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Hoirisch-Clapauch S. The Impact of Emotional Responses on Female Reproduction: Fibrinolysis in the Spotlight. Semin Thromb Hemost 2024. [PMID: 39029520 DOI: 10.1055/s-0044-1788324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2024]
Abstract
Fibrinolytic enzymes modify various substrates required for tissue remodeling, playing a crucial role in mechanisms underlying resilience, reward processing, ovulation, embryo implantation, and placentation. Individuals with low resilience and reduced reward responsiveness, when exposed to chronic stress, are at increased risk of experiencing a range of negative emotions. Chronic anxiety and melancholia are examples of negative emotions associated with hypercortisolism, while fear and atypical depression are characterized by systemic inflammation. Both cortisol and inflammatory cytokines stimulate the production of plasminogen activator inhibitor-1 (PAI-1), a potent fibrinolysis inhibitor. Chronic anxiety, fear, and depression are among the many hypofibrinolytic conditions increasing the risk of oligo-anovulation, miscarriage, fetal growth restriction, and preeclampsia. Although significant, the impact of negative emotions on implantation is not as obvious as on ovulation or placentation. Other hypofibrinolytic conditions that may affect female reproduction through mechanisms dependent or independent of PAI-1 include metabolic disturbances (e.g., due to consumption of highly palatable foods, often used to alleviate negative affect), inflammation, hyperhomocysteinemia, hypothyroidism, hypercortisolism, antiphospholipid antibodies, and the 4G allele of the PAI-1 gene. Benzodiazepines and antidepressants should be used with caution in the first trimester as this combination may cause malformations. Also, selective serotonin reuptake inhibitors have fibrinolytic properties that increase the risk of bleeding after surgical procedures. Psychological interventions, especially group therapy, are effective in the prevention of reproductive disorders. Controlled trials are needed to test the hypothesis that female reproductive health depends on psychological well-being, a balanced diet and physical activity, suppression of inflammation and autoantibodies, and homocysteine and hormonal homeostasis.
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Affiliation(s)
- Silvia Hoirisch-Clapauch
- Hematology Department, Vascular Medicine, Hospital Federal dos Servidores do Estado, Rio de Janeiro, Brazil
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Kontovazainitis CG, Gialamprinou D, Theodoridis T, Mitsiakos G. Hemostasis in Pre-Eclamptic Women and Their Offspring: Current Knowledge and Hemostasis Assessment with Viscoelastic Tests. Diagnostics (Basel) 2024; 14:347. [PMID: 38337863 PMCID: PMC10855316 DOI: 10.3390/diagnostics14030347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/22/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
Pre-eclampsia (PE) is a placenta-mediated disease and remains a major cause of maternal and neonatal mortality and morbidity. As PE develops, normal pregnancy's hypercoagulable balance is disrupted, leading to platelet hyperactivation, excessive pathological hypercoagulability, and perturbed fibrinolysis. This narrative review aims to summarize the current knowledge regarding hemostasis in PE compared with healthy gestation and the potential effects of maternal PE on neonatal hemostasis. Finally, it aims to discuss hemostasis assessments for normal pregnancies and PE, emphasizing the role of viscoelastic tests, namely, thromboelastography (TEG) and thromboelastometry (ROTEM), for monitoring PE-associated hemostatic alterations. The use of TEG/ROTEM for assessing the hemostatic profile of PE women has been little considered, even though conventional coagulation tests (CCTs) have not helped to monitor hemostasis in this population. Compared with normal pregnancy, TEG/ROTEM in PE reveals an excessive hypercoagulability analogous with the severity of the disease, characterized by higher-stability fibrin clots. The TEG/ROTEM parameters can reflect PE severity and may be used for monitoring and as predictive markers for the disease.
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Affiliation(s)
- Christos-Georgios Kontovazainitis
- 2nd Neonatal Department and Neonatal Intensive Care Unit (NICU), “Papageorgiou” University Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece; (C.-G.K.); (D.G.)
| | - Dimitra Gialamprinou
- 2nd Neonatal Department and Neonatal Intensive Care Unit (NICU), “Papageorgiou” University Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece; (C.-G.K.); (D.G.)
| | - Theodoros Theodoridis
- 1st Department of Obstetrics and Gynecology, “Papageorgiou” University Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece;
| | - Georgios Mitsiakos
- 2nd Neonatal Department and Neonatal Intensive Care Unit (NICU), “Papageorgiou” University Hospital, Aristotle University of Thessaloniki, 56403 Thessaloniki, Greece; (C.-G.K.); (D.G.)
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Liew-Spilger AE, Sorg NR, Brenner TJ, Langford JH, Berquist M, Mark NM, Moore SH, Mark J, Baumgartner S, Abernathy MP. Viscoelastic Hemostatic Assays for Postpartum Hemorrhage. J Clin Med 2021; 10:3946. [PMID: 34501395 PMCID: PMC8432102 DOI: 10.3390/jcm10173946] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 12/15/2022] Open
Abstract
This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.
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Affiliation(s)
- Alyson E. Liew-Spilger
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA;
| | - Nikki R. Sorg
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Toby J. Brenner
- Division of Natural Sciences, Indiana Wesleyan University, Marion, IN 46953, USA;
| | - Jack H. Langford
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN 46208, USA;
| | - Margaret Berquist
- College of Science, University of Notre Dame, Notre Dame, IN 46556, USA;
| | - Natalie M. Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Spencer H. Moore
- Marian University College of Osteopathic Medicine, Indianapolis, IN 46222, USA;
| | - Julie Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Sara Baumgartner
- Department of Obstetrics and Gynecology, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Mary P. Abernathy
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
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Xie X, Wang M, Lu Y, Zeng J, Wang J, Zhang C, Zhu H, Song Y, Han L, Liu Y, Zhang J, Li L, Chen L, Zhai Y, Cao Z. Thromboelastography (TEG) in normal pregnancy and its diagnostic efficacy in patients with gestational hypertension, gestational diabetes mellitus, or preeclampsia. J Clin Lab Anal 2021; 35:e23623. [PMID: 33067885 PMCID: PMC7891543 DOI: 10.1002/jcla.23623] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Thromboelastography (TEG) provides global assessment of hemostatic function and has been recommended to monitor potential coagulopathies during pregnancy in which hypercoagulable state is favored. In present study, we established the reference intervals (RIs) of the TEG parameters (R, K, MA, and α-angle) with Chinese pregnant women of third trimester. In addition, we examined the diagnostic efficacies of the TEG parameters in the patients diagnosed of gestational hypertension (GH), gestational diabetes mellitus (GDM), or preeclampsia (PE). METHODS With specified including and excluding criteria, non-pregnant controls, healthy pregnant women, and pregnant women with GH, GDM, or PE had their venous blood drawn at Beijing Obstetrics and Gynecology Hospital, followed by TEG tests performed in the clinical laboratory. RESULTS The RIs determined with the healthy pregnant women (in third trimester) for R, K, MA, and α-angle were 4.0-7.7, 1.2-3.2, 51.9-70.1, and 41.4-74.4, respectively. When compared with the healthy pregnancy group, the K value was significantly decreased in GH patients but increased in PE patients; MA was significantly lower in the PE group. In the receiver operating characteristic curve (ROC) analyses, K value was able to efficiently distinguish normal pregnancy from the GH patients, with an AUC of 0.86 which is far better than those of R (AUC = 0.57) and MA (AUC = 0.56). For the PE patients, the AUC of MA (0.69) was significantly greater than that of R (0.50). CONCLUSIONS Thromboelastography may provide more accurate experimental basis for monitoring coagulation functions especially in pregnant women with complications of GH and PE.
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Affiliation(s)
- Xin Xie
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Meng Wang
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Yifan Lu
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Jiazi Zeng
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Jing Wang
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Chunhong Zhang
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Hongyuan Zhu
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Yujie Song
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Lican Han
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Ying Liu
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Jingnan Zhang
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Lei Li
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Lu Chen
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Yanhong Zhai
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
| | - Zheng Cao
- Department of Laboratory MedicineBeijing Obstetrics and Gynecology HospitalCapital Medical UniversityBeijingChina
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Amgalan A, Allen T, Othman M, Ahmadzia HK. Systematic review of viscoelastic testing (TEG/ROTEM) in obstetrics and recommendations from the women's SSC of the ISTH. J Thromb Haemost 2020; 18:1813-1838. [PMID: 32356929 DOI: 10.1111/jth.14882] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/13/2020] [Accepted: 04/24/2020] [Indexed: 12/13/2022]
Abstract
Thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are point-of-care viscoelastic devices that use whole blood samples to assess coagulation and fibrinolysis. These devices have been studied extensively in cardiac surgery, but there is limited robust evidence supporting its use in obstetrics. The hesitancy toward its routine use in obstetrics may be due to the current lack of randomized controlled trials and large observational studies. The study aims to systematically review studies that investigated TEG/ROTEM use in pregnancy or peripartum, and to provide recommendations for future studies to fill current research gaps. We performed a systematic review of studies on viscoelastic testing in obstetrics. Included studies were original research, used TEG or ROTEM during pregnancy or peripartum, and published in English. Ninety-three studies, spanning 31 years from 1989 to 2020 and with a total of 32,817 participants, were included. Sixty-two (66.7%) of the studies used TEG and 31 (33.3%) used ROTEM. To date, there are a total of two randomized controlled trials on TEG/ROTEM use in obstetrics. ROTEM may be used to guide transfusion therapy for postpartum hemorrhage. TEG and ROTEM can detect the hypercoagulable changes associated with pregnancy. Variability between study protocols and results suggests the need for future large prospective high-quality studies with standardized protocols to investigate the utility of TEG/ROTEM in assessing risk for thrombosis and hemorrhage as well as in guiding prophylaxis and treatment in obstetric patients. This review identifies the gaps and provides concrete recommendations for future studies to fill those gaps.
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Affiliation(s)
| | - Terrence Allen
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St. Lawrence College, Kingston, ON, Canada
| | - Homa K Ahmadzia
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Kelliher S, Maguire PB, Szklanna PB, Weiss L, Ewins K, O'Doherty R, Angelov D, Ní Áinle F, Kevane B. Pathophysiology of the Venous Thromboembolism Risk in Preeclampsia. Hamostaseologie 2020; 40:594-604. [PMID: 32450576 DOI: 10.1055/a-1162-3905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Preeclampsia complicates up to 8% of pregnancies and is a leading cause of fetomaternal morbidity andmortality. Treatment options are limited, with supportive care and delivery of the placenta representing the cornerstone of current management strategies. Derangements in blood coagulation are wellrecognised in this disorder and appear to favour an increased risk of venous thromboembolism among affected women. This risk appears to be most significant in the postpartum period. The mechanisms underlying this increased thrombosis risk remain to be fully elucidated although increased expression of procoagulant factors, endothelial dysfunction, attenuation of endogenous anticoagulant activity and increased platelet activity have been implicated in the prothrombotic tendency. Preeclampsia is also occasionally complicated by life-threatening haemorrhagic events and current evidence suggests that in some severe manifestations of this disease a coagulopathy with a clinical bleeding tendency may be the predominant haemostatic abnormality. Identifying affected women at significant risk of thrombosis and managing the competing thrombotic and haemorrhagic risks continue to be a significant clinical challenge. Derangements in blood coagulation are also implicated in the pathogenesis of preeclampsia; however, the role of antiplatelet or anticoagulant drugs in the prevention and treatment of this disorder remains a source of considerable debate. In addition, the potential role of specific haemostatic markers as diagnostic or screening tools for preeclampsia has also yet to be determined. Further characterisation of the underlying molecular mechanisms would likely be of major translational relevance and could provide insights into the pathogenesis of this disease as well as the associated haemostatic dysfunction.
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Affiliation(s)
- Sarah Kelliher
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland.,Irish Network for VTE Research (INViTE), Dublin, Ireland
| | - Patricia B Maguire
- Irish Network for VTE Research (INViTE), Dublin, Ireland.,UCD Conway SPHERE Research Group, Dublin, Ireland.,School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Paulina B Szklanna
- UCD Conway SPHERE Research Group, Dublin, Ireland.,School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Luisa Weiss
- UCD Conway SPHERE Research Group, Dublin, Ireland.,School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Karl Ewins
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland.,Irish Network for VTE Research (INViTE), Dublin, Ireland.,Department of Haematology, Rotunda Hospital, Dublin, Ireland
| | - Roseann O'Doherty
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Daniel Angelov
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland.,Irish Network for VTE Research (INViTE), Dublin, Ireland.,UCD Conway SPHERE Research Group, Dublin, Ireland.,Department of Haematology, Rotunda Hospital, Dublin, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland
| | - Barry Kevane
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland.,Irish Network for VTE Research (INViTE), Dublin, Ireland.,UCD Conway SPHERE Research Group, Dublin, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland
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Yang J, Yang H, Tang A, Liu X, Sun X, Ma J, Zhao J, Ming L. Trimester-specific reference intervals for kaolin-activated thromboelastography (TEG®) in healthy Chinese pregnant women. Thromb Res 2019; 184:81-85. [DOI: 10.1016/j.thromres.2019.09.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/06/2019] [Accepted: 09/28/2019] [Indexed: 12/29/2022]
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Wang P, Yang H, Wang G, Tian J. Predictive value of thromboelastography parameters combined with antithrombin III and D-Dimer in patients with recurrent spontaneous abortion. Am J Reprod Immunol 2019; 82:e13165. [PMID: 31283067 DOI: 10.1111/aji.13165] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 06/02/2019] [Accepted: 06/22/2019] [Indexed: 12/29/2022] Open
Abstract
PROBLEM To investigate the value of thromboelastography (TEG) combined with antithrombin III (AT-III) and D-Dimer in predicting the occurrence of recurrent spontaneous abortion (RSA). METHOD OF STUDY One hundred and five RSA patients and 40 fertile women were enrolled. The subjects were subjected into four groups: group 1 (40 fertile women), group 2 (58 women with 2 abortions), group 3 (30 women with 3 abortions), and group 4 (17 women with four abortions). TEG was conducted on all subjects. Clotting time, reaction time, angle degree, coagulation index, and maximum amplitude were measured. The levels AT-III, D-Dimer, platelet counts, and fibrinogen concentration were determined. The ROC curve analysis was done using MedCalc software to analyse the diagnosis accuracy of the parameters of interest and the combined approach. RESULTS The AT-III level in all group 4 was significantly lower than in fertile women. The D-Dimer concentration, platelet count, and MA in patients with four prior abortions were significantly higher than the other three groups. CI and fibrinogen concentration in patients with four prior pregnancy losses were significantly higher than group 1. The ROC curves suggested that combined use of CI, MA, AT-III, and D-Dimer was with the highest accuracy 92.8%, thus predicting the most accurate diagnosis for RSA. CONCLUSION Recurrent spontaneous abortion is associated with abnormal coagulation and anticoagulation. TEG combined with detection of AT-III and D-Dimer levels can distinguish patient with RSA from those with normal fertility and highly possibly predict the occurrence of RSA.
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Affiliation(s)
- Ping Wang
- Department of Reproductive Medicine, Dezhou People's Hospital, Dezhou, China
| | - Hongjun Yang
- Department of Reproductive Medicine, Dezhou People's Hospital, Dezhou, China
| | - Guoying Wang
- Department of Reproductive Medicine, Dezhou People's Hospital, Dezhou, China
| | - Jun Tian
- Inspection Section, Dezhou People's Hospital, Dezhou, China
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