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Zhou Y, Chen Y, Xue M, Zheng X, Guan Y. Pregnancy outcomes in 16 women with previous catheter-directed thrombolysis and stenting for acute left iliofemoral deep vein thrombosis. Phlebology 2023; 38:445-450. [PMID: 37345252 DOI: 10.1177/02683555231183782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
BACKGROUND Whether iliac vein stents affect pregnancy or whether they will be affected by pregnancy was rarely reported in the literature. The aim of this study was to report our experience of pregnancy in women who received thrombolysis and stenting for a previous deep vein thrombosis (DVT). METHODS 16 patients with previous stenting for treatment of acute left iliofemoral DVT who had subsequent pregnancies were identified. Patient demographic information and outcomes were recorded. Duplex scanning and venography were performed as scheduled to evaluate the patency of stents in perinatal period and at 12 months after delivery. RESULTS None of the patients had a hemorrhagic complication and recurrent venous thromboembolism during their pregnancies and postpartum. No stent compression/occlusion and structural damage occurrence in all patients during follow-up. CONCLUSION Pregnancy managed with prophylactic dalteparin resulted in no re-thrombotic events or structural damage to the iliac stents and did not appear to negatively affect pregnancy outcomes.
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Affiliation(s)
- Yadong Zhou
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yingying Chen
- Department of Pediatric Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ming Xue
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xuexun Zheng
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yunbiao Guan
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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2
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Hong DK, Cho HY, Kim JY, Park HJ, Cha DH, Shim SS, Yun BS. Intrapartum Factors Affecting Abnormal Lipid Profiles in Early Postpartum Period. J Pers Med 2023; 13:jpm13030444. [PMID: 36983626 PMCID: PMC10054016 DOI: 10.3390/jpm13030444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/26/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
The aim of this research is to investigate the risk factors during pregnancy affect abnormal lipid profiles in women with early postpartum period. This was a single-center retrospective study including 869 women who delivered between December 2017 and May 2019. We collected total cholesterol levels, both at 24–28 GWs and 1 month before delivery. Lipid profiles such as total cholesterol, high-density lipoprotein (HDL), triglyceride (TG) and low-density lipoprotein (LDL) at 6 weeks after delivery were retrieved. Subjects were categorized into 3 groups such as normal, borderline and abnormal group according to the lipid profile levels. The risk factors associated with borderline to abnormal HDL level were body mass index (BMI) of pre-pregnancy (OR = 1.182, 95% CI: 1.116–1.252, p < 0.001), weight gain during pregnancy (OR = 1.085, 95% CI: 1.042–1.131, p < 0.001) and hypertension (HTN) (OR = 3.451, 95% CI: 1.224–9.727, p = 0.02). The risk factors associated with borderline or abnormal TG were BMI of pre-pregnancy, weight gain during pregnancy and weight reduction after delivery. HTN was associated with borderline to abnormal TG in postpartum (OR = 2.891, 95% CI: 1.168–7.156, p = 0.02), while GDM correlated purely with abnormal TG in postpartum (OR = 2.453, 95% CI: 1.068–5.630, p = 0.03). Abnormal lipid profiles in postpartum were significantly associated with BMI of pre-pregnancy, weight gain during pregnancy and weight reduction after delivery. In addition, pregnancy-related HTN was highly associated with abnormal HDL level, and GDM was associated with abnormal TG level in the early postpartum period.
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Affiliation(s)
- Da Kyung Hong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul 06125, Republic of Korea
| | - Hee Young Cho
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul 06125, Republic of Korea
- Department of Obstetrics and Gynecology,
Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Ji Youn Kim
- Department of Obstetrics and Gynecology, CHA Ilsan Medical Center, CHA University, Goyang-Si 10414, Republic of Korea
| | - Hee Jin Park
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul 06125, Republic of Korea
| | - Dong Hyun Cha
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul 06125, Republic of Korea
| | - Sung Shin Shim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul 06125, Republic of Korea
- Correspondence: (S.S.S.); (B.S.Y.)
| | - Bo Seong Yun
- Department of Obstetrics and Gynecology, CHA Ilsan Medical Center, CHA University, Goyang-Si 10414, Republic of Korea
- Correspondence: (S.S.S.); (B.S.Y.)
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3
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Tsuchida T, Wada T, Nakae R, Fujiki Y, Kanaya T, Takayama Y, Suzuki G, Naoe Y, Yokobori S. Gender-related differences in the coagulofibrinolytic responses and long-term outcomes in patients with isolated traumatic brain injury: A 2-center retrospective study. Medicine (Baltimore) 2023; 102:e32850. [PMID: 36820585 PMCID: PMC9907995 DOI: 10.1097/md.0000000000032850] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
Coagulation function differs by gender, with women being characterized as more hypercoagulable. Even in the early stages of trauma, women have been shown to be hypercoagulable. Several studies have also examined the relationship between gender and the prognosis of trauma patients, but no certain conclusions have been reached. Patients with isolated traumatic brain injury (iTBI) are known to have coagulopathy, but no previous studies have examined the gender differences in detail. This is a retrospective analysis of a prospective registry conducted at 2 centers. The study included adult patients with iTBI enrolled from April 2018 to March 2021. Coagulofibrinolytic markers were measured in each patient at 1 hour, 24 hours, 3 days, and 7 days after injury, and neurological outcomes were assessed with the Glasgow Outcome Scale Extended at 6 months. Subgroup analysis was also performed by categorizing patients into groups according to neurological prognosis or age at 50 years. Males (n = 31) and females (n = 21) were included in the analysis. In males, there was a significant difference in the levels of activated partial thromboplastin time (P = .007), fibrin/fibrinogen degradation products (P = .025), D-dimer (P = .034), α2-plasmin inhibitor (P = .030), plasmin-α2-plasmin inhibitor complex (P = .004) at 1 hour after injury between favorable and unfavorable long-term neurological outcome groups, while in females there was no significant difference in these markers between 2 groups. In the age group under 50 years, there were significant gender differences in fibrinogen (day 3: P = .018), fibrin/fibrinogen degradation products (1 hour: P = .037, day 3: P = .009, day 7: P = .037), D-dimer (day 3: P = .005, day 7: P = .010), plasminogen (day 3: P = .032, day 7: P = .032), and plasmin-α2-plasmin inhibitor complex (day 3: P = .001, day 7: P = .001), and these differences were not evident in the age group over 50 years. There were differences in coagulofibrinolytic markers depending on gender in patients with iTBI. In male patients, aggravation of coagulofibrinolytic markers immediately after traumatic brain injury may be associated with poor neurologic outcome 6 months after injury.
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Affiliation(s)
- Takumi Tsuchida
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Takeshi Wada
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Faculty of Medicine, Sapporo, Japan
- * Correspondence: Takeshi Wada, Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hokkaido University, N15W7 Kita-ku, Sapporo 060-8638, Japan (e-mail: )
| | - Ryuta Nakae
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Yu Fujiki
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Takahiro Kanaya
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Yasuhiro Takayama
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Go Suzuki
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Yasutaka Naoe
- Emergency and Critical Care Center, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
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Abstract
Hyperemesis gravidarum (HG), severe nausea and vomiting in pregnancy, can lead to vitamin deficiencies. Little is known about HG-related vitamin K deficiency. We aimed to summarise available evidence on the occurrence of HG-related vitamin K deficiency and corresponding maternal and neonatal complications. A systematic review was conducted, searching Medline and EMBASE from inception to 12 November 2020. We identified 1564 articles, of which we included fifteen in this study: fourteen case reports (n 21 women) and one retrospective cohort study (n 109 women). Nine out of twenty-one women reported in case reports had a prolonged prothrombin time (PT). The cohort study measured PT in 39/109 women with HG, of whom 10/39 women (26 %) had prolonged PT. In total, 30-50 % women received vitamin K supplementation after vitamin K deficiency had been diagnosed. Four case reports (n 4 women) reported corresponding maternal complications, all consisting of coagulopathy-related haemorrhage. Nine case reports (n 16 neonates) reported corresponding neonatal complications including intracranial haemorrhage (n 2 neonates) and embryopathy (n 14 neonates), which consisted of Binder phenotype (n 14 neonates), chondrodysplasia punctata (n 9 neonates) and grey matter heterotopia (n 3 neonates). In conclusion, vitamin K deficiency and related complications occur among women with HG. In our systematic review, we were unable to assess the incidence rate.
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Mohamed A, Shemanski SM, Saad MO, Ploetz J, Haines MM, Schlachter AB, Hamarshi MS. Anti-Xa Directed Thromboprophylaxis in Critically Ill Patients with Coronavirus Disease 2019. Clin Appl Thromb Hemost 2022; 28:10760296221116350. [PMID: 35924413 PMCID: PMC9358597 DOI: 10.1177/10760296221116350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To compare Anti-Xa directed thromboprophylaxis using low molecular weight heparin (LMWH) (anti-Xa peak goal 0.2-0.5 IU/mL) to alternative anticoagulation strategies in critically ill COVID-19 patients. Methods: This was a retrospective, multicenter, single health-system study. Primary outcomes were thromboembolic events and clinically important bleeding events. Secondary outcomes included dosing comparisons between LMWH cohorts. Main Results: A total of 695 patients were included. No differences were found in the incidence of thrombotic events with any of the dosing strategies. The incidence of major bleeding was significantly higher in the standard dose thromboprophylaxis, intermediate dose subcutaneous heparin (SQH), and therapeutic anticoagulation cohorts. Forty-nine percent of patients within the anti-Xa directed group had their first anti-Xa peak at goal, while 43% were above goal. Patients who had levels above goal had dose modifications made, therefore anti-Xa directed LMWH resulted in significantly lower total daily doses compared to intermediate dose LMWH. Conclusions: Anti-Xa directed LMWH dosing provided comparable thromboprophylaxis with lower total daily doses of LMWH in critically ill COVID-19 patients. Further randomized controlled trials are needed to confirm our findings.
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Affiliation(s)
- Adham Mohamed
- 24091Saint Luke's Hospital of Kansas City, Kansas City, MO, USA
| | | | - Mohamed O Saad
- Al-Wakra Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | | | - Michelle M Haines
- 24091Saint Luke's Hospital of Kansas City, Kansas City, MO, USA.,12272University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Andrew B Schlachter
- 24091Saint Luke's Hospital of Kansas City, Kansas City, MO, USA.,12272University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Majdi S Hamarshi
- 24091Saint Luke's Hospital of Kansas City, Kansas City, MO, USA.,12272University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
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Akbari A, Kunkel E, Bota SE, Harel Z, Le Gal G, Cox C, Hundemer GL, Canney M, Clark E, Massicotte-Azarniouch D, Eddeen AB, Knoll G, Sood MM. Proteinuria and venous thromboembolism in pregnancy: a population-based cohort study. Clin Kidney J 2021; 14:2101-2107. [PMID: 34671466 PMCID: PMC8521786 DOI: 10.1093/ckj/sfaa278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/28/2020] [Indexed: 11/14/2022] Open
Abstract
Background Pregnancy-associated venous thromboembolism (VTE) is associated with high morbidity and mortality. Identification of risk factors of VTE may lead to improved maternal and foetal outcomes. Proteinuria confers a pro-thrombotic state, however, its association with VTE in pregnancy remains unknown. We set out to assess the association of proteinuria and VTE during pregnancy. Methods We conducted a population-based, retrospective cohort study of all pregnant women (≥16 years of age) with a proteinuria measure within 20 weeks of conception (n = 306 244; mean age 29.8 years) from Ontario, Canada. Proteinuria was defined by any of the following: urine albumin:creatinine ratio ≥3 mg/mmol, urine protein:creatinine ratio ≥5 mg/mmol or urine dipstick proteinuria ≥1. The main outcome measure was a diagnosis of VTE up to 24-weeks post-partum. Results A positive proteinuria measurement occurred in 8508 (2.78%) women and was more common with a history of kidney disease, gestational or non-gestational diabetes mellitus and hypertension. VTE events occurred in 625 (0.20%) individuals, with a higher risk among women with positive proteinuria [32 events (0.38%)] compared with women without proteinuria [593 events (0.20%); inverse probability-weighted risk ratio 1.79 (95% confidence interval 1.25-2.57)]. The association was consistent using a more specific VTE definition, in the post-partum period, in high-risk subgroups (hypertension or diabetes) and when the sample was restricted to women with preserved kidney function. Conclusions The presence of proteinuria in the first 20 weeks of pregnancy is associated with a significantly higher risk of VTE.
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Affiliation(s)
- Ayub Akbari
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | - Ziv Harel
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Gregoire Le Gal
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Conor Cox
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Gregory L Hundemer
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mark Canney
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Edward Clark
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | - Greg Knoll
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,ICES, Toronto, ON, Canada
| | - Manish M Sood
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,ICES, Toronto, ON, Canada
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7
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Abstract
Obstetrician-gynecologists are the leading experts in the health care of women, and obesity is the most common medical condition in women of reproductive age. Obesity in women is such a common condition that the implications relative to pregnancy often are unrecognized, overlooked, or ignored because of the lack of specific evidence-based treatment options. The management of obesity requires long-term approaches ranging from population-based public health and economic initiatives to individual nutritional, behavioral, or surgical interventions. Therefore, an understanding of the management of obesity during pregnancy is essential, and management should begin before pregnancy and continue through the postpartum period. Although the care of the obese woman during pregnancy requires the involvement of the obstetrician or other obstetric care professional, additional health care professionals, such as nutritionists, can offer specific expertise related to management depending on the comfort level of the obstetric care professional. The purpose of this Practice Bulletin is to offer an integrated approach to the management of obesity in women of reproductive age who are planning a pregnancy.
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8
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Stafford IA, Moustafa AS, Spoo L, Berra A, Burgess A, Turrentine M. Association between Maternal Obesity Class, Adherence to Labor Guidelines, and Perinatal Outcomes. AJP Rep 2021; 11:e105-e112. [PMID: 34277129 PMCID: PMC8282364 DOI: 10.1055/s-0041-1732409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 04/06/2020] [Indexed: 12/02/2022] Open
Abstract
Background Data are limited concerning rates of perinatal complications in women with a body mass index (BMI) ≥40 kg/m2 compared to women with other BMI classes when guidelines for the safe prevention of the primary cesarean delivery are applied. Objective The aim of the study is to evaluate labor guideline adherence by BMI class and to compare perinatal outcomes across BMI classes with guideline adherent management. Study Design This retrospective study included low-risk women admitted for delivery between April 2014 and April 2017 after the labor guidelines were implemented. BMI closest to delivery was used for analysis. Women with cesarean for nonreassuring fetal status were excluded. Results Guideline adherence decreased with increasing BMI, with 93% adherence among women of normal weight compared to 81% for class III obese women ( p < 0.0001). Among women who had guideline-adherent management, there was increased rates of cesarean among class III versus other obesity classes; however, there were no differences in rates of infectious morbidity ( p = 0.98) or hemorrhage ( p = 0.93). Although newborns of women with class III obesity had higher rates of meconium at birth, neonatal outcomes were not different with increasing maternal BMI ( p = 0.65). Conclusion There were no differences in adverse perinatal outcomes with increasing BMI.
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Affiliation(s)
- Irene A. Stafford
- Department of Obstetrics and Gynecology, University of Texas Health Science Center, Houston, Texas
| | - Ahmed S.Z. Moustafa
- Department of Obstetrics and Gynecology, Hurley Medical Center, Michigan State University, Flint, Michigan
| | - Lauren Spoo
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Alexandra Berra
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Angela Burgess
- Department of Obstetrics and Gynecology, University of Texas Health Science Center, Houston, Texas
| | - Mark Turrentine
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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9
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Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2021; 89:971-981. [PMID: 32590563 PMCID: PMC7587238 DOI: 10.1097/ta.0000000000002830] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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10
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Park JE, Park Y, Yuk JS. Incidence of and risk factors for thromboembolism during pregnancy and postpartum: A 10-year nationwide population-based study. Taiwan J Obstet Gynecol 2021; 60:103-110. [PMID: 33494981 DOI: 10.1016/j.tjog.2020.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Knowledge of the incidence of pregnancy-related thromboembolism and its risk factors is clinically important because thromboembolism is the leading cause of maternal death. However, there are insufficient large population-based studies on this topic. The purpose of this study was to estimate the incidence of and identify the risk factors for thromboembolism during pregnancy and puerperium. MATERIALS AND METHODS We analyzed data from 2007 to 2016 using the Health Insurance Review and Assessment Service (HIRA) database. Women who gave birth in the Republic of Korea were identified. Thromboembolism was defined as the simultaneous presence of both the diagnostic and test codes. Risk factors for thromboembolism were identified using logistic regression. RESULTS A total of 1,188 delivery episodes with thromboembolism were extracted from 4,243,393 delivery episodes. The incidence of thromboembolism was 0.28 per 1,000 deliveries, and it increased over the 10-year period. The incidence of antepartum thromboembolism was 0.1 per 1,000 deliveries (418 cases), and the incidence of postpartum thromboembolism was 0.18 per 1,000 deliveries (770 cases). Thromboembolism was associated with ovarian hyperstimulation syndrome, low socioeconomic status, multiple birth, cesarean birth, preeclampsia, postpartum hemorrhage, placenta previa, advanced maternal age, hyperemesis and primiparity. The factors associated with mortality from thromboembolism were cesarean birth and preterm premature rupture of membranes. CONCLUSION The incidence of pregnancy-related thromboembolism increased over the 10-year study period. Low socioeconomic status, ovarian hyperstimulation syndrome, cesarean delivery and premature rupture of membranes were high-risk factors. This study provides an important reference for thromboprophylaxis for pregnancy-related thromboembolism.
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Affiliation(s)
- Ji Eun Park
- Department of Obstetrics and Gynecology, College of Medicine, Gyeongsang National University, Gyeongsang National University Changwon Hospital, Republic of Korea
| | - Yongwhi Park
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Gyeongsang National University, Gyeongsang National University Changwon Hospital, Republic of Korea
| | - Jin-Sung Yuk
- Department of Obstetrics and Gynecology, College of Medicine, Inje University, Sanggye Paik Hospital, Republic of Korea.
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11
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Iroz CB, Dahl CM, Cassimatis IR, Wescott AB, Miller ES. Prophylactic anticoagulation for preterm premature rupture of membranes: a decision analysis. Am J Obstet Gynecol MFM 2021; 3:100311. [PMID: 33493702 DOI: 10.1016/j.ajogmf.2021.100311] [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: 10/05/2020] [Revised: 01/05/2021] [Accepted: 01/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The current standard of care in the setting of preterm premature rupture of membranes involves antenatal hospitalization until delivery. The reduced physical activity during this time compounds the heightened risk for venous thromboembolism in pregnancy. Prophylactic anticoagulation can decrease this risk of venous thromboembolism; however, this benefit must be balanced against the risks of precluding neuraxial analgesia or increasing the risk of postpartum hemorrhage. OBJECTIVE The objective of this study was to determine the optimal modality for venous thromboembolism prophylaxis during hospitalization for preterm premature rupture of membranes using a decision analysis model. STUDY DESIGN A decision-analytical Markov model was constructed using the TreeAge software comparing the use of unfractionated heparin, low-molecular-weight heparin or no anticoagulation in women with a singleton pregnancy who were hospitalized for preterm premature rupture of membranes after 24 weeks and remained hospitalized until delivery. Maternal outcomes examined included attainment of neuraxial analgesia (vs no analgesia for vaginal delivery or general anesthesia for cesarean delivery), venous thromboembolism, postpartum hemorrhage, and maternal death. Probabilities and utilities were derived from existing literature. Sensitivity analyses were performed to interrogate model assumptions, and a Monte Carlo probabilistic sensitivity analysis was performed to examine the robustness of the model. RESULTS In this decision-analytical model, no prophylactic anticoagulation maximized maternal utilities. Clinical outcomes among a theoretical cohort of 100,000 women are shown in the Table. The 1- and 2-way sensitivity analyses supported this conclusion. Monte Carlo probabilistic sensitivity analysis indicated that no prophylaxis was the preferred choice in 56% of simulations, unfractionated heparin in 34% of simulations, and low-molecular-weight heparin in 10% of simulations. CONCLUSION Our results do not support the routine use of prophylactic anticoagulation in women admitted to the hospital for preterm premature rupture of membranes. These findings can be used to inform clinical decisions when admitting low-risk singleton pregnancies to the hospital in the setting of preterm premature rupture of membranes.
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Affiliation(s)
- Cassandra B Iroz
- Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Carly M Dahl
- Feinberg School of Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL
| | - Irina R Cassimatis
- Feinberg School of Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL
| | - Annie B Wescott
- Feinberg School of Medicine, Galter Health Sciences Library, Northwestern University, Chicago, IL
| | - Emily S Miller
- Feinberg School of Medicine, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL
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12
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Beyer-Westendorf J, Tittl L, Bistervels I, Middeldorp S, Schaefer C, Paulus W, Thomas W, Kemkes-Matthes B, Marten S, Bornhauser M. Safety of direct oral anticoagulant exposure during pregnancy: a retrospective cohort study. LANCET HAEMATOLOGY 2020; 7:e884-e891. [PMID: 33242445 DOI: 10.1016/s2352-3026(20)30327-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have largely replaced vitamin K antagonists in many indications for anticoagulation. Prescribed to millions of patients, including women of reproductive age, exposure to DOACs in early pregnancy is not uncommon, but data on the embryotoxic risks are scarce. We aimed to assess the risk of DOAC embryotoxicity in a large sample of reported cases. METHODS In this retrospective cohort study, we collected individual case reports of DOAC exposure in pregnancy from gynaecologists, haematologists, and vascular specialists starting from May, 2015. We obtained exports in April and October, 2017, August, 2018, and December, 2019, from the pharmacovigilance databases of the DOAC manufacturers, the European Medicines Agency (EMA), the German drug authority, and searched the homepage of the US Food and Drug Administration (FDA) for pregnancy exposure reports. Data from the International Society of Thrombosis and Haemostasis (ISTH) registry were obtained in August, 2018, and on July 21, 2020; data from the Teratology Information Service in Ulm, Germany, were received July 22, 2020. We also ran a systematic literature search on July 22, 2020, for cases of DOAC exposure. These data were compiled with those from our 2016 risk assessment and duplicate reports were excluded. Fetal or neonatal abnormalities were classified as a major birth defect according to the European Concerted Action on Congenital Anomalies and Twins (EUROCAT) classification and adjudicated into four categories: relation to DOAC exposure likely, possible, unlikely, or unrelated. FINDINGS We identified 1193 reports of DOAC exposure during pregnancy: 49 from physicians, 48 from the ISTH registry, 29 from the Teratology Information Service, 62 from the German drug authority, 536 from Bayer (extracted from the Bayer pharmacovigilance system, the WHO VigiBase, and from the FDA Adverse Event Reporting System), 87 from Boehringer Ingelheim, 16 from Daiichi Sankyo, 98 from the literature search, two from the FDA homepage search, ten from the Risk Evaluation and Mitigation Strategy Review, and 256 from the EMA reports. After excluding potential duplicates, we identified 614 unique cases of DOAC exposure in pregnancy occurring between Feb 1, 2007, and July 9, 2020, that consisted of rivaroxaban in 505 (82%) pregnancies, dabigatran in 36 (6%), apixaban in 50 (8%), and edoxaban in 23 (4%). The median duration of DOAC exposure was 5·3 weeks (IQR 4·0-7·0) into pregnancy. Information on pregnancy outcome was available in 336 (55%) of 614 pregnancies: 188 (56%) livebirths, 74 (22%) miscarriages, and 74 (22%) elective pregnancy terminations. 21 (6%; 95% CI 4-9) of 336 showed fetal abnormalities, of which 12 (4%; 2-6) were adjudicated as major birth defects potentially related to DOAC exposure. INTERPRETATION Although reports of pregnancy outcomes after DOAC exposure are missing important details and predominantly describe rivaroxaban exposures, the available data do not suggest that DOAC exposure in pregnancy carries a high risk of embryopathy. The 2016 ISTH guidance against elective pregnancy termination for fear of DOAC embryotoxicity and the recommendation in favour of close pregnancy surveillance is still valid. Pregnancy outcome data are inconsistently captured in pharmacovigilance databases, indicating a strong need for a more robust system of reporting. FUNDING None.
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Affiliation(s)
- Jan Beyer-Westendorf
- Department of Medicine I, Division of Haematology and Haemostaseology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Luise Tittl
- Department of Medicine I, Division of Haematology and Haemostaseology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ingrid Bistervels
- Department of Vascular Medicine, Amsterdam University Medical Center, Cardiovascular Sciences, Amsterdam, Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam University Medical Center, Cardiovascular Sciences, Amsterdam, Netherlands
| | - Christof Schaefer
- Pharmacovigilance Institute for Embryotoxicology, Institute of Clinical Pharmacology and Toxicology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany
| | - Wolfgang Paulus
- Teratology Information Service, Department of Obstetrics and Gynaecology, University of Ulm, Ulm, Germany
| | - Will Thomas
- Department of Haematology, Cambridge Biomedical Campus, Cambridge, UK; Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Sandra Marten
- Department of Medicine I, Division of Haematology and Haemostaseology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Martin Bornhauser
- Department of Medicine I, Division of Haematology and Haemostaseology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Wang J, Lu J. Anesthesia for Pregnant Women with Pulmonary Hypertension. J Cardiothorac Vasc Anesth 2020; 35:2201-2211. [PMID: 32736999 DOI: 10.1053/j.jvca.2020.06.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 12/12/2022]
Abstract
Despite advances in the therapy for pulmonary hypertension over the past decades, the prognosis of pregnant patients with pulmonary hypertension remains poor, with high maternal mortality. This poses a particular challenge for the mother and her medical team. In the present review, the authors have updated the classification and definition of pulmonary hypertension, summarized the current knowledge with regard to perioperative management and anesthesia considerations for these patients, and stressed the importance of a "pregnancy heart team" to improve long-term outcomes of pregnant women with pulmonary hypertension.
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Affiliation(s)
- Jiawan Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jiakai Lu
- Department of Anesthesiology, Beijing An-Zhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China.
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Reference Values of D-Dimers and Fibrinogen in the Course of Physiological Pregnancy: the Potential Impact of Selected Risk Factors-A Pilot Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3192350. [PMID: 32596295 PMCID: PMC7273490 DOI: 10.1155/2020/3192350] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 05/11/2020] [Indexed: 11/23/2022]
Abstract
Pregnancy predisposes to thrombotic hemostasis, reflected in the laboratory as, e.g., increased levels of D-Dimers and fibrinogen, but in physiological pregnancy, the risk of venous thrombosis does not increase. Risk may increase if gestational diabetes mellitus (GDM) or nicotinism coexists. Study aims were to determine reference values for D-Dimers and fibrinogen concentrations in each trimester of pregnancy, corrected for GDM and nicotinism. Subjects and Methods. The study involved 71 pregnant women aged 25-44 y. Venous blood was collected three times: in the first (11-14 weeks), second (20-22 weeks), and third (30-31 weeks) trimesters. D-Dimer concentrations were determined by an enzyme-linked fluorescence assay, fibrinogen concentrations by a coagulation method according to Clauss. Results. Significant increases in D-Dimers and fibrinogen concentrations were observed, increasing with successive trimesters (p ANOVA < 0.0001). Furthermore, a positive correlation between D-Dimers and fibrinogen was detected in the second trimester of pregnancy (r = 0.475; p < 0.0001). In addition, a significantly higher fibrinogen concentration was found in women with GDM compared to without GDM (p = 0.0449). Reference ranges for D-Dimers were established, in trimester order, as follows: 167-721 ng/mL, 298-1653 ng/mL, and 483-2256 ng/mL. After adjusting for risk factors, significantly higher D-Dimer values (mainly second and third trimesters) were obtained: 165-638 ng/mL, 282-3474 ng/mL, and 483-4486 ng/mL, respectively. Reference ranges for fibrinogen were, in trimester order, 2.60-6.56 g/L, 3.40-8.53 g/L, and 3.63-9.14 g/L and, after adjustment for risk factors, 3.34-6.73 g/L, 3.40-8.84 g/L, and 3.12-9.91 g/L. Conclusions. We conclude that the increase in D-Dimers and fibrinogen levels in women with physiological pregnancy was compounded by gestational diabetes (GDM) and nicotinism. Therefore, D-Dimers and fibrinogen pregnancy reference values require correction for these risk factors.
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Rice LW, Espey E, Fenner DE, Gregory KD, Askins J, Lockwood CJ. Universal access to contraception: women, families, and communities benefit. Am J Obstet Gynecol 2020; 222:150.e1-150.e5. [PMID: 31542250 DOI: 10.1016/j.ajog.2019.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/27/2019] [Accepted: 09/12/2019] [Indexed: 11/28/2022]
Abstract
Universal access to contraception benefits society: unintended pregnancies, maternal mortality, preterm birth, abortions, and obesity would be reduced by increasing access to affordable contraception. Women should be able to choose when and whether to use contraception, choose which method to use, and have ready access to their chosen method. State and national government should support unrestricted access to all contraceptives. As obstetrician-gynecologists, we have a critical mandate, based on principle and mission, to step up with leadership on this vital medical and public health issue, to improve the lives of women, their families, and society. The field of Obstetrics and Gynecology must provide the leadership for moving forward. The American Gynecological and Obstetrical Society (AGOS), representing academic and public policy leaders from across all disciplines of Obstetrics and Gynecology, is well positioned to serve as a unifying organization, focused on developing a strong unified advocacy voice to fight for accessible contraception for all in the United States.
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Affiliation(s)
- Laurel W Rice
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI.
| | - Eve Espey
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Dee E Fenner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Kimberly D Gregory
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jacquelyn Askins
- Department of Obstetrics and Gynecology, University of Wisconsin-Madison, Madison, WI
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Davies GAL, Maxwell C, McLeod L. No. 239-Obesity in Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 40:e630-e639. [PMID: 30103887 DOI: 10.1016/j.jogc.2018.05.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review the evidence and provide recommendations for the counselling and management of obese parturients. OUTCOMES Outcomes evaluated include the impact of maternal obesity on the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality. EVIDENCE Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The evidence obtained was reviewed and evaluated by the Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible. RECOMMENDATIONS
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17
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[What are the special features of the treatment of venous thombo-embolic disease in the course of pregnancy and post-partum?]. Rev Mal Respir 2019; 38 Suppl 1:e145-e152. [PMID: 31208886 DOI: 10.1016/j.rmr.2019.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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18
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Davies GA, Maxwell C, McLeod L. Archivée: N° 239 - Obésité et grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:e640-e651. [PMID: 30103888 DOI: 10.1016/j.jogc.2018.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Vitner D, Harris K, Maxwell C, Farine D. Obesity in pregnancy: a comparison of four national guidelines. J Matern Fetal Neonatal Med 2018; 32:2580-2590. [PMID: 29447091 DOI: 10.1080/14767058.2018.1440546] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Obesity in pregnancy has become one of the most important challenges in obstetrical care given its prevalence and potential adverse impact on both mother and fetus. The primary objective of this descriptive review is to identify common themes and distinctions within the current recommendations for maternal obesity in the most updated version of four published national guidelines. METHODS We reviewed the following guidelines for obesity in pregnancy: American College of Obstetricians and Gynecologists (ACOG) 2015, Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) 2013, Royal College of Obstetrics and Gynecology (RCOG) 2010, and Society of Obstetrics and Gynecologists of Canada (SOGC) 2010. RESULTS There were no major contradictions between the guidelines, however, variations did exist. Recognition of overweight and obese populations prenatally was uniformly emphasized, so that appropriate nutrition and exercise counseling could be provided prior to pregnancy. Obesity in pregnancy was consistently defined as a body mass index of 30 kg/m2 or more, and weight gain recommendations were in line with the Institute of Medicine guidelines. Counseling patients regarding the specific maternal and fetal complications in pregnancy, delivery, and postpartum which are associated with obesity was consistently emphasized. Most guidelines recommended early screening for gestational diabetes, however, specific details were not provided. All guidelines stressed the importance of available resources in clinics and the operating room specific to the obese population. Disparities were found regarding recommendations for high-dose folic acid, vitamin D supplementation, and low-dose aspirin. Thromboprophylaxis is a matter of debate, with most guidelines recommending use on an individual patient basis. CONCLUSIONS In general, the guidelines emphasized the importance of counseling women regarding the risks associated with obesity in pregnancy, and stressed the necessity of screening for these adverse outcomes. Initiatives to develop common terminology and reporting of outcomes in women's health are important for the development of cohesive and uniform recommendations for patient care. Disparities existed with respect to management strategies and where the further research and systematic reviews should be targeted, to allow clinicians to provide an appropriate obstetrical care pathway for obese women.
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Affiliation(s)
- Dana Vitner
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Toronto , Toronto , Canada.,b Ruth and Bruce Rappaport Faculty of Medicine , Technion - Israel Institute of Technology , Haifa , Israel
| | - Kristin Harris
- c Department of Obstetrics and Gynaecology , University of Toronto , Toronto , Canada
| | - Cynthia Maxwell
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Toronto , Toronto , Canada
| | - Dan Farine
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Toronto , Toronto , Canada
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20
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Robson SJ, Norman RJ. It is ethical to recommend against assisted reproductive treatment for women with a high body mass index. Aust N Z J Obstet Gynaecol 2017; 57:575-578. [PMID: 28872659 DOI: 10.1111/ajo.12693] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/24/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Stephen J Robson
- Australian National University Medical School, Garran, Australian Capital Territory, Australia.,Royal Australian and New Zealand College of Obstetricians and Gynaecologists, East Melbourne, Victoria, Australia
| | - Robert J Norman
- Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia.,Fertility SA, Adelaide, South Australia, Australia
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Catalano PM, Shankar K. Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child. BMJ 2017; 356:j1. [PMID: 28179267 PMCID: PMC6888512 DOI: 10.1136/bmj.j1] [Citation(s) in RCA: 635] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Obesity is the most common medical condition in women of reproductive age. Obesity during pregnancy has short term and long term adverse consequences for both mother and child. Obesity causes problems with infertility, and in early gestation it causes spontaneous pregnancy loss and congenital anomalies. Metabolically, obese women have increased insulin resistance in early pregnancy, which becomes manifest clinically in late gestation as glucose intolerance and fetal overgrowth. At term, the risk of cesarean delivery and wound complications is increased. Postpartum, obese women have an increased risk of venous thromboembolism, depression, and difficulty with breast feeding. Because 50-60% of overweight or obese women gain more than recommended by Institute of Medicine gestational weight guidelines, postpartum weight retention increases future cardiometabolic risks and prepregnancy obesity in subsequent pregnancies. Neonates of obese women have increased body fat at birth, which increases the risk of childhood obesity. Although there is no unifying mechanism responsible for the adverse perinatal outcomes associated with maternal obesity, on the basis of the available data, increased prepregnancy maternal insulin resistance and accompanying hyperinsulinemia, inflammation, and oxidative stress seem to contribute to early placental and fetal dysfunction. We will review the pathophysiology underlying these data and try to shed light on the specific underlying mechanisms.
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Affiliation(s)
- Patrick M Catalano
- Department of Obstetrics and Gynecology, Center for Reproductive Health/MetroHealth Medical Center, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Kartik Shankar
- Arkansas Children's Nutrition Center, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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22
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Tyurenkov IN, Perfilova VN, Smirnov AV, Reznikova LB, Poroyskaya AV, Verovsky VE. Features of endothelial dysfunction and morphofunctional changes of the uteroplacental complex in experimentally induced pre-eclampsia. Pregnancy Hypertens 2016; 6:423-430. [PMID: 27939494 DOI: 10.1016/j.preghy.2016.11.001] [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: 04/11/2016] [Revised: 10/28/2016] [Accepted: 11/02/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Pre-eclampsia is considered to be a severe complication of pregnancy. Theoretical investigation of its etiology and pathogenesis, development of strategies for its prevention and treatment are conditioned by the development of appropriate experimental models of this pathology. METHODS The study involved Wistar rat lines weighing 220-240g. Experimental pre-eclampsia was modeled by replacing drinking water consumed by pregnant female rats with 1.8% NaCl solution throughout gestation. Arterial pressure, protein concentration in urine and tissue hydration extent were measured on the 1st and 21st days of gestation. Uteroplacental blood flow, vasodilating and antithrombotic endothelial functions were also assessed. For pathomorphological and immunohistochemical investigation murine monoclonal antibodies against vascular endothelial growth factor (VEGF), polyclonal rabbit antibodies against inducible and endothelial NO-synthases were used. RESULTS Replacing drinking water with 1.8% NaCl solution in female rats throughout gestation elevates arterial pressure, causes proteinuria and edema, impairs vasodilating and antithrombotic endothelial properties, and suppresses uteroplacental blood circulation. A morphological examination of the animals revealed the signs of focal duodenitis, spasms of myometrium arteries with no invasion of syncytiotrophoblast into its walls which also involved a raised VEGF and reduced eNOS expression in the endothelium of myometrial vessels, as well as cytoplasmic expression of iNOS in the cells of inflammatory infiltrate. CONCLUSIONS These findings make it possible to conclude that replacing drinking water with 1.8% NaCl solution causes a number of changes typical of pre-eclampsia and, therefore, can be regarded as an experimental model of this pathologic condition.
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Affiliation(s)
- I N Tyurenkov
- Department of Pharmacology and Biopharmacy of the Department for Refresher Training, Volgograd State Medical University, 400001 Volgograd, Russia
| | - V N Perfilova
- Department of Pharmacology and Biopharmacy of the Department for Refresher Training, Volgograd State Medical University, 400001 Volgograd, Russia.
| | - A V Smirnov
- Department of Pathological Anatomy, Volgograd State Medical University, Volgograd, Russia
| | - L B Reznikova
- Department of Pharmacology and Biopharmacy of the Department for Refresher Training, Volgograd State Medical University, 400001 Volgograd, Russia
| | - A V Poroyskaya
- Department of Pharmacology and Biopharmacy of the Department for Refresher Training, Volgograd State Medical University, 400001 Volgograd, Russia
| | - V E Verovsky
- Department of Theoretical Biochemistry with a Course of Clinical Biochemistry, Volgograd State Medical University, Volgograd, Russia
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23
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Stevens SM, Woller SC, Bauer KA, Kasthuri R, Cushman M, Streiff M, Lim W, Douketis JD. Guidance for the evaluation and treatment of hereditary and acquired thrombophilia. J Thromb Thrombolysis 2016; 41:154-64. [PMID: 26780744 PMCID: PMC4715840 DOI: 10.1007/s11239-015-1316-1] [Citation(s) in RCA: 168] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Thrombophilias are hereditary and/or acquired conditions that predispose patients to thrombosis. Testing for thrombophilia is commonly performed in patients with venous thrombosis and their relatives; however such testing usually does not provide information that impacts management and may result in harm. This manuscript, initiated by the Anticoagulation Forum, provides clinical guidance for thrombophilia testing in five clinical situations: following 1) provoked venous thromboembolism, 2) unprovoked venous thromboembolism; 3) in relatives of patients with thrombosis, 4) in female relatives of patients with thrombosis considering estrogen use; and 5) in female relatives of patients with thrombosis who are considering pregnancy. Additionally, guidance is provided regarding the timing of thrombophilia testing. The role of thrombophilia testing in arterial thrombosis and for evaluation of recurrent pregnancy loss is not addressed. Statements are based on existing guidelines and consensus expert opinion where guidelines are lacking. We recommend that thrombophilia testing not be performed in most situations. When performed, it should be used in a highly selective manner, and only in circumstances where the information obtained will influence a decision important to the patient, and outweigh the potential risks of testing. Testing should not be performed during acute thrombosis or during the initial (3-month) period of anticoagulation.
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Affiliation(s)
- Scott M Stevens
- Department of Medicine, Intermountain Medical Center, 5121 Cottonwood Street, Murray, UT, 84157-7000, USA.
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, 5121 Cottonwood Street, Murray, UT, 84157-7000, USA
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Kenneth A Bauer
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Raj Kasthuri
- Johns Hopkins Comprehensive Hemophilia Treatment Center, Baltimore, MD, USA
| | - Mary Cushman
- Department of Medicine, Cardiovascular Research Institute of Vermont, University of Vermont, Burlington, VT, USA
| | - Michael Streiff
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Wendy Lim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Patil AS, Clapp T, Gaston PK, Kuhl D, Rinehart E, Meyer NL. Increased unfractionated heparin requirements with decreasing body mass index in pregnancy. Obstet Med 2016; 9:156-159. [PMID: 27829874 DOI: 10.1177/1753495x16659401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/14/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Pregnant women receiving low-molecular-weight heparin for therapeutic anticoagulation are often converted to unfractionated heparin in anticipation of labor. We aim to characterize the impact of maternal body mass index on attainment of target anticoagulation during the conversion process. METHODS We conducted a five-year retrospective study of a pregnancy cohort converted from low-molecular-weight heparin to unfractionated heparin in the third trimester. Patient demographics, anticoagulation regimens, and clinical outcomes were extracted from the medical record. Nonparametric statistical methods were used for analysis by body mass index (<30, 30-35, and >35). RESULTS Thirty-one subjects were evenly distributed by body mass index (p = 0.97). Linear regression revealed an inverse correlation between patient body mass index and unfractionated heparin dose needed to achieve therapeutic anticoagulation (p = 0.04). Subjects with body mass index > 35 attained therapeutic activated partial thromboplastin time levels at 18 U (Units)/kg/h, while subjects with body mass index < 30 required 25 U/kg/h (p = 0.02). CONCLUSION Higher doses of unfractionated heparin are needed to achieve anticoagulation in patients with body mass index < 30 during pregnancy. This paradoxical relationship may be explained by physiologic characteristics that increase unfractionated heparin elimination, including diminished adiposity and increased renal clearance.
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Affiliation(s)
- Avinash S Patil
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Indiana University School of Medicine, Indianapolis, IN, USA; Division of Clinical Pharmacology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Tracy Clapp
- Department of Pharmacy, Regional Medical Center, Memphis, TN, USA
| | - Piyamas K Gaston
- Department of Pharmacy, Regional Medical Center, Memphis, TN, USA
| | - David Kuhl
- School of Pharmacy, Union University, Jackson, TN, USA
| | - Eliza Rinehart
- Department of Pharmacy, Regional Medical Center, Memphis, TN, USA
| | - Norman L Meyer
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Tennessee HSC, Memphis, TN, USA
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Salim R, Nachum Z, Gavish I, Romano S, Braverman M, Garmi G. Adjusting enoxaparin dosage according to anti-FXa levels and pregnancy outcome in thrombophilic women. A randomised controlled trial. Thromb Haemost 2016; 116:687-95. [PMID: 27440463 DOI: 10.1160/th16-03-0221] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 06/22/2016] [Indexed: 02/03/2023]
Abstract
Women with thrombophilias and previous placenta-mediated pregnancy complications (PMPC) have an increased risk of both recurrent PMPC and venous thromboembolism (VTE) during subsequent pregnancies. We aimed to examine whether enoxaparin dose adjusted according to anti-factor Xa levels compared to a fixed dose would reduce the risk of PMPC in subsequent pregnancies. In a randomised trial, conducted at a single teaching hospital, pregnant women with thrombophilia and previous PMPC were enrolled in a 1:1 ratio to either a fixed dose of 40 mg daily enoxaparin or adjusted dose according to anti-factor Xa plasma levels. The primary outcome was a composite that included any of the following: pregnancy loss after enrollment, pre-eclampsia, birthweight <10th percentile, placental abruption, or VTE. Overall, 144 women were needed to detect a decrease of 20 % in the incidence of the composite outcome among the adjusted dose group. Between 2009 and 2015, 144 women consented; four in the fixed-dose group were excluded. Overall, 66 and 74 in the fixed- and adjusted-dose groups, respectively, were included. Demographic and obstetric characteristics were comparable. Composite outcome occurred in 12 (18.2 %) and 20 (27.0 %) women in the fixed- and adjusted-dose groups, respectively (p=0.24). Gestational age at delivery, preterm births, and birthweights were similar between the two groups. In conclusion, dose of enoxaparin adjusted according to anti-factor Xa levels compared to fixed dose, does not reduce the risk of PMPC recurrence in thrombophilic women.
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Affiliation(s)
- Raed Salim
- Raed Salim, MD, Department of Obstetrics and Gynecology, Emek Medical Center, Afula 18101, Israel, Tel.: +972 4 649 4031, E-mail:
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Beyer-Westendorf J, Michalski F, Tittl L, Middeldorp S, Cohen H, Abdul Kadir R, Arachchillage DJ, Arya R, Ay C, Marten S. Pregnancy outcome in patients exposed to direct oral anticoagulants - and the challenge of event reporting. Thromb Haemost 2016; 116:651-8. [PMID: 27384740 DOI: 10.1160/th16-04-0305] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 05/25/2016] [Indexed: 11/05/2022]
Abstract
Today, direct oral anticoagulants (DOAC) are widely used alternatives to Vitamin-K antagonists (VKA). Women of reproductive age may become pregnant during anticoagulation and, while VKA carry an embryotoxic potential, the risk of DOAC embryopathy is unknown. As a result, some patients elect to terminate pregnancy for fear of DOAC embryotoxicity. To assess the risk of DOAC embryopathy, we reviewed cases of DOAC exposure in pregnancy collected from physicians, literature and pharmacovigilance systems of drug authorities and manufacturers. A total of 357 reports including duplicates were available from which 233 unique cases could be identified. Information on pregnancy outcome was available in only 137/233 cases (58.8 %): 67 live births (48.9 %); 31 miscarriages (22.6 %); 39 elective pregnancy terminations (28.5 %). In 93 cases (39.9 %) no outcome data were available (including 3 cases of ongoing pregnancy). Of the 137 pregnancies with reported outcomes, seven showed abnormalities (5.1 %) of which three (2.2 %) could potentially be interpreted as embryopathy: live birth with facial dysmorphism; miscarriage in week 10 with limb abnormality; elective pregnancy termination due to a foetal cardiac defect in a woman who had to terminate a previous pregnancy due to Fallot tetralogy. Within its limitations (small numbers, incomplete outcome data) our results do not indicate that DOAC exposure in pregnancy carries a high risk of embryopathy or that DOAC exposure per se should be used to direct patient counselling towards pregnancy termination. Pregnancy outcome data are inconsistently captured in pharmacovigilance databases indicating the strong need for a more robust system of reporting.
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Affiliation(s)
- Jan Beyer-Westendorf
- Jan Beyer-Westendorf, Center for Vascular Medicine and Department of Medicine III, Division of Angiology University Hospital "Carl Gustav Carus", Technische Universität Dresden, Fetscherstrasse 74; 01307 Dresden, Germany, Tel.: +49 351 4583659, Fax: +49 531 4584359, E-mail:
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Abstract
We present a case of a 39-year-old, gravida 3 para 2, Chinese female with a history of inherited type 1 Antithrombin deficiency and multiple prior episodes of venous thromboembolism. She presented at 29+4 weeks' gestation with severe pre-eclampsia complicated by haemolysis, elevated liver enzymes and low platelet (HELLP) syndrome. She subsequently underwent an emergency caesarean section for non-reassuring fetal status, which was complicated by postpartum haemorrhage secondary to uterine atony, requiring a B-Lynch suture intraoperatively.
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Affiliation(s)
- Shivani Durai
- Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore, Singapore
| | - Lay Kok Tan
- Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore, Singapore
| | - Serene Lim
- Department of Obstetrics & Gynaecology, Singapore General Hospital, Singapore, Singapore
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Stephenson ML, Serra AE, Neeper JM, Caballero DC, McNulty J. A randomized controlled trial of differing doses of postcesarean enoxaparin thromboprophylaxis in obese women. J Perinatol 2016; 36:95-9. [PMID: 26658126 DOI: 10.1038/jp.2015.130] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/07/2015] [Accepted: 09/09/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To compare two enoxaparin dosing strategies at achieving prophylactic anti-Xa levels in women with a body mass index (BMI) ⩾35 (kg m(-2)) postcesarean delivery. STUDY DESIGN Women with BMI ⩾35 were randomized to receive prophylactic enoxaparin at a fixed dose of 40 mg daily or weight-based dosing of 0.5 mg kg(-1) twice daily. The primary outcome was the proportion of subjects with peak anti-Xa levels in the prophylactic range of 0.2 to 0.6 IU ml(-1). RESULT From August 2013 through February 2014, 84 demographically similar women completed the protocol. In the weight-based group, 88% (37/42) of the women reached prophylactic anti-Xa levels versus 14% (6/42) in the fixed dose group (odds ratio 44.4, 95% confidence interval 12.44, 158.48, P<0.001). No anti-Xa level exceeded 0.48 IU ml(-1). There were no venous thromboembolic or bleeding events requiring reoperation or transfusion in either group. CONCLUSION Compared with fixed dosing daily, weight-based dosing twice daily more effectively achieved prophylactic anti-Xa levels without reaching the therapeutic range.
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Affiliation(s)
- M L Stephenson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, USA.,Department of Obstetrics and Gynecology, Memorial Care Center for Women at Miller Children's Hospital, Long Beach Memorial Medical Center, Long Beach, CA, USA
| | - A E Serra
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, USA.,Department of Obstetrics and Gynecology, Memorial Care Center for Women at Miller Children's Hospital, Long Beach Memorial Medical Center, Long Beach, CA, USA
| | - J M Neeper
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California Irvine Medical Center, Orange, CA, USA.,Department of Obstetrics and Gynecology, Memorial Care Center for Women at Miller Children's Hospital, Long Beach Memorial Medical Center, Long Beach, CA, USA
| | - D C Caballero
- Department of Obstetrics and Gynecology, Memorial Care Center for Women at Miller Children's Hospital, Long Beach Memorial Medical Center, Long Beach, CA, USA
| | - J McNulty
- Department of Obstetrics and Gynecology, Memorial Care Center for Women at Miller Children's Hospital, Long Beach Memorial Medical Center, Long Beach, CA, USA
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Abstract
Physiologic changes of pregnancy result in a hypercoagulable state, placing the risk for venous thromboembolic events at 1 in 1600 births. Venous thromboembolic events are one of the leading causes of maternal mortality. A correlation among venous thromboembolic events, pregnancy complications, and inherited thrombophilia continues to be investigated. This article primarily focuses on the impact of inherited thrombophilias on pregnancy, labor, and birth and yet also addresses acquired thrombophilia. Prophylactic and therapeutic perinatal anticoagulation are lifesaving and pregnancy-sparing interventions. Interprofessional management of these high-risk pregnancies allows for increased surveillance to reduce perinatal morbidity and mortality.
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Thomas O, Larsson A, Tynngård N, Schött U. Thromboelastometry versus free-oscillation rheometry and enoxaparin versus tinzaparin: an in-vitro study comparing two viscoelastic haemostatic tests' dose-responses to two low molecular weight heparins at the time of withdrawing epidural catheters from ten patients after major surgery. BMC Anesthesiol 2015; 15:170. [PMID: 26603039 PMCID: PMC4659161 DOI: 10.1186/s12871-015-0145-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 11/11/2015] [Indexed: 11/24/2022] Open
Abstract
Background Monitoring low molecular weight heparins (LMWH’s) in the perioperative period is prudent in patients at high risk of coagulative complications, especially when the patient has an epidural catheter requiring withdrawal, which is associated with the risk of spinal haematoma. The aim of this study was to evaluate the in vitro dose-responses of two different LMWH’s on two different viscoelastic haemostatic tests, using blood sampled from patients with normal routine coagulation parameters, on the day after major surgery when their epidural catheters were due to be withdrawn. Methods Enoxaparin or tinzaparin were added in vitro to blood from ten patients who had undergone oesophageal resection, to obtain plasma concentrations of approximately 0, 0.5, 1.0 and 1.5 IU/mL. Coagulation was monitored using thromboelastometry (ROTEM®) using the InTEM® activating reagent; and free oscillation rheometry (FOR: ReoRox®), activated using thromboplastin. Clot initiation was measured using ROTEM-CT, ReoRox-COT1 and ReoRox–COT2. Clot propagation was measured using ROTEM-CFT, ROTEM-Alpha Angle and ReoRox-Slope. Clot stability was measured using ROTEM-MCF and ReoRox-G’max, and clot lysis was measured using ROTEM-ML and ReoRox-ClotSR. Results Clot initiation time assessed by thromboelastometry and FOR was prolonged by increasing concentrations of both LMWH’s (P < 0.01). Equivalent doses of tinzaparin in international units (anti-FXa units) per millilitre prolonged clot initiation more than enoxaparin (P < 0.05). There was significant inter-individual variation – the ranges of CT and COT1 at LMWH-concentrations of 0 and 1.5 IU/mL overlapped. None of the tests reflecting clot formation rate or stability showed a dose–response to either LMWH but clot lysis showed a tentative negative dose–response to the LMWH’s. Conclusions Clot initiation time’s dose-dependent prolongation by LMWH’s in this study agrees with previous research, as does tinzaparin’s stronger anti-coagulative effect than enoxaparin at equivalent levels of anti-FXa activity. This casts doubt on the validity of using anti-FXa assays alone to guide dosage of LMWH’s. The significant inter-individual variation in dose–response suggests that the relationship between dose and effect in the postoperative period is complicated. While both ROTEM and FOR may have some role in postoperative monitoring, more research is needed before any conclusion can be made about their clinical usefulness. Electronic supplementary material The online version of this article (doi:10.1186/s12871-015-0145-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Owain Thomas
- Medical Faculty, University of Lund, Lund, Sweden. .,Department of Paediatric Anaesthesia and Intensive Care, SUS Lund University Hospital, Lund, Sweden.
| | - Anna Larsson
- Medical Faculty, University of Lund, Lund, Sweden
| | - Nahreen Tynngård
- Department of Clinical Immunology and Transfusion Medicine, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Clinical Chemistry, Department of Clinical Experimental Medicine, Linköping University, Linköping, Sweden
| | - Ulf Schött
- Medical Faculty, University of Lund, Lund, Sweden.,Department of Anaesthesia and Intensive Care, SUS Lund University Hospital, Lund, Sweden
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Sandström A, Cnattingius S, Wikström AK, Stephansson O, Iliadou AN. Does Use of Low-Molecular-Weight Heparin during Pregnancy Influence the Risk of Prolonged Labor: A Population-Based Cohort Study. PLoS One 2015; 10:e0140422. [PMID: 26465918 PMCID: PMC4605614 DOI: 10.1371/journal.pone.0140422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 09/26/2015] [Indexed: 12/25/2022] Open
Abstract
Background The use of low-molecular-weight heparins (LMWHs) during pregnancy is increasing. In vitro studies and small clinical studies support the hypothesis that LMWH treatment during pregnancy may reduce duration of labor. The aim of this study was to investigate if use of LMWH is associated with a reduced risk of diagnosis of prolonged labor, after taking maternal, fetal and other delivery characteristics into account. Methods and Findings A population-based cohort study from the Swedish Medical Birth Register from April 2006 through December 2011. We identified 514 875 term (≥37 weeks) deliveries of live singleton infants in cephalic presentation with spontaneous or induced onsets of labor. The Birth Register was linked to the Prescribed Drug Register to retrieve information on dispensed LMWH during pregnancy and to the Patient Register for information on underlying diagnosis for use of LMWH. Diagnosis of prolonged labor in the Birth Register was retrieved from diagnosis at discharge from the delivery hospital. The risk of diagnosis of prolonged labor in relation to treatment with LMWH was assessed using logistic regression analysis to estimate unadjusted and adjusted odds ratios. A total of 5 275 (1.0%) of the pregnant women used LMWH. The absolute risk of diagnosis of prolonged labor for nulliparous women was 19.9% among women using LMWH in third trimester, and 21.2% in women without use of LMWH. For parous women the corresponding absolute risks were 4.3% and 4.7%, respectively. Compared to nulliparous women without use of LMWH, nulliparous women with LMWH during third trimester had an odds ratio (OR) of 0.92 (95% CI 0.81–1.05, p-value: 0.051) for diagnosis of prolonged labor in unadjusted analyses and after adjustments for maternal characteristics, gestational age and epidural analgesia the OR was 1.00 (95% CI 0.87–1.15, p-value: 0.673). Parous women treated with LMWH in third trimester presented the same pattern, unadjusted OR for diagnosis of prolonged labor was 0.92 (95% CI 0.76–1.12, p-value: 0.418) and after adjustments OR was 0.99 (95% CI 0.80–1.22, p-value: 0.892). One limitation with the study was that information on prolonged labor was based on discharge diagnoses from the delivery hospital according to the International Classification of Diseases (ICD). Conclusions Treatment with LMWH during pregnancy is not associated with a risk of diagnosis of prolonged labor after adjustments for maternal, fetal and delivery characteristics.
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Affiliation(s)
- Anna Sandström
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska University Hospital, and Institutet, Stockholm, Sweden
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska University Hospital, and Institutet, Stockholm, Sweden
- * E-mail:
| | - Sven Cnattingius
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska University Hospital, and Institutet, Stockholm, Sweden
| | - Anna-Karin Wikström
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska University Hospital, and Institutet, Stockholm, Sweden
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Olof Stephansson
- Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska University Hospital, and Institutet, Stockholm, Sweden
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska University Hospital, and Institutet, Stockholm, Sweden
| | - Anastasia N. Iliadou
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Management and outcome of pregnancies in women with antithrombin deficiency. Blood Coagul Fibrinolysis 2015; 26:798-804. [DOI: 10.1097/mbc.0000000000000348] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Radović-Janošević D, Popović J, Tubić-Pavlović A, Krtinić D. THROMBOPHILIA IN PREGNANCY – CURRENT ISSUE OF MODERN PERINATOLOGY. ACTA MEDICA MEDIANAE 2015. [DOI: 10.5633/amm.2015.0309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Perioperative and peripartum prevention of venous thromboembolism in patients with hereditary antithrombin deficiency using recombinant antithrombin therapy. Blood Coagul Fibrinolysis 2015; 25:444-50. [PMID: 24686101 DOI: 10.1097/mbc.0000000000000076] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Recombinant human antithrombin (rhAT; ATryn), isolated from the milk of transgenic goats, provides an alternative to human plasma-derived antithrombin (AT) concentrate for perioperative and peripartum prophylaxis of venous thromboembolism (VTE) in patients with hereditary AT deficiency. Optimized rhAT dosing algorithms and improved plasma AT monitoring protocol were used in an open-label, single-arm, multinational, pivotal safety and efficacy study that was conducted in patients with hereditary AT deficiency in perioperative and peripartum settings. Loading and maintenance doses were calculated on the basis of pretreatment AT activity levels. Specific dosing regimens were used for pregnant and surgical patients; rhAT was to be given for at least 3 days and for 14 days or less. The primary efficacy end point was the incidence of any thromboembolic event during rhAT therapy or within 7 days of rhAT discontinuation. Safety and AT activity levels were secondary end points. Six surgical and 12 pregnant patients were treated for a median of 3.2 days (range 0.9-14 days). With the optimized dosing regimens, a median of 1 dose adjustment (range 0-6 dose adjustments) was needed to maintain AT activity levels within 80-120% of normal. No confirmed VTEs occurred during treatment or in the subsequent 7 days. Overall, rhAT was well tolerated, but some bleeding complications occurred after rhAT discontinuation and anticoagulation reinstitution. No antibodies to rhAT or goat milk proteins were detected. Perioperative and peripartum prophylactic rhAT therapy in patients with hereditary AT deficiency is well tolerated and effective in preventing VTE.
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Yuksel H, Kayatas S, Boza AT, Api M, Ertekin AA, Cam C. Low molecular weight heparin use in unexplained recurrent miscarriage. Pak J Med Sci 2015; 30:1232-7. [PMID: 25674114 PMCID: PMC4320706 DOI: 10.12669/pjms.306.5477] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 08/13/2014] [Accepted: 08/13/2014] [Indexed: 11/29/2022] Open
Abstract
Objective: The aim of the study was to investigate whether the use of low molecular weight heparin (LMWH) improve live birth rates when compared with control group in patients with unexplained recurrent miscarriages (URM). Methods: In this prospective observational study 150 women with a history of two or more previous unexplained first trimester pregnancy loss who received LMWH; either enoxaparin (n=50), tinzaparin (n=50) or nothing (n=50) were followed for the pregnancy outcome measures. Only the patients who have used standardized dosage of LMWH (4000 IU/day enoxaparin or 3500 IU/day tinzaparin ) were included to the study. The primary end point was the live birth rate and secondary end points were the side effects, late pregnancy complications and neonatal outcome in the study cohorts. Results: Live birth was achieved 85% of the LMWH group and 66% of the control group (p=0.007). According to the subgroup analysis; live birth rates did not differ significantly between the enoxaparin and tinzaparin group (84% and 86%, respectively). Maternal and neonatal side effects were not statistically significant among the study participants. Conclusion: Thromboprophylaxis with LMWH resulted in a improved live-birth rate in patient with 2 or more consecutive unexplained recurrent pregnancy loss. Nevertheless these findings need to be confirmed in larger randomized trials.
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Affiliation(s)
- Halide Yuksel
- Halide Yuksel, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
| | - Semra Kayatas
- Semra Kayatas, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
| | - Aysen Telce Boza
- Aysen Telce Boza, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
| | - Murat Api
- Murat Api, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
| | - A Aktug Ertekin
- A.Aktug Ertekin, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
| | - Cetin Cam
- Cetin Cam, Zeynep Kamil Women and Children Diseases Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, 34668
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van den Bosch AE, Ruys TPE, Roos-Hesselink JW. Use and impact of cardiac medication during pregnancy. Future Cardiol 2015; 11:89-100. [DOI: 10.2217/fca.14.68] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
ABSTRACT Cardiovascular disease is the most encountered cause of maternal death during pregnancy in the western world and an increase in maternal mortality due to cardiac causes has been observed. More women with congenital or acquired heart disease have the desire to become pregnant. Pregnancy is known to impose a major hemodynamic burden and also has impacts on the coagulation system. The risk of developing complications is clearly increased as compared with the normal population. For optimal management, it is crucial to have information on the effects of cardiac medications on the fetus. The focus of this article is to discuss the management of cardiac disease in pregnancy, as well as the known safety of cardiac medications for the mother and/or fetus.
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Affiliation(s)
- Annemien E van den Bosch
- Department of Cardiology, Thorax Center, Erasmus Medical Center, ‘s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Titia PE Ruys
- Department of Cardiology, Thorax Center, Erasmus Medical Center, ‘s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
| | - Jolien W Roos-Hesselink
- Department of Cardiology, Thorax Center, Erasmus Medical Center, ‘s-Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands
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Fournet-Fayard A, Lebreton A, Ruivard M, Storme B, Godeau B, Bonnin M, Delabaere A, Gallot D. Prise en charge anténatale des patientes à risque d’hémorragie du post-partum (hors anomalies de l’insertion placentaire). ACTA ACUST UNITED AC 2014; 43:951-65. [DOI: 10.1016/j.jgyn.2014.09.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Rodger MA, Hague WM, Kingdom J, Kahn SR, Karovitch A, Sermer M, Clement AM, Coat S, Chan WS, Said J, Rey E, Robinson S, Khurana R, Demers C, Kovacs MJ, Solymoss S, Hinshaw K, Dwyer J, Smith G, McDonald S, Newstead-Angel J, McLeod A, Khandelwal M, Silver RM, Le Gal G, Greer IA, Keely E, Rosene-Montella K, Walker M, Wells PS. Antepartum dalteparin versus no antepartum dalteparin for the prevention of pregnancy complications in pregnant women with thrombophilia (TIPPS): a multinational open-label randomised trial. Lancet 2014; 384:1673-83. [PMID: 25066248 DOI: 10.1016/s0140-6736(14)60793-5] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Thrombophilias are common disorders that increase the risk of pregnancy-associated venous thromboembolism and pregnancy loss and can also increase the risk of placenta-mediated pregnancy complications (severe pre-eclampsia, small-for-gestational-age infants, and placental abruption). We postulated that antepartum dalteparin would reduce these complications in pregnant women with thrombophilia. METHODS In this open-label randomised trial undertaken in 36 tertiary care centres in five countries, we enrolled consenting pregnant women with thrombophilia at increased risk of venous thromboembolism or with previous placenta-mediated pregnancy complications. Eligible participants were randomly allocated in a 1:1 ratio to either antepartum prophylactic dose dalteparin (5000 international units once daily up to 20 weeks' gestation, and twice daily thereafter until at least 37 weeks' gestation) or to no antepartum dalteparin (control group). Randomisation was done by a web-based randomisation system, and was stratified by country and gestational age at randomisation day with a permuted block design (block sizes 4 and 8). At randomisation, site pharmacists (or delegates) received a randomisation number and treatment allocation (by fax and/or e-mail) from the central web randomisation system and then dispensed study drug to the local coordinator. Patients and study personnel were not masked to treatment assignment, but the outcome adjudicators were masked. The primary composite outcome was independently adjudicated severe or early-onset pre-eclampsia, small-for-gestational-age infant (birthweight <10th percentile), pregnancy loss, or venous thromboembolism. We did intention-to-treat and on-treatment analyses. This trial is registered with ClinicalTrials.gov, number NCT00967382, and with Current Controlled Trials, number ISRCTN87441504. FINDINGS Between Feb 28, 2000, and Sept 14, 2012, 292 women consented to participate and were randomly assigned to the two groups. Three women were excluded after randomisation because of ineligibility (two in the antepartum dalteparin group and one in the control group), leaving 146 women assigned to antepartum dalteparin and 143 assigned to no antepartum dalteparin. Some patients crossed over to the other group during treatment, and therefore for on-treatment and safety analysis there were 143 patients in the dalteparin group and 141 in the no dalteparin group. Dalteparin did not reduce the incidence of the primary composite outcome in both intention-to-treat analysis (dalteparin 25/146 [17·1%; 95% CI 11·4-24·2%] vs no dalteparin 27/143 [18·9%; 95% CI 12·8-26·3%]; risk difference -1·8% [95% CI -10·6% to 7·1%)) and on-treatment analysis (dalteparin 28/143 [19·6%] vs no dalteparin 24/141 [17·0%]; risk difference +2·6% [95% CI -6·4 to 11·6%]). In safety analysis, the occurrence of major bleeding did not differ between the two groups. However, minor bleeding was more common in the dalteparin group (28/143 [19·6%]) than in the no dalteparin group (13/141 [9·2%]; risk difference 10·4%, 95% CI 2·3-18·4; p=0·01). INTERPRETATION Antepartum prophylactic dalteparin does not reduce the occurrence of venous thromboembolism, pregnancy loss, or placenta-mediated pregnancy complications in pregnant women with thrombophilia at high risk of these complications and is associated with an increased risk of minor bleeding. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, and Pharmacia and UpJohn.
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Affiliation(s)
- Marc A Rodger
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - William M Hague
- Obstetric Medicine, Robinson Institute, University of Adelaide, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - John Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Susan R Kahn
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC, Canada
| | - Alan Karovitch
- Department of Medicine, University of Ottawa/Ottawa Hospital, Ottawa, ON, Canada
| | - Mathew Sermer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | | | - Suzette Coat
- Robinson Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Wee Shian Chan
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Joanne Said
- Maternal Fetal Medicine, NorthWest Academic Center, University of Melbourne, Melbourne, Australia
| | - Evelyne Rey
- Departments of Medicine and Obstetrics and Gynecology, University of Montreal, and CHU Sainte-Justine Research Center, Montreal, QC, Canada
| | - Sue Robinson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Rshmi Khurana
- Departments of Medicine and Obstetrics and Gynecology, University of Alberta, Royal Alexandra Hospital, Edmonton, AB, Canada
| | | | - Michael J Kovacs
- Department of Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada
| | - Susan Solymoss
- Department of Medicine, McGill University, St Mary's Hospital Center, Montreal, QC, Canada
| | - Kim Hinshaw
- Department of Obstetrics, Sunderland Royal Hospital, Sunderland, Tyne and Wear, UK
| | - James Dwyer
- Department of Obstetrics and Gynaecology, York Hospital, York, UK
| | - Graeme Smith
- Department of Obstetrics and Gynecology, Queen's University, Kingston, ON, Canada
| | - Sarah McDonald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Department of Radiology, and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | | | - Anne McLeod
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Meena Khandelwal
- Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University/Cooper Hospital, Camden, NJ, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Gregoire Le Gal
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa/Ottawa Hospital, Ottawa, ON, Canada
| | - Ian A Greer
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Erin Keely
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa/Ottawa Hospital, Ottawa, ON, Canada
| | - Karen Rosene-Montella
- Department of Medicine, The Warren Alpert Medical School of Brown University, Women's Medicine Collaborative, Providence, RI, USA
| | - Mark Walker
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Philip S Wells
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Medicine, University of Ottawa/Ottawa Hospital, Ottawa, ON, Canada
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Bleau N, Patenaude V, Abenhaim HA. Risk of Venous Thromboembolic Events in Pregnant Patients With Autoimmune Diseases. Clin Appl Thromb Hemost 2014; 22:285-91. [DOI: 10.1177/1076029614553023] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Objective: The objective of this study is to evaluate the effect of autoimmune disease on the risk of venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE) in pregnant women. Methods: Using the Health Care Cost and Utilization Project, Nationwide Inpatient Sample database from 2003 to 2011, the risk of developing DVT, PE, and VTE among pregnant patients with selected autoimmune diseases was estimated using unconditional logistic regression analysis. Results: Our study cohort consisted of 7 917 453 women of which 43 523 had underlying autoimmune diseases. Risk of VTE was high in pregnant women with systemic lupus erythematosus, dermatomyositis, rheumatoid arthritis, type 1 diabetes mellitus, ulcerative colitis, and Crohn’s disease. Conclusion: Most autoimmune diseases considerably increase the risk of VTE. Thromboprophylaxis may be considered in pregnancies with autoimmune disease, particularly those with systemic lupus erythematosus and dermatomyositis.
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Affiliation(s)
- Nathalie Bleau
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Valerie Patenaude
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
| | - Haim A. Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
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Abstract
Coagulation is an organized and well-orchestrated process that depends on the intrinsic balance between procoagulants, anticoagulants, and fibrinolytic systems. During pregnancy, this balance is affected in various ways and becomes more critical due to the physiologic changes and obligate hemorrhage after delivery. In some instances, this equilibrium will be disrupted. In this article, we describe the anesthetic implications of bleeding disorders, thrombophilias, and anticoagulation for the safe management of the parturient, with an emphasis on how this impacts decision-making by the anesthesiologist.
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Affiliation(s)
| | - Andrew Eisenberger
- Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, NY
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Pommerening MJ, Schwartz DA, Cohen MJ, Schreiber MA, del Junco DJ, Camp EA, Wade CE, Holcomb JB, Cotton BA. Hypercoagulability after injury in premenopausal females: A prospective, multicenter study. Surgery 2014; 156:439-47. [DOI: 10.1016/j.surg.2014.04.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 04/14/2014] [Indexed: 11/24/2022]
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Figueiró-Filho EA, Aydos RD, Senefonte FRDA, Ferreira CM, Pereira EFDV, Oliveira VMD, Menezes GPD, Bósio MAC. Effects of enoxaparin and unfractionated heparin in prophylactic and therapeutic doses on the fertility of female Wistar rats. Acta Cir Bras 2014; 29:410-6. [PMID: 25054870 DOI: 10.1590/s0102-86502014000700001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 05/22/2014] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate the effects of exposure of enoxaparin and unfractionated heparin (UFH) in prophylactic and therapeutic doses on the fertility rates of pregnant healthy Wistar rats. METHODS Enoxaparin and UFH were administered in prophylactic doses 1 mg/Kg/day 72 UI/Kg/day, and in therapeutic doses at 2 mg/kg/day 400UI/Kg/day. The rats were divided into five groups. The number of live and dead foetuses was quantified. The uterine horns were dissected and the presence of early and late reabsorptions (abortions) was determined. A p<0.05 was considered statistically significant. RESULTS We did not observe statistically significant differences between groups when comparing the average weight of the foetuses and placentas, rate of female VS males, rates of pre-implantation loss (RPL), rates of efficiency implantation (REI), rates of post-implantation loss (RPIL) and rates of foetal viability (RFV). CONCLUSIONS There was no significant effect on fertility with the use of anticoagulant drugs in pregnant healthy Wistar rats.
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Ghidini A, Gratacos E. Can prenatal screening reduce the adverse obstetric outcomes related to abnormal placentation? Prenat Diagn 2014; 34:613-7. [DOI: 10.1002/pd.4423] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 05/13/2014] [Accepted: 05/13/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Alessandro Ghidini
- Perinatal Diagnostic Center; Inova Alexandria Hospital; Alexandria VA USA
| | - Eduard Gratacos
- BCNatal, Barcelona Center for Maternal-Fetal and Neonatal Medicine; Hospital Clinic and Hospital Sant Joan de Deu, IDIBAPS, CIBERER and Universitat de Barcelona; Spain
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Super obesity in pregnancy: difficulties in clinical management. J Perinatol 2014; 34:495-502. [PMID: 24503915 DOI: 10.1038/jp.2014.4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 12/23/2013] [Accepted: 01/07/2014] [Indexed: 01/29/2023]
Abstract
As the obesity pandemic continues in the United States, obesity in pregnancy has become an area of interest. Many studies focus on women with body mass index (BMI) ⩾ 30 kg m(-2). Unfortunately, the prevalence of patients with BMI ⩾ 50 kg m(-2) is rapidly increasing, and there are few studies specifically looking at pregnant women in this extreme category. The purpose of this article is to highlight some of the challenges faced and review the literature available to help guide obstetricians who might encounter such patients.
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Butwick A, Hass C, Wong J, Lyell D, El-Sayed Y. Anticoagulant prescribing practices and anesthetic interventions among anticoagulated pregnant patients: a retrospective study. Int J Obstet Anesth 2014; 23:238-45. [PMID: 24910353 DOI: 10.1016/j.ijoa.2014.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 02/27/2014] [Accepted: 03/16/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The peripartum management of anticoagulated patients poses important challenges for obstetric anesthesiologists, especially when deciding to perform neuraxial block. However, there is limited evidence evaluating anticoagulant prescribing practices and neuraxial block utilization in this setting. Our objective was to examine peripartum anticoagulant prescribing and anesthetic practices in a cohort of anticoagulated patients receiving subcutaneous enoxaparin, and subcutaneous or intravenous unfractionated heparin. METHODS We performed a retrospective study of anticoagulant prescribing patterns and anesthetic interventions among patients receiving enoxaparin and/or unfractionated heparin who delivered at a USA obstetric center over a seven-year period. RESULTS We identified 101 patients who received enoxaparin and/or unfractionated heparin before delivery. Thirty-nine (38.6%) patients received enoxaparin only, 41 (40.6%) patients received enoxaparin bridged to subcutaneous unfractionated heparin, 11 (10.9%) patients received enoxaparin and were converted to intravenous unfractionated heparin and 10 (9.9%) patients received only subcutaneous unfractionated heparin. The overall rate of neuraxial block utilization was 80.2%. The median [IQR] time-period between the last dose of enoxaparin and neuraxial block was significantly shorter for patients who received only enoxaparin vs. enoxaparin with subcutaneous unfractionated heparin (54h [12-192h] (n=26) vs. 216h [39-504h] (n=23), P=0.04). Among patients who received only subcutaneous unfractionated heparin, the time period between unfractionated heparin and neuraxial block was 24h [19-51h]. CONCLUSION In this study, the neuraxial block rate was high among patients receiving enoxaparin and/or subcutaneous unfractionated heparin with patients undergoing relatively long periods off anticoagulation. Careful multidisciplinary planning is recommended for the peripartum management of anticoagulated pregnant patients.
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Affiliation(s)
- A Butwick
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA.
| | - C Hass
- NYU School of Medicine, New York, NY, USA
| | - J Wong
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - D Lyell
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Y El-Sayed
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
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Ghidini A. Overview of low molecular weight heparin for preventative treatment of adverse obstetric outcomes related to abnormal placentation. Prenat Diagn 2014; 34:649-54. [PMID: 24752745 DOI: 10.1002/pd.4385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/07/2014] [Accepted: 04/09/2014] [Indexed: 11/10/2022]
Abstract
Different proportions of cases of preterm and severe preeclampsia, placental abruption, fetal growth restriction, and fetal death share a common causal pathway of abnormal placental implantation. Documentation of an association between the risk of such adverse pregnancy outcomes (APOs) and inherited thrombophilias prompted initial studies to evaluate the benefit of anticoagulants for the prevention of recurrences both in patients with and without inherited thrombophilias. Prenatal administration of low molecular weight heparin (LMWH) has been evaluated in case control, cohort and randomized clinical trials. The evidence suggests a benefit of LMWH in the reduction of recurrences of APOs, with a number needed to treat of 6 (95% confidence interval: 4-10) to prevent one case of recurrent APOs. Such benefit is independent of the presence of inherited thrombophilias or the administration of low dose aspirin. Further studies are needed to establish the optimal duration for the prophylaxis, to better delineate the mechanism of action of LMWH and to explore the role, if any, of maternal serum markers and uterine artery Doppler findings in the modulation of the LMWH prophylaxis.
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Affiliation(s)
- Alessandro Ghidini
- Perinatal Diagnostic Center, Inova Alexandria Hospital, Alexandria, VA, USA
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Newstead-Angel J, Gibson PS. Cardiac drug use in pregnancy: safety, effectiveness and obstetric implications. Expert Rev Cardiovasc Ther 2014; 7:1569-80. [DOI: 10.1586/erc.09.152] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Venous thromboembolism remains in the top three leading causes of maternal death in the US, representing 10.2% of pregnancy-related deaths. Risk of developing a pulmonary embolus appears to increase throughout pregnancy, with a peak in incidence in the early postpartum period. Overall the incidence of VTE is 0.6-1.8 VTEs per 1000 deliveries. Diagnosis and management of pulmonary embolus can prove challenging, but the aim should be to optimize maternal outcome while minimizing hemorrhagic complications. Low-molecular-weight heparin is a safe and effective treatment for the majority of cases of pregnancy-related pulmonary embolus.
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Affiliation(s)
- Jennifer C Donnelly
- Department of OB/GYN, Columbia University Medical Center, 622 West 168th St, PH 12-32, New York, NY 10032, USA.
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[Antithrombotic therapy and pregnancy]. Presse Med 2013; 42:1251-8. [PMID: 23855993 DOI: 10.1016/j.lpm.2013.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 05/27/2013] [Accepted: 06/12/2013] [Indexed: 11/21/2022] Open
Abstract
The incidence of venous thromboembolism (VTE) during pregnancy is about one event per 1000 pregnancies and placenta-mediated pregnancy complications (PC) occurred in 15%. Knowing the biological combined with clinical risk factors would help to prevent problems during the pregnancy. Several antithrombotic therapies exist, including very recent ones but LMWH and aspirin are still molecules of choice. The women should be assessed for VTE and PC risk in order to improve the outcome.
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