Thromboprophylaxis in Pregnancy

Anticoagulation Regimens in Pregnancy

This article explores current recommendations for anticoagulation therapy in pregnancy, including antepartum, intrapartum, and postpartum guidelines. The authors review various screening strategies used to assess whether a patient is an appropriate candidate for anticoagulation during pregnancy and the postpartum period. The article includes dosing regimens, optimal surveillance, and medication reversal. The authors also address the challenges of transitioning between low-molecular-weight heparin and unfractionated heparin. Finally, there is a discussion of intrapartum anticoagulation management, especially as it relates to the administration of regional anesthesia, and the indications for and timing of thromboprophylaxis following delivery.

Use of thrombomodulin-modified thrombin generation in uncomplicated pregnancy: the normal range and prothrombotic phenotype

Pregnancy is a hypercoagulable state associated with an increased risk of venous thrombosis. Thrombomodulin(TM)-modified thrombin generation is a promising laboratory method to detect the thrombotic tendency and prothrombotic phenotype. 141 women were enrolled: 30 healthy non-pregnant controls, 85 healthy pregnant women (26 in 1st trimester, 28 in 2nd trimester, 31 in 3rd trimester), and 26 patients with gestational diabetes mellitus (GDM). Thrombin generation was measured using platelet poor plasma (PPP) TM + and PPP TM- reagents. The parameters were endogenous thrombin potential (ETP), Lagtime, Peak Height, time to peak and ETP ratio(ETP(TM+)/ETP(TM-)). Protein S-depleted plasma samples with different activity were prepared and measured. Pregnancy was associated with a significant decrease of ETP in the presence of TM, compared with that found in the absence of TM. This was observed in all trimesters (1st trimester 1185.67 ± 284.95 nM*min vs.1510.39 ± 281.90 nM*min, p < .001; 2nd trimester 1458.96 ± 349.65 nM*min vs. 1929.10 ± 316.98 nM*min, p < .001; 3rd trimester 1391.60 ± 317.05 nM*min vs. 1854.88 ± 327.60 nM*min, p < .001). The ETP ratio was also markedly increased in all trimesters (0.78 ± 0.10, 0.76 ± 0.11 and 0.74 ± 0.12) compared with that of non-pregnant controls (0.51 ± 0.17, p < .001). The results of ETP ratio in protein S-depleted plasmas were 0.986, 0.943 and 0.880 with 0%, 16% and 40% of protein S activity, which indirect represented the thrombotic phenotype of PS deficiency in pregnancy. TM-modified thrombin generation serves as a useful test for hypercoagulation in pregnant women. The ETP ratio and the reference range of ETP in the presence of TM could provide the basis to predict the risk of thrombotic complications during pregnancy.

Delivery decision in pregnant women rescued by ECMO for severe ARDS: a retrospective multicenter cohort study

Background

Although rarely addressed in the literature, a key question in the care of critically pregnant women with severe acute respiratory distress syndrome (ARDS), especially at the time of extracorporeal membrane oxygenation (ECMO) decision, is whether delivery might substantially improve the mother’s and child’s conditions. This multicenter, retrospective cohort aims to report maternal and fetal short- and long-term outcomes of pregnant women with ECMO-rescued severe ARDS according to the timing of the delivery decision taken before or after ECMO cannulation.

Methods

We included critically ill women with ongoing pregnancy or within 15 days after a maternal/child-rescue-aimed delivery supported by ECMO for a severe ARDS between October 2009 and August 2021 in four ECMO centers. Clinical characteristics, critical care management, complications, and hospital discharge status for both mothers and children were collected. Long-term outcomes and premature birth complications were assessed.

Results

Among 563 women on venovenous ECMO during the study period, 11 were cannulated during an ongoing pregnancy at a median (range) of 25 (21–29) gestational weeks, and 13 after an emergency delivery performed at 32 (17–39) weeks of gestation. Pre-ECMO PaO₂/FiO₂ ratio was 57 (26–98) and did not differ between the two groups. Patients on ECMO after delivery reported more major bleeding (46 vs. 18%, p = 0.05) than those with ongoing pregnancy. Overall, the maternal hospital survival was 88%, which was not different between the two groups. Four (36%) of pregnant women had a spontaneous expulsion on ECMO, and fetal survival was higher when ECMO was set after delivery (92% vs. 55%, p = 0.03). Among newborns alive, no severe preterm morbidity or long-term sequelae were reported.

Conclusion

Continuation of the pregnancy on ECMO support carries a significant risk of fetal death while improving prematurity-related morbidity in alive newborns with no difference in maternal outcomes. Decisions regarding timing, place, and mode of delivery should be taken and regularly (re)assess by a multidisciplinary team in experienced ECMO centers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04189-5.

The impact of levothyroxine exposure on delivery outcome in hypothyroid pregnant women (PETAL study): A five-year retrospective cohort study

Background

Hypothyroidism affects 3% of pregnant women, and to date, no studies have addressed the impact levothyroxine-treated hypothyroidism on delivery outcome.

Methods

This retrospective cohort study was conducted among 750 women with a singleton pregnancy who gave birth between 2015 and 2019. Delivery modes were compared between 250 hypothyroid women exposed to levothyroxine and 500 euthyroid control women. The aim of this study was to determine the impact of levothyroxine exposure on delivery outcome.

Results

Multiple logistic regression showed no significant association between exposure to levothyroxine and the overall rate of caesarean delivery (aOR 1.1; 95% CI 0.8 to 1.6). Mean TSH concentrations were significantly higher throughout the pregnancy in hypothyroid women despite levothyroxine treatment. Maternal and neonatal outcomes in both groups were not different.

Conclusion

Hypothyroidism treated with levothyroxine during pregnancy according to local guidelines is not a significant risk factor for caesarean delivery.

Tromboprofilaxis durante el embarazo

Introducción. En mujeres, el riesgo de desarrollar enfermedad tromboembólica venosa (ETV) es 5 a 6 veces mayor durante el embarazo, riesgo que puede aumentar considerablemente si existen antecedentes personales o familiares de otros estados protrombóticos. La ETV es una de las principales causas de morbimortalidad en esta población, por lo que para evaluar la pertinencia de usar tromboprofilaxis, ya sea farmacológica o no farmacológica, es necesario reconocer oportunamente los factores de riesgo clínico asociados a esta condición.Objetivo. Describir el uso de pruebas de tamizaje de estados protrombóticos y de la tromboprofilaxis farmacológica y no farmacológica para prevenir la ETV durante la gestación, durante el parto y durante el puerperio.Materiales y métodos. Se realizó una revisión de la literatura en Embase, ClinicalKey, ScienceDirect, Access Medicine, Scopus, ProQuest, PubMed y LILACS. Se buscaron estudios sobre trombofilia y trombofilaxis en el embarazo publicados entre enero de 2004 y marzo de 2018 en inglés y en español.Resultados. En la búsqueda inicial se identificaron 128 artículos, de los cuales 54 cumplieron los criterios de inclusión. La mayoría de estudios correspondió a revisiones narrativas (n=16), guías de práctica clínica (n=13) y revisiones sistemáticas (n=8).Conclusión. Se recomienda el uso de pruebas de tamizaje de estados protrombóticos durante la gestación, el parto y el puerperio, ya que la identificación oportuna de la ETV permitirá disminuir las tasas de morbimortalidad en esta población mediante la implementación de medidas tromboprofilácticas, sean o no farmacológicas.

Maternal and fetal outcomes in pregnancies with long-term corticosteroid use

PURPOSE

Long-term corticosteroids are administered in pregnant patients with an array of autoimmune and inflammatory disorders. Our objective is to determine whether long-term corticosteroid use is associated with increased maternal and neonatal adverse outcomes.

MATERIALS AND METHODS

We performed a retrospective cohort study using the Healthcare Cost and Utilization Project-national Inpatient Sample from the USA. All pregnant patients on long-term corticosteroids were identified using International Classification of Disease-9 coding from 2003 to 2015. The effect of long-term corticosteroid use on maternal and neonatal outcomes was evaluated using multivariate logistic regression.

RESULTS

Out of the 10,491,798 births included in our study, 3999 were among women with long-term use of steroids, for an overall prevalence of 38 per 100,000 births. There was a steady increase in chronic steroid use from 2 to 81 per 100,000 births over the 13-year study period (p < .0001). Women on long-term steroids were more likely to have pregnancies complicated by preeclampsia, 1.72 (1.30-2.29) and were at greater risk of preterm premature rupture of membranes, 1.63 (1.01-2.44), pyelonephritis, 4.81 (1.18-19.61), and venous thromboembolisms, 2.50 (1.32-4.73). Neonates born from mothers on long-term steroids were more likely to suffer from prematurity, 1.51 (1.13-2.05), and lower weight for gestational age, 2.10 (1.34-3.30).

CONCLUSION

Long-term corticosteroids use in pregnancy is associated with maternal and fetal adverse outcomes. These patients would benefit from close follow-up throughout their pregnancy to minimize complications.

Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1)

This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for preoperative, intraoperative, and postoperative phases with, primarily, a maternal focus. The focused pathway process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery Guideline will consider from the time from decision to operate (starting with the 30-60 minutes before skin incision) to hospital discharge. The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Section," "Cesarean Section Delivery" and all pre- and intraoperative ERAS items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses that evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system, as used and described in previous ERAS Guidelines. The ERAS Cesarean Delivery Guideline/Pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with ERAS cesarean delivery consensus recommendations preoperative elements (anesthetic medications, fasting, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ), intraoperative elements (anesthetic management, maternal hypothermia prevention, surgical technique, hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin closure), perioperative fluid management, and postoperative elements (chewing gum, management of nausea and vomiting, analgesia, timing of food intake, glucose management, antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal and neonate discharge). Limited topics for optimized care and for antenatal education and counselling and the immediate neonatal needs at delivery are discussed. Strong recommendations for element use were given for preoperative (antenatal education and counselling, use of antacids and histamine, H2 receptor antagonists, 2-hour fasting and small meal within 6 hours surgery, antimicrobial prophylaxis and skin preparation/chlorhexidine-alcohol), intraoperative (regional anesthesia, prevention of maternal hypothermia [forced warm air, warmed intravenous fluids, room temperature]), perioperative (fluid management for euvolemia and neonatal immediate care needs that include delayed cord clamping), and postoperative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia with nonsteroidal antiinflammatory drugs/paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic compression stocking for venous thromboembolism prophylaxis, immediate removal of urinary catheter). Recommendations against the element use were made for preoperative (maternal sedation, bowel preparation), intraoperative (neonatal oral suctioning or increased inspired oxygen), and postoperative (heparin should not be used routinely venous thromboembolism prophylaxis). Because these ERAS cesarean delivery pathway recommendations (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, this will create an opportunity for the focused and optimized areas of care research with further enhanced care and recommendation.