A population-based study of venous thrombosis in pregnancy in Scotland 1980–2005

Guideline-based venous thromboprophylaxis in postpartum women: An in-depth evaluation of ACOG and RCOG recommendations and real-life implementation

OBJECTIVES

Venous thromboembolism is one of the most serious complications of the postpartum period, and international societies have various thromboprophylaxis guidelines for its prevention. This study compares postpartum venous thromboprophylaxis recommendations from the American College of Obstetrics and Gynecology (ACOG) and the Royal College of Obstetricians and Gynecologists (RCOG) with real-life clinical practices.

STUDY DESIGN

Data analysis of 1000 postpartum women at a tertiary care center focused on patient demographics, venous thromboembolism risk factors, and clinical thromboprophylaxis practices. Patient-specific risk factors were compared between ACOG and RCOG guidelines, assessing Low-Molecular-Weight-Heparin dosages and durations. Guideline compliance, undertreatment/overtreatment rates, and the required number of prefilled Low-Molecular-Weight-Heparin syringes were evaluated.

RESULTS

Significant discrepancies were observed between ACOG and RCOG guidelines, particularly in Low Molecular Weight Heparin dosages and durations. Consensus rates with clinical approaches were around 53%, with inconsistencies leaning towards undertreatment (RCOG) and overtreatment (ACOG). The number of required prefilled Low-Molecular-Weight-Heparin syringes was notably higher according to RCOG compared to ACOG guidelines.

CONCLUSION

Postpartum Venous thromboembolism prophylaxis guidelines from American College of Obstetrics and Gynecology and Royal College of Obstetricians and Gynecologists exhibit substantial differences, leading to variations in clinical practice. Further research on the significance of Venous thromboembolism risk factors is essential for improving risk assessment tools and refining guideline recommendations for pregnancy-related Venous thromboembolism prevention.

Obesity at term: What to consider? How to deliver?

Obesity presents significant challenges during pregnancy, increasing the risk of complications and adverse outcomes for both mother and baby. With the rising prevalence of obesity among pregnant women, questions arise regarding optimal management, including timing of delivery and choice of delivery mode. Labour induction in obese women may require a combination of mechanical and pharmacological methods due to increased risk of failed induction. Caesarean section in obese women presents unique challenges, requiring comprehensive perioperative planning and specialized care to optimize outcomes. However, specific guidelines tailored to obese patients undergoing caesarean sections are lacking. Postpartum care should include vigilant monitoring for complications. Addressing obesity in pregnancy necessitates a multidisciplinary approach and specialized care to ensure the best outcomes.

Pulmonary Thromboembolism in Pregnancy: A Case Report and Literature Review

Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism are limited. Despite a lack of compelling evidence in some practices, clinical practice guidelines focus on the management of these patients. We present the case of a 24-year-old patient at 36 weeks of pregnancy in whom pulmonary thromboembolism (PTE) was diagnosed in a timely manner also with hemodynamic instability and echocardiographic images with clear involvement of the right cavities. She received thrombolytic therapy with alteplase 100 mg intravenously over 2 hours, which resulted in excellent outcomes for both the pregnant woman and fetus. Understanding the acute approach and management of these patients will improve our clinical practice; therefore, we reviewed a case report of a pregnant patient with high-risk PTE and compared it with current evidence. In conclusion, PE is a common disease with a high mortality rate during pregnancy. Therefore, having made a timely diagnosis using the relevant diagnostic aids and performing thrombolysis with rtPA increase the probability of survival in our patient, leading to successful results for both her and the fetus.

Management of Postpartum Extensive Venous Thrombosis after Second Pregnancy

Background: Pregnancy induces a physiological prothrombotic state. The highest risk period for venous thromboembolism and pulmonary embolism in pregnant women is during the postpartum period. Materials and Methods: We present the case of a young woman who gave birth 2 weeks before admission and was transferred to our clinic for edema. She had an increased temperature in her right limb, and a venous Doppler of the limb confirmed thrombosis of the right femoral vein. From the paraclinical examination, we obtained a CBC with leukocytosis, neutrophilia, and thrombocytosis, and a positive D-dimer test. Thrombophilic tests were negative for AT III, lupus anticoagulant negative, and protein S and C, but were positive for heterozygous PAI-1, heterozygous MTHFR A1298C, and EPCR with A1/A2 alleles. After 2 days of UFH with therapeutic APTT, the patient had pain in her left thigh. We performed a venous Doppler, which revealed bilateral femoral and iliac venous thrombosis. During the computed tomography examination, we assessed the venous thrombosis extension on the inferior cava, common iliac, and bilateral common femoral veins. Thrombolysis was initiated with 100 mg of Alteplase given at a rate of 2 mg/h; however, this did not lead to a considerable reduction in the thrombus. Additionally, the treatment with UFH was continued under therapeutic APTT. After 7 days of UFH and triple antibiotic therapy for genital sepsis, the patient had a favorable evolution with remission of venous thrombosis. Results: Alteplase is a thrombolytic agent that is created with recombinant DNA technology, and it was successfully used to treat thrombosis that occurred in the postpartum period. Conclusions: Thrombophilias are associated with a high VTE risk but also with adverse pregnancy outcomes, including recurrent miscarriages and gestational vascular complications. In addition, the postpartum period is associated with a higher VTE risk. A thrombophilic status with heterozygous PAI-1, heterozygous MTHFR A1298C, and EPCR with A1/A2 positive alleles is associated with a high risk of thrombosis and cardiovascular events. Thrombolysis can be successfully used postpartum to treat VTEs. Thrombolysis can be used successfully in VTE developed in the postpartum period.

A retrospective study on the use of low-molecular-weight heparin for prevention of pregnancy-related recurrent venous thromboembolism and obstetrical complications

BACKGROUND

The risk of venous thromboembolism (VTE) is increased during pregnancy and it is further increased together with pregnancy complications in women with personal history of VTE and thrombophilia abnormalities. It is unclear how the use of low-molecular-weight heparin (LMWH) may prevent such complications.

OBJECTIVE

To evaluate the potential benefits and risks of the use of LMWH for prevention of pregnancy-related VTE and obstetrical complications in the first pregnancy after a previous VTE.

METHODS

This retrospective cohort study includes fertile women referred to the Thrombosis Center from January 2000 to September 2018 for a thrombophilia work-up, after having had at least one previous VTE and one pregnancy thereafter. Data on pregnancy-related recurrent VTE, pregnancy outcomes and the use of LMWH were collected.

RESULTS

Among 208 women, no thrombosis or major bleeding was recorded in 138 pregnancies conducted with LMWH, whereas 10 VTE (14%) were recorded in 70 pregnancies conducted without. Nine women (90%) with recurrent VTE had had a previous hormone-related event. The incidence of miscarriage was lower in pregnancies with LMWH than in those without (11% vs. 26%, relative risk 0.4, 95% confidence interval: 0.2-0.8), whereas late obstetrical complications and terminations were similar in the two groups. The prevalence of terminations was doubled in women with thrombophilia (12%) than in those without (6%).

CONCLUSIONS

LMWH prophylaxis during pregnancy appears to be effective and safe for the prevention of recurrent VTE and may reduce the incidence of miscarriage.

Venous Thromboembolism During Pregnancy and the Postpartum Period: Risk Factors, Diagnostic Testing, and Treatment

Importance

The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but pulmonary embolism is typically of greater concern as it contributes to far higher morbidity and mortality. Diagnosis and treatment of VTE during pregnancy differ substantially from the general nonpregnant population.

Objective

This review describes the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of VTE during pregnancy and the postpartum period.

Evidence Acquisition

First, we reviewed the VTE guidelines from professional societies in obstetrics, cardiology, hematology, emergency medicine, pulmonology, and critical care. Second, we examined references from these documents and used PubMed to identify recent articles that cited the guidelines. Finally, we searched PubMed and Google Scholar for articles published since 2018 that included terms for pregnancy and the epidemiology, risk factors, diagnostic imaging, or treatment of VTE.

Results

Venous thromboembolism risk increases throughout pregnancy and peaks shortly after delivery. More than half of pregnancy-related VTE are associated with thrombophilia; other major risks include cesarean delivery, postpartum infection, and the combination of obesity with immobilization. Most VTE can be treated with low molecular weight heparin, but cases of limb- or life-threatening VTE require consideration of thrombolysis and other reperfusion therapies.

Conclusions and Relevance

Venous thromboembolism is far more frequent in antepartum and postpartum women than age-matched controls, and clinical suspicion for VTE in this population should incorporate pregnancy-specific risks. Treatment of limb- or life-threatening antepartum or postpartum VTE requires multispecialty coordination to optimize maternal and fetal outcomes.

Allergic rhinitis is associated with thromboembolic disease in pregnancy

Finding the risk factors for thromboembolic (TE) disease and preventing its development in pregnant women is important. Allergic rhinitis (AR) is a common chronic disease. We aim to find if AR is a risk factor. From 2004 to 2011, 55,057 pregnant women were recruited from a Taiwan database. They were grouped into AR and non-AR groups. The rate of TE and venous complications during pregnancy and 60 days after childbirth were compared between non-AR and the AR group. Those with AR diagnosed both before and after childbirth, meaning AR was not changed during pregnancy, the rates of TE (OR 2.64) and venous complications (OR 1.35) were higher compared to non-AR subjects. In those who underwent cesarean delivery, the rate was also higher in group 3 (OR 4.14). Those with AR before childbirth, without after, meaning AR was well controlled during pregnancy, the rate of TE was not higher than that of the non-AR subjects. Pregnant women with AR have an increased rate of TE. An increased rate of venous complications in these subjects might explain the increase in TE. If AR is well controlled during pregnancy, the rate of TE does not appear to increase.

Preeclampsia and Venous Thromboembolism: Pathophysiology and Potential Therapy

Preeclampsia (PET) is a multisystem inflammatory disorder that represents a leading cause of feto-maternal morbidity and mortality, complicating 2–5% of all pregnancies. PET incurs an increased risk of venous thromboembolism, which is one of the leading causes of death in pregnancy and in the postpartum period. This prothrombotic phenotype is attributable to the maternal phase of PET, which is characterized by a systemic inflammatory response and coagulation activation. Research continues to be undertaken in terms of preventative measures, however, currently revolves around pharmacological low dose aspirin initiated in the first trimester of pregnancy for those with risk factors. Treatment involves antenatal corticosteroids for fetal lung development in preterm birth, parenteral magnesium sulfate for fetal neuroprotection and maternal seizure prophylaxis, and timely birth of the fetus and placenta being the only definitive treatment of PET. Patients with a venous thromboembolism (VTE) risk deemed to be >1–3% are treated with pharmacological thromboprophylaxis in the form of low molecular weight heparin. Completing each woman’s VTE risk assessment is crucial, particularly in the setting of PET, as there is also a proven associated competing hemorrhagic risk.

Venous thromboembolism during pregnancy and postpartum period

Venous thromboembolism (VTE) is one of the leading causes of maternal mortality. Rates of VTE during pregnancy and the postpartum period have not decreased over the past two decades and pregnancyassociated VTE continues to pose a significant health challenge. Pregnant and postpartum women are at a higher risk for VTE owing to many factors. There are hormonally mediated and pregnancy-specific alterations of coagulation that favor thrombosis, including increased production of clotting factors. There are physiologic and anatomic mechanisms that also contribute, including a decreased rate of venous blood flow from the lower extemities as pregnancy progresses. Cesarean delivery also introduces VTE risk. In addition, studies have demonstrated that pregnancy-associated complications such as pre-eclampsia or peri-partum infections are associated with increased VTE rates. In this review, we discuss the recent epidemiological studies, pathogenesis, risk factors and clinical presentation as well as therapeutic options for VTE during pregnancy and the postpartum period. We also provide proposed diagnostic algorithms for diagnosis and management of VTE during pregnancy and the postpartum period based on updated evidence. Finally, we highlight knowledge gaps to guide future research.

Approach to the Evaluation and Treatment of Venous Thromboembolism in Pregnancy

Thrombosis in pregnancy is a major cause of maternal and fetal morbidity and mortality. Risk stratification of venous thromboembolism (VTE) during pregnancy is complex. The hypercoagulability observed in pregnant women can reduce bleeding during childbirth, but may cause thrombosis especially in the presence of additional prothrombotic risk factors such as antiphospholipid antibodies or genetic thrombophilic defects. The availability of large datasets allows for the identification of additional independent risk factors, including assisted reproductive technologies (ARTs), endometriosis, and recurrent pregnancy loss. Data on the risk of VTE linked to COVID-19 in pregnant women are very limited, but suggest that infected pregnant women have an increased risk of VTE. Current guidelines on the prevention and treatment of VTE in pregnancy are based on available, albeit limited, data and mainly present expert opinion. Low-molecular-weight heparins (LMWHs) are the mainstay of anticoagulation to be employed during pregnancy. Administration of LMWH for VTE treatment in pregnancy should be based on the personalized approach, taking into account a weight-based adjusted scheme. During gestation, due to physiological changes, in women at high risk of VTE, monitoring of anti-Xa activity is performed to ensure adequate LMWH dosing. As for the treatment duration for pregnant women with acute VTE, guidelines suggest that anticoagulation should be continued for at least 6 weeks postpartum for a minimum total duration of therapy of 3 months.

Contemporary best practice in the management of pulmonary embolism during pregnancy

Approximately 1–2 per 1000 pregnancies are complicated by venous thromboembolism (VTE). VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE) and the diagnostic management of pregnancy-related VTE is challenging. Current guidelines vary greatly in their approach to diagnosing PE in pregnancy as they base their recommendations on scarce and weak evidence. The pregnancy-adapted YEARS diagnostic algorithm is well tolerated and is the most efficient diagnostic algorithm for pregnant women with suspected PE, with 39% of women not requiring computed tomographic pulmonary angiography. Low-molecular-weight heparin is the first-choice anticoagulant treatment in pregnancy and should be continued until 6 weeks postpartum and for a minimum of 3 months. Direct oral anticoagulants should be avoided in women who want to breastfeed. Management of delivery needs a multidisciplinary approach in order to decide on an optimal delivery plan. Neuraxial analgesia can be given in most patients, provided time windows since last low-molecular-weight heparin dose are respected. Women with a history of VTE are at risk of recurrence during pregnancy and in the postpartum period. Therefore, in most women with a history of VTE, thromboprophylaxis in subsequent pregnancies is indicated.

The reviews of this paper are available via the supplemental material section.

Efficacy and safety of postural intervention on prevention of deep venous thrombosis of lower extremity in postpartum women with pregnancy-induced hypertension: A protocol for systematic review and meta-analysis

BACKGROUND

Deep venous thrombosis (DVT) is a relatively serious complication commonly seen in pregnant women, especially parturients with pregnancy-induced hypertension (PIH), whose incidence of DVT is higher. Because it can lead to pulmonary embolism (PE) and endanger the lives of patients, it has been paid much attention in clinic. Nursing plays an important role in the prevention and treatment of DVT. Early posture intervention can prevent postpartum DVT in hypertensive pregnant women, which has certain clinical value, but there is no evidence of evidence-based medicine. This study aims to systematically study the effectiveness and safety of postural intervention on prevention of deep venous thrombosis of lower extremity in postpartum women with PIH.

METHODS

Use the computer to retrieve the English databases (PubMed, Embase, Web of Science, the Cochrane Library) and the Chinese databases (China Knowledge Network, Wanfang, Weipu, China Biomedical Database), in addition to the manual retrieval of Baidu academic, Google academic, from the construction of database to December 2020, for randomized controlled clinical studies of postural intervention on prevention of deep venous thrombosis of lower extremity in postpartum women with PIH. Two researchers independently extracted the data and evaluated the quality of the included research, and used RevMan5.3 software to do meta-analyze of the included literature.

RESULTS

This study assessed the efficacy and safety of potential intervention on prevention of deep venous thrombosis of lower extremities with lower extremity hypertension by mean velocity of femoral venous flow in the lower extremities, lower extremity skin status, swelling level, and pain condition, lower extremity deep venous thrombosis rate, and incidence of pulmonary embolism.

CONCLUSION

This study will provide reliable evidence-based evidence for the clinical application of postural intervention on prevention of deep venous of lower extremity in Postpartum women with PIH.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/4NPKW.

Incidence of and risk factors for thromboembolism during pregnancy and postpartum: A 10-year nationwide population-based study

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.

Fatality rates and use of systemic thrombolysis in pregnant women with pulmonary embolism

AIMS

Data on the early course and use of systemic thrombolysis in pregnant women with pulmonary embolism associated or not with haemodynamic failure are scarce. We investigated these aspects using the information from the German Nationwide Inpatient Registry (years 2005-2016).

METHODS AND RESULTS

In Germany, all diagnoses referring to hospitalized patients are coded according to the International Classification of Diseases and Related Health Problems, 10th Revision with German Modification. We analysed data of pregnant women aged 18-50 years for whom the following diagnoses were recorded during hospitalization: (i) pulmonary embolism (I26) during pregnancy or peripartum (O09) or (ii) obstetric thromboembolism (O88.2). Haemodynamic failure at any time during the in-hospital stay was defined as need for cardiopulmonary resuscitation (OPS code 8-77) or the presence of shock (International Classification of Diseases and Related Health Problems, 10th Revision with German Modification code R57). The primary study outcome was in-hospital death. A total of 8 271 327 births were registered in Germany from 2005 to 2016. During this 12 year time period, there were 1846 hospitalizations for pregnancy-associated pulmonary embolism in patients aged 18-50, corresponding to 2.2 [95% confidence interval (CI): 2.1-2.3] cases every 10 000 births and 0.2% of all hospitalizations for pulmonary embolism in Germany. The median age was 31 years, and the median length of hospitalization was 8 days. A total of 63 deaths were reported, corresponding to an overall in-hospital fatality rate of 3.4% (95% CI: 2.7-4.4) and a pulmonary embolism-related mortality rate of 0.8 (95% CI: 0.6-1.0) per 100 000 (live) births per year. Pulmonary embolism-related deaths in hospitalized pregnant women represented 14% of all maternal deaths recorded in Germany between 2005 and 2016. A total of 135 (7.3%) women had haemodynamic failure, of whom 51 (37.8%) received systemic thrombolysis and 50 (37.0%) died.

CONCLUSIONS

Pulmonary embolism-related fatality remains substantial in pregnant women with pulmonary embolism and represents a frequent cause of maternal mortality. The use of systemic thrombolysis was reported in one third of pregnant women with pulmonary embolism and haemodynamic failure. Better preventive and management strategies should be urgently implemented in this vulnerable patient group.

Temporal Trends in Pregnancy-Associated Stroke and Its Outcomes Among Women With Hypertensive Disorders of Pregnancy

Background

Stroke is a serious complication of hypertensive disorders of pregnancy (HDP), with potentially severe and long‐term sequelae. However, the temporal trends, predictors, and outcomes of stroke in women with HDP at delivery remain unknown.

Methods and Results

All HDP delivery hospitalizations with or without stroke event (ischemic, hemorrhagic, or unspecified) between 2004 and 2014 in the United States National Inpatient Sample were analyzed to examine incidence, predictors, and prognostic impact of stroke. Of 4 240 284 HDP delivery hospitalizations, 3391 (0.08%) women had stroke. While the prevalence of HDP increased over time, incident stroke rates decreased from 10 to 6 per 10 000 HDP delivery hospitalizations between 2004 and 2014. Women with stroke were increasingly multimorbid, with some risk factors being more strongly associated with ischemic strokes, including congenital heart disease, peripheral vascular disease, dyslipidemia, and sickle cell disease. Delivery complications were also associated with stroke, including cesarean section (odds ratio [OR], 1.58; 95% CI, 1.33–1.86), postpartum hemorrhage (OR, 1.91; 95% CI, 1.33–1.86), and maternal mortality (OR, 99.78; 95% CI, 59.15–168.31), independently of potential confounders. Women with stroke had longer hospital stays (median, 6 versus 3 days), higher hospital charges (median, $14 655 versus $4762), and a higher proportion of nonroutine discharge locations (38% versus 4%).

Conclusions

The incidence of stroke in women with HDP has declined over time. While a relatively rare event, identification of women at highest risk of ischemic or hemorrhagic stroke on admission for delivery is important to reduce long‐term sequelae.

Preventing postpartum venous thromboembolism: A call to action to reduce undue maternal morbidity and mortality

Postpartum venous thromboembolism (VTE) is a leading cause of maternal mortality in developed countries and can carry significant long-term morbidity. Despite being able to identify postpartum VTE risk factors in a large proportion of the obstetrical population, there is little high-quality evidence available to guide practice on who should receive postpartum thromboprophylaxis. Based on epidemiological data, women with a prior history of VTE or known potent thrombophilia are likely to benefit from an extended duration of low-molecular-weight heparin (LMWH) prophylaxis. However, significant controversy exists around the benefit and harm of postpartum thromboprophylaxis in women with more modest risk factors, such as those with mild thrombophilias or transient situational risk factors around labor and delivery, such as cesarean delivery. We review the available data for postpartum VTE risk factors and thromboprophylaxis in these patients. This review highlights the latest evidence in the area of postpartum VTE prevention, and is a call to action for further research in this area to improve maternal morbidity and mortality.

Prevention of Venous Thromboembolism during Pregnancy and the Puerperium with a Special Focus on Women with Hereditary Thrombophilia or Prior VTE-Position Paper of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH)

Venous thromboembolism (VTE) is a major cause of maternal morbidity during pregnancy and the postpartum period. Because there is a lack of adequate study data, management strategies for the prevention of VTE during pregnancy have mainly been deduced from case-control and observational studies and extrapolated from recommendations for non-pregnant patients. The decision for or against pharmacologic thromboprophylaxis must be made on an individual basis weighing the risk of VTE against the risk of adverse side effects such as severe bleeding complications. A comprehensive, multidisciplinary approach is often essential as the clinical scenario is made more complex by the specific obstetric context, especially in the peripartum period. As members of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH), we summarize the evidence from the available literature and aim to establish a more uniform strategy for VTE risk assessment and thromboprophylaxis in pregnancy and the puerperium. In this document, we focus on women with hereditary thrombophilia, prior VTE and the use of anticoagulants that can safely be applied during pregnancy and the lactation period.

United Kingdom recommendations for obstetric venous thromboembolism prophylaxis: Evidence and rationale

Venous thromboembolism (VTE) is a leading cause of maternal death in the United Kingdom. To address this problem guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) has been developed that recommends the assessment of a woman's risk of thrombosis at specific time-points during pregnancy and postnatally at the time of delivery. The RCOG guidelines provide clinicians with a framework to inform decision-making on the use of thromboprophylaxis and are based on the premise that the higher risk a woman has for VTE, the more likely she is to benefit from prophylaxis - determining her level of risk is based on the number and characteristics of the risk factors that she has. This article will address the pathophysiology of VTE in pregnancy, evidence behind the risk factors for VTE and the use of thromboprophylactic agents. Further, it will reflect on the rationale behind the RCOG guidance.

Long-Term Outcome of Catheter-Directed Thrombolysis in Pregnancy-Related Venous Thrombosis

BACKGROUND Venous thromboembolism (VT) is a leading cause of maternal mortality and morbidity worldwide. Catheter-directed thrombolysis (CDT) is an effective and safe treatment modality for VT patients. However, the long-term outcome of CDT in pregnancy-related venous thrombosis are unclear. The aim of this study was to assess long-term results of pregnancy-related VT patients. MATERIAL AND METHODS We reviewed 41 pregnancy-related deep venous thrombosis (DVT) patients who underwent CDT from February 2008 to May 2015. Clinical data, including demographic variables, disease location, vascular risk factors, treatment regimen, interventional procedure and complications, were collected retrospectively. Clinical and color-duplex ultrasonography were performed to monitor venous patency during follow-up. Post-thrombotic syndrome (PTS) was assessed with the Villalta scale and quality of life (QOL) was evaluated by the VEINES-QOL/Sym questionnaire. RESULTS Twenty-three patients underwent spontaneous abortion or induced abortion within 3 months before DVT, and 18 patients had DVT during the first 3 months after delivery. Technical success was achieved in all patients. Grade III (complete) lysis was obtained in 15 patients and grade II (partial) lysis was obtained in 21 patients. The follow-up period was 3 years. Twenty-eight patients had venous patency at 3-year follow-up; 36.6% of patients developed mild or moderate PTS (Villalta score 5-14) and 4.8% with severe PTS (Villalta score ≥15). VEINES-QOL/Sym scores were 55.24±7.35 and 53.25±6.65, respectively. CONCLUSIONS Catheter-directed thrombolysis is a reliable and safe treatment modality for postnatal or abortion patients with DVT. CDT can reduce the incidence rate of PTS and increase the quality of life.

Selecting pregnant or postpartum women with suspected pulmonary embolism for diagnostic imaging: the DiPEP diagnostic study with decision-analysis modelling

BACKGROUND

Pulmonary embolism (PE) is a leading cause of death in pregnancy and post partum, but the symptoms of PE are common in normal pregnancy. Simple diagnostic tests are needed to select women for diagnostic imaging.

OBJECTIVE

To estimate the accuracy, effectiveness and cost-effectiveness of clinical features, decision rules and biomarkers for selecting pregnant or postpartum women with a suspected PE for imaging.

DESIGN

An expert consensus study to develop new clinical decision rules, a case-control study of women with a diagnosed PE or a suspected PE, a biomarker study of women with a suspected PE or diagnosed deep-vein thrombosis (DVT) and decision-analysis modelling.

SETTING

Emergency departments and consultant-led maternity units.

PARTICIPANTS

Pregnant/postpartum women with a diagnosed PE from any hospital reporting to the UK Obstetric Surveillance System research platform and pregnant/postpartum women with a suspected PE or diagnosed DVT at 11 prospectively recruiting sites.

INTERVENTIONS

Clinical features, decision rules and biomarkers.

MAIN OUTCOME MEASURES

Sensitivity, specificity, area under receiver operating characteristic (AUROC) curve, quality-adjusted life-years (QALYs) and health-care costs.

RESULTS

The primary analysis involved 181 women with PE and 259 women without PE in the case-control study and 18 women with DVT, 18 with PE and 247 women without either in the biomarker study. Most clinical features showed no association with PE. The AUROC curves for the clinical decision rules were as follows: primary consensus, 0.626; sensitive consensus, 0.620; specific consensus, 0.589; PE rule-out criteria, 0.621; simplified Geneva score, 0.579; Wells's PE criteria (permissive), 0.577; and Wells's PE criteria (strict), 0.732. The sensitivities and specificities of the D-dimer measurement were 88.4% and 8.8%, respectively, using a standard threshold, and 69.8% and 32.8%, respectively, using a pregnancy-specific threshold. Previous venous thromboembolism, long-haul travel, multiple pregnancy, oxygen saturation, recent surgery, temperature and PE-related chest radiograph abnormality were predictors of PE on multivariable analysis. We were unable to derive a rule through multivariable analysis or recursive partitioning with adequate accuracy. The AUROC curves for the biomarkers were as follows: activated partial thromboplastin time - 0.669, B-type natriuretic peptide - 0.549, C-reactive protein - 0.542, Clauss fibrinogen - 0.589, enzyme-linked immunosorbent assay D-dimer - 0.668, Innovance D-dimer (Siemens Healthcare Diagnostics Products GmbH, distributed by Sysmex UK Ltd, Milton Keynes, UK) - 0.651, mid-regional pro-atrial natriuretic peptide (MRproANP) - 0.524, prothrombin fragment 1 + 2 - 0.562, plasmin-antiplasmin - 0.639, Prothombin time - 0.613, thrombin generation lag time - 0.702, thrombin generation endogenous potential - 0.559, thrombin generation peak - 0.596, thrombin generation time to peak - 0.655, tissue factor - 0.531 and troponin - 0.597. The repeat analysis excluding women who had received anticoagulation was limited by the small number of women with PE (n = 4). The health economic analysis showed that a strategy of scanning all women with a suspected PE accrued more QALYs and incurred fewer costs than any selective strategy based on a clinical decision rule and was therefore the dominant strategy.

LIMITATIONS

The findings apply specifically to the diagnostic assessment of women with a suspected PE in secondary care.

CONCLUSIONS

Clinical features, decision rules and biomarkers do not accurately, effectively or cost-effectively select pregnant or postpartum women with a suspected PE for diagnostic imaging.

FUTURE WORK

New diagnostic technologies need to be developed to detect PE in pregnancy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN21245595.

FUNDING DETAILS

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 47. See the NIHR Journals Library website for further project information.

APC-resistance as a possible predictor of recurrent thrombosis in women with Factor V Leiden

Hypothesis/aims of study. The current analysis was undertaken to elucidate the role of Factor Va resistance to proteolytic cleavage by activated protein C in FVL(1691)GA female carriers in the development of acute and recurrent thromboses. Study design, materials and methods. A prospective clinical cohort study of 1100 women of reproductive age was conducted, with the course and outcomes of 2,707 pregnancies analyzed. Two cohorts were specified: the main group consisted of 500 patients with FV(1691)GA genotype, and the control group consisted of 600 patients with FVL(1691)GG genotype. Results. FVL(1691)GA genotype was significantly associated with the development of venous thromboembolic complications (VTEC) compared to FVL(1691)GG genotype (OR 9.3; p < 0.0001). Episodes of recurrent thrombosis during and outside of pregnancy were registered only in FVL(1691)GA patients (OR 5.7, p = 0.2). In all cases, at the time of the thrombotic event and during the period before the episode of acute or recurrent thrombosis, an APC resistance normalized ratio (NR) value was ≤ 0.49, with no episodes of VTEC registered with an APC resistance NR value ≥ 0.5. Conclusion. Venous thromboses occur under the condition of expressed APC resistance with underlying FVL(1691)GA carriage. The APC resistance index can serve as an objective biochemical marker to determine the feasibility of thromboprophylaxis within the framework of personalized medicine.

The laboratory control of anticoagulant thromboprophylaxis during the early postpartum period after cesarean delivery

INTRODUCTION

The incidence of venous thromboembolism (VTE) after cesarean section is up to 0.6%, and the widespread use of cesarean section draws attention to this group. The dosage and duration of low-molecular-weight heparin (LMWH) prophylaxis after delivery is estimated by anamnestic risk-scales; however, the predictive potency for an individual patient's risk can be low. Laboratory hemostasis assays are expected to solve this problem. The aim of this study was to estimate the potency of tests to reflect the coagulation state of patients receiving LMWH in the early postpartum period.

MATERIALS AND METHODS

We conducted an observational study on 97 women undergoing cesarean section. Standard coagulation tests (Fg, APTT, prothrombin, D-dimer), an anti-Xa assay, rotation thromboelastometry and thrombodynamics/thrombodynamics-4D were performed. Coagulation assay parameters were compared in groups formed in the presence or absence of LMWH to estimate the laboratory assays' sensitivity to anticoagulation.

RESULTS

Coagulation assays revealed hypercoagulation after delivery and a tendency toward normalization of coagulation during early postpartum. The thromboprophylaxis results revealed a higher percentage of coagulation parameters within the normal range in the LMWH group.

CONCLUSION

This research is potentially beneficial for the application of thrombodynamics and thrombodynamics-4D in monitoring coagulation among patients with high VTE risk who receive thromboprophylaxis with heparin.

The DiPEP (Diagnosis of PE in Pregnancy) biomarker study: An observational cohort study augmented with additional cases to determine the diagnostic utility of biomarkers for suspected venous thromboembolism during pregnancy and puerperium

This study aimed to estimate the diagnostic utility of biomarkers for suspected venous thromboembolism (VTE) in pregnancy and the puerperium. Research nurses/midwives collected blood samples from 310 pregnant/postpartum women with suspected pulmonary emboli (PE) and 18 with diagnosed deep vein thrombosis (DVT). VTE was diagnosed using imaging, treatment and adverse outcome data. Primary analysis was limited to women with conclusive imaging (36 with VTE, 247 without). The area under the curve (AUC) for each biomarker was: activated partial thromboplastin time 0·669 (95% confidence interval 0·570-0·768), B-type natriuretic peptide 0·549 (0·453-0·645), C-reactive protein 0·542 (0·445-0·639), Clauss fibrinogen 0·589 (0·476-0·701), D-Dimer (by enzyme-linked immunosorbent assay) 0·668 (0·561-0·776), near-patient D-Dimer 0·651 (0·545-0·758), mid-regional pro-atrial natriuretic peptide 0·524 (0·418-0·630), prothrombin fragment 1 + 2 0·562 (0·462-0·661), plasmin-antiplasmin complexes 0·639 (0·536-0·742), prothombin time 0·613 (0·508-0·718), thrombin generation lag time 0·702 (0·598-0·806), thrombin generation endogenous potential 0·559 (0·437-0·681), thrombin generation peak 0·596 (0·478-0·715), thrombin generation time to peak 0·655 (0·541-0·769), soluble tissue factor 0·531 (0·424-0·638) and serum troponin 0·597 (0·499-0·695). No diagnostically useful threshold for diagnosing or ruling out VTE was identified. In pregnancy and the puerperium, conventional and candidate biomarkers have no utility either for their negative or positive predictive value in the diagnosis of VTE.

Clinical 'Pearls' of maternal critical care: part I

PURPOSE OF REVIEW

This review outlines the challenges in looking after pregnant women with thromboembolism and sepsis who either become or are at risk of becoming critically ill during pregnancy.

RECENT FINDINGS

The Pregnancy Mortality Surveillance systems in both the USA and UK record the most common causes of maternal death as thromboembolism and sepsis. Both of these conditions have improved outcomes with timely maternal critical care provided by a multidisciplinary team.

SUMMARY

In this review, we discuss the pathophysiology, diagnosis, and management of thromboembolism and sepsis, two very important conditions with high mortality requiring admission to intensive care.

Compliance with the 2009 Royal College of Obstetricians and Gynaecologists guidelines for venous thromboembolic disease prophylaxis in pregnancy and postpartum period in Uruguay

: Venous thromboembolism remains as one of the leading causes of maternal death. Prevention of venous thromboembolism in the obstetric population is challenging as recommendations for prophylaxis have low grade of evidence. Risk factors and prophylaxis guidelines have been highlighted by Royal College of Obstetricians and Gynaecologists. In 2014, we developed a written alert following this guidelines to guide thromboprophylaxis. The aim of this study is to assess recommendations compliance. This study was conducted at University-Hospital in Uruguay from January 2014 to December 2016. A total of 1035 women were enrolled and stratified in high, intermediate or low risk based on Royal College of Obstetricians and Gynaecologists guidelines. Thromboprophylaxis was recommended for women at intermediate and high risk. Women were followed up to assess symptomatic thromboembolism or haemorrhagic complications. A total of 309 were pregnant and 731 puerperal. Median age was 24 (19-29) years old. Of them, 3.0% (n = 31) were at high risk and 35.4% (n = 366) at intermediate risk. All high-risk women received prophylaxis with low-molecular-weight heparin. Of the 366 intermediate-risk women, 52.7% received prophylaxis. Venous thromboembolism was developed in only one woman of the intermediate group, who had received prophylaxis. Bleeding complications were not observed. Awareness of the thrombotic risk, as conferred by an easy and suitable risk assessment, has the potential to improve venous thromboembolism prophylaxis in pregnant and puerperal women. We have a good guidelines compliance with the written alert in the high-risk women group. However, we have to improve low-molecular-weight heparin indication in intermediate-risk group, especially in postcaesarean women.

Preventing venous thromboembolism during pregnancy and postpartum: crossing the threshold

When should a patient with a known thrombophilia or prior venous thromboembolism (VTE) receive low-molecular-weight heparin (LMWH) prophylaxis during pregnancy and/or the postpartum period? Accurately predicting thrombotic and bleeding risks and knowing what to do with this information is at the heart of decision-making in these challenging scenarios. This article will explore the concept of a risk threshold from clinician and patient perspectives and provide guidance for the use of antepartum and postpartum LMWH prophylaxis in women with a known thrombophilia or prior VTE. Advice for the management of LMWH prophylaxis use around labor and delivery is also reviewed.

Thrombosis: A major contributor to global disease burden

Thrombosis is a common pathology underlying ischaemic heart disease, ischaemic stroke, and venous thromboembolism (VTE). The Global Burden of Disease Study 2010 (GBD 2010) documented that ischaemic heart disease and stroke collectively caused one in four deaths worldwide. GBD 2010 did not report data for VTE as a cause of death and disability. We performed a systematic review of the literature on the global disease burden due to VTE in low, middle and high income countries. Studies from Western Europe, North America, Australia, and Southern Latin America (Argentina) yielded consistent results with annual incidences ranging from 0.75 to 2.69 per 1,000 individuals in the population. The incidence increased to between 2 and 7 per 1,000 among those 70 years of age or more. Although the incidence is lower in individuals of Chinese and Korean ethnicity, their disease burden is not low because of population aging. VTE associated with hospitalisation was the leading cause of disability-adjusted-lifeyears (DALYs) lost in low and middle income countries, and second in high income countries, responsible for more DALYs lost than nosocomial pneumonia, catheter-related blood stream infections, and adverse drug events. VTE causes a major burden of disease across low, middle, and high income countries. More detailed data on the global burden of VTE should be obtained to inform policy and resource allocation in health systems, and to evaluate if improved utilisation of preventive measures will reduce the burden.

Note: The copyright for the article is being held by the International Society on Thrombosis and Haemostasis under a CC-BY-NC-ND license.

"Pulmonary embolism diagnostics of pregnant patients: What is the recommended clinical pathway considering the clinical value and associated radiation risks of available imaging tests?"

Pulmonary embolism (PE) during pregnancy remains the leading preventable cause of maternal morbidity and mortality in the developed countries. Diagnosis of PE in pregnant patients is a challenging clinical problem, since pregnancy-related physiologic changes can mimic signs and symptoms of PE. Patient mismanagement may result into unjustified anticoagulant treatment or unnecessary imaging tests involving contrast-related or/and radiation-related risks for both the expectant mother and embryo/fetus. On the other hand, missing or delaying diagnosis of PE could lead to life-threatening conditions for both the mother and the embryo/fetus. Thus, a timely and accurate diagnostic approach is required for the optimal management of pregnant patients with suspected PE. Aim of the current review is to discuss a pregnancy-specific clinical pathway for the early diagnosis of PE with non-ionizing radiation- and ionizing radiation-based imaging modalities taking into account previously reported data on diagnostic value of available imaging tests, and radiation related concerns.

Surgical Embolectomy for Acute Pulmonary Thromboembolism

Acute pulmonary thromboembolism is a catastrophic event, especially for hospitalized patients. The prognosis of pulmonary thromboembolism depends on the degree of pulmonary arterial occlusion. The mortality of massive pulmonary embolism is reportedly as high as 25% without cardiopulmonary arrest and 65% with cardiopulmonary arrest. In patients with unstable hemodynamics due to pulmonary thromboembolism, surgical pulmonary embolectomy is indicated for patients with a contraindication to thrombolysis, failed catheter therapy, or failed thrombolysis. Thrombolytic therapy adds an additional burden on patients who are at risk of potential hemorrhagic complications. It is also indicated if patients are already on a veno-arterial extra-corporate membrane oxygenator for circulatory collapse or cardiopulmonary arrest. The outcome for patients who require cardiopulmonary resuscitation for longer than 30 minutes is poor. Therefore, early triage for massive and sub-massive pulmonary embolism is crucial. A team approach including a cardiovascular surgeon may be effective to save critically ill patients. Prompt removal of emboli reduces the right ventricular load with quick recovery of cardiopulmonary function in the early postoperative period. A recent series reported excellent results, with in-hospital mortality of less than 10%. Surgical pulmonary embolectomy is an effective, safe, and easy procedure to save critical patients due to pulmonary thromboembolism.

Pitfalls in the diagnostic management of pulmonary embolism in pregnancy

Women are at increased risk of venous thromboembolism (VTE) during pregnancy and VTE remains one of the main causes of maternal mortality in developed countries (Konstantinides SV, et al. Eur Heart J 2014; 35(43):3033-69, 69a-69k). Although an accurate diagnosis of acute pulmonary embolism (PE) in pregnant patients is thus of crucial importance, the diagnostic management of suspected PE is challenging for this specific patient category. As D-dimer levels increase physiologically throughout pregnancy, the optimal D-dimer threshold to rule out PE during pregnancy remains unknown. Available clinical decision rules, such as the Wells score and the revised Geneva rule, have not been evaluated in pregnant patients. Also, although ventilation-perfusion (V-Q) lung scan and computed tomography pulmonary angiography (CTPA) can be used in the pregnant population, both modalities have disadvantages of radiation exposure to both mother and foetus. Because of these uncertainties, clinical guidelines provide contradicting recommendations with weak levels of evidence. In this review, we illustrate these dilemmas and provide practice recommendation for the diagnostic management of suspected PE in pregnancy using two real-life patient cases.

Diagnosis and management of factor V Leiden

INTRODUCTION

The discovery of the factor V Leiden (FVL) missense mutation (Arg506Gln) causing factor V resistance to the anticoagulant action of activated protein C was a landmark that allowed a better understanding of the basis of inherited thrombotic risk. FVL mutation is currently the most common known hereditary defect predisposing to venous thrombosis. Areas covered: Novel data-driven FVL diagnosis and therapeutic approaches in the management of FVL carriers in various clinical settings. Brief conclusions on topics of direct clinical relevance including currently available indications for primary and secondary prophylaxis, the management of female, pediatric carriers and asymptomatic relatives. Latest evidence on the association between FVL and cancer, as well as the possible use of direct oral anticoagulant therapy. Expert commentary: Although FVL diagnosis nowadays is highly accurate, many doubts remain regarding the best management and therapeutic protocols. The main role of clinicians is to tailor therapeutic strategies to carriers and their relatives. High familial penetrance, distinctive aspects of the first thrombotic event (provoked/unprovoked, age, etc.) and laboratory biomarkers can guide the optimal management of secondary antithrombotic prophylaxis, primary prophylaxis in asymptomatic individuals, and whether to screen relatives.

Profilaxia de tromboembolismo venoso na gestação

O tromboembolismo venoso é importante causa de morbidade e mortalidade obstétrica. Durante a gestação, o risco de sua ocorrência aumenta entre cinco e dez vezes quando comparado ao de mulheres não gestantes de mesma idade. Associado a esse fato, a gestante apresenta algumas limitações para o diagnóstico clínico (alta frequência de dor e edema nos membros inferiores), ecográfico (menor sensibilidade e especificidade no diagnóstico de trombose venosa de ilíaca com a evolução da gestação) e laboratorial (o D-dímero apresenta aumento progressivo no decorrer da gravidez). Uma estratificação criteriosa de risco de tromboembolismo venoso de cada mulher antes da gestação pode diminuir a incidência dessa doença, frequente e de difícil diagnóstico na gravidez, e suas complicações.

Hereditary risk factors for thrombophilia and probability of venous thromboembolism during pregnancy and the puerperium

Venous thromboembolism (VTE) is a leading cause of maternal mortality. Few studies have evaluated the individual risk of gestational VTE associated with heritable thrombophilia, and current recommendations for antenatal thromboprophylaxis in women with severe thrombophilia such as homozygous factor V Leiden mutation (FVL) depend on a positive family history of VTE. To better stratify thromboprophylaxis in pregnancy, we aimed to estimate the individual probability (absolute risk) of gestational VTE associated with thrombophilia and to see whether these risk factors are independent of a family history of VTE in first-degree relatives. We studied 243 women with the first VTE during pregnancy and the puerperium and 243 age-matched normal women. Baseline incidence of VTE of 1:483 pregnancies in women ≥35 years and 1:741 deliveries in women <35 years was assumed, according to a recent population-based study. In women ≥35 years (<35 years), the individual probability of gestational VTE was as follows: 0.7% (0.5%) for heterozygous FVL; 3.4% (2.2%) for homozygous FVL; 0.6% (0.4%) for heterozygous prothrombin G20210A; 8.2% (5.5%) for compound heterozygotes for FVL and prothrombin G20210A; 9.0% (6.1%) for antithrombin deficiency; 1.1% (0.7%) for protein C deficiency; and 1.0% (0.7%) for protein S deficiency. These results were independent of a positive family history of VTE. We provide evidence that unselected women with these thrombophilias have an increased risk of gestational VTE independent of a positive family history of VTE. In contrast to current guidelines, these data suggest that women with high-risk thrombophilia should be considered for antenatal thromboprophylaxis regardless of family history of VTE.

Guidance for the treatment and prevention of obstetric-associated venous thromboembolism

Venous thromboembolism (VTE), which may manifest as pulmonary embolism (PE) or deep vein thrombosis (DVT), is a serious and potentially fatal condition. Treatment and prevention of obstetric-related VTE is complicated by the need to consider fetal, as well as maternal, wellbeing when making management decisions. Although absolute VTE rates in this population are low, obstetric-associated VTE is an important cause of maternal morbidity and mortality. This manuscript, initiated by the Anticoagulation Forum, provides practical clinical guidance on the prevention and treatment of obstetric-associated VTE based on existing guidelines and consensus expert opinion based on available literature where guidelines are lacking.

SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014

This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.

Epidemiology of venous thromboembolism (VTE) associated with pregnancy

This review is focused on the epidemiology of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), associated with pregnancy. Superficial vein thrombosis, a less hazardous and less studied type of thrombosis in pregnant women, is beyond the scope of this review. This study discusses the VTE incidence rate in women from developed countries for both antepartum and postpartum periods and for subpopulations of women affected by additional risk factors, such as thrombophilias, circulatory diseases, preeclampsia of varying degrees of severity, and Caesarean section. To minimize bias due to historical changes in medical and obstetric practices, lifestyle, diet, etc., this review is generally limited to relatively recent studies, i.e., those that cover the last 35 years. The absolute risk or incidence rate was used to ascertain risk of VTE associated with pregnancy. For the studies where the direct incidence rates of VTE were not reported, we calculated an estimate of the observed but not reported absolute incidence rates using the data presented in respective articles.

Thrombosis: a major contributor to global disease burden

BACKGROUND

Thrombosis is the common pathology underlying ischemic heart disease, ischemic stroke, and venous thromboembolism (VTE). The Global Burden of Disease Study 2010 (GBD 2010) documented that ischemic heart disease and stroke collectively caused 1 in 4 deaths worldwide. GBD 2010 did not report data for VTE as a cause of death and disability.

OBJECTIVE

To review the literature on the global burden of disease caused by VTE.

APPROACH AND RESULTS

We performed a systematic review of the literature on the global disease burden because of VTE in low-, middle-, and high-income countries. Studies from Western Europe, North America, Australia, and Southern Latin America (Argentina) yielded consistent results with annual incidences ranging from 0.75 to 2.69 per 1000 individuals in the population. The incidence increased to between 2 and 7 per 1000 among those aged ≥70 years. Although the incidence is lower in individuals of Chinese and Korean ethnicity, their disease burden is not low because of population aging. VTE associated with hospitalization was the leading cause of disability-adjusted life-years lost in low- and middle-income countries, and second in high-income countries, responsible for more disability-adjusted life-years lost than nosocomial pneumonia, catheter-related blood stream infections, and adverse drug events.

CONCLUSIONS

VTE causes a major burden of disease across low-, middle-, and high-income countries. More detailed data on the global burden of VTE should be obtained to inform policy and resource allocation in health systems and to evaluate whether improved use of preventive measures will reduce the burden.

Systemic lupus erythematosus and outcomes in first and subsequent births based on data from a national birth registry

OBJECTIVE

To examine the associations between systemic lupus erythematosus (SLE) and outcomes in first and subsequent births.

METHODS

Data from the Medical Birth Registry of Norway during the period December 1, 1998 to December 31, 2009 were used to assess maternal and perinatal outcomes in women diagnosed with SLE compared with the general population. Outcomes of first and subsequent births were analyzed separately. Associations between SLE and pregnancy outcomes were assessed in logistic regression analyses and are shown as adjusted odds ratios (aORs) after adjustment for maternal age, gestational age, smoking habits, and previous cesarean section (CS), when relevant.

RESULTS

We analyzed 95 first and 145 subsequent births in patients and compared them with references. The risk of CS was two-fold higher in SLE patients in first and subsequent births. More newborns of patients had a birth weight <2,500 gm (aOR 5.00 [95 % confidence interval (95% CI) 3.02, 8.27] in first births and aOR 4.33 [95% CI 2.64, 7.10] in subsequent births). Additionally, preterm birth was more frequent among SLE patients (aOR 4.04 [95% CI 2.45, 6.56] in first births and aOR 3.13 [95% CI 1.97, 4.98] in subsequent births). Congenital malformations were more prevalent among children of patients than references (aOR 2.71 [95% CI 1.25, 5.86] in first births and aOR 3.13 [95% CI 1.69, 5.79] in subsequent births). Perinatal death was more frequent in first births among patients (aOR 7.34 [95% CI 2.69, 20.03]), but no difference was observed in subsequent births.

CONCLUSION

Pregnancy complications were more frequent in SLE patients than references, and the greatest differences between groups were observed in first births.

Thrombosis: a major contributor to global disease burden

Thrombosis is a common pathology underlying ischemic heart disease, ischemic stroke, and venous thromboembolism (VTE). The Global Burden of Disease Study 2010 (GBD 2010) documented that ischemic heart disease and stroke collectively caused one in four deaths worldwide. GBD 2010 did not report data for VTE as a cause of death and disability. We performed a systematic review of the literature on the global disease burden due to VTE in low, middle and high income countries. Studies from Western Europe, North America, Australia, and Southern Latin America (Argentina) yielded consistent results with annual incidences ranging from 0.75 to 2.69 per 1,000 individuals in the population. The incidence increased to between 2 and 7 per 1,000 among those 70 years of age or more. Although the incidence is lower in individuals of Chinese and Korean ethnicity, their disease burden is not low because of population aging. VTE associated with hospitalization was the leading cause of disability-adjusted-life-years (DALYs) lost in low and middle income countries, and second in high income countries, responsible for more DALYs lost than nosocomial pneumonia, catheter-related blood stream infections, and adverse drug events. VTE causes a major burden of disease across low, middle, and high income countries. More detailed data on the global burden of VTE should be obtained to inform policy and resource allocation in health systems, and to evaluate if improved utilization of preventive measures will reduce the burden.

Thrombosis: a major contributor to the global disease burden

Thrombosis is a common pathology underlying ischemic heart disease, ischemic stroke, and venous thromboembolism (VTE). The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2010 documented that ischemic heart disease and stroke collectively caused one in four deaths worldwide. GBD 2010 did not report data for VTE as a cause of death and disability. We performed a systematic review of the literature on the global disease burden caused by VTE in low-income, middle-income and high-income countries. Studies from western Europe, North America, Australia and southern Latin America (Argentina) yielded consistent results, with annual incidence rates ranging from 0.75 to 2.69 per 1000 individuals in the population. The incidence increased to between 2 and 7 per 1000 among those aged ≥ 70 years. Although the incidence is lower in individuals of Chinese and Korean ethnicity, their disease burden is not low, because of population aging. VTE associated with hospitalization was the leading cause of disability-adjusted life-years (DALYs) lost in low-income and middle-income countries, and the second most common cause in high-income countries, being responsible for more DALYs lost than nosocomial pneumonia, catheter-related bloodstream infections, and adverse drug events. VTE causes a major burden of disease across low-income, middle-income and high-income countries. More detailed data on the global burden of VTE should be obtained to inform policy and resource allocation in health systems, and to evaluate whether improved utilization of preventive measures will reduce the burden.

Thromboembolism in pregnancy: challenges and controversies in the prevention of pregnancy-associated venous thromboembolism and management of anticoagulation in women with mechanical prosthetic heart valves

Thromboembolism in pregnancy is an important clinical issue. Despite identification of maternal and pregnancy-specific risk factors for development of pregnancy-associated venous thromboembolism, limited data are available to inform on optimal approaches for prevention. The relatively low overall prevalence of pregnancy-associated venous thromboembolism has prompted debate about the validity of recommendations, which are mainly based on expert opinion, and have resulted in an increased use of pharmacological thromboprophylaxis in pregnancy and postpartum. A pragmatic approach is required in the absence of more robust data. Anticoagulation management of pregnant women with mechanical prosthetic heart valves is particularly challenging. Continuation of therapeutic anticoagulation during pregnancy is essential to prevent valve thrombosis. Warfarin, the most effective anticoagulant, is associated with adverse fetal outcomes, including embryopathy and stillbirth. Fetal outcome is improved with therapeutic-dose low-molecular-weight heparin, but there may be more thromboembolic complications. More intensive anticoagulation, targeting higher trough anti-Xa levels, may reduce the risk of valve thrombosis.