Anticoagulation in Pregnancy

Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners

Diagnostic and therapeutic decision-making in pregnancy with suspected pulmonary embolism (PE) is challenging. European and other international professional societies have proposed various recommendations that are ambiguous, probably due to the unavailability of randomized controlled trials. In the following sections, we discuss the supporting diagnostic steps and treatments. We suggest a standardized diagnostic work-up in pregnant patients presenting with symptoms of PE to make evidence-based diagnostic and therapeutic decisions. We strongly recommend that clinical decisions on treatment in pregnant patients with intermediate- or high-risk pulmonary embolism should include a multidisciplinary team approach involving emergency physicians, pulmonologists, angiologist, cardiologists, thoracic and/or cardiovascular surgeons, radiologists, and obstetricians to choose a tailored management option including an interventional treatment. It is important to be aware of the differences among guidelines and to assess each case individually, considering the specific views of the different specialties. This review summarizes key concepts of the diagnostics and acute management of pregnant women with suspected PE that are supportive for the clinician on duty.

The Role of Helicobacter pylori and Metabolic Syndrome-Related Mast Cell Activation Pathologies and Their Potential Impact on Pregnancy and Neonatal Outcomes

Helicobacter pylori infection, a significant global burden beyond the gastrointestinal tract, has long been implicated in various systemic pathologies. Rising evidence suggests that the bacterium's intricate relationship with the immune system and its potential to induce chronic inflammation impact diverse pathophysiological processes in pregnant women that may in turn affect the incidence of several adverse pregnancy and neonate outcomes. Helicobacter pylori infection, which has been linked to metabolic syndrome and other disorders by provoking pericyte dysfunction, hyperhomocysteinemia, galectin-3, atrial fibrillation, gut dysbiosis, and mast cell activation pathologies, may also contribute to adverse pregnancy and neonatal outcomes. Together with increasing our biological understanding of the individual and collective involvement of Helicobacter pylori infection-related metabolic syndrome and concurrent activation of mast cells in maternal, fetus, and neonatal health outcomes, the present narrative review may foster related research endeavors to offer novel therapeutic approaches and informed clinical practice interventions to mitigate relevant risks of this critical topic among pregnant women and their offspring.

Pregnancy-Associated Spontaneous Coronary Acute Dissection as a Cause of Sudden Cardiac Death-Autopsy Findings and Literature Review: Is COVID-19 Related?

Sudden cardiac death (SCD) is the leading cause of mortality globally (violent or non-violent), with few to no feasible remedies. The etiopathogenesis of SCD involves a complex and multilayered substrate in which dynamic factors interact with a preexistent cardiovascular pathology, which is often undiagnosed and untreated, leading to the rapid development of cardiac rhythm disorders and cardiac arrest. Cardiovascular disease is a rare but emerging factor in maternal mortality that can be justified by an upward trend in the mean age of pregnant individuals. Spontaneous coronary artery dissection (SCAD) is defined as a non-traumatic and non-iatrogenic separation of the coronary arterial wall by intramural hemorrhage with or without an intimal tear. The resulting intramural hematoma compresses the coronary arteries, reducing blood flow and causing myocardial ischemia. SCAD continues to be misdiagnosed, underdiagnosed, and managed as an atherosclerotic acute coronary syndrome, which may harm patients with SCAD. The latest research shows that individuals who have or have had coronavirus disease 2019 (COVID-19) may also present coagulation abnormalities, so infection with COVID-19 during pregnancy can increase this hypercoagulable condition, thus increasing the risk of SCAD and SCD. This present study reports two cases over 35 years, one being infected with SARS-COV2 one month before the event and the other being tested positive during admission, both asymptomatic, who were declared healthy on periodic clinical evaluations, with pregnancies over 35 weeks, with normal fetal development, which suddenly caused chest pain, dyspnea, and loss of consciousness, required emergency c-sections, and died suddenly after they were performed. In both cases, the cause of death was SCAD on the anterior-descending artery. In both cases, emergency percutaneous coronary intervention was performed. The second part of the study represents a literature overview of SCAD during COVID-19. In addition to pregnancy hormonal changes, other potential hormone-mediated SCAD triggers are still under discussion.

Myocardial Infarction With Non-obstructive Coronary Arteries: Risk Factors and Associated Comorbidities

Myocardial infarction with non-obstructive coronary arteries (MINOCA), despite a lower burden of coronary atherosclerosis, has a non-negligible prognostic impact. The label of MINOCA includes an array of different aetiologies and pathologic conditions, thus the identification of the underlying disease is crucial to patient management. Myocardial infarction with obstructive coronary artery disease and MINOCA share only some risk factors and comorbid conditions. While traditional cardiovascular risk factors have a lower prevalence in MINOCA patients, atypical ones—e.g., anxiety, depression, and autoimmune diseases—are much more frequent in this population. Other conditions—e.g., pregnancy, cancer, and anti-cancer therapy—can predispose to or even induce MINOCA through various mechanisms. The evidence of such risk factors for MINOCA is still scarce and contradicting, as no randomised controlled trials exist in this field. In our work, we performed a review of registries, clinical studies, and case reports of MINOCA, in order to summarise the available data and analyse its possibile pathogenic mechanisms.

Society for Maternal-Fetal Medicine Consult Series #61: Anticoagulation in pregnant patients with cardiac disease

Pregnancy in individuals with a mechanical heart valve has been classified as very high risk because of a substantially increased risk of maternal mortality or severe morbidity. Lifelong therapeutic anticoagulation is a principal component of the medical management of mechanical heart valves to prevent valve thrombosis. Anticoagulation regimens indicated outside of pregnancy for patients with mechanical valves should be continued during pregnancy with the possibility of modifications based on the type of valve, the trimester of pregnancy, individual risk tolerance, and circumstances around the time of delivery. The purpose of this document is to provide recommendations regarding the management of anticoagulation for common cardiac conditions complicating pregnancy, including mechanical heart valves, atrial fibrillation, systolic heart failure, and congenital heart disease.

Clinical Characteristics of 10 Pregnant and Postpartum Women With Extracorporeal Membrane Oxygenation: A Retrospective Study

Background: The aim of study was to summarize the clinical characteristics and experience of extracorporeal membrane oxygenation (ECMO) in pregnant and postpartum patients. Methods and Results: We retrospectively reviewed 131 consecutive ECMO patients at our center from May 2015 to May 2021. A total of 10 Chinese patients were pregnant or postpartum at the time of ECMO initiation. Patients ranged in age from 25 to 36 years (median age 30.5 years). The ECMO duration ranged from 3 to 31 days (median duration 8 days). There was a stabilizing trend of acid-base balance and decreasing lactic acid over the 3 days following ECMO initiation. Seven (70%) patients survived at least 48 h after weaning from ECMO. Four (40%) patients survived until discharge, and four (40%) fetuses survived until discharge. Conclusion: ECMO provides a suitable temporary cardiopulmonary support for pregnant and postpartum patients. ECMO shows a favorable effect on short-term stability in critical obstetric patients.

Pregnancy-related acute myocardial infarction: a review of the recent literature

Pregnancy-related acute myocardial infarction is a rare and potentially life-threatening cardiovascular event, the incidence of which is growing due to the heightened prevalence of several risk factors, including increased maternal age. Its main aetiology is spontaneous coronary artery dissection, which particularly occurs in pregnancy and may engender severe clinical scenarios. Therefore, despite frequently atypical and deceptive presentations, early recognition of such a dangerous complication of gestation is paramount. Notwithstanding diagnostic and therapeutic improvements, pregnancy-related acute myocardial infarction often carries unfavourable outcomes, as emergent management is difficult owing to significant limitations in the use of ionising radiation-e.g. during coronary angiography, potentially harmful to the foetus even at low doses. Notably, however, maternal mortality has steadily decreased in recent decades, indicating enhanced awareness and major medical advances in this field. In our paper, we review the recent literature on pregnancy-related acute myocardial infarction and highlight the key points in its management.

Managing anticoagulation in pregnancy for the anaesthetist on the labour ward

Pregnancy is a hypercoaguable state. As part of the multidisciplinary team on labour ward, the anaesthetist plays a role particularly in advising the women and the obstetric team regarding the timing and even choice of regional analgesia given the potential risk of complications, as this may be affected by the anticoagulation treatment pregnant women may be on. It is important to understand the type of anticoagulation regimens parturients might be on and what sort of risk assessment they must undergo, as this has obstetric and anaesthetic implications. Although a rare presentation, management of women with mechanical prosthetic heart valves who are pregnant requires detailed and highly specialised care in tertiary care centres with a well-developed multidisciplinary team and pathway. Despite their rare presentation, it is important to understand the intricate and complex management that these women require as they have a high morbidity and mortality rate.

Pulmonary Embolism After Vaginal Delivery in a Fontan Patient

The Fontan procedure was created to address the mixing of pulmonary and systemic venous return in patients with a single functional ventricle. The patient in this case with a Fontan repair experienced multiple pulmonary emboli 10 days post-partum. We outline management and recommendations when treating these patients. (Level of Difficulty: Beginner.).

Valvular Heart Disease in Pregnancy: Anticoagulation and the Role of Percutaneous Treatment

Valvular heart disease is present in about 1% of pregnancies, and it poses a management challenge as both fetal and maternal lives are at risk of complications. Pregnancy is associated with significant hemodynamic changes, which can compromise the cardiac status in women with underlying valvular disorders. Management of valvular heart diseases has undergone considerable innovation and advancement with newer techniques, approaches and devices being employed. The decision regarding the management of anticoagulation, especially in patients with prosthetic valves, raises distinct questions and challenges. In this review, we describe the management of common valvular heart diseases encountered during pregnancy, role of percutaneous catheter based therapeutic interventions, the importance of a team-based approach, and the challenges given existing gaps in the literature.

High-Versus Low-Dose Warfarin-Related Teratogenicity: A Case Report and Systematic Review

OBJECTIVE

The optimal anticoagulant therapy during pregnancy in women with mechanical heart valves remains controversial. This study highlights a case of high-dose warfarin ingestion throughout pregnancy and performed a systematic review to assess rates of teratogenicity with high versus low warfarin dosing (≤5 mg daily).

METHODS

A literature search for all case reports and available literature was conducted in PubMed, Medline, and EMBASE up to December 2016 using medical subject heading terms "mechanical prosthetic valves," "pregnancy," "oral anticoagulants," "warfarin," "coumarins," "heparin, low-molecular-weight," and "thromboembolism." To be included, warfarin had to be administered anytime between 6 and 12 weeks of gestation with the dose being specified. The Newcastle-Ottawa Scale was used to assess quality of the cohort data.

RESULTS

The woman in the studied case received the highest reported warfarin doses throughout pregnancy (14.5-16.5 mg daily) and delivered a baby with no evidence of teratogenicity to the current age of 5 years. The study identified 23 case reports, with all demonstrating warfarin teratogenicity regardless of high-dose (n = 12) or low-dose (n = 11) warfarin. Twelve cohort studies identified a warfarin teratogenicity rate of 5.0%, with rates of 2.4% and 10.5% with low- and high-dose warfarin, respectively. Risk of bias was moderate (median Newcastle-Ottawa Scale score of 6) for all of the cohort studies.

CONCLUSION

Although a lower prevalence of warfarin-induced teratogenicity is reported with low-dose warfarin, a safe "cut-off" dose is misleading. Teratogenic risk with warfarin is unpredictable, mandating individual decisions regardless of the dose.

Heart disease and pregnancy: State of the art

The association between heart disease and pregnancy is increasingly prevalent. Although most women with heart disease tolerate the physiological changes of pregnancy, there are heart conditions that manifest for the first time during pregnancy and others that totally contraindicate a pregnancy. It is therefore important to establish multidisciplinary teams dedicated to the management of women with heart disease who intend to become, or who already are, pregnant. The aim of this article is to systematically review current knowledge on the approach to women with high-risk cardiovascular disease during pregnancy.

Hematological malignancies during pregnancy

Hematological malignancy during pregnancy is a rare event, therefore most data on this issue is based on case studies, retrospective studies and expert opinion. The purpose of the present narrative review was to provide an overview of the diagnosis and recommended management of the most common hematological malignancies during pregnancy, based on current literature, with clinical cases, and discussion of the diagnostic and therapeutic options. The therapeutic consensus while coping with hematological malignancies in pregnancy is to salvage the mother, while trying to preserve pregnancy and avoid treatment-related-toxicity to the fetus. In most scenarios, particularly during late trimesters, the goal is to administer the same treatment as outside of pregnancy, if possible. Further research is needed for better evidence-based management.

Antithrombotic Management of Patients With Prosthetic Heart Valves

Valvular heart disease is a major public health issue. The prevalence of valvular heart disease is expected to increase due to an aging population. Valve dysfunction manifests as valve stenosis, regurgitation, or both due to various etiologies. Valve repair and replacement are the main treatment options for severe valve dysfunction. Valve replacement is achieved by using either a mechanical or a bioprosthetic valve. Mechanical valves are more durable but require lifelong anticoagulation with associated complications. Bioprosthetic valves usually require anticoagulation only transiently after implantation but are less durable and degenerate more rapidly. In this article, we discuss antithrombotic regimens in persons after valve operations. We discuss general issues and antithrombotic recommendations for patients undergoing surgical bioprosthetic valve replacement, mechanical valve replacement (including different regimens for different positions and types of mechanical valves), mitral valve repair, and transcatheter aortic valve replacement. In addition, we discuss the antithrombotic management of patients in special circumstances, including patients with mechanical valves who have recurrent bleeding or thrombotic events, patients with mechanical valves undergoing surgery, and pregnant women with mechanical valves.

Evaluation of thromboelastography in bitches with pyometra

We investigated the effect of pyometra on kaolin-activated thromboelastography (TEG). Eighteen client-owned dogs with pyometra and 8 healthy spayed dogs were recruited. TEG parameters and packed cell volume were determined. Results from spayed females and from intact females with pyometra were compared using a Student t-test and Wilcoxon rank sum test. Bitches with pyometra were hypercoagulable compared to spayed bitches as evidenced by elevated maximum amplitude, G, and alpha angle. There were no significant group differences in R time, K time, or clot lysis at 30 or 60 min. Dogs with pyometra should be anticipated to have hypercoagulable TEG variables, and this should be addressed when planning surgical and medical therapy.

Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Pediatric Cardiology (SICP), and Italian Society of Gynaecologists and Obstetrics (SIGO): pregnancy and congenital heart diseases

The success of cardiac surgery over the past 50 years has increased numbers and median age of survivors with congenital heart disease (CHD). Adults now represent two-thirds of patients with CHD; in the USA alone the number is estimated to exceed 1 million. In this population, many affected women reach reproductive age and wish to have children. While in many CHD patients pregnancy can be accomplished successfully, some special situations with complex anatomy, iatrogenic or residual pathology are associated with an increased risk of severe maternal and fetal complications. Pre-conception counselling allows women to come to truly informed choices. Risk stratification tools can also help high-risk women to eventually renounce to pregnancy and to adopt safe contraception options. Once pregnant, women identified as intermediate or high risk should receive multidisciplinary care involving a cardiologist, an obstetrician and an anesthesiologist with specific expertise in managing this peculiar medical challenge. This document is intended to provide cardiologists working in hospitals where an Obstetrics and Gynecology Department is available with a streamlined and practical tool, useful for them to select the best management strategies to deal with a woman affected by CHD who desires to plan pregnancy or is already pregnant.

Atrial fibrillation with a structurally normal heart in pregnancy: An international survey on current practice

BACKGROUND

Little evidence exists for the optimal management of atrial fibrillation with a structurally normal heart in pregnancy.

METHODS

A survey was sent to members of two associations to obtain input on optimal management of atrial fibrillation in pregnancy. The survey presented four cases with respect to (1) baseline investigations; (2) rate versus rhythm control; (3) chemical versus electrical cardioversion; and (4) anticoagulation.

RESULTS

Sixty-one responders from 11 countries participated. High agreement was noted for baseline investigations. A quarter (25%) of participants chose elective cardioversion even with a reversible precipitant. Electrical cardioversion was preferred over chemical (p < 0.05). Anticoagulation strategies were heterogeneous except in the presence of a left atrial appendage thrombus.

DISCUSSION

This study revealed that there was little consensus in current practice in pregnancy beyond basic investigations. An adaptation of established guidelines to the pregnant population would require a meeting of Cardiologists with input from colleagues in Obstetric Medicine.

Evaluation and Management of Maternal Cardiac Arrhythmias

Pregnant women often complain of palpitations. The differential diagnosis for new-onset palpitations in pregnancy ranges from benign conditions to life-threatening arrhythmias. Maternal arrhythmias can occur in isolation or in the setting of underlying structural heart disease. Optimal management of maternal cardiac arrhythmias includes identification of the specific arrhythmia, diagnosis of comorbid conditions, and appropriate intervention. In general, management of maternal cardiac arrhythmias is similar to that of the general population. Special consideration must be given as to the effects of medications and procedures on both the mother and fetus to optimize outcomes. The importance of multidisciplinary care with cardiology, obstetrics, and anesthesia is emphasized.

Atrial Fibrillation and Atrial Flutter in Pregnant Women-A Population-Based Study

Background

The goal of this study was to determine the prevalence of atrial fibrillation and atrial flutter (AF) in pregnant women and to examine the impact of AF on maternal and fetal outcomes.

Methods and Results

Between January 1, 2003 and December 31, 2013, there were 264 730 qualifying pregnancies (in 210 356 women) in the Kaiser Permanente Southern California hospitals, among whom AF was noted in 157 pregnancies (129 women; 61.3 per 100 000 women, or 59.3 per 100 000 pregnancies). Prevalence of AF (per 100 000 women) in white, black, Asian, and Hispanic women was 111.6, 101.7, 45.0, and 34.3, respectively. Older age was associated with higher odds of having AF. Compared to women <25 years of age, the odds ratio (OR) of AF was 4.1 in women age 30 to 34 years, 4.9 in women age 35 to 39 years, and 5.2 in women age ≥40. Odds of AF episodes were higher during the third trimester compared to the first trimester (OR, 3.2; 95% CI: 1.5–7.7). Among AF patients, adverse maternal cardiac events were rare—2 women developed heart failure and there were no strokes or systemic embolic events and no maternal death. There were 156 live births (99.4% of all pregnancies). Compared to women without AF, fetal birth weights were similar, but rate for neonates’ admission to the neonatal intensive care unit was higher (10.8% vs 5.1%; P=0.003).

Conclusions

AF is rare in pregnant women. Certain factors such as increased maternal age and white race increase the odds of having AF. Major maternal and fetal complications are infrequent, albeit a source of concern.

Early postpartum mitral valve thrombosis requiring extra corporeal membrane oxygenation before successful valve replacement

Pregnancy is associated with an increased risk of thrombosis in women with mechanical prosthetic heart valves. We present the case of a 29-year-old woman who developed early postpartum mitral valve thrombus after an elective cesarean delivery. The patient had a mechanical mitral valve and was treated with warfarin in the second trimester, which was replaced with high-dose dalteparin during late pregnancy. Elective cesarean delivery was performed under general anesthesia at 37weeks of gestation. The patient was admitted to the intensive care unit for postoperative care and within 30min she developed dyspnea and hypoxia requiring mechanical ventilation. She deteriorated rapidly and developed pulmonary edema, worsening hypoxia and severe acidosis. Urgent extra corporeal membrane oxygenation was initiated. Transesophageal echocardiography revealed a mitral valve thrombus. The patient underwent a successful mitral valve replacement after three days on extra corporeal membrane oxygenation. This case highlights the importance of multidisciplinary care and frequent monitoring of anticoagulation during care of pregnant women with prosthetic heart valves.

The pharmacist's role in promoting preconception health

OBJECTIVE

To review the pharmacist's role in preconception health.

DATA SOURCES

PubMed search using the terms preconception, immunizations, epilepsy, diabetes, depression, tobacco, asthma, hypertension, anticoagulation, pharmacist, pregnancy, and current national guidelines.

DATA SYNTHESIS

Preconception health has become recognized as an important public health focus to improve pregnancy outcomes. Pharmacists have a unique role as accessible health care providers to optimize preconception health by screening women for tobacco use, appropriate immunizations, and current medication use. Counseling patients on preconception risk factors and adequate folic acid supplementation as well as providing recommendations for safe and effective management of chronic conditions are also critical and within the scope of practice for pharmacists.

CONCLUSION

Pharmacists play an important role in medication screening, chronic disease state management, and preconception planning to aid women in preparing for healthy pregnancies.

Aspiration thrombectomy in a case of acute myocardial infarction due to coronary emboli in a patient with peripartum cardiomyopathy and mural thrombus

Acute coronary syndrome (ACS) due to embolic phenomenon in the setting of peripartum cardiomyopathy (PPCM) and left ventricular mural thrombus is a rare occurrence. There have been two known cases described in medical literature. We present a unique case in which catheter-based aspiration thrombectomy was used to successfully treat a patient with ACS due to coronary emboli in the setting of PPCMand left ventricular mural thrombus. We believe this to be the first report of the use of aspiration thrombectomy in such a clinical case.

Monitoring of Anti-Xa in Pregnant Patients With Mechanical Prosthetic Valves Receiving Low-Molecular-Weight Heparin

Objectives:

We hypothesized that the guideline-recommended peak anti-Xa levels for pregnant women with mechanical prosthetic heart valves (MPHVs) receiving adjusted dose low-molecular-weight heparin (LMWH) are associated with subtherapeutic trough levels and consequently with an inadequate level of anticoagulation.

Background:

Low-molecular-weight heparin is often used for anticoagulation in pregnant women including those with MPHV. American College of Cardiology/American Heart Association guidelines recommend monitoring of plasma anti-Xa factor peak levels and adjustment of the dose to achieve peak levels of 0.7 to 1.2 U/mL. In spite of these recommendations, cases of valve thrombosis during pregnancy continue to occur.

Methods and Results:

We studied 30 pregnant patients receiving anticoagulation for various indications with adjusted dose LMWH given subcutaneously twice a day which had both trough and peak anti-Xa levels throughout pregnancy for a total of 187 paired determinations. The recommended peak anti-Xa levels (0.7-1.2 U/mL) were obtained in 123 (66%) of the measurements but in 80% of them, the trough levels were found to be subtherapeutic (<0.6 U/mL). Subtherapeutic trough levels were found in 8 (73%) of the 11 measurements with peak levels of 0.7 to 0.79 U/mL, 17 (74%) of the 23 of 0.8 to 0.89 U/mL, 21 (72%) of the 29 of 0.9 to 0.99 U/mL, and 28 (44%) of the 63 of 1.0 to 1.2 U/mL. There were 42 measurements with peak anti-Xa levels >1.2 U/mL and even in these cases, 13 (31%) of the trough levels were found to be subtherapeutic.

Conclusions:

Anticoagulation with adjusted dose LMWH aimed to achieve guideline-recommended peak levels of anti-Xa for patients with MPHVs is commonly associated with subtherapeutic trough levels. Routine measurement of trough anti-Xa levels is therefore advisable in women with MPHV treated with LMWH during pregnancy to assure adequate level of anticoagulation.

Neurology of pregnancy

Pregnancy creates alterations in maternal physiology which predispose to unique neurologic disorders. Pre-eclampsia, eclampsia, certain types of ischemic and hemorrhagic stroke, reversible cerebral vasoconstriction syndrome, posterior reversible encephalopathy syndrome, and thunderclap headache all appear to share a common origin from vascular endothelial dysfunction, with overlapping clinical presentations. Multiple sclerosis often improves during pregnancy. Compression mononeuropathies may occur in the extremities. Myasthenia gravis may affect second stage labor. Various inflammatory peripheral neuropathies, dystrophies, myopathies may occur during pregnancy. The safety of specific immune suppressants is reviewed. Epilepsy does not have a significant effect upon the course of pregnancy, albeit there is a modest increase in the need for cesarean section. Certain antiepileptic drugs may produce fetal malformations, most notably valproic acid. Brain tumors are rare during pregnancy, but may increase in size due to activation of hormonal receptors on tumor cells surfaces, water retention, and engorged blood vessels.