.
department and cared for in the same neonatal unit. One infant was given whole blood due to haemorrhagic shock. Blood sornpling Blood specimens were obtained 2 to 24 hours after delivery from an indwelling plastic catheter inserted in one of the umbilical arteries for therapeutic and diagnostic purposes. The blood was collected with the silicone technique, and citrated plasma was prepared as described previously (32). Owing to the general condition and smallness of the infants as well as technical difficulties it was not always possible to obtain sufficient blood for a complete set of determinations. The determinations made are given in Table I .
( 6 ) . Prothrombin, factor VII and factor X were measured by the P&P method of Owren & Aas (56). Factor V activity was determined according to Wolf ( 6 5 ) . and factor VlII according to Nilsson et al. (51). Fibrinogen was measured by an immunochemical method of Karaca et al. (31). Plasminogen was determined by an immunochemical method according to Ganrot & Nilkhn (22). Fibrinolytic activity of plasma was measured on unheated bovine fibrin plates described by Nilsson & Olow (52). Fibrin/fibrinogen degradation products (FDP) were determined with the immunochemical method of NilChn (50). The determinations of FDP were performed on serum obtained from blood collected in tubes containing thrombin and EACA. The ethanol gelation test described by Godal & Abildgaard (23) was used as a test for fibrin monomers. Statistictrl procedures The significance of differences between means was estimated with Student's t-test. Significances of differences between the factors in various diagnostic groups were studied with the X*-test.
RESULTS The normal ranges of the various factors are based on a survey given by Bleyer et al. ( 7 ) and on personal studies (28). The factor levels were compared between the IRDS P S
I
)IED
:D )IED
LABORATORY METHODS Pkatelet counts were made by the method of Bjorkman 60
Table I . Laboratory stitdies in entire material (87 infkzts)
k LO
Determination
**
Infants examined
-
Factor V l l l P&P Factor V Fibrinogen Platelet9 Fibrin/fibrinogen degradation products Plasminogen Fibrin plates Ethanol gelation
71 53 65 65 62
xi
18 10
.
-_.
....
1.. t
l0 o
82
.-
......
t
Fig. 2. Comparison of P&P in infants with IRDS and mixed disorders and in surviving and nun-surviving infants. Dashed and dotted lines denote lower limits in healthy term and preterm infants.
Abnormal proteolysis in sick newborns
-
hCT
:D
IF
SURV -
MIXED
!IED
320-
SURV.
DIE0
8
.A
I
329
0
h
220. 200 180-
0
A
0 0 0
5
0 0 0000
160-
oAo
140-
120.
. .
'O-
.
__ 1. 60-
3 8-4 - .-.L
0
OBO 0%
8 -O-
.*
0%
..
0.
:
...... ....
......
0-
Fig. 3. Comparison of F VIIl in infants with IRDS and mixed disorders and in surviving and non-surviving infants.
group and the mixed group and between the surviving and the dead. The IRDS group did not differ from the mixed group in maturity @'0.05). Those who had succumbed3 however, had had a lower gestational age than those who had survived @O.OS). F V (Fig. 4). I n the total IRDS group the factor V levels ranged between 5 % and 100% (mean S7%, S.D.?23%) and in the toial mixed group between 0% and 107% (mean SS%, S.D.+27%). There was no significant difference between the two groups @>O.OS). A difference was found between the infants who had survived (range 10-107%, mean 60%, S.D.+21%) and those who had died (range 0-loo%, mean 4496, S.D.+33%) (p
