Management of Venous Thromboembolism in Pregnancy

Spontaneous subcapsular hepatic hematoma in pregnant patients

Spontaneous subcapsular hepatic hematoma (SSHH) with or without previous history of preeclampsia and/or HELLP syndrome represents a very rare pathological condition in pregnancy and postpartum, (1/45,000-1/225,000 pregnancies). Its importance for the anesthesiologist lays in its association with high morbidity and mortality for the mother (60-86%, 39%) and newborn (42%). After a high clinical suspicion, the certainty clinical diagnosis is settled by different imaging techniques. However, in most cases the diagnosis of SSHH is a casual intraoperative finding associated to a maternal or foetal compromise. Nowadays the obstetric and anaesthetic management of a SSHH is not standardized and depends on its integrity, hemodynamic stability and the gestational period when diagnosed. The possibility of an acute critic haemorrhage with necessity of massive transfusion, makes advisable to provide updated protocols for the treatment of obstetric hemorrhage, adapting them to the clinical peculiarities of these patients. After the acute phase, close attention should be kept on thromboembolic complications.

An update on teratogens for pediatric healthcare providers

PURPOSE OF REVIEW

To review updates regarding teratogens and give pediatric healthcare providers insight into the prevention of teratogenic exposures.

RECENT FINDINGS

Application of the principles of teratology can help to assess the potential for exposures to be teratogenic. Identification of Zika virus as a teratogen, the most recent teratogenic agent identified, allowed public health measures to be put in place to mitigate its spread. Risk management strategies for teratogenic medications have resulted in a decrease but often not elimination of prenatal exposures. The failure to include pregnant persons in clinical trials results in their being less likely to receive needed medications and vaccines in a timely manner.

SUMMARY

Pediatricians play an important role in the prevention of teratogenic exposures. Ensuring optimal management of patients with chronic illnesses that might increase their risk of birth defects during pregnancy due to the illness itself or its treatment is essential. For patients with pregnancy potential who are on teratogenic medications, ensuring effective contraception is also important. Inclusion of pregnant persons in clinical trials and research studies will be critical to advancing our knowledge of the safety of medications and other exposures during pregnancy.

Risk factors, diagnosis and management of venous thromboembolic disease in pregnancy

Venous thromboembolism (VTE) in pregnancy is a leading cause of maternal morbidity and mortality. However, despite the significant associated clinical burden and potentially devastating societal impact, there is still a paucity of data surrounding its prevention and management. Consequently, international guideline recommendations vary widely. Exclusion of pregnant women from clinical trials in the past has contributed to knowledge gaps. However, recently published and ongoing studies demonstrate that excellent clinical trials in pregnancy are achievable. This review will discuss prevention, diagnosis and treatment of VTE in pregnancy, and will also explore priorities for future research.

Venous thromboembolism in pregnancy is a leading cause of maternal morbidity and mortality. However, individualised clinical risk assessment and recent advances in clinical prediction rules for pulmonary embolism have the potential to improve management.https://bit.ly/3mjtHg2

Endovascular Therapy for the Management of Acute Ilio-femoral Deep Vein Thrombosis

Ilio-femoral deep vein thrombosis (DVT) has a high rate of long-term morbidity in the form of the postthrombotic syndrome (PTS). Therefore, management of acute thrombosis should not only focus on the prevention of acute complications such as propagation or embolisation of the initial clot but also on preventing recurrent thrombosis and PTS. Contemporary catheter-based treatments of deep vein thrombosis have proven to be safe and effective in selected patients. Current guidelines recommend medical therapy with anticoagulation alone for all but the most severe, limb-threatening thrombosis. They additionally allow for consideration of endovascular catheter-based treatment in selected patients with acute proximal ilio-femoral DVT and low risk of bleeding complications to prevent PTS. 

Imaging-guided, catheter-based endovascular therapy has been used in selected patients to alleviate these sequelae, but important questions remain about their optimal use. In this article, we review the available evidence and summarize the rationale for use of catheter-based therapy in specific patient groups with acute iliofemoral DVT.

Pulmonary thromboembolism during pregnancy and puerperium: Comparison of survival and death cases

AIM

In Japan, the frequency of maternal deaths due to obstetric hemorrhage has been decreasing in the last decade, while that resulting from other causes such as pulmonary thromboembolism (PTE) was consistent. To help reduce maternal deaths due to PTE, we investigated PTE during pregnancy and puerperium and compared the survival and death cases, and aimed to find out life and death factors.

METHODS

This study was a retrospective analysis based on a clinical chart review in 407 maternal and perinatal centers. We compared the survival and death cases of PTE during pregnancy and puerperium from 2013 to 2017.

RESULTS

In PTE during pregnancy, the survival cases underwent significantly earlier diagnoses than the death cases, and thromboprophylaxis was performed in most of both the survival and death cases of PTE during puerperium according to the existing Japanese guidelines; however, only one fourth of the total cases underwent anticoagulation to prevent venous thromboembolism (VTE).

CONCLUSIONS

Early diagnosis of PTE in suspected cases was associated with better survival during pregnancy.

Pulmonary Embolism in the Intensive Care Unit: Therapy in Subpopulations

The optimal management of a submassive or massive pulmonary embolism (PE) during pregnancy is unclear because of a lack of large clinical trials. Evaluation of the patient who may be a candidate for more aggressive therapy includes the use of biomarkers and echocardiogram for risk stratification. PE Response teams (PERTs) have gained increasing acceptance by the medical community and are being implemented in hospitals in the United States and worldwide. PERTs bring together a team of specialists from different disciplines to enhance decision-making in the patient with acute submassive and massive PE.

Management of postpartum pulmonary embolism combined with retained placenta accreta: A case report

RATIONALE

Retained placenta accreta is an increasing obstetric problem in recent years, and pulmonary embolism (PE) during pregnancy and the postpartum period is a vital condition, but lack of standard therapy guidelines. This report describes a case of postpartum PE combined with retained placenta accreta.

PATIENT CONCERNS

A 27-year-old woman presenting with fever and dyspnea after delivery was admitted to our hospital with retained placenta accreta.

DIAGNOSES

The patient was diagnosed with the infection, postpartum PE, and residual placenta.

INTERVENTIONS

The antibiotics and low molecular weight heparin were initially started to cure the infection and control PE. Mifepristone was then used to promote the necrosis of residual placenta while long-term use of warfarin was served as continuous anticoagulant therapy. Hysteroscopic resection of retained placenta was not performed until thrombi had been almost disappeared after more than 2 months of anticoagulation therapy.

OUTCOMES

The patient's menstruation returned to normal within several weeks after hysteroscopic resection and she completely recovered from PE after 3 months of anticoagulant therapy.

LESSONS

Treatment of retained placenta accreta can be postponed when encountering complicated cases, such as postpartum PE. PE in perinatal stage can be managed referring to nonmaternal PE.

Biosimilars of low molecular weight heparins: Relevant background information for your drug formulary

Biosimilars of low molecular weight heparins (LMWHs) are more alike the originator than different branded LMWHs. The latter differ largely in molecular weight, anti-FXa/anti-FIIa ratio and antithrombin binding. The Food and Drug Administration and European Medicines Agency guidelines are sufficient for the clinical use of high quality LMWHs. However, the Food and Drug Administration guideline lacks the results of a phase I clinical trial in the approval process. Most information about biosimilars is available for enoxaparin given that many biosimilars of enoxaparin have received market access. The guidelines of many International Thrombosis Societies for LMWH biosimilars are too stringent, not updated and impractical for formulary uptake discussions. This review gives background information on critical factors for the formulary uptake process of LMWHs with special attention for the use of the System of Objectified Judgment Analysis/Infomatrix model.

Pulmonary embolism management in the critical care setting

The American Heart Association (AHA) categorizes pulmonary embolism (PE) into three main categories based on the presence or absence of hemodynamic changes and evidence of right ventricular dysfunction. The AHA characterizes massive PE as occurring in the setting of persistent hypotension, profound bradycardia, or pulselessness; submassive PE as occurring with evidence of right ventricular dysfunction or myocardial necrosis in the absence of hemodynamic changes; and low-risk PE as occurring in the absence of markers of massive and submassive PE. This chapter provides an overview of how to identify and manage patients with submassive and massive pulmonary embolism. Delivery planning considerations are discussed. We also address the management of critically ill obstetric patients with respect to VTE risk. The American Heart Association (AHA) categorizes pulmonary embolism (PE) into three main categories based on the presence or absence of hemodynamic changes and evidence of right ventricular dysfunction. The AHA characterizes massive PE as occurring in the setting of persistent hypotension, profound bradycardia, or pulselessness; submassive PE as occurring with evidence of right ventricular dysfunction or myocardial necrosis in the absence of hemodynamic changes; and low-risk PE as occurring in the absence of markers of massive and submassive PE.¹ This chapter provides an overview of how to identify and manage patients with submassive and massive pulmonary embolism. Delivery planning considerations are discussed. We also address the management of critically ill obstetric patients with respect to VTE risk.