DIC score in pregnant women--a population based modification of the International Society on Thrombosis and Hemostasis score.

ObjectivesThe objectives of this study were: 1) To determine the component needed to generate a validated DIC score during pregnancy. 2) To validate such scoring system in the identification of patients with clinical diagnosis of DIC.Material and methodsThis is a population based retrospective study, including all women who gave birth at the 'Soroka University Medical Center' during the study period, and have had blood coagulation tests including complete blood cell count, prothrombin time (PT)(seconds), partial thromboplastin time (aPTT), fibrinogen, and D-dimers. Nomograms for pregnancy were established, and DIC score was constructed based on ROC curve analyses.Results1) maternal plasma fibrinogen concentrations increased during pregnancy; 2) maternal platelet count decreased gradually during gestation; 3) the PT and PTT values did not change with advancing gestation; 4) PT difference had an area under the curve (AUC) of 0.96 (p<0.001), and a PT difference ≥1.55 had an 87% sensitivity and 90% specificity for the diagnosis of DIC; 5) the platelet count had an AUC of 0.87 (p<0.001), an 86% sensitivity and 71% specificity for the diagnosis of DIC; 6) fibrinogen concentrations had an AUC of 0.95 (p<0.001) and a cutoff point ≤3.9 g/L had a sensitivity of 87% and a specificity of 92% for the development of DIC; and 7) The pregnancy adjusted DIC score had an AUC of 0.975 (p<0.001) and at a cutoff point of ≥26 had a sensitivity of 88%, a specificity of 96%, a LR(+) of 22 and a LR(-) of 0.125 for the diagnosis of DIC.ConclusionWe could establish a sensitive and specific pregnancy adjusted DIC score. The positive likelihood ratio of this score suggests that a patient with a score of ≥26 has a high probability to have DIC

Effect of adenosine receptor subtype autoregulation on the inflammatory process.

<p>(A) Early expression of A₁R after bacterial inoculation decreases cAMP levels, enhances production of local pro-inflammatory cytokines and promotes leukocyte migration. (B) In a later phase of peritonitis A_2AR expression increase by A₁R which leads to increase in cAMP levels. High cAMP markedly decreases local pro-inflammatory cytokines and leukocyte recruitment, hence restraining inflammatory flames.</p

Effect of adenosine on A_2AR and A₁R levels <i>in vitro</i>.

<p>To simulate the gradual increase of adenosine that occurs during peritonitis, cultured primary PMC were treated with multiple and increasing concentrations of adenosine (0.1, 1 and 10 µM at 3 hour intervals). Total RNA was extracted after 9 hours and analyzed for A₁R and A_2AR mRNA levels. Results are normalized to β-actin. Data represent five experiments and are expressed as mean±SEM fold of control. * <i>p</i><0.05, ** <i>p</i><0.01 between expression levels of each receptor to expression at time 0, <i>n</i> = 3 for each experiment.</p

A₁R trigger the induction of A_2AR <i>in vitro</i>.

<p>(A) PMΦ or (B) PMC were exposed to increasing concentrations of adenosine or A₁R agonist (CHA), (0.1, 1 and 10 µM 3 hours intervals) in the presence or absence of A₁R antagonist (DPCPX, 50 nM, 30 min before treatment) (C) PMC were treated with PTX for 18 hr and then with increasing concentrations of CHA. (D) PMC were treated with increasing concentrations of adenosine, A₁R agonists (CHA and CCPA) or A_2AR agonist (CGS21680) in the presence or absence of A_2AR antagonist (ZM241385, 50 nM). Total RNA was extracted from cells and analyzed for A_2AR mRNA levels and normalized to β-actin. CT, non-treated cells. Data represent four experiments and are expressed as mean±SEM fold of control. ** <i>p</i><0.01, *** <i>p</i><0.001 from CT for B and D, <i>n</i> = 3 for each experiment.</p

A₁R and A_2AR expression in peritoneal leukocytes during inflammation <i>in vivo.</i>

<p>Peritonitis was induced in mice by <i>E. coli</i> inoculation at a sub-lethal dose. To examine the dynamic expression of the two high-affinity adenosine receptors, A₁R and A_2AR, peritoneal lavage was performed at indicated time points. A₁R and A_2AR mRNA levels in peritoneal leukocytes were analyzed by real time PCR and normalized to β-actin levels. Data represent three experiments and are expressed as mean±SEM. * <i>p</i><0.05, between expression levels of each receptor to expression at time 0, <i>n</i> = 5 for each experiment.</p

Treatment with A₁R antagonist blocked the anti-inflammatory effect of A₁R agonists.

<p>2 hours prior to administration of A₁R agonist, (A) CCPA (0.1 mg/kg) or (B) CHA (0.02 mg/kg), mice were injected with A₁R antagonist (DPCPX, 1 mg/kg) or vehicle. After 24 hours, peritonitis was induced by bacterial inoculation. At 12 hours from inoculation, IL-6 and TNFα were analyzed in sera and lavage fluids. Data represent two experiments and are expressed as mean±SEM. * <i>p</i><0.05, between vehicle and CHA or CCPA, <i>n</i> = 5 for each experiment.</p

The effect of A₁R agonist, in A_2AR^−/− and in the presence of A_2AR antagonist.

<p>Mice were administrated with A₁R agonist (CHA, 0.1 mg/kg) or vehicle 24 prior to bacterial inoculation. 30 min before inoculation the A_2AR antagonist (ZM241385, 1 mg/kg) or the A_2AR agonist (CGS21680, 1 mg/kg) were administered to the same animals or to untreated animals. (A) sera IL-6 and TNFα (12 hours) and (B) lavage fluids IL-6 and TNFα (12 hours). (C) A_2AR⁻^/− mice or their WT littermates were treated with the A₁R agonist (CHA, 0.1 mg/kg) i.p. or vehicle 24 hours prior to bacterial inoculation. 12 hours following inoculation sera were collected and analyzed for IL-6 and TNFα levels. Data are representative of three individual experiments and are expressed as mean±SEM. * <i>p</i><0.05, ** <i>p</i><0.01 between vehicle and CHA or CGS21680 and between CHA with or without ZM241385, <i>n</i> = 5 for each experiment.</p

The anti-inflammatory effect of pretreatment with the A₁R agonist.

<p>Mice were treated with the A₁R agonist (CHA, i.p., 0.1 mg/kg) or vehicle 24 hours prior to bacterial inoculation. (A) Sera levels of IL-6 and TNFα at 12 hours. (B) Chemokine mRNA levels. 12 hours after inoculation PMC were scraped from the peritoneal membrane and total RNA was extracted, analyzed for MCP-1 and MIP-2 mRNA levels and normalized to β-actin. (C) Total cell count at 24 hours after inoculation. Cell exudates were collected from peritoneal lavage fluid. Data represent five experiments and are expressed as mean±SEM for serum cytokine levels and as mean±SEM fold of control for chemokine mRNA levels.* <i>p</i><0.05, ** <i>p</i><0.01, <i>n</i> = 5 for each experiment.</p