Chapter 48 THROMBOPHILIAS IN PREGNANCY Charles J. Lockwood, MD, and Robert Silver, MD Venous thromboembolism (VTE) of the systemic and pul- monary circulation is a leading cause of maternal mortality in United States. Second and third. trimester fetal loss, intrauterine fetal growth restriction (IUGR), abruption, and severe, early-onset, preeclampsia are associated with throm- bosis ofthe uteroplacental circulation and are leading causes of perinatal morbidity and mortality. Inherited and) acquired thrombophilias have recently been linked to many cases of matemal VTE as well as these adverse obstettical outcomes (Lockwood and Rand, 1994; Girling and de Swiet, 1998; Guideline, 2001; Lockwood, 2001). Identification of these thrombophilic states can provide a unique opportunity to iden- patients at tisk and prevent untoward maternal and fetal The inherited chrombophilias vary in terms of prevalence and thrombogenic potential. The rarest and most thrombo- genic of these conditions are homozygosity or compound heterozygosity for the factor V Leiden and prothrombin G2O210A mutations and autosomal dominant antithrombin deficiency. Conversely, the most common (though least thrombogenic) of the inherited thrombophilias are homo gosity for the 4G/4G mutation in the type-I plasminogen acti- vator inhibitor (PALI) gene and the thermolabile variant of ethylenetetrahydrofolate reductase (C677T MTHER) gene. The latter is the most common cause of hypethomocystein- emia, Inherited thrombophilias that are both relatively common and relatively thrombogenic are heterozygosity for the factor V Leiclen and prothrombin G20210A mutation and autosomal dominant deficiencies of protein C and protein S. Taken together, these conditions are present in 15%-20% of ethnic European populations (Guideline, 2001). The most common acquired thrombophilic condition is the antiphospholipid antibody syndrome present in 0.2%-2% of abstetrical patients (Lockwoox! and Rand, 1994). These anti- bodies result from perturbations in endothelial and platelet cell membranes, which cause conformation changes in negatively charged phospholipid-binding proteins such as prothrombin and -2-glycoprotein-1. This conformational change renders them antigenic, and the resultant antibodies promote thrombosis, Taken together, the inherited and acquired thrombophilias cause more than half of all maternal VTE and have been linked toa two- to fivefold increased risk of fetal loss, IUGR, abruption. and early-onset, severe preeclampsia (Preston et al, 1996; Girling and de Swiet, 1998; Kupfermine et al, 1999; Gris et al. 1999; Lockwood, 2001; Rey et al, 2003), This chapter will review the physiological initiation and regulation of clotting, the effects of pregnancy on hemostasis, and the etiology, patho- genesis, diagnosis, and management of the inherited and acquired thrombophilias. ™@ PHYSIOLOGICAL REGULATION OF HEMOSTASIS Initiation and Maintenance of Hemostasis Tissue factor (TE), a cell membrane-bound glycoprotein, is the primary initiator of hemostasis. It is expressed by perivas- cular cells throughout the body, but not by endothelial cells (Fiz, 48-1) (Lockwood, 2001). In the reproductive tract, uterine decidual cells synthesize tissue factor in high abun- dance (Lockwood et al., 1993, Lockwood et al., 1994; Runic et al. 1997); there, its presence appears vital to the preventic of lethal postpartum hemorrhage (Parry et al., 1998). Ind complete deficiency in tissue factor expression is lethal in the transgenic mouse embryo. Following blood vessel damage, cell membrane-bound TE complexes with plasma-derived factor VIL. The complex of TF and factor VII directly converts factor X to Xa (formerly termed the extrinsic pathway). Factor Vila is the only clotting factor zymogen to display innate enzymatic activity (Nemerson, 1988). Activation of factor VII by throm- bin or factor Xa, however, results in a 100-fold increase in activity: The TE/Vila complex can also indirectly generate Xa by converting factor IX to IXa, which, in turn, complexes with its cofactor, factor VIlla, to convert X to Xa (formerly termed the inerinsic pathway). The TE pathway inhibitor (TFPI), which binds to the TF/VIa/Xa complex, rapidly inhibits this initial clotting activity. The clotting cascade, howev via thrombin and factor XIla-activated factor Xla, which serves as an alternative activator of factor IX on the surface of newly ageregated platelets embedded in the nascent fibrin clot Regardless of how it is generated, factor Xa then complexes with its cofactor, Va, to convert prothrombin (factor Il) to thrombin (Ila). Thrombin cleaves fibrinogen to generate fibrin monomers, which spontaneously polymerize and are cross linked by thrombir-activated factor XIlla to form the stable clot (see Fig. 48-1). is maintained Physiological Inhibition of Hemostasis Hemostasis is inhibited by a series of potent antiproteases (Fig. 48-2). These include the TFPI, activated Protein C com- plexed with Protein S (APC/S), and the potent antithrombin/ 10051006 48/Thrombophilias in Pregnancy Factor Xia be ——___ Ss xa villa TrMlla xe, aN Platelet =< Thrombin Prothrombin Adhesion and aggregation Xille —= Fibrin Fibrinogen + 1PAVPlasmin FDP FIGURE 48-1 m The hemostatic system showing the coagulation and fibrinolytic pathways, factor Xa agents, antithtombin, heparin cofactor H, and a: macroglobulin. Fibrinolysis is mediated by tissue-type plasmino- gen activator (PA) and is primarly inhibiced by plasminogen activator inhibitor-l (PAL-). The latter also exerts ancithtom- bin effects The tissue factor (aka. the extrinsic pathway) inhibitor (TFPI) is the initial inhibitor of TF/Vila mediated clotting (Lockwood, 1999}. The TFPI molecule contains two Kunitz- type inhibitory domains; the first binds to factor Xa, while the second binds to the TF/VIla complex (Giraed et al, 1989). The resultant quaternary inhibitory complex blunts TE-VUa wenerated clotting (see Fig. 48-2). Endothelial cells synthesize and sequester TFPI, with 80% of the circulating moiety bound to lipoproteins. Heparin promotes release of endothelial TEP] and enhances its activity (Bombell et al., 1997). Plasma levels of TEP] also increase in the third trimester and in labor (Girard et al., 1989; Warr et al., 1989; Novorny et al., 1991; Bombell et al, 1997; Lockwood, 1999). Thrombin binds to endothelial cell membrane-bound thrombomodulin in the presence of ionized calcium, and the resultant complex induces a conformational change in throm- bin resulting in its ability to activate protein C (PC) (Esmon, 1993; Bonabell etal, 1997) (Fig. 48-3). Activated PC attaches to negatively charged (anionic) endothelial cell membrane phospholipids or binds to the Endothelial Cell Protein C Receptor (EPCR) to inactivate procoagulant factors Va and Villa. Activated PCs (APC) inactivation of factor Va and Villa is enhanced twofold and 6.4-fold, respectively, by binding to its cofactor, protein S (PS). This process can occur on both endothelial and activated platelet membranes and is a crucial damper of the clotting cascade, Protein S also ean act as a direct anticoagulant protein by binding exposed, pro: thrombotic, anionic phospholipids. Protein C and PS have shore half-lives in the circulation—8 and 42 hours, respec- tively. Circulating PS exists in both free (40%) and bound (60%) forms. The complement 4b-binding protein (C4b-BP) serves asa carrier protein for PS. Pregnancy, inflammation, and surgery increase C4b-BP levels and reduce PS activity (Delorme et al., 1992). Levels of total and free protein S decline about 40% during pregnaney (Delorme et al., 1992), Thrombin plays the pivotal role in hemostasis, yet overpro- duction of thrombin can lead to fatal thrombotic diseases (Seiler, 1996). Icis not surprising that a large number of potent serine protease inhibitors (SERPINs), including heparin cofac- tor Il, 6-2 macroglobulin, and antithrombin, can serve to inac- tivare both thrombin and factor Xa (see Fig. 48-2). After either thrombin or factor Xa complexes to one of these inhibitors, the resultant complex binds to vitronectin (Vn), a large plasma and extracellular matrix glycoprotein (Preissner et al., 1996). This three-molecule (ternary) complex. then binds heparin or other glycosaminoglycans, a step which ‘greatly augments the rate of thrombin or factor Xa inactivation (Ill and Rouslabti, 1985; Preissner et al., 1987; Delorme et al, 1992; de Boer etal, 1993; Fsmon, 1993; Seiler, 1996; Preissner et al., 1996). The most physiologically active anti-thrombin/ factor Xa compound is the aptly named antithrombin (AT), Levels of the thrombin-AT complex increase during preg- nancy; indicating that pregnancy is associated with increased thrombin generation, but absolute AT. levels remain unchanged in preynaney (Delorme et al., 1992), ‘A last level of inhibition of fibrin clot propagation is the fibrinolytic system. Tissue-cype plasminogen activator («PA) binds to the fibrin clot to generate plasmin (see Fig. 48-2). Plasmin cleaves fibrin to generate fibrin degradation products (FDPs). Type-1 plasminogen activator inhibitor (PALI) is the 50,000 MW fast inactivator of the plasminogen activators.48{Thrombophilias in Pregnancy 1007 x xia x xa © «wress) Teva © TFPI x xa we la © rors) 0 © heparin GoFIIVN © a-2macroglebulnivn Fon © AtWn Fibrinogen © Pariaz iva a c2-antiglasmin | ***Pismin Or } FOP: FIGURE 48.2 m The hemostatic system showing the coagulation, anticoagulation, fbrnoytic, and aniifibrnolytic pathways. Crculeting or endothelia-bound TF pathway inhibitor (TFP0) binds to the TEvialxa comple to quickly stop TF-mediatea clotting. Thrombin-activated factor X1 maintains loting, however, by serving as an slternativa activator of factor IX. Thus, dampening of the clotting Cascade requires activated protein © complexed with protein S (APC/S) inactivation of the factor (Xa land Xa cofactors, Villa and Va, respectively, The most crucial endogenous anticoagulants directly inactivate thrombin and Xe and include alpha-2-macroglobulin, heparin cofactor I and, enost Important, antthrombin (AT). These antincoteases bind to heparin and vitronectin (Vn) as well a3 thrombin or Xe 1o shut down the clotting cascade, Finally, fibrinolysis breaks down the fibrin lot Fiorinolysis is mediated by tissue-lype plasminogen activator (tPA), vihich binds t0 fibrin, wher it Activates plasmin. Plasmin, in tuin, degrades fibrin but can be inactivated by alpha-2antiplasmin mbedded in the finn clot, Fibrinalysis s primarily inhibited by type-1 plasminogen activator Inhibtor PAM], the fast inactivator of tPA, and in pregnancy, placental-derived PAL-2, which exists in its active form bound to Vn. TAFI acts as a Utd potent antifioinoiytic, Another member of the SERPIN family of antiproeases, PAL-L acts as the primary inhibitor of fibrinolysis (see Fig. 48-2). ‘The principal source of PAL isthe endothelium. In pregnancy, the uterine decidua is an alternative rich source of PAF syn- thesis (Schatz and Lockwood, 1993), while the placenta pro- duces PAL-2 (Estelles et al., 1989). The PAls are also maintained in their active forms in plasma as a result of tight binding to Vn (van Meijer et al., 1994). Levels of a third antifibrinolytic protein, thrombin-activatable fibrinolysis inhibitor (TAF), also increase in pregnancy (Chablor et al., 2001). Plasmain is directly inhibited by the action of o-2-antiplasmin, which is embedded in the fibrin clot (Lijnen, 2001). Pregnancy-Associated Changes in Hemostasis and Fibrinolysis Pregnancy is associated with up to a 200% increase in levels ‘of fibrinogen and factors II, VIL, X, VIII, and XI and PAL-1 (Lockwood, 2001). As noted previously, pregnancy causes significant reductions in PS and significant increases in PAI-1 and PAL-2. The net effect of these pregnancy-induced changes is to exacerbate the clinical effects of the inherited throm- bophilias (Lockwood, 2001). ™@ PATHOPHYSIOLOGY OF THE INHERITED AND ACQUIRED THROMBOPHILIAS Inherited Thrombophilias Factor V Leiden Mutation The factor V Leiden (FVL) mutation is the most common clinically significant thrombophilia in ethnic European populations, with a prevalence varying from 5% to 15% (Guideline, 2001; Lockwood, 2001). Ie is rarely found in persons of Asian or African descent (Guideline, 2001; Lockwood, 2001). A (GA) mutation in nucleotide 1691 of the factor V gene results in the substitution of a glutamine for an arginine at position 506 in the factor V polypeptide (FV 506), Because amino acid 506 is the site of APC/S's inacti- vation, the FVL mutation confers resistance to APC. Indeed, the FVL mutation is the most common cause of APC