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Fernández-Buhigas I. Obstetric management of the most common autoimmune diseases: A narrative review. Front Glob Womens Health 2022; 3:1031190. [PMID: 36505012 PMCID: PMC9728613 DOI: 10.3389/fgwh.2022.1031190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/10/2022] [Indexed: 11/24/2022] Open
Abstract
Historically, women with an autoimmune disease (AD) could not get pregnant due to infertility frequently linked to the medical condition or because the pregnancy was contraindicated, as it could harm the mother and the future child. Sometimes, pregnancy was contraindicated because the medication needed to control the AD could not be given during pregnancy. All these items are no longer true nowadays. Fertility treatments have advanced, obstetric care is better, and the medical treatments of autoimmune diseases have progressed, so women with any kind of AD are encouraged to get pregnant, and their presence in obstetric clinics is arising. This is challenging for the obstetricians, as to be sure that these pregnancies are safe for the mother and the future child, the obstetricians need to know the natural evolution of these conditions, the impact of pregnancy and postpartum on the illness, and the impact of the AD in the pregnancy. In this narrative review, we aim to make a brief resume of the obstetric management of the most common diseases (Systemic lupus erythematosus, antiphospholipid syndrome, the Anti-Ro/SSA and Anti-La/SSB antigen-antibody systems, rheumatoid arthritis, Sjögren's syndrome and Undifferentiated systemic rheumatic disease and overlap syndromes).
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Affiliation(s)
- Irene Fernández-Buhigas
- Obstetrics and Gynecology Department, Hospital Universitario de Torrejón, Madrid, Spain,School of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain,Correspondence: Irene Fernández-Buhigas
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2
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Gris JC, Guillotin F, Chéa M, Bourguignon C, Nouvellon É, Bouvier S. Antiphospholipid Antibodies in Pregnancy: Maternal and Neonatal Implications. Semin Thromb Hemost 2022; 49:337-347. [PMID: 36108650 DOI: 10.1055/s-0042-1756193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractAntiphospholipid antibodies (aPL Abs) have long been associated with the occurrence of certain specific pregnancy morbidities, affecting both mother and fetus. Antithrombotic-based prophylactic regimens are the standard of care. Their intensity is modulated by the thrombotic history and has greatly improved the prognosis related to spontaneous morbidity. Observational studies show that this treatment is still associated with the persistence of excess of late-pregnancy placental diseases, calling for new or complementary developments, yet to be validated. Rigorous prospective multicentric validation of clinical and laboratory parameters capable of identifying those women and fetuses at a risk of pejorative evolution, thus early prognosis, is a priority issue. These will make it possible to develop customized treatments and test them. Furthermore, there are still concerns, particularly neurodevelopmental ones, about children born to aPL Ab-positive mothers, and clarification based on regular, more systematic evaluations is required. Even after pregnancy, women with a pure obstetrical antiphospholipid syndrome are at a greater risk of venous and arterial thrombosis over time, and prevention needs to be improved. These women also appear to develop more psychiatric and mood disorders. Central nervous system imaging using high-resolution techniques has shown subtle impairments in the white matter, associated with the most pathogenic aPL Abs and the clinical significance of this is under investigation. These mothers also seem to develop an excess of cancers. The systemic impact of aPL Abs is gradually being suspected, although this requires further evidence, and prevention should be envisaged.
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Affiliation(s)
- Jean-Christophe Gris
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- Department of Hematology, Faculty of Pharmaceutical and Biological Sciences, Montpellier University, France
- UMR UA11 INSERM IDESP - Montpellier University, France
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | | | - Mathias Chéa
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
| | - Chloé Bourguignon
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- UMR UA11 INSERM IDESP - Montpellier University, France
| | - Éva Nouvellon
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- UMR UA11 INSERM IDESP - Montpellier University, France
| | - Sylvie Bouvier
- Department of Hematology, CHU Nîmes, Univ Montpellier, Nîmes, France
- Department of Hematology, Faculty of Pharmaceutical and Biological Sciences, Montpellier University, France
- UMR UA11 INSERM IDESP - Montpellier University, France
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Cohen AJ, Boggio L, Billett HH, DeSancho MT, Gaddh M, Kouides P, Lim M, Nyak L, Rajan S, Rosovsky R, Streiff M, Wang TF, Baumann Kreuziger L. North American Physician Practice Patterns in the Management of Anticoagulation in Pregnancy. J Womens Health (Larchmt) 2020; 30:829-836. [PMID: 33232187 DOI: 10.1089/jwh.2020.8385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background: During pregnancy and in the postpartum period women are at increased risk of venous thromboembolism (VTE) owing to hypercoagulability and mechanical issues, as well as nonpregnancy conditions including inherited and acquired thrombophilia. Although guidelines exist for the use of thromboprophylaxis in this setting, there are differences in the specifics of the recommendations among expert societies. We assessed the current practice patterns of North American providers in the prevention of pregnancy-associated VTE in women with thrombophilia. Methods: A survey was created and distributed with case studies and questions addressing VTE prevention during the antepartum and postpartum periods. Results: Surveys were completed by 28% of adult providers queried, with broad geographic representation. There was consistent use of a prophylactic dose of low-molecular weight heparin (LMWH) ante- and postpartum for individuals with low-risk thrombophilia and past estrogen-provoked VTE but a lack of a consensus of anticoagulant (AC) use and dose in individuals with higher risk thrombophilia. There was variability in the dose selection and monitoring of AC when using induction versus spontaneous labor, with 47% of providers switching from LMWH to unfractionated heparin for those not having a scheduled delivery, and there were differences in the duration of postpartum prophylaxis based upon delivery mode. Conclusion: In this survey of North American experienced specialists' responses to a variety of commonly encountered scenarios of thrombophilia and pregnancy and the management of AC were not always consistent with published guidelines.
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Affiliation(s)
- Alice J Cohen
- Division of Hematology/Oncology, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Lisa Boggio
- Departments of Medicine and Pediatrics, Hemophilia and Thrombosis Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Henny H Billett
- Division of Hematology, Department of Oncology, Montetiore Health Systems and the Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Maria Teresa DeSancho
- Department of Medicine, Division of Hematology and Medical Oncology, Weill Cornell Medical College, New York, New York, USA
| | - Manila Gaddh
- Department of Hematology and Medical Oncology, Emory University, Atlanta, Georgia, USA
| | - Peter Kouides
- University of Rochester School of Medicine, Hematology Unit, Rochester General Hospital, Rochester, New York, USA
| | - Ming Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Lalitha Nyak
- Division of Hematology and Oncology, Department of Internal Medicine, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, Ohio, USA
| | - Sandeep Rajan
- Division of Hematology and Oncology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Rachel Rosovsky
- Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael Streiff
- Department of Medicine and Pathology, Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa at the Ottawa Hospital and Ottawa Research Institute, Ottawa, Canada
| | - Lisa Baumann Kreuziger
- Medical College of Wisconsin, Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
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Hart C, Bauersachs R, Scholz U, Zotz R, Bergmann F, Rott H, Linnemann B. 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). Hamostaseologie 2020; 40:572-590. [PMID: 32590872 DOI: 10.1055/a-1132-0750] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Christina Hart
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt, Germany.,Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Ute Scholz
- MVZ Labor Dr. Reising-Ackermann und Kollegen, Zentrum für Blutgerinnungsstörungen, Leipzig, Germany
| | - Rainer Zotz
- Centrum für Blutgerinnungsstörungen und Transfusionsmedizin, Düsseldorf, Germany
| | - Frauke Bergmann
- MVZ Wagnerstibbe, Amedes-Gruppe, Hannover, Lower Saxony, Germany
| | | | - Birgit Linnemann
- Division of Angiology, University Center of Vascular Medicine, University Hospital Regensburg, Regensburg, Germany
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Cáliz Cáliz R, Díaz Del Campo Fontecha P, Galindo Izquierdo M, López Longo FJ, Martínez Zamora MÁ, Santamaria Ortiz A, Amengual Pliego O, Cuadrado Lozano MJ, Delgado Beltrán MP, Ortells LC, Pérez ECC, Rego GDC, Corral SG, Varela CF, López MM, Nishishinya B, Navarro MN, Testa CP, Pérez HS, Silva-Fernández L, Taboada VMM. Recommendations of the Spanish Rheumatology Society for Primary Antiphospholipid Syndrome. Part II: Obstetric Antiphospholipid Syndrome and Special Situations. REUMATOLOGIA CLINICA 2020; 16:133-148. [PMID: 30686569 DOI: 10.1016/j.reuma.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 10/31/2018] [Accepted: 11/09/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. METHODS A panel of 4rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for the document elaboration, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network, SIGN levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). RESULTS Forty-six recommendations were drawn up, addressing 5main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the last 25, referring to the areas of: obstetric APS and special situations. The document provides a table of recommendations and treatment algorithms. CONCLUSIONS Update of SER recommendations on APS is presented. This document corresponds to part II, related to obstetric SAF and special situations. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A part I has also been prepared, which addresses aspects related to diagnosis, evaluation and treatment.
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Affiliation(s)
- Rafael Cáliz Cáliz
- Servicio de Reumatología, Hospital Universitario Virgen de las Nieves, Facultad de Medicina, Universidad de Granada, España.
| | | | | | | | - María Ángeles Martínez Zamora
- Unidad de Ginecología y Obstetricia, Hospital Clinic, Barcelona, España; Representante de la Sociedad Española de Ginecología y Obstetricia (SEGO), Madrid, España
| | - Amparo Santamaria Ortiz
- Unidad de Hemostasia y Trombosis, Servicio de Hematología. Hospital Vall d́Hebron, Barcelona, España; Representante de la Sociedad Española de Trombosis y Hemostasia (SETH), Madrid, España
| | - Olga Amengual Pliego
- Departamento de Reumatología, Endocrinología y Nefrología. Facultad de Medicina. Universidad de Hokkaido, Sapporo, Japón
| | | | | | | | | | | | | | - Clara Fuego Varela
- Servicio de Reumatología. Hospital Regional Universitario de Málaga. Hospital Civil, Málaga, España
| | - María Martín López
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Betina Nishishinya
- Servicio de Reumatología y Medicina del deporte. Medicina del Deporte. Clínica Quirón, Barcelona, España
| | | | | | - Hiurma Sánchez Pérez
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - Lucia Silva-Fernández
- Servicio de Reumatología. Complexo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, España
| | - Víctor Manuel Martínez Taboada
- Facultad de Medicina, Universidad de Cantabria, Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
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6
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Cáliz Cáliz R, Díaz Del Campo Fontecha P, Galindo Izquierdo M, López Longo FJ, Martínez Zamora MÁ, Santamaría Ortiz A, Amengual Pliego O, Cuadrado Lozano MJ, Delgado Beltrán MP, Carmona Ortells L, Cervantes Pérez EC, Díaz-Cordovés Rego G, Garrote Corral S, Fuego Varela C, Martín López M, Nishishinya B, Novella Navarro M, Pereda Testa C, Sánchez Pérez H, Silva-Fernández L, Martínez Taboada VM. Recommendations of the Spanish Rheumatology Society for Primary Antiphospholipid Syndrome. Part I: Diagnosis, Evaluation and Treatment. REUMATOLOGIA CLINICA 2020; 16:71-86. [PMID: 30713012 DOI: 10.1016/j.reuma.2018.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The difficulty in diagnosis and the spectrum of clinical manifestations that can determine the choice of treatment for primary antiphospholipid syndrome (APS) has fostered the development of recommendations by the Spanish Society of Rheumatology (SER), based on the best possible evidence. These recommendations can serve as a reference for rheumatologists and other specialists involved in the management of APS. METHODS A panel of four rheumatologists, a gynaecologist and a haematologist with expertise in APS was created, previously selected by the SER through an open call or based on professional merits. The stages of the work were: identification of the key areas for drafting the document, analysis and synthesis of the scientific evidence (using the Scottish Intercollegiate Guidelines Network [SIGN] levels of evidence) and formulation of recommendations based on this evidence and formal assessment or reasoned judgement techniques (consensus techniques). RESULTS 46 recommendations were drawn up, addressing five main areas: diagnosis and evaluation, measurement of primary thromboprophylaxis, treatment for APS or secondary thromboprophylaxis, treatment for obstetric APS and special situations. These recommendations also include the role of novel oral anticoagulants, the problem of recurrences or the key risk factors identified in these subjects. This document reflects the first 21, referring to the areas of: diagnosis, evaluation and treatment of primary APS. The document provides a table of recommendations and treatment algorithms. CONCLUSIONS An update of the SER recommendations on APS is presented. This document corresponds to partI, related to diagnosis, evaluation and treatment. These recommendations are considered tools for decision-making for clinicians, taking into consideration both the decision of the physician experienced in APS and the patient. A partII has also been prepared, which addresses aspects related to obstetric SAF and special situations.
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Affiliation(s)
- Rafael Cáliz Cáliz
- Servicio de Reumatología, Hospital Universitario Virgen de las Nieves, Facultad de Medicina, Universidad de Granada, Granada, España.
| | | | | | | | - María Ángeles Martínez Zamora
- Unidad de Ginecología y Obstetricia, Hospital Clínic, Barcelona, España; Representante de la Sociedad Española de Ginecología y Obstetricia (SEGO), Madrid, España
| | - Amparo Santamaría Ortiz
- Unidad de Hemostasias y Trombosis, Servicio de Hematología, Hospital Vall d'Hebron, Barcelona, España; Representante de la Sociedad Española de Trombosis y Hemostasia (SETH), Madrid, España
| | - Olga Amengual Pliego
- Departamento de Reumatología, Endocrinología y Nefrología, Facultad de Medicina, Universidad de Hokkaido, Sapporo, Japón
| | | | | | | | | | | | | | - Clara Fuego Varela
- Servicio de Reumatología, Hospital Regional Universitario de Málaga. Hospital Civil, Málaga, España
| | - María Martín López
- Servicio de Reumatología, Hospital Universitario 12 de Octubre, Madrid, España
| | - Betina Nishishinya
- Servicio de Reumatología y Medicina del deporte, Clínica Quirón, Barcelona, España
| | | | | | - Hiurma Sánchez Pérez
- Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, España
| | - Lucia Silva-Fernández
- Servicio de Reumatología, Complexo Hospitalario Universitario de Ferrol, Ferrol, A Coruña, España
| | - Víctor Manuel Martínez Taboada
- Facultad de Medicina, Universidad de Cantabria; Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, España
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Olsson M, Stanne TM, Pedersen A, Lorentzen E, Kara E, MartinezâPalacian A, RÃnnow Sand NP, Jacobsen AF, Sandset PM, Sidelmann JJ, EngstrÃm G, Melander O, Kanse SM, Jern C. Genome-wide analysis of genetic determinants of circulating factor VII-activating protease (FSAP) activity. J Thromb Haemost 2018; 16:2024-2034. [PMID: 30070759 PMCID: PMC6485504 DOI: 10.1111/jth.14258] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Indexed: 01/17/2023]
Abstract
Essentials Knowledge of genetic regulators of plasma factor VII activating protease (FSAP) levels is limited. We performed a genome-wide analysis of variants influencing FSAP activity in Scandinavian cohorts. We replicated an association for Marburg-1 and identified an association for a HABP2 stop variant. We identified a novel locus near ADCY2 as a potential additional regulator of FSAP activity. SUMMARY Background Factor VII-activating protease (FSAP) has roles in both coagulation and fibrinolysis. Recent data indicate its involvement in several other processes, such as vascular remodeling and inflammation. Plasma FSAP activity is highly variable among healthy individuals and, apart from the low-frequency missense variant Marburg-I (rs7080536) in the FSAP-encoding gene HABP2, determinants of this variation are unclear. Objectives To identify novel genetic variants within and outside of the HABP2 locus that influence circulating FSAP activity. Patients/Methods We performed an exploratory genome-wide association study (GWAS) on plasma FSAP activity amongst 3230 Swedish subjects. Directly genotyped rare variants were also analyzed with gene-based tests. Using GWAS, we confirmed the strong association between the Marburg-I variant and FSAP activity. HABP2 was also significant in the gene-based analysis, and remained significant after exclusion of Marburg-I carriers. This was attributable to a rare HABP2 stop variant (rs41292628). Carriers of this stop variant showed a similar reduction in FSAP activity as Marburg-I carriers, and this finding was replicated. A secondary genome-wide significant locus was identified at a 5p15 locus (rs35510613), and this finding requires future replication. This common variant is located upstream of ADCY2, which encodes a protein catalyzing the formation of cAMP. Results and Conclusions This study verified the Marburg-I variant to be a strong regulator of FSAP activity, and identified an HABP2 stop variant with a similar impact on FSAP activity. A novel locus near ADCY2 was identified as a potential additional regulator of FSAP activity.
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Affiliation(s)
- M. Olsson
- Department of Pathology and GeneticsInstitute of BiomedicineThe Sahlgrenska Academy at University of GothenburgGothenburgSweden
| | - T. M. Stanne
- Department of Pathology and GeneticsInstitute of BiomedicineThe Sahlgrenska Academy at University of GothenburgGothenburgSweden
| | - A. Pedersen
- Department of Pathology and GeneticsInstitute of BiomedicineThe Sahlgrenska Academy at University of GothenburgGothenburgSweden
| | - E. Lorentzen
- Bioinformatics Core FacilityUniversity of GothenburgGothenburgSweden
| | - E. Kara
- Institute of Basic Medical SciencesFaculty of MedicineUniversity of OsloOsloNorway
| | - A. MartinezâPalacian
- Institute of Basic Medical SciencesFaculty of MedicineUniversity of OsloOsloNorway
| | - N. P. RÃnnow Sand
- Department of CardiologyHospital of South West DenmarkEsbjerg and Department of Regional Health ResearchFaculty of Health ScienceUniversity of Southern DenmarkEsbjergDenmark
| | - A. F. Jacobsen
- Department of ObstetricsOslo University Hospital and University of OsloOsloNorway
| | - P. M. Sandset
- Department of HematologyOslo University Hospital and University of OsloOsloNorway
| | - J. J. Sidelmann
- Unit for Thrombosis ResearchDepartment of Regional Health ResearchFaculty of Health ScienceUniversity of Southern DenmarkEsbjergDenmark
| | - G. EngstrÃm
- Department of Clinical Sciences, MalmÃLund UniversityLundSweden
| | - O. Melander
- Department of Clinical Sciences, MalmÃLund UniversityLundSweden
| | - S. M. Kanse
- Institute of Basic Medical SciencesFaculty of MedicineUniversity of OsloOsloNorway
| | - C. Jern
- Department of Pathology and GeneticsInstitute of BiomedicineThe Sahlgrenska Academy at University of GothenburgGothenburgSweden
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Chayoua W, Kelchtermans H, Moore GW, Musiał J, Wahl D, de Laat B, Devreese KMJ. Identification of high thrombotic risk triple-positive antiphospholipid syndrome patients is dependent on anti-cardiolipin and anti-β2glycoprotein I antibody detection assays. J Thromb Haemost 2018; 16:2016-2023. [PMID: 30079628 DOI: 10.1111/jth.14261] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Indexed: 12/31/2022]
Abstract
Essentials Triple-positivity is associated with a high risk for a first thrombotic event and recurrence. Identification of triple-positives is dependent on the solid phase assay used. In triple-positivity, IgM only adds value in thrombotic risk stratification together with IgG. Thrombotic risk in triple-positive patients with IgM only, depends on the platform. ABSTRACT Background The antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy morbidity with the persistent presence of antiphospholipid antibodies (aPL). Triple-positivity (i.e. positivity for lupus anticoagulant [LAC], anti-cardiolipin [aCL] and anti-β2glycoprotein I [aβ2GPI] antibodies) is associated with a high thrombotic risk. Objectives We investigated the variability in triple-positivity detection by measuring the same samples with four commercially available solid phase assays. In addition, the added clinical value of aPL in LAC-positive patients was investigated, as well as the association of IgM triple-positivity and thrombosis. Patients/Methods We included 851 patients from seven European medical centers. Anti-CL and aβ2GPI IgG/IgM antibodies were determined by four platforms: BioPlex® 2200, ImmunoCap® EliA, ACL AcuStar® and QUANTA Lite ELISA® . Results Triple-positivity detection by solid phase assays varied, ranging from 89 up to 118 in thrombotic APS patients (n = 258), of which 86 were detected independent of the platform. Lupus anticoagulant positivity resulted in an odds ratio (OR) for thrombosis of 3.4; triple-positivity (irrespective of the isotype) increased the OR from 4.3 up to 5.2, dependent on the platform. Triple-positivity solely for the IgM isotype did not increase the OR for thrombosis compared with LAC positivity. The highest OR for thrombosis was reached for positivity for IgG and IgM aβ2GPI and aCL (8.6 up to 28.9). Conclusions Triple-positivity proved to be highly associated with thrombosis, but identification is assay dependent. Within triple-positivity, IgM antibodies only have an added clinical value in patients positive for IgG antibodies.
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Affiliation(s)
- W Chayoua
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
- Synapse Research Institute, Maastricht, the Netherlands
| | - H Kelchtermans
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
- Synapse Research Institute, Maastricht, the Netherlands
| | - G W Moore
- Viapath Analytics, Department of Haemostasis and Thrombosis, Guy's and St Thomas' Hospitals, London, UK
| | - J Musiał
- Department of Internal Medicine, Allergy and Immunology, Jagiellonian University Medical College, Kraków, Poland
| | - D Wahl
- Inserm, DCAC, Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Centre Hospitalier Regional Universitaire de Nancy, Université de Lorraine, Nancy, France
| | - B de Laat
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, the Netherlands
- Synapse Research Institute, Maastricht, the Netherlands
| | - K M J Devreese
- Coagulation Laboratory, Department of Diagnostic Sciences, Ghent University Hospital, Gent, Belgium
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9
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Skeith L. Preventing venous thromboembolism during pregnancy and postpartum: crossing the threshold. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:160-167. [PMID: 29222251 PMCID: PMC6142533 DOI: 10.1182/asheducation-2017.1.160] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
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.
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Affiliation(s)
- Leslie Skeith
- Division of Hematology, Department of Medicine, University of Ottawa, and Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Dahm A, Jacobsen AF, Sandvik L, Sandset PM, Bergrem A. Differential haemostatic risk factors for pregnancy-related deep-vein thrombosis and pulmonary embolism. Thromb Haemost 2017; 108:1165-71. [DOI: 10.1160/th12-05-0350] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 09/07/2012] [Indexed: 11/05/2022]
Abstract
SummaryLimited data exist on thrombophilia and the risk of venous thrombosis (VT) during pregnancy and postpartum. The objectives of the present study were to investigate the role of haemostatic risk factors for pregnancy-related VT and their phenotypic expression in deep-vein thrombosis (DVT) and pulmonary embolism (PE). Total 313 cases with objectively verified first time VT and 353 controls were selected from a source population of 377,155 women with 613,232 pregnancies. The adjusted odds ratio (aOR) for pregnancy-related VT was 1.7 (95% confidence interval [CI] 1.1–2.8) for women with factor VIII >90th percentile. The aOR for VT for endogenous thrombin potential and D-dimer values >90thpercentiles were 1.8 (95% CI 1.1–3.0) and 2.1 (95% CI 1.3–3.3), respectively. Factor IX >90thpercentile or free protein S ≤the 5th percentile increased the risk for PE, and the aORs were 2.4 (95% CI 1.1–5.0) and 3.1 (95% CI 1.3–7.2), respectively. Women carrying the factor V Leiden (F5 rs6025) polymorphism, or who had reduced sensitivity to activated protein C (aPC) in the absence of F5 rs6025, had increased risk for DVT, with unadjusted ORs 7.7 (95% CI 4.7–12.7) and 3.5 (95% CI 2.2–5.4), respectively. Women with a history of pregnancy-related VT showed activation of coagulation and had elevated factor VIII. Furthermore, high levels of factor IX and low levels of free protein S were associated with increased risk for PE, whereas aPC resistance and F5 rs6025 were risk factors for DVT and not PE.
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Kelchtermans H, Pelkmans L, de Laat B, Devreese KM. IgG/IgM antiphospholipid antibodies present in the classification criteria for the antiphospholipid syndrome: a critical review of their association with thrombosis. J Thromb Haemost 2016; 14:1530-48. [PMID: 27279342 DOI: 10.1111/jth.13379] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Indexed: 01/08/2023]
Abstract
UNLABELLED Essentials The clinical value of IgM antibodies in thrombotic antiphospholipid syndrome (APS) is debated. By review of literature, we reconsidered the clinical value of IgM antibodies in thrombotic APS. More significant correlations with thrombosis were found for the IgG compared to IgM isotype. Unavailability of paired IgG/IgM results hampers evaluating the added value of IgM positivity. Click to hear Dr de Groot's perspective on antiphospholipid syndrome SUMMARY Background Despite the update of the classification criteria for the antiphospholipid syndrome (APS), difficulties persist in the identification of patients at risk for thrombosis. Current guidelines include assays detecting IgG/IgM anti-β2 -glycoprotein I and anti-cardiolipin antibodies, although the relevance of IgM antibodies has been debated. Objectives Through a review of the literature from 2001 to 2014, we aimed to formally establish the thrombotic risk stratification potential of IgM as compared with IgG anti-phospholipid antibodies (aPLs). Patients/methods One thousand two hundred and twenty-eight articles were selected by a computer-assisted search of the literature. Of the 177 studies that met our inclusion criteria, the clinical value of IgG/IgM aPLs was established through analysis of odds ratios for thrombosis or percentage of positives in the thrombotic population. Results/conclusions We clearly found more significant correlations with thrombosis for the IgG than for the IgM isotype. Nonetheless, in a minority of studies, significant associations with thrombosis were found for IgM but not IgG antibodies. The unavailability of paired results of IgG and IgM for each separate patient hampers evaluation of the added value of isolated IgM positivity. To fully take advantage of results obtained by future studies, we strongly encourage scientists to provide all studied information per patient. We planned a large multicenter study to investigate clinical associations of isolated/combined positivity for criteria/non-criteria aPLs. Importantly, because of the presence of non-pathogenic aPLs, quantitative assays are characterized by a high false-positivity rate. Optimization of functional assays, such as thrombin generation measuring the whole scheme of coagulation, may help to reduce APS-related morbidity and mortality.
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Affiliation(s)
- H Kelchtermans
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
- Synapse BV, Maastricht, the Netherlands
| | - L Pelkmans
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
- Synapse BV, Maastricht, the Netherlands
| | - B de Laat
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
- Synapse BV, Maastricht, the Netherlands
| | - K M Devreese
- Coagulation Laboratory, Department of Clinical Chemistry, Microbiology and Immunology, Ghent University Hospital, Ghent, Belgium
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Bates SM, Middeldorp S, Rodger M, James AH, Greer I. Guidance for the treatment and prevention of obstetric-associated venous thromboembolism. J Thromb Thrombolysis 2016; 41:92-128. [PMID: 26780741 PMCID: PMC4715853 DOI: 10.1007/s11239-015-1309-0] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute (TaARI), 1280 Main Street West, HSC 3W11, Hamilton, ON, L8S 4K1, Canada.
| | - Saskia Middeldorp
- Department of Vascular Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc Rodger
- Departments of Medicine, Epidemiology and Community Medicine, and Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada
| | - Andra H James
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - Ian Greer
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, UK
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Dahm AEA, Tiscia G, Holmgren A, Jacobsen AF, Skretting G, Grandone E, Sandset PM. Genetic variations in the annexin A5 gene and the risk of pregnancy-related venous thrombosis. J Thromb Haemost 2015; 13:409-13. [PMID: 25495894 DOI: 10.1111/jth.12817] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 12/09/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Annexin A5 is a natural anticoagulant assumed to have thrombomodulary functions as it shields phospholipid layers from coagulation complexes. It was recently shown that the M2 haplotype within the annexin A5 gene (ANXA5) promoter reduces the transcriptional activity of the gene. In a previous report, the M2 haplotype was found to be associated with pregnancy-related venous thrombosis (VT). OBJECTIVES To investigate whether the M1 or M2 haplotypes or other genetic variations in ANXA5 are associated with pregnancy-related VT. PATIENTS/METHODS We investigated samples from 313 cases and 353 controls included in the VIP study, which is a case-control study of pregnancy-related VT. We analyzed tag single nucleotide polymorphisms (SNPs) selected from the CEU population (Utah Residents with Northern and Western European Ancestry) of HapMap and the M1 and the M2 haplotypes of the promoter. Odds ratios for VT were calculated for each haplotype with the wild type as the reference and for each tag SNP with the most common genotype as reference. RESULTS We did not find any association between genetic variants in ANXA5 and the risk of pregnancy related VT, but some of the genetic variants were not in Hardy-Weinberg equilibrium. CONCLUSION Neither the M1/M2 haplotypes nor the tag SNPs in ANXA5 were convincingly associated with pregnancy related VT, but other studies in this field are needed.
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Affiliation(s)
- A E A Dahm
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Bates SM. Preventing thrombophilia-related complications of pregnancy: an update. Expert Rev Hematol 2013; 6:287-300. [PMID: 23782083 DOI: 10.1586/ehm.13.18] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Approximately half of all pregnancy-related venous thromboembolic events are associated with thrombophilia. Although the most compelling data for a link between thrombophilia and other adverse pregnancy outcomes derive from women with antiphospholipid antibodies, some studies also suggest an association between these pregnancy complications and hereditary thrombophilias. Management of thrombophilia often involves anticoagulant therapy; however, use of these agents during pregnancy is challenging. There is a paucity of high-quality studies and consequently, recommendations are based largely on extrapolation from data in nonpregnant women, in addition to observational studies and a few small randomized studies. This article will review the impact of the thrombophilias on pregnancy and its outcome, evidence for therapies aimed at the prevention of thrombophilia-related pregnancy complications, and the most recent recommendations contained in the 9th Edition of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada.
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Danowski A, Rego J, Kakehasi AM, Funke A, de Carvalho JF, Lima IV, Silva de Souza AW, Levy RA. Diretrizes para o tratamento da síndrome do anticorpo antifosfolipídeo. REVISTA BRASILEIRA DE REUMATOLOGIA 2013. [DOI: 10.1590/s0482-50042013000200005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Helgadóttir LB, Turowski G, Skjeldestad FE, Jacobsen AF, Sandset PM, Roald B, Jacobsen EM. Classification of stillbirths and risk factors by cause of death--a case-control study. Acta Obstet Gynecol Scand 2013; 92:325-33. [PMID: 23157574 DOI: 10.1111/aogs.12044] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 11/01/2012] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate risk factors for stillbirths by cause, using the Causes of Death and Associated Conditions (CODAC) classification system for perinatal deaths. DESIGN Case-control study. SETTING Two university hospitals in Oslo, Norway, January 1990 through December 2003. SAMPLE Women with stillbirth after 22 gestational weeks (n = 377) and controls with live births (n = 1 215), and a subsample of 105 cases and 262 controls. METHODS Socio-demographic, clinical and thrombophilic risk factors for stillbirths were assessed by cause of death in univariate and multivariable logistic regression analyses. Stillbirths were classified according to CODAC based on information from medical records and validated placenta histology. MAIN OUTCOME MEASURES Causes of stillbirths in percentages, prevalence, odds ratios and adjusted odds ratios for potential risk factors. RESULTS Approximately half of the women (n = 190) had placental and 19.4% (n = 73) unknown cause of stillbirth. Placental-associated conditions were registered in 18% (n = 68) of cases with a non-placental or an unknown cause. Smoking and small-for-gestational age were more prevalent in all causal groups, compared with controls, whereas twin pregnancy, hypertension and diabetes were more prevalent only among women with placental and unknown causes of stillbirth. The F2rs179963 polymorphism and combined thrombophilia were significant risk factors for stillbirth with placental causes and antiphospholipid antibodies for stillbirth with non-placental causes. CONCLUSIONS Two-thirds of all stillbirths (68%) were caused by or associated with placental pathology. Risk factors differed somewhat according to cause, apart from smoking and small-for-gestational age, which were significant risk factors across the causal groups.
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Abstract
Abstract
Antiphospholipid syndrome (APS) is an acquired autoimmune thrombotic tendency that is identified by the presence of abnormal antiphospholipid laboratory tests in patients who have a history of vascular thrombosis and/or pregnancy complications including recurrent spontaneous miscarriages and a group of other complications due to placental insufficiency. Diagnostic testing for APS is often problematic because of many misconceptions regarding these empirically derived assays. This chapter is intended to provide hematology-oncology consultants with practical information about the uses and limitations of assays used to diagnose APS.
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Wik HS, Jacobsen AF, Sandvik L, Sandset PM. Long-term impact of pregnancy-related venous thrombosis on quality-of-life, general health and functioning: results of a cross-sectional, case-control study. BMJ Open 2012; 2:e002048. [PMID: 23144263 PMCID: PMC3533094 DOI: 10.1136/bmjopen-2012-002048] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 10/02/2012] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES To evaluate the long-term consequences of pregnancy-related venous thrombosis (VT) by the assessment of generic quality-of-life (QOL), well-being, general health and daily-life functioning. We also wanted to evaluate the impact of the frequently occurring complication post-thrombotic syndrome (PTS) after that of deep vein thrombosis (DVT). DESIGN Population-based cross-sectional, case-control study. SETTING 18 Norwegian hospitals during 1990-2003. PARTICIPANTS The study population comprised 559 cases with a validated first-ever, pregnancy-related VT and 1229 controls naïve for VT at the time of index pregnancy. Cases were identified using the Norwegian Patient Register and the Medical Birth Registry of Norway and the latter was used to select as controls women who gave birth at the same time as a case. After exclusion of two cases with missing location of VT, the final study population comprised 311 cases and 353 controls. METHODS Self-completion of a comprehensive questionnaire in 2006. MAIN OUTCOME MEASURES Generic QOL and well-being assessed by the Ferrans and Powers QOL Index (QLI) and the General Health Questionnaire (GHQ-20). RESULTS QOL assessed by QLI did not differ between cases and controls; mean score 23.1 (95% CI 22.7 to 23.5) vs 23.7 (23.3 to 24.0), neither did well being assessed by GHQ-20; 18.7 (18.0 to 19.4) vs 17.9 (17.3 to 18.4). However, cases reported pain other than in the lower limbs and muscle-skeletal problems more often and were more often physically worn out after work compared with controls. Cases which developed PTS reported poorer health, had pain more often, developed skin and psychiatric problems, used analgesic drugs more frequently and were more often on sick leave as compared to those without PTS. CONCLUSIONS Long-term generic QOL and subjective well-being 3-16 years after a pregnancy-related VT were not different from a reference population, but women with PTS after DVT seemed to have poorer QOL and an impaired general health.
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Affiliation(s)
- Hilde Skuterud Wik
- Department of Haematology and Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
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The association of antiphospholipid antibodies with intrauterine fetal death: A case–control study. Thromb Res 2012; 130:32-7. [DOI: 10.1016/j.thromres.2011.11.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 10/04/2011] [Accepted: 11/16/2011] [Indexed: 11/20/2022]
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20
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Gravensteen IK, Helgadottir LB, Jacobsen EM, Sandset PM, Ekeberg Ø. Long-term impact of intrauterine fetal death on quality of life and depression: a case-control study. BMC Pregnancy Childbirth 2012; 12:43. [PMID: 22676992 PMCID: PMC3405471 DOI: 10.1186/1471-2393-12-43] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 06/07/2012] [Indexed: 01/13/2023] Open
Abstract
Background Intrauterine fetal death (IUFD) is a serious incidence that has been shown to impact mothers’ psychological well-being in the short-term. Long-term quality of life (QOL) and depression after IUFD is not known. This study aimed to determine the association between intrauterine fetal death and long-term QOL, well-being, and depression. Methods Analyses were performed on collected data among 106 women with a history of intrauterine fetal death (IUFD) and 262 women with live births, 5–18 years after the event. Univariable and multivariable linear and logistic regression models were used to quantify the association between previous fetal death and long-term QOL, well-being and depression. QOL was assessed using the QOL Index (QLI), symptoms of depression using the Center for Epidemiological Studies Depression Scale (CES-D), and subjective well-being using the General Health Questionnaire 20 (GHQ-20). Results More of the cases had characteristics associated with lower socioeconomic status and did not rate their health as good as did the controls. The QLI health and functioning subscale score was slightly but significantly lower in the cases than in the controls (22.3. vs 23.5, P = .023). The CES-D depressed affect subscale score (2.0 vs 1.0, P = 0.004) and the CES-D global score (7.4 vs 5.0, P = .017) were higher in the cases. Subjective well-being did not differ between groups (20.6 vs 19.4, P = .094). After adjusting for demographic and health-related variables, IUFD was not associated with global QOL (P = .674), subjective well-being (P = .700), or global depression score (adjusted odds ratio = 0.77, 95% confidence interval 0.37–1.57). Conclusions Women with previous IUFD, of which the majority have received short-term interventions, share the same level of long-term QOL, well-being and global depression as women with live births only, when adjusted for possible confounders. Trial registration The study was registered at http://www.clinicaltrials.gov, with registration number NCT 00856076.
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Lussana F, Coppens M, Cattaneo M, Middeldorp S. Pregnancy-related venous thromboembolism: Risk and the effect of thromboprophylaxis. Thromb Res 2012; 129:673-80. [DOI: 10.1016/j.thromres.2012.01.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 01/27/2012] [Accepted: 01/31/2012] [Indexed: 11/24/2022]
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Wik HS, Jacobsen AF, Sandvik L, Sandset PM. Prevalence and predictors for post-thrombotic syndrome 3 to 16 years after pregnancy-related venous thrombosis: a population-based, cross-sectional, case-control study. J Thromb Haemost 2012; 10:840-7. [PMID: 22452811 DOI: 10.1111/j.1538-7836.2012.04690.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The long-term outcome of pregnancy-related venous thrombosis (VT) is not known. OBJECTIVES To assess predictors and long-term frequency of post-thrombotic syndrome (PTS) after pregnancy-related VT. PATIENTS/METHODS In 2006, 313 women with pregnancy-related VT during 1990-2003 and 353 controls answered a comprehensive questionnaire that included self-reported Villalta score as a measure of PTS. Cases were identified from 18 Norwegian hospitals using the Norwegian Patient Registry and the Medical Birth Registry of Norway. The latter was used to select as possible controls women who gave birth at the same time as a case. Thirty-nine patients and four controls were excluded because of VT outside the lower limbs/lungs or missing Villalta scores. Two hundred and four patients had DVT in the lower limb and 70 had pulmonary embolism (PE). The control group comprised 349 women naive for VT at the time of the index pregnancy. RESULTS Forty-two per cent of cases with DVT in the lower limb, compared with 24% of cases with PE and 10% of controls, reported a Villalta score of ≥ 5. Severe PTS (Villalta score of ≥ 15) was reported among 7%, 4% and 1%. Proximal postnatal, but not antenatal, thrombosis was a strong predictor of PTS with an adjusted odds ratio of 6.3 (95% confidence interval, 2.0-19.8; P = 0.002). Daily smoking before the index pregnancy and age above 33 years at event were independent predictors for post-thrombotic syndrome. CONCLUSIONS PTS is a common long-term complication after pregnancy-related DVT. Proximal postnatal thrombosis, smoking and higher age were independent predictors of the development of PTS.
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Affiliation(s)
- H S Wik
- Department of Haematology, Clinical Research, Oslo University Hospital, and Institute of Clinical Medicine, Oslo, Norway
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Dahm AEA, Bezemer ID, Bergrem A, Jacobsen AF, Jacobsen EM, Skretting G, Rosendaal FR, Sandset PM. Candidate gene polymorphisms and the risk for pregnancy-related venous thrombosis. Br J Haematol 2012; 157:753-61. [PMID: 22533697 DOI: 10.1111/j.1365-2141.2012.09121.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 03/06/2012] [Indexed: 11/29/2022]
Abstract
Venous thrombosis (VT) is one of the leading causes of maternal death in the western world, but the genetic causes of pregnancy-related VT are insufficiently understood. The aim of this study was to investigate the association between common genetic variations in candidate genes and pregnancy-related VT. We undertook a hospital based case-control study of women with VT during pregnancy or puerperium; controls were women giving birth without having VT. Single nucleotide polymorphisms (SNPs) were selected in 49 pre-specified candidate genes involved in coagulation, inflammation, and hormonal metabolism in 313 cases and 353 controls. We found new associations between SNPs and total pregnancy-related VT in the genes encoding coagulation factors V and VIII, and p-selectin. Additional new associations between SNPs and antenatal VT were found in the genes encoding the epidermal growth factor receptor, the pregnane X receptor, and protein S. Of 21 SNPs previously associated with thrombotic disease, rs2289252 in F11 and rs3917643 in F3 were associated with pregnancy-related VT, while rs4524 in F5 was associated with antenatal VT.
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Affiliation(s)
- Anders E A Dahm
- Department of Haematology, Oslo University Hospital Rikshospitalet, Oslo, Norway
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Abstract
Pregnancy is associated with an increased risk of venous thromboembolism (VTE) and this condition remains an important cause of maternal morbidity and mortality. The use of anticoagulant therapy for treatment and prophylaxis of VTE during pregnancy is challenging because of the potential for fetal, as well as maternal, complications. Although evidence-based recommendations for the use of anticoagulants have been published, given the paucity of available data, guidelines are based largely upon observational studies and from data in nonpregnant patients. This article reviews the available literature and provides guidance for the management and prevention of VTE during pregnancy.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University & Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
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Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e691S-e736S. [PMID: 22315276 PMCID: PMC3278054 DOI: 10.1378/chest.11-2300] [Citation(s) in RCA: 834] [Impact Index Per Article: 69.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The use of anticoagulant therapy during pregnancy is challenging because of the potential for both fetal and maternal complications. This guideline focuses on the management of VTE and thrombophilia as well as the use of antithrombotic agents during pregnancy. METHODS The methods of this guideline follow the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS We recommend low-molecular-weight heparin for the prevention and treatment of VTE in pregnant women instead of unfractionated heparin (Grade 1B). For pregnant women with acute VTE, we suggest that anticoagulants be continued for at least 6 weeks postpartum (for a minimum duration of therapy of 3 months) compared with shorter durations of treatment (Grade 2C). For women who fulfill the laboratory criteria for antiphospholipid antibody (APLA) syndrome and meet the clinical APLA criteria based on a history of three or more pregnancy losses, we recommend antepartum administration of prophylactic or intermediate-dose unfractionated heparin or prophylactic low-molecular-weight heparin combined with low-dose aspirin (75-100 mg/d) over no treatment (Grade 1B). For women with inherited thrombophilia and a history of pregnancy complications, we suggest not to use antithrombotic prophylaxis (Grade 2C). For women with two or more miscarriages but without APLA or thrombophilia, we recommend against antithrombotic prophylaxis (Grade 1B). CONCLUSIONS Most recommendations in this guideline are based on observational studies and extrapolation from other populations. There is an urgent need for appropriately designed studies in this population.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.
| | - Ian A Greer
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, England
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Anne-Marie Prabulos
- Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, CT
| | - Per Olav Vandvik
- Medical Department, Innlandet Hospital Trust and Norwegian Knowledge Centre for the Health Services, Gjøvik, Norway
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The association of inherited thrombophilia and intrauterine fetal death. Blood Coagul Fibrinolysis 2011; 22:651-6. [DOI: 10.1097/mbc.0b013e32834a614c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wik HS, Enden TR, Jacobsen AF, Sandset PM. Long-term quality of life after pregnancy-related deep vein thrombosis and the influence of socioeconomic factors and comorbidity. J Thromb Haemost 2011; 9:1931-6. [PMID: 21848904 DOI: 10.1111/j.1538-7836.2011.04468.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Little is known about the long-term impact of pregnancy-related deep vein thrombosis (DVT) of the lower limbs. OBJECTIVES To evaluate the long-term consequences of pregnancy-related DVT by assessment of self-reported, disease-specific quality of life (QOL) and symptom severity using the Venous Insufficiency Epidemiological and Economic Study (VEINES)-QOL/Sym questionnaire, and to investigate the influence of socioeconomic factors and comorbidity. PATIENTS/METHODS In this cross-sectional case-control study, 313 women with validated pregnancy-related DVT and 353 controls completed a comprehensive questionnaire, including the disease-specific VEINES-QOL/Sym questionnaire. After exclusion of DVT outside the lower limbs and missing scores, the study population comprised 208 patients and 347 controls. A VEINES-QOL/Sym score < the 25th percentile was defined as a clinically relevant reduced outcome compared with scores ≥ the 50th percentile. Predictors for low scores were identified in multivariate logistic regression models. RESULTS Cases reported lower mean VEINES-QOL/Sym scores than controls, 45.6/45.4 vs. 52.8/52.7, respectively (P < 0.001), and QOL among cases was still reduced compared with controls when adjusted for possible confounders. Low education was an independent predictor for both low VEINES-QOL and VEINES-Sym scores, and in addition being married/cohabitating predicted low VEINES-Sym scores. CONCLUSIONS Long-term QOL and symptom scores as assessed with the VEINES-QOL/Sym questionnaire were lower in women with previous pregnancy-related DVT than in controls, and also when adjusted for possible confounders. By logistic regression, low education was an independent predictor for low scores. This supports the use of the VEINES-QOL/Sym questionnaire in studies on pregnancy-related DVT.
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Affiliation(s)
- H S Wik
- Department of Haematology, Oslo University Hospital, Oslo, Norway
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Bergrem A, Dahm AEA, Jacobsen AF, Mowinckel MC, Sandvik L, Sandset PM. Resistance to activated protein C is a risk factor for pregnancy-related venous thrombosis in the absence of the F5 rs6025 (factor V Leiden) polymorphism. Br J Haematol 2011; 154:241-7. [DOI: 10.1111/j.1365-2141.2011.08712.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jacobsen AF, Dahm A, Bergrem A, Jacobsen EM, Sandset PM. Risk of venous thrombosis in pregnancy among carriers of the factor V Leiden and the prothrombin gene G20210A polymorphisms. J Thromb Haemost 2010; 8:2443-9. [PMID: 20735725 DOI: 10.1111/j.1538-7836.2010.04038.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Pregnancy is associated with a 10-fold increased risk of venous thrombosis (VT), with different risk profiles for the antenatal and postnatal periods. The purpose of this study was to assess the risk of pregnancy-related VT associated with the factor (F)V Leiden and prothrombin gene G20210A polymorphisms. MATERIALS AND METHODS The study comprised 377,155 women with 613,232 pregnancies at 18 Norwegian hospitals from 1 January 1990 to 31 December 2003. Of a total 559 cases with a validated first lifetime diagnosis of VT in pregnancy or within 14 weeks postpartum, and 1229 controls naive for VT, 313 cases and 353 controls donated biological material. RESULTS The odds ratios for VT during pregnancy or puerperium were 5.0 [95% confidence interval (CI) 3.1-8.3] and 9.4 (95% CI 2.1-42.4) for heterozygous carriers of the FV Leiden and the prothrombin gene polymorphisms, respectively. All homozygous carriers of the FV Leiden polymorphism (n = 8) and the prothrombin polymorphism (n = 1) developed VT, indicating a very high risk of VT. We estimated that pregnancy-related VT occurred in 1.1/1000 non-carriers, in 5.4/1000 heterozygous carriers of the FV Leiden polymorphism, and in 9.4/1000 heterozygous carriers of the prothrombin polymorphism. To avoid one VT, the number of pregnant women needed to be screened for these two polymorphisms and the number needed to be given thromboprophylaxis were 2015 and 157, respectively. CONCLUSIONS Although the relative risk for VT during pregnancy and after delivery was increased among carriers of the FV Leiden and the prothrombin polymorphisms, the overall probability for pregnancy-related VT was low.
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Affiliation(s)
- A F Jacobsen
- Department of Haematology, Oslo University Hospital, Oslo, Norway
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