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Davis S, Pandor A, Sampson FC, Hamilton J, Nelson-Piercy C, Hunt BJ, Daru J, Goodacre S, Carser R, Rooney G, Clowes M. Thromboprophylaxis during pregnancy and the puerperium: a systematic review and economic evaluation to estimate the value of future research. Health Technol Assess 2024; 28:1-176. [PMID: 38476084 PMCID: PMC11017156 DOI: 10.3310/dfwt3873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
Background Pharmacological prophylaxis to prevent venous thromboembolism is currently recommended for women assessed as being at high risk of venous thromboembolism during pregnancy or in the 6 weeks after delivery (the puerperium). The decision to provide thromboprophylaxis involves weighing the benefits, harms and costs, which vary according to the individual's venous thromboembolism risk. It is unclear whether the United Kingdom's current risk stratification approach could be improved by further research. Objectives To quantify the current decision uncertainty associated with selecting women who are pregnant or in the puerperium for thromboprophylaxis and to estimate the value of one or more potential future studies that would reduce that uncertainty, while being feasible and acceptable to patients and clinicians. Methods A decision-analytic model was developed which was informed by a systematic review of risk assessment models to predict venous thromboembolism in women who are pregnant or in the puerperium. Expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty and should be the target of future research. To find out whether future studies would be acceptable and feasible, we held workshops with women who have experienced a blood clot or have been offered blood-thinning drugs and surveyed healthcare professionals. Expected value of sample information analysis was used to estimate the value of potential future research studies. Results The systematic review included 17 studies, comprising 19 unique externally validated risk assessment models and 1 internally validated model. Estimates of sensitivity and specificity were highly variable ranging from 0% to 100% and 5% to 100%, respectively. Most studies had unclear or high risk of bias and applicability concerns. The decision analysis found that there is substantial decision uncertainty regarding the use of risk assessment models to select high-risk women for antepartum prophylaxis and obese postpartum women for postpartum prophylaxis. The main source of decision uncertainty was uncertainty around the effectiveness of thromboprophylaxis for preventing venous thromboembolism in women who are pregnant or in the puerperium. We found that a randomised controlled trial of thromboprophylaxis in obese postpartum women is likely to have substantial value and is more likely to be acceptable and feasible than a trial recruiting women who have had a previous venous thromboembolism. In unselected postpartum women and women following caesarean section, the poor performance of risk assessment models meant that offering prophylaxis based on these models had less favourable cost effectiveness with lower decision uncertainty. Limitations The performance of the risk assessment model for obese postpartum women has not been externally validated. Conclusions Future research should focus on estimating the efficacy of pharmacological thromboprophylaxis in pregnancy and the puerperium, and clinical trials would be more acceptable in women who have not had a previous venous thromboembolism. Study registration This study is registered as PROSPERO CRD42020221094. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR131021) and is published in full in Health Technology Assessment; Vol. 28, No. 9. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona C Sampson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Beverley J Hunt
- Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jahnavi Daru
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rosie Carser
- Patient and Public Involvement, Thrombosis UK, Llanwrda, UK
| | - Gill Rooney
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Chen X, Peng W, Zhang Y, Zhou H, Zhang M. Development and validation of a facile rapid assessment scale for perinatal venous thromboembolism in puerperium in Chinese women. BMC Pregnancy Childbirth 2023; 23:607. [PMID: 37620792 PMCID: PMC10464158 DOI: 10.1186/s12884-023-05901-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 08/06/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND It is still urgent and challenge to develop a simple risk assessment scale for venous thromboembolism (VTE) in puerperium in Chinese women. METHODS The study, a retrospective case-control study, was conducted in 12 hospitals in different cities in China. A total of 1152 pregnant women were selected, including 384 cases with VTE and 768 cases without VTE. A logistic regression method was conducted to determine the risk factors of VTE. RESULTS Age, BMI before delivery, gestational diabetes mellitus, family history (thrombosis, diabetes, cardiovascular disease), and assisted reproductive technology were independent risk factors (P<0.05). The difference between the high-risk group and the low-risk group was statistically significant(P<0.001) with a sensitivity of 0.578, specificity of 0.756, Yuden index o.334, and area under the ROC curve of 0.878. CONCLUSIONS The age (≥ 35 years), BMI before delivery (≥ 30 kg/m2), gestational diabetes mellitus, family history of related diseases and assisted reproductive technology are more likely to cause VTE after full-time delivery. The simple and rapid assessment scale of VTE in women after full-term delivery has perfect discrimination (P < 0.001), which can be applied to predict the risk of VTE in Chinese full-term postpartum women.
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Affiliation(s)
- Xiujuan Chen
- Nursing Department, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wei Peng
- Department of Obstetrics, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yan Zhang
- Department of Obstetrics, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Huansheng Zhou
- Department of Obstetrics, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meng Zhang
- Department of Obstetrics, the Affiliated Hospital of Qingdao University, Qingdao, China.
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Pandor A, Daru J, Hunt BJ, Rooney G, Hamilton J, Clowes M, Goodacre S, Nelson-Piercy C, Davis S. Risk assessment models for venous thromboembolism in pregnancy and in the puerperium: a systematic review. BMJ Open 2022; 12:e065892. [PMID: 36223963 PMCID: PMC9562726 DOI: 10.1136/bmjopen-2022-065892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To assess the comparative accuracy of risk assessment models (RAMs) to identify women during pregnancy and the early postnatal period who are at increased risk of venous thromboembolism (VTE). DESIGN Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES MEDLINE, Embase, Cochrane Library and two research registers were searched until February 2021. ELIGIBILITY CRITERIA All validation studies that examined the accuracy of a multivariable RAM (or scoring system) for predicting the risk of developing VTE in women who are pregnant or in the puerperium (within 6 weeks post-delivery). DATA EXTRACTION AND SYNTHESIS Two authors independently selected and extracted data. Risk of bias was appraised using PROBAST (Prediction model Risk Of Bias ASsessment Tool). Data were synthesised without meta-analysis. RESULTS Seventeen studies, comprising 19 externally validated RAMs and 1 internally validated model, met the inclusion criteria. The most widely evaluated RAMs were the Royal College of Obstetricians and Gynaecologists guidelines (six studies), American College of Obstetricians and Gynecologists guidelines (two studies), Swedish Society of Obstetrics and Gynecology guidelines (two studies) and the Lyon score (two studies). In general, estimates of sensitivity and specificity were highly variable with sensitivity estimates ranging from 0% to 100% for RAMs that were applied to antepartum women to predict antepartum or postpartum VTE and 0% to 100% for RAMs applied postpartum to predict postpartum VTE. Specificity estimates were similarly diverse ranging from 28% to 98% and 5% to 100%, respectively. CONCLUSIONS Available data suggest that external validation studies have weak designs and limited generalisability, so estimates of prognostic accuracy are very uncertain. PROSPERO REGISTRATION NUMBER CRD42020221094.
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Affiliation(s)
| | - Jahnavi Daru
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | | | - Gill Rooney
- ScHARR, The University of Sheffield, Sheffield, UK
| | | | - Mark Clowes
- ScHARR, The University of Sheffield, Sheffield, UK
| | | | | | - Sarah Davis
- ScHARR, The University of Sheffield, Sheffield, UK
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Raia-Barjat T, Edebiri O, Chauleur C. Venous Thromboembolism Risk Score and Pregnancy. Front Cardiovasc Med 2022; 9:863612. [PMID: 35479289 PMCID: PMC9037588 DOI: 10.3389/fcvm.2022.863612] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Venous thromboembolism (VTE) is a major contributor to maternal morbidity and mortality worldwide. Pregnancy is associated with the development of a baseline hypercoagulable state. The two strongest risk factors for pregnancy-associated VTE are previous VTE and/or high risk thrombophilia. The others risk factors for VTE during pregnancy are well known such as maternal, pregnancy and delivery characteristics. Considering the variation in recommendation in guidelines and low-quality evidence on the prevention, diagnosis and treatment, practice differs between countries and clinical institutions. Some authors developed risk scores, enabling individualized estimation of thrombotic risk during pregnancy, and permitting implementation of a risk-adapted strategy for thromboprophylaxis during pregnancy and postpartum. This review describes the existing VTE risk scores during the antenatal and postnatal period. The important message beyond the score used is that all women should undergo VTE risk factor assessment. The use of a Computerized Clinical Decision Support System for VTE risk assessment should be explored in obstetrics.
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Kadir RA, Kobayashi T, Iba T, Erez O, Thachil J, Kazi S, Malinowski AK, Othman M. COVID-19 coagulopathy in pregnancy: Critical review, preliminary recommendations, and ISTH registry-Communication from the ISTH SSC for Women's Health. J Thromb Haemost 2020; 18:3086-3098. [PMID: 32846051 PMCID: PMC7461532 DOI: 10.1111/jth.15072] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/16/2020] [Accepted: 08/18/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Novel coronavirus (SARS-CoV-2), which causes COVID-19, has thus far affected more than 15 million individuals, resulting in more than 600 000 deaths worldwide, and the number continues to rise. In a large systematic review and meta-analysis of the literature including 2567 pregnant women, 7% required intensive care admission, with a maternal mortality ~1% and perinatal mortality below 1%. There has been a rapid increase in publications on COVID-19-associated coagulopathy, including disseminated intravascular coagulopathy and venous thromboembolism, in the non-pregnant population, but very few reports of COVID-19 coagulopathy during pregnancy; leaving us with no guidance for care of this specific population. METHODS This is a collaborative effort conducted by a group of experts that was reviewed, critiqued, and approved by the International Society on Thrombosis and Haemostasis Subcommittee for Women's Health Issues in Thrombosis and Hemostasis. A structured literature search was conducted, and the quality of current and emerging evidence was evaluated. Based on the published studies in the non-pregnant and pregnant population with a moderate to high risk of bias as assessed by Newcastle-Ottawa scale and acknowledging the absence of data from randomized clinical trials for management of pregnant women infected with SARS-CoV-2, a consensus in support of a guidance document for COVID-19 coagulopathy in pregnancy was identified. RESULTS AND CONCLUSIONS Specific hemostatic issues during pregnancy were highlighted, and preliminary recommendations to assist in the care of COVID-19-affected pregnant women with coagulopathy or thrombotic complications were developed. An international registry to gather data to support the management of COVID-19 and associated coagulopathy in pregnancy was established.
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Affiliation(s)
- Rezan Abdul Kadir
- Katharine Dormandy Haemophilia and Thrombosis Centre and Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation Hospital, London, UK
- University College, London, UK
| | - Takao Kobayashi
- Department of Obstetrics and Gynecology, Hamamatsu Medical Center, Shizuoka, Japan
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Offer Erez
- Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | | | - Ann Kinga Malinowski
- Division of Maternal Fetal Medicine Mount Sinai Hospital, Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
| | - Maha Othman
- Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, ON, Canada
- School of Baccalaureate Nursing, St Lawrence College, Kingston, ON, Canada
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Pregnancy-related thrombosis risk in patients with protein C deficiency and comparison with pregnant women with heterozygous factor V Leiden mutation. Blood Coagul Fibrinolysis 2019; 31:55-59. [PMID: 31833868 DOI: 10.1097/mbc.0000000000000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: The risk of pregnancy-related venous thromboembolism is high in patients with inherited thrombophilia. The aim of this study was to compare the risk of pregnancy related-venous thromboembolism of women with protein C (PC) deficiency to patients with heterozygous factor V Leiden mutation. 145 consecutive pregnant women with confirmed PC deficiency or heterozygous factor V Leiden mutation were prospectively enrolled in the study. Lyon venous thromboembolism-risk score was used to individually tailor antithrombotic prophylaxis. The use of a validated clinical score presents the advantage to have a homogenous management of the venous thromboembolism risk in patients having similar risk factors. 53 pregnancies with PC deficiency were compared with 190 pregnancies in heterozygous factor V Leiden mutation carriers. 50% of the patients with PC deficiency and 64% of the heterozygous factor V Leiden mutation carriers were asymptomatic. According to the Lyon-venous thromboembolism risk score, 50% of patients with PC deficiency and 51% of heterozygous factor V Leiden carriers did not received any antepartum heparin prophylaxis. 34 and 37% of patients respectively received heparin prophylaxis during the third trimester only. No venous thromboembolism was observed in patients with PC deficiency and one postpartum venous thromboembolism occurred in a patient with heterozygous factor V Leiden. In the absence of randomized controlled clinical studies, we report here a large prospective series of pregnant women with PC deficiency. In our cohort, no difference of outcome, in terms of venous thromboembolism, was observed between pregnant women with PC deficiency and those with heterozygous factor V Leiden. Based on our results, low-molecular-weight heparin prophylaxis should not be mandatory in all pregnant women with PC deficiency. Similar prophylaxis strategies may be applied to women with factor V Leiden mutation or PC deficiency.
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Dargaud Y, Rugeri L, Fleury C, Battie C, Gaucherand P, Huissoud C, Rudigoz RC, Desmurs-Clavel H, Ninet J, Trzeciak MC. Personalized thromboprophylaxis using a risk score for the management of pregnancies with high risk of thrombosis: a prospective clinical study. J Thromb Haemost 2017; 15:897-906. [PMID: 28231636 DOI: 10.1111/jth.13660] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Indexed: 12/30/2022]
Abstract
Essentials Pregnancy is a risk factor for thrombosis. Management of thrombosis risk in pregnancy remains a challenge. Prophylaxis needs to be personalized. Our score may be a helpful tool for the management of pregnancies at high risk of thrombosis. SUMMARY Background Patients with thrombophilia and/or a history of venous thromboembolism (VTE) are at risk of thrombosis during pregnancy. A risk score for pregnancies with an increased risk of VTE was previously described by our group (Lyon VTE score). Objectives The aim of this prospective study was to assess the efficacy and safety of our score-based prophylaxis strategy in 542 pregnancies managed between 2005 and 2015 in Lyon University Hospitals. Patients/Methods Of 445 patients included in the study, 36 had several pregnancies during the study period. Among these 445 patients, 279 had a personal history of VTE (62.7%), 299 patients (67.2%) had a thrombophilia marker, and 131 (29.4%) thrombophilic women had a personal history of VTE. During pregnancy, patients were assigned to one of three prophylaxis strategies according to the risk scoring system. Results In the antepartum period, low molecular weight heparin (LMWH) prophylaxis was prescribed to 64.5% of patients at high risk of VTE. Among them, 34.4% were treated in the third trimester only, and 30.1% were treated throughout pregnancy. During the postpartum period, all patients received LMWH for at least 6 weeks. Two antepartum-related VTEs (0.37%; one with a score of < 3 and the other with a score of > 6) and four postpartum-related VTEs (0.73%; three with scores of 3-5 and one with a score of > 6) occurred. No case of pulmonary embolism was observed during the study period. The rate of bleeding was 0.37%. No serious bleeding requiring transfusions or surgery occurred during the study period. Conclusion The use of a risk score may provide a rational decision process to implement safe and effective antepartum thromboprophylaxis in pregnant women at high risk of VTE.
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Affiliation(s)
- Y Dargaud
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, CHU de Lyon, France
| | - L Rugeri
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, CHU de Lyon, France
| | - C Fleury
- Laboratoire d'Explorations Vasculaires, pavillon M, Hopital Edouard Herriot, CHU de Lyon, France
| | - C Battie
- Service d'Obstetrique, Hopital Femme Mere Enfant, CHU de Lyon, France
| | - P Gaucherand
- Service d'Obstetrique, Hopital Femme Mere Enfant, CHU de Lyon, France
| | - C Huissoud
- Service d'Obstetrique, Hopital de la Croix Rousse, CHU de Lyon, France
| | - R C Rudigoz
- Service d'Obstetrique, Hopital de la Croix Rousse, CHU de Lyon, France
| | - H Desmurs-Clavel
- Service de Medecine Interne, pavillon O, Hopital Edouard Herriot, CHU de Lyon, France
| | - J Ninet
- Service de Medecine Interne, pavillon O, Hopital Edouard Herriot, CHU de Lyon, France
| | - M C Trzeciak
- Unite d'Hemostase Clinique, Hopital Cardiologique Louis Pradel, CHU de Lyon, France
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Testa S, Passamonti SM, Paoletti O, Bucciarelli P, Ronca E, Riccardi A, Rigolli A, Zimmermann A, Martinelli I. The "Pregnancy Health-care Program" for the prevention of venous thromboembolism in pregnancy. Intern Emerg Med 2015; 10:129-34. [PMID: 25078669 DOI: 10.1007/s11739-014-1111-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 07/21/2014] [Indexed: 01/11/2023]
Abstract
Venous thromboembolism (VTE), i.e., deep vein thrombosis and pulmonary embolism, are among the main causes of morbidity and mortality in pregnancy with an estimated incidence of 1 per thousand women years. Recommendations on antithrombotic prophylaxis are weak. The aim of the "Pregnancy Health-care Program" (PHP) was to evaluate the individual risk of VTE in a cohort of pregnant women, and manage them with the aim of reducing the rate of VTE. The study was conducted from Jan 2008 to Dec 2010 in the hospital and obstetrical outclinics in Cremona, Italy, and included 1,787 pregnant women who received clinical observation (n = 1,197), above-knee compression stockings (n = 437) or compression stockings and low-molecular-weight heparin (LMWH) (n = 85) depending on their individual VTE risk, evaluated with a risk score (0.5-3.0) derived from the relative risk estimates of a number of risk factors. Visits were scheduled at the end of each trimester and at hospital discharge after delivery. No VTE occurred, but one superficial vein thrombosis was observed 3 days after vaginal delivery in a woman who received clinical observation (0.6 per thousand). No bleeding was observed in LMWH users. The PHP based on stratification of individual VTE risk resulted in a low incidence of VTE events.
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Affiliation(s)
- Sophie Testa
- Hemostasis and Thrombosis Center, Clinical Pathology Department, AO Istituti Ospitalieri di Cremona, Viale Concordia 1, 26100, Cremona, Italy,
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9
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Weintraub AY, Press F, Wiznitzer A, Sheiner E. Maternal thrombophilia and adverse pregnancy outcomes. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2.2.203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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10
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[Antithrombotic therapy and pregnancy]. Presse Med 2013; 42:1251-8. [PMID: 23855993 DOI: 10.1016/j.lpm.2013.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 05/27/2013] [Accepted: 06/12/2013] [Indexed: 11/21/2022] Open
Abstract
The incidence of venous thromboembolism (VTE) during pregnancy is about one event per 1000 pregnancies and placenta-mediated pregnancy complications (PC) occurred in 15%. Knowing the biological combined with clinical risk factors would help to prevent problems during the pregnancy. Several antithrombotic therapies exist, including very recent ones but LMWH and aspirin are still molecules of choice. The women should be assessed for VTE and PC risk in order to improve the outcome.
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11
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Effects of prothrombotic markers and non-O blood group in maternal venous thromboembolism during pregnancy and postpartum. Blood Coagul Fibrinolysis 2013; 23:649-52. [PMID: 22885768 DOI: 10.1097/mbc.0b013e3283574f05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Our aim was to assess thrombophilic risk factors and the non-O blood group as contributors to the development of venous thromboembolism during pregnancy and the postpartum period. A total of 199 women underwent blood typing and an extensive thombophilia screening. Factor V Leiden, FII G20210A, protein C deficiency and non-O blood group were significantly associated with venous thromboembolism during pregnancy and postpartum period. A known thrombophilic factor may have consequences for future pregnancies and could have implications for clinical practice. For this reason, women with a history of thromboembolism should be screened for thrombophilia. The non-O blood group could also have an important influence, especially when concomitant with another prothrombotic risk factor mainly pregnancy and thrombophilia.
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12
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Alonso-Coello P, Ebrahim S, Guyatt GH, Tikkinen KAO, Eckman MH, Neumann I, McDonald SD, Akl EA, Bates SM. Evaluating patient values and preferences for thromboprophylaxis decision making during pregnancy: a study protocol. BMC Pregnancy Childbirth 2012; 12:40. [PMID: 22646475 PMCID: PMC3495041 DOI: 10.1186/1471-2393-12-40] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 05/30/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pregnant women with prior venous thromboembolism (VTE) are at risk of recurrence. Low molecular weight heparin (LWMH) reduces the risk of pregnancy-related VTE. LMWH prophylaxis is, however, inconvenient, uncomfortable, costly, medicalizes pregnancy, and may be associated with increased risks of obstetrical bleeding. Further, there is uncertainty in the estimates of both the baseline risk of pregnancy-related recurrent VTE and the effects of antepartum LMWH prophylaxis. The values and treatment preferences of pregnant women, crucial when making recommendations for prophylaxis, are currently unknown. The objective of this study is to address this gap in knowledge. METHODS We will perform a multi-center cross-sectional interview study in Canada, USA, Norway and Finland. The study population will consist of 100 women with a history of lower extremity deep vein thrombosis (DVT) or pulmonary embolism (PE), and who are either pregnant, planning pregnancy, or may in the future consider pregnancy (women between 18 and 45 years). We will exclude individuals who are on full dose anticoagulation or thromboprophylaxis, who have undergone surgical sterilization, or whose partners have undergone vasectomy. We will determine each participant's willingness to receive LMWH prophylaxis during pregnancy through direct choice exercises based on real life and hypothetical scenarios, preference-elicitation using a visual analog scale ("feeling thermometer"), and a probability trade-off exercise. The primary outcome will be the minimum reduction (threshold) in VTE risk at which women change from declining to accepting LMWH prophylaxis. We will explore possible determinants of this choice, including educational attainment, the characteristics of the women's prior VTE, and prior experience with LMWH. We will determine the utilities that women place on the burden of LMWH prophylaxis, pregnancy-related DVT, pregnancy-related PE and pregnancy-related hemorrhage. We will generate a "personalized decision analysis" using participants' utilities and their personalized risk of recurrent VTE as inputs to a decision analytic model. We will compare the personalized decision analysis to the participant's stated choice. DISCUSSION The preferences of pregnant women at risk of VTE with respect to the use of antithrombotic therapy remain unexplored. This research will provide explicit, quantitative expressions of women's valuations of health states related to recurrent VTE and its prevention with LMWH. This information will be crucial for both guideline developers and for clinicians.
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Affiliation(s)
- Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, CIBERESP-IIB Sant Pau, Barcelona, 08041, Spain
| | - Shanil Ebrahim
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kari AO Tikkinen
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
- Department of Urology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Mark H Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH, USA
| | - Ignacio Neumann
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sarah D McDonald
- Departments of Obstetrics & Gynecology, Radiology, and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Elie A Akl
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
- Department of Medicine, State University of New York at Buffalo, New York, NY, USA
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
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13
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Actualités sur les facteurs de risque et la prévention des complications thrombotiques de la grossesse. ACTA ACUST UNITED AC 2012; 40:301-7. [DOI: 10.1016/j.gyobfe.2012.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Accepted: 02/15/2012] [Indexed: 11/20/2022]
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14
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Chauleur C, Gris JC, Laporte S, Rancon F, Varlet MN, Decousus H, Mismetti P. Use of the Delphi method to facilitate antithrombotics prescription during pregnancy. Thromb Res 2010; 126:88-92. [DOI: 10.1016/j.thromres.2010.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 10/22/2009] [Accepted: 01/17/2010] [Indexed: 10/19/2022]
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Tooher R, Gates S, Dowswell T, Davis LJ. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. Cochrane Database Syst Rev 2010:CD001689. [PMID: 20464719 PMCID: PMC4175551 DOI: 10.1002/14651858.cd001689.pub2] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Venous thromboembolic disease (TED), although rare, is a major cause of maternal mortality and morbidity, hence methods of prophylaxis are often used for women at risk. This may include women delivered by caesarean section, those with a personal or family history of TED and women with inherited or acquired thrombophilias (conditions that predispose people to thrombosis). Many methods of prophylaxis carry a risk of side effects, and as the risk of TED is low, it is possible that the benefits of thromboprophylaxis may be outweighed by harm. Current guidelines for clinical practice are based on expert opinion only, rather than high quality evidence from randomised trials. OBJECTIVES To determine the effects of thromboprophylaxis in women who are pregnant or have recently delivered and are at increased risk of TED on the incidence of venous TED and side effects of treatment. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009). SELECTION CRITERIA Randomised trials comparing one method of thromboprophylaxis with placebo or no treatment, and randomised trials comparing two (or more) methods of thromboprophylaxis. DATA COLLECTION AND ANALYSIS Two review authors extracted data independently and resolved any discrepancies by discussion. MAIN RESULTS Sixteen trials met the inclusion criteria but only 13 trials, involving 1774 women, examining a range of methods of thromboprophylaxis, contributed data for the outcomes of interest. Four of them compared methods of antenatal prophylaxis: low molecular weight heparin (LMWH) versus unfractionated heparin (UFH) (two studies), and heparin versus no treatment (two studies). Eight studies assessed postnatal prophylaxis after caesarean section; one compared hydroxyethyl starch with unfractionated heparin; four compared heparin with placebo; and the other three compared UFH with LMWH. One study examined prophylaxis in the postnatal period.The small number of statistically significant findings in this review are largely derived from trials which are not of high methodological quality. It was not possible to assess the effects of any of these interventions on most outcomes, and especially on rare outcomes such as death, TED and osteoporosis, because of small sample sizes and the small number of trials making the same comparisons.There was some evidence of side effects associated with thromboprophylaxis. AUTHORS' CONCLUSIONS There is insufficient evidence on which to base recommendations for thromboprophylaxis during pregnancy and the early postnatal period. Large scale randomised trials of currently-used interventions should be conducted.
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Affiliation(s)
- Rebecca Tooher
- Paediatric Trials Unit, Children,Youth and Women’s Health Service, Adelaide, Australia
| | - Simon Gates
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Therese Dowswell
- Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive Medicine, The University of Liverpool, Liverpool, UK
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Dargaud Y, Rugeri L, Vergnes MC, Arnuti B, Miranda P, Negrier C, Bestion A, Desmurs-Clavel H, Ninet J, Gaucherand P, Rudigoz RC, Berland M, Champion F, Trzeciak MC. A risk score for the management of pregnant women with increased risk of venous thromboembolism: a multicentre prospective study. Br J Haematol 2009; 145:825-35. [DOI: 10.1111/j.1365-2141.2009.07698.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Dargaud Y, Rugeri L, Ninet J, Négrier C, Trzeciak MC. Feasibility of an easy-to-use risk score in the prevention of venous thromboembolism and placental vascular complications in pregnant women. A rebuttal. Thromb Res 2008; 122:715-6; author reply 717-8. [DOI: 10.1016/j.thromres.2008.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 04/30/2008] [Accepted: 06/16/2008] [Indexed: 11/28/2022]
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Nelson SM, Greer IA. Thromboembolic events in pregnancy: pharmacological prophylaxis and treatment. Expert Opin Pharmacother 2007; 8:2917-31. [DOI: 10.1517/14656566.8.17.2917] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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The cost-benefit ratio of screening pregnant women for thrombophilia. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2007; 5:189-203. [PMID: 19204775 DOI: 10.2450/2007.0022-07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 06/07/2007] [Indexed: 11/21/2022]
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Weintraub AY, Sheiner E. Anticoagulant therapy and thromboprophylaxis in patients with thrombophilia. Arch Gynecol Obstet 2007; 276:567-71. [PMID: 17828548 DOI: 10.1007/s00404-007-0409-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Accepted: 06/12/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this review was to discuss the effectiveness of anticoagulant therapy and thromboprophylaxis in patients with thrombophilia. METHODS A MEDLINE search was performed using the keywords: "anticoagulant therapy", "pregnancy", "thromboprophylaxis", "thrombophilia", "adverse pregnancy outcomes", "venous thromboembolism", "heparin" and "low molecular weight heparin". RESULTS The identification of a link between thrombophilic factors and adverse pregnancy outcome offers treatment possibilities. Until recently, it has not been clear whether antithrombotic therapy is useful in women with previous placental dysfunction and inherited thrombophilia. Anticoagulant therapy is indicated during pregnancy for the prevention and treatment of venous thromboembolism, for the prevention and treatment of systemic embolism in patients with mechanical heart valves and, for the prevention of pregnancy complications in women with antiphospholipid antibody syndrome or other thrombophilic disorders and previous pregnancy complications. At present, limited data exist regarding the efficacy of anticoagulants during pregnancy. Recommendations are largely based on data extrapolated from non-pregnant patients, case reports, and case series of pregnant patients. Many physicians have been treating such women with antithrombotic therapy on the basis of logic and anecdotal evidence. CONCLUSION A regimen for thrombophylaxis and treatment of thrombophilic parturient based on thrombophilia type is proposed.
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Affiliation(s)
- Adi Y Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Science, Ben Gurion University of the Negev, P.O Box 151, Beer-Sheva, Israel
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