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Campello E, Bucciarelli P, Catalani F, Erba N, Squizzato A, Poli D. Anticoagulant Therapy in Pregnant Women with Mechanical Heart Valves: Italian Federation of Centers for Diagnosis and Surveillance of the Antithrombotic Therapies (FCSA) Position Paper. Thromb Haemost 2024; 124:695-708. [PMID: 38744424 PMCID: PMC11259494 DOI: 10.1055/a-2325-5658] [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] [Received: 10/12/2023] [Accepted: 02/18/2024] [Indexed: 05/16/2024]
Abstract
The management of anticoagulant therapy in pregnant women with mechanical heart valves (MHVs) is difficult and often challenging even for clinicians experienced in the field. These pregnancies, indeed, are burdened with higher rates of complications for both the mother and the fetus, compared to those in women without MHVs. The maternal need for an optimal anticoagulation as provided by vitamin K antagonists is counterbalanced by their teratogen effect on the embryo and fetus. On the other hand, several concerns have been raised about the efficacy of heparins in pregnant women with MHVs, considering the high risk of thrombotic complications in these patients. Therefore, numerous clinical issues about the management of pregnant women with MHVs remain unanswered, such as the selection of the best anticoagulant agent, the optimal anticoagulation levels to be achieved and maintained, and the evaluation of long-term effects for both the mother and the fetus. Based on a comprehensive review of the current literature, the Italian Federation of the Centers for the Diagnosis and the Surveillance of the Antithrombotic Therapies (FCSA) proposes experience-based suggestions and expert opinions. Particularly, this consensus document aims at providing practical guidance for clinicians dealing with pregnant women with MHVs, to optimize maternal and fetal outcomes while guaranteeing adequate anticoagulation. Finally, FCSA highlights the need for the creation of multidisciplinary teams experienced in the management of pregnant women with MHVs during pregnancy, delivery, and postpartum, in order to better deal with such complex clinical issues and provide a comprehensive counseling to these patients.
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Affiliation(s)
- Elena Campello
- Department of Medicine, General Medicine and Thrombotic and Hemorrhagic Unit, University of Padova, Padova, Italy
| | - Paolo Bucciarelli
- Fondazione IRCCS Ca' Granda – Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
| | - Filippo Catalani
- Department of Medicine, General Medicine and Thrombotic and Hemorrhagic Unit, University of Padova, Padova, Italy
| | | | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
| | - Daniela Poli
- Thrombosis Center, “Careggi” Hospital, Florence, Italy
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2
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Palareti G, Santagata D, De Ponti C, Ageno W, Prandoni P. Anticoagulation and compression therapy for proximal acute deep vein thrombosis. VASA 2024. [PMID: 39017921 DOI: 10.1024/0301-1526/a001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
The treatment of proximal deep vein thrombosis (DVT) of the lower limbs includes an initial management phase, covering the first 1 to 3 weeks, a primary treatment phase, lasting a minimum of 3 months, and a secondary treatment phase for those patients requiring continuing anticoagulation beyond the first 3 to 6 months. During the initial phase most patients with DVT can be managed as outpatients. Exclusion criteria for home treatment include high risk of bleeding, limb threatening DVT or other conditions requiring hospitalisation. Anticoagulant drugs represent the mainstay of treatment and include parenteral drugs such as unfractionated heparin or low molecular weight heparin, and oral drugs such as the vitamin K antagonists and the direct oral anticoagulants (DOACs). DOACs are currently recommended as the first line of treatment for proximal DVT of the lower limbs, with no preference for one DOAC over another. Factors to consider when choosing the anticoagulant strategy include, among others, renal and liver function, underlying diseases such as cancer or the antiphospholipid syndrome, and patient preferences. Indefinite duration of anticoagulation beyond the first 3 to 6 months is recommended for patients with unprovoked DVT and patients with permanent, chronic risk factors. Two DOACs, namely apixaban and rivaroxaban, can be administered at low doses for the secondary prevention of DVT. Elastic compression stockings (ECS) have been used for decades in patients with proximal DVT with the aim of counteracting the venous hypertension generated by the vascular disorder and reducing leg edema and to prevent the post-thrombotic syndrome.
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Affiliation(s)
| | - Davide Santagata
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
| | - Chiara De Ponti
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
| | - Walter Ageno
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
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3
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Eiland LS, Harris JB, Holmes AP. Considerations for Treating Nonobstetric Diseases in Pregnant Patients in the Emergency Department Setting. Ann Pharmacother 2023; 57:1415-1424. [PMID: 37076990 DOI: 10.1177/10600280231167775] [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: 04/21/2023] Open
Abstract
OBJECTIVE To provide nonobstetric practitioners with an overview of key concepts for the pregnant patient and review treatment of 3 common acute nonobstetric diseases encountered in the emergency department setting. DATA SOURCES A literature search of PubMed was performed (1997-February 2023) using key search terms related to pregnancy, pain, urinary tract infection (UTI), venous thromboembolism (VTE), and anticoagulants. STUDY SELECTION AND DATA EXTRACTION Relevant articles in English and humans were considered. DATA SYNTHESIS When caring for a pregnant patient, it is important to utilize appropriate assessments, understand terms used in this population, and recognize how the physiological and pharmacokinetic changes that occur in pregnancy can influence medication use. Pain, UTIs, and VTE are common in this population. Acetaminophen is the most widely used medication for the management of pain during pregnancy and the drug of choice for mild pain in pregnancy not responsive to nonpharmacologic treatment. Pyelonephritis is the most common nonobstetric cause of hospitalization for pregnant patients. Antimicrobial treatment should consider maternal-fetal safety and local resistance patterns. Pregnant and postpartum patients have a 4- to 5-fold increased risk of developing a VTE compared with nonpregnant patients. Low-molecular-weight heparin is the preferred treatment. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Pregnant patients often seek acute care in the emergency department setting for nonobstetric needs. Pharmacists in this setting should understand appropriate assessment questions and terms used within this population, the basics of physiological and pharmacokinetic changes in pregnancy that can impact treatment, and which resources are best to utilize for drug information of the pregnant patient. CONCLUSION Practitioners in the acute care setting commonly encounter pregnant patients seeking care for nonobstetric concerns. This article covers key pregnancy-related information for the nonobstetric practitioner and focuses on the management of acute pain, UTI, and VTE during pregnancy.
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Affiliation(s)
- Lea S Eiland
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - John Brock Harris
- Education and Pharmaceutical Sciences Department, Wingate University School of Pharmacy, Wingate, NC, USA
| | - Amy P Holmes
- Department of Pharmacy, Atrium Wake Forest Baptist Health, Winston-Salem, NC, USA
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4
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Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, Zentner D. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy. Heart Rhythm 2023; 20:e175-e264. [PMID: 37211147 DOI: 10.1016/j.hrthm.2023.05.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/23/2023]
Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.
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Affiliation(s)
- José A Joglar
- The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Elizabeth V Saarel
- St. Luke's Health System, Boise, Idaho, and Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | | | | | | | | | | | - Luis D Pacheco
- The University of Texas Medical Branch at Galveston, Galveston, Texas
| | | | - Andrea Sarkozy
- University Hospital of Antwerp, University of Antwerp, Antwerp, Belgium
| | | | - Danna Spears
- University Health Network, Toronto, Ontario, Canada
| | - Sindhu K Srinivas
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Carolyn M Zelop
- The Valley Health System, Ridgewood, New Jersey; New York University Grossman School of Medicine, New York, New York
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5
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Urriago-Osorio GA, Melo-Burbano LÁ, López-Van Den Berghe J, Muñoz-Córdoba AM, Daza-Arana JE, Contreras-Zúñiga E. Pulmonary Thromboembolism in Pregnancy: A Case Report and Literature Review. Open Access Emerg Med 2023; 15:217-225. [PMID: 37292453 PMCID: PMC10246571 DOI: 10.2147/oaem.s404941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 04/18/2023] [Indexed: 06/10/2023] Open
Abstract
Data on the optimal diagnostic management of pregnant women with suspected pulmonary embolism are limited. Despite a lack of compelling evidence in some practices, clinical practice guidelines focus on the management of these patients. We present the case of a 24-year-old patient at 36 weeks of pregnancy in whom pulmonary thromboembolism (PTE) was diagnosed in a timely manner also with hemodynamic instability and echocardiographic images with clear involvement of the right cavities. She received thrombolytic therapy with alteplase 100 mg intravenously over 2 hours, which resulted in excellent outcomes for both the pregnant woman and fetus. Understanding the acute approach and management of these patients will improve our clinical practice; therefore, we reviewed a case report of a pregnant patient with high-risk PTE and compared it with current evidence. In conclusion, PE is a common disease with a high mortality rate during pregnancy. Therefore, having made a timely diagnosis using the relevant diagnostic aids and performing thrombolysis with rtPA increase the probability of survival in our patient, leading to successful results for both her and the fetus.
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Affiliation(s)
- Gustavo Andrés Urriago-Osorio
- Department of Health, Internal Medicine Specialization Program, Universidad Santiago de Cali, Santiago de Cali, Colombia
- Emergency Department, Clínica de Occidente S.A, Santiago de Cali, Colombia
| | - Luis Álvaro Melo-Burbano
- Department of Health, Internal Medicine Specialization Program, Universidad Santiago de Cali, Santiago de Cali, Colombia
- Emergency Department, Clínica de Occidente S.A, Santiago de Cali, Colombia
| | | | | | - Jorge Enrique Daza-Arana
- Department of Health, Internal Medicine Specialization Program, Universidad Santiago de Cali, Santiago de Cali, Colombia
- Health and Movement Research Group, Universidad Santiago de Cali, Santiago de Cali, Colombia
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Jaramillo N, Raidah A, Pradas KF, Lev S, Ramanathan A. Extensive Postpartum Upper and Lower Extremity Deep Vein Thrombosis in a Patient With a History of Preeclampsia. Cureus 2023; 15:e41109. [PMID: 37519553 PMCID: PMC10382326 DOI: 10.7759/cureus.41109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
We describe the case of a 19-year-old woman with no significant medical history who developed progressive right-sided neck pain and palpitations one month following a pregnancy complicated by preeclampsia. Family history was significant for unprovoked deep vein thrombosis (DVT) and pulmonary embolism (PE) in her father at age 44. Systemic examination revealed mild swelling of the right upper extremity with pain on palpation. Computed tomography (CT) of the thorax with contrast demonstrated extensive occlusion of right upper extremity veins and collateralization of chest wall veins. Pulmonary emboli were present bilaterally in the segmental and subsegmental branches of the lower lobe pulmonary arteries. CT of the abdomen with contrast revealed thrombi in the left common and external iliac veins. Thrombophilia screening was normal. The patient was treated with enoxaparin and ampicillin/sulbactam. Her clinical condition improved, and she was discharged with an outpatient clinic follow-up appointment.
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Affiliation(s)
- Nolberto Jaramillo
- Surgery, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, USA
| | - Anisa Raidah
- Surgery, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, USA
| | | | - Steven Lev
- Neuroradiology, Nassau University Medical Center, East Meadow, USA
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7
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James AH, Sugrue R, Federspiel JJ. Novel Antithrombotic Agents in Pregnancy Anticoagulants and Antiplatelet Agents. Clin Obstet Gynecol 2023; 66:196-207. [PMID: 36044626 PMCID: PMC10083711 DOI: 10.1097/grf.0000000000000740] [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] [Indexed: 01/24/2023]
Abstract
Increasing rates of thromboembolic complications have required increasing use of anticoagulant and antiplatelet agents during and after pregnancy. Furthermore, thromboembolism is both a cause and a complication of severe maternal morbidity requiring intensive care. As a consequence, almost all patients admitted to intensive care units receive an anticoagulant or an antiplatelet agent (or both) for either treatment or prevention of thromboembolism. In this review, we summarize commonly used anticoagulants and antiplatelet agents and outline the potential role of newly developed (novel) antithrombotic agents for pregnant and postpartum patients.
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Affiliation(s)
- Andra H. James
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC
| | - Ronan Sugrue
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC
| | - Jerome J. Federspiel
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, NC
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8
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Cherian L. Women and Ischemic Stroke. Neurol Clin 2023; 41:265-281. [PMID: 37030957 DOI: 10.1016/j.ncl.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Although men are at higher risk of stroke throughout most of their lifespan, the incidence of stroke in women climbs with age, increasing after menopause and rising sharply after 85 years. This, combined with women's longer life expectancy, results in most of the stroke deaths occurring in women. In addition to accounting for a larger proportion of strokes, women may also suffer a survival disadvantage, which may be due to several factors. In many families, women are the primary caretakers. When they become disabled, there may be limited options to care for them. Others suggest that some of the disparities in stroke outcomes in women may be related to age, pre-stroke functional status, and comorbidities. Regardless of the cause, the increased disability and post-stroke care requirements of women, particularly in our aging population, highlight the importance of determining successful strategies for stroke prevention, acute stroke treatments, optimization of stroke rehabilitation, and effective secondary prevention measures in women.
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9
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Serebriakoff P, Cafferkey J, de Wit K, Horner DE, Reed MJ. Pulmonary embolism management in the emergency department: part 2. J Accid Emerg Med 2023; 40:69-75. [PMID: 35383107 DOI: 10.1136/emermed-2021-212001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 03/20/2022] [Indexed: 01/10/2023]
Abstract
Pulmonary embolism (PE) can present with a range of severity. Prognostic risk stratification is important for efficacious and safe management. This second of two review articles discusses the management of high-, intermediate- and low-risk PE. We discuss strategies to identify patients suitable for urgent outpatient care in addition to identification of patients who would benefit from thrombolysis. We discuss specific subgroups of patients where optimal treatment differs from the usual approach and identify emerging management paradigms exploring new therapies and subgroups.
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Affiliation(s)
| | - John Cafferkey
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Daniel E Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK .,Acute Care Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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10
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Umetsu M, Akamatsu D, Serizawa F, Tajima Y, Suzuki S, Horii S, Ogasawara N, Takahashi H, Nagaoka Y, Shimizu K, Kimura S, Hashimoto M, Goto H, Watanabe T, Kamei T. Anticoagulation Therapy for Pregnancy-Associated Thrombosis: A Retrospective Observational Study. Ann Vasc Dis 2022; 15:317-323. [PMID: 36644260 PMCID: PMC9816033 DOI: 10.3400/avd.oa.22-00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/23/2022] [Indexed: 12/04/2022] Open
Abstract
Objectives: Pregnancy-associated deep vein thrombosis (DVT) is a rare disease, and data on anticoagulation therapy are lacking. The present study examined the treatment outcome with unfractionated heparin (UFH) subcutaneous injection in patients with pregnancy-associated DVT. Methods: This single-center, retrospective, observational study enrolled 15 patients with pregnancy-associated DVT treated from January 2014 to April 2021. Results: The median age was 35 years. The median gestation week at onset was 10 (interquartile range is 8-11). All patients presented with painful symptoms with edema. All patients had proximal DVT. Anticoagulation therapy using UFH was performed in 14 patients. The median continuous dose of heparin was 18,750 U/day, and the median subcutaneous dose was 20,000 U/day. During the outpatient period, the values of activated partial thromboplastin time fluctuated wildly, but the fibrin monomer complex level remained consistently low. There were two mild bleeding complications, but neither prevented the continuation of anticoagulation therapy. During delivery, thrombi were not detected in 10 of 13 patients (77%), whereas three patients (23%) exhibited regression without resolution of the thrombus. Conclusion: Anticoagulation using UFH subcutaneous injection was safely performed in patients with pregnancy-associated DVT without serious complications or progression of thrombosis.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Kota Shimizu
- Tohoku University Hospital, Sendai, Miyagi, Japan
| | | | | | - Hitoshi Goto
- South Miyagi Medical Center, Shibata, Miyagi, Japan
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11
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Zhang X, Huangfu Z. Management of pregnant patients with pulmonary arterial hypertension. Front Cardiovasc Med 2022; 9:1029057. [PMID: 36440029 PMCID: PMC9684470 DOI: 10.3389/fcvm.2022.1029057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/27/2022] [Indexed: 09/19/2023] Open
Abstract
Pregnant individuals with pulmonary arterial hypertension (PAH) have significantly high risks of maternal and perinatal mortality. Profound changes in plasma volume, cardiac output and systemic vascular resistance can all increase the strain being placed on the right ventricle, leading to heart failure and cardiovascular collapse. Given the complex network of opposing physiological changes, strict contraception and reduction of hemodynamic fluctuations during pregnancy are important methods of minimizing the risk of maternal mortality and improving the outcomes following pregnancy. In this review, we discuss the recent research progress into pre-conception management and the various therapeutic strategies for pregnant individuals with PAH.
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Affiliation(s)
- Xiao Zhang
- Department of Gynecology and Obstetrics, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhao Huangfu
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
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12
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Schreiber K, Frishman M, Russell MD, Dey M, Flint J, Allen A, Crossley A, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: comorbidity medications used in rheumatology practice. Rheumatology (Oxford) 2022; 62:e89-e104. [PMID: 36318967 PMCID: PMC10070063 DOI: 10.1093/rheumatology/keac552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Karen Schreiber
- Thrombosis & Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust , London, UK
- Department of Rheumatology, Danish Hospital for Rheumatic Diseases , Sonderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark , Odense, Denmark
| | - Margreta Frishman
- Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust , London, UK
| | - Mark D Russell
- Centre for Rheumatic Diseases, King’s College London , London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool , Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust , Shropshire, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology , London, UK
| | | | - Mary Gayed
- Rheumatology, University Hospital Birmingham NHS Foundation Trust , Birmingham, UK
| | - Kenneth Hodson
- The UK Teratology Information Service , Newcastle upon Tyne, UK
| | - Munther Khamashta
- Division of Women’s Health, Lupus Research Unit, King's College London , London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady’s Hospice and Care Service , Dublin, Ireland
| | - Sonia Panchal
- Rheumatology, South Warwickshire NHS Foundation Trust , Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital , Bath, UK
| | | | - Katherine Saxby
- Pharmacology, University College London Hospitals NHS Foundation Trust , London, UK
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust , London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham NHS Trust , Birmingham, UK
| | | | - Louise Warburton
- Shropshire Community NHS Trust , Shropshire, UK
- Primary Care and Health Sciences, Keele University , Keele, UK
| | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust , London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw, Teaching Hospitals NHS Foundation Trust , Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham , Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London , London, UK
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13
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Lasica R, Asanin M, Djukanovic L, Radovanovic N, Savic L, Polovina M, Stankovic S, Ristic A, Zdravkovic M, Lasica A, Kravic J, Perunicic J. Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application. Pharmaceuticals (Basel) 2022; 15:ph15091146. [PMID: 36145366 PMCID: PMC9501350 DOI: 10.3390/ph15091146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Correspondence:
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nebojsa Radovanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Polovina
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Arsen Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | | | | | - Jelena Kravic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jovan Perunicic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Areia AL, Mota-Pinto A. Experience with direct oral anticoagulants in pregnancy - a systematic review. J Perinat Med 2022; 50:457-461. [PMID: 35073471 DOI: 10.1515/jpm-2021-0457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The experience and use of the new direct oral anti coagulants (DOACs) in pregnancy is limited, but as they offer many practical advantages compared to low molecular weight heparin (LMWH), the pursue of their safety is challenging. METHODS Systematic review of studies in which DOACs were used during pregnancy and the puerperal period (PROSPERO registry-CRD42021237688). Searches were performed on MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library databases, until July 2021 and secondary sources using the MeSH terms 'pregnancy', 'pregnancy complications', 'venous thrombosis', 'congenital abnormalities', 'Factor Xa Inhibitors,' and names of specific DOACs. Search was limited to human studies, with English or French as languages of report. RESULTS Literature search yielded 1,989 results which, after duplicate exclusion, resulted in 672 publications. Studies were then screened using the specified eligibility criteria described and studies that did not meet the criteria were excluded, resulting in 21 full text studies to an in-depth analysis and data extraction. Overall, 339 cases of DOACs usage during pregnancy were reported until now. The data demonstrated 56% live births but a miscarriage rate of 22.2% and an elective termination of pregnancy in 21.8%; fetal abnormalities related to DOACs occurred in 3.6%. Our meta-analysis displayed a higher rate of fetal loss and fetal abnormalities with DOACs use compared to LMWH, notwithstanding similar bleeding complications. CONCLUSIONS The current information available for the 339 cases herein reported does not allow a conclusion that DOACs can be safely used in pregnancy.
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Affiliation(s)
- Ana Luísa Areia
- Obstetrics Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Centre of Investigation in Environment, Genetics and Oncobiology (Cimago), Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Anabela Mota-Pinto
- Centre of Investigation in Environment, Genetics and Oncobiology (Cimago), Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Søgaard M, Skjøth F, Nielsen PB, Beyer-Westendorf J, Larsen TB. First Trimester Anticoagulant Exposure and Adverse Pregnancy Outcomes in Women with Preconception Venous Thromboembolism: A Nationwide Cohort Study. Am J Med 2022; 135:493-502.e5. [PMID: 34798098 DOI: 10.1016/j.amjmed.2021.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 10/13/2021] [Accepted: 10/13/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate first trimester anticoagulant exposure and risks of adverse pregnancy-related and fetal outcomes. METHODS Using Danish nationwide registries, we identified all pregnant women with preconception venous thromboembolism, 2000-2017, and linked data on exposure to low-molecular-weight heparin (LMWH), vitamin K antagonist (VKA), or non-VKA oral anticoagulant (NOAC) during pregnancy. We assessed pregnancy-related and fetal outcomes associated with first trimester anticoagulant exposure. RESULTS Among 4490 pregnancies in women with preconception venous thromboembolism (mean age 31 years, 40% nulliparous) during the first trimester, 63.1% were unexposed, 25.9% were exposed to LMWH, 10.4% VKA, and 0.6% NOAC. Adverse outcomes were lowest in unexposed and LMWH exposed. Compared with unexposed, VKA was associated with higher risks of preterm (adjusted odds ratio [OR] 2.26; 95% confidence interval [CI], 1.70-2.99) and very preterm birth (adjusted OR 3.78; 95% CI, 1.91-7.49), shorter mean gestational age was associated with VKA (-7.5 days; 95% CI, -9.1 to -5.9 days) or NOAC (-2.3 days; 95% CI, -8.4-3.8), and lower mean birthweight with VKA (-55 g; 95% CI, -103.1 to -8.5) or NOAC (-190 g; 95% CI, -364.1 to -16.4). Adjusted ORs for small-for-gestational-age infants were 1.07 (95% CI, 0.77-1.50) with VKA, and 3.29 (95% CI, 1.26-7.95) with NOAC. Mean 5-minute Apgar score (9.8) and congenital defect prevalence (8.4%-10%) varied little across exposure groups. CONCLUSIONS Fetal risk was lowest in unexposed and LMWH-exposed pregnancies, supporting the recommendation of LMWH during pregnancy. NOAC safety during pregnancy is unclear due to the rarity of NOAC exposure.
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Affiliation(s)
- Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark.
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark; Unit for Clinical Biostatistics, Aalborg University Hospital, Denmark
| | - Peter Brønnum Nielsen
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital "Carl Gustav Carus", Dresden, Germany
| | - Torben Bjerregaard Larsen
- Department of Cardiology, Aalborg University Hospital, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Denmark
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16
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Management of venous thromboembolism in pregnancy. Thromb Res 2022; 211:106-113. [DOI: 10.1016/j.thromres.2022.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/17/2022] [Accepted: 02/02/2022] [Indexed: 11/23/2022]
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17
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Moumneh T, Penaloza A, Armand A, Robert-Ebadi H, Righini M, Douillet D, Le Gal G, Roy PM. Diagnostic de l’embolie pulmonaire dans le contexte de la grossesse. ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les problématiques posées par la prise en charge de la femme enceinte suspecte d’embolie pulmonaire (EP) aux urgences sont multiples. Les modifications physiologiques au cours de la grossesse majorent les sollicitations médicales pour des tableaux de douleur thoracique, de dyspnée, de malaise… En parallèle, ces manifestations aux cours de la grossesse peuvent se confondre avec les éléments évocateurs d’une EP et interférer sur nos capacités d’appréciation de sa probabilité. Enfin, l’élévation physiologique des D-dimères et le taux d’imageries thoraciques non conclusives complexifient la démarche diagnostique. C’est pourtant dans le contexte de la grossesse qu’il est particulièrement souhaitable de ne pas manquer un diagnostic d’EP, tout en évitant d’exposer inutilement la patiente et son foetus à l’imagerie thoracique. Pour aider dans les prises de décision, deux stratégies ont été validées dans le contexte de la grossesse. La première repose sur le score de Genève, incluant la réalisation d’une échographie de compression proximale chez les patientes à probabilité forte ou ayant un D-dimère supérieur à 500 μg/L. La seconde repose sur l’algorithme YEARS, avec réalisation d’une échographie uniquement chez les patientes ayant des symptômes évocateurs d’une thrombose veineuse des membres inférieurs associée, puis un dosage des D-dimères avec un seuil à 500 ou 1 000 μg/L en fonction de la probabilité clinique. La fiabilité de ces deux stratégies a été démontrée. La première stratégie présente l’avantage de ne reposer que sur des données objectives, et la deuxième de reposer le seuil décisionnel à 1 000 μg/L chez les patientes n’ayant aucun des critères YEARS.
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18
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Carré J, Jourdi G, Gendron N, Helley D, Gaussem P, Darnige L. Recent Advances in Anticoagulant Treatment of Immune Thrombosis: A Focus on Direct Oral Anticoagulants in Heparin-Induced Thrombocytopenia and Anti-Phospholipid Syndrome. Int J Mol Sci 2021; 23:ijms23010093. [PMID: 35008518 PMCID: PMC8744910 DOI: 10.3390/ijms23010093] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/17/2021] [Accepted: 12/17/2021] [Indexed: 12/25/2022] Open
Abstract
For more than 10 years, direct oral anticoagulants (DOACs) have been increasingly prescribed for the prevention and treatment of thrombotic events. However, their use in immunothrombotic disorders, namely heparin-induced thrombocytopenia (HIT) and antiphospholipid syndrome (APS), is still under investigation. The prothrombotic state resulting from the autoimmune mechanism, multicellular activation, and platelet count decrease, constitutes similarities between HIT and APS. Moreover, they both share the complexity of the biological diagnosis. Current treatment of HIT firstly relies on parenteral non-heparin therapies, but DOACs have been included in American and French guidelines for a few years, providing the advantage of limiting the need for treatment monitoring. In APS, vitamin K antagonists are conversely the main treatment (+/− anti-platelet agents), and the use of DOACs is either subject to precautionary recommendations or is not recommended in severe APS. While some randomized controlled trials have been conducted regarding the use of DOACs in APS, only retrospective studies have examined HIT. In addition, vaccine-induced immune thrombotic thrombocytopenia (VITT) is now a part of immunothrombotic disorders, and guidelines have been created concerning an anticoagulant strategy in this case. This literature review aims to summarize available data on HIT, APS, and VITT treatments and define the use of DOACs in therapeutic strategies.
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Affiliation(s)
- Julie Carré
- Hematology Department, CHU de Poitiers, 86021 Poitiers, France
- Correspondence:
| | - Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC H1T 1C8, Canada;
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Nicolas Gendron
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, University of Paris, 75006 Paris, France; (N.G.); (P.G.); (L.D.)
- Biosurgical Research Lab (Carpentier Foundation), AP-HP, 75015 Paris, France
- Biological Hematology Department, Assistance Publique-Hôpitaux de Paris-Centre (AP-HP.CUP), 75015 Paris, France;
| | - Dominique Helley
- Biological Hematology Department, Assistance Publique-Hôpitaux de Paris-Centre (AP-HP.CUP), 75015 Paris, France;
- Paris Cardiovascular Research Center, INSERM UMR-S970, 75015 Paris, France
| | - Pascale Gaussem
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, University of Paris, 75006 Paris, France; (N.G.); (P.G.); (L.D.)
- Biological Hematology Department, Assistance Publique-Hôpitaux de Paris-Centre (AP-HP.CUP), 75015 Paris, France;
| | - Luc Darnige
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, University of Paris, 75006 Paris, France; (N.G.); (P.G.); (L.D.)
- Biological Hematology Department, Assistance Publique-Hôpitaux de Paris-Centre (AP-HP.CUP), 75015 Paris, France;
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19
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Gunawardena T. Direct oral anticoagulants: A review for the non-specialist. Hematol Rep 2021; 13:9239. [PMID: 35003572 PMCID: PMC8672212 DOI: 10.4081/hr.2021.9239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
Thrombin inhibitors and direct factor Xa inhibitors represent a major breakthrough in the field of anticoagulation pharmacotherapy. These novel agents have replaced warfarin as the oral anticoagulant of choice in certain indications, as they possess equal or superior efficacy and better safety profiles. They have a quick onset of action, predictable pharmacokinetic properties and minimal drug and food interactions. So they do not require frequent blood monitoring and dose adjustments as with warfarin. Considering all the advantages, there seems to be a rapid increase in the number of patients who are started on these novel anticoagulants. In this review, we highlight the pharmacology of these direct oral anticoagulants and the evidence-based indications for their use. We aim to provide a clinical overview for the non-specialist who may be called upon to manage a patient who is currently on one of these novel anticoagulants.
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Affiliation(s)
- Thilina Gunawardena
- Department of vascular and transplant surgery, National Hospital of Sri Lanka, Colombo, Sri Lanka
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20
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Sasannejad C, Sheth KN. Anticoagulation in Acute Neurological Disease. Semin Neurol 2021; 41:530-540. [PMID: 34619779 DOI: 10.1055/s-0041-1733793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
While anticoagulation and its reversal have been of clinical relevance for decades, recent academic and technological advances have expanded the repertoire of its application in neurological disease. The advent of direct oral anticoagulants provides effective, mechanistically elegant, and relatively safer therapeutic options than warfarin for eligible patients at risk for neurological sequelae of prothrombotic states, particularly given the recent availability of corresponding reversal agents. In this review, we examine the provenance, indications, safety, and reversal tools for anticoagulant medications in the context of neurological disease, with specific attention to acute ischemic stroke, cerebral venous sinus thrombosis, and intracerebral hemorrhage. We will use specific clinical scenarios to illustrate the complex factors that must be considered in the use of anticoagulation, including intracranial pathology such as intracerebral hemorrhage, traumatic brain injury, or malignancy; metabolic complications such as chronic kidney disease; pregnancy; and advanced age.
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Affiliation(s)
- Cina Sasannejad
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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21
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[Vascular emergencies in pregnant patients : Peripartum hemorrhage, thromboembolic events and hypertensive diseases in pregnancy]. Anaesthesist 2021; 70:895-908. [PMID: 34495345 DOI: 10.1007/s00101-021-00945-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 10/20/2022]
Abstract
In developed countries, peripartum hemorrhage, thromboembolic events and hypertensive pregnancy disorders are the most frequent complications in pregnancy. They pose a significant challenge for the interdisciplinary team of gynecology and anesthesiology. Untreated, these pregnancy-related complications result in a fulminant course. Close consultation between the specialist departments and knowledge of the area of responsibility are essential. In the case of acute bleeding the anesthesiologist is responsible for maintaining adequate circulatory conditions and management of hemostasis. Thromboembolic events require immediate anticoagulation and focused diagnostics. Thereby, both the fetal and the maternal risks must be weighed up. The hypertensive diseases in pregnancy have a very high risk of complications. In addition to symptomatic treatment in the intensive care unit, the optimal time of delivery must be determined by an interdisciplinary consensus. This is the only causal treatment option possible.
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22
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Abstract
Heart failure (HF) remains the most common major cardiovascular complication arising in pregnancy and the postpartum period. Mothers who develop HF have been shown to experience an increased risk of death as well as a variety of adverse cardiac and obstetric outcomes. Recent studies have demonstrated that the risk to neonates is significant, with increased risks in perinatal morbidity and mortality, low Apgar scores, and prolonged neonatal intensive care unit stays. Information on the causal factors of HF can be used to predict risk and understand timing of onset, mortality, and morbidity. A variety of modifiable, nonmodifiable, and obstetric risk factors as well as comorbidities are known to increase a patient's likelihood of developing HF, and there are additional elements that are known to portend a poorer prognosis beyond the HF diagnosis. Multidisciplinary cardio‐obstetric teams are becoming more prominent, and their existence will both benefit patients through direct care and increased awareness and educate clinicians and trainees on this patient population. Detection, access to care, insurance barriers to extended postpartum follow‐up, and timely patient counseling are all areas where care for these women can be improved. Further data on maternal and fetal outcomes are necessary, with the formation of State Maternal Perinatal Quality Collaboratives paving the way for such advances.
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Affiliation(s)
- Rachel A Bright
- Division of Cardiovascular Medicine Department of Medicine State University of New YorkStony Brook University Medical CenterRenaissance School of Medicine Stony Brook NY
| | - Fabio V Lima
- Division of Cardiology Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute Providence RI
| | - Cecilia Avila
- Department of Obstetrics, Gynecology and Reproductive Medicine Stony Brook University Medical Center Stony Brook NY
| | - Javed Butler
- Department of Medicine University of Mississippi Jackson MS
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23
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Ueberham L, Hindricks G. Anticoagulation in special patient populations with atrial fibrillation. Herz 2021; 46:323-328. [PMID: 34223913 DOI: 10.1007/s00059-021-05042-1] [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] [Accepted: 04/21/2021] [Indexed: 11/29/2022]
Abstract
Anticoagulation in patients with atrial fibrillation (AF) should be guided by considerations of the risk of thromboembolism, stroke, and bleeding as well as the patient's preference. Well-recognized scores have been developed to help the clinician in daily risk assessment, but there are several special patient populations for whom scores are not developed or validated. Furthermore, these patients were not adequately represented in the pivotal randomized trials for non-vitamin K antagonist oral anticoagulants (NOACs). In patients with cancer, the intrinsic hypercoagulable state has to be balanced against an increased risk of bleeding, and a dynamic concept should be applied, taking into account the cancer type, current disease state, therapeutic strategy, and patient-related factors, with NOACs playing an increasingly larger role. In women with planned pregnancy or already pregnant, NOACs should be avoided. However, accidental exposure during pregnancy should not lead to recommendations for pregnancy termination in view of current observational data. Whether patients on dialysis with AF benefit from anticoagulation at all is questionable. But if the decision for anticoagulation is made, NOACs may contribute to a more favorable risk-benefit profile than vitamin- K antagonists. Finally, patients on the ward deserve special considerations regarding periprocedural management of anticoagulation. Although for the majority of procedures a short discontinuation of oral anticoagulation seems appropriate, there are some low-bleeding-risk procedures that do not require cessation. The aim of the present review is to discuss the major particularities of these four patient subgroups and thus to facilitate the clinical decision-making.
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Affiliation(s)
- Laura Ueberham
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany.
- Leipzig Heart Institute, Leipzig, Germany.
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
- Leipzig Heart Institute, Leipzig, Germany
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24
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Malaiyandi D, James E, Peglar L, Karim N, Henkel N, Guilliams K. Neurocritical Care of the Pregnant Patient. Curr Treat Options Neurol 2021; 23:22. [PMID: 34177249 PMCID: PMC8214980 DOI: 10.1007/s11940-021-00676-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 02/07/2023]
Abstract
Purpose of review To summarize recent changes in management and emerging therapies for pregnant neurocritical care patients. Recent findings Diagnostic and treatment options for managing neurologic emergencies in pregnant patients have expanded with both greater understanding of the effects of imaging modalities and medications on pregnancy and application of standard treatments for non-pregnant patients to pregnant populations. Specifically, this includes cerebrovascular diseases (pregnancy-associated ischemic stroke, pregnancy-associated intracerebral hemorrhage, cerebral venous sinus thrombosis), post-maternal cardiac arrest care, seizures and status epilepticus, myasthenia gravis, and fetal somatic support in maternal death by neurologic criteria. Summary With the exception of direct abdominal computed tomography (CT), most imaging studies are reasonably safe in pregnancy. When emergent imaging is needed to prevent maternal morbidity or mortality, any CT sequence with or without contrast is appropriate to pursue. Though new safety data on antiplatelets, antihypertensives, thrombolytics, and antiepileptic drugs have increased options for disease management in pregnancy, unfractionated and low-molecular weight heparin remain the safest options for anticoagulation. Early studies on hypothermia, ketamine, and immunomodulating therapies in pregnancy are promising. In myasthenia gravis, new data on adjunct devices may allow more patients to undergo safe vaginal delivery, avoiding cesarean section and the associated risk of crisis. When difficult decisions regarding preterm delivery arise, recent outcome studies can help inform discussion. Lastly, when the feared complication of maternal death by neurologic criteria occurs, fetal somatic support may help to save at least one life.
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Affiliation(s)
- Deepa Malaiyandi
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,University of Toledo/ProMedica Neurosciences Center, 2130 W Central Ave, Ste. 201, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Elysia James
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Lindsay Peglar
- Department of Neurology, Washington University, St. Louis, MO USA
| | - Nurose Karim
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Nicholas Henkel
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Kristin Guilliams
- Department of Neurology, Washington University, St. Louis, MO USA.,Department of Pediatrics, Washington University, St. Louis, MO USA
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Roberti R, Iannone LF, Palleria C, Curcio A, Rossi M, Sciacqua A, Armentaro G, Vero A, Manti A, Cassano V, Russo E, De Sarro G, Citraro R. Direct Oral Anticoagulants: From Randomized Clinical Trials to Real-World Clinical Practice. Front Pharmacol 2021; 12:684638. [PMID: 34122113 PMCID: PMC8188985 DOI: 10.3389/fphar.2021.684638] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/26/2021] [Indexed: 12/21/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are a more manageable alternative than vitamin K antagonists (VKAs) to prevent stroke in patients with nonvalvular atrial fibrillation and to prevent and treat venous thromboembolism. Despite their widespread use in clinical practice, there are still some unresolved issues on optimizing their use in particular clinical settings. Herein, we reviewed the current clinical evidence on uses of DOACs from pharmacology and clinical indications to safety and practical issues such as drugs and food interactions. Dabigatran is the DOAC most affected by interactions with drugs and food, although all DOACs demonstrate a favorable pharmacokinetic profile. Management issues associated with perioperative procedures, bleeding treatment, and special populations (pregnancy, renal and hepatic impairment, elderly, and oncologic patients) have been discussed. Literature evidence shows that DOACs are at least as effective as VKAs, with a favorable safety profile; data are particularly encouraging in using low doses of edoxaban in elderly patients, and edoxaban and rivaroxaban in the treatment of venous thromboembolism in oncologic patients. In the next year, DOAC clinical indications are likely to be further extended.
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Affiliation(s)
- Roberta Roberti
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Luigi Francesco Iannone
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Caterina Palleria
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Antonio Curcio
- Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Marco Rossi
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Angela Sciacqua
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giuseppe Armentaro
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Ada Vero
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Antonia Manti
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Velia Cassano
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giovambattista De Sarro
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Rita Citraro
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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27
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Hong J, Ahn SY, Lee YJ, Lee JH, Han JW, Kim KH, Yhim HY, Nam SH, Kim HJ, Song J, Kim SH, Bang SM, Kim JS, Mun YC, Bae SH, Kim HK, Jang S, Park R, Choi HS, Kim I, Oh D. Updated recommendations for the treatment of venous thromboembolism. Blood Res 2021; 56:6-16. [PMID: 33627521 PMCID: PMC7987480 DOI: 10.5045/br.2021.2020083] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 01/06/2021] [Accepted: 01/06/2021] [Indexed: 12/13/2022] Open
Abstract
Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, is a condition characterized by abnormal blood clot formation in the pulmonary arteries and the deep venous vasculature. It is often serious and sometimes even fatal if not promptly and appropriately treated. Moreover, the later consequences of VTE may result in reduced quality of life. The treatment of VTE depends on various factors, including the type, cause, and patient comorbidities. Furthermore, bleeding may occur as a side effect of VTE treatment. Thus, it is necessary to carefully weigh the benefits versus the risks of VTE treatment and to actively monitor patients undergoing treatment. Asian populations are known to have lower VTE incidences than Western populations, but recent studies have shown an increase in the incidence of VTE in Asia. A variety of treatment options are currently available owing to the introduction of direct oral anticoagulants. The current VTE treatment recommendation is based on evidence from previous studies, but it should be applied with careful consideration of the racial, genetic, and social characteristics in the Korean population.
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Affiliation(s)
- Junshik Hong
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Department of Hematology-Oncology, Korea
| | - Seo-Yeon Ahn
- Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yoo Jin Lee
- Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Ji Hyun Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Dong-A University College of Medicine, Dong-A University Hospital, Busan, Korea
| | - Jung Woo Han
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Jeonju, Korea
| | - Kyoung Ha Kim
- Department of Oncology and Hematology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Department of Internal Medicine, Jeonju, Korea
| | - Ho-Young Yhim
- Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | | | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaewoo Song
- Department of Laboratory Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Sung-Hyun Kim
- Division of Hematology and Oncology, Department of Internal Medicine, Dong-A University College of Medicine, Dong-A University Hospital, Busan, Korea
| | - Soo-Mee Bang
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Department of Internal Medicine, Seoul, Korea
| | - Yeung-Chul Mun
- Ewha Womans University College of Medicine, Seoul, Korea
| | - Sung Hwa Bae
- Daegu Catholic University School of Medicine, Daegu Catholic University Hospital, Daegu, Department of Laboratory Medicine, Korea
| | - Hyun Kyung Kim
- Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seongsoo Jang
- University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Rojin Park
- Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Hyoung Soo Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Inho Kim
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Department of Hematology-Oncology, Korea
| | - Doyeun Oh
- Division of Hematology-Oncology, Department of Internal Medicine, CHA University School of Medicine, Seongnam, Korea
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How I treat venous thromboembolism in pregnancy. Blood 2021; 136:2133-2142. [PMID: 32797192 DOI: 10.1182/blood.2019000963] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/11/2020] [Indexed: 12/11/2022] Open
Abstract
One to 2 pregnant women in 1000 will experience venous thromboembolism (VTE) during pregnancy or postpartum. Pulmonary embolism (PE) is a leading cause of maternal mortality, and deep vein thrombosis leads to maternal morbidity, with postthrombotic syndrome potentially diminishing quality of life for a woman's lifetime. However, the evidence base for pregnancy-related VTE management remains weak. Evidence-based guideline recommendations are often extrapolated from nonpregnant women and thus weak or conditional, resulting in wide variation of practice. In women with suspected PE, the pregnancy-adapted YEARS algorithm is safe and efficient, rendering computed tomographic pulmonary angiography to rule out PE unnecessary in 39%. Low molecular weight heparin (LMWH) in therapeutic doses is the treatment of choice during pregnancy, and anticoagulation (LMWH or vitamin K antagonists [VKAs]) should be continued until 6 weeks after delivery, with a 3-month minimum total duration. LMWH or VKA use does not preclude breastfeeding. Postpartum, direct oral anticoagulants are an option if a woman does not breastfeed and long-term use is intended. Management of delivery, including type of analgesia, requires a multidisciplinary approach and depends on local preferences and patient-specific conditions. Several options are possible, including waiting for spontaneous delivery with temporary LMWH interruption. Prophylaxis for recurrent VTE prevention in subsequent pregnancies is indicated in most women with a history of VTE.
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Gangat N, Tefferi A. Myeloproliferative neoplasms and pregnancy: Overview and practice recommendations. Am J Hematol 2021; 96:354-366. [PMID: 33296529 DOI: 10.1002/ajh.26067] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 01/08/2023]
Abstract
Pregnancy in the context of myeloproliferative neoplasms (MPN) poses unique fetal and maternal challenges. Current literature in this regard mostly involves essential thrombocythemia (ET) and less so polycythemia vera (PV) or myelofibrosis. In ET, live birth rate is estimated at 70% with first trimester fetal loss (˜ 30%) as the major complication. Risk of pregnancy-associated complications is higher in PV, thus mandating a more aggressive treatment approach. Herein, we appraise the relevant literature, share our own experience and propose management recommendations. Aspirin therapy may offer protection against fetal loss; however the additive benefit of systemic anticoagulation or cytoreductive therapy, in the absence of high risk disease, is unclear. We recommend cytoreductive therapy in the form of interferon alpha in all high risk and select low-risk ET and PV patients with history of recurrent fetal loss, prominent splenomegaly or suboptimal hematocrit control with phlebotomy. In addition, all women with PV should maintain strict hematocrit control <45% with the aid of phlebotomy. Systemic anticoagulation with low molecular weight heparin is advised in patients with history of venous thrombosis. Further clarification awaits prospective clinical trials that implement risk adapted therapeutic interventions.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology Mayo Clinic Rochester Minnesota USA
| | - Ayalew Tefferi
- Division of Hematology Mayo Clinic Rochester Minnesota USA
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 555] [Impact Index Per Article: 185.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e35-e71. [PMID: 33332149 DOI: 10.1161/cir.0000000000000932] [Citation(s) in RCA: 353] [Impact Index Per Article: 117.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 819] [Impact Index Per Article: 273.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2021; 77:450-500. [DOI: 10.1016/j.jacc.2020.11.035] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Panahi L, Udeani G, Horseman M, Weston J, Samuel N, Joseph M, Mora A, Bazan D. Review of Medical Therapies for the Management of Pulmonary Embolism. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:110. [PMID: 33530544 PMCID: PMC7912594 DOI: 10.3390/medicina57020110] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 12/12/2022]
Abstract
Traditionally, the management of patients with pulmonary embolism has been accomplished with anticoagulant treatment with parenteral heparins and oral vitamin K antagonists. Although the administration of heparins and oral vitamin K antagonists still plays a role in pulmonary embolism management, the use of these therapies are limited due to other options now available. This is due to their toxicity profile, clearance limitations, and many interactions with other medications and nutrients. The emergence of direct oral anticoagulation therapies has led to more options now being available to manage pulmonary embolism in inpatient and outpatient settings conveniently. These oral therapeutic options have opened up opportunities for safe and effective pulmonary embolism management, as more evidence and research is now available about reversal agents and monitoring parameters. The evolution of the pharmacological management of pulmonary embolism has provided us with better understanding regarding the selection of anticoagulants. There is also a better understanding and employment of anticoagulants in pulmonary embolism in special populations, such as patients with liver failure, renal failure, malignancy, and COVID-19.
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Affiliation(s)
- Ladan Panahi
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 1010 W Ave B, Kingsville, TX 78363, USA; (M.H.); (J.W.); (N.S.); (M.J.); (A.M.); (D.B.)
| | - George Udeani
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 1010 W Ave B, Kingsville, TX 78363, USA; (M.H.); (J.W.); (N.S.); (M.J.); (A.M.); (D.B.)
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Reynolds ML, Herrera CA. Chronic Kidney Disease and Pregnancy. Adv Chronic Kidney Dis 2020; 27:461-468. [PMID: 33328062 DOI: 10.1053/j.ackd.2020.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022]
Abstract
Women with chronic kidney disease (CKD) are at high risk for adverse outcomes in pregnancy. In the United States, pregnancy rates in women with risk factors for CKD such as obesity and advanced maternal age are increasing; thus, more pregnancies are likely to be affected by CKD. Strategies that involve coordinated multidisciplinary care to optimize preconception health, perform meticulous antenatal monitoring, and provide continued care in the postpartum "fourth trimester" appear to be most beneficial for both the mother and baby. Discussions surrounding preconception risk stratification should be individualized based on CKD stage/serum creatinine level, degree of hypertension and proteinuria, and comorbid conditions. Preparation for pregnancy should include optimization of comorbidities and medication adjustments to those compatible with pregnancy. Unless contraindicated, all women with CKD should be prescribed low-dose aspirin in pregnancy to reduce risk of preeclampsia. After delivery, women with CKD may benefit from an early postpartum visit (within 7-10 days) for blood pressure check and may require serial monitoring of serum creatinine and proteinuria as appropriate. Breastfeeding is safe and can be recommended for most women with CKD. A contraceptive plan that includes patients' preferences, feasibility, medical eligibility, duration, and effectiveness of the contraceptive method should be implemented.
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Abstract
Pulmonary arterial hypertension is a rare disease that predominantly affects women. The pathophysiology of the disease is complex, with both genetic and hormonal influences. Pregnancy causes significant physiologic changes that may not be well tolerated with underlying pulmonary arterial hypertension, in particular leading to volume overload and increased pulmonary pressures. A multidisciplinary approach and careful monitoring are essential for appropriate management of pulmonary arterial hypertension during pregnancy. Nonetheless, outcomes are still poor, and pregnancy is considered a contraindication in patients with pulmonary arterial hypertension.
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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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Abstract
Anthracycline-associated cardiomyopathy and peripartum cardiomyopathy are nonischemic cardiomyopathies that often afflict previously healthy young patients; both diseases have been well described since at least the 1970s and both occur in the settings of predictable stressors (ie, cancer treatment and pregnancy). Despite this, the precise mechanisms and the ability to reliably predict who exactly will go on to develop cardiomyopathy and heart failure in the face of anthracycline exposure or childbirth have proven elusive. For both cardiomyopathies, recent advances in basic and molecular sciences have illuminated the complex balance between cardiomyocyte and endothelial homeostasis via 3 broad pathways: reactive oxidative stress, interference in apoptosis/growth/metabolism, and angiogenic imbalance. These advances have already shown potential for specific, disease-altering therapies, and as our mechanistic knowledge continues to evolve, further clinical successes are expected to follow.
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Affiliation(s)
- Joshua A Cowgill
- From the Department of Cardiovascular Medicine, Maine Medical Center, Portland
| | - Sanjeev A Francis
- From the Department of Cardiovascular Medicine, Maine Medical Center, Portland
| | - Douglas B Sawyer
- From the Department of Cardiovascular Medicine, Maine Medical Center, Portland
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Wiegers HMG, Middeldorp S. Contemporary best practice in the management of pulmonary embolism during pregnancy. Ther Adv Respir Dis 2020; 14:1753466620914222. [PMID: 32425105 PMCID: PMC7238314 DOI: 10.1177/1753466620914222] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/25/2020] [Indexed: 12/25/2022] Open
Abstract
Approximately 1-2 per 1000 pregnancies are complicated by venous thromboembolism (VTE). VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE) and the diagnostic management of pregnancy-related VTE is challenging. Current guidelines vary greatly in their approach to diagnosing PE in pregnancy as they base their recommendations on scarce and weak evidence. The pregnancy-adapted YEARS diagnostic algorithm is well tolerated and is the most efficient diagnostic algorithm for pregnant women with suspected PE, with 39% of women not requiring computed tomographic pulmonary angiography. Low-molecular-weight heparin is the first-choice anticoagulant treatment in pregnancy and should be continued until 6 weeks postpartum and for a minimum of 3 months. Direct oral anticoagulants should be avoided in women who want to breastfeed. Management of delivery needs a multidisciplinary approach in order to decide on an optimal delivery plan. Neuraxial analgesia can be given in most patients, provided time windows since last low-molecular-weight heparin dose are respected. Women with a history of VTE are at risk of recurrence during pregnancy and in the postpartum period. Therefore, in most women with a history of VTE, thromboprophylaxis in subsequent pregnancies is indicated. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Hanke M. G. Wiegers
- Department of Vascular Medicine, Amsterdam UMC,
University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9,
Amsterdam, North Holland 1105 AZ, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC,
University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The
Netherlands
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Abstract
PURPOSE OF REVIEW Peripartum cardiomyopathy (PPCM) is an important condition with high morbidity and mortality worldwide. Patients with PPCM are at risk of developing life-long cardiac disease, requiring regular management and medical intervention. This article conducts a review of recent literature and gives insight into this disease. RECENT FINDINGS There is promising research in the fields of vascular, hormonal and genetics. A number of genetic markers are being analyzed; including TTNC1, TTN and STAT3. Mutations to these genes have been found to be prevalent in PPCM. These combined with the secretion of placental angiogenic factors potentially create imbalance in angiogenesis as the primary etiology. SUMMARY Current biomarkers do not differentiate between PPCM and other variants of heart failure. Women with PPCM are more likely to have a cesarean section, have hypertensive disease, at greater risk of major adverse cardiac events and to have lifelong morbidity.
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Affiliation(s)
- Lindsay C Ballard
- Department of Emergency Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Portland, Oregon 97239-3098
| | - Adrian Cois
- School of Medicine, University of Notre Dame, 32 Mouat St, Fremantle WA 6160, Australia
| | - Bory Kea
- Department of Emergency Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd MC CR114, Portland, Oregon 97239-3098
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Lamont MC, McDermott C, Thomson AJ, Greer IA. United Kingdom recommendations for obstetric venous thromboembolism prophylaxis: Evidence and rationale. Semin Perinatol 2019; 43:222-228. [PMID: 30935752 DOI: 10.1053/j.semperi.2019.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of maternal death in the United Kingdom. To address this problem guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) has been developed that recommends the assessment of a woman's risk of thrombosis at specific time-points during pregnancy and postnatally at the time of delivery. The RCOG guidelines provide clinicians with a framework to inform decision-making on the use of thromboprophylaxis and are based on the premise that the higher risk a woman has for VTE, the more likely she is to benefit from prophylaxis - determining her level of risk is based on the number and characteristics of the risk factors that she has. This article will address the pathophysiology of VTE in pregnancy, evidence behind the risk factors for VTE and the use of thromboprophylactic agents. Further, it will reflect on the rationale behind the RCOG guidance.
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Affiliation(s)
- M Christy Lamont
- Department of Obstetrics & Gynaecology, NHS Greater Glasgow & Clyde, Scotland
| | | | - Andrew J Thomson
- Department of Obstetrics & Gynaecology, NHS Greater Glasgow & Clyde, Scotland.
| | - Ian A Greer
- President and Vice Chancellor, Queen's University Belfast, Northern Ireland
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Rosenbloom JI, Macones GA. Future research directions for prevention and treatment of obstetric venous thromboembolism. Semin Perinatol 2019; 43:213-217. [PMID: 30935753 DOI: 10.1053/j.semperi.2019.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pregnant patients are at high risk for venous thromboembolism, which accounts for 9% of maternal deaths in the United States. However, there are still a number of unanswered questions with regards to prevention, diagnosis, and treatment of this condition. This article highlights areas for future research with regards to three questions pertaining to venous thromboembolism in pregnancy: 1) how can risk stratification be improved; 2) what are the most effective means of prevention; 3) what is the role of novel oral anticoagulants in pregnancy and the postpartum period?
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Affiliation(s)
- Joshua I Rosenbloom
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis.
| | - George A Macones
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis
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Direct-acting oral anticoagulants (DOACs) in pregnancy: new insight from VigiBase ®. Sci Rep 2019; 9:7236. [PMID: 31076635 PMCID: PMC6510783 DOI: 10.1038/s41598-019-43715-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/15/2019] [Indexed: 02/05/2023] Open
Abstract
We aimed to perform an analysis of individual case safety reports retrieved after the Standardized MedDRA Query “Pregnancy and neonatal topics” for which Direct-Acting Oral Anticoagulants (DOACs) were claimed as suspected/interacting drugs. Additionally, to investigate if exists a disproportion of cases reporting “Pregnancy and neonatal topics” adverse events rather than other adverse events for DOACs in comparison with all other drugs registered in VigiBase or warfarin. VigiBase, the World Health Organization (WHO)’s global database of individual case safety reports was used as data source. Forty-two cases of abortion were detected of which 18 (42.8%) had alternative causes for its occurrence. Fourteen cases reported congenital anomaly (8 cases) or low birth weight baby/fetal growth restriction (6 cases) of which 62.5% and 33.3% had at least one confounder, respectively. In the disproportionality analyses, a potential safety signal for spontaneous abortion emerged for rivaroxaban (Reporting Odds Ratio, ROR 2.70; 95% CI 1.79–4.07) and apixaban (ROR 6.76; 95% CI 2.99–15.25). However, when the same analyses were performed using only cases without alternative causes, no statistically significant associations for rivaroxaban when compared to all other drugs (ROR 1.05; 95% CI 0.54–2.02) or warfarin (ROR 0.79; 95% CI 0.47–1.32) were found. For apixaban, we found a statistically significant ROR for induced abortion when compared to all other drugs or warfarin. For the majority of cases claiming DOACs-induced teratogenic effects, spontaneous or induced abortion there was at least one alternative cause explaining the occurrence of the adverse events. For rivaroxaban, when cases without confounders were considered, no safety signals emerged. However, for apixaban, we found a potential safety signal suggesting an increased probability of reporting spontaneous/induced abortion rather than other events when compared to all other drugs or warfarin.
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S. Aleidan F. Oral anticoagulants: Optimizing venous thromboembolism management. JOURNAL OF APPLIED HEMATOLOGY 2019. [DOI: 10.4103/joah.joah_47_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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