Neonates Dying Within 48 Hours of Birth

Arch Dis Child: first published as 10.1136/adc.42.224.401 on 1 August 1967. Downloaded from

Arch. Dis. Childh., 1967, 42, 401.

Disseminated Fibrin Thromboembolism among Neonates Dying within 48 Hours of Birth

J. F. BOYD From Brownlee Laboratory, Department of Infectious Diseases, University and Ruchill Hospital, Glasgow, and University Department of Pathology, Western Infirmary, Glasgow

The cause of death within 7 days of birth remains Flute, 1964; Merskey, Johnson, Pert, and Wohl, uncertain in about 14% of neonates (Butler and 1964). In pursuing the original argument, Boyd Bonham, 1963). Many authors have commented (1957) reported fibrin deposits on the viii of many on the presence of thrombosis in neonatal deaths, placentae, and suggested that these minor deposits, for example, Cruickshank (1930) noted thrombosis which could become major and result in 'infarctions', in 30 of 800 deaths. Zuschlag (1947) reported a could represent another manifestation ofthis process study of lung infarction in 38 children, one of whom of intravascular thrombosis. The next step was to was less than a month old. These infarctions were determine if placental thromboplastin could enter frequently associated with thrombi and often related the foetal circulation to cause effects there similar to to infection. More recently, Emery (1953) made a those in fatal maternal hypofibrinogenaemia. Two similar observation, two of his cases being 51 days possible examples were reported in 1958 (Boyd), and and 9 days old, respectively; no aetiology was both are incorporated in greater detail in the present

apparent in the younger case. Groniowski (1963) article. A larger series of stillbirths and neonatal copyright. reported 15 more cases and while at least half of deaths was reported recently (Boyd, 1965), and a them had obvious infections (mainly otitis media), complete series of stillbirths showing the syndrome the pulmonary thrombi were not obviously infected. has also been reported (Boyd, 1966). In the present Lately, Scott (1965) and Sanerkin, Edwards, and article the findings among neonates dying within Jacobs (1966) have reported thrombosis with and 48 hours of birth are recorded. without embolism as a consequence of prolonged umbilical vein catheterization. Material and Methods Dieckmann (1936) established that cases of http://adc.bmj.com/ abruptio placentae and concealed accidental haemor- These have been detailed elsewhere (Boyd, 1965). Of rhage showed hypofibrinogenaemia, and that the 755 perinatal deaths studied, nearly 66% was a prospec- fatal cases showed widespread pulmonary thrombo- tive series, and blocks of tissue were taken from all major sis and embolism. This view received support from organs regardless of whether or not distinct pathological features were visible. In addition to H. and E. sections, Schneider (1950, 1951), McKay, Merrill, Weiner, a duplicate set of sections was stained by Lieb's (1948) Hertig, and Reid (1953), and Johnstone and phosphotungstic acid haematoxylin (PTAH), by which McCallum (1956). The lesions were localized at method fibrin is stained blue-black. Rarely, results capillary level and the circulating blood became were confirmed by employing other stains for fibrin. on September 26, 2021 by guest. Protected depleted of fibrinogen. Schneider showed that placenta and uterine decidua were very rich in tissue Antemortem fibrin thromboemboli. In this thromboplastin, and suggested that this substance survey of 226 neonates dying within 48 hours of birth, was released into the circulation during one of these intravascular fibrin deposits were noted in one or more catastrophes to lead to the pathological and histo- organs in 58 cases (26%). The fibrin deposits were considered to be postmortem, agonal, or antemortem in logical findings described above. Further studies type from the morphological disposition of the fibrin have shown the syndrome of hypofibrinogenaemia strands. In the case of antemortem fibrin thrombo- of pregnancy to be a complex state involving at emboli, the fibrin strands tend to be parallel to one times the fibrinolytic system (Stefanini, 1958; another and to the vessel wall, to lie along the direction Phillips, 1959; Schneider, 1959; Sherry, Fletcher, of blood flow, and to be long. They may be packed and Alkjaersig, 1959; Stefanini and Turpini, 1959; tightly together, they stain deeply, and they show a saddle embolus effect at bifurcations. Such thrombo- Received November 3, 1966. emboli may acquire a varying component of platelets, or 401 Arch Dis Child: first published as 10.1136/adc.42.224.401 on 1 August 1967. Downloaded from 402 J. F. Boyd TABIJ Findings in Eight Neonates Living for Less than 48 Hoar

Maternal State Length Case of State of No. Age (yr.) Parity Antepartum Intrapartum Postpartum Gestation Placenta (w

1 ? ? Pre-eclamptic 28 Monovular toxaemia; twins 2 ? 2 Rh neg. with Mild postpartum 40 - antibodies haemorrhage 3 46 13 Mild antepartum Pyrexia 36 Old infarction haemorrhage 4 28 5 Mixed accidental 34 Retroplacental haemorrhage haematoma 5 31 4 Chronic bronchitic, Pyrexia due to 38 - hypertension exac. of chronic bronchitis 6 38 3 Premature rupture Miod. postpartum 39 of membranes haemorrhage puerperal pyrexia 7 v 40

8 31 3 Disproportion Lower segment 40 + - caesarian section * + and - indicate presence or absence of thromboemboli; a blank indicates that no histological examination was made. of white or red corpuscles, but these elements must be in Case 1. Mother admitted when 26 weeks' pregnant, the minority so that the essential fibrin nature of the draining blood-stained liquor, showing mild pre- thromboemboli remains clear, thus suggesting that the eclamptic toxaemia, and x-ray examination confirmed lesions have formed selectively from the circulating twins. Premature labour started 2 weeks later, and plasma. Other evidence of antemortem formation is the monochorionic male twins were delivered. The finding of ischaemic changes in the organs, tissues, and puerperium was satisfactory. The first twin died when cells in the vicinity of the lesions. Older thromboemboli less than 12 hours old, and the second twin died some show adhesion to the vessel wall, retraction, and lining time later. copyright. of the exposed faces by vascular endothelium, and even Necropsy of twin I showed patchy atelectasis and a older lesions show gradual loss of their customary blood-stained right pleural effusion. Four blocks of lung staining properties. showed patchy expansion of atria and alveoli, without This series revealed eight cases with fibrin thrombo- infection. Sections stained by PTAH showed wide- emboli to match the description given above, one of spread intravascular thromboembolism in three blocks. which (Case 6 below) also had streptococcal septicaemia, The lesions were composed entirely of fibrin, and were but the fibrin thromboemboli showed no evidence of located in the arterioles, in the capillaries (Fig. 1) to the being infected. (A ninth case showed antemortem extent that capillary beds of whole lung lobules had mixed thrombosis which was considered to be infected. become functionless, and in pulmonary venules. The http://adc.bmj.com/ This last case is not reported.) affected parenchyma showed ischaemic changes though frank infarction was absent. It was estimated that three- Case Reports quarters of the vascular bed of three of the four blocks The eight cases are reported in order of increasing was obstructed by thromboemboli. survival after birth. Necropsy of twin II showed immaturity and atelectasis. on September 26, 2021 by guest. Protected

FIG. .-Case 1. Lung. Extensive capillary fibrin thromboembolism; alveolar oedemna shows delicate network offibrin. (PTAH 170.) Arch Dis Child: first published as 10.1136/adc.42.224.401 on 1 August 1967. Downloaded from Disseminated Fibrin Thromboembolism Among Neonates Dying Within 48 Hours of Birth 403 and Showing Disseminated Fibrin Thromboembolism

Length of Organs Showing Fibrin Thromboembolism* Infant's Survival Adrenal Lung Liver Brain Heart Kidney Thymus Thyroid Pancreas Pituitary ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~(hr.)~ <12 ++! 12 12 ++ + ++ + + + 12 ++ --+ - - - 1IN + + 21 - + +±+ - + ++ _ _

25 + [+] - - - -

31 ++ - - - - + + 32 + - ++

Histological examination of the lungs failed to reveal any that recorded by Scott (1965) as an iatrogenic lesion additional finding. following prolonged umbilical vein catheterization. This finding is very uncommon among neonatal deaths Case 2. Mother para-2, blood group 0 rhesus in my investigation which was completed before negative, and anti-D titre of 11128 at term, though the prolonged umbilical vein catheterization was a common

titre had been low on previous tests. At birth, the baby practice. Mixed platelet and fibrin thromboemboli, incopyright. was grey and limp. There was a mild post-partum small numbers and of small size, were found in the haemorrhage. The cord blood tests revealed a 'mod- thyroid gland, thymus, myocardium, and in the pancreas erately affected rhesus infant', whose condition improved (Fig. 3). Similar lesions occurred in the cerebral during replacement transfusion, but the child collapsed cortex, in cerebral white matter, and in the cerebellum. suddenly at the end of this procedure, and died when They appeared to be most dense, however, in the brain- less than 12 hours old. Necropsy showed the features stem close to the nuclei of the glossopharyngeal and of erythroblastosis foetalis, and this was confirmed on vagus nerves. No secondary effects were identified.

histological examination. Fibrin thromboemboli were not present in the kidneys http://adc.bmj.com/ Lieb's PTAH showed fibrin thromboemboli in or in the spleen. several pulmonary arteries (Fig. 2). The lesions were dense and the individual fibrin strands difficult to Case 3. Mother, 46 years, para-13, admitted with identify because of tight packing and a heavy overcoating vaginal bleeding and passing several clots. The by platelets. In the liver, scanty agonal thrombi were membranes ruptured spontaneously on the following day present, and, rarely, venules carried a coating of almost and labour started one week later, the 36th week of pure platelet thrombus. This appearance is similar to pregnancy. A male infant of 1930 g. was cyanotic on September 26, 2021 by guest. Protected

FIG. 2.-Case 2. Lung. Dense fibrin/platelet thrombo- FIG. 3.-Case 2. Pancreas. Fibrin/platelet thrombus in embolus in arteriole. (PTAH x 95.) arteriole. (PTAH x 310.) Arch Dis Child: first published as 10.1136/adc.42.224.401 on 1 August 1967. Downloaded from

404 J. F. Boyd

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FIG. 4.-Case 3. Adrenal. Fibrin thromboemboli emana- FIG. 5.-Case 4. Adrenal. Two spherical haemorrhagic copyright. ting from medullary sinusoids to form mixed thrombus in cortical infarctions with much sinusoidal fibrin, and vein. (PTAH x 95.) thrombus in vein. (PTAH x 3 5.) and limp. The placenta showed a large, old infarc- was dense the sinusoids were collapsed, and the sinusoids tion. The mother developed pyrexia which responded of neighbouring areas showed attempted compensatory well to penicillin. The cord blood fibrinogen level by dilatation even though some of these also contained the micro-Kjeldahl method was 458 mg./100 ml., being fibrin deposits. In some areas the fibrin deposits no greater than the normal mean + 2 SE (unpublished longer occupied the central portion of the sinusoid, but results). lay on the endothelial lining. The deposits involved a http://adc.bmj.com/ The infant responded slowly to resuscitative measures. tributary of the adrenal vein, where laminated mixed Breathing became established and intramuscular oxy- thrombus was present (Fig. 4). The liver showed tetracycline was given. Later, cyanotic attacks occurred widespread sinusoidal fibrin thromboemboli scattered while aeration remained good. Following the appear- evenly throughout the organ. ance of haematuria, 1 mg. vitamin K was given. The child lived 12 hours. Case 4. Mother, 28 years, para-5, admitted with Necropsy showed mild cyanosis. Only the right mixed accidental haemorrhage and shock. Next day, middle lobe of the lungs showed aeration. The heart membranes were ruptured artificially. Blood-stained on September 26, 2021 by guest. Protected was normal. The liver (109 g.) and both kidneys liquor was obtained. On the following day a female showed severe congestion. Both adrenal glands showed infant of 2380 g. was delivered. There was a 240 ml. medullary haemorrhages which did not distort the retroplacental clot. The puerperium was satisfactory. shapes of the glands. The brain (275 g.) showed The infant's breathing was laboured at first, its colour severe congestion, and bilateral intraventricular haemor- becoming satisfactory later. Respirations became sigh- rhages. Histological examination confirmed these ing in character, and it died at 13j hours after a nasal findings. There was no evidence of respiratory haemorrhage. Necropsy showed extensive petechiae infection. over both pleurae and the pericardium. Numerous Lieb's PTAH showed antemortem sinusoidal pure pulmonary haemorrhages were present, and congestion fibrin thromboemboli in one adrenal gland and in the of the liver and brain was marked. The kidneys were liver. There was none elsewhere. In the adrenal pale and there was apoplexy of both adrenal glands. gland, the sinusoidal fibrin was situated in relation to the Histological examination confirmed these findings and haemorrhagic infarctions. The fibrin strands were long, showed no evidence of infection. deeply stained, and in many areas lay in the axial stream Sections stained by PTAH showed intravascular fibrin parallel to the sinusoid walls. In areas where the fibrin thromboemboli only in the adrenal glands and most Arch Dis Child: first published as 10.1136/adc.42.224.401 on 1 August 1967. Downloaded from

Disseminated Fibrin Thromboembolism Among Neonates Dying Within 48 Hours of Birth 405 concentrated in the foci ofhaemorrhage (Fig. 5). Nearly portal vein of the left lobe (Fig. 6), with widespread pure all lay centrally in the sinusoids. Adrenal vein thrombo- fibrin thromboembolism in the small radicles and with sis was well developed (Fig. 5) and was very rich in fibrin smaller seedlings in some central and subhepatic veins, at its origins, but assumed a more mixed character at its while the branches in the right lobe were free from head. involvement. One vegetation on the tricuspid valve was composed mainly of platelets, but there was a basic Case 5. Mother, 31 years, para-4, had chronic network of fibrin strands which were most dense at the bronchitis and high blood pressure and gave birth to a base of the lesion. There were no polymorphs, red female infant of 2550 g. after a normal pregnancy of 38 blood corpuscles, or clumps of bacteria, and the valve weeks. In the puerperium the mother had an exacerba- stroma showed no reaction to the mass. These features tion of chronic bronchitis and showed early heart failure, suggested that the mass had no infective basis, and to both of which responded well to treatment. lend support to this, aerobic and anaerobic culture of the The infant was well for 3 hours. Then she became second vegetation gave no growth of organisms. cyanotic, and the respirations were grunting. Air entry Similar thrombus of mixed fibrin-platelet composition was good and fine rales were audible. With oxygen the was found in a myocardial venule, having possibly colour improved. Oxytetracycline was given. A sys- entered the coronary sinus during diastole. All lobes of tolic murmur became audible 10 hours later. The both lungs showed scanty pure fibrin thromboemboli in infant's condition began to deteriorate and she died at the pulmonary arterioles, but there were very numerous 21 hours. thromboemboli of mixed fibrin-platelet composition, and Necropsy showed mild jaundice, well-aerated lungs, one or two of these were retracted to one side of the and dilatation of the right side of the heart. Dissection vessel wall. Extensive pure fibrin thromboemboli were showed two firm pale vegetations on the posterior cusp found in the straight vessels of the renal medullary of the tricuspid valve. There was no evidence of pyramids (Fig. 7). fibroelastosis. The pulmonary artery, aorta, and ductus arteriosus were normal. The lungs histologically Case 6. Mother, 38 years, para-3, gave birth to a showed moderate hyaline membrane. Intravascular female infant of 4110 g. after a normal pregnancy of 39 fibrin thromboemboli were present in several organs. weeks. The membranes ruptured spontaneously two In the liver there was laminated mixed thrombus in the days before labour started. A true knot was present in copyright. http://adc.bmj.com/

FIG. 6.-Case 5. Liver. Fibrin thromboemboli in several 1portal veins, and mixed laminated thrombus in a large portal vein. (PT'AH x 25.) on September 26, 2021 by guest. Protected

FIG. 7.-Case 5. Kidney. Antemortem fibrin thromboemboli in the straight vessels of a medullary pyramid. (PTAH x 310.) Arch Dis Child: first published as 10.1136/adc.42.224.401 on 1 August 1967. Downloaded from

406 J. F. Boyd

FIG. 8.-Case 7. Adrenal. Fibrin thromboemboli in axial stream in sinusoids of cortex. (PTAH x 310.) copyright.

FIG. 9.-Case 7. Thyroid. Fibrin thromboemboli in FIG. 10.-Case 7. Thyroid. Delicate capillary fibrin capillaries around vesicles. (PTAH x 170.) strands elsewhere in the gland. These may be agonal. (PTAH x 310.) the cord, and a brisk moderate post-partum haemorrhage Necropsy showed dilatation of all cardiac chambers followed expulsion of the placenta. The mother associated with marked elevation of the diaphragm and http://adc.bmj.com/ developed fever of 40° C.; haemolytic streptococci were an extremely tense abdominal wall, the surgical wound cultured from a high vaginal swab. Response to being perfectly healthy. Histological examination treatment was satisfactory. showed no other abnormality and scanty fibrin thrombo- The infant was well for 6 hours when cyanosis emboli were found at two points in one adrenal gland developed, and later peripheral circulatory failure (Fig. 8) and at one point in the thyroid gland (Fig. 9). appeared; death occurred at 25 hours. Necropsy The thyroid gland also showed a more delicate intra- showed bilateral haemorrhagic bronchopneumonia, vascular fibrin deposition (Fig. 10), the significance of blood-stained pleural effusions, marked fatty change in which is uncertain but which I consider to be a variety on September 26, 2021 by guest. Protected the liver, haemorrhages in the splenic pulp, bilateral of agonal thrombosis. The pituitary showed several enlargement of the adrenal glands with central medullary short blunt fibrin thromboemboli, capable of being softening, and petechial subcapsular haemorrhages over interpreted as either antemortem or agonal. both kidneys. Histological examination showed a suppurative haemorrhagic pneumonia and septicaemia. Case 8. Mother, 31 years and para-3, had been well Gram-positive cocci in chains were seen in many organs. throughout pregnancy and was admitted with delayed Fibrin thromboembolism was minimal, being found only labour at term. Disproportion was confirmed and a in one portion of one adrenal gland. lower uterine segment caesarean section was performed, with delivery of a male infant of 4680 g. At birth, the Case 7. The infant, a full-term male weighing 2950 g. baby was pale. Later, cyanotic attacks appeared, the was born in hospital after a normal pregnancy. He limbs were spastic and death occurred at 32 hours. was transferred because of a large exomphalos which was Necropsy showed severe congestion of all thoracic and repaired satisfactorily. Small feeds were started on the abdominal organs and of the brain, where there were also following day, but he became cyanotic with laboured multiple confluent haemorrhages in the left frontal lobe respirations, and died after 31 hours. with early cerebral softening. Arch Dis Child: first published as 10.1136/adc.42.224.401 on 1 August 1967. Downloaded from

Disseminated Fibrin Thromboembolism Among Neonates Dying Within 48 Hours of Birth 407 Fibrin thromboemboli were present only in the brain an exacerbation of chronic bronchitis. It appears, and adrenal glands. In the brain, most haemorrhages therefore, that there is no correlation between the were devoid of stainable fibrin, but intravascular fibrin occurrence of the syndrome in the infant dying was found only in the left frontal lobe (Fig. 11). Fibrin within 48 hours of birth and the presence of any was not present elsewhere in the brain. Occasionally in the mother. Nor was there wisps of fibrin were found in haemorrhages, but their particular upset any configuration suggested that they had lain originally in common placental abnormality on inspection, or vessels. In the adrenal glands, scanty loosely-formed histologically. fibrin deposits were present deep in the 'foetal zone' of The question is raised of platelets from the fresh the adrenal cortex. These may be agonal, though the blood transfused to Case 2 being responsible for the disposition of the major strands suggests that there could mixed thrombotic picture noted histologically, a be an antemortem element to the deposits. situation recently described by Scott (1965) and by Sanerkin et al. (1966). But since a similar picture of fibrin/platelet thromboemboli was noted in Case 5 which received no transfusion of any kind, it is possible that the platelets are the infant's own platelets. In Case 5, it may be valid to suggest that the thromboplastin responsible for initiating the fibrin thromboembolic process was not of platelet origin. Scott's cases were subjected to prolonged umbilical vein catheterization, a situation that did not take place at the time when the present series was being collected, and catheterization of the umbilical vein was not carried out in any other case in this report. ::F.:...:.W.:... !:::,,. .-_...... :et analogy with infarctions in other organs, it is FIG. 11.-Case 8. Brain. Antemortem annular laminated By fibrin thromboembolus in cerebral vessel below. Vessel improbable that the lesions of the adrenal glands of disrupting with loosening of fibrin network peripherally. Case 3 are only 12 hours old (the length of the Petechial haemorrhages elsewhere, mostly devoid of fibrin. infant's extrauterine survival), and the haemorrhagic copyright. (PTAH x 310.) infarctions are more likely to be about 7 days old. If these assumptions are correct, they take us back Discussion in time to the mother's admission with a mild There is no consistent background maternal state antepartum haemorrhage. The thromboembolic to the eight cases recorded in this article. More of process in the liver is thought to be of more recent the mothers had antepartum complications in this origin, and may have so depleted the infant's blood series than occurred in a comparable number of offibrinogen after birth that extensive haemorrhages mothers whose stillborn infants showed this occurred, in the ventricles of the brain, in the http://adc.bmj.com/ condition (Boyd, 1966). Four mothers had no adrenal glands, and as an episode of haematuria. abnormality during pregnancy and one of the others In contrast to Case 3, the fibrin thromboe-mboli of had a twin pregnancy with mild pre-eclampsia. Case 4 are situated axially in the adrenal sinusoids. Another had a mild antepartum haemorrhage and Since this infant had an extrauterine survival of 13 one had a mixed accidental haemorrhage. The hours and survived in utero for 32 hours after a other case had chronic bronchitis and hypertension. mixed accidental haemorrhage, a total of 45 hours,

(In the stillbirth series, five, and possibly six, there is support for accepting the histological on September 26, 2021 by guest. Protected mothers of the eight 'positive' cases showed no findings as being compatible with the shorter maternal upset.) During the intrapartum period, history. only one mother showed any upset, which was delay Case 6 is an early example of the question to be due to disproportion. In the post-partum period encountered among the later neonatal deaths (i.e. two had small and moderate haemorrhages, and one those occurring after 48 hours), when other factors of these also had pyrexia associated with puerperal enter, which become increasingly difficult to sepsis. There was no clinical evidence that these segregate from the possible role of disseminated haemorrhagic episodes were related to the hypo- fibrin thromboembolism. Death in this case fibrinogenaemic state, though haematological tests resulted from severe suppurative bronchopneumonia were not carried out in either case since they arose in and septicaemia, probably due to the haemolytic 1952 and 1953 before simple methods for estimating streptococci responsible for puerperal pyrexia in the the plasma fibrinogen were in regular use. Two mother. Very little fibrin thromboembolism was other patients had pyrexia which was due in one to encountered histologically and the questions which Arch Dis Child: first published as 10.1136/adc.42.224.401 on 1 August 1967. Downloaded from

408 J. F. Boyd are raised include: was there never very much, or statement fully (Roberts, Davies, and Bloom, 1966). was there some in the lungs which has now been This series of infants apparently either did not digested by a-fibrinolysin? Further, were the possess a fibrinolytic system, or death occurred widespread haemorrhagic manifestations part of a before the system had been mobilized to a sufficient septicaemic state, the result of action by the degree. This situation was more convincingly streptococci, or were they part of the secondary illustrated in the series of stillbirths, because some haemorrhagic state following defibrination? foetuses had died in utero and had remained there The lesions noted in Case 7 are minor and do not for up to four weeks before delivery, and still appear to be due to cardiac embarrassment. exhibited lesions. It is known that fibrinolysis can Death in Case 8 was due to cerebral and pulmon- occur in the cadaver, and especially if the body is ary haemorrhage. This would normally be attri- retained in a warm environment (Mole, 1948). buted to asphyxia associated with prolonged labour. An association between hepatic sinusoidal fibrin The site of the cerebral haemorrhage is unusual, thrombi and pulmonary hyaline membrane forma- however, and it was not associated with fracture of tion has been considered by Wade-Evans (1961, the skull or with a tear of one of the dural sinuses. 1962). My own, partly comparable, series (Boyd, Special staining reveals features which could be 1966) fails to yield similar results, but they do not attributed to fibrin thromboembolism and the invalidate one of his conclusions, namely that anoxia secondary bleeding tendency could be responsible may play some part in the initiation ofthese thrombi. for bleeding into the damaged part of the brain and Anoxia may be responsible for the release of also into the lung substance. placental thromboplastin in the first instance. In the Comparison of the distribution of fibrin thrombo- present series, 10 neonates showed both hepatic embolism in these 8 neonatal deaths, with the earlier sinusoidal fibrin thrombi as well as hyaline mem- series of 9 stillbirths (Boyd, 1966), shows that fewer branes and I have observed that the more fibrin that neonates had involvement of the liver (3 cases only, was present in the hepatic sinusoids, the less deeply compared with 7 stillbirths), but 3 neonates showed blue-black did pulmonary hyaline membranes stain lesions in the lungs compared with the stillbirths with Lieb's PTAH. The explanation may be that copyright. which failed to show any lesions there. The high when most of the circulating fibrinogen is precipi- incidence of involvement (63%) of the adrenal tated in the hepatic sinusoids, less remains in glands compares strikingly with the stillbirth series circulation to precipitate as an integral part of the where only one example was encountered. The pulmonary hyaline membranes. foetal heart had ceased for at least 1 hour before Study of the eight reported cases as well as of the delivery in the case of 4 of the 9 stillbirths. negative cases of the series suggests that newborn The part played by the process of disseminated infants may have a varying amount of circulating fibrinogen, and that the infants who exhibit the most fibrin thromboembolism in causing death is http://adc.bmj.com/ important: it was considered to have been entirely severe state of disseminated fibrin thromboembolism responsible for the deaths of Cases 1, 2,4, 5, and 8; to are those who, besides other criteria, have had a have been partly responsible for death in Cases 3 and reasonably high plasma fibrinogen level before the 7; and to have been an incidental finding in Case 6. episode of thromboembolism occurs. This high In theory, therefore, half of this series might have fibrinogen level does not appear to be a function of been saved, had the condition been known to exist foetal maturity or immaturity. and if it had been recognized clinically. There are no recognizable symptoms and clinical signs, and Summary on September 26, 2021 by guest. Protected once the haemorrhagic state ensues, the condition is liable to be mistaken for hypoprothrombinaemia of Eight neonates, dying within 48 hours of birth, the newborn, as Case 5 was. Even by invoking showed disseminated fibrin thromboembolism, a laboratory tests for prothrombin, the clinician is histological condition that is very similar to one liable to be confused because the result will likely form of maternal hypofibrinogenaemia. confirm his clinical suspicion. The difference The mothers had had more antepartum and post- between this syndrome and that due to pure partum complications than would be expected in a hypoprothrombinaemia is that disseminated fibrin series of normal neonates, and more than was thromboembolism causes depletion of all clotting encountered in a series of stillbirths showing the factors whereas only prothrombin ought to be same condition and reported elsewhere. reduced in hypoprothrombinaemia. However, when The condition is not confined to any particular dealing with neonates of confirmed or doubtful period of gestation, and one twin can show the maturity, the clinician can never accept the above condition while the other does not. The incidence Arch Dis Child: first published as 10.1136/adc.42.224.401 on 1 August 1967. Downloaded from

Disseminated Fibrin Thromboembolism Among Neonates Dying Within 48 Hours of Birth 409 was 8 in 226 neonates dying within 48 hours of Johnstone, J. M., and McCallum, H. M. (1956). Hypofibrino- genaemia in pregnancy: report of a case. Scot. med. J., 1, 360. birth (3 5%). Lieb, E. (1948). Modified phosphotungstic acid-hematoxylin stain. Haemorrhagic manifestations may appear about Arch. Path., 45, 559. McKay, D. G., Merrill, S. J., Weiner, A. E., Hertig, A. T., and 12 hours after birth and may be confused with Reid, D. E. (1953). The pathologic anatomy of eclampsia, hypoprothrombinaemia of the newborn. The bilateral renal cortical necrosis, pituitary necrosis, and other infant acute fatal complications of pregnancy, and its possible relation- usually shows some difficulty in establishing ship to the generalized Shwartzman phenomenon. Amer. J. respiration at birth. Obstet. Gynec., 66, 507. Merskey, C., Johnson, A. J., Pert, J. H., and Wohl, H. (1964). Pathogenesis of fibrinolysis in defibrination syndrome: effect of I am grateful to Professor D. F. Cappell, Dr. A. D. T. heparin administration. Blood, 24, 701. Govan, Dr. A. D. MacDonald, and Dr. R. A. Rankin Mole, R. H. (1948). Fibrinolysin and the fluidity of the blood for giving me many facilities for carrying out this work; post mortem. J. Path. Bact., 60, 413. and to the obstetricians and paediatricians for permission Phillips, L. L. (1959). Etiology of afibrinogenemia; fibrinogenolytic to extract the relevant case records. Mr. N. L. Russell, and fibrinolytic phenomena. Ann. N. Y. Acad. Sci., 75, 676. Mr. D. Johnstone, and Miss M. Malcolm (Mrs. Roberts, J. T., Davies, A. J., and Bloom A. L. (1966). Coagulation Hamilton) carried out the technical work. The studies in massive pulmonary haemorrhage of the newborn. J. clin. Path., 19, 334. photographs were made by Mr. G. Kerr. Sanerkin, N. G., Edwards, P., and Jacobs, J. (1966). Pulmonary thromboembolic phenomena in the newborn. J. Path. Bact., 91, 569. REFERENCES Schneider, C. L. (1950). Complications of late pregnancy in Boyd, J. F. (1957). The possible role of the placenta in hypo- rabbits induced by experimental placental trauma. Surg. fibrinogenemia. Surg. Gynec. Obstet., 105, 741. Gynec. Obstet., 90, 613. - (1958). Two possible cases of acquired hypofibrinogenemia (1951). 'Fibrin embolism' (disseminated intravascular in the newborn. ibid., 106, 176. coagulation) with defibrination as one of the end results during (1965). Disseminated fibrin thrombo-embolism among placenta abruptio. ibid., 92, 27. stillbirths and neonatal deaths. J. Path. Bact., 90, 53. (1959). Etiology of fibrinopenia: fibrination defibrination. (1966). Disseminated fibrin thrombo-embolism in stillbirths: Ann. N.Y. Acad. Sci., 75, 634. a histological picture similar to one form of maternal hypo- Scott, J. M. (1965). Iatrogenic lesions in babies following umbilical fibrinogenaemia. J. Obstet. Gynaec. Brit. Cwlth, 73, 629. vein catheterization. Arch. Dis. Childh., 40, 426. Butler, N. R., and Bonham, D. G. (1963). Perinatal Mortality. Sherry, S., Fletcher, A. P., and Alkjaersig, N. (1959). Fibrinolysis The First Report of the 1958 British Perinatal Mortality Survey. and fibrinolytic activity in man. Physiol. Rev., 39, 343. Livingstone, Edinburgh and London. Stefanini, M. (1958). Fibrinolysis as a mechanism of hemorrhagic Cruickshank, J. N. (1930). Child life investigations. The causes tendency. Acta haemat. (Basel), 20, 85. copyright. of neonatal death. Spec. Rep. Ser. med. Res. Coun. (Lond.), No. 145. -, and Turpini, R. A. (1959). Fibrinogenopenic accident of Dieckmann, W. J. (1936). Blood chemistry and renal function in pregnancy and delivery: a syndrome with multiple etiological abruptio placentae. Amer. J. Obstet. Gynec., 31, 734. mechanisms. Ann. N.Y. Acad. Sci., 75, 601. Emery, J. L. (1953). Pulmonary thrombosis and its association Wade-Evans, T. (1961). Thrombi in the hepatic sinusoids of the with unexpected death in childhood. Arch. Dis. Childh., 28, newborn and their relation to pulmonary hyaline membrane 187. formation. Arch. Dis. Childh., 36, 286. Flute, P. T. (1964). Haemorrhage and fibrinolysis. Proc. roy. - (1962). The formation of pulmonary hyaline membranes in Soc. Med., 57, 603. the newborn baby. ibid., 37, 470. Groniowski, J. (1963). Thrombotic arteriolar lesions in lungs of Zuschlag, E. (1947). Infarction of the lung in children. Amer. J3. newborn. Arch. Path., 75, 144. Dis. Child., 74, 399. http://adc.bmj.com/ on September 26, 2021 by guest. Protected