ORIGINAL ARTICLE

Effect of lactation suppressants mechanism

A. M.

on

the

coagulation
et

Wodzicki, A.R.T.,

b.a.

and A. T.

Coopland,*

m.d.,

f.r.c.s.[c], Winnipeg, Man.

sur les sans 10 en

on the coagulation mechanism of lactation suppressants was determined by comparing observations on a group of untreated women and two other groups, one receiving Vallestril (methallenestril 20 mg) and the other Ortho-Novum 5 (5 mg norethindrone and 0.075 mg mestranol). Blood was drawn on the first, fourth and tenth days post partum. Patients given Ortho-Novum 5 showed a continued significant elevation of levels of factors VIII and IX for the duration of the study, and the partial thromboplastin time reflected this increase on days 4 and 10. Vallestril appeared to have the same effect on factors VIII and IX, although to a lesser, nonsignificant degree. In addition, the day 10 levels of fibrinogen and factors Vll and X, as well as platelet adhesiveness, of the untreated group were lower than those of the groups undergoing treatment, although the medication had been discontinued five days previously. However, this difference was not statistically

Summary: The effect

que le groupe

facteurs VIII et X, mais a un degre moindre signification reelle. En outre, les niveaux du jour fibrinogene et en facteurs Vll et X, de meme I'adhesivite plaquettaire, etaient inferieure chez
non

traite bien que la medication att ete

interrompue cinq jours auparavant chez les sujets traites. Cette difference n'etait pas cependant sensible au point de vue statistique.
Comme les preuves s'accumulent
a

I'effet que la maladie

thromboembolique est plus frequente durant l'etat puerp6ral, il est peut-etre deraisonnable de donner des medicaments qui modifient le systeme de coagulation plasmatique, tels ceux qu'on vient de decrire, a des sujets qui sont deja en etat d'hypercoagulation.
The use of estrogen for lactation suppression has become almost traditional in North American obstetric practice. Although the necessity and efficacy of this treatment have been widely debated, its safety had never been seriously questioned until Daniel, Campbell and Turnbull1 suggested that the use of diethylstilbestrol for this purpose was associated with a significant increase in the incidence of puerperal thromboembolic disorders. The following year Jeffcoate et aP studied the incidence of thromboembolic disease in puerperal patients and con sidered that, although estrogen therapy may be causally related, other factors such as age, parity, operative delivery, obesity, and a past history of thromboembolic episodes were of greater etiological importance. He also noted that the incidence of puerperal thromboembolism has not increased in recent years despite a progressive decrease in breast

significant.

In view of the growing evidence of the increased incidence of thromboembolic disease during the puerperium, it is perhaps unwise to give drugs that cause changes in the plasma coagulation system, such as those we have described, to patients who are already in a

hypercoagulable

state.
sur

Resume: Les effets des inhibiteurs de la lactation le mdcanisme de la coagulation

Nous avons determine I'effet des inhibiteurs de la lactation sur le mecanisme de la coagulation en comparant nos observations sur un groupe de femmes ne recevant pas ces agents suppresseurs a celles de deux autres groupes, I'un recevant le Vallestril (20 mg de methallenestril) et I'autre recevant I'Ortho-Novum 5 (5 mg de norethindrone et 0.075 mg de mestranol). Du sang a ete preleve le premier, le quatrieme et le dixieme jours post partum. Chez les sujets recevant I'Ortho-Novum 5, on a note une nette etevation continue des niveaux des facteurs VIII et IX pendant toute la duree de l'etude. Le temps de thromboplastine partieHe refletait cette augmentation aux jours 4 et 10. Le Vallestril a eu le meme effet
?Associate Professor, Department of Obstetrics and Gynaecology, University of Manitoba, Winnipeg Supported by Health and Welfare Canada grant no. 606-7-188 Reprint requests to: Dr. A. T. Coopland, S-025, Women's Centre, 735 Notre Dame Ave., Winnipeg, Man. R3E 0L8

feeding. Although a relationship between increased levels of blood coagulation factors and thromboembolic disease has not yet been firmly established, the significantly increased levels of factor IX which Daniel's group3 was able to demonstrate in puerperal patients treated with diethylstilbes trol cannot be disregarded, particularly in view of the evidence given by Wessler and Reimer4 that only factors IX, XI and XII are essential for the development of seruminduced venous thrombosis. A further report5 of increased factor IX levels associated with the use of estrogen for lactation suppression corroborates Daniel's findings, but to date no thorough coagulation studies on such patients have been reported. Accordingly, we have carried out an extensive coagula tion profile on three groups of puerperal women. Those
CMA

JOURNAL/APRIL 20, 1974/VOL. 110 <H>5

in the first group served as controls. The other two groups composed of patients receiving either Vallestril (methallenestril 20 mg) or Ortho-Novum 5 (5 mg nore thindrone and 0.075 mg mestranol) for the purpose of suppressing lactation.
were

Materials and methods Patients ranged in age from 15 to 41 years. All patients less than 33 years of age except for two women in the control group who were aged 39 and 41. There were five patients in the control group and four in the OrthoNovum group with four children or more. The remainder of the patients in these two groups had fewer than four children. All except one of the patients in the Vallestril group had fewer than four children. All of the mothers had had a normal labour, delivery and puerperium. There was no history of thromboembolic episodes and no such disorders were encountered during the study. Three groups of women were studied: (1) 20 women who were receiving no drugs for lactation suppression, and who may or may not have been breast feeding; (2) 21 patients in whom lactation was suppressed by the use of Ortho-Novum 5, 10 mg orally tid for five days; and (3) 24 patients in whom lactation was suppressed by the use of Vallestril, 20 mg orally bid for five days. The patients were assigned randomly to the three groups and
were

entered in the study at different times. Both drug regimens were begun within 12 hours after delivery. Unfortunately, many mothers did not return for their 10-day follow-up and this accounts for the low number of subjects tested on the 10th day. Blood samples were taken on the first, fourth and tenth days post partum. Nine ml of venous blood was transferred to tubes containing 1 ml of acid citrate. Plasma was separated within one hour by centrifugation for 10 minutes at 10,000 r.p.m. at 4C and frozen at .20C. Platelets were counted by the direct method and platelet adhesiveness was measured as described by Salzman.6 The bleeding time was determined by the Ivy method. The partial thromboplastin time was determined by the onestage method of Hunter and Allensworth7 using 0.7% Celite in 0.85% NaCl (Ortho Research Foundation, Raritan, New Jersey) and 1/1000 cephalin extracted in our laboratory from human brain; the cephalin was diluted with veronal buffer. The prothrombin time estimation was carried out by the one-stage method using brain thrombo plastin (Ortho Diagnostics, Don Mills, Ont.). The thrombin time was determined by the method of Fletcher, Alkjaersig and Sherry.8 Factors VIII and IX were measured by the one-stage method described by Niemetz and Nossel.9 The factor-VIII-deficient and factor-IX-deficient plasmas used in our study were of one lot number each. Factors VII and X were assayed by the method of Eichelberger,10 using
were

Table

I.Bleeding time, platelet count and platelet adhesiveness

in the three groups of

subjects

Figures in parentheses represent number of subjects whose blood samples were tested. ?Significant difference between Ortho-Novum and control values and between Ortho-Novum and Vallestril values.

Ortho-Novum fSignificant difference between values on 4and control values and between Ortho-Novum and Vallestril values. days and 1 for (Significant difference between Ortho-Novum and control patients receiving Ortho-Novum. values. IT Significant difference between
906 CMA JOURNAL/APRIL 20, 1974/VOL. 110

?Normal values: 35 to 45 seconds

veronal buffer as a diluent in the standard curve and by factor-X-deficient substrate made by Diagen Diag nostic Reagents Ltd., Thame, Oxon., England. The fibri nogen level was measured using the method described by Astrup, Brakman and Nissen.11

using

265-1
P--

Results

24<H
215H
Control -Ortho-Novum -Vallestril

Table I shows that the platelet counts of the Ortho-Novum group were significantly lower than those of the other two groups on days 1, 4 and 10 (P < 0.05). On day 4 the mean Ortho-Novum partial thromboplastin time was 32.2 see, significantly faster than the day 1 mean value of 36.0 see (P < 0.05), and the day 4 mean value of the control and Vallestril groups, 37.4 see and 37.1 see, respectively (P < 0.01) (Table II and Fig. 1). As seen in Table II and Fig. 2, the mean factor VIII level when Ortho-Novum was given rose significantly from 209.7% on day 1 to 254.8% on day 4 (P < 0.05). This day 4 value was also highly significant when compared with the day 4 control value of 153.3% and the day 4 Vallestril value of 192.7% (P < 0.01). On day 10 the mean factor VIII level of the Ortho-Novum group was 252.5%, significantly higher than the control value of 92.4% (P < 0.01) and the Vallestril value of 145.2% (P < 0.05). The Vallestril mean values were higher than those of the control on all three days, but the differences were not
Table II and Fig. 3 illustrate the highly significant difference in factor IX levels on day 4 between the control subjects and the patients treated with Ortho-Novum (P < 0.01). The mean control value was 132.6% and the mean Ortho-Novum value 210.4%. As seen with factor VIII the Ortho-Novum day 4 mean value was also significantly higher than that for day 1, 172.6% (P < 0.05).

.*

*>
<

190~

165-1
14(H
115H

significant.

90.r i
Days

t-1 4 10 Post Partum

25-i
30H

-Control -Ortho-Novum -Vallestril

FIG. 2.Mean factor VIII values in the three groups of on the three test days.

subjects

215-1

19(H -Control
U

-Ortho-Novum

.= o

35H

-Vallestril

<

165"

E
*

40H
451
"1

140-

115H

10

90-

.i

10

FIG. 1.Mean partial thromboplastin time in the three groups of subjects on the three test days.

Days

Post Partum

FIG. 3.Mean factor DC values in the three groups of subjects on the three test days. CMA JOURNAL/APRIL 20, 1974/VOL. 110 907

Days

Post Partum

day 10 the Ortho-Novum mean value of 202.6% was significantly higher than the Vallestril as well as the control values, 132.2 and 99.4%, respectively (P < 0.05). All three Vallestril factor IX mean levels were higher than those of the control but, as with factor VIII, the dif ferences were not significant. Table III indicates that on days 1 and 4 mothers treated with Ortho-Novum showed a prothrombin time which was significantly longer than that shown by those treated with Vallestril (P < 0.01). The thrombin time of the Ortho-Novum patients was consistently longer than that for the two other groups on all three days, but only on days 1 and 4 were these differences significant (P < 0.01) (Table IV). There was no significant difference in bleeding time, platelet adhesiveness and levels of fibrinogen and factors VII and X between any of the groups at any time during the study, although the mothers treated with Ortho-Novum tended to have a lower platelet adhesiveness and lower levels of fibrinogen and factors VII and X on days 1 and 4
On
than the* other two groups (Tables I, III and IV).

Discussion
The fibrinogen and factors VIII and IX levels of our control patients on days 1 and 4 post partum compared favourably with those recorded by Nilsson and Kullander,12 but their mean prothrombin and proconvertin values were lower than our mean values for factors VII and X for those same days. Our control day 10 fibrinogen mean value was similar to that estimated by Bonnar, McNicol and Douglas13 for one week post partum. The day 10 factors VII and X mean level of our control mothers was close to the value found by Davidson and Tomlin14 who studied a group of mothers seven to ten days post partum. On the other hand, they reported a lower mean

statistically significant. The significantly longer thrombin times on days 1 and 4 of the group treated with Ortho-Novum appear to be associated with the lower fibrinogen levels, and the significantly shorter prothrombin times on days 1 and 4 of the group treated with Vallestril seem to reflect the higher levels of factors VII and X of that group. The decreased platelet counts of the Ortho-Novum group are not consistent with the rest of the study and we are unable to explain this phenom enon. Except for the Ortho-Novum group of patients the apparent rise in platelet counts on day 10 post partum is not accompanied by a significant rise in platelet adhe siveness. This is not in agreement with the findings of Wright,15 who observed maximum values for platelet num ber and adhesiveness on day 10 post partum. With the exception of bleeding time, platelet count and adhesiveness, a comparison of the results from an earlier study of the coagulation mechanism in a group of nonpregnant women pretreated with chlormadinone acetate16 with the results of the present study appears to indicate that the patients in our treated groups, and to a lesser extent the control patients, were in a state of hypercoagulability. Under the
nomenon was not

level and higher mean levels of factors VIII and IX for that same period. Our results demonstrate that patients given Ortho-Novum 5 for suppressing lactation showed a continued elevation of factors VIII and IX throughout the duration of the study. The increase in factor IX is similar to the findings of Daniel et al1 and Hakim et al.5 Vallestril appears to have the same effect on factors VIII and IX, although to a lesser degree. The partial thromboplastin time reflects the maximum increase of factors VIII and IX on days 4 and 10 in the Ortho-Novum group of patients. In addition, the day 10 levels of fibrinogen and factors VII and X of the untreated group appear to be lower than those of the groups undergoing treatment. However, this phe

fibrinogen

Table Ili.Prothrombin time and factors Vll and X assay in the three groups of subjects

?Significant difference between Ortho-Novum and Vallestril values.

Table IV.Thrombin time and fibrinogen levels in the three groups of subjects

*Normal values for two units of thrombin: 22 to 28 seconds. fSignificantdifference between Ortho-Novum and control values and between Ortho-Novum and Vallestril values. 908 CMA JOURNAL/APRIL 20, 1974/VOL. 110

conditions outlined by Jeffcoate which are reviewed in the introduction, such a state of hypercoagulability could be associated with an increased risk of thromboembolic disease. According to Owren"7 the increased adhesion-aggregation of blood platelets is more important than hypercoagulability (which he defines as characterized particularly by an increased activity of factor VIII) for initiating arterial thrombosis. With this in mind it is interesting to note that, although the values are not significant, both treated groups have a relatively high day 10 platelet adhesiveness compared with that of the control. Nevertheless, the wisdom of giving drugs which cause changes in the plasma coagulation system such as those we have described is to be questioned seriously, particularly in view of the increased incidence of thromboembolic disease during the puerperium.1' We are indebted to Miss E. Ogibowski and Mrs. L. Dunbar for their technical assistance.
References
1. DANIEL DG, CAMPBELL H, TURNBULL AC: Puerperal thromboembolism and suppression of lactation. Lancet II: 287, 1967 2. JEFFCOATE TN, MILLER J, Roos RF, et al: Puerperal thromboembolism in relation to the inhibition of lactation by oestrogen therapy. Br Med J III: 19, 1968

3. DANIEL DG, BLOOM AL, GIDDINGS JC, et al: Increased factor IX levels in puerperium during administration of diethylstilboestrol. Br Med J I: 801, 1968 4. WESSLER S, REIMER SM: The role of human coagulation factors in serum-induced thrombosis. J Clin Invest 39: 262, 1960 5. HAKIM CA, ELDER MG, HAWKINS DF: Plasma factor IX levels in patients given hexoestrol or stilboestrol to suppress lactation. Br Med J IV 82 1969 6. SALZMAN EW: Iieasurement of platelet adhesiveness: a simple in vitro technique demonstrating an abnormality in von Willebrand's disease. J Lab Clin Med 62: 724, 1963 7. HUNTER DT, ALLENSWORTH JL: Improved coagulation screening by an activated recalcification test. J CTin Pathol 20: 244, 1967 8. FLETCHER AP, ALKJAERSiG N, SHERRY S: The maintenance of a sustained thrombolytic state in man. I. Induction and effects. J Clin Invest 38: 1096, 1959 9. NIEMETZ J, NOSSEL HL: Activated coagulation factors: in vivo and in vitro studies. Br J Haematol 16: 337, 1969 10. EICHELBERGER JW JR: Laboratory methods in blood coagulation. New York, Harper, 1965, p 35 11. AsTRUP T, BRAKMAN P, NLSSEN U: The estimation of fibrinogen, A revision. Scand J Clin Lab Invest 17: 57, 1965 12. NILSSON IM, KULLANDER S: Coagulation and fibrinolytic studies during pregnancy. Acta Ostet Gynecol Scand 46: 273, 1967 13. BONNAR J, McNIcoL GP, DOUGLAS AS: Fibrinolytic enzyme system and pregnancy. Br Med J III: 387, 1969 14. DAVIDSON E, TOMLIN S: The levels of the plasma coagulation factors after trauma and childbirth. J Clin Pathol 16: 112, 1963 15. WRIGHT HP: Changes in adhesiveness of blood platelets following parturition and surgical operations. J Pathol Bacteriol 54: 461, 1942 16. WODZICKI AM, COOPLAND AT: Chlormadinone acetate and its effect on the hemostatic mechanism. Can Med Assoc J 107: 38, 1972 17. OwREN PA: Coronary thrombosis: its mechanism and possible prevention by linolenic acid. Ann Intern Med 63: 167, 1965 18. HUSNI EA, PENA LI, LENHERT AE: Thrombophlebitis in pregnancy. Am I Obstet Gynecol 97: 901, 1967

Retrospect Dirty paper money In the earlier days of the campaign against harmful germs attention was directed to the many objects which might carry them. While infectious material may certainly be carried by objects, the human carrier has recently attained greater prominence. At the end of the last century dirty money came in for its share of condemnation. At that time bacteriological investigation failed to produce evidence of any abundant distribution of micro-organisms even on the dirtiest of paper currency. There appears to be something In the composition of the printed bill that acts unfavourably to bacterial life. The flood of paper money that- has inundated Central Europe has directed attention anew to this medium of exchange as a carrier of disease. Investigations of Kiefer in Bonn indicate that the condition of the bill is no index to the degree of bacterial contamination. Mark notes in ordinary commerce may carry widely varying numbers of viable germs, though the total number is niot large. In some cases the life of pathogenic organisms on German paper money was found to be preserved for long periods. This reported contamination of our paper currency would appear to demand further investigation. It may be that German paper money owing to cheaper methods of manufacture possesses a lowered bacteriological property than paper currency in this country. Metallic money, it is noted, is far less liable to be contaminated by living micro-organisms, owing apparently to a germicidal action of metal surfaces. Can Med Assoc J 14: 331 1924

CMA JOURNAL/APRIL 20, 1974/VOL. 110 909