Objective To determine the behaviour of the coagulation variables antithrombin I11 (ATIII), protein C , thrombin/antithrombin 111 (TATIII); fibrinolytic activity, tissue plasminogen activator antigen (t-PA), plasminogen activator inhibitors (PAI) 1 and 2, and endothelial involvement by fibronectin assay in normal and pre-eclamptic pregnancies. Design Longitudinal and cross-sectional observational study.Setting Antenatal clinic and maternity hospital.Subjects Thirty-six primigravid normotensive Caucasian patients, four of whom subsequently developed pre-eclampsia, and 12 patients with established pre-eclampsia.Main outcome measures Plasma levels of PAI-1, PAI-2 and t-PA antigen were determined using an ELISA technique as were TATIII complex levels of fibronectin. ATIII and protein C plasma levels were assayed using chromogenic substrate techniques.Results PAI-1 and PAL2 antigen levels rose progressively throughout normal pregnancy. Among the established pre-eclamptic group compared with matched normal pregnancies, the PAI-2 antigen level was significantly lower (48.5 f 22.8 versus 183.5 k 37.4; P c 0*001), the PAI-I antigen level was significantly higher (122k34.4 versus 79.2f 19.7; P c 0.001), ATIII activity was significantly lower (87.8k27.1 versus 110.9+ 19.3; P c O*OOl) and TATIII complex levels were significantly higher (16.9k6.4 versus 102+ 5.9; P c 0.001). Among the four initially normotensive patients who subsequently developed pre-eclampsia, fibronectin levels were significantly elevated from as early as nine weeks of gestation.Conclusion Significantly elevated levels of PAI-1 and fibronectin occurring early in pregnancies that subsequently develop pre-eclampsia suggest that these variables may have predictive values. PAI-2 would seem to be a marker of placental function in pre-eclampsia while increased t-PA and TATIII complex levels reflect the severity of the condition.Despite recent advances in antenatal care, pre-eclampsia remains a major cause of maternal and perinatal mortality and morbidity (WHO 1987). Many centres have investigated markers for coagulation and fibrinolytic activation and for endothelial injury in order to characterise

aObjective To compare semi-quantitative visual and automated methods of urine testing with fully quantitative point of care urinalysis for the detection of significant proteinuria (0.3 g/24 hours) in pregnancy complicated by hypertension. Design A prospective comparative study.Setting A large teaching maternity hospital.Sample One hundred and seventy-one pregnant women referred to the obstetric day-care unit for assessment of newly arisen hypertension. Methods Early morning urine specimens were tested with four dipstick techniques (Multistix 8SG visual and automated and microalbumin/creatinine ratio visual and automated; Bayer, Elkhart, USA) as well as a fully quantitative measure of the microalbumin creatinine ratio with the DCA 2000 (a point of care assay for albumin; Bayer). These results were compared to a 24-hour urine protein measurement and measures of diagnostic accuracy/prediction are reported. Main outcome measures Significant proteinuria (!0.3 g/24 hours) measured by laboratory assay.Results Automated dipstick urinalysis using the Clinitek 50 has significantly better predictive values for significant proteinuria (LR þ 4.27, 95% CI 2.78 to 6.56; LR À 0.225, 95% CI 0.14 to 0.37) than conventional visual dipstick urinalysis (LR þ 2.27, 95% CI 1.47 to 3.51; LR À 0.635, 95% CI 0.49 to 0.82). Dipstick microalbumin/creatinine ratio testing did not improve overall detection rates with automated or visual testing. Fully quantitative point of care measurement of albumin/creatinine ratio (ACR) was significantly better than any dipstick technique (LR þ 14.6, 95% CI 6.74 to 31.8; LR À 0.069, 95% CI 0.030 to 0.16).Conclusions This study confirms that in pregnancy automated dipstick urinalysis is a more accurate screening test for the detection of proteinuria than visual testing. ACR testing can offer a significant improvement over conventional urinalysis if a fully quantitative method of detection is employed that uses pregnancy-specific thresholds. Dipstick assessment of ACR does not improve the detection rate of significant proteinuria.

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