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Klaserner EL, Popova KJ, Gaudet RL. Venous Thromboembolism Prophylaxis in Obstetric Patients. J Pharm Pract 2024; 37:1183-1196. [PMID: 38621760 DOI: 10.1177/08971900241247628] [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: 04/17/2024]
Abstract
Venous thromboembolism (VTE), including both pulmonary embolism (PE) and deep vein thrombosis (DVT), is the leading cause of maternal death in developed countries. Pregnancy is associated with an increased risk of VTE due to physiologic changes during the obstetric period that promote a hypercoagulable state. Appropriate use of prophylactic anticoagulants can decrease the event rate of thrombus formation in at-risk patients. In the United States, there is not a validated risk-assessment tool for VTE in obstetric patients or a clear consensus on initiation and optimal dosing strategy for the prophylactic use of anticoagulants. This article reviews the mechanism of coagulation disturbance that leads to an increased risk of VTE in obstetric patients, as well as the available literature surrounding pharmacologic prophylaxis.
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Affiliation(s)
- Emma L Klaserner
- Department of Pharmacy, University of Michigan Health Department of Pharmacy Services, Ann Arbor, MI, USA
| | - Kayla J Popova
- Department of Pharmacy, University of Michigan Health Department of Pharmacy Services, Ann Arbor, MI, USA
| | - Rikki-Leigh Gaudet
- Department of Pharmacy, University of Michigan Health Department of Pharmacy Services, Ann Arbor, MI, USA
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2
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Kilkenny K, Frishman W. Venous Thromboembolism in Pregnancy: A Review of Diagnosis, Management, and Prevention. Cardiol Rev 2024:00045415-990000000-00306. [PMID: 39051770 DOI: 10.1097/crd.0000000000000756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism, is a leading cause of maternal morbidity and mortality worldwide. Physiological changes that occur in a normal pregnancy increase the risk for VTE by 4-5-fold in the antepartum period and 30-60-fold in the immediate postpartum period. Compressive ultrasonography is the diagnostic test of choice for deep vein thrombosis. Both ventilation/perfusion scanning and computed tomography pulmonary angiography can reliably diagnose pulmonary embolism. Anticoagulation for a minimum of 3 months, typically with low molecular weight heparin, is the treatment of choice for pregnancy-associated VTE (PA-VTE). Despite the significant societal burden and potentially devastating consequences, there is a paucity of data surrounding the prevention of PA-VTE, resulting in major variations between international guidelines. This review will summarize the current recommendations for diagnosis, management, and prevention of PA-VTE.
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Affiliation(s)
- Katherine Kilkenny
- From the Department of Medicine, New York Presbyterian-Weill Cornell Medicine, New York, NY
- Department of Medicine, New York Medical College, School of Medicine, Valhalla, NY
| | - William Frishman
- Department of Medicine, New York Medical College, School of Medicine, Valhalla, NY
- Department of Medicine, Westchester Medical Center, Valhalla, NY
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3
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Folkins S, Miller A, Nash CM. Risk of venous thromboembolism in pregnant patients with active malignancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:645-652. [PMID: 37968882 PMCID: PMC10993334 DOI: 10.1111/aogs.14712] [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: 08/08/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION Cancer currently occurs in about 1 in 1000 pregnancies. Both active malignancy and pregnancy are individual risk factors for venous thromboembolism (VTE). The purpose of this systematic review/meta-analysis was to evaluate the rate of VTE in pregnant patients with active malignancy compared with pregnant patients without malignancy. MATERIAL AND METHODS Embase, Medline/PubMed, Cochrane Database, and clinicaltrial.gov were search by a trained librarian from inception until June 2021, and limited to English and French language human studies using keywords related to pregnancy, neoplasm, and thrombosis. This study was prospectively registered with PROSPERO (CRD42021245886). Title, abstract, and full-text review was performed using the Covidence data management system. Two authors reviewed the studies independently. Of the 3821 articles screened, seven cohort studies were included that reported VTE rate in patients with active malignancy in pregnancy. RESULTS A total of 5928 individuals had active malignancy and pregnancy. Active malignancy in pregnancy significantly increased the odds of a VTE (odds ratio [OR] 6.8, 95% confidence interval [CI] 3.8-12.1). Specifically, patients with thyroid (OR 2.7, 95% CI 1.3-6.3), cervix (OR 6.6, 95% CI 2.4-18.0), or other gynecological (OR 10.6, 95% CI 4.4-25.8) cancers; Hodgkin's lymphoma (OR 8.7, 95% CI 3.3-23.4); or acute leukemia (OR 17.1, 95% CI 10.9-26.8) all had increased odds, whereas those with brain cancer (OR 6.1, 95% CI 0.4-98.2), breast cancer (OR 2.5, 95% CI 0.3-17.4), malignant melanoma (OR 5.5, 95% CI 0.3-88.1), or non-Hodgkin's lymphoma (OR 3.2, 95% CI 0.8-12.9) malignancies did not have statistically significant increased odds for VTE. No studies reported whether prophylactic anticoagulation was used during pregnancy in this population; nor did they report timing in pregnancy of the VTE. The absolute risk for VTE in those with active malignancy was 0.9% compared with 0.2% in those without active malignancy in pregnancy. CONCLUSIONS Pregnancy with active malignancy confers a significant increased risk for VTE compared with pregnancy alone. Given this finding, prophylactic anticoagulation during pregnancy and postpartum could be considered in this patient population. Data are underpowered to make firm recommendations per cancer type.
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Affiliation(s)
- Sara Folkins
- Dalhousie University Medical School, Halifax, Nova Scotia, Canada
| | - Ashley Miller
- Division of General Internal Medicine, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christopher M Nash
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada
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4
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James AH, Strouse JJ. How I treat sickle cell disease in pregnancy. Blood 2024; 143:769-776. [PMID: 37979134 DOI: 10.1182/blood.2023020728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/15/2023] [Accepted: 10/12/2023] [Indexed: 11/19/2023] Open
Abstract
ABSTRACT Fifty years ago, people with sickle cell disease (SCD) were discouraged from becoming pregnant, but now, most should be supported if they choose to pursue a pregnancy. They and their providers, however, should be aware of the physiological changes of pregnancy that aggravate SCD and pregnancy's unique maternal and fetal challenges. Maternal problems can arise from chronic underlying organ dysfunction such as renal disease or pulmonary hypertension; from acute complications of SCD such as acute anemia, vaso-occlusive crises, and acute chest syndrome; and/or from pregnancy-related complications such as preeclampsia, sepsis, severe anemia, thromboembolism, and the need for cesarean delivery. Fetal problems include alloimmunization, opioid exposure, fetal growth restriction, preterm delivery, and stillbirth. Before and during pregnancy, in addition to the assessment and care that every pregnant patient should receive, patients with SCD should be evaluated and treated by a multidisciplinary team with respect to their unique maternal and fetal issues.
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Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University, Durham, NC
- Division of Hematology, Department of Medicine, Duke University, Durham, NC
| | - John Joseph Strouse
- Division of Hematology, Department of Medicine, Duke University, Durham, NC
- Division of Hematology/Oncology, Department of Pediatrics, Duke University, Durham, NC
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5
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Vlachodimitropoulou E, Mogharbel H, Kuo KHM, Hwang M, Ward R, Shehata N, Malinowski AK. Pregnancy outcomes and iron status in β-thalassemia major and intermedia: a systematic review and meta-analysis. Blood Adv 2024; 8:746-757. [PMID: 38181780 PMCID: PMC10847873 DOI: 10.1182/bloodadvances.2023011636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/22/2023] [Accepted: 12/19/2023] [Indexed: 01/07/2024] Open
Abstract
ABSTRACT Advancements in orally bioavailable iron chelators and MRI methods have improved life expectancy and reproductive potential in thalassemia major (TM) and thalassemia intermedia (TI). Pregnancy is associated with adverse maternal and neonatal outcomes, frequency of which has not been well delineated. This systematic review aims to provide risk estimates of maternal and fetal outcomes in TM and TI and explore pregnancy's impact on iron homeostasis. Fifteen studies (429 participants, 684 pregnancies) were included. Meta-analysis revealed a higher thrombosis risk in TI (3.7%) compared to TM (0.92%), unchanged from prepregnancy. Heart failure risks in the earlier years appeared similar (TM 1.6% vs TI 1.1%), and maternal mortality in TM was 3.7%, but with current management, these risks are rare. Gestational diabetes and pre-eclampsia occurred in 3.9% and 11.3% of TM pregnancies, respectively. Caesarean section rates were 83.9% in TM and 67% in TI. No significant difference in stillbirth, small for gestational age neonates, or preterm birth incidence between TM and TI was observed. In TM pregnancies, red cell requirements significantly increased (from 102 to 139 ml/kg/year, P = 0.001), and 70% of TI pregnancies required blood transfusions. As expected, increased transfusion alongside chelation cessation led to a significant increase in serum ferritin during pregnancy (TM by 1005 ng/mL; TI by 332 ng/mL, P < 0.0001). Deterioration in iron status was further reflected by an increase in liver iron concentration (from 4.6 to 11.9 mg/g dry weight, P < 0.0001), and myocardial T2-star (T2∗) magnetic resonance imaging decreased (from 36.2 ± 2.5 ms to 31.1 ms) during pregnancy. These findings emphasize the elevated maternal risk of iron-related cardiomyopathy during pregnancy and labor, stressing the importance of cardiac monitoring and postpartum chelation therapy resumption.
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Affiliation(s)
| | - Hussain Mogharbel
- Division of Maternal-Fetal Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Kevin H. M. Kuo
- Division of Haematology, University of Toronto, Toronto, ON, Canada
| | - Michelle Hwang
- Sidney Liswood Health Sciences Library, Mount Sinai Hospital, Toronto, ON, Canada
| | - Richard Ward
- Division of Haematology, University of Toronto, Toronto, ON, Canada
| | - Nadine Shehata
- Departments of Medicine and Laboratory Medicine and Pathobiology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Ann Kinga Malinowski
- Division of Maternal-Fetal Medicine, Mount Sinai Hospital, Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada
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6
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Meyerowitz EA, Scott J, Richterman A, Male V, Cevik M. Clinical course and management of COVID-19 in the era of widespread population immunity. Nat Rev Microbiol 2024; 22:75-88. [PMID: 38114838 DOI: 10.1038/s41579-023-01001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/21/2023]
Abstract
The clinical implications of COVID-19 have changed since SARS-CoV-2 first emerged in humans. The current high levels of population immunity, due to prior infection and/or vaccination, have been associated with a vastly decreased overall risk of severe disease. Some people, particularly those with immunocompromising conditions, remain at risk for severe outcomes. Through the course of the pandemic, variants with somewhat different symptom profiles from the original SARS-CoV-2 virus have emerged. The management of COVID-19 has also changed since 2020, with the increasing availability of evidence-based treatments in two main classes: antivirals and immunomodulators. Selecting the appropriate treatment(s) for patients with COVID-19 requires a deep understanding of the evidence and an awareness of the limitations of applying data that have been largely based on immune-naive populations to patients today who most likely have vaccine-derived and/or infection-derived immunity. In this Review, we provide a summary of the clinical manifestations and approaches to caring for adult patients with COVID-19 in the era of vaccine availability and the dominance of the Omicron subvariants, with a focus on the management of COVID-19 in different patient groups, including immunocompromised, pregnant, vaccinated and unvaccinated patients.
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Affiliation(s)
- Eric A Meyerowitz
- Division of Infectious Diseases, Montefiore Medical Center, Bronx, NY, USA
| | - Jake Scott
- Division of Infectious Diseases and Geographic Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Aaron Richterman
- Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria Male
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Muge Cevik
- Division of Infection and Global Health Research, School of Medicine, University of St Andrews, St Andrews, UK.
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Jadhav KP, Sridhar KS, Kandi S, Jariwala PV. A 'dreaded' complication of stuck prosthetic valve in the first trimester pregnancy. J Cardiol Cases 2023; 28:261-264. [PMID: 38126053 PMCID: PMC10730274 DOI: 10.1016/j.jccase.2023.08.007] [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: 03/28/2023] [Revised: 07/12/2023] [Accepted: 08/14/2023] [Indexed: 12/23/2023] Open
Abstract
A dramatic rise in cardiac output with a decrease in afterload are the hallmark of hemodynamic variations induced by normal pregnancy, which requires significant cardiac adaptation. Females with rheumatic mitral valve disease who have had a mitral valve replacement in the past are increasingly choosing to become pregnant. Hypercoagulability of pregnancy, problems with anticoagulant therapy along with hemodynamic changes in pregnancy increase the risk of cardiac complications in this subset. There is a paucity of research on the management of problems in patients with cardiac prosthetic valves. We present a case of primigravida with a history of mitral valve replacement, presenting with a stuck valve. Learning objectives •Pregnancy is a pro-thrombotic state•Pregnancy with a mechanical heart valve has high risk of stuck vale despite adequate anti-coagulation•Management of such high-risk cases must be carried out at a tertiary care center with all facilities•Multi-disciplinary approach is required to deal with pregnant women with mechanical heart valve.
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Affiliation(s)
| | - Kale Satya Sridhar
- Department of Cardiothoracic Surgery, Yashoda Hospital, Somajiguda, Hyderabad, India
| | - Sujatha Kandi
- Department of Obstetrics and Gynaecology, Yashoda Hospital, Somajiguda, Hyderabad, India
| | - Pankaj V. Jariwala
- Department of Cardiology, Yashoda Hospital, Somajiguda, Hyderabad, India
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8
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Agarwal S, Stanek JR, Vesely SK, Creary SE, Cronin RM, Roe AH, O’Brien SH. Pregnancy-related thromboembolism in women with sickle cell disease: An analysis of National Medicaid Data. Am J Hematol 2023; 98:1677-1684. [PMID: 37551881 PMCID: PMC10592294 DOI: 10.1002/ajh.27045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 08/09/2023]
Abstract
Pregnancy and sickle cell disease (SCD) both individually carry a risk of thromboembolism (TE). Pregnancy in people with SCD may further enhance the prothrombotic effect of the underlying disease. The objectives of this study were to determine the rate and risk factors for arterial and venous thrombosis in pregnant people with SCD. Administrative claims data from the United States Centers for Medicare and Medicaid Service Analytic eXtract from 2006 to 2018 were used. The study population included people with SCD from the start of their first identified pregnancy until 1 year postpartum and a control cohort of pregnant people without SCD of similar age and race. Outcomes of interest were identified with ICD-9 or 10 codes. Logistic regression analyses were used to analyze risk factors. We identified infant deliveries in 6388 unique people with SCD and 17 110 controls. A total of 720 venous thromboembolism (11.3%) and 335 arterial TE (5.2%) were observed in people with SCD compared to 202 (1.2%) and 95 (0.6%) in controls. People with SCD had an 8-11 times higher odds of TE compared to controls (p < .001). Within the SCD cohort, age, hemoglobin SS (HbSS) genotype, hypertension, and history of thrombosis were identified as independent risk factors for pregnancy-related TE. Pregnancy-specific factors (pre-eclampsia, eclampsia, multigestational pregnancy) were not associated with TE. In conclusion, the risk of pregnancy-related TE is considerably higher in people with SCD compared with controls without SCD. Hence, people with SCD, particularly those with multiple risk factors may be candidates for thromboprophylaxis during pregnancy and the postpartum period.
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Affiliation(s)
- Shreya Agarwal
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
| | - Joseph R Stanek
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
- Biostatistics Resource at Nationwide Children’s Hospital, Columbus, OH
| | - Sara K. Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma, Oklahoma City, OK
| | - Susan E. Creary
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Robert M Cronin
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Andrea H. Roe
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Sarah H. O’Brien
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
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Zhu W, Xu M, Zhu M, Song Y, Zhang J, Zheng C. Cuyun Recipe ameliorates pregnancy loss by regulating macrophage polarization and hypercoagulable state during the peri-implantation period in an ovarian hyperstimulation mouse model. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 119:154974. [PMID: 37523838 DOI: 10.1016/j.phymed.2023.154974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/09/2023] [Accepted: 07/15/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND The Chinese herbal prescription Cuyun Recipe (CYR) has been widely used to treat clinical infertility and has shown good efficacy. Animal experiments have shown that CYR can promote implantation in mice, however, the exact mechanism underlying the implantation has not been elucidated. PURPOSE To investigate the effect and mechanism of CYR on regulating macrophage polarization and hypercoagulability during the peri-implantation period in mice with ovarian hyperstimulation. METHODS An ovarian hyperstimulation mouse model was developed, followed by treatment with CYR. Mice were sacrificed on day (D)4.5, D6, or D8 of gestation. The number of implantation sites, the pathological changes of the uterus and ovaries were assessed. The polarization of monocytes/macrophages in the spleen and endometrium, the expression and localization of cytokines were further detected. Furthermore, analyses of hypercoagulable state of the blood were also performed. RESULTS Treatment with CYR increased the average number of implantation sites, promoted angiogenesis in endometrial, and regulated monocytes/macrophages and the cytokine levels. Moreover, CYR downregulated the overexpression of D-dimer and fgl2 after ovarian hyperstimulation. CONCLUSION CYR facilitates embryo implantation by alleviating ovarian hyperstimulation, promoting endometrial decidualization and angiogenesis, regulating macrophage polarization, and reversing the hypercoagulable state of the blood.
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Affiliation(s)
- Wenxin Zhu
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
| | - Menghao Xu
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
| | - Mengdi Zhu
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
| | - Yufan Song
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
| | - Jinmin Zhang
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China
| | - Cuihong Zheng
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, China.
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10
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Xiao H, Yu W, Li L, Yin X, Zhai Q, Hu D, Zhang X, Wang F. Trimester-specific reference intervals of hemostasis biomarkers for healthy pregnancy. Scand J Clin Lab Invest 2023; 83:379-383. [PMID: 37491076 DOI: 10.1080/00365513.2023.2233903] [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: 10/06/2020] [Revised: 07/02/2023] [Accepted: 07/02/2023] [Indexed: 07/27/2023]
Abstract
Physiological changes in hemostasis during pregnancy have been reported by several authors. This study aimed at establishing reference intervals for the hemostasis biomarkers thrombin-antithrombin complex (TAT), α2-plasmininhibitor-plasmin complex (PIC), thrombomodulin (TM) and tissue plasminogen activator-inhibitor complex (tPAI-C), in healthy pregnancies. After excluding outliers, a total of 496 healthy pregnant women (128 first-trimester, 142 second-trimester, 107 third-trimester and 119 pre-labor) and 103 healthy nonpregnant women were enrolled from Shenzhen Bao'an Women's and Children's Hospital. Hemostasis biomarkers, TAT, PIC, TM and tPAI-C, were measured by using a quantitative chemiluminescence enzyme immunoassay performed on HISCL automated analysers. The median and reference intervals (the 2.5th and 97.5th percentiles) were calculated to establish trimester-specific reference intervals for healthy pregnant women. The reference intervals for TAT, PIC, TM and tPAI-C in the first trimester were 0.7-7.6 1 µg/L, 0.2-0.9 mg/L, 2.8-11.0 TU/ml, and 1.2-6.5 1 µg/L, respectively. The reference intervals in the second trimester were 1.7-12.0 1 µg/L, 0.2-1.0 mg/L, 3.7-11.6 TU/ml, and 2.8-8.8 1 µg/L, respectively. The reference intervals in the third trimester were 2.7-16.1 1 µg/L, 0.1-1.4 mg/L, 2.9-12.9 TU/ml, and 1.9-8.0 1 µg/L, respectively. At pre-labor, the reference intervals were 4.8-32.9 1 µg/L, 0.2-1.9 mg/L, 4.2-12.6 TU/ml, and 2.8-15.4 1 µg/L, respectively. Gestational reference intervals for TAT, PIC, TM and tPAI-C in healthy pregnancies are provided, but only for TAT with increasing concentrations throughout pregnancy, the reference intervals for non-pregnant were not applicable.
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Affiliation(s)
- Haijun Xiao
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Weijian Yu
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Lihua Li
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Xiaoqin Yin
- Shenzhen Longhua New District People's Hospital, P.R. China
| | - Qingna Zhai
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Die Hu
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Xiufa Zhang
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
| | - Feng Wang
- Shenzhen Baoan Women's and Children's Hospital, Guangdong, P.R. China
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11
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Guyon M, Degez M, Artifoni M, Goronflot T, Misbert E, Dochez V, Winer N. Adrenal Gland Necrosis in Pregnancy: How to Manage? Case Series at Nantes University Hospital and Literature Review. J Clin Med 2023; 12:6036. [PMID: 37762978 PMCID: PMC10531684 DOI: 10.3390/jcm12186036] [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: 08/09/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Adrenal necrosis is a rare but serious cause of abdominal pain of thrombotic origin during pregnancy. There is often a delay in diagnosis and treatment. The objective was to specify the clinical and paraclinical signs suggestive of adrenal necrosis, making it possible to improve the delay in diagnostic. The secondary objective was to establish a multidisciplinary protocol regarding management. This is a case report of pregnant women with a radiological diagnosis of adrenal gland necrosis. In parallel, we carried out a systematic review in the same period. We studied these patients' clinical, biological and radiological data. We included eight patients with a computed tomography scan diagnosis of adrenal necrosis and fifteen articles in the literature describing twenty-four cases. All the patients presented with the same symptoms. The treatment was based on curative anticoagulation. The diagnosis of adrenal gland necrosis is worth suggesting in view of the array of sudden morphine-resistant abdominal pain associated with a biological inflammatory syndrome. The diagnosis is based on the computed tomography scan. Three to six months of curative anticoagulation is recommended as well as a thrombophilia and endocrinological assessment to rule out adrenal insufficiency.
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Affiliation(s)
- Mathilde Guyon
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Manon Degez
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Mathieu Artifoni
- Department of Internal Medicine, Nantes University Hospital, 44000 Nantes, France;
| | - Thomas Goronflot
- Data Clinic, National Institute for Health and Medical Research, Nantes University Hospital, 44000 Nantes, France;
| | - Emilie Misbert
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Vincent Dochez
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
| | - Norbert Winer
- Department of Gynecology-Obstetrics, Nantes University Hospital, 44000 Nantes, France (V.D.); (N.W.)
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12
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Malikova I, Husakova M, Bilkova J, Brzezkova R, Kvasnicka T. Thrombin Decrease in Thrombin Generation after Heparin Administration in a Homozygous Type II Heparin Binding Site Antithrombin-Deficient Pregnant Woman. Med Princ Pract 2023; 32:1. [PMID: 37703851 PMCID: PMC10659590 DOI: 10.1159/000533801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023] Open
Abstract
OBJECTIVES There is a major problem in providing prophylactic treatment in antithrombin (AT)-deficient pregnant women with a homozygous mutation of the heparin binding site (HBS) and AT level of 17 %. The aim of the study was to determine the effectiveness of heparin by monitoring changes in thrombin generation (TG) in vitro so that pregnant women are not exposed to stress in vivo. METHODS We used the chromogenic method for determination of factor Xa (FXa) inhibition for enoxaparine, nadroparine, dalteparine, fondaparinux and unfractionated heparin (UFH) and the Thrombin Generation Assay (TGA). RESULTS We found that the degree of inhibition is very different when different heparins are compared. Nadroparin reduces TG the most compared to low molecular weight heparins (LMWH). CONCLUSION Routine monitoring of anti FXa activity should be supplemented with TG monitoring, where the effect of LMWH does not manifest itself as this could help in estimating thrombophilic risk during pregnancy.
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Bannow BS, Konkle BA. How I approach bleeding in hospitalized patients. Blood 2023; 142:761-768. [PMID: 36652635 PMCID: PMC10562531 DOI: 10.1182/blood.2021014766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/20/2023] Open
Abstract
Excessive bleeding is relatively common in adult inpatients, whether as the primary reason for admission or as a development during the hospital stay. Common causes include structural issues, medication effects, and systemic illnesses; occasionally, unexpected bleeding can develop as a result of an undiagnosed or newly acquired bleeding disorder. The first step in caring for the inpatient who is bleeding is to determine whether the bleeding symptom is truly new or whether the patient has a history of abnormal bleeding. Patients with a history of abnormal bleeding may warrant evaluation for inherited bleeding disorders, such as platelet function disorders, von Willebrand disease, hemophilia, or rare factor deficiencies. Patients with no history of bleeding, for whom other causes, such as liver dysfunction, medication effect, disseminated intravascular coagulation, or certain vitamin deficiencies have been ruled out may require evaluation for acquired coagulopathies, such as acquired hemophilia or acquired von Willebrand disease. Here, we present 3 cases to discuss the diagnosis and management of the 2 most common acquired bleeding disorders as well as a patient with a congenital bleeding disorder with a historical diagnosis.
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Affiliation(s)
- Bethany Samuelson Bannow
- Division of Hematology/Medical Oncology, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Barbara A Konkle
- Division of Hematology, Department of Medicine, Washington Center for Bleeding Disorders, University of Washington, Seattle, WA
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14
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Okada M, Nomura T, Kunihiro Y, Takegami K, Uehara T, Tokurei S. Lung iodine mapping images of acute postpartum dyspnea without pulmonary thromboembolism using dual-energy CT. Acta Radiol 2023; 64:2401-2408. [PMID: 37203191 DOI: 10.1177/02841851231174460] [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: 05/20/2023]
Abstract
BACKGROUND Postpartum dyspnea is commonly observed, but its cause is often unknown. PURPOSE To investigate postpartum dyspnea, we compared lung iodine mapping (LIM) using dual-energy computed tomography (DECT) between postpartum women and women suspected of having pulmonary thromboembolism (PTE). MATERIAL AND METHODS In this retrospective study, 109 women of reproductive age (50 postpartum women, 59 women unrelated to pregnancy) underwent DECT between March 2009 and August 2020. Among the postpartum women, 23 patients were excluded due to late-onset dyspnea (n=20: >48 h after delivery) or the presence of PTE (n=3). A total of 86 patients were divided into three groups (27 postpartum women [postpartum group], 19 women with PTE [PTE group], and 40 women without PTE [non-PTE group]). Quantitation was applied to a decreased LIM value (LIM5; defined as <5 HU) and the relative value of LIM5 to whole LIM volume (%LIM5). LIM defects were classified into five patterns (0 = none, 1 = wedge-shaped, 2 = reticular/liner, 3 = diffuse granular/patchy, 4 = massive defects) based on a consensus between two readers. RESULTS There were significant differences in the LIM5 and %LIM5 values among the three groups. The LIM5 and %LIM5 were largest in the PTE group, and postpartum women showed intermediate values between the non-PTE and PTE groups. Wedge-shaped defects were prominent in the PTE group, and diffuse granular/patchy defect was a typical feature in the postpartum group. CONCLUSION Postpartum women with dyspnea showed granular/patchy defects on DECT with a median quantitative value between the PTE and non-PTE groups.
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Affiliation(s)
- Munemasa Okada
- Department of Radiology, National Hospital Organization, Kanmon Medical Center, Shimonoseki, Japan
| | - Takafumi Nomura
- Department of Radiology, Ube-Kohsan Central Hospital, Ube, Japan
| | - Yoshie Kunihiro
- Department of Radiology, Yamaguchi University School of Medicine, Ube, Japan
| | - Kazuki Takegami
- Department of Radiology, Yamaguchi University Hospital, Ube, Japan
| | - Takuya Uehara
- Department of Radiology, Yamaguchi University Hospital, Ube, Japan
| | - Shogo Tokurei
- Department of Radiological Science, Faculty of Health Sciences, Junshin Gakuen University, Fukuoka, Japan
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15
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Ubom EO, Wang C, Klocksieben F, Flicker AB, Diven L, Rochon M, Quiñones JN. Enhanced recovery protocol after cesarean delivery: impact on opioid use and pain perception. AJOG GLOBAL REPORTS 2023; 3:100220. [PMID: 37645650 PMCID: PMC10461238 DOI: 10.1016/j.xagr.2023.100220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Opioids are routinely prescribed to patients postoperatively after cesarean delivery. With rates of cesarean deliveries increasing globally and the opioid epidemic continuing to have deleterious effects, finding methods to achieve effective pain control without opioids is of increasing importance. The ERAS (Enhanced Recovery After Surgery) protocol applied following cesarean delivery engages multimodal perioperative management techniques to encourage early recovery. In the obstetrical surgery setting, these interventions include increasing scheduled nonsteroidal anti-inflammatory drug administration and laxative use to improve postoperative gastrointestinal motility and pain scores. Postcesarean patients are also encouraged to use abdominal binders, incentive spirometry, and early movement as pain modulators. OBJECTIVE This quality improvement study aimed to measure whether the introduction of an ERAS protocol following cesarean delivery at a United States-based health network would improve outcomes such as the use of opioid medications for pain and pain control. STUDY DESIGN This single-center retrospective cohort study compared patients who gave birth via cesarean delivery before (n=1425) and after (n=3478) the implementation of the postsurgical recovery protocol. Outcomes of interest included total postoperative opioid medications used, discharge opioid prescription, average pain score, pain scores by postoperative day, and highest pain score. Patients with a history of opioid use disorder, those who underwent a cesarean hysterectomy, and those who experienced a major surgical complication at delivery were excluded. Data were collected from the electronic medical record. RESULTS Patients in the postimplementation period used significantly fewer opioid medications than those who gave birth before the protocol was introduced at the institution. The total median opioid use before implementation was 75 morphine milligram equivalents (interquartile range, 45-112.5) vs 30 (interquartile range, 15-52.5) after implementation (P<.001). The median discharge prescription was 225 (interquartile range, 150-225) before implementation vs 112.5 (interquartile range, 75-150) after implementation (P<.001). Pain scores were also significantly lower after implementation. The median highest pain score was 8 (interquartile range, 6-8) on a 10-point pain scale before implementation vs 7 (interquartile range, 6-8) after implementation (P<.001). The average pain score before implementation was 3.4 (interquartile range, 2.4-4.5) vs 2.9 (interquartile range, 1.9-3.9) after implementation (P<.001). Results of paired-sample analyses of 177 patients who gave birth by cesarean delivery in both time periods showed statistically significant outcomes similar to those of the larger cohort groups. CONCLUSION Implementation of multimodal pain regimens following cesarean delivery, such as the ERAS protocol, which incorporate both pharmacologic (nonsteroidal anti-inflammatory drugs, laxatives) and nonpharmacologic methods (abdominal binders, deep breathing, movement) can be effective for pain control and may decrease postoperative opioid prescribing needs, thus mitigating the potential for opioid misuse and dependence.
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Affiliation(s)
- Ememobong O. Ubom
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA (Drs Ubom, Flicker, and Diven)
| | - Carrie Wang
- University of South Florida Morsani College of Medicine, University of South Florida, Tampa, FL (Mses Wang and Klocksieben)
| | - Farina Klocksieben
- University of South Florida Morsani College of Medicine, University of South Florida, Tampa, FL (Mses Wang and Klocksieben)
| | - Amanda B. Flicker
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA (Drs Ubom, Flicker, and Diven)
| | - Liany Diven
- Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA (Drs Ubom, Flicker, and Diven)
| | - Meredith Rochon
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA (Drs Rochon and Quiñones)
| | - Joanne N. Quiñones
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA (Drs Rochon and Quiñones)
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16
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Varrias D, Spanos M, Kokkinidis DG, Zoumpourlis P, Kalaitzopoulos DR. Venous Thromboembolism in Pregnancy: Challenges and Solutions. Vasc Health Risk Manag 2023; 19:469-484. [PMID: 37492280 PMCID: PMC10364824 DOI: 10.2147/vhrm.s404537] [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: 06/02/2023] [Accepted: 07/13/2023] [Indexed: 07/27/2023] Open
Abstract
Venous thromboembolism (VTE) is a serious medical condition that can lead to severe morbidity and mortality, making it a significant public health concern. VTE is a multifactorial condition that results from the interaction of genetic, acquired, and environmental factors. Physiological changes during pregnancy increase the risk of VTE as they express Virchow's triad (increased coagulation factors, decreased fibrinolysis, trauma, and venous stasis). Moreover, pregnancy-related risk factors, such as advanced maternal age, obesity, multiple gestations, and cesarean delivery, further increase the risk of VTE. Managing VTE in pregnancy is challenging due to the complexity of balancing the risks and benefits of anticoagulant therapy for both the mother and the fetus. A multidisciplinary approach involving obstetricians, hematologists, and neonatologists, is necessary to ensure optimal outcomes for both the mother and baby. This review aims to discuss the current challenges associated with VTE in pregnancy and identify potential solutions for improving outcomes for pregnant women at risk for VTE.
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Affiliation(s)
- Dimitrios Varrias
- Department of Medicine, Jacobi Medical Center, Bronx, NY, 10461, USA
- Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Michail Spanos
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Panagiotis Zoumpourlis
- Department of Medicine, Jacobi Medical Center, Bronx, NY, 10461, USA
- Albert Einstein College of Medicine, Bronx, NY, 10461, USA
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17
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Warren BB, Moyer GC, Manco-Johnson MJ. Hemostasis in the Pregnant Woman, the Placenta, the Fetus, and the Newborn Infant. Semin Thromb Hemost 2023; 49:319-329. [PMID: 36750218 DOI: 10.1055/s-0042-1760332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The hemostasis system is composed of procoagulant, anticoagulant, and fibrinolytic proteins that interact with endothelial and blood cells and with each other in a complex system of checks and balances to maintain blood flow while preventing both hemorrhage and thrombosis. Pregnancy is a unique physiological state in which biological alterations predispose both mother and fetus to both bleeding and clotting. The placenta is a vascular interface for maternal and fetal blood exchange which predisposes the mother to hemorrhage. Maternal hemostasis presents a compensatory hypercoagulability including elevated factor VIII, von Willebrand factor, fibrinogen and thrombin generation, decreased thrombin regulation with resistance to activated protein C and decreased free protein S, and decreased fibrinolysis with increased plasminogen activator inhibitors. The placental vascular surface is of fetal trophoblastic origin that derives many characteristics of endothelium but differs in that tissue factor is constitutively expressed. Ontogeny of fetal hemostasis is characteristic. Platelets, von Willebrand factor, factor VIII, and fibrinogen are expressed and mature early in gestation, while vitamin K-dependent and contact factors exhibit delayed development. The fetal hemostatic system has a decreased capacity to generate or regulate thrombin, resulting in a fragile balance with little capacity to compensate under stress conditions, particularly in the infant born prematurely. Dysfunction of the maternal/placental/fetal unit gives rise to gestational disorders including preeclampsia, fetal growth restriction, placental abruption, and premature delivery. Knowledge of normal hemostasis levels and function are critical to evaluate bleeding or clotting syndromes in the pregnant woman and her fetus or newborn infant.
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Affiliation(s)
- Beth Boulden Warren
- University of Colorado Hemophilia and Thrombosis Center, Aurora, Colorado
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | - Genevieve C Moyer
- University of Colorado Hemophilia and Thrombosis Center, Aurora, Colorado
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
| | - Marilyn J Manco-Johnson
- University of Colorado Hemophilia and Thrombosis Center, Aurora, Colorado
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children's Hospital Colorado, Aurora, Colorado
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18
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Lopez CE, Salloum J, Varon AJ, Toledo P, Dudaryk R. The Management of Pregnant Trauma Patients: A Narrative Review. Anesth Analg 2023; 136:830-840. [PMID: 37058718 DOI: 10.1213/ane.0000000000006363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Trauma is the leading nonobstetric cause of maternal death and affects 1 in 12 pregnancies in the United States. Adhering to the fundamentals of the advanced trauma life support (ATLS) framework is the most important component of care in this patient population. Understanding the significant physiologic changes of pregnancy, especially with regard to the respiratory, cardiovascular, and hematologic systems, will aid in airway, breathing, and circulation components of resuscitation. In addition to trauma resuscitation, pregnant patients should undergo left uterine displacement, insertion of 2 large bore intravenous lines placed above the level of the diaphragm, careful airway management factoring in physiologic changes of pregnancy, and resuscitation with a balanced ratio of blood products. Early notification of obstetric providers, initiation of secondary assessment for obstetric complications, and fetal assessment should be undertaken as soon as possible but without interference to maternal trauma assessment and management. In general, viable fetuses are monitored by continuous fetal heart rate for at least 4 hours or more if abnormalities are detected. Moreover, fetal distress may be an early sign of maternal deterioration. When indicated, imaging studies should not be limited out of fear for fetal radiation exposure. Resuscitative hysterotomy should be considered in patients approaching 22 to 24 weeks of gestation, who arrive in cardiac arrest or present with profound hemodynamic instability due to hypovolemic shock.
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Affiliation(s)
- Carmen E Lopez
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joe Salloum
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Albert J Varon
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Paloma Toledo
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
| | - Roman Dudaryk
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, Miami, Florida
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19
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Nguyen KP, Aqui TLB, Milestone H. Factor VII Deficiency and Second Trimester Abortion: A Case Report. Cureus 2023; 15:e37039. [PMID: 37143638 PMCID: PMC10153760 DOI: 10.7759/cureus.37039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2023] [Indexed: 04/04/2023] Open
Abstract
The prevalence of factor VII deficiency (F7D) is 1 in 500,000. Due to its rarity, the management of bleeding disorders in pregnancy is not well established. We examine a case of an 18-year-old (gravida 1, para 0) woman at approximately 19 weeks gestation with a known history of F7D who presents after a motor vehicle accident. Fetal demise was confirmed necessitating a medical induction. She also had multiple fractures requiring surgical intervention. A multidisciplinary team consisting of orthopedic surgery, obstetrics and gynecology, and hematology/oncology was consulted for optimal timing of factor VII replacement prior to procedures. The patient underwent successful left tibial intramedullary nailing with minimal bleeding. She received factor VII and tolerated an uncomplicated vaginal delivery. Her postpartum and postoperative courses were uncomplicated, requiring one unit of packed red blood cells. The patient was discharged on postpartum day three. Management of this second-trimester abortion with a history of F7D was possible with effective communication and the organization of a multidisciplinary team to account for the risk of thrombosis versus hemorrhage and the availability of factor VII replacement therapy.
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20
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Hilali C, Aboulaghras S, Lamalmi N. Pathophysiological, immunogenetic, anatomopathological profile of thrombophilia in pregnancy. Transfus Clin Biol 2023:S1246-7820(23)00043-5. [PMID: 37028589 DOI: 10.1016/j.tracli.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/24/2023] [Accepted: 03/31/2023] [Indexed: 04/08/2023]
Abstract
Thrombophilic states have been associated with early and/or late pregnancy loss and possibly other severe obstetrical complications. Pregnancy-induced hypercoagulability, increased stasis, and the consequences of inherited and acquired thrombophilia are just a few of the factors that contribute to the development of thrombosis in pregnancy. In this review, we illustrate the impact that these factors have on the development of thrombophilia during pregnancy. We also explore how thrombophilia impact pregnancy outcomes. Next, we discuss how human leukocyte antigen G plays a part in thrombophilia during pregnancy by regulating cytokine release to prevent trophoblastic cell invasion and maintain local immunotolerance constant. Human leukocyte antigen class E is briefly explored with thrombophilia in pregnancy. Regarding the anatomopathologic aspect, we describe the different histopathological lesions of the placenta found in women with thrombophilia.
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21
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Chen J, Huai J, Lin L, Li B, Zhu Y, Yang H. Low-dose aspirin in the prevention of pre-eclampsia in China: postpartum hemorrhage in subgroups of women according to their characteristics and potential bleeding risk. Chin Med J (Engl) 2023; 136:550-555. [PMID: 36914957 PMCID: PMC10106256 DOI: 10.1097/cm9.0000000000002545] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND The APPEC study is a large-population randomized controlled trial in China evaluating the role of low-dose aspirin prophylactic treatment for pre-eclampsia. There was no statistically significant difference in postpartum hemorrhage (PPH) incidence between the aspirin and control groups. This study aimed to evaluate the potential bleeding risk of 100 mg aspirin in high-risk pregnant women and the difference in the incidence of PPH according to maternal characteristics. METHODS This is a secondary data analysis of the APPEC study. Platelet counts and coagulation test results were collected at five follow-up visits. Subgroups defined by maternal age (<35 years and ≥35 years), pre-pregnancy body mass index (pre-BMI, <28 kg/m 2 and ≥28 kg/m 2 ), parity, gestational age at enrollment, and medical history, including pre-eclampsia, chronic hypertension, and diabetes mellitus, were analyzed. Logistic regression analysis was used to determine the statistical significance of the difference in the incidence of PPH after aspirin administration in pregnant women in each subgroup. Adjustment using multiple logistic regression models followed these analyses. Binary logistic regression was used to determine the relationship between pre-BMI and PPH. RESULTS There was no significant difference between the aspirin and control groups in bleeding risk (3.4% [16/464] vs. 3.0% [13/434], T = 0.147, P = 0.701). No significant difference was found in the incidence of PPH in total (relative risk = 1.220, 95% confidence interval [CI] = 0.720-2.067, P = 0.459; aspirin group vs. control group, 6.5% [30/464] vs. 5.3% [23/434], P = 0.459) or in subgroup analysis. A significant correlation between pre-BMI and PPH was found in the aspirin group, while in the control group there was no significant correlation (aspirin group, odds ratio [OR] = 1.086, 95% CI = 1.004-1.175, P = 0.040; control group, OR = 1.060, 95% CI = 0.968-1.161, P = 0.209). CONCLUSIONS A dosage of 100 mg of aspirin per day, initiated from 12 to 20 gestational weeks until 34 weeks of gestation, did not increase the risk of potential bleeding and PPH regardless of the maternal characteristic. In the aspirin group, the positive correlation between BMI and PPH was significant. TRIAL REGISTRATION ClinicalTrials.gov, NCT01979627.
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Affiliation(s)
- Jiahui Chen
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing 100034, China
| | - Jing Huai
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing 100034, China
| | - Li Lin
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing 100034, China
| | - Boya Li
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing 100034, China
| | - Yuchun Zhu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing 100034, China
| | - Huixia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
- Beijing Key Laboratory of Maternal Fetal Medicine of Gestational Diabetes Mellitus, Beijing 100034, China
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22
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Ram S, Ram HS, Neuhof B, Shperling RB, Chodick G, Yogev Y. Venous thromboembolism during pregnancy: Trends, incidence, and risk patterns in a large cohort population. Int J Gynaecol Obstet 2023; 160:962-968. [PMID: 35979847 DOI: 10.1002/ijgo.14414] [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: 05/27/2022] [Revised: 07/25/2022] [Accepted: 08/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the incidence and risk factors for pregnancy-associated venous thromboembolism (VTE). METHODS An observational retrospective study was conducted using data from 452 176 live births between the years 2010 and 2019. The study group consisted of women who were diagnosed with VTE during pregnancy or the postpartum period. The exclusion criteria included women who purchased anticoagulant drugs during pregnancy or postpartum. The hazard ratios (HRs) of VTE per week of each trimester and the postpartum period were calculated. RESULTS A total of 421 125 live births were included in the study. Among the study population, 302 cases (0.71 cases/1000 pregnancies) were diagnosed with VTE during pregnancy and postpartum. The overall rates of diagnosis did not change significantly during the study period but followed a declining trend in the postpartum period. The highest risk of VTE was found to be during the third trimester (HR 0.002% per week, 95% confidence interval [CI] 0.0016-0.0023), while the lowest rate was during the postpartum period (HR 0.0007% per week, 95% CI 0.0004-0.0011). CONCLUSION Pregnancy and the puerperium are well-established risk factors for VTE. The present study demonstrates a declining trend in the risk and incidence of VTE during the postpartum period, which can be explained by a liberal and effective VTE prevention policy.
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Affiliation(s)
- Shai Ram
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hila S Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | - Bitya Neuhof
- Hebrew University of Jerusalem, Department of statistics and data science
| | - Roza B Shperling
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Chodick
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Maccabi Healthcare Services, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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23
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Abstract
This article explores current recommendations for anticoagulation therapy in pregnancy, including antepartum, intrapartum, and postpartum guidelines. The authors review various screening strategies used to assess whether a patient is an appropriate candidate for anticoagulation during pregnancy and the postpartum period. The article includes dosing regimens, optimal surveillance, and medication reversal. The authors also address the challenges of transitioning between low-molecular-weight heparin and unfractionated heparin. Finally, there is a discussion of intrapartum anticoagulation management, especially as it relates to the administration of regional anesthesia, and the indications for and timing of thromboprophylaxis following delivery.
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Affiliation(s)
- Antonio Saad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77555, USA.
| | - Melody Safarzadeh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77555, USA
| | - Megan Shepherd
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77555, USA
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24
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Wang J, Qian MF, Jeng MR, Teng JMC. Assessment of Hormonal Contraceptive Utilization and Associated Odds of Hypercoagulopathy in Patients with Venous Malformations Using a National Claims Database. Clin Drug Investig 2023; 43:141-145. [PMID: 36626046 DOI: 10.1007/s40261-022-01228-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Vascular anomalies that exhibit a slow velocity of blood flow, specifically venous malformations (VM), are associated with hypercoagulability. There is limited literature on the utilization of hormonal contraceptives (HCs) and the development of clotting events in female individuals diagnosed with VM. OBJECTIVE We aimed to characterize HC utilization and associated odds of hypercoagulopathy in patients with VM of child-bearing age. METHODS Using a national administrative claims database, we identified female patients with VM aged 15-49 years and a control population, matched for age and length of insurance enrollment, from 2016 to 2021. Multivariable logistic regression was used to estimate the odds of hypercoagulation events associated with HC use. RESULTS Two hundred and sixty-seven (47.2%) patients with VM and 1284 (45.4%) control patients utilized HCs during the study period. Oral contraceptives were the most common HC for patients with and without VM (73.8% and 76.9% of those taking HCs, respectively), and estrogen-containing combination HCs (70.4% in patients with VM and 75.9% in controls) were more prevalent than progestin-only HCs in both populations. Despite a heightened baseline odds of hypercoagulopathy in patients with VM relative to patients without VM (odds ratio = 12.54; 95% confidence interval 7.73-20.3), HC use was not associated with an increased odds of hypercoagulation in the VM subpopulation (odds ratio = 0.82; 95% confidence interval 0.46-1.46). In contrast, tobacco use (odds ratio = 2.12; 95% confidence interval 1.09-4.12) and a history of coagulopathy (odds ratio = 3.92; 95% confidence interval 1.48-10.36) were predictive of thromboembolic events in the VM cohort. CONCLUSIONS These findings suggest that patients with VM may safely use HCs with careful consideration of other risk factors for thromboses.
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Affiliation(s)
- Jami Wang
- Western University of Health Sciences, Pomona, CA, USA
| | - Mollie F Qian
- Stanford University School of Medicine, Stanford, CA, USA
| | - Michael R Jeng
- Department of Pediatrics-Hematology/Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Joyce M C Teng
- Department of Dermatology, Stanford University School of Medicine, 700 Welch Road, 3rd Floor, Suite 301 MC 5896, Palo Alto, CA, 94304-5896, USA.
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Abstract
Postpartum haemorrhage (PPH) remains the leading cause of pregnancy-related deaths worldwide. Typically, bleeding is controlled by timely obstetric measures in parallel with resuscitation and treatment of coagulopathy. Early recognition of abnormal coagulation is crucial and haemostatic support should be considered simultaneously with other strategies as coagulopathies contribute to the progression to massive haemorrhage. However, there is lack of agreement on important topics in the current guidelines for management of PPH. A clinical definition of PPH is paramount to understand the situation to which the treatment recommendations relate; however, reaching a consensus has previously proven difficult. Traditional definitions are based on volume of blood loss, which is difficult to monitor, can be misleading and leads to treatment delay. A multidisciplinary approach to define PPH considering vital signs, clinical symptoms, coagulation and haemodynamic changes is needed. Moreover, standardised algorithms or massive haemorrhage protocols should be developed to reduce the risk of morbidity and mortality and improve overall clinical outcomes in PPH. If available, point-of-care testing should be used to guide goal-directed haemostatic treatment. Tranexamic acid should be administered as soon as abnormal bleeding is recognised. Fibrinogen concentrate rather than fresh frozen plasma should be administered to restore haemostasis where there is elevated risk of fibrinogen deficiency (e.g., in catastrophic bleeding or in cases of abruption or amniotic fluid embolism) as it is a more concentrated source of fibrinogen. Lastly, organisational considerations are equally as important as clinical interventions in the management of PPH and have the potential to improve patient outcomes.
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Andersen MK, Rüdiger IH, Vestergaard AL, Palarasah Y, Bor P, Larsen A, Bor MV. Vitamin D Deficiency is Associated With Increased Plasminogen Activator Inhibitor 1/Plasminogen Activator Inhibitor 2 Ratio in Pregnancy. Clin Appl Thromb Hemost 2023; 29:10760296231201855. [PMID: 37722759 PMCID: PMC10510367 DOI: 10.1177/10760296231201855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/18/2023] [Accepted: 08/30/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Vitamin D deficiency has recently been suggested as an independent risk factor for thrombosis. Notably, vitamin D deficiency is common in pregnant populations, whom already have an increased thrombotic risk. However, pregnant women are commonly excluded from studies investigating the hemostatic system, and knowledge on the impact of vitamin D on hemostasis in pregnancy is therefore limited. METHODS A cross-sectional study comparing the hemostatic profile of pregnant women (gestational week 12.9 ± 0.7) with vitamin D deficiency (≤50 nmol/L) (n = 70) and high adequate vitamin D status (≥100 nmol/L) (n = 59). RESULTS Vitamin D deficient women displayed increased plasminogen activator inhibitor 1 levels and an increased plasminogen activator inhibitor 1/plasminogen activator inhibitor 2 ratio, even after adjusting for factors with potential influence on hemostasis (body mass index, smoking and use of fish oil supplements). CONCLUSIONS Vitamin D deficiency is associated with increased plasminogen activator inhibitor 1/plasminogen activator inhibitor 2 ratio in pregnant women. As an increased plasminogen activator inhibitor 1/plasminogen activator inhibitor 2 ratio with high plasminogen activator inhibitor 1 levels may increase thrombotic risk and is associated with the development of pregnancy complications, further research is needed to determine the optimal vitamin D supplementation in pregnancy.
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Affiliation(s)
- Matilde Kanstrup Andersen
- Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Anna Louise Vestergaard
- Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Yaseelan Palarasah
- Department of Molecular Medicine, Research Unit for Cancer and Inflammation, University of Southern Denmark, Odense, Denmark
| | - Pinar Bor
- Department of Obstetrics and Gynecology, Randers Regional Hospital, Randers, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Agnete Larsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Mustafa Vakur Bor
- Department of Regional Health Research, Thrombosis Research, University of Southern Denmark, Esbjerg, Denmark
- Department of Clinical Biochemistry, University Hospital of Southern Denmark, Esbjerg, Denmark
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Outcomes in Pregnant Women with Valvular Heart Disease from Portuguese-Speaking African Countries Treated in Portugal through an International Agreement of Health Cooperation. Glob Heart 2023; 18:4. [PMID: 36817227 PMCID: PMC9936910 DOI: 10.5334/gh.1183] [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: 07/10/2022] [Accepted: 01/12/2023] [Indexed: 02/15/2023] Open
Abstract
Aims We performed a clinical audit of maternal and fetal outcomes in pregnant women with valvular heart disease (VHD) from Portuguese-speaking African countries who were transferred for their care, during a twenty-year period, through a memorandum of agreement of international cooperation. Methods and results A retrospective analysis of 81 pregnancies in 45 patients with VHD (median age 24, interquartile range 22-29 years) from 2000 to 2020 was performed. The main outcome measures were maternal cardiovascular and fetal outcomes. History of rheumatic heart disease was present in 60 (74.1%) pregnancies. Most were in New York Heart Association (NYHA) functional class I or II; at the first evaluation, 35 (43.2%) were on cardiac medication and 49 (60.5%) were anticoagulated. Forty-eight pregnancies had at least one valvular prosthesis, including 38 mechanical heart valves. During pregnancy, deterioration in NYHA functional class occurred in 35 (42.0%), and eight (9.9%) patients required initiation or intensified cardiac medication. Mechanical valve thrombosis complicated four (4.9%) pregnancies, all cases on heparin, and resulted in one maternal death. Haemorrhagic complications happened in 7 (8.6%) anticoagulated patients, in the immediate postpartum or puerperal period. The 81 pregnancies resulted in 56 (69.1%) live births, while miscarriage and fetal malformations occurred in 19 (23.5%) and 12 (14.8%) pregnancies, respectively. In multivariate analysis, vitamin K antagonist therapy was the only independent predictor of an unsuccessful pregnancy (p = 0.048). Conclusion In a high-income country, successful pregnancy was possible with low rate of maternal events in women with VHD transferred from five low-middle income countries in Africa. The use of anticoagulation with a vitamin K antagonist was associated with an unsuccessful pregnancy.
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Malikova I, Husakova M, Bilkova J, Brzezkova R, Hrachovinova I, Kvasnicka T. Thrombin Generation Decrease After LMWH Administration in an Antithrombin-Deficient Pregnant Woman With a Homozygous HBS II Mutation. Clin Appl Thromb Hemost 2023; 29:10760296231197174. [PMID: 37670493 PMCID: PMC10483976 DOI: 10.1177/10760296231197174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/04/2023] [Accepted: 08/08/2023] [Indexed: 09/07/2023] Open
Abstract
The cases of antithrombin (AT)-deficient pregnant women with a homozygous HBS II mutation are relatively rare and are accompanied by an increased thrombophilic risk, which is manifested by increased thrombin generation (TG). It is very difficult to ensure their prophylactic treatment during pregnancy. We aimed to determine the utility of the thrombin generation assay (TGA) and anti-factor Xa (anti-FXa) test to monitor the effects of a prophylactic dose of low-molecular-weight heparin (LMWH) in a 28-year-old woman with homozygous AT deficiency caused by mutation c.391C > T#, (p.Leu131Phe†) in the SERPINC1 gene and to compare the findings with those from a group of pregnant and non-pregnant women also treated with LMWH. TG monitoring was chosen due to severe AT deficiency that was manifested by low levels of anti-FXa activity when monitoring the efficacy of LMWH treatment. A significant decrease in TG was detected in all monitored groups (P < .05). There were no thrombotic complications during the whole pregnancy of the woman with AT deficiency. Consistent monitoring of TG with LMWH anticoagulant therapy administration during pregnancy together with AT administration before and after delivery may improve the overall condition of pregnant women and the quality of their care.
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Affiliation(s)
- Ivana Malikova
- Central Hematological Laboratory, General University Hospital and Charles University First Faculty of Medicine, Prague, Czech Republic
| | - Martina Husakova
- Central Hematological Laboratory, General University Hospital and Charles University First Faculty of Medicine, Prague, Czech Republic
| | - Jana Bilkova
- Thrombotic Centre of Institute of Medical Biochemistry and Laboratory Diagnostics, General University Hospital and Charles University First Faculty of Medicine, Prague, Czech Republic
| | - Radka Brzezkova
- Thrombotic Centre of Institute of Medical Biochemistry and Laboratory Diagnostics, General University Hospital and Charles University First Faculty of Medicine, Prague, Czech Republic
| | | | - Tomas Kvasnicka
- Thrombotic Centre of Institute of Medical Biochemistry and Laboratory Diagnostics, General University Hospital and Charles University First Faculty of Medicine, Prague, Czech Republic
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Ram S, Shalev-Ram H, Neuhof B, Shlezinger R, Shalev-Rosental Y, Chodick G, Yogev Y. Air travel during pregnancy and the risk of venous thrombosis. Am J Obstet Gynecol MFM 2023; 5:100751. [PMID: 36115570 DOI: 10.1016/j.ajogmf.2022.100751] [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: 07/06/2022] [Revised: 09/06/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pregnancy and air travel independently increase the risk of venous thrombosis. However, there is a lack of data regarding the added risk, if at all, of thrombosis after air travel during pregnancy. OBJECTIVE This study aimed to determine the potential added risk of venous thromboembolism among pregnant women who traveled by air. STUDY DESIGN This was an observational retrospective study using data from 452,663 live births between the years 2010 to 2019. The study group consisted of women who flew during pregnancy. Data of pregnant women who flew during pregnancy were compared with that of pregnant women who did not fly during pregnancy. The primary outcome was venous thromboembolism during pregnancy and in the postpartum period. A case of venous thromboembolism was deemed related to air travel only if it occurred up to 8 weeks after the return flight (exposure time). Propensity score weighting Poisson regression was calculated to assess the effect and to control selection biases. Risk per day was calculated. RESULTS Overall, 421,125 live births were included. Of those cases, 33,674 (8%) had traveled by air during pregnancy (study group), and 387,451 (92%) did not (control group). There were 6 cases of venous thromboembolism after a flight that occurred during the exposure time of 8 weeks and 285 cases of venous thromboembolism in the control group (0.05% vs 0.07%; P=.158). When the propensity weighting Poisson regression was calculated as risk per day, there was a significantly increased risk between the study and control groups (0.00031% vs 0.00022%; hazard ratio, 1.406; P=.005). CONCLUSION The overall risk of venous thromboembolism after air travel is low; however, our study found that the risk of venous thromboembolism during pregnancy is increased by air traveling.
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Affiliation(s)
- Shai Ram
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel (Drs Ram and Yogev); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Ram, Shalev-Ram, Shalev-Rosenthal, Chodick, and Yogev).
| | - Hila Shalev-Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Ram, Shalev-Ram, Shalev-Rosenthal, Chodick, and Yogev); Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel (Dr Shalev-Ram)
| | - Bitya Neuhof
- Department of Statistics and Data Science, Hebrew University of Jerusalem, Jerusalem, Israel (Ms Neuhof and Ms Shlezinger)
| | - Roei Shlezinger
- Department of Statistics and Data Science, Hebrew University of Jerusalem, Jerusalem, Israel (Ms Neuhof and Ms Shlezinger)
| | - Yael Shalev-Rosental
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Ram, Shalev-Ram, Shalev-Rosenthal, Chodick, and Yogev)
| | - Gabriel Chodick
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Ram, Shalev-Ram, Shalev-Rosenthal, Chodick, and Yogev); Maccabi Healthcare Services, Tel Aviv, Israel (Dr Chodick)
| | - Yariv Yogev
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel (Drs Ram and Yogev); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Ram, Shalev-Ram, Shalev-Rosenthal, Chodick, and Yogev)
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Thrombophilia and Pregnancy. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2022. [DOI: 10.2478/sjecr-2020-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Leading cause of death in pregnant women still remains venous thromboembolism, with an incidence of 1.4 to 4.9 per 100,000 pregnancies. A special group of inherited and acquired coagulation disorders associated with a susceptibility to thrombosis is thrombophilia. Physiological changes during the pregnancy also contribute to the occurrence thromboembolic diseases (VTE) in pregnancy. Total rate of venous thromboembolism is 100 per 100,000 pregnancies and 200 per 100,000 births. Etiopathogenesis of obstetric complications in thrombophilia is not clearly defined, which is one of the reasons for the occasional failure of therapy. In pregnancies with hereditary thrombophilia the oxidative stress is considered to be a cause of complications, similar to preeclampsia. Based on the findings so far, additional research should clarify questions regarding the anticoagulants role in pregnancy loss prevention. In this paper, we analyze the effect of the screening on pregnancy outcomes, consider the justification for the use of anticoagulation therapy in difficult situations, discuss about previous knowledge in the field and argue the use of new specific protocols. In short, we address the justification for prescribing anticoagulants and evaluation of their effect within thrombophilia therapeutic strategies.
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Hemostasis System and Plasminogen Activity in Retrochorial Hematoma in the First Trimester of Pregnancy. Biomedicines 2022; 10:biomedicines10092284. [PMID: 36140384 PMCID: PMC9496394 DOI: 10.3390/biomedicines10092284] [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: 07/06/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022] Open
Abstract
(1) Background: The components of the fibrinolytic system and its main component, plasminogen, play a key role in the first months of pregnancy. The effect of autoantibodies interacting with plasminogen in the formation of retrochorial hematoma is unknown. The aim of our study was to determine the role of plasminogen and IgA, IgM, and IgG, which bind to plasminogen, in retrochorial hematoma. (2) Methods: Prothrombin time (PT), thrombin time (TT), partial activated thromboplastin time (aPTT), soluble fibrin-monomer complex (SFMC), D-dimer, plasminogen activity (%Plg), plasminogen concentration (Plg), and the levels of IgG (IgG-Plg), IgM (IgM-Plg), IgA (IgA-Plg) interacting with plasminogen were determined in plasma samples of 57 women with normal pregnancy and 16 with retrochorial hematoma. (3) Results: %Plg in plasma samples from women with retrochorial hematoma was significantly lower than in plasma samples from women with normal pregnancy. The diagnostic significance of %Plg in the ROC analysis was AUC = 0.85. A direct correlation was found between aPTT and the level of autologous IgM interacting with plasminogen. (4) Conclusions: A decrease in the activity of plasminogen in the blood serum of women in the first trimester of pregnancy may indicate disturbances in the hemostasis system and the formation of retrochorial hematoma. According to the results of the study, it is possible to recommend the determination of plasminogen activity in the management of pregnant women in gynecological practice.
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Briller JE, Aggarwal NR, Davis MB, Hameed AB, Malhamé I, Mahmoud Z, McDonald EG, Moraes de Oliveira G, Quesada O, Scott NS, Sharma J. Cardiovascular Complications of Pregnancy-Associated COVID-19 Infections. JACC: ADVANCES 2022; 1:100057. [PMID: 35967591 PMCID: PMC9364954 DOI: 10.1016/j.jacadv.2022.100057] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/17/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022]
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Wujcicka WI, Kacerovsky M, Krygier A, Krekora M, Kaczmarek P, Grzesiak M. Association of Single Nucleotide Polymorphisms from Angiogenesis-Related Genes, ANGPT2, TLR2 and TLR9, with Spontaneous Preterm Labor. Curr Issues Mol Biol 2022; 44:2939-2955. [PMID: 35877427 PMCID: PMC9322696 DOI: 10.3390/cimb44070203] [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: 05/17/2022] [Revised: 06/25/2022] [Accepted: 06/27/2022] [Indexed: 12/07/2022] Open
Abstract
In this study, we hypothesized that the changes localized at angiopoietin-2 (ANGPT2), granulocyte-macrophage colony-stimulating factor (CSF2), fms-related tyrosine kinase 1 (FLT1) and toll-like receptor (TLR) 2, TLR6 and TLR9 genes were associated with spontaneous preterm labor (PTL), as well as with possible genetic alterations on PTL-related coagulation. This case-control genetic association study aimed to identify single nucleotide polymorphisms (SNPs) for the aforementioned genes, which are correlated with genetic risk or protection against PTL in Polish women. The study was conducted in 320 patients treated between 2016 and 2020, including 160 women with PTL and 160 term controls in labor. We found that ANGPT2 rs3020221 AA homozygotes were significantly less common in PTL cases than in controls, especially after adjusting for activated partial thromboplastin time (APTT) and platelet (PLT) parameters. TC heterozygotes for TLR2 rs3804099 were associated with PTL after correcting for anemia, vaginal bleeding, and history of threatened miscarriage or PTL. TC and CC genotypes in TLR9 rs187084 were significantly less common in women with PTL, compared to the controls, after adjusting for bleeding and gestational diabetes. For the first time, it was shown that three polymorphisms-ANGPT2 rs3020221, TLR2 rs3804099 and TLR9 rs187084 -were significantly associated with PTL, adjusted by pregnancy development influencing factors.
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Affiliation(s)
- Wioletta Izabela Wujcicka
- Scientific Laboratory of the Center of Medical Laboratory Diagnostics and Screening, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland
- Correspondence: or ; Tel.: +48-42-271-15-20; Fax: +48-42-271-15-10
| | - Marian Kacerovsky
- Department of Obstetrics and Gynecology, University Hospital Hradec Kralove, Charles University, 500 03 Hradec Kralove, Czech Republic;
- Biomedical Research Center, University Hospital Hradec Kralove, 500 03 Hradec Kralove, Czech Republic
| | - Adrian Krygier
- Laboratory of Molecular Diagnostics and Pharmacogenomics, Department of Pharmaceutical Biochemistry and Molecular Diagnostics, Medical University of Lodz, 90-151 Lodz, Poland;
| | - Michał Krekora
- Department of Obstetrics and Gynecology, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland;
- Department of Gynecology and Obstetrics, Medical University of Lodz, 93-338 Lodz, Poland;
| | - Piotr Kaczmarek
- Department of Gynecology, Reproduction and Fetal Therapy, and Diagnostics and Treatment of Infertility, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland;
| | - Mariusz Grzesiak
- Department of Gynecology and Obstetrics, Medical University of Lodz, 93-338 Lodz, Poland;
- Department of Perinatology, Obstetrics and Gynecology, Polish Mother’s Memorial Hospital-Research Institute, 93-338 Lodz, Poland
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Scheres LJJ, van Hylckama Vlieg A, Cannegieter SC. Sex-specific aspects of venous thromboembolism: What is new and what is next? Res Pract Thromb Haemost 2022; 6:e12722. [PMID: 35619638 PMCID: PMC9127145 DOI: 10.1002/rth2.12722] [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: 11/24/2021] [Revised: 04/01/2022] [Accepted: 04/19/2022] [Indexed: 11/08/2022] Open
Abstract
Men seem to have a higher intrinsic risk of venous thromboembolism (VTE) than women, regardless of age. To date, this difference has not been explained. By integrating state-of-the-art research presented at the International Society on Thrombosis and Haemostasis Congress of 2021 with the available literature, we address potential explanations for this intriguing risk difference between men and women. We discuss the role of exogenous and endogenous sex hormones as the most important known sex-specific determinants of VTE risk. In addition, we highlight clues on the role of sex hormones and VTE risk from clinical scenarios such as pregnancy and the polycystic ovary syndrome. Furthermore, we address new potential sex-specific risk factors and unanswered research questions, which could provide more insight in the intrinsic risk difference between men and women, such as body height and differences in body fat distribution, leading to dysregulation of metabolism and inflammation.
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Affiliation(s)
- Luuk J. J. Scheres
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | | | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal MedicineSection of Thrombosis and HaemostasisLeiden University Medical CenterLeidenThe Netherlands
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Katsafanas C, Bushnell C. Pregnancy and stroke risk in women. Neurobiol Dis 2022; 169:105735. [PMID: 35477033 DOI: 10.1016/j.nbd.2022.105735] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 04/05/2022] [Accepted: 04/13/2022] [Indexed: 10/18/2022] Open
Abstract
Stroke associated with pregnancy and post-partum occurs in about 30 per 100,000 deliveries, and includes subtypes of ischemic and hemorrhagic stroke as well as cerebral venous sinus thrombosis (CVST). There are a wide variety of underlying causes and risk factors, some that are common to both pregnant and non-pregnant women, and others that are unique to pregnancy. Although some of the strokes that occur may be a direct result of the pregnancy itself, such as hypertensive disorders of pregnancy, others could be anticipated or prevented by understanding the risk factors. These may include the presence of pre-pregnancy clotting disorders, aneurysms or arteriovenous malformations, hypertension, diabetes, or advanced maternal age. Treatment of stroke during pregnancy is based on the current recommendations for non-pregnant stroke patients, assuming the benefit of these treatments is likely higher than the risks. These decisions must be made with the appropriate specialists in stroke and endovascular treatment, as well as high-risk obstetrician/gynecologists, and most importantly, patient and family preferences.
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Affiliation(s)
- Constance Katsafanas
- University of Florida at Jacksonville, Department of Neurology, United States of America
| | - Cheryl Bushnell
- Wake Forest School of Medicine, Department of Neurology, United States of America.
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Alghamdi N, Alqahani S, Allehyani L, Alosaimi H, Almutairi W, Alobaid S, Albackr HB, Aldakhil L, Alotaibi GS, Alqahtani FH. The Safety and Efficacy of Low-Molecular-Weight Heparin in Pregnant Women With Rheumatic Heart Disease and Valves Replacement. Cureus 2022; 14:e23052. [PMID: 35464573 PMCID: PMC9001812 DOI: 10.7759/cureus.23052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/30/2022] Open
Abstract
Background: In patients with rheumatic heart disease (RHD) and prosthetic valve replacement, the risk of thromboembolic complications is the highest during and immediately after pregnancy. Therapeutic anticoagulation during this period is crucial to minimize the risk of thromboembolic complications. The use of low-molecular-weight heparin (LMWH) remains an off-label indication. The type of anticoagulants used, dosing regimens, target anti-Xa levels, and frequency of anti-Xa monitoring are highly variable in the pregnant population and have been derived from pilots, observational studies, and empirical evidence. Herein, in a real-world setting, we sought to examine the efficacy and safety of variable anticoagulation options with a focus on LMWH in the management of RHD-related valvular disease in pregnant women. Methods: This study is a retrospective study conducted at a large university-affiliated tertiary care center (King Saud University Medical City) between January 2011 and February 2020. All pregnant women with RHD who had heart valve replacements were reviewed. Patient data were extracted for demographic information, baseline characteristics, anticoagulation type, and primary outcomes. Primary endpoints were thromboembolic events, hemorrhagic complications, and fetal outcomes. Results: A total of 744 pregnancies in 149 women were identified. The mean age ± SD of the women was 43.8 ± 12 years. A total of 86 women (58%) were on the LMWH regimen, 35 women (23%) were on LMWH and warfarin regimen, and 28 women (19%) were on unfractionated heparin (UFH) and warfarin regimen. Overall, thromboembolic events developed in five (0.7%) pregnancies. Of those, two were in the LMWH group, two were in the LMWH and warfarin group, and one was in the UFH and warfarin group. In addition, significant hemorrhagic complications occurred in five pregnancies. Of these, two occurred in the LMWH group, two in the LMWH and warfarin group, and one in the UFH and warfarin group. No adverse maternal and fetal outcomes were noted. Conclusion: This study presents the largest retrospective study of variable anticoagulation options in pregnant women with RHD and prosthetic valve replacement. LMWH is both safe and effective in preventing major thromboembolic complications compared to other forms of anticoagulation used during pregnancy.
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Collins A, Memtsa M, Kirk E, Othman M, Abdul Kadir R. The risk of venous thromboembolism in early pregnancy loss: Review of the literature and current guidelines and the need for guidance - Communication from the SSC on Women's Health Issues for thrombosis and haemostasis. J Thromb Haemost 2022; 20:767-776. [PMID: 34897975 DOI: 10.1111/jth.15621] [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: 05/14/2021] [Revised: 12/04/2021] [Accepted: 12/07/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Thromboembolic disease is one of the major causes of mortality and morbidity in pregnancy and the puerperium, with 1 death per 100 000 births attributed to venous thromboembolism (VTE). Factors associated with development of thrombosis are all present in pregnancy, with some of these changes seen from conception. OBJECTIVE Given how common early pregnancy loss is, the aim of this review is to evaluate the uncertainty surrounding the risk of VTE following early pregnancy loss and termination of pregnancy. METHODS A structured literature search was conducted to identify existing evidence as well as international pregnancy-specific guidelines regarding assessment and prevention of VTE risk in pregnant women. This review was reviewed, critiqued, and approved by all members of the International Society on Thrombosis and Haemostasis subcommittee for Women's Health Issues in Thrombosis and Haemostasis. RESULTS Four published original research studies, one clinical comment paper, and six guidelines were reviewed. Despite clear evidence of the increased risk of VTE in pregnancy, there is a lack of guidance regarding evaluation and management after early pregnancy loss. CONCLUSION International collaborative research to determine the risk of VTE and its prevention in women undergoing surgical termination of pregnancy or following surgical management of early pregnancy loss is urgently needed. Pregnancy-specific risk assessment taking into account preexisting risk factors is advocated. Education of health care professionals involved in early pregnancy care and guidance on management, albeit based on limited existing evidence, are necessary to highlight the need for individualized care.
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Affiliation(s)
| | - Maria Memtsa
- Institute for Women's Health, University College London, London, UK
| | - Emma Kirk
- The Royal Free NHS Foundation Hospital, London, UK
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Rezan Abdul Kadir
- Institute for Women's Health, University College London, London, UK
- The Royal Free NHS Foundation Hospital, London, UK
- Katharine Dormandy Haemophilia and Thrombosis Centre, Department of Obstetrics and Gynaecology, The Royal Free NHS Foundation Hospital, London, UK
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Antic D, Lefkou E, Otasevic V, Banfic L, Dimakakos E, Olinic D, Milić D, Miljić P, Xhepa S, Stojkovski I, Kozak M, Dimulescu DR, Preradović TK, Nancheva J, Pazvanska EE, Tratar G, Gerotziafas GT. Position Paper on the Management of Pregnancy-Associated Superficial Venous Thrombosis. Balkan Working Group for Prevention and Treatment of Venous Thromboembolism. Clin Appl Thromb Hemost 2022; 28:1076029620939181. [PMID: 35187959 PMCID: PMC8864277 DOI: 10.1177/1076029620939181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Venous thromboembolism (VTE) is a multifactorial disease that can possibly affect
any part of venous circulation. The risk of VTE increases by about 2 fold in
pregnant women and VTE is one of the major causes of maternal morbidity and
mortality. For decades superficial vein thrombosis (SVT) has been considered as
benign, self-limiting condition, primarily local event consequently being out of
scope of well conducted epidemiological and clinical studies. Recently, the
approach on SVT has significantly changed considering that prevalence of lower
limb SVT is twice higher than both deep vein thrombosis (DVT) and pulmonary
embolism (PE). The clinical severity of SVT largely depends on the localization
of thrombosis, when it concerns the major superficial vein vessels of the lower
limb and particularly the great saphenous vein. If untreated or inadequately
treated, SVT can potentially cause DVT or PE. The purpose of this review is to
discuss the complex interconnection between SVT and risk factors in pregnancy
and to provide evidence-based considerations, suggestions, and recommendations
for the diagnosis and treatment of this precarious and delicate clinical
entity.
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Affiliation(s)
- Darko Antic
- University Clinical Center of Serbia
- University of Belgrade, Faculty of Medicine, Belgrade, Serbia
| | - Eleftheria Lefkou
- Sorbonne University, INSERM, UMR_S 938, Research Group “Cancer,
Biology and Therapeutics - Cancer, Haemostasis, Angiogenesis” Centre de recherche
Saint-Antoine (CRSA), Institut Universitaire de Cancérologie, Paris, France
| | | | - Ljiljana Banfic
- Department of Cardiovascular Diseases, Zagreb University Hospital
Centre, School of Medicine, Croatia
| | - Evangelos Dimakakos
- Vascular Unit of 3rd Internal Medicine Department of the University
of Athens-Sotiria General Hospital, Athens, Greece
| | - Dan Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy,
Cluj-Napoca, Romania
| | | | - Predrag Miljić
- University Clinical Center of Serbia
- University of Belgrade, Faculty of Medicine, Belgrade, Serbia
| | - Sokol Xhepa
- Service of Vascular Surgery, University Hospital Center “Mother
Theresa” of Tirana, Albania
| | - Igor Stojkovski
- University Clinic for Oncology and Radiotherapy, Faculty of
Medicine, Ss Cyril and Methodius University of Skopje, Republic of North
Macedonia
| | - Matija Kozak
- University Medical Centre Ljubljana, Department for Vascular
Diseases, Ljubljana, Slovenia
| | - Doina Ruxandra Dimulescu
- University of Medicine and Pharmacy “Carol Davila” Bucharest,
Ponderas Academic Hospital Bucharest, Cardiology Department, Romania
| | | | - Jasminka Nancheva
- University Clinic for Orthopedic Diseases, Medical Faculty,
University “Ss. Cyril and Methodius” Skopje, Republic of North Macedonia
| | | | - Gregor Tratar
- Department of Angiology, University Medical Centre, Ljubljana,
Slovenia
| | - Grigoris T. Gerotziafas
- Sorbonne University, INSERM, UMR_S 938, Research Group “Cancer,
Biology and Therapeutics - Cancer, Haemostasis, Angiogenesis” Centre de recherche
Saint-Antoine (CRSA), Institut Universitaire de Cancérologie, Paris, France
- Sorbonne University, INSERM, UMR_S 938, Research Group "Cancer,
Biology and Therapeutics - Cancer, Haemostasis, Angiogenesis" Centre de recherche
Saint-Antoine (CRSA), Institut Universitaire de Cancõrologie, Paris, France
- Grigoris T. Gerotziafas, MD, PhD, INSERM
U938 Bâtiment Kourilsky, 34 rue Crozatier, Hôpital Saint Antoine, Paris, Cedex
75012, France.
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Shah N, Deshmukh H, Akbar MJ, Saeed Y, Akbar S, Malik S, Allan B. Unilateral adrenal infarction in pregnancy with associated acute hypoadrenalism and subsequent spontaneous biochemical and radiological resolution. Clin Case Rep 2022; 10:e05442. [PMID: 35169476 PMCID: PMC8831941 DOI: 10.1002/ccr3.5442] [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: 10/12/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Abstract
Adrenal infarction is a rare cause of abdominal pain during pregnancy, and if missed, it can result in devastating clinical consequences for the mother and the child. The authors report a case of a young female who presented with severe abdominal pain and nausea. The biochemistry showed raised inflammatory markers and significant lactic acidosis. As the cause of the symptoms was not clear and the patient continued to deteriorate, a contrast-enhanced CT abdomen and pelvis was done which was suggestive of an acute left adrenal infarction. Subsequently, the patient was confirmed to have biochemical hypoadrenalism and required replacement doses of hydrocortisone until recovery of the adrenal glucocorticoid reserve and anticoagulation for the duration of pregnancy. We discuss the workup including diagnostic imaging, follow-up, and considerations for future pregnancies in this case.
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Affiliation(s)
- Najeeb Shah
- Hull University Teaching Hospitals NHS TrustHull Royal InfirmaryHullUK
- University of HullHullUK
| | - Harshal Deshmukh
- Hull University Teaching Hospitals NHS TrustHull Royal InfirmaryHullUK
- University of HullHullUK
| | | | - Yamna Saeed
- Hull University Teaching Hospitals NHS TrustHull Royal InfirmaryHullUK
| | - Shahzad Akbar
- York and Scarborough Teaching Hospitals NHS Foundation TrustYorkUK
| | - Shah Malik
- Hull University Teaching Hospitals NHS TrustHull Royal InfirmaryHullUK
| | - Belinda Allan
- Hull University Teaching Hospitals NHS TrustHull Royal InfirmaryHullUK
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40
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Erez O, Othman M, Rabinovich A, Leron E, Gotsch F, Thachil J. DIC in Pregnancy - Pathophysiology, Clinical Characteristics, Diagnostic Scores, and Treatments. J Blood Med 2022; 13:21-44. [PMID: 35023983 PMCID: PMC8747805 DOI: 10.2147/jbm.s273047] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/15/2021] [Indexed: 01/04/2023] Open
Abstract
Obstetrical hemorrhage and especially DIC (disseminated intravascular coagulation) is a leading cause for maternal mortality across the globe, often secondary to underlying maternal and/or fetal complications including placental abruption, amniotic fluid embolism, HELLP syndrome (hemolysis, elevated liver enzymes and low platelets), retained stillbirth and acute fatty liver of pregnancy. Various obstetrical disorders can present with DIC as a complication; thus, increased awareness is key to diagnosing the condition. DIC patients can present to clinicians who may not be experienced in a variety of aspects of thrombosis and hemostasis. Hence, DIC diagnosis is often only entertained when the patient already developed uncontrollable bleeding or multi-organ failure, all of which represent unsalvageable scenarios. Beyond the clinical presentations, the main issue with DIC diagnosis is in relation to coagulation test abnormalities. It is widely believed that in DIC, patients will have prolonged prothrombin time (PT) and partial thromboplastin time (PTT), thrombocytopenia, low fibrinogen, and raised D-dimers. Diagnosis of DIC can be elusive during pregnancy and requires vigilance and knowledge of the physiologic changes during pregnancy. It can be facilitated by using a pregnancy specific DIC score including three components: 1) fibrinogen concentrations; 2) the PT difference - relating to the difference in PT result between the patient's plasma and the laboratory control; and 3) platelet count. At a cutoff of ≥26 points, the pregnancy specific DIC score has 88% sensitivity, 96% specificity, a positive likelihood ratio (LR) of 22, and a negative LR of 0.125. Management of DIC during pregnancy requires a prompt attention to the underlying condition leading to this complication, including the delivery of the patient, and correction of the hemostatic problem that can be guided by point of care testing adjusted for pregnancy.
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Affiliation(s)
- Offer Erez
- Maternity Department “D”, Division of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences Ben Gurion University of the Negev, Beer Sheva, Israel
- Department of Obstetrics and Gynecology, Hutzel Women’s Hospital, Wayne State University, Detroit, MI, USA
| | - Maha Othman
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen’s University, Kingston, ON, Canada
| | - Anat Rabinovich
- Thrombosis and Hemostasis Unit, Hematology Institute, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Elad Leron
- Division of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Francesca Gotsch
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Universitaria Integrata, AOUI Verona, University of Verona, Verona, Italy
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
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Alhousseini A, Romero R, Benshalom-Tirosh N, Gudicha D, Pacora P, Tirosh D, Kabiri D, Yeo L, Thachil J, Hsu CD, Hassan SS, Erez O. Nonovert disseminated intravascular coagulation (DIC) in pregnancy: a new scoring system for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion. J Matern Fetal Neonatal Med 2022; 35:242-257. [PMID: 31931643 PMCID: PMC9019739 DOI: 10.1080/14767058.2020.1716330] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Nonovert disseminated intravascular coagulation (DIC) is a subclinical hemostatic dysfunction that has not yet reached the decompensation stage. The detection of pregnant patients at this stage may assist in the identification of those who will develop severe obstetrical hemorrhage, as it is one of the leading causes for preventable maternal mortality. Currently, nonovert DIC is diagnosed by a scoring system based on nonpregnant patients, originally generated by the International Society on Thrombosis and Hemostasis (ISTH), which does not address the physiologic changes of the hemostatic system during pregnancy. OBJECTIVES (1) To develop a pregnancy-specific nonovert DIC score, (2) to determine the diagnostic performance of this score in detecting women at risk for obstetrical hemorrhage requiring blood product transfusion, and (3) to compare it to the existing ISTH nonovert DIC score. STUDY DESIGN This retrospective study has longitudinal and cross-sectional components and includes three steps: (1) characterization of the longitudinal changes in the components of modified ISTH nonovert DIC scores, including these parameters - fibrinogen, antithrombin III, protein C, prothrombin time (PT), platelets, thrombin-antithrombin (TAT) complex, and D-dimer - during gestation in a group of normal pregnancies (n = 50); (2) development of a pregnancy-specific nonovert DIC score in a cross-sectional design of high-risk (n = 152) and control (n = 50) pregnancies, based on the predictive performance of each analyte for the detection of women at risk for obstetrical hemorrhage requiring blood product transfusion and a logistic regression model; and (3) comparison between the diagnostic performance of the pregnancy-specific nonovert DIC score and the modified ISTH nonovert DIC score to detect, upon admission, women who are at increased risk for subsequent development of obstetrical hemorrhage requiring blood product transfusion. RESULTS (1) The study cohort included 202 patients, of which 21 (10%) had obstetrical hemorrhage that required blood product transfusion and were considered to have nonovert DIC; (2) using the nonpregnant ISTH nonovert DIC score, 92% of the patients had a D-dimer concentration above the 0.5 mg/L threshold, and only 2% were identified to have a low fibrinogen concentration (<100 mg/dL); thus, this scoring system was unable to identify any of the patients with nonovert DIC based on the suggested cutoff of a score of ≥5; (3) the parameters included in the pregnancy-specific nonovert DIC score were selected based on their contribution to the performance of the model for the prediction of women at risk for obstetrical hemorrhage requiring blood product transfusion; as a result, we excluded the PT difference parameter from the score and the TAT complex concentration was added; and (4) a pregnancy-specific nonovert DIC score of ≥3 had a sensitivity of 71.4% and a specificity of 77.9% to identify patients at risk for obstetrical hemorrhage requiring blood product transfusion. CONCLUSION We propose (1) a pregnancy-specific nonovert DIC score adjusted for the physiologic changes in the hemostatic system during gestation; and (2) that the pregnancy-specific nonovert DIC score can be a useful tool for the identification of patients at risk for obstetrical hemorrhage requiring blood product transfusion.
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Affiliation(s)
- Ali Alhousseini
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA,Detroit Medical Center, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Miami International University, Miami, Florida, USA
| | - Neta Benshalom-Tirosh
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Dereje Gudicha
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Dan Tirosh
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Doron Kabiri
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Lami Yeo
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Sonia S. Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA,Perinatal Research Initiative in Maternal, Perinatal and Child Health, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Offer Erez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Detroit, Michigan, USA,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA,Maternity Department “D,” Division of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel
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Hofer S, Schlimp CJ, Casu S, Grouzi E. Management of Coagulopathy in Bleeding Patients. J Clin Med 2021; 11:jcm11010001. [PMID: 35011742 PMCID: PMC8745606 DOI: 10.3390/jcm11010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 02/06/2023] Open
Abstract
Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.
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Affiliation(s)
- Stefan Hofer
- Department of Anaesthesiology, Westpfalz-Klinikum Kaiserslautern, 67655 Kaiserlautern, Germany
- Correspondence: ; Tel.: +49-631-203-1030
| | - Christoph J. Schlimp
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital Linz, 4010 Linz, Austria;
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, 1200 Vienna, Austria
| | - Sebastian Casu
- Emergency Department, Asklepios Hospital Wandsbek, 22043 Hamburg, Germany;
| | - Elisavet Grouzi
- Transfusion Service and Clinical Hemostasis, Saint Savvas Oncology Hospital, 115 22 Athens, Greece;
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Giaglis S, Sur Chowdhury C, van Breda SV, Stoikou M, Tiaden AN, Daoudlarian D, Schaefer G, Buser A, Walker UA, Lapaire O, Hoesli I, Hasler P, Hahn S. Circulatory Neutrophils Exhibit Enhanced Neutrophil Extracellular Trap Formation in Early Puerperium: NETs at the Nexus of Thrombosis and Immunity. Int J Mol Sci 2021; 22:ijms222413646. [PMID: 34948443 PMCID: PMC8704360 DOI: 10.3390/ijms222413646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/17/2021] [Accepted: 12/17/2021] [Indexed: 11/16/2022] Open
Abstract
Pregnancy is associated with elevated maternal levels of cell-free DNA of neutrophil extracellular trap (NET) origin, as circulatory neutrophils exhibit increased spontaneous NET formation, mainly driven by G-CSF and finely modulated by sex hormones. The postpartum period, on the other hand, involves physiological alterations consistent with the need for protection against infections and fatal haemorrhage. Our findings indicate that all relevant serum markers of neutrophil degranulation and NET release are substantially augmented postpartum. Neutrophil pro-NETotic activity in vitro is also upregulated particularly in post-delivery neutrophils. Moreover, maternal puerperal neutrophils exhibit a strong pro-NETotic phenotype, associated with increased levels of all key players in the generation of NETs, namely citH3, MPO, NE, and ROS, compared to non-pregnant and pregnant controls. Intriguingly, post-delivery NET formation is independent of G-CSF in contrast to late gestation and complemented by the presence of TF on the NETs, alterations in the platelet activity status, and activation of the coagulation cascade, triggered by circulating microparticles. Taken together, our results reveal the highly pro-NETotic and potentially procoagulant nature of postpartum neutrophils, bridging an overt immune activation with possible harmful thrombotic incidence.
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Affiliation(s)
- Stavros Giaglis
- Laboratory for Prenatal Medicine, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (C.S.C.); (S.V.v.B.); (M.S.); (G.S.); (O.L.); (I.H.); (S.H.)
- University Women’s Hospital, University Hospital Basel, 4056 Basel, Switzerland
- Division of Rheumatology, Department of Internal Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland;
- Laboratory for Experimental Rheumatology, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (A.N.T.); (D.D.); (U.A.W.)
- Department of Rheumatology, University Hospital Basel, 4031 Basel, Switzerland
- Correspondence:
| | - Chanchal Sur Chowdhury
- Laboratory for Prenatal Medicine, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (C.S.C.); (S.V.v.B.); (M.S.); (G.S.); (O.L.); (I.H.); (S.H.)
- University Women’s Hospital, University Hospital Basel, 4056 Basel, Switzerland
- Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Shane Vontelin van Breda
- Laboratory for Prenatal Medicine, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (C.S.C.); (S.V.v.B.); (M.S.); (G.S.); (O.L.); (I.H.); (S.H.)
- University Women’s Hospital, University Hospital Basel, 4056 Basel, Switzerland
- Division of Rheumatology, Department of Internal Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland;
| | - Maria Stoikou
- Laboratory for Prenatal Medicine, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (C.S.C.); (S.V.v.B.); (M.S.); (G.S.); (O.L.); (I.H.); (S.H.)
- University Women’s Hospital, University Hospital Basel, 4056 Basel, Switzerland
| | - André N. Tiaden
- Laboratory for Experimental Rheumatology, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (A.N.T.); (D.D.); (U.A.W.)
- Department of Rheumatology, University Hospital Basel, 4031 Basel, Switzerland
| | - Douglas Daoudlarian
- Laboratory for Experimental Rheumatology, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (A.N.T.); (D.D.); (U.A.W.)
- Department of Rheumatology, University Hospital Basel, 4031 Basel, Switzerland
| | - Guenther Schaefer
- Laboratory for Prenatal Medicine, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (C.S.C.); (S.V.v.B.); (M.S.); (G.S.); (O.L.); (I.H.); (S.H.)
- University Women’s Hospital, University Hospital Basel, 4056 Basel, Switzerland
| | - Andreas Buser
- Swiss Red Cross, Blood Transfusion Center, Department of Internal Medicine, Division of Hematology, University Hospital Basel, 4031 Basel, Switzerland;
| | - Ulrich A. Walker
- Laboratory for Experimental Rheumatology, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (A.N.T.); (D.D.); (U.A.W.)
- Department of Rheumatology, University Hospital Basel, 4031 Basel, Switzerland
| | - Olav Lapaire
- Laboratory for Prenatal Medicine, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (C.S.C.); (S.V.v.B.); (M.S.); (G.S.); (O.L.); (I.H.); (S.H.)
- University Women’s Hospital, University Hospital Basel, 4056 Basel, Switzerland
| | - Irene Hoesli
- Laboratory for Prenatal Medicine, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (C.S.C.); (S.V.v.B.); (M.S.); (G.S.); (O.L.); (I.H.); (S.H.)
- University Women’s Hospital, University Hospital Basel, 4056 Basel, Switzerland
| | - Paul Hasler
- Division of Rheumatology, Department of Internal Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland;
| | - Sinuhe Hahn
- Laboratory for Prenatal Medicine, Department of Biomedicine, University of Basel, 4001 Basel, Switzerland; (C.S.C.); (S.V.v.B.); (M.S.); (G.S.); (O.L.); (I.H.); (S.H.)
- University Women’s Hospital, University Hospital Basel, 4056 Basel, Switzerland
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Babik B, Kupcsulik S, Fazakas J. Gestational hemostasis: a natural model for hemostasis resuscitation of major periprocedural blood loss : "Look deep into nature, and then you will understand everything better." Albert Einstein. Perioper Med (Lond) 2021; 10:54. [PMID: 34895336 PMCID: PMC8667437 DOI: 10.1186/s13741-021-00225-0] [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: 05/03/2021] [Accepted: 10/03/2021] [Indexed: 11/10/2022] Open
Abstract
Early goal-directed treatment is an evidence-based approach to guide hemostatic therapy during major periprocedural bleeding. If viscoelastic coagulation tests are not available, an algorithm, termed the pyramid of hemostatic interventions, can help manage severe bleeding. Pregnant women accumulate huge reserves of prothrombotic and antifibrinolytic hemostatic elements to avoid peripartum blood loss. We provide comparison of therapeutic hemostatic approaches and natural gestational process and identified remarkable analogy between early goal-directed management of bleeding and hemostatic adaptation of pregnant woman. Therefore, gestational hemostasis serves as a natural model for goal-directed hemostasis resuscitation and can foster understanding of hemostatic management of periprocedural bleeding.
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Affiliation(s)
- Barna Babik
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged, Szeged, Hungary.
| | - Szilvia Kupcsulik
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, University of Szeged, Szeged, Hungary
| | - János Fazakas
- Clinic of Transplantation and Surgery, Semmelweis University, Baross Str. 23, Budapest, Hungary
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Eke AC. An update on the physiologic changes during pregnancy and their impact on drug pharmacokinetics and pharmacogenomics. J Basic Clin Physiol Pharmacol 2021; 33:581-598. [PMID: 34881531 DOI: 10.1515/jbcpp-2021-0312] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 11/21/2021] [Indexed: 01/23/2023]
Abstract
For many years, the medical community has relied in clinical practice on historic data about the physiological changes that occur during pregnancy. However, some newer studies have disputed a number of assumptions in these data for not being evidence-based or derived from large prospective cohort-studies. Accurate knowledge of these physiological changes is important for three reasons: Firstly, it facilitates correct diagnosis of diseases during pregnancy; secondly, it enables us to answer questions about the effects of medication during pregnancy and the ways in which pregnancy alters pharmacokinetic and drug-effects; and thirdly, it allows for proper modeling of physiologically-based pharmacokinetic models, which are increasingly used to predict gestation-specific changes and drug-drug interactions, as well as develop new knowledge on the mode-of-action of drugs, the mechanisms underlying their interactions, and any adverse effects following drug exposure. This paper reviews new evidence regarding the physiologic changes during pregnancy in relation to existing knowledge.
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Affiliation(s)
- Ahizechukwu C Eke
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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46
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Micaily I, Samuelson Bannow BT. VTE and anticoagulation in menstruating women. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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47
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Anticoagulation of women with congenital heart disease during pregnancy. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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48
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Mendelson MA. Pregnancy in women with left-to-right cardiac shunts: Any risk? INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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49
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Samuel R, Alfadhel M, McAlister C, Nestelberger T, Saw J. Coronary Events in the Pregnant Patient: Who Is at Risk and How Best to Manage? Can J Cardiol 2021; 37:2026-2034. [PMID: 34530109 DOI: 10.1016/j.cjca.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/23/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022] Open
Abstract
Coronary events in pregnancy are a rare but growing cause of maternal morbidity and mortality. Pregnancy presents unique challenges across a broad spectrum of disciplines and requires a multidisciplinary approach to optimise maternal and fetal outcomes. The early involvement of the "cardio-obstetrics" team in prepregnancy counselling, the antenatal period, delivery, and postpartum is vital to ensuring better outcomes for patients at high risk of coronary pathology. The overall risk for coronary events complicating pregnancy is increasing owing to a number of factors, including advancing maternal age and increases in traditional cardiac risk factors contributing to higher rates of maternal morbidity and mortality. The majority of pregnant women experiencing a coronary event do not have previous coronary disease, and the pathologic mechanisms involved are predominantly nonatherosclerotic. Diagnosis and management should follow standard guideline-based practices for acute coronary syndrome (ACS), including the use of diagnostic coronary angiography to guide percutaneous intervention when needed. Management of ACS should not be delayed to facilitate delivery, which can proceed following stent implantation and dual antiplatelet therapy. The timing and mode of delivery should be based on assessment of maternal and fetal status, but vaginal delivery is preferred when possible. This review aims to provide an overview of the major etiologies, risk factors, diagnoses, and management strategies for patients at risk of or presenting with coronary events in pregnancy.
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Affiliation(s)
- Rohit Samuel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Mesfer Alfadhel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Cameron McAlister
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Thomas Nestelberger
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada.
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Sharma G, Ying W, Silversides CK. The Importance of Cardiovascular Risk Assessment and Pregnancy Heart Team in the Management of Cardiovascular Disease in Pregnancy. Cardiol Clin 2021; 39:7-19. [PMID: 33222816 DOI: 10.1016/j.ccl.2020.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pregnancy-related maternal morbidity and mortality is increasing because of complications from cardiovascular disease. Pregnancy results in physiologic changes that can adversely impact the cardiovascular system and lead to adverse pregnancy outcomes. A multidisciplinary pregnancy heart team is essential to safely navigate women with heart disease through pregnancy. This role of the pregnancy heart team is to offer preconception counseling, determine pregnancy risks and educate women about those risks, develop a comprehensive antenatal and delivery plan, and ensure appropriate postpartum follow-up. These steps are important to improve cardiovascular outcomes in pregnancy.
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Affiliation(s)
- Garima Sharma
- Division of Cardiology, Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine and Hospital, 1800 Orleans Street, Zayed 7125s, Baltimore, MD 21287, USA.
| | - Wendy Ying
- Division of Cardiology, Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine and Hospital, 1800 Orleans Street, Zayed 7125s, Baltimore, MD 21287, USA. https://twitter.com/WendyYingMD
| | - Candice K Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Research Program, Mount Sinai and Toronto General Hospitals, 700 University Avenue, Room 3-913, Toronto, Ontario M5G 1Z5, Canada. https://twitter.com/CandiceSilvers1
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