Valores de antitrombina, proteína C y proteína S en parejas madre-recién nacido durante el posparto / Thrombin, protein C, and protein S values in mother-infant dyads in the postpartum period

Introducción: El objetivo fue establecer valores de normalidad de antitrombina (AT), la proteína C (PC) y la proteína S (PS) dentro de la primera semana después del nacimiento en el binomio madre-recién nacido, ajustados por factores obstétricos y perinatales, según 2 métodos de laboratorio diferentes. Métodos: Se realizaron determinaciones en 83 neonatos a término sanos y sus madres, con 3 grupos de edad posparto: días 1-2, 3 y 4-7. Resultados :No hubo diferencias para ninguna de las proteínas en los distintos grupos de edad de los neonatos y las madres dentro de la primera semana posparto. El análisis ajustado no mostró ninguna asociación con factores obstétricos o perinatales. Los valores de AT y PC en las madres fueron mayores que en los neonatos (p<0,001), mientras que la PS mostró valores similares. La correlación global de los valores entre los pares madre-recién nacido fue escasa, salvo para la PS libre en los en los siguientes 2 días al parto. Aunque no se encontraron diferencias entre los 2 métodos de laboratorio, los valores absolutos fueron diferentes. (AU)

Introduction: The objective of the study was to establish the normal range for the levels of antithrombin (AT), protein C (PC), and protein S (PS) in the first week post birth in mother-infant dyads, adjusting for obstetric and perinatal factors, based on 2 different laboratory methods. Methods: We took measurements in 83 healthy term neonates and their mothers, establishing 3 postpartum age groups: 1-2 days, 3 days, and 4-7 days. Results: There were no differences in the levels of any of the proteins between the different age groups in neonates or mothers in the first week post birth. The adjusted analysis found no association with obstetric or perinatal factors. The AT and PC levels were higher in mothers compared to infants (P<.001), while the PS levels were similar in both. Overall, the correlation of maternal and infant protein values was poor, except for the levels of free PS in the first 2 days post birth. Although we found no differences based on which of the 2 laboratory methods was applied, the absolute values did differ. (AU)

Thrombin, protein C, and protein S values in mother-infant dyads in the postpartum period.

INTRODUCTION: The objective of the study was to establish the normal range for the levels of antithrombin (AT), protein C (PC), and protein S (PS) in the first week post birth in mother-infant pairings, adjusting for obstetric and perinatal factors, based on 2 different laboratory methods. METHODS: Determinations were carried out in 83 healthy term neonates and their mothers, establishing 3 postpartum age groups: 1-2 days, 3 days, and 4-7 days. RESULTS: There were no differences in the levels of any of the proteins between the different age groups in neonates or mothers in the first week post birth. The adjusted analysis found no association with obstetric or perinatal factors. The AT and PC levels were higher in mothers compared to infants (P < .001), while the PS levels were similar in both. Overall, the correlation of maternal and infant protein values was poor, except for the levels of free PS in the first 2 days after delivery. Although we found no differences based on which of the 2 laboratory methods was applied, the absolute values did differ.

The addition of Tirofiban infusión to heparin for intraoperative heparin resistance associated with Marfan Syndrome / Adición de una infusión de Tirofiban a heparina en caso de resistencia intraoperatoria a la heparina asociada al Síndrome de Marfan

Abstract Marfan syndrome classically presents with aortic root aneurysms. Aortic ectasia causes diverse blood flow alterations, influencing the behavior of coagulation factors and platelet activity. Heparin resistance has also been reported associated with Marfan Syndrome in a small number of patients, probably due to antithrombin III (ATIII) deficiency or various mutations. The ascending aorta and the aortic valve are replaced with prosthetic material during Bentall- de Bonno procedures. Resistance to anticoagulation during extracorporeal circulation, represents a significant challenge for both anesthesiologists and the surgical team. Resistance to heparin was observed in a patient with Marfan syndrome undergoing a Bentall procedure. ATIII concentrate was not available, and Activated Coagulation Time did not increase despite high doses of heparin. An alternate anticoagulation approach was used successfully.

Resumen El síndrome de Marfan clásicamente se presenta con aneurismas de la raíz de la aorta. La ectasia aórtica produce alteraciones en el flujo sanguíneo que influyen sobre el comportamiento de los factores de la coagulación y la actividad de las plaquetas. También se ha reportado resistencia a la heparina asociada al Síndrome de Marfan en un menor número de pacientes, probablemente debido a deficiencia de antitrombina III (ATIII) o a diversas mutaciones. La aorta ascendente y la válvula aórtica se reemplazan con material prostético en los procedimientos Bentall- de Bonno. La resistencia a la anticoagulación durante circulación extracorpórea significa un enorme desafío tanto para los anestesiólogos, como para el equipo quirúrgico. Se observó resistencia a la heparina en un paciente con Síndrome de Marfan sometido a un procedimiento de Bentall. No había disponibilidad de concentrado ATIII y no aumentó el Tiempo de Coagulación Activada a pesar de las elevadas dosis de heparina. Se utilizó exitosamente un abordaje alterno de anticoagulación.

Púrpura fulminans relacionada con deficiencia de antitrombina III en paciente agudo críticamente enfermo con aislamiento de Enterococcus faecalis / Purpura fulminans related with antithrombin III deficiency in critical ill patient with Enterococcus faecalis isolation / Purpura fulminans relacionada à deficiência de antitrombina III em paciente em estado crítico com isolamento de Enterococcus faecalis

Resumen: La coexistencia entre el fracaso fibrinolítico y la presencia de infección es más frecuente de lo que parece; desafortunadamente muchas veces pasa por alto y es concebido como algo incidental, generando consigo catástrofes vasculares y serias disfunciones endoteliales. Presentamos el caso de un adulto joven quien debuta con choque obstructivo de acuerdo con la cardioscopia invasiva y a la información gasométrica requiere terapias tempranas dirigidas por objetivos en el contexto de sepsis severa con aislamientos de Enterococcus faecalis y púrpura fulminans postinfecciosa aguda en el escenario clínico de deficiencia de antitrombina III. De acuerdo con el perfil hemodinámico referido y manifestaciones eléctricas presentadas se documentaron marcadores de actividad fibrinolítica, por lo cual fue llevado a perfusión pulmonar documentándose enfermedad pulmonar tromboembólica. Evoluciona favorablemente y es trasladado a piso para continuar atención médica en salud por los servicios de neumología y hematología.

Abstract: Coexistence between fibrinolytic failure and the presence of infection is more common than it seems; unfortunately it often is not recognized and is conceived as incidental; leading to vascular catastrophes and serious endothelial dysfunctions. We present the case of a young adult who debuts with purpura fulminans related to Enterococcus faecalis isolation in the clinical setting of antithrombin III deficiency and thromboembolic pulmonary disease. According to the hemodynamic profile referred and electrical manifestations presented, markers of fibrinolytic activity were documented, for which it was taken to pulmonary perfusion documenting thromboembolic lung disease. He evolves favorably and is transferred to continue medical health care by the services of pulmonology and hematology.

Resumo: A coexistência entre falência fibrinolítica e presença de infecção é mais frequente do que parece; Infelizmente, muitas vezes é negligenciado e concebido como algo incidental, gerando catástrofes vasculares e graves disfunções endoteliais. Apresentamos o caso de um adulto jovem que apresenta choque obstrutivo de acordo com cardioscopia invasiva e informações gasométricas, requer terapias precoces direcionadas por objetivos no contexto de sepse grave com isolamento de Enterococcus fecalis e púrpura fulminante pós-infecciosa aguda no cenário clínico de deficiência de antitrombina III. De acordo com o perfil hemodinâmico referido e manifestações elétricas apresentadas, foram documentados marcadores de atividade fibrinolítica, para o qual foi encaminhado para perfusão pulmonar, documentando doença pulmonar tromboembólica. O paciente progride favoravelmente e é transferido para o leito para continuar o atendimento médico nos serviços de pneumologia e hematologia.

Low levels of coagulation inhibitors: A high-risk thrombotic factor in thalassemic patients. / Bajos niveles de inhibidores de la coagulación: un factor de alto riesgo trombogénico en pacientes talasémicos.

BACKGROUND AND AIM: The ß-thalassemia major (ß-TM) is defined as a hereditary red blood cell-related disease. Thrombotic events are associated with thalassemia in adult patients. Thus, the present investigation was aimed to examine some hemostatic parameters, including anti thrombin-III (AT-III), protein-C (PRC) and protein-S (PRS) in ß-TM patients. METHODS: Thirty B-TM patients who referred for routine follow-up admission to the thalassemia clinic of Kerman Special Disease Center alongside with 30 healthy subjects were selected and enrolled in the present study. Further registration, the peripheral blood specimens were collected after 3 weeks of last transfusion and then the plasma concentrations of AT-III, PRC and PRS were measured in them. RESULTS: We have observed that the concentrations of natural coagulation inhibitors (PRC and PRS) were significantly attenuated in ß-TM patients (P<0.05), while the plasma level of AT-III was not remarkably differed in ß-TM patients in compare to healthy subjects. CONCLUSION: According to the findings of present work, significant changes in the PRC, PRS and AT-III which could be observed in multi transfused ß-TM patients may attribute as critical risk factors for the development of upcoming thromboembolic events in their future life.

Manejo obstétrico de la deficiencia hereditaria de antitrombina durante el embarazo y puerperio. Dos casos clínicos / Obstetric management of hereditary antithrombin deficiency in pregnancy and postpartum. Two case studies

La deficiencia de antitrombina III hereditaria es una rara enfermedad que afecta al 0.02-0.2 por cento de la población. Puede presentar mayor frecuencia de complicaciones y resultados adversos tanto en la madre como en el feto. Se presenta el manejo obstétrico de dos gestaciones consecutivas en una mujer con deficiencia de antitrombina III. Descripción: en ambos embarazos la madre realiza profilaxis de la enfermedad tromboembólica con heparina de bajo peso molecular para evitar la aparición de esta patología tanto en el embarazo como en el puerperio y mejorar el flujo útero-placen-tario. Con respecto a las complicaciones obstétricas, sólo existe un enlentecimiento del crecimiento fetal que obliga a un control obstétrico estricto. En ambas gestaciones los estudios eco-Doppler están dentro de la normalidad lo que permite una conducta expectante, consiguiendo llegar a término. Discusión: la profilaxis con heparina de bajo peso molecular en las gestantes con esta trombofilia y las intervenciones preventivas de factores de riesgo de enfermedad tromboembólica, junto con un control obstétrico adecuado, ha conseguido evitar la apari-ción de complicaciones derivadas de esta patología en el embarazo y en el puerperio. Por otra parte, el control del crecimiento fetal y el estudio Eco-Doppler han permitido asegurar el bienestar fetal no adelan-tando el parto, consiguiendo partos a término...

Hereditary antithrombin III deficiency is a rare disease that affects 0.02-0.2 percent of the population. It may be associated with a higher rate of complications and adverse outcomes in both mother and fetus. The present study describes the management of a woman with antithrombin III deficiency and two consecutive pregnancies. Description: in both pregnancies, the woman under went prophylaxis with low molecular weigh heparin, to prevent thromboembolic disease and improve the utero-placental flow during pregnancy and the postpartum period. The only obstetric compli-cation was fetal growth retardation requiring strict obstetric control. In these two cases the eco-Doppler studies offeto-placentalflow were normal, leading to the expectation of managing a term birth. Discussion: low molecular weigh heparin prophylaxis in pregnant women with thrombophilia and preventive interventions for risk factors for throm-boembolic disease, together with appropriate obstetric care managed to avoid the emergence of complications of this disease in pregnancy and puer-perium. Fetal growth control and a Doppler study also help to ensure the well-being of the fetus and avoid a preterm birth...

Antitrombina III / Antithrombin III

Antitrombina III Antithrombin IIICódigo SCPC (Sociedad Colombiana de Patología Clínica): 10700. Código CUPS (CodificaciónÚnica de Procedimientos en salud): 902007. Sección: Hematología. Nivel de complejidad:alto. Metodología: colorimetría. Sinónimos: actividad de antitrombina.DefiniciónLa prueba de antitrombina III, un inhibidor natural de la coagulación, es útil para el diagnóstico del riesgo de trombosis o bien para definir la etiología en pacientes con episodios previos de tromboembolismo venoso. La actividad de la antitrombina se determina mediante un método colorimétrico a partir de muestras de plasma citratado.Espectro clínico de aplicaciónLa antitrombina es una glicoproteína dependiente de vitamina K, sintetizada en el hígado, que actúa como un inhibidor natural de la coagulación mediante la unión irreversible a la trombina y al factor Xa y, en menor medida, a los factores Ixa, XIa, XIIa, plasmina y calicreína. De esta forma, la antitrombina inhibe múltiples puntos la cascada de la coagulación y, debido a esto, su deficiencia funcional o cuantitativa predispone a la trombosis.En la población general la deficiencia de antitrombina es variable, afectando alrededor de una por cada 500-5.000 personas. La deficiencia de antitrombina puede corresponder a una deficienciaen la concentración, la actividad o ambas; a su vez, puede ser hereditaria, congénita o adquirida. Existen varios tipos de deficiencia congénita y hereditaria que se resumen en la tabla 1. Por su parte, la deficiencia adquirida de antitrombina se puede presentar en pacientes con enfermedades hepáticas, coagulación intravascular diseminada, síndrome nefrótico, bypass cardiopulmonar, sepsis o con historia de nacimiento prematuro.

[Role of antithrombin iii in cardiac surgery]. / Papel de la antitrombina iii en cirugía cardiaca.

Coagulation of blood is of multidisciplinary interest. Cardiac surgery produces major changes in the delicate balance between pro-and anti-coagulant serum factors. The role of antithrombin iii has been analysed after finding evidence that associated decreased levels of protein activity to postoperative morbidity and mortality. Supplementing exogenous antithrombin is considered with the aim of optimising outcomes. Its intrinsic anticoagulant and anti-inflammatory properties have stimulated a growing interest, and suggests new lines of research.

Trombofilia como causa de embolismo pulmonar perioperatorio / Thrombophilia as a cause of Perioperative pulmonary embolism

Introducción: Virshow definió el síndrome de hipercoagulabilidad como parte de la triada causal de trombosis venosa (VTE) y la primera causa identificable de esta condición fue el déficit de antitrombina (AT). Objetivo: Mostrar nuestra experiencia sobre la conducta de una paciente con trombofilia como causa de embolismo pulmonar perioperatorio. Material y Método: Paciente programada para histerectomía abdominal electiva por severa menometrorragia que desarrolló un embolismo pulmonar (EP) en el momento de la inducción anestésica. Discusión: Los estudios hechos para identificar la causa de esta complicación demostraron bajos niveles de AT. La presencia de un fenómeno embolico asociado o no a este diagnóstico aumenta el riesgo de recurrencia. La anticoagulación usando un puente entre los antagonistas de la vitamina K y la heparina es mandatoria. Conclusión: La sospecha clínica, el diagnóstico precoz y la participación multidisciplinaria fueron elementos claves para el manejo exitoso de esta enferma.

Introduction: Virshow defined the hypercoagulability syndrome as part of causal triad of venous thromboembolism (VTE), and the first identifiable cause of this condition was a antithrombin deficit (AT), Objective: To demonstrate our experience on the behavior of a patient presenting with thrombophilia as cause of Perioperative pulmonary embolism. Material and Methods: Patient programmable for elective abdominal hysterectomy from a severe menometrorrhagia provoking a pulmonary embolism (PE) from the moment of anesthesia induction. Discussion: Studies performed to identify the cause of this complication showed low levels of AT. Presence of an embolic phenomenon associated or not to this diagnosis, increases the recurrence risk. Anticoagulant therapy using a bridge among vitamin K antagonist and heparin is mandatory. Conclusion: Clinical suspicion, an early diagnosis and multidisciplinary participation were key elements to successful management of this patient.

Effect of estrogen-progestin hormonal replacement therapy on blood coagulation and fibrinolysis in postmenopausal women

OBJECTIVE: To evaluate antithrombin III (AT), thrombin (Fragment 1+2 [F1+2] and thrombin-antithrombin [TAT]) generation markers, as well as other coagulation parameters, such as prothrombin time, partial activated thromboplastin time, thrombin time, fibrinogen, euglobulin lysis time, and platelet count, in postmenopausal women after hormonal therapy. STUDY DESIGN: Forty-five patients who received either 0.625 mg/day unopposed oral conjugated equine estrogen (CEE), 0.625 mg/day oral CEE plus medroxyprogesterone acetate (MP), or 50 µg/day transdermal 17beta-estradiol plus MP, were included. Tests were performed before (T0) and after 3 (T3), 6 (T6) and 12 (T12) months of treatment. AT was determined by an amidolytic method, whereas F1+2 and TAT complex were measured by ELISA. RESULTS: There was a significant reduction in the AT level of patients who received oral CEE plus MP at T3. There was no AT reduction in patients taking either oral CEE alone or transdermal 17beta-estradiol plus MP. F1+2 increased in all patients, but it reached statistical significance only in patients receiving transdermal 17beta-estradiol MP at T3. CONCLUSIONS: The CEE associated with MP treatment may reduce AT levels, whereas unopposed CEE or transdermal 17beta-estradiol plus MP does not change AT. These changes might not be clinically relevant in the general population; however, hormonal replacement therapy may increase the risk of thrombosis in women with congenital or acquired thrombophilia.

OBJETIVO: Avaliar os marcadores antitrombina III (AT), fragmento 1 + 2 da trombina (F1+2) e complexo trombina-antitrombina (TAT), bem como outros parâmetros da coagulação, como tempo de pró-trombina, tempo parcial de tromboplastina ativado, tempo de trombina, fibrinogênio e tempo de lise da euglobulina em mulheres na pós-menopausa após terapia hormonal. DESENHO DO ESTUDO: Foram incluídas 45 voluntárias que receberam estrogênios conjugados eqüinos (ECE) 0,625 mg/dia, isoladamente ou associado ao acetato de medroxiprogesterona (AMP) ou usaram o 17beta-estradiol (50 µg/dia) transdérmico com AMP. Os exames foram realizados antes do tratamento (T0) e após três (T3), seis (T6) e doze (T12) meses após o início do tratamento. AT foi avaliada pelo método amidolítico, enquanto que o F1+2 e o complexo TAT por ELISA. RESULTADOS: Houve redução significante nos níveis de AT em pacientes que receberam ECE associado ao AMP no T3. Não houve redução na AT em mulheres que usaram ECE isoladamente ou aquelas com 17beta-estradiol transdérmico e AMP. O F1+2 aumentou em todos os grupos, mas apenas o grupo com 17beta-estradiol transdérmico e AMP apresentou diferença significante durante o T3. CONCLUSÕES: A associação de ECE e AMP pode reduzir os níveis de AT, enquanto ECE isoladamente ou 17beta-estradiol transdérmico com AMP não modificam-o acentuadamente. Essas alterações poderiam ser mais relevantes clinicamente na análise populacional. Todavia, a terapia de reposição hormonal aumentaria o risco de trombose em mulheres com trombofilia prévia congênita ou adquirida.

Deficiência de inibidores naturais: diagnóstico laboratorial / Deficiency of natural inhibitor: laboratory diagnosis

Neste relato são apresentados aspectos clínicos e a importância da deficiência dos inibidores da coagulação, antitrombina, proteina C e proteína S, ressaltando-se o diagnóstico laboratorial desta anomalia.

The clinical aspects and the importance of the deflciency of the three coagulation inhibitors, antithrombin, protein C and protein S, are discussed in this report.