FETAL AND M E D IC IN E
NEONATAL RichardE. Behrman,
Editor
Alphal-antitrypsin in amniotic fluid and cord blood of preterm infants with the respiratory distress syndrome Total protein, alphal-antitrypsin, and alpha2-macroglobulin were measured on amniotic fluid in 125 pregnancies between 11 and 42 weeks" gestation, and on the cord blood o f 66 newborn infants. Amniotic fluid surface active material was assessed by the foam stability test. Amniotic fluid alphal-antitrypsin is linearly and directly related to amniotic fluid total protein (r = O. 703, p < 0.001). The cord alphalantitrypsin is also linearly related to cord total protein, lntrapartum complication s are associated with a significant lowering o f the cord alphal-antitrypsin, lnfants with a negative foam stability test had R D S regardless of the amniotic fluid alpha,-antitrypsin concentration. However, R D S occurred in several infants with an intermediate or positive foam stability test; and this combination was generally associated with an increase o f amniotic fluid alphal-antitrypsin. The cord blood alphal-antitrypsin value did not appear to be related to amniotic fluid surface active material There were 23 infants with cord alphalantitrypsin of less than 0.2 gm/dl and with an intermediate or positive foam stability test; 19 o f them had respiratory difficulties o f varying severity. It is conceivable that infants', in spite o f apparent adequate prenatal lung surfactant, develop respiratory disturbances on the basis of pulmonary fluid and protein transudation and~or reduction or inhibition o f pulmonary surfactant incident to intrapartum complications.
Allan D. Singer, M.D.,* Donald W. Thibeault, M.D.,** Calvin J. Hobel, M.D., and Douglas C. Heiner, M.D., Ph.D., Torrance, Calif.
THE SERUM PROTEINASE INHIB!TORS, alphal-antitrypsin and alpha~,macroglobulin, have been shown to be decreased in the cord blood of infants who subsequently develop RDS. 1-~ Indeed, the outcome of infants with the respiratory distress syndrome may be predicted at birth from the umbilical cord serum levels of the serum trypsin inhibitor capacity. 1 Since the amniotic fluid surface active material is also highly predictive of the risk of a newborn infant to develop RDS, it would be of interest to explore the relationship of amniotic fluid surface material to cord From the Divisions of Perinatal Medicine and Immunology-A llergy, Departments o f Pediatrics and Obstetrics, Harbor General Hospital, UCLA School o f Medicine, *Supported in part by a grant from Hoechst Pharmaceuticals, Inc., Somerville, N. J. **Reprint address: Department of Pediatrics, Harbor General Hospital, 1000 West Carson St., Torrance, Calif. 90509.
and amniotic fluid alphacantitrypsin> 8 To our knowledge, a systematic study of amniotic fluid alphaxantitrypsin throughout gestations and of its relationship to amniotic fluid surface material has not been made> 9. ,o Abbreviations used al-AT: alphal-antitrypsin a2-M: alpha2-macroglobulin RD: respiratorydistress FST: foam stability test TP: total protein cord: umbilical cord It is the purpose of this communication to report studies regarding the concentrations of cord and amniotic fluid alphal-antitrypsinin normal and complicated pregnancies and the relationship of these concentrations to amniotic fluid surface active material. The Journal o f P E D I A T R IC S Vol. 88, No. 1, pp. 87-93
87
88
Singer et al.
The Journal of Pediatrics January 1976
Table I. Intrapartum factors* considered to be detrimental to the fetus in 66 high-risk pregnancies
I No. Five minute apgar score --,
9 120-
e-
-
E
.
I.
OX
X 0
p
o
o
~
-
8o
@9
Intermediate
FOAM
STABILITY
Positive TEST
Fig. 7. The relationship of the cord alphal-antitrypsin concentration to the foam stability test. The cord alphal-antitrypsin concentration did not appear to be related to the amniotic fluid surface active material.
X 0
0
Negative
Intermediate
FOAM
STABILITY
Positive TEST
Fig. 6,The relationship of the amniofic fluid alpha]-antitrypsin to the amniotic fluid surface active material as assessed by the foam stability test. The two columns above the terms intermediate and positive refer to dilutions of amniotic fluid described under methods. There is a progressive increase in surfactant concentration as one moves from negative to positive at the highest dilution. The alphax-antitrypsin concentration does not appear to be related to the FST. Note that RDS occurred in the majority of infants with intermediate or positive FST when the alphalantitrypsin was elevated above 0.05 gm/dl.
protein in amniotic fluid would be that protein synthesis in the fetus increases during the first two trimesters when the capillaries are relatively permeable. As the capillaries become less permeable, t h e amniotic fluid alphaiantitrypsin and total protein decrease. Fierer and associates 6 showed that the decreased serum aI-AT in infants with RDS was probably not due to a failure of release o f a c A T from the liver. Our data in infants with respiratory disturbances are consistent with their findings, since the low cord al-AT was associated with high levels o f amniotic fluid a~-AT. This finding suggests losses from the blood rather than a decreased production o f a~-AT. This view is supported by the finding of Fierer and associates ' and Mathis and associates 5 who detected a~-AT as an integral part of the hyaline membranes o f infants who died with RDS.
Amniotic fluid and cord serum al-AT do not appear to be related to the amount of amniotic fluid surface active material. Infants with low amniotic fluid surface active material developed RDS regardless o f the concentrations of amniotic fluid or cord al-AT. On the other hand, those infants with intermediate or positive F S T who developed RDS had high levels of amniotic fluid al-AT and low levels of cord a~-AT. It is conceivable that these infants, in spite of apparent adequate prenatal lung surfactant, develop respiratory disturbances on the basis of pulmonary fluid transudation a n d / o r reduction of pulmonary surfactant incident to intrapartum complications, l'~ We are indebted to Dr. Jack Lieberman, City of Hope National Medical Center, Duarte, California, for attempting to compare the alphal-antitrypsin phenotypes of amniotic fluid with those of maternal serum. REFERENCES
1. Kotas RV, Fazen LE, and Moore TE: Umbilical cord serum trypsin inhibitor capacity and the idiopathic respiratory distress syndrome, J PEDIATR81:593, 1972. 2. Evans HE, Levi M, and Mandl I: Serum enzyme inhibitor concentrations in the respiratory distress syndrome, Am Rev Resp Dis 101:359, 1970. 3. Evans HE, Keller S, and Mandl I: Serum trypsin inhibitory capacity and the idiopathic respiratory distress syndrome, J PEDIATR81:588, 1972. 4. E1-Bardeesy MW, and Johnson AM: Serum proteinase inhibitors in infants with hyaline membrane disease, J PEDIATR81:579, 1972. 5. Mathis RK, Freier EF, Hunt CF, Krivit W, and Sharp HL:
Volume 88 Number 1
6.
7.
8.
9.
Alphal-antitrypsin in the respiratory distress syndrome, N Engl J Med 288:59, 1973. Fierer JA, Mandl I, and Evans HE: Alphal-antitrypsin in the lungs of newborn infants with respiratory distress syndrome, J PEDIATR85:698, 1974. Gtuck L Kulovich MV, Borer RC Jr, Brenner PH, Anderson GC, and Spellacy WN: The diagnosis of the respiratory distress syndrome (RDS) by amniocentesis, Am J Obstet Gynecol 109:440, 1971. Clements JA, Platzker ACG, Tierney DF, Hobel C J, Creasy RK, Margolis AJ, Thibeault DW, Tooley WH, and Oh W: Assessment of the risk of the respiratory distress syndrome by a rapid test for surfactant in amniotic fluid, N Engl J Med 286:10771 1972. Gitlin B, and Biasucci A: Development of,/G, -/A, "/M, Bic/ Bia, C'I esterase inhibitor, ceruloplasmin, transferrin, hemopexin, haptoglobin, fibrinogen, plasminogen, cq-antitrypsin, orosomucoid, B-lipoprotein, a2-macroglobulin, and prealbumin in the human conceptus, J Clin Invest 48:1433, 1969.
A lphafantitrypsin in amniotic fluid
93
10. Guibaud S, Bonnet M, Thoulon JM, and Duman TM: Alphaa-antitrypsin in amniotic fluid, Obstet Gynecol 45:34, 1974. 11. Avery ME, Gatewood OE, and Brumley G: Transient tachypnea of the newborn, Am J Dis Child 111:380, 1966. 12. Lowry OH, Rosebrough NJ, Farr AL, and Randall PJ: Protein measurement with the Folin phenol reagent, J Biol Chem 198:265, 1951. 13. Seal LA, Carp DA, and George RB: Comparison of commercially available radial immunodiffusion kits for the determination of serum al-antitrypsin concentrations, Am Rev Resp Dis 111:97, 1975. 14. Queenan JT, Thompson W, Whitfield CR, and Shah SI: Amniotic fluid volumes in normal pregnancies, Am J Obstet Gynecol 114:34, 1972. 15. Gtuck L, Kulovich MV, Eidelman A, Cordero L, and Khazin AF: Biochemical development of surface activity in mammalian lung. IV. Pulmonary lecithin synthesis in the human fetus and newborn and etiology of the respiratory distress syndrome, Pediatr Res 6:81, 1972.
NEONATAL RichardE. Behrman,
Editor
Alphal-antitrypsin in amniotic fluid and cord blood of preterm infants with the respiratory distress syndrome Total protein, alphal-antitrypsin, and alpha2-macroglobulin were measured on amniotic fluid in 125 pregnancies between 11 and 42 weeks" gestation, and on the cord blood o f 66 newborn infants. Amniotic fluid surface active material was assessed by the foam stability test. Amniotic fluid alphal-antitrypsin is linearly and directly related to amniotic fluid total protein (r = O. 703, p < 0.001). The cord alphalantitrypsin is also linearly related to cord total protein, lntrapartum complication s are associated with a significant lowering o f the cord alphal-antitrypsin, lnfants with a negative foam stability test had R D S regardless of the amniotic fluid alpha,-antitrypsin concentration. However, R D S occurred in several infants with an intermediate or positive foam stability test; and this combination was generally associated with an increase o f amniotic fluid alphal-antitrypsin. The cord blood alphal-antitrypsin value did not appear to be related to amniotic fluid surface active material There were 23 infants with cord alphalantitrypsin of less than 0.2 gm/dl and with an intermediate or positive foam stability test; 19 o f them had respiratory difficulties o f varying severity. It is conceivable that infants', in spite o f apparent adequate prenatal lung surfactant, develop respiratory disturbances on the basis of pulmonary fluid and protein transudation and~or reduction or inhibition o f pulmonary surfactant incident to intrapartum complications.
Allan D. Singer, M.D.,* Donald W. Thibeault, M.D.,** Calvin J. Hobel, M.D., and Douglas C. Heiner, M.D., Ph.D., Torrance, Calif.
THE SERUM PROTEINASE INHIB!TORS, alphal-antitrypsin and alpha~,macroglobulin, have been shown to be decreased in the cord blood of infants who subsequently develop RDS. 1-~ Indeed, the outcome of infants with the respiratory distress syndrome may be predicted at birth from the umbilical cord serum levels of the serum trypsin inhibitor capacity. 1 Since the amniotic fluid surface active material is also highly predictive of the risk of a newborn infant to develop RDS, it would be of interest to explore the relationship of amniotic fluid surface material to cord From the Divisions of Perinatal Medicine and Immunology-A llergy, Departments o f Pediatrics and Obstetrics, Harbor General Hospital, UCLA School o f Medicine, *Supported in part by a grant from Hoechst Pharmaceuticals, Inc., Somerville, N. J. **Reprint address: Department of Pediatrics, Harbor General Hospital, 1000 West Carson St., Torrance, Calif. 90509.
and amniotic fluid alphacantitrypsin> 8 To our knowledge, a systematic study of amniotic fluid alphaxantitrypsin throughout gestations and of its relationship to amniotic fluid surface material has not been made> 9. ,o Abbreviations used al-AT: alphal-antitrypsin a2-M: alpha2-macroglobulin RD: respiratorydistress FST: foam stability test TP: total protein cord: umbilical cord It is the purpose of this communication to report studies regarding the concentrations of cord and amniotic fluid alphal-antitrypsinin normal and complicated pregnancies and the relationship of these concentrations to amniotic fluid surface active material. The Journal o f P E D I A T R IC S Vol. 88, No. 1, pp. 87-93
87
88
Singer et al.
The Journal of Pediatrics January 1976
Table I. Intrapartum factors* considered to be detrimental to the fetus in 66 high-risk pregnancies
I No. Five minute apgar score --,
9 120-
e-
-
E
.
I.
OX
X 0
p
o
o
~
-
8o
@9
Intermediate
FOAM
STABILITY
Positive TEST
Fig. 7. The relationship of the cord alphal-antitrypsin concentration to the foam stability test. The cord alphal-antitrypsin concentration did not appear to be related to the amniotic fluid surface active material.
X 0
0
Negative
Intermediate
FOAM
STABILITY
Positive TEST
Fig. 6,The relationship of the amniofic fluid alpha]-antitrypsin to the amniotic fluid surface active material as assessed by the foam stability test. The two columns above the terms intermediate and positive refer to dilutions of amniotic fluid described under methods. There is a progressive increase in surfactant concentration as one moves from negative to positive at the highest dilution. The alphax-antitrypsin concentration does not appear to be related to the FST. Note that RDS occurred in the majority of infants with intermediate or positive FST when the alphalantitrypsin was elevated above 0.05 gm/dl.
protein in amniotic fluid would be that protein synthesis in the fetus increases during the first two trimesters when the capillaries are relatively permeable. As the capillaries become less permeable, t h e amniotic fluid alphaiantitrypsin and total protein decrease. Fierer and associates 6 showed that the decreased serum aI-AT in infants with RDS was probably not due to a failure of release o f a c A T from the liver. Our data in infants with respiratory disturbances are consistent with their findings, since the low cord al-AT was associated with high levels o f amniotic fluid a~-AT. This finding suggests losses from the blood rather than a decreased production o f a~-AT. This view is supported by the finding of Fierer and associates ' and Mathis and associates 5 who detected a~-AT as an integral part of the hyaline membranes o f infants who died with RDS.
Amniotic fluid and cord serum al-AT do not appear to be related to the amount of amniotic fluid surface active material. Infants with low amniotic fluid surface active material developed RDS regardless o f the concentrations of amniotic fluid or cord al-AT. On the other hand, those infants with intermediate or positive F S T who developed RDS had high levels of amniotic fluid al-AT and low levels of cord a~-AT. It is conceivable that these infants, in spite of apparent adequate prenatal lung surfactant, develop respiratory disturbances on the basis of pulmonary fluid transudation a n d / o r reduction of pulmonary surfactant incident to intrapartum complications, l'~ We are indebted to Dr. Jack Lieberman, City of Hope National Medical Center, Duarte, California, for attempting to compare the alphal-antitrypsin phenotypes of amniotic fluid with those of maternal serum. REFERENCES
1. Kotas RV, Fazen LE, and Moore TE: Umbilical cord serum trypsin inhibitor capacity and the idiopathic respiratory distress syndrome, J PEDIATR81:593, 1972. 2. Evans HE, Levi M, and Mandl I: Serum enzyme inhibitor concentrations in the respiratory distress syndrome, Am Rev Resp Dis 101:359, 1970. 3. Evans HE, Keller S, and Mandl I: Serum trypsin inhibitory capacity and the idiopathic respiratory distress syndrome, J PEDIATR81:588, 1972. 4. E1-Bardeesy MW, and Johnson AM: Serum proteinase inhibitors in infants with hyaline membrane disease, J PEDIATR81:579, 1972. 5. Mathis RK, Freier EF, Hunt CF, Krivit W, and Sharp HL:
Volume 88 Number 1
6.
7.
8.
9.
Alphal-antitrypsin in the respiratory distress syndrome, N Engl J Med 288:59, 1973. Fierer JA, Mandl I, and Evans HE: Alphal-antitrypsin in the lungs of newborn infants with respiratory distress syndrome, J PEDIATR85:698, 1974. Gtuck L Kulovich MV, Borer RC Jr, Brenner PH, Anderson GC, and Spellacy WN: The diagnosis of the respiratory distress syndrome (RDS) by amniocentesis, Am J Obstet Gynecol 109:440, 1971. Clements JA, Platzker ACG, Tierney DF, Hobel C J, Creasy RK, Margolis AJ, Thibeault DW, Tooley WH, and Oh W: Assessment of the risk of the respiratory distress syndrome by a rapid test for surfactant in amniotic fluid, N Engl J Med 286:10771 1972. Gitlin B, and Biasucci A: Development of,/G, -/A, "/M, Bic/ Bia, C'I esterase inhibitor, ceruloplasmin, transferrin, hemopexin, haptoglobin, fibrinogen, plasminogen, cq-antitrypsin, orosomucoid, B-lipoprotein, a2-macroglobulin, and prealbumin in the human conceptus, J Clin Invest 48:1433, 1969.
A lphafantitrypsin in amniotic fluid
93
10. Guibaud S, Bonnet M, Thoulon JM, and Duman TM: Alphaa-antitrypsin in amniotic fluid, Obstet Gynecol 45:34, 1974. 11. Avery ME, Gatewood OE, and Brumley G: Transient tachypnea of the newborn, Am J Dis Child 111:380, 1966. 12. Lowry OH, Rosebrough NJ, Farr AL, and Randall PJ: Protein measurement with the Folin phenol reagent, J Biol Chem 198:265, 1951. 13. Seal LA, Carp DA, and George RB: Comparison of commercially available radial immunodiffusion kits for the determination of serum al-antitrypsin concentrations, Am Rev Resp Dis 111:97, 1975. 14. Queenan JT, Thompson W, Whitfield CR, and Shah SI: Amniotic fluid volumes in normal pregnancies, Am J Obstet Gynecol 114:34, 1972. 15. Gtuck L, Kulovich MV, Eidelman A, Cordero L, and Khazin AF: Biochemical development of surface activity in mammalian lung. IV. Pulmonary lecithin synthesis in the human fetus and newborn and etiology of the respiratory distress syndrome, Pediatr Res 6:81, 1972.
