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早产儿脐血维生素K依赖因子水平及产前补充维生素K1对其影响的研究

目的了解早产儿是否存在维生素(Vit)K依赖因子水平低下及其与早产儿脑室周围-脑室内出血的关系,探讨产前补充维生素(Vit)K1对早产儿血浆VitK依赖因子水平的影响及对脑室周围-脑室内出血的预防作用.方法将有早产可能且至分娩时孕周不足35周的孕妇分为两组对照组133例,在产前给予地塞米松注射;对照组44例,产前给予地塞米松+VitK1.两组早产儿各30例留取脐动脉血离心零下20℃以下保存用凝固法检测Ⅱ、Ⅶ、Ⅸ、Ⅹ等凝血因子活性水平,同时留取同期出生的健康足月新生儿30例脐血标本作对照.两组早产儿生后1周内常规作头颅超声检查以明确有无脑室周围-脑室内出血及其程度.结果早产儿与足月新生儿脐血VitK依赖因子活性水平分别为Ⅱ(25.6±9.5)%对(36.7±4.9)%,Ⅶ(59.0±17.7)%对(64.5±10.6)%,Ⅸ(24.7±8.9)%对(30.2±5.7)%,Ⅹ(30.2±5.0)%对(34.3±12.6)(P<0.05).母亲产前补充VitK1后其婴儿脐血VitK依赖因子水平分别为Ⅱ(36.4±6.9)%,Ⅶ(69.6±16.6)%,Ⅸ(25.7±10.9)%和Ⅹ(39.3±8.0)%,除Ⅸ因子外,Ⅱ、Ⅶ和Ⅹ因子活性均显著升高(P<0.05).脑室周围-脑室内出血发生率在对照组为52.6%,观察组为31.8%(χ2=5.744,P=0.017);重度出血对照组为12.0%,观察组为2.3%(χ2=3.626,P=0.057).结论早产儿存在VitK依赖因子水平低下,可能为其易于发生脑室周围-脑室内出血的原因之一.分娩前母亲补充VitK1可显著提高其血浆Ⅱ、Ⅶ和Ⅹ因子水平,并对脑室周围-脑室内出血有一定的预防作用.     

Vitamin K1 levels and K1-dependent coagulation factors II and X in preterm and small-for-date neonates

In 17 preterm neonates and 7 small-for-date neonates, all formula-fed, vitamin K-dependent coagulation factors II and X remained near 45% of adult values from the moment of birth until 28 days postnatally. Vitamin K₁ levels, however, showed a remarkable rise from below the detection limit of 0.022 ng/ml in umbilical cord blood, to serum levels with a range of 0.99–7.29 ng/ml vitamin K₁ on day 3, with a further rise on days 7 and 28 postnatally. Vitamin K₁ (Konakion) parenterally given to a third group of four preterm neonates as a 1 mg dose resulted in very high serum levels of vitamin K₁ (64.08–157.10 ng/ml), but without any significant increase in plasma levels of vitamin K-dependent coagulation factors II and X, compared to the group without any extra vitamin K₁. It is concluded that in healthy preterm and small-for-date neonates no correlation is seen between serum levels of vitamin K₁ and plasma levels of coagulation factors II and X. After administration of 1 mg Konakion no accelerated increase is seen in coagulatin factor activities.     

Vitamin K-dependent carboxylation in the developing rat: evidence for a similar mechanism of action of warfarin in fetal and adult livers

Our report presents data on maturation of the vitamin K-dependent carboxylation system in fetal and neonatal rat livers. This system which converts precursors of clotting factors II, VII, IX, X, protein S, and protein C to gamma-carboxylated proteins exhibited low gamma-carboxylation activity before birth. However, around the time of birth there was a sudden increase in all enzyme activities associated with the vitamin K-dependent carboxylation system. In 2-d neonatal rats these activities dropped to levels that were measured in fetal livers whereupon the activities had risen to adult levels in 7-d neonatal rats. However, the activities of the two pathways that provide the carboxylase with reduced vitamin KH2 cofactor were never as high as that measured in maternal livers. It appeared that the pathway which is insensitive to coumarin anticoagulant drugs matures later than the coumarin drug-sensitive pathway. This conclusion is supported by the finding of a late appearance in development of the vitamin K-reducing enzyme DT-diaphorase. Warfarin, when administered to the mother, affected the fetal livers at all stages of development studied (d 16-21). This was clearly demonstrated by vitamin K-dependent 14C-labeling of a 70-kD liver protein that has been shown previously to be a marker for the effect of this drug on the liver. The data demonstrate a similar mechanism of action of warfarin in fetal and neonatal rat livers and an ongoing maturation process of the vitamin K-dependent carboxylation system in these rats.     

Dexamethasone stimulates vitamin K-dependent carboxylase activity in neonatal rats and cultured fetal hepatocytes

gamma-Carboxylation of vitamin K-dependent clotting factors may be a key regulatory element in output of these proteins from liver to blood in the developing neonate. We have investigated the effect of hormones and growth factor on the vitamin K-dependent carboxylation system in neonatal rats and cultured fetal hepatocytes. Of the hormones and growth factor tested, only dexamethasone had a significant effect on the system. When dexamethasone was administered to newborn rats, there was a delayed response that produced significant enhancement of carboxylase activity 6 d after injection of the drug. A similar delayed response to the drug could also be demonstrated in cultured fetal hepatocytes. When cultured in the presence of 0.1-1 microM dexamethasone, cellular carboxylase activity was little affected by the drug the first 2 d of culture but the activity was increased more than threefold by 4 d in culture. Microsomal membranes from neonatal rat livers and fetal hepatocytes treated with dexamethasone showed enhanced vitamin K-dependent 14C labeling of the factor X membrane precursor pool. Enhanced labeling of the factor X membrane precursor pool has also been demonstrated in rats and HepG2 cells treated with warfarin. The data suggest that 1) gamma-carboxylation of clotting factors is regulated by glucocorticoids in the developing liver, and 2) dexamethasone stimulates intracellular gamma-carboxylation of the factor X precursor by a mechanism that currently is unknown.     

Hepatic impairment in fetuses of preeclamptic mothers

Cord blood from preeclamptic and normal gestations were analyzed for the vitamin K-dependent proteins, factors II, VII, IX, X, and protein C, and for fibrinogen and albumin. Factor II, factor IX, protein C, and albumin protein levels were reduced in the preeclamptic group, whereas there was no significant change in the fibrinogen or factor X protein levels. The data suggest that these findings are probably due to decreased synthesis and are not indicative of vitamin K deficiency.     

Vitamin K1 increases sister chromatid exchange in vitro in human leukocytes and in vivo in fetal sheep cells: a possible role for "vitamin K deficiency" in the fetus

The levels of the vitamin K-dependent clotting factors are markedly lower in the human fetus and newborn than in older infants and adults. Direct measurement of vitamin K1 in cord plasma records low or undetectable levels. This phenomenon, although the norm, is referred to as vitamin K deficiency and is a significant risk factor for hemorrhage in the fetus and newborn. Sister chromatid exchange (SCE), which may be used as an index of mutagenic activity, was assayed in cultured leukocytes of placental and adult blood following phytohemagglutinin stimulation. The mean number of SCEs per metaphase in human placental blood was 3.32 +/- SE 0.219 as compared with levels of 5.13 +/- SE 0.273 in young adults (p less than 0.01), and in the presence of added vitamin K1 at a concentration of 1 X 10(-6) M the SCE increased significantly in both adult and placental cells. In vitro SCE dose response curves to K1 in the blood of fetal and maternal sheep were obtained. When five fetal sheep were given 1 mg of K1 by catheter into the femoral vein the SCE increased from 3.94 +/- SE 0.15 preinjection to 5.38 +/- SE 0.23 at 24 h postinjection (p less than 0.01). In the pretreatment fetal sheep, serum vitamin K1 was below detectable levels in all seven animals in which it was assayed and reached levels as high as 0.3 X 10(-6) M 1 h post-K1 injection. The low level of K1 in the fetus may in fact confer some biological advantage by reducing the risk of mutagenic events during a period of rapid cell proliferation.     

A comparative study of coagulation systems in newborn animals

Appropriate animal experimentation can enhance our understanding of thrombotic and hemorrhagic problems in the human neonate. Which newborn animal species' coagulation system most closely resembles the human neonate is unknown. The objective of the study was to assess the newborn coagulation system in four animal species and compare them with the human neonate. Blood samples were drawn on days 1 and 7 of life from lambs (n = 10), piglets, (n = 12), rabbit pups (n = 12), and beagle pups (n = 7). Coagulation screening tests, specific factor assays, and specific inhibitors of the coagulation system were measured. All factor assays were expressed as a percent of the respective species pooled adult plasma. The results from the animals were compared to normal values from our laboratory for healthy full-term infants. The coagulation systems of all species tested, except the rabbit pup, were immature at birth with most factor levels being lower than the adult of their species. The coagulation systems were influenced by the postnatal age of the animal and the factor levels reached adult values in fewer days relative to the human. The coagulation system for the piglet most closely approximated the human neonate. The shared characteristics were prolonged screening tests, increased factor VIII:C, generally low levels for the contact and vitamin K-dependent factors, and low antithrombin III levels relative to the adult. The beagle pup also showed many similar characteristics but in contrast to the human neonate factor VIII:C and V were low on day 1 of life and prekallikrein was not measurable in the adult or newborn beagle.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of oral and intramuscular vitamin K prophylaxis on vitamin K1, PIVKA-II, and clotting factors in breast fed infants.

A randomised clinical trial was conducted to establish the effects of oral and intramuscular administration of vitamin K at birth on plasma concentrations of vitamin K1, proteins induced by vitamin K absence (PIVKA-II), and clotting factors. Two groups of about 165 healthy breast fed infants who received at random 1 mg vitamin K1 orally or intramuscularly after birth were studied at 2 weeks and 1 and 3 months of age. Although vitamin K1 concentrations were statistically significantly higher in the intramuscular group, blood coagulability, activities of factors VII and X and PIVKA-II concentrations did not reveal any difference between the two groups. At 2 weeks of age vitamin K1 concentrations were raised compared with reported unsupplemented concentrations and no PIVKA-II was detectable. At 3 months vitamin K1 concentrations were back at unsupplemented values and PIVKA-II was detectable in 11.5% of infants. Therefore, a repeated oral prophylaxis will be necessary to completely prevent (biochemical) vitamin K deficiency beyond the age of 1 month.     

Vitamin K-dependent carboxylase activity in fetal rat lung: developmental effects of dexamethasone and triiodothyronine

Dexamethasone (Dex) and triiodothyronine (T3) were administered to pregnant rats during late gestation to evaluate potential developmental effects on fetal lung vitamin K-dependent carboxylation. Maternal rats were injected on the 2 d before study with Dex (0.2 mg/kg intraperitoneally), with T3 (0.7, 3.5, or 7 mg/kg intramuscularly), or with a combination of both hormones. Fetal lung microsomes were prepared at 18, 19, and 20 d of gestation, and carboxylase activity was assessed by measuring the incorporation of 14CO2 into a synthetic pentapeptide substrate. Dex alone resulted in a small but consistent increase in activity in all three gestational ages. T3 alone increased activity approximately 85% at 20 d of gestation. Treatment with a combination of Dex and T3 caused a 60% increase in vitamin K-dependent carboxylation at each gestational age. Decreased lung growth was noted with combination hormone treatment in all rats studied at 19 and 20 d of gestation. Lung growth expressed as lung wt/body wt was more sensitive to the effects of Dex plus T3 than was carboxylase activity. Decreased lung wt/body wt (decreased 25%) was noted with Dex plus T3 (0.7 mg/kg); however, no induction of carboxylase enzyme activity was evident at this dose. This study demonstrates that vitamin K-dependent carboxylase activity in fetal rat lung can be induced by the exogenous administration of Dex and T3 to pregnant rats. Fetal lung microsomes contain multiple endogenous substrates for the vitamin K-dependent carboxylase enzyme. These hormones play a significant developmental role not only in protein biosynthesis, but in posttranslational processing as well.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effect of formula versus breast feeding and exogenous vitamin K1 supplementation on circulating levels of vitamin K1 and vitamin K-dependent clotting factors in newborns

The influence of breast or formula feeding together with that of a single supplementation of vitamin K₁ at birth, on the vitamin K₁ level and vitamin K-dependent clotting factors were studied in 65 breast and 15 formula fed infants. All breast fed newborns without supplementation (n=25) had very low serum vitamin K₁ at weeks 1 and 6. Oral vitamin K supplementation (n=22) or i.m. (n=18) at birth resulted in high serum levels at week 1, while at week 6 the effect had disappeared. Formula fed infants had vitamin K₁ values within the normal adult range at all study points. The low serum levels of vitamin K₁ were not associated with haemorrhagic disorders or coagulation abnormalities. The mean values of vitamin K₁ in maternal sera at weeks 1 and 6 were 2.3 nmol/l and 1.8 nmol/l and in breast milk 2.7 nmol/l and 2.0 nmol/l respectively. No correlation existed between the values in breast milk and maternal serum. To maintain serum levels of vitamin K₁ within the adult physiological range, repeated administration of low doses is needed in breast fed newborns beyond 1 week of age.