Search

The release of fibrinolytic agents from human cornea was studied by culturing foetal corneal explants in the presence of a standard fibrin clot and measuring the fibrin degradation products formed in the culture medium. Cultures of cornea were found to invariably release a significant amount of fibrinolytic agents, probably fibrinolytic activators, since Tranexamic acid, an inhibitor of plasminogen activation into plasmin, completely blocked the dissolution of the clot in the culture system. The function of these fibrinolytic activators is presumably to keep the cornea free from fibrin deposits which may occur after injury or inflammation.

A report is presented of a young, otherwise apparently healthy, woman who had had three pregnancies which for some unknown reason terminated in intrauterine death (macerated foetuses). During the third pregnancy a coagulation defect was diagnosed, which was characterized by prolonged coagulation times and prolonged one-stage prothrombin time. This defect disappeared after the end of the pregnancy, but returned during the fourth pregnancy. This time a circulating anticoagulant was found, which inhibited the action of thromboplastin. The values found for the various coagulation factors were normal. The anticoagulant titre rose during the pregnancy from 1/2 to 1/10. Leucocyte agglutinating as well as Iymphocytotoxic antibodies directed against the husband's cells were demonstrated in the patient during the pregnancy. In this case, by passage of cell fragments and thromboplastic substances to the mother, the foetus had probably induced the development of antibodies against the foetal tissues. The foetus may be regarded as an incompatible transplant. The fourth pregnancy was terminated by caesarean section in the 34th week. The child weighed 1440 g and, after three exchanges of blood, did very well. The placenta was severely infarcted. It is postulated that the development of antithromboplastin during pregnancy may be a contributory cause of intrauterine death.

It is known that factor VIII related antigen (VIIIR:Ag) and plasminogen activator (PA) are synthesized in the vascular endothelial cells from which they may be released in response to certain stimuli such as venous occlusion (VO) or infusion of DDAVP (1-desamino-8-D-arginine vasopressin). To elucidate the possible association between these two factors we studied the response of factor VIII related activities and PA to VO and DDAVP (i.v. and i.n.) in 104 normal individuals, two patients with severe haemophilia A and 16 with various forms of von Willebrand's disease (vWd). Analysis of the results from each of the normal persons revealed a positive correlation between the maximal increase in plasma concentrations of VIIIR:Ag and PA after DDAVP. Furthermore, it could be demonstrated that some individuals responded repeatedly with either very high or very low F VIII and PA release. In four patients with severe vWd (no detectable VIIIR:Ag by an immunoradiometric method (IRMA)), DDAVP did not affect factor VIII related activities and no increase in PA was observed. Infusion of antihaemophilic factor (fraction I-O, Kabi) prior to the administration of DDAVP failed to increase the PA levels. VO of the arms had no effect on PA in these patients. Four patients with moderate vWd (0.01 U/dl VIIIR:Ag by IRMA) developed fibrinolytic activity after DDAVP, however, within the lower limit of the normal range. In nine patients with mild or variant vWd (0.1 U/dl by IRMA), DDAVP caused increases both in factor VIII related activities and PA. The two haemophiliacs responded to DDAVP and VO with normal increases in PA and VIIIR:Ag. The combined data indicate that there is an association between the release of PA and factor VIII related activities in normals, haemophiliacs and patients with vWd.

A case of advanced breast cancer with cerebral metastasis and pleurisy is reported in which irradiation and cytostatics had failed to retard progressive growth and spread of the tumour. Adjuvant therapy with heparin combined with the fibrinolytic inhibitor tranexamic acid was followed by regression of the cerebral metastasis as well as the pleurisy. When last seen one year later, the patient was free from symptoms.

Urokinase plasminogen activator (u-PA) plays a pivotal role in tissue degradation during tumor spread and metastasis. We have quantitated u-PA in tissue homogenates of 31 serous ovarian tumors and localized u-PA and its mRNA in tissue sections of 26 serous ovarian tumors. The content of u-PA was higher in malignant than in benign tumors, with the highest levels being found in poorly differentiated cancers. In tissue sections, the u-PA mRNA was hybridized with a radiolabeled RNA probe. Signals were almost exclusively found in the epithelium in benign and borderline tumors and in well-differentiated cancers. Poorly differentiated tumors and metastases exhibited prominent stromal expression of u-PA mRNA, whereas epithelial expression was weak or absent. Immuno-histochemical staining co-localized u-PA antigen with its mRNA in the epithelium of benign and borderline tumors and in well-differentiated cancers. Poorly differentiated malignant tumors showed extensive immunostaining in the epithelium in addition to stromal staining. The u-PA mRNA-expressing and u-PA-immunostained cells in the stroma were not tumor cells since no cells in the stroma were positive for cytokeratin. Poorly differentiated tumors had increased numbers of stromal macrophages (CD68), and they co-localized with some of the u-PA-positive cells. The presence of u-PA antigen and the absence of u-PA mRNA in tumor epithelium of poorly differentiated tumors and metastases together with the presence of u-PA mRNA in the stroma suggests production in stromal cells and subsequent binding to receptor sites in tumor cells.

Marked changes in the hemostasis system, especially increases in PAI-2, are observed during pregnancy and at delivery. This inhibitor is produced by placental trophoblasts and by macrophages. PAI-2 occurs in two forms, a LMW and a HMW form. LMW PAI-2 is intracellular, HMW PAI-2 is secreted. PAI-2 inhibits both u-PA and two-chain t-PA. PAI-2 seems to be involved in the processes of invasion and remodeling of fetal and uterine tissues. It may protect against premature placental separation and secure hemostasis at parturition. Excess levels of PAI-2 in amniotic fluid may protect membranes from premature rupture. An imbalance between fibrinolytic activators and inhibitors may also be related to intracranial hemorrhage in premature infants. During preeclampsia t-PA and PAI-1 levels are markedly increased in plasma, and in cases of intrauterine growth retardation, u-PA and PAI-2 levels are decreased. While elevated PAI-1 concentrations might be helpful markers of severity of preeclampsia, decreased PAI-2 levels seem to indicate decreased placental function and intrauterine growth retardation.

The concentrations of the specific activators (u-PA and t-PA) and the specific inhibitors (PAI-1 and PAI-2) of the fibrinolytic system were analyzed in the peritoneal fluid in women suffering from intra-abdominal adhesions, endometriosis or pelvic inflammatory diseases (PID). Peritoneal fluids were collected from ten women in whom a laparotomy was performed and an additional 108 in whom a laparoscopy was carried out. In comparison with the normal control patients all activators and inhibitors were significantly increased in cases of PID and when a second-look laparoscopy was performed one week after laparotomy with adhesiolysis. At laparoscopies, when adhesions were verified, u-PA in the peritoneal fluid was significantly increased and in cases of endometriosis PAI-2 was significantly reduced. The start of a laparotomy in order to remove adhesions, initiates a process, resulting in a significant increase of PAI-2 antigen in the pelvic fluid. The results imply that the fibrinolytic system is comprehensively activated in the peritoneal cavity during ongoing inflammatory reaction, and after adhesiolysis. The increase in plasminogen activators in the peritoneal fluid in established cases of pelvic adhesions or endometriosis may indicate that the fibrinolytic system is continuously active to inhibit the further formation of adhesions.

OBJECTIVE: Resistance to activated protein C is an inherited mutation of the coagulation factor V gene, a major factor predisposing to thromboembolic events. The purpose of this study was to investigate the occurrence of heterozygote and homozygote activated protein C resistance in women with preeclampsia. STUDY DESIGN: Activated protein C resistance and protein C and antithrombin III levels were determined in women ( n = 50) with a history of preeclampsia and in controls (50 women with a previous normal pregnancy). The mutation of the factor V gene was analyzed. RESULTS: Activated protein C resistance was found in 22% of women with previous preeclampsia compared with 10% among controls. Two women in the previous preeclampsia group had a homozygote mutation of factor V; the others were heterozygous. There was a significant difference in the activated protein C ratio between women with previous preeclampsia and the control group, 2.6 ± 0.4 versus 3.1 ± 0.5 ( p = 0.04). None of the women had protein C or antithrombin III deficiency. CONCLUSION: The results indicate that activated protein C resistance may be a contributory factor in the pathogenesis of preeclampsia.(Am J Obstet Gynecol 1997;176:457-60.)

Summary Cumulative evidence suggests plasminogen activator inhibitor type-2 (PAI-2) has a tumor suppressive effect owing to its inhibition of urokinase-type plasminogen activator (u-PA) activity. One strategy for anti-tumor treatment might be to stimulate the endogenous production of PAI-2 by monocytes/macrophages. In the present study, human peripheral blood mononuclear cells (PBMC) were incubated with Linomide, a quinoline-3-carboxamide previously shown to exert anti-tumor effects in several animal models. We found Linomide to increase the antigen concentration and enhance the mRNA levels of PAI-2 in a dose-dependent way. In situ hybridization, performed to localize PAI-2 mRNA in PBMC, showed PAI-2 to be exclusively expressed in the monocyte population in which Linomide treatment induced enhanced mRNA expression. Stimulation of endogenous PAI-2 production might be a new approach in tumor therapy.

The plasminogen activator inhibitor type 2 (PAI-2) is present in its high molecular weight, glycosylated form in pregnancy plasma. When the protein was purified from retroplacental blood by immunoaffinity chromatography on a PAI-2 antibody column and the retained material was further fractionated by gel filtration chromatography, it was always contaminated by apolipoprotein A1, the latter protein being identified by its N-terminal sequence, molecular weight in SDS-PAGE and immunological properties. The co-purification of the two proteins seemed to indicate a strong affinity between them, suggesting apolipoprotein A1 to be a carrier protein for this PAI-2 form. Further investigation to check this hypothesis showed that the binding of apolipoprotein A1 to the immunoaffinity support was PAI-2-independent and caused by a general surface affinity. This finding was corroborated by a study of the microtitre plate binding properties of the proteins. Pure, high molecular weight PAI 2 did not bind to apolipoprotein A1-coated wells, but the latter protein bound to coated as well as to uncoated wells. Thus, there is no evidence for a specific binding between the two proteins.

The objective of this study was to evaluate a minimal laser conization procedure during pregnancy for safe diagnosis and treatment of carcinoma in situ. This was a clinical prospective study in a University Hospital. Seventy-five pregnant women selected on the basis of a cervical smear showing carcinoma in situ or dysplasia, or an extensive picture confirmed by colposcopy, were referred for minimal conization procedure. A free-hand minimal conization procedure using a carbon dioxide (CO2) laser was performed in ambulant care under local anaesthesia. The minimal conization procedure is defined as the removal of a 7.0 mm high, slightly conical tissue specimen from the uterine cervix containing the entire transformation zone. After the cone specimen was taken, routine cervical curettage was also performed. There were no complications attributable to the conization procedure and no adverse effects either during pregnancy or at delivery. Histopathological examination of the cone specimens from 75 patients revealed carcinoma in situ or dysplasia in 65 cases. More advanced malignancy was found in 10 cases; micro-invasive carcinoma stage 1A (n = 7) or stage 1B (n = 3). The minimal conization procedure with CO2 laser during pregnancy enables safe diagnosis of carcinoma in situ selected by cytology and colposcopy. It also proved useful for diagnosis and treatment of stage 1A or stage 1B carcinoma, enabling pregnancy to be preserved and radical cancer treatment to be postponed until delivery.

Malignant cells possess a high degree of proteolytic activity in which the plasminogen activator system plays an important role. An increased expression of urokinase type plasminogen activator (uPA) is of significance for degradation of the extracellular tumor matrix, facilitating invasiveness and growth. Inhibition of the active site of uPA makes it possible to evaluate the significance of uPA in tumor growth. We report here experiments on a uPA-producing human prostate xenograft (DU 145) using a competitive inhibitor of uPA, p-aminobenzamidine. In vitro experiments with DU 145 cells showed that p-aminobenzamidine caused a dose-dependent inhibition of uPA activity. DU 145 cells were inoculated s.c. in SCID mice and, once tumors were established, treatment with p-aminobenzamidine added to drinking water was started and lasted for 23 days. Mice receiving 250 mg/kg/day of p-aminobenzamidine showed a clear decrease in tumor-growth rate compared to the non-treated mice, resulting in 64% lower final tumor weight. In addition, uPA-antigen levels in the membrane fractions of DU 145 tumors from p-aminobenzamidine-treated mice were found to be decreased by 59%. We also show that p-aminobenzamidine has an anti-proliferative effect in cell culture at low cell number, correlating with a dose-dependent decrease in uPA production. In conclusion, we show that a low-molecular-weight uPA-inhibitor, p-aminobenzamidine, has a growth-inhibitory effect on a solid uPA-producing tumor.

Summary Macrophages, derived from blood monocytes, have a central role in inflammation. One important function is their role in extracellular proteolysis. Inflammatory reactions in the gingival region have been shown to aggravate during puberty and pregnancy. The altered hormonal state might influence the plasminogen activating system of the macrophages and thereby pericellular proteolysis. The aim of this study was therefore to investigate the influence of estradiol and progesterone on the plasminogen activating system of macrophages. Human monocyte cultures were prepared from peripheral blood monocytes from both men and women. The effect of estradiol and progesterone was studied in LPS-activated as well as non-activated cells. Immunochemical analyses were performed for t-PA, u-PA, PAI-1 and PAI-2. The results showed that t-PA, u-PA and PAI-1 were found only in trace amounts with no influence of estradiol and progesterone. The total production of PAI-2, intra-cellular and released, was reduced by estradiol and progesterone in combination. Monocytes from men and women showed no difference in this response. However, monocytes from women had a lower mean basal production of PAI-2, and also a lower increase in response to LPS than monocytes from men. The observed decrease in production of PAI-2 from monocytes in response to estradiol and progesterone may allow increased pericellular proteolysis which might contribute to an aggravation of gingivitis during periods of altered hormonal influence.

We studied systemic changes in the plasminogen activating system induced by local intra-arterial infusion of recombinant t-PA (rt-PA) in ten patients with arterial occlusion. The arterial infusion of rt-PA resulted in an immediate increase of t-PA activity and antigen in venous plasma. Concomitantly the plasma was depleted of PAI-1 activity with a moderate decrease of PAI-1 antigen, presumably due to immediate complexing of rt-PA by PAI-1 and gradual elimination of the rt-PA/PAI-1 complex from the circulation. Activation of plasminogen in the circulation was reflected by the occurrence of fibrinogen/fibrin degradation products. This rapid systemic activation of the fibrinolytic system at local intra-arterial administration of rt-PA might be due to the opening of small collaterals or backward flow through open arteries, allowing rt-PA to enter the general circulation. The disappearance of detectable PAI-1 activity during rt-PA infusion was followed by a rebound effect with a significant increase of PAI-1 antigen. As this increase may have contributed to the reocclusion which occurred in four patients, it might be advisable to replace heparin by rt-PA at a lower dosage in the immediate phase following rt-PA infusion.

The passage of the menopause has been reported to be followed by a steadily increasing risk of cardio-vascular disease (CVD). Changes in the concentrations of certain coagulation factors and fibrinolytic components are considered risk factors for CVD. We evaluated the differences in some of these variables between a premenopausal group (A) n = 28) and two postmenopausal groups, one of women less than 18 months past the menopause (B) n = 28), the other of women more than 18 months past the menopause (C) n = 21). The variables measured were serum oestradiol content, plasma antithrombin III (AT III) activity, protein C activity and the plasma concentrations of tissue type plasminogen activator (t-PA) antigen, plasminogen activator inhibitor (PAI-I) antigen, and fibrinogen. As compared with the premenopausal women (group A), group C showed significantly higher values for AT III and protein C activity and for t-PA and PAI-I antigen; and group B and C both showed significantly higher fibrinogen concentrations. This probably means that haemostatic balance was maintained in the postmenopausal women, although the increased concentrations of fibrinogen and PAI-1 might constitute risk factors for the development of cardiovascular disease.

Background and Methods. Variation in fibrinolytic capacity during normal pregnancy is still the subject of debate. In recent studies of newer fibrinolytic components, values have been obtained at different gestational ages, but not followed in individual cases throughout pregnancy. We therefore carried out a longitudinal study where fibrinolytic components were followed throughout normal pregnancy in 48 women sampled at 10, 20, 25, 28, 32, 36 and 38 weeks of gestation, and in the first stage of labour. Results. The plasma concentrations of t-PA antigen, u-PA antigen, PAI-1 antigen, PAI-1 activity, PAI-2 antigen, and D-dimer were measured. All these variables manifested marked increases to the end of the 38th week, after which they all began to decrease except t-PA antigen and D-dimer which continued to increase. Conclusions. The results obtained from individual samples yield the actual pattern of development during pregnancy for each component, a requirement for further research of fibrinolytic components under pathological conditions. The change from increase to decrease after the 38th week for u-PA and PAI-2, components chiefly involved in growth regulation, probably mirrors the end of the placenta remodelling process. The increase of t-PA antigen and the decrease of PAI-1 antigen and activity after the 38th week contributes to a remaining fibrinolytic potential capable of degrading fibrin deposits, as reflected in a further increase in the plasma D-dimer concentration.

Pancreatic carcinoma is associated with a high frequency of thrombosis. Most patients with thrombotic disease have a defective fibrinolytic defense system caused either by plasminogen activator deficiency, excess of plasminogen activator inhibitor (PAI-1), or a combination of the two. In the current series of 27 patients with pancreatic carcinoma, 17 had had deep vein thrombosis (DVT) since the onset of their malignant disease, and most were found to have high plasma concentrations of PAI-1 antigen and PAI-1 activity. Analysis of singleton samples from each patient yielded no correlation between previous DVT and currently high plasma PAI-1 concentrations. However, serial samples from 14 patients (8 of whom had histories of thrombosis) showed individual values varied sharply with time, with intermittent peaks both in PAI-1 antigen and PAI-1 activity for 11 of the 14 patients. Such variability may contribute to intermittently excessive hypercoagulability because of a relative reduction in fibrinolytic potential. These changes may predispose the patient to have thrombotic events in association with pancreatic carcinoma.

The binding of 125I-labelled urokinase plasminogen activator (uPA) to cell membranes of ovarian tumours was characterised. Binding was fast, specific to HMW-uPA, and saturated at low concentration [1.5 (range 1.2-1.6) nmol/l]. Scatchard analysis suggested a single class of binding sites with Kd 1.1 (0.9-1.3) nmol/l. These data indicate the presence of a specific cell membrane receptor for uPA in ovarian tumours, whose characteristics are similar to those reported for uPA receptors in other tissues. Endogenously occupied receptors were uncovered by exposing the membranes to acid conditions (pH 2) before assay, thereby allowing quantitation of the total amount of receptor. uPA receptors were assayed in 10 malignant and 6 benign epithelial ovarian tumours. The total number of receptors was higher in the malignant tumours. This was secondary to increases of both free and occupied receptors. We conclude that this reflects the biological function of cell surface bound plasminogen activation in tumour growth and spread.

Gingival crevicular fluid (GCF) is an extracellular exudate protecting periodontal tissue. Pathological changes in the periodontium are reflected in the composition of GCF. Crevicular fluid was collected from healthy volunteers on Millipore® filter disks, and eluted at 100-fold dilution. The samples were tested for fibrinolytic activity and the presence of the plasminogen activators, t-PA and u-PA, and the specific plasminogen activator inhibitors, PAI-1 and PAI-2. In the diluted samples, t-PA was found at concentrations of 4–33 gmg/l, and PAI-2 at concentrations of 19–84 μg/l, whereas u-PA and PAI-1 were hardly detectable. Analyses of parotid and whole saliva yielded no evidence of gingival fluid contamination from these sources. The fibrinolytic activity of gingival fluid was completely quenched both by antibodies against t-PA and by PAI-2, indicating the presence of t-PA in its two chain form which is more susceptible to inhibition. This inhibition by PAI-2 may serve a regulatory purpose and prevent excessive proteolysis and tissue destruction.

Summary A u-PA-producing human prostatic tumour was inoculated into SCID mice, rPAI-2 being administered daily from day 8 after inoculation, when the solid tumours had become established. Repeated measurements of tumour size showed tumour growth to differ increasingly between the rPAI-2-treated and control groups, being significantly reduced in the treatment group at euthanisation on day 30, when mean tumour weight was only 0.509 g in the rPAI-2 treated group, as compared to 1.309 in the control group. This tumour suppressive effect of rPAI-2 is probably due to its u-PA inhibitory property.

SummaryTranexamic acid (AMCA) is an inhibitor of fibrinolysis used to treat fibrinolytic bleeding (e.g., menorrhagia and gastro-intestinal haemorrhage), and to prevent bleeding at surgery, in cases of abruptio placentae and general haemorrhage. As AMCA stabilises preformed clots and prolongs their dissolution, it has been debated whether treatment with AMCA might predispose to thrombosis by depressing the fibrinolytic system. Pregnant women constitute a group with low fibrinolytic capacity and an increased frequency of thrombosis further increased after Caesarean section, and are thus more likely to be susceptible to antifibrinolytic therapy. We therefore carried out a retrospective analysis of the case records of 2,102 patients with various bleeding disorders during pregnancy. Of the 256 patients treated with AMCA (mean duration of treatment, 46 days), 169 were delivered by Caesarean section. Of the remaining 1,846 patients (i.e., controls), 443 were delivered by Caesarean section. The relationship between the use of AMCA and the occurrence of thrombo-embolism was calculated with 95% confidence limits.Of the AMCA treated group (n = 256), two patients – one of whom belonged to the Caesarean section subgroup (n = 168) – had pulmonary embolism. Of the controls (n = 1,846), three patients had deep vein thrombosis and one had pulmonary embolism, all four cases belonging to the Caesarean section subgroup (n = 443). Thus, the findings in this high risk group of women with complicated pregnancies, frequently entailing delivery by Caesarean section, provided no evidence of any thrombogenic effect of AMCA.

Acute massive pulmonary embolism occluding 60-70% of the pulmonary circulation occurred in a young primipara during the 28th week of pregnancy. She was critically ill despite 40 h of heparin infusion and thrombolytic therapy with streptokinase was initiated. After a 10-h infusion she went into labor and streptokinase treatment was stopped. One hour later she gave birth spontaneously to a preterm infant in footling breech delivery. The infant did well neonatally. Streptokinase infusion was recommenced 8 h after delivery. Because of increasing blood loss on the second day after delivery, streptokinase was withdrawn after a total treatment time of 29 h. Total hemorrhage amounted to 8.9 litres. Serial perfusion lung scans showed complete resolution of the emboli and normal lung function was restored.

Objective: To determine whether there is a difference in fibrinolytic compounds in endometriotic tissue, endometrium, peritoneal fluid (PF), and plasma from women with endometriosis and in endometrium and PF from healthy women. Design: Prospective study. Setting: Two university clinics. Patient(s): Regularly menstruating women with and without endometriosis. Intervention(s): Tissue samples, PF, and blood were collected at surgery performed for clinical reasons. Main Outcome Measure(s): The antigen concentrations of plasminogen activators and plasminogen activator inhibitors (PAIs) in tissue homogenates, PF, and plasma were assayed by ELISA. Result(s): The concentrations of urokinase plasminogen activator (u-PA) and PAI-1 were higher in endometrium from women with endometriosis than in endometrium from controls and even higher in endometriotic tissue than in endometrium from both groups. In PF, the concentration of PAI-2 was higher in women with endometriosis than in controls. Conclusion(s): The high concentrations of u-PA and PAI-1 in endometrium from women with endometriosis might facilitate implantation of endometrial cells and the high concentration in endometriotic tissue might contribute to their invasive growth. The inflammatory reaction may contribute to the high concentration of PAI-2.

Background and Purpose Abnormal endogenous fibrinolytic activity may be a risk factor for stroke. Since the possible variation of tissue-type plasminogen activator (TPA) antigen and plasminogen activator inhibitor-1 (PAI-1) antigen concentrations over time after stroke has been rarely studied, it was examined in plasma from stroke patients in the acute and convalescent phases of the disease and in a control group. Methods Plasma concentrations of TPA and PAI-1 were determined in 135 stroke patients and in 77 control subjects. All but 4 patients were examined within 7 days after stroke onset, and 32 patients and 18 control subjects were reexamined 2 to 4 years later. Results In the acute phase, stroke patients had significantly higher TPA (median, 10 μg/L) and PAI-1 (median, 14 μg/L) antigen concentrations, compared with control subjects (median values, 6 μg/L [ P =.0001] and 8 μg/L [ P P =.0001), whereas the corresponding difference for PAI-1 antigen levels just failed to reach significance ( P =.05). TPA antigen levels were correlated with concentrations of serum cholesterol (Spearman’s ρ=0.15; P P =.0001), and plasma homocysteine (ρ=0.19; P P =.0001). At reexamination after 2 to 4 years, neither TPA nor PAI-1 levels had changed significantly from the baseline values. Conclusions In stroke patients, high TPA antigen concentrations may indicate an activation of the fibrinolytic system or may be due to a delayed clearance of TPA complexed with inhibitors. High PAI-1 antigen concentrations in patients with cerebral infarction represent increased fibrinolytic inhibition. The findings in this longitudinal study suggest that TPA and PAI-1 antigen concentrations both differ little between the acute and convalescent phases after stroke.

Objectives: To assess the effect of estrogen replacement therapy on hemostatic risk factors for cardiovascular disease (CVD) in postmenopausal women during 2 years of treatment. Methods: In an open prospective study, patients (n = 42) were investigated before and during 2 years of treatment, and compared to an untreated postmenopausal control group (n = 18) followed during the same period, healthy premenopausal women (n = 20) being included as a reference group for premenopausal values. The patients underwent treatment with transdermal 17β-estradiol (E2) (50 μg/24 h), oral medroxyprogesterone acetate (5 mg/day) being added for 12 days every second month. Results: After 2 years of treatment there was a significant increase in t-PA antigen (P = 0.01) and a significant decrease in F VII antigen (P = 0.01). PAI-1 antigen concentrations decreased slightly. Fibrinogen concentrations were already significantly decreased at 3-month follow-up (P = 0.01), and were still low after 2 years. By contrast, at 2-year follow-up the postmenopausal control group manifested significant increases in F VII and PAI-1 antigen and slight increases in fibrinogen, which resulted in significant differences between patients and controls. Regression analysis showed the increase in the serum estradiol concentrations to be inversely correlated to the decreases in the plasma concentrations of F VII antigen (r = −0.34, P = 0.001) and fibrinogen (r = −0.35, P = 0.001). There were no changes in AT III or protein C in any group. Conclusions: The increase in serum estradiol concentrations due to replacement therapy did not adversely affect the studied components of the fibrinolytic and protein C defense system against thrombosis, and resulted in beneficial decreases in F VII antigen and fibrinogen. These findings may help to explain the beneficial effects of estrogen replacement therapy in terms of protection from cardiovascular disease.

Objective To compare the effect of Kabi 2161 (a prodrug of tranexamic acid) and placebo on the reduction of menstrual blood loss in women suffering from idiopathic menorrhagia and to evaluate tolerance and effectiveness in a two-dose regimen. Design A randomised, double blind parallel group study using double dummy technique. Setting The departments of gynaecology at three medical centres in Sweden. Subjects Ninety-one outpatients visiting the gynaecological clinics from March 1991 to May 1992 were randomised into the study; 68 women fulfilled the study. Interventions Two run-in cycles, followed by administrations of Kabi 2161 (600 mg) tablets (1 four times daily or 2 twice daily) or placebo for the first five days of three menstrual cycles. Main outcome measures Objective measurement of the change in menstrual blood loss during the treatment periods compared with menstrual blood loss during the run-in periods. Results A statistically significant reduction of menstrual blood loss was found for each treatment group, compared with the placebo group (P < 0.001). The mean reduction with 95% confidence interval (CI) was 33 % (24–40) in the group treated with 1 four times daily and 41 % (33–49) in the group treated 2 twice daily. The difference between the treated groups in reduction of menstrual blood loss is not significant. No significant differences were found in the frequencies of reported unwanted events during run-in and during treatment between the different treatment groups. There were also no significant differences between the treatment groups and the placebo group. Conclusion Kabi 2161 in a dosage of 2.4 g per day gave a statistically significant reduction in objectively measured menstrual blood loss in a two (41 %) as well as in a four (33 %) dosage regimen compared with placebo. Frequency of unwanted events did not differ from those during run-in or from those in the placebo group. The optimal daily dosage needs to be further evaluated in a dose titration study.

Coumarin derivatives and anticonvulsants administered during pregnancy enter the fetal circulation, interfering with the action of vitamin K. Vitamin K plays a crucial part in the gamma-carboxylation of glutamic acid residues of the vitamin K-dependent coagulation factors prothrombin, FVII, FIX, and FX. Other vitamin K-dependent proteins in the coagulation cascade are protein C and protein S. Vitamin K-dependent bone proteins are osteocalcin and gamma-carboxyglutamate matrix protein. Administration of coumarol derivatives results in under carboxylation of the vitamin K-dependent proteins. Anticoagulation therapy with warfarin is followed by an increased risk of embryopathy, which has been shown to be greatest between gestational weeks 6 and 12. Administration of warfarin is also followed by an increased risk both of fetal intraventricular hemorrhage, and of cerebral microbleedings, which may result in microencephaly and mental retardation. Treatment with coumarol derivatives should therefore be avoided during pregnancy, even in pregnant women with artificial heart valves, and replaced by heparin. Hemorrhage in the newborn related to the use of anticonvulsant drugs during pregnancy occurs very early within the first 24 hours, probably due to increased degradation of vitamin K. Transplacental administration of vitamin K has been shown to prevent neonatal hemorrhage induced by maternal anticonvulsant therapy. Prophylactic administration of vitamin K, especially by intramuscular injection, has been reported to be associated with an increased risk of childhood cancer. However, subsequent extensive studies have yielded no evidence of any relationship between prophylactic vitamin K administration and the occurrence of childhood cancer.

Our purpose was to study the plasma concentrations of the plasminogen activator of urokinase type and its specific inhibitor of placental type in pregnancies complicated by hypertension or fetal growth retardation.Consecutive patients with pregnancy-induced hypertension (n = 17), mild preeclampsia (n = 17), severe preeclampsia (n = 19), and intrauterine growth retardation (n = 19) were studied. Blood samples were obtained just before delivery (mean 2 days). Women with normal pregnancies (n = 40), longitudinally followed between the tenth and fortieth gestational weeks, served as a control group.The plasma concentrations of the urokinase type antigen were significantly lower in women with severe preeclampsia or intrauterine growth retardation than those in women with normal pregnancies (p0.001). In all four groups with complicated pregnancies the antigen concentrations of the urokinase type and its inhibitor were significantly correlated with both placental weight and birth weight.The plasma concentration of the urokinase type antigen would appear to reflect placental function, and both the antigen and its inhibitor concentrations are correlated with placental and fetal growth.

We quantitated urokinase and tissue plasminogen activator (u-PA, t-PA), plasminogen activator inhibitor 1 and 2 (PAI-1, PAI-2), and fibrinolytic activity in peripheral blood (PB), tumour blood (TB), peritoneal/ascitic fluid (PAF) and cystic fluid (CF) from 104 patients with benign and 36 patients with malignant ovarian tumours, and in peripheral blood from 62 healthy controls. PB levels of u-PA were higher in patients with benign and malignant tumours than in controls. High concentrations of u-PA were found in CF, but not in TB, suggesting that u-PA is released by the tumour tissue, but not by the tumour vasculature. PB levels of t-PA were higher in both tumour groups than in controls. Increased levels of t-PA were found in TB, but not in CF, indicating that t-PA is released by the tumour vasculature, but not by the tumour tissue. PB levels of PAI-1 were higher in patients with both benign and malignant tumours than in controls. High levels of PAI-1 were present in both TB and CF from malignant tumours, suggesting that PAI-1 is released from the tumour vasculature as well as the tumour tissue. Elevated concentrations of PAI-2 were found in CF, but not in TB, indicating release from the tumour tissue, but not from the vasculature. High levels of t-PA, PAI-1 and PAI-2 were found in PAF of malignant tumours, and resorption from this compartment may explain elevated PB levels in patients with ascites. None of the PAs/PAIs proved useful as a PB marker for detection of early stage ovarian cancer. However, an index based on PAF levels of t-PA and PAI-1 discriminated between malignant and benign ovarian cysts in the absence of ascites. In addition, our study stresses the importance of including patients with benign tumours as well as healthy controls when markers for malignant tumours are evaluated.

Urokinase (u-PA) dissolves and removes fibrin deposits in the renal secretory pathways in various renal diseases. During pregnancy nephropathy creates a problem in preeclampsia and diabetes, but the underlying mechanism of glomerular damage is different. Preeclamptic nephropathy is characterized as 'glomerular endotheliosis' with hypertrophy of the intracapillary cells, and diabetic nephropathy as 'glomerulosclerosis' with hyaline deposits. The role of fibrin deposition for the etiology of renal damage in preeclampsia is controversial. Changes of the urinary secretion of u-PA may reflect the type of glomerular damage. Our hypotheses were that renal insufficiency is associated with a low u-PA activity in both conditions, and that severe disease is parallel to declining concentrations of u-PA. We compared the glomerular filtration rate, S-Creatinine and S-Urate with urinary u-PA excretion in 24 hypertensive and 20 diabetic pregnant women. In diabetic patients, a low u-PA concentrations was associated with an impaired renal function. In hypertensive pregnancy, the u-PA excretion did not reflect the severity of the hypertensive disease or renal function. No association was found between u-PA excretion and renal function post partum in any group. We conclude that renal urokinase activity plays a role for renal function in diabetic but not in hypertensive pregnancy.

During a 9-year period, 92 women with squamous cell carcinoma of the cervix, FIGO stages IA1-IIA, were subjected to primary surgery according to Wertheim Meigs. Grading according to a malignancy grading score (MGS) and evaluation of tumor size before surgery together with surgical findings of positive nodes or insufficient surgical margin at the primary site were used to identify persons prospectively at high risk for relapse. Twenty-five women thus received postoperative treatment. Results among node-positive patients were good; only 2 out of 12 patients relapsed. Among 67 node-negative patients in stages IA2-IIA, 4 relapses occurred. These 4 patients had greater than or equal to 16 risk points according to MGS, but small tumors. Instead of tumor size, supplementary risk factor is therefore needed. Among the few patients in stage IA1, no high-point patients relapsed. These patients would probably have done just as well with less-extensive surgery.

Thrombolytic treatment has been tried in various forms for acute limb ischaemia with varying degrees of success but is also often accompanied by bleeding problems. The present investigation compares the effect of surgical thrombectomy (TE) and thrombolysis (TL) using recombinant tissue plasminogen activator (rt-PA). Twenty patients with a need for intervention owing to ischaemia lasting more than 24 h but less than 14 days were included. Patients randomised to TE were operated under epidural anaesthesia and patients in the TL group received 30 mg rt-PA during a 3 h period through a catheter placed into the thrombus and advanced as lysis was achieved. Thrombectomy resulted in an immediate restitution of blood flow in six out of nine cases, in three cases a bypass procedure was performed, and one of these failed with a resultant amputation. Thrombolysis gave a good primary result in six cases which lasted in four of them. Three had a subsequent percutaneous transluminal angioplasty. Partial lysis was seen in two cases and a further two failed. Five went to surgery with three bypass and two fogarty procedures being necessary. There was no hospital mortality and there were no bleeding complications due to the rt-PA treatment in this series. In 19 out of 20 patients the circulation was re-established. Appropriate handling of acute ischaemic conditions implies the use of both thrombolysis and appropriate surgical procedures, including distal bypass grafts.

The highly specific plasminogen activator inhibitor of placental type, PAI-2, occurs in the placenta in a low molecular mass form of 46.6 kDa, and in pregnancy plasma in a (possibly glycosylated) high molecular mass form of 60 kDa. Extensive knowledge is available about the functional properties of PAI-2 as a plasminogen activator inhibitor and about its molecular biology and regulation. Of the several placenta proteins (PP) isolated, one of them, PP10, has a molecular mass of 48 kDa and its occurrence in malignancy and in complications during pregnancy has been the topic of a number of studies, though its properties and physiological significance are unknown. The present findings constitute evidence of immunological identity between PP10 and PAI-2. The sections of the amino acid sequence of PP10 analysed here were found to have identical counterparts in the sequence of the low molecular mass form of PAI-2, but in several preparations PP10 was found to occur in an inactive two-chain form due to cleavage of an Arg Thr bond, the two peptide chains being linked to each other by a disulphide bridge. The cleavage site is identical to that observed in the reaction between PAI-2 and urokinase. The results make it possible to coordinate and correlate the findings of many separate studied and our own observations on PP10 and PAI-2.

Prevention and treatment of deep vein thrombosis during pregnancy presents special problems. The benefit of treatment for the original condition must be weighed against the subsequent risk of placental or fetal haemorrhage. Owing to the high risk of recurrence, prophylactic treatment is required throughout pregnancy, during delivery, and in the puerperium. At an early stage of pregnancy, the risk ot teratogenetic effects needs also to be taken into consideration.

In two cases of eclampsia with consumptive thrombocytopenia, the maximum increase in blood pressure and the lowest platelet count coincided with the maximum degree of neurologic and neuroradiologic abnormality. Computed tomograms showed decreased attenuation, and T2-weighted magnetic resonance images showed increased signal intensity focally in the cerebral cortex and the deep gray and white matter. Blood pressure, platelet count, clinical status, and roentgenograms normalized completely in both cases. Severe arterial hypertension and disseminated transitory microvascular occlusions presumably caused multiple small foci of brain edema that resolved without remaining detectable ischemic brain damage.

Ten amniotic fluid samples obtained at elective caesarian section were examined for the presence of tissue-type plasminogen activator (t-PA), urokinase-type plasminogen activator (u-PA) and the two specific plasminogen activator inhibitors, PAI-1 and PAI-2. u-PA antigen was demonstrated in all samples (mean concentration equivalent to 0.35 iu/ml), but its bioactivity was very low (mean activity 0.13 iu/ml) when assessed by a bioimmuno-assay (BIA) using chromogenic substrate. None of the samples analysed by ELISA technique had measurable levels of t-PA, neither could any activity of t-PA be demonstrated by a sensitive BIA or fibrin plate technique. Significant amounts of both PAI-1 and PAI-2 antigen were present in all samples, and the mean values were 12.2 and 43.4 ng/ml, respectively. The average inhibitory capacity per ml of amniotic fluid measured by assessing the residual t-PA activity following addition of a known amount of single chain t-PA to the samples was 17.3. Thus, this study demonstrates a fibrinolytic system in amniotic fluid, which is characterised by absence of t-PA activity, low bioactivity of u-PA and excess of the two specific inhibitors, PAI-1 and PAI-2. This inhibitory capacity of amniotic fluid may play a role in preventing premature rupture of membranes.

Coagulation and fibrinolytic studies on 17beta-estradiol and synthetic estrogens are reported. The content of fibrinolytic activators in the vessel wall were examined by a histochemical method in vein biopsy specimens from superficial veins taken from 20 postmenopausal women. They received 250 mcg ethinyl estradiol/day for 10 days. An interesting observation was made of a highly significant decrease (p

Two types of plasminogen activator (PA), t-PA (tissue type) and u-PA (urokinase type), are released from endometrial tissue in organ culture, as judged by immunological identification and molecular weight. Addition of estradiol to the medium greatly enhanced the release of u-PA, whereas that of t-PA was not low. Addition of progesterone, on the other hand, after priming of the endometrial tissue with estradiol, resulted in a much lower release of both types of PA. This pattern of PA release in response to hormonal stimulation in vitro agrees with previous observations of the PA activity of endometrial secretion in vivo. Endometrial tissue also released a PA inhibitor with molecular weight of approximately 50,000, which complexed both t-PA and u-PA. In cultures stimulated with estradiol the amount of free u-PA increased gradually during incubation and minor amounts of free t-PA appeared after 4-6 days culture. The amount of complexes, and thus the amount of PA inhibitor also increased under influence of estradiol. In cultures stimulated with progesterone, on the other hand, only minor amounts of free u-PA and no free t-PA was detected. The inhibitor might be of either the endothelial or the placental type, or both.

Amniotic fluid was obtained by transabdominal amniocentesis in 51 women in the 29th-36th week of pregnancy. The lecithin/sphingomyelin ratio was determined. In 28 patients,the ratio was less than 2.2. Beta-methasone was given for three days to 14 of them; the rest served as controls. On the fourth day, a second amniocentesis was performed on all patients. The lecithin/sphingomyelin ratio rose to a value greater than 2.2 in 4 of the patients in the betamethasone-treated group and in one of the controls. The percentage of palmitic acid in the lecithin increased concomitantly with increasing lecithin/sphingomyelin ratio. These results suggest that glucocorticoid induced acceleration of fetal pulmonary maturation may be reflected in the amniotic fluid as changes in its phospholipid composition. The lecithin/sphingomyelin ratio was found to be greater than 2.2 in 23 patients at the first amniocentesis. In such cases treatment with glucocorticoids can be avoided.

Specimens of human veins were incubated in culture media, in which the concentrations of urokinase (UK) and tissue plasminogen activator (t-PA) were determined by radioimmunoassay and immunoradiometric assay. Both UK and t-PA were released to the media, in which the concentration of plasminogen activators was correlated to the weight of the specimens. The release of t-PA was maximal on the first day, after which it rapidly decreased, and t-PA was not demonstrable after the third day of incubation. By contrast, UK was continuously liberated to the media during the study period of 5 days. The present results indicate that both UK and t-PA are present in the vein wall and probably released by different cells.

125I-labelled urokinase was incubated with plasma and plasminogen free plasma, and the incubation mixtures were analyzed by agarose gel electrophoresis. Autoradiography demonstrated that non-reacted urokinase remained around the slit and that complex-formation with inhibitors altered the migration and resulted in two bands, a major one and a minor one. Crossed immunoelectrophoresis combined with autoradiography showed that the major band contained a complex between alpha 2-antiplasmin and urokinase. The minor band contained a complex between alpha 2-macroglobulin and urokinase. Also di-isopropylfluorophosphate-inactivated urokinase was bound to alpha 2-macroglobulin but not to alpha 2-antiplasmin. Thus, an intact active site of urokinase is not necessary for complex formation with alpha 2-macroglobulin.

The influence of ethinylestradiol (EE2) and d-norgestrel (d-Ng) was studied in a melanoma cell line producing a tissue-type plasminogen activator (t-PA) very similar to or identical with the t-PA isolated in extracts from human uterus. The cell cultures were exposed to the two contraceptive steroids by addition of EE2 or d-Ng dissolved in a week alcoholic solution to the culture media, in which the released t-PA was assayed by an immunoradiometric method. A strongly stimulating effect of ethanol (0.76% w/v) on the t-PA production was demonstrated. Whereas, EE2 in the concentration of 1.7 X 10(-7)M and d-Ng in the concentration of 8.6 X 10(-7)M both caused a significantly reduced secretion of t-PA, and this effect was independent of whether the cell cultures were grown to confluency in the presence of the two synthetic steroids or not. It was concluded, that the two contraceptive steroids had an inhibitory effect on the production of t-PA in melanoma cell culture.

Ultrasound scan for detection of ovarian enlargements was performed in a target group of out-patients attending the clinic for various reasons in the 40-70 years range. Overall 805 women were examined, in 99% of whom the ovaries and/or their vessels could be identified. Pathological findings were suspected in 83 patients at the first scan, and were confirmed in 50 after a repeat scan, 39 of whom subsequently underwent surgery. Various ovarian lesions were found in 35 women, including five mucinous and serous cystadenomas, one carcinoma, two borderline tumours, and a cancer of the caecum. None of the borderline or malignant ovarian lesions were found by manual pelvic examination. Ultrasound screening appears to be a useful diagnostic aid, though its usefulness might be further improved if other risk factors such as heredity and period of ovulatory activity are taken into consideration.

An inhibitor present in placenta and released in placental tissue culture forms specific complexes with each of two molecular forms of urokinase. Audoradiography demonstrated that the inhibitor shifted the electrophoretic position of 125 I-labelled urokinase. It did not change the migration of diisopropyl-fluorophosphate-inactivated 125 I-labelled urokinase, thereby indicating complex formation dependent on active serine site in urokinase. The inhibitor had a strong neutralizing effect on the plasminogen activators released from human ovarian carcinoma in tissue culture. The placental inhibitor might prove useful in inhibiting the fibrinolytic process necessary for proliferation of tumour vessels.

A histochemical technique was used to identify the activity of the plasminogen activator (PA) in the vessel wall of veins. Antibodies against melanoma cell activator and urokinase (UK), both raised in goats, were mixed into the fibrin film. The PA activity was quenched by the antibodies against melanoma activator but remained unchanged when antibodies against UK, or an IgG preparation of normal goat serum, was mixed in the fibrin film. The results of this study show that the PA activity in the vein vessel wall is immunologically similar to or identical to the PA derived from melanoma cells which has previously been shown to cross-react with the tissue-like PA. No UK-like activity was present in the vessel wall.