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Eiland LS, Harris JB, Holmes AP. Considerations for Treating Nonobstetric Diseases in Pregnant Patients in the Emergency Department Setting. Ann Pharmacother 2023; 57:1415-1424. [PMID: 37076990 DOI: 10.1177/10600280231167775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVE To provide nonobstetric practitioners with an overview of key concepts for the pregnant patient and review treatment of 3 common acute nonobstetric diseases encountered in the emergency department setting. DATA SOURCES A literature search of PubMed was performed (1997-February 2023) using key search terms related to pregnancy, pain, urinary tract infection (UTI), venous thromboembolism (VTE), and anticoagulants. STUDY SELECTION AND DATA EXTRACTION Relevant articles in English and humans were considered. DATA SYNTHESIS When caring for a pregnant patient, it is important to utilize appropriate assessments, understand terms used in this population, and recognize how the physiological and pharmacokinetic changes that occur in pregnancy can influence medication use. Pain, UTIs, and VTE are common in this population. Acetaminophen is the most widely used medication for the management of pain during pregnancy and the drug of choice for mild pain in pregnancy not responsive to nonpharmacologic treatment. Pyelonephritis is the most common nonobstetric cause of hospitalization for pregnant patients. Antimicrobial treatment should consider maternal-fetal safety and local resistance patterns. Pregnant and postpartum patients have a 4- to 5-fold increased risk of developing a VTE compared with nonpregnant patients. Low-molecular-weight heparin is the preferred treatment. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Pregnant patients often seek acute care in the emergency department setting for nonobstetric needs. Pharmacists in this setting should understand appropriate assessment questions and terms used within this population, the basics of physiological and pharmacokinetic changes in pregnancy that can impact treatment, and which resources are best to utilize for drug information of the pregnant patient. CONCLUSION Practitioners in the acute care setting commonly encounter pregnant patients seeking care for nonobstetric concerns. This article covers key pregnancy-related information for the nonobstetric practitioner and focuses on the management of acute pain, UTI, and VTE during pregnancy.
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Affiliation(s)
- Lea S Eiland
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - John Brock Harris
- Education and Pharmaceutical Sciences Department, Wingate University School of Pharmacy, Wingate, NC, USA
| | - Amy P Holmes
- Department of Pharmacy, Atrium Wake Forest Baptist Health, Winston-Salem, NC, USA
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2
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Trautmann A, Grän F, Stoevesandt J. Delayed-Type Heparin Allergy: Intravenous Tolerance Despite Inflammatory Skin Reaction After Subcutaneous Injection. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2977-2983.e1. [PMID: 35788063 DOI: 10.1016/j.jaip.2022.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/09/2022] [Accepted: 06/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Heparin allergy most frequently manifests as delayed-type hypersensitivity (DTH) causing an itchy inflammatory skin reaction at the site of subcutaneous injection. An important differential diagnosis is circumscribed skin necrosis due to heparin-induced thrombocytopenia. OBJECTIVES An inflammatory skin reaction to subcutaneously injected heparin generally entails the quest for alternative anticoagulation; concerns may particularly arise in an emergency situation requiring intravenous heparin administration. METHODS All heparin DTH cases seen in our department over the last 17 years underwent standardized allergy diagnostics including challenge testing, that is, subcutaneous injection of fondaparinux and intravenous administration of unfractionated heparin (UFH). RESULTS Of a total of 50 patients with confirmed heparin allergy, DTH was found in 48 (96.0%), and immediate-type, presumably IgE-mediated hypersensitivity was diagnosed in only 2 (4.0%). In the 48 DTH cases, intradermal testing revealed broad cross-reactivity between UFH and low-molecular-weight heparins (LMWH) including nadroparin, dalteparin, and enoxaparin. Cross-reactivity with (or concomitant sensitization to) fondaparinux was seen in only 3 (6.3%) cases. Intravenous administration of UFH was tolerated by all 45 patients challenged, despite DTH to UFH and LMWH as demonstrated by intradermal testing. CONCLUSIONS If an inflammatory skin reaction at the site of subcutaneously injected heparin is observed or reported without any evidence of skin necrosis or thrombocytopenia, intravenous administration of UFH seems to be sufficiently safe and may be considered without allergy testing if urgently indicated in an emergency situation. Fondaparinux is the most suitable alternative for subcutaneous application.
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Affiliation(s)
- Axel Trautmann
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany.
| | - Franziska Grän
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
| | - Johanna Stoevesandt
- Department of Dermatology and Allergy, University Hospital Würzburg, Würzburg, Germany
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How I treat venous thromboembolism in pregnancy. Blood 2021; 136:2133-2142. [PMID: 32797192 DOI: 10.1182/blood.2019000963] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/11/2020] [Indexed: 12/11/2022] Open
Abstract
One to 2 pregnant women in 1000 will experience venous thromboembolism (VTE) during pregnancy or postpartum. Pulmonary embolism (PE) is a leading cause of maternal mortality, and deep vein thrombosis leads to maternal morbidity, with postthrombotic syndrome potentially diminishing quality of life for a woman's lifetime. However, the evidence base for pregnancy-related VTE management remains weak. Evidence-based guideline recommendations are often extrapolated from nonpregnant women and thus weak or conditional, resulting in wide variation of practice. In women with suspected PE, the pregnancy-adapted YEARS algorithm is safe and efficient, rendering computed tomographic pulmonary angiography to rule out PE unnecessary in 39%. Low molecular weight heparin (LMWH) in therapeutic doses is the treatment of choice during pregnancy, and anticoagulation (LMWH or vitamin K antagonists [VKAs]) should be continued until 6 weeks after delivery, with a 3-month minimum total duration. LMWH or VKA use does not preclude breastfeeding. Postpartum, direct oral anticoagulants are an option if a woman does not breastfeed and long-term use is intended. Management of delivery, including type of analgesia, requires a multidisciplinary approach and depends on local preferences and patient-specific conditions. Several options are possible, including waiting for spontaneous delivery with temporary LMWH interruption. Prophylaxis for recurrent VTE prevention in subsequent pregnancies is indicated in most women with a history of VTE.
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Bates SM. Pulmonary Embolism in Pregnancy. Semin Respir Crit Care Med 2021; 42:284-298. [PMID: 33548928 DOI: 10.1055/s-0041-1722867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Even though venous thromboembolism is a leading cause of maternal mortality in high-income countries, there are limited high-quality data to assist clinicians with the management of pulmonary embolism in this patient population. Diagnosis, prevention, and treatment of pregnancy-associated pulmonary embolism are complicated by the need to consider fetal, as well as maternal, well-being. Recent studies suggest that clinical prediction rules and D-dimer testing can reduce the need for diagnostic imaging in a subset of patients. Low-molecular-weight heparin is the preferred anticoagulant for both prophylaxis and treatment in this setting. Direct oral anticoagulants are contraindicated during pregnancy and in breastfeeding women. Thrombolysis or embolectomy should be considered for pregnant women with pulmonary embolism complicated by hemodynamic instability. Treatment of pregnancy-associated pulmonary embolism should be continued for at least 3 months, including 6 weeks postpartum. Management of anticoagulants at the time of delivery should involve a multidisciplinary individualized approach that uses shared decision making to take patient and caregiver values and preferences into account.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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Zhao L, Bi S, Fu J, Qi L, Li L, Fu Y. Retrospective Analysis of Fondaparinux and Low-Molecular-Weight Heparin in the Treatment of Women With Recurrent Spontaneous Abortion. Front Endocrinol (Lausanne) 2021; 12:717630. [PMID: 34721290 PMCID: PMC8553245 DOI: 10.3389/fendo.2021.717630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/17/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To compare the clinical efficacy of fondaparinux and LMWH and provide clinical evidence for the effectiveness of fondaparinux in the treatment of recurrent spontaneous abortion caused by PTS. METHODS A retrospective analysis was conducted for 120 patients diagnosed with a recurrent spontaneous abortion caused by PTS in Qingdao Jinhua Women's Hospital from March 2019 to April 2020. The patients were divided into two groups: 68 cases in the control group, treated with LMWH, 52 cases in the observational group, treated with fondaparinux. The pregnancy outcomes and adverse reactions between the two groups of recurrent miscarriage patients were compared. RESULTS No significant difference was detected in the general data between the two groups of patients before treatment (P>0.05). In the observational group, the R value was increased, and the α and MA values were decreased after three months of treatment compared to those before treatment (P<0.05). In the control group, the R value was increased, and the MA value was decreased after three months of treatment compared to those before treatment (P<0.05). After treatment, no significant difference was observed in the pregnancy outcome between the two groups (P>0.05). The total adverse reaction rate of the fondaparinux group was lower than that of the LMWH group (P<0.05). CONCLUSIONS In this study, no significant difference was detected in the pregnancy outcome between fondaparinux and LMWH in the treatment of recurrent spontaneous abortion caused by PTS, but fondaparinux had a low occurrence rate of adverse reactions and high safety.
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Affiliation(s)
- Long Zhao
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Long Zhao,
| | - Shuqin Bi
- Department of Obstetrics, Qingdao Jinhua Gynecology Hospital, Qingdao, China
| | - Jinhua Fu
- Department of Obstetrics, Qingdao Jinhua Gynecology Hospital, Qingdao, China
| | - Lijuan Qi
- Department of Obstetrics, Qingdao Jinhua Gynecology Hospital, Qingdao, China
| | - Lin Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yinghui Fu
- Department of Obstetrics, Qingdao Jinhua Gynecology Hospital, Qingdao, China
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Gelincik A, Brockow K, Çelik GE, Doña I, Mayorga C, Romano A, Soyer Ö, Atanaskovic‐Markovic M, Barbaud A, Torres MJ. Diagnosis and management of the drug hypersensitivity reactions in Coronavirus disease 19: An EAACI Position Paper. Allergy 2020; 75:2775-2793. [PMID: 32511784 PMCID: PMC7300843 DOI: 10.1111/all.14439] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023]
Abstract
Coronavirus disease 2019 (COVID-19), a respiratory tract infection caused by a novel human coronavirus, the severe acute respiratory syndrome coronavirus 2, leads to a wide spectrum of clinical manifestations ranging from asymptomatic cases to patients with mild and severe symptoms, with or without pneumonia. Given the huge influence caused by the overwhelming COVID-19 pandemic affecting over three million people worldwide, a wide spectrum of drugs is considered for the treatment in the concept of repurposing and off-label use. There is no knowledge about the diagnosis and clinical management of the drug hypersensitivity reactions that can potentially occur during the disease. This review brings together all the published information about the diagnosis and management of drug hypersensitivity reactions due to current and candidate off-label drugs and highlights relevant recommendations. Furthermore, it gathers all the dermatologic manifestations reported during the disease for guiding the clinicians to establish a better differential diagnosis of drug hypersensitivity reactions in the course of the disease.
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Affiliation(s)
- Aslı Gelincik
- Department of Internal Medicine Division of Immunology and Allergic Diseases Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein Faculty of Medicine Technical University of Munich Munich Germany
| | - Gülfem E. Çelik
- Department of Chest Diseases Division of Immunology and Allergy Ankara University School of Medicine Ankara Turkey
| | - Inmaculada Doña
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Cristobalina Mayorga
- Research Laboratory IBIMA‐Regional University Hospital of Malaga‐UMA‐ARADyAL Malaga Spain
| | - Antonino Romano
- IRCCS Oasi Maria S.S. Troina Italy
- Fondazione Mediterranea G.B. Morgagni Catania Italy
| | - Özge Soyer
- Pediatric Allergy Department Hacettepe University School of Medicine Ankara Turkey
| | | | - Annick Barbaud
- Department of Dermatology and Allergology, Tenon Hospital (AP‐HP) Sorbonne Universities, Pierre et Marie Curie University Paris France
- Institut Pierre Louis d’Epidémiologie et de Santé Publique AP‐HP Sorbonne Université Paris France
| | - Maria Jose Torres
- Allergy Unit Regional University Hospital of Malaga‐IBIMA‐UMA‐BIONAND‐ARADyAL Malaga Spain
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Wiegers HMG, Middeldorp S. Contemporary best practice in the management of pulmonary embolism during pregnancy. Ther Adv Respir Dis 2020; 14:1753466620914222. [PMID: 32425105 PMCID: PMC7238314 DOI: 10.1177/1753466620914222] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/25/2020] [Indexed: 12/25/2022] Open
Abstract
Approximately 1-2 per 1000 pregnancies are complicated by venous thromboembolism (VTE). VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE) and the diagnostic management of pregnancy-related VTE is challenging. Current guidelines vary greatly in their approach to diagnosing PE in pregnancy as they base their recommendations on scarce and weak evidence. The pregnancy-adapted YEARS diagnostic algorithm is well tolerated and is the most efficient diagnostic algorithm for pregnant women with suspected PE, with 39% of women not requiring computed tomographic pulmonary angiography. Low-molecular-weight heparin is the first-choice anticoagulant treatment in pregnancy and should be continued until 6 weeks postpartum and for a minimum of 3 months. Direct oral anticoagulants should be avoided in women who want to breastfeed. Management of delivery needs a multidisciplinary approach in order to decide on an optimal delivery plan. Neuraxial analgesia can be given in most patients, provided time windows since last low-molecular-weight heparin dose are respected. Women with a history of VTE are at risk of recurrence during pregnancy and in the postpartum period. Therefore, in most women with a history of VTE, thromboprophylaxis in subsequent pregnancies is indicated. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Hanke M. G. Wiegers
- Department of Vascular Medicine, Amsterdam UMC,
University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9,
Amsterdam, North Holland 1105 AZ, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC,
University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The
Netherlands
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Scheres LJ, Bistervels IM, Middeldorp S. Everything the clinician needs to know about evidence-based anticoagulation in pregnancy. Blood Rev 2019; 33:82-97. [DOI: 10.1016/j.blre.2018.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/25/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
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Schindewolf M, Paulik M, Kroll H, Kaufmann R, Wolter M, Boehncke W, Lindhoff‐Last E, Recke A, Ludwig RJ. Low incidence of heparin‐induced skin lesions in orthopedic surgery patients with low‐molecular‐weight heparins. Clin Exp Allergy 2018; 48:1016-1024. [DOI: 10.1111/cea.13159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 01/29/2018] [Accepted: 02/22/2018] [Indexed: 12/24/2022]
Affiliation(s)
- M. Schindewolf
- Department of Internal Medicine Division of Hemostaseology Goethe University Hospital Frankfurt Frankfurt am Main Germany
- Division of Vascular Medicine Swiss Cardiovascular Center Inselspital Bern University Hospital Bern Switzerland
| | - M. Paulik
- Department of Internal Medicine Division of Hemostaseology Goethe University Hospital Frankfurt Frankfurt am Main Germany
| | - H. Kroll
- Institute for Transfusion Medicine Dessau Red Cross Blood Transfusion Service NSTOB Dessau Germany
| | - R. Kaufmann
- Department of Dermatology Goethe University Hospital Frankfurt Frankfurt am Main Germany
| | - M. Wolter
- Department of Dermatology Goethe University Hospital Frankfurt Frankfurt am Main Germany
| | - W.‐H. Boehncke
- Division of Dermatology and Venereology Geneva University Hospitals Geneva Switzerland
- Department of Pathology and Immunology University of Geneva Geneva Switzerland
| | - E. Lindhoff‐Last
- Department of Internal Medicine Division of Hemostaseology Goethe University Hospital Frankfurt Frankfurt am Main Germany
- Agaplesion Bethanien Hospital Cardiovascular Centre Bethanien (CCB) Frankfurt am Main Germany
| | - A. Recke
- Department of Dermatology and Lübeck Institute of Experimental Dermatology University of Lübeck Lübeck Germany
| | - R. J. Ludwig
- Department of Dermatology and Lübeck Institute of Experimental Dermatology University of Lübeck Lübeck Germany
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Haruta S, Maruta K, Nakajima Y, Masaoka N. Use of fondaparinux for thromboprophylaxis in an unfractionated heparin-intolerant pregnant woman with thrombotic predisposition. J Obstet Gynaecol Res 2017; 43:943-945. [PMID: 28437037 DOI: 10.1111/jog.13302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 11/08/2016] [Accepted: 12/26/2016] [Indexed: 11/29/2022]
Abstract
A 34-year-old primigravida who had undergone thrombectomy for deep venous thrombosis (DVT) in her leg and exhibited low protein S activity, indicating predisposition to thrombosis, developed DVT of the leg. No pulmonary embolism was detected. After anticoagulant therapy with unfractionated heparin was discontinued because of liver dysfunction, danaparoid treatment was administered in hospital. The patient had a normal delivery after 39 weeks' gestation with no recurrence of thrombosis. During her second pregnancy four years later, she gave herself fondaparinux injections. She delivered normally after 38 weeks' gestation without experiencing DVT. Fondaparinux may be a useful anticoagulant for heparin-intolerant pregnant women.
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Affiliation(s)
- Shoji Haruta
- Department of Cardiology, Tokyo Women's Medical University, Yachiyo Medical Center, Yachiyo, Japan
| | - Kana Maruta
- Department of Maternal and Fetal Medicine, Tokyo Women's Medical University, Yachiyo Medical Center, Yachiyo, Japan
| | - Yoshiyuki Nakajima
- Department of Maternal and Fetal Medicine, Tokyo Women's Medical University, Yachiyo Medical Center, Yachiyo, Japan
| | - Naoki Masaoka
- Department of Maternal and Fetal Medicine, Tokyo Women's Medical University, Yachiyo Medical Center, Yachiyo, Japan
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11
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Schindewolf M, Recke A, Zillikens D, Lindhoff-Last E, Ludwig RJ. Nadroparin carries a potentially high risk of inducing cutaneous delayed-type hypersensitivity responses. Contact Dermatitis 2017; 77:35-41. [DOI: 10.1111/cod.12764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 12/09/2016] [Accepted: 12/21/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Marc Schindewolf
- Division of Haemostaseology, Department of Internal Medicine; Goethe University Hospital; 60590 Frankfurt am Main Germany
- Division of Vascular Medicine, Swiss Cardiovascular Centre; University Hospital Bern; 3010 Bern Switzerland
| | - Andreas Recke
- Department of Dermatology and Lübeck Institute of Experimental Dermatology; University of Lübeck; 23538 Lübeck Germany
| | - Detlef Zillikens
- Department of Dermatology and Lübeck Institute of Experimental Dermatology; University of Lübeck; 23538 Lübeck Germany
| | - Edelgard Lindhoff-Last
- Division of Haemostaseology, Department of Internal Medicine; Goethe University Hospital; 60590 Frankfurt am Main Germany
- Agaplesion Bethanien Hospital, Cardiovascular Centre Bethanien (CCB); 60389 Frankfurt am Main Germany
| | - Ralf J. Ludwig
- Department of Dermatology and Lübeck Institute of Experimental Dermatology; University of Lübeck; 23538 Lübeck Germany
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van Mens TE, Scheres LJJ, de Jong PG, Leeflang MMG, Nijkeuter M, Middeldorp S. Imaging for the exclusion of pulmonary embolism in pregnancy. Cochrane Database Syst Rev 2017; 1:CD011053. [PMID: 28124411 PMCID: PMC6464730 DOI: 10.1002/14651858.cd011053.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pulmonary embolism is a leading cause of pregnancy-related death. An accurate diagnosis in pregnant patients is crucial to prevent untreated pulmonary embolism as well as unnecessary anticoagulant treatment and future preventive measures. Applied imaging techniques might perform differently in these younger patients with less comorbidity and altered physiology, who largely have been excluded from diagnostic studies. OBJECTIVES To determine the diagnostic accuracy of computed tomography pulmonary angiography (CTPA), lung scintigraphy and magnetic resonance angiography (MRA) for the diagnosis of pulmonary embolism during pregnancy. SEARCH METHODS We searched MEDLINE and Embase until July 2015. We used included studies as seeds in citations searches and in 'find similar' functions and searched reference lists. We approached experts in the field to help us identify non-indexed studies. SELECTION CRITERIA We included consecutive series of pregnant patients suspected of pulmonary embolism who had undergone one of the index tests (computed tomography (CT) pulmonary angiography, lung scintigraphy or MRA) and clinical follow-up or pulmonary angiography as a reference test. DATA COLLECTION AND ANALYSIS Two review authors performed data extraction and quality assessment. We contacted investigators of potentially eligible studies to obtain missing information. In the primary analysis, we regarded inconclusive index test results as a negative reference test, and treatment for pulmonary embolism after an inconclusive index test as a positive reference test. MAIN RESULTS We included 11 studies (four CTPA, five lung scintigraphy, two both) with a total of 695 CTPA and 665 lung scintigraphy results. Lung scintigraphy was applied by different techniques. No MRA studies matched our inclusion criteria.Overall, risk of bias and concerns regarding applicability were high in all studies as judged in light of the review research question, as was heterogeneity in study methods. We did not undertake meta-analysis. All studies used clinical follow-up as a reference standard, none in a manner that enabled reliable identification of false positives. Sensitivity and negative predictive value were therefore the only valid test accuracy measures.The median negative predictive value for CTPA was 100% (range 96% to 100%). Median sensitivity was 83% (range 0% to 100%).The median negative predictive value for lung scintigraphy was 100% (range 99% to 100%). Median sensitivity was 100% (range 0% to 100%).The median frequency of inconclusive results was 5.9% (range 0.9% to 36%) for CTPA and 4.0% (range 0% to 23%) for lung scintigraphy. The overall median prevalence of pulmonary embolism was 3.3% (range 0.0% to 8.7%). AUTHORS' CONCLUSIONS Both CTPA and lung scintigraphy seem appropriate for exclusion of pulmonary embolism during pregnancy. However, the quality of the evidence mandates cautious adoption of this conclusion. Important limitations included poor reference standards, necessary assumptions in the analysis regarding inconclusive test results and the inherent inability of included studies to identify false positives. It is unclear which test has the highest accuracy. There is a need for direct comparisons between diagnostic methods, including MR, in prospective randomized diagnostic studies.
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Affiliation(s)
- Thijs E van Mens
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Luuk JJ Scheres
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Paulien G de Jong
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Mariska MG Leeflang
- Academic Medical Center, University of AmsterdamDepartment of Clinical Epidemiology, Biostatistics and BioinformaticsP.O. Box 22700AmsterdamNetherlands1100 DE
| | - Mathilde Nijkeuter
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
- University Medical Centre UtrechtDepartment of Internal MedicineHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Saskia Middeldorp
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105 AZ
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Low-molecular-weight heparin to prevent recurrent venous thromboembolism in pregnancy: Rationale and design of the Highlow study, a randomised trial of two doses. Thromb Res 2016; 144:62-8. [PMID: 27289488 DOI: 10.1016/j.thromres.2016.06.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/04/2016] [Accepted: 06/01/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Women with a history of venous thromboembolism (VTE) have a 2% to 10% absolute risk of VTE recurrence during subsequent pregnancies. Therefore, current guidelines recommend that all pregnant women with a history of VTE receive pharmacologic thromboprophylaxis. The optimal dose of low-molecular-weight heparin (LMWH) for thromboprophylaxis is unknown. In the Highlow study (NCT 01828697; www.highlowstudy.org), we compare a fixed low dose of LMWH with an intermediate dose of LMWH for the prevention of pregnancy-associated recurrent VTE. We present the rationale and design features of this study. METHODS The Highlow study is an investigator-initiated, multicentre, international, open-label, randomised trial. Pregnant women with a history of VTE and an indication for ante- and postpartum pharmacologic thromboprophylaxis are included before 14weeks of gestation. The primary efficacy outcome is symptomatic recurrent VTE during pregnancy and 6weeks postpartum. The primary safety outcomes are clinically relevant bleeding, blood transfusions before 6weeks postpartum and mortality. Patients are closely monitored to detect cutaneous reactions to LMWH and are followed for 3months after delivery. A central independent adjudication committee adjudicates all suspected outcome events. CONCLUSION The Highlow study is the first large randomised controlled trial in pregnancy that will provide high-quality evidence on the optimal dose of LWMH thromboprophylaxis for the prevention of recurrent VTE in pregnant women with a history of VTE.
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Bates SM, Middeldorp S, Rodger M, James AH, Greer I. Guidance for the treatment and prevention of obstetric-associated venous thromboembolism. J Thromb Thrombolysis 2016; 41:92-128. [PMID: 26780741 PMCID: PMC4715853 DOI: 10.1007/s11239-015-1309-0] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Venous thromboembolism (VTE), which may manifest as pulmonary embolism (PE) or deep vein thrombosis (DVT), is a serious and potentially fatal condition. Treatment and prevention of obstetric-related VTE is complicated by the need to consider fetal, as well as maternal, wellbeing when making management decisions. Although absolute VTE rates in this population are low, obstetric-associated VTE is an important cause of maternal morbidity and mortality. This manuscript, initiated by the Anticoagulation Forum, provides practical clinical guidance on the prevention and treatment of obstetric-associated VTE based on existing guidelines and consensus expert opinion based on available literature where guidelines are lacking.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute (TaARI), 1280 Main Street West, HSC 3W11, Hamilton, ON, L8S 4K1, Canada.
| | - Saskia Middeldorp
- Department of Vascular Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc Rodger
- Departments of Medicine, Epidemiology and Community Medicine, and Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada
| | - Andra H James
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - Ian Greer
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, UK
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Rodger M, Sheppard D, Gándara E, Tinmouth A. Haematological problems in obstetrics. Best Pract Res Clin Obstet Gynaecol 2015; 29:671-84. [PMID: 25819750 DOI: 10.1016/j.bpobgyn.2015.02.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 02/20/2015] [Accepted: 02/23/2015] [Indexed: 02/02/2023]
Abstract
Physiologic changes occur during pregnancy, which influence normal haematologic values and impact the diagnosis and management of haematologic disease in pregnancy. Physiologic changes of pregnancy also commonly lead to mimicking symptoms of haematologic disease that may prompt investigations for haematologic disease. The toxicity and radiation associated with the diagnostic imaging and pharmacologic management of both benign and malignant haematological conditions during pregnancy present unique challenges. Strategies for diagnosis and treatment must weigh the benefits and risks to the mother while also taking foetal outcome into consideration. In this review, we highlight the common haematologic diseases encountered by obstetricians and try to provide guidance for the most prevalent diagnostic and therapeutic questions. At the other end of the spectrum, we also comment on less common but very challenging haematologic diseases in pregnancy that require multidisciplinary effort to arrive at difficult individual diagnostic and treatment decisions.
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Affiliation(s)
- Marc Rodger
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Dawn Sheppard
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Esteban Gándara
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Alan Tinmouth
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada; Canadian Blood Services, Ottawa, Canada.
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Abstract
Several aspects of the diagnostic and therapeutic management of women with venous thrombosis are uncertain, because of the absence of adequately sized observational or intervention studies. Here, I will discuss the rationale and design of two currently ongoing investigator-initiated, international, randomized controlled trials of LMWHin pregnancy. The Highlow study (www.highlowstudy.org; NCT Clinicaltrials.gov) 01828697) investigates two doses of low-molecular-weight heparin to prevent recurrent venous thromboembolism (VTE) in pregnant women with a history of VTE. The ALIFE2 study (www.alife2study.org; www.trialregister.nl, NTR 3361) investigates the effect of LMWH on live birth in women with inherited thrombophilia and two or more miscarriages.
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Affiliation(s)
- Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.
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Guimicheva B, Czuprynska J, Arya R. The prevention of pregnancy-related venous thromboembolism. Br J Haematol 2014; 168:163-74. [DOI: 10.1111/bjh.13159] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Boriana Guimicheva
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
| | - Julia Czuprynska
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
| | - Roopen Arya
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
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Elsaigh E, Thachil J, Nash MJ, Tower C, Hay CRM, Bullough S, Byrd L. The use of fondaparinux in pregnancy. Br J Haematol 2014; 168:762-4. [PMID: 25270038 DOI: 10.1111/bjh.13147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Esra Elsaigh
- Manchester Medical School, University of Manchester, Manchester, UK
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20
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Rodger MA, Langlois NJ, de Vries JIP, Rey É, Gris JC, Martinelli I, Schleussner E, Ramsay T, Mallick R, Skidmore B, Middeldorp S, Bates S, Petroff D, Bezemer D, van Hoorn ME, Abheiden CNH, Perna A, de Jong P, Kaaja R. Low-molecular-weight heparin for prevention of placenta-mediated pregnancy complications: protocol for a systematic review and individual patient data meta-analysis (AFFIRM). Syst Rev 2014; 3:69. [PMID: 24969227 PMCID: PMC4094595 DOI: 10.1186/2046-4053-3-69] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 06/10/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Placenta-mediated pregnancy complications include pre-eclampsia, late pregnancy loss, placental abruption, and the small-for-gestational age newborn. They are leading causes of maternal, fetal, and neonatal morbidity and mortality in developed nations. Women who have experienced these complications are at an elevated risk of recurrence in subsequent pregnancies. However, despite decades of research no effective strategies to prevent recurrence have been identified, until recently. We completed a pooled summary-based meta-analysis that strongly suggests that low-molecular-weight heparin reduces the risk of recurrent placenta-mediated complications. The proposed individual patient data meta-analysis builds on this successful collaboration. The project is called AFFIRM, An individual patient data meta-analysis oF low-molecular-weight heparin For prevention of placenta-medIated pRegnancy coMplications. METHODS/DESIGN We conducted a systematic review to identify randomized controlled trials with a low-molecular-weight heparin intervention for the prevention of recurrent placenta-mediated pregnancy complications. Investigators and statisticians representing eight trials met to discuss the outcomes and analysis plan for an individual patient data meta-analysis. An additional trial has since been added for a total of nine eligible trials. The primary analyses from the original trials will be replicated for quality assurance prior to recoding the data from each trial and combining it into a common dataset for analysis. Using the anonymized combined data we will conduct logistic regression and subgroup analyses aimed at identifying which women with previous pregnancy complications benefit most from treatment with low-molecular-weight heparin during pregnancy. DISCUSSION The goal of the proposed individual patient data meta-analysis is a thorough estimation of treatment effects in patients with prior individual placenta-mediated pregnancy complications and exploration of which complications are specifically prevented by low-molecular-weight heparin. SYSTEMATIC REVIEW REGISTRATION PROSPERO (International Prospective Registry of Systematic Reviews) 23 December 2013, CRD42013006249.
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Affiliation(s)
- Marc A Rodger
- The Ottawa Hospital, Centre for Practice-Changing Research, 501 Smyth Road, Box 201, Ottawa, ON K1H 8 L6, Canada
| | - Nicole J Langlois
- The Ottawa Hospital Research Institute, Centre for Practice-Changing Research, 501 Smyth Road, Box 201, Ottawa, ON K1H 8 L6, Canada
| | - Johanna IP de Vries
- Department of Obstetrics and Gynaecology, VU University Medical Center, PO Box 7057, Amsterdam MB 1007, The Netherlands
| | - Évelyne Rey
- CHU Ste-Justine, 3175 chemin de la Côte-Sainte-Catherine, local 4804, Montreal, QC H3T 1C5, Canada
| | - Jean-Christophe Gris
- Consultations et Laboratoire d'Hématologie & Délégation à la Recherche Clinique et à l'Innovation, Place du Pr. Robert Debré, Nîmes cédex 09 F-30029, France
| | - Ida Martinelli
- Department of Internal Medicine and Medical Specialties, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, University of Milan, Via Pace 9, Milan 20122, Italy
| | - Ekkehard Schleussner
- Department of Obstetrics and Gynaecology, Jena University Hospital, Bach Street 18, Jena 07743, Germany
| | - Timothy Ramsay
- The Ottawa Hospital Research Institute, Centre for Practice-Changing Research, 501 Smyth Road, Box 201, Ottawa, ON K1H 8 L6, Canada
| | - Ranjeeta Mallick
- The Ottawa Hospital Research Institute, Centre for Practice-Changing Research, 501 Smyth Road, Box 201, Ottawa, ON K1H 8 L6, Canada
| | - Becky Skidmore
- Independent information specialist, 3104 Apple Hill Drive, Ottawa, ON K1T 3Z2, Canada
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, Amsterdam F4-276, 1105 AZ, The Netherlands
| | - Shannon Bates
- Department of Medicine, McMaster University Room HSC 3 W11, 1280 Main Street West, Hamilton, ON L8S 4 K1, Canada
| | - David Petroff
- Clinical Trial Centre, University of Leipzig, Haertelstr 16-18, Leipzig 04107, Germany
| | - Dick Bezemer
- Department of Obstetrics and Gynaecology, VU University Medical Center, PO Box 7057, Amsterdam MB 1007, The Netherlands
| | - Marion E van Hoorn
- Department of Obstetrics and Gynaecology, VU University Medical Center, PO Box 7057, Amsterdam MB 1007, The Netherlands
| | - Carolien NH Abheiden
- Department of Obstetrics and Gynaecology, VU University Medical Center, PO Box 7057, Amsterdam MB 1007, The Netherlands
| | - Annalisa Perna
- Laboratorio di Biostatistica, Centro di Ricerche Cliniche per le Malattie Rare Aldo e Cele Daccò, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Villa Camozzi - via G. Camozzi 3, Ranica BG 24020, Italy
| | - Paulien de Jong
- Academic Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Risto Kaaja
- Turku University and Satakunta Central Hospital, Helsinki University Hospital, Sairaalantie 3, 28500 Pori, Finland
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Bleker SM, Coppens M, Middeldorp S. Sex, thrombosis and inherited thrombophilia. Blood Rev 2014; 28:123-33. [DOI: 10.1016/j.blre.2014.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
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Middeldorp S, Bleker SM. Women admitted to hospital during pregnancy have increased risk of venous thromboembolism that persists up to 28 days postdischarge. Evid Based Nurs 2014; 17:103. [PMID: 24644302 DOI: 10.1136/eb-2013-101706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Saskia Middeldorp
- Department of Internal Medicine, University of Amsterdam, Amsterdam, The Netherlands
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23
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Bates SM. Preventing thrombophilia-related complications of pregnancy: an update. Expert Rev Hematol 2013; 6:287-300. [PMID: 23782083 DOI: 10.1586/ehm.13.18] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Approximately half of all pregnancy-related venous thromboembolic events are associated with thrombophilia. Although the most compelling data for a link between thrombophilia and other adverse pregnancy outcomes derive from women with antiphospholipid antibodies, some studies also suggest an association between these pregnancy complications and hereditary thrombophilias. Management of thrombophilia often involves anticoagulant therapy; however, use of these agents during pregnancy is challenging. There is a paucity of high-quality studies and consequently, recommendations are based largely on extrapolation from data in nonpregnant women, in addition to observational studies and a few small randomized studies. This article will review the impact of the thrombophilias on pregnancy and its outcome, evidence for therapies aimed at the prevention of thrombophilia-related pregnancy complications, and the most recent recommendations contained in the 9th Edition of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada.
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24
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Schindewolf M, Gobst C, Kroll H, Recke A, Louwen F, Wolter M, Kaufmann R, Boehncke WH, Lindhoff-Last E, Ludwig RJ. High incidence of heparin-induced allergic delayed-type hypersensitivity reactions in pregnancy. J Allergy Clin Immunol 2013; 132:131-9. [DOI: 10.1016/j.jaci.2013.02.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 01/02/2013] [Accepted: 02/27/2013] [Indexed: 10/26/2022]
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Abstract
BACKGROUND Although an association between thrombophilia and pregnancy loss has been observed in many studies, little is known about the pathophysiological mechanisms behind this association. Considering the association between thrombophilia and pregnancy loss, the efficacy of antithrombotic therapy for women with pregnancy loss (with or without thrombophilia) has been studied for the past 30 years. METHODS We performed a comprehensive review of the literature on the strength of the association between thrombophilia and pregnancy loss, the pathophysiological mechanisms and the efficacy of antithrombotic therapy to increase the chance of live birth. RESULTS The association between pregnancy loss and thrombophilia varies according to the type of thrombophilia (e.g. antiphospholipid syndrome versus forms of inherited thrombophilia) and according to the type of pregnancy loss (single versus recurrent pregnancy loss and early versus late pregnancy loss). Thrombophilia may induce thrombosis in decidual vessels or impair placentation through hypercoagulability and inflammation, but these hypotheses need further verification. For women with antiphospholipid syndrome, evidence from small-sized trials suggests a beneficial effect of antithrombotic therapy but additional randomized controlled trials are essential to confirm this. Whether antithrombotic therapy increases the chance of live birth in women with inherited thrombophilia is unknown. Recent randomized controlled trials have consistently shown that antithrombotic therapy does not increase the chance of live birth in women with unexplained recurrent miscarriage. CONCLUSIONS There are large gaps in knowledge and a lack of evidence for treatment of women with pregnancy loss with thrombophilia. To provide a solid base for clinical practice, further studies on the role of coagulation in reproduction, as well as international collaborations in randomized controlled trials of antithrombotic therapy in women with pregnancy loss, and antiphospholipid syndrome or inherited thrombophilia are urgently needed.
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Affiliation(s)
- Paulien G de Jong
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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26
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Lonjaret L, Lairez O, Minville V, Bayoumeu F, Fourcade O, Mercier F. Embolie pulmonaire et grossesse. ACTA ACUST UNITED AC 2013; 32:257-66. [DOI: 10.1016/j.annfar.2013.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 01/22/2013] [Indexed: 10/27/2022]
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Sasaki H, Yonemoto N, Hanada N, Mori R. Methods for administering subcutaneous heparin during pregnancy. Cochrane Database Syst Rev 2013:CD009136. [PMID: 23543570 DOI: 10.1002/14651858.cd009136.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pregnant women with a history of venous thromboembolism (VTE), antithrombin deficiency, or other risk factors for VTE, need heparin (unfractionated heparin (UFH) or low-molecular weight heparin (LMWH)) prophylaxis, mainly through administering subcutaneously. Several methods of administering heparin (UFH or LMWH) subcutaneously have been introduced to prevent adverse pregnant outcomes. The effectiveness and safety of different methods administering subcutaneous heparin (UFH or LMWH) during pregnancy have not been systematically evaluated. OBJECTIVES To compare the effectiveness and safety of different methods of administering subcutaneous heparin (UFH or LMWH) to pregnant women. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013) and reference lists of retrieved studies. SELECTION CRITERIA All randomised controlled trials (individual and cluster) comparing the effectiveness and safety of different methods of administering subcutaneous heparin (UFH or LMWH) during pregnancy. Studies reported only as abstracts were eligible for inclusion and would have been placed in studies awaiting assessment, pending the full publication of their results. Quasi-randomised studies and cross-over trials were not eligible for inclusion..Methods of administering subcutaneous heparin include intermittent injections versus indwelling catheters or programmable (auto) external infusion pumps, or any other devices to facilitate the subcutaneous administration of heparin (UFH or LMWH) during pregnancy. DATA COLLECTION AND ANALYSIS If eligible trials had been identified, trial quality would have been assessed and data extracted, unblinded by review authors independently. MAIN RESULTS No trials met the inclusion criteria for the review. AUTHORS' CONCLUSIONS There is no evidence from randomised controlled trials to evaluate the effectiveness and safety of different methods of administering subcutaneous heparin (UFH or LMWH) to pregnant women.
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Affiliation(s)
- Hatoko Sasaki
- Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan
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28
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Abstract
Heparins are widely used for prophylaxis and treatment of thromboembolic diseases. Besides bleeding complications, heparin-induced skin lesions are the most frequent unwanted adverse effects of subcutaneous heparin treatment. Evidence suggests that these lesions are more common than previously thought. Lesions are most frequently due to either allergic reactions or to possibly life-threatening heparin-induced thrombocytopenia. Early recognition and adequate treatment are highly important, because although both complications initially show a similar clinical picture, their treatment should be fundamentally different. Furthermore, risk factors associated with the patient, drug, and treatment regimen have been identified. We review the clinical range of heparin-induced skin lesions, emphasise evidence and controversies in epidemiology, diagnosis, and differential diagnosis, and discuss the management of patients with these skin lesions.
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Affiliation(s)
- Marc Schindewolf
- Division of Vascular Medicine and Haemostaseology, Department of Internal Medicine, Hospital of the Johann Wolfgang Goethe University, Frankfurt am Main, Germany
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30
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Lussana F, Coppens M, Cattaneo M, Middeldorp S. Pregnancy-related venous thromboembolism: Risk and the effect of thromboprophylaxis. Thromb Res 2012; 129:673-80. [DOI: 10.1016/j.thromres.2012.01.017] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 01/27/2012] [Accepted: 01/31/2012] [Indexed: 11/24/2022]
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31
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Abstract
Pregnancy is associated with an increased risk of venous thromboembolism (VTE) and this condition remains an important cause of maternal morbidity and mortality. The use of anticoagulant therapy for treatment and prophylaxis of VTE during pregnancy is challenging because of the potential for fetal, as well as maternal, complications. Although evidence-based recommendations for the use of anticoagulants have been published, given the paucity of available data, guidelines are based largely upon observational studies and from data in nonpregnant patients. This article reviews the available literature and provides guidance for the management and prevention of VTE during pregnancy.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University & Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
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Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e691S-e736S. [PMID: 22315276 PMCID: PMC3278054 DOI: 10.1378/chest.11-2300] [Citation(s) in RCA: 843] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The use of anticoagulant therapy during pregnancy is challenging because of the potential for both fetal and maternal complications. This guideline focuses on the management of VTE and thrombophilia as well as the use of antithrombotic agents during pregnancy. METHODS The methods of this guideline follow the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS We recommend low-molecular-weight heparin for the prevention and treatment of VTE in pregnant women instead of unfractionated heparin (Grade 1B). For pregnant women with acute VTE, we suggest that anticoagulants be continued for at least 6 weeks postpartum (for a minimum duration of therapy of 3 months) compared with shorter durations of treatment (Grade 2C). For women who fulfill the laboratory criteria for antiphospholipid antibody (APLA) syndrome and meet the clinical APLA criteria based on a history of three or more pregnancy losses, we recommend antepartum administration of prophylactic or intermediate-dose unfractionated heparin or prophylactic low-molecular-weight heparin combined with low-dose aspirin (75-100 mg/d) over no treatment (Grade 1B). For women with inherited thrombophilia and a history of pregnancy complications, we suggest not to use antithrombotic prophylaxis (Grade 2C). For women with two or more miscarriages but without APLA or thrombophilia, we recommend against antithrombotic prophylaxis (Grade 1B). CONCLUSIONS Most recommendations in this guideline are based on observational studies and extrapolation from other populations. There is an urgent need for appropriately designed studies in this population.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.
| | - Ian A Greer
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, England
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Anne-Marie Prabulos
- Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, CT
| | - Per Olav Vandvik
- Medical Department, Innlandet Hospital Trust and Norwegian Knowledge Centre for the Health Services, Gjøvik, Norway
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Abstract
Abstract
Thrombophilia is found in many patients presenting with venous thromboembolism (VTE). However, whether the results of such tests help in the clinical management of such patients has not been determined. Thrombophilia testing in asymptomatic relatives may be useful in families with antithrombin, protein C, or protein S deficiency or homozygosity for factor V Leiden, but is limited to women who intend to become pregnant or who would like to use oral contraceptives. Careful counseling with knowledge of absolute risks helps patients in making an informed decision in which their own preferences can be taken into account. Observational studies show that patients who have had VTE and have thrombophilia are at most at a slightly increased risk for recurrence. In an observational study, the risk of recurrent VTE in patients who had been tested for inherited thrombophilia was not lower than in patients who had not been tested. In the absence of trials comparing routine and prolonged anticoagulant treatment in patients testing positive for thrombophilia, testing for such defects to prolong anticoagulant therapy cannot be justified. Diagnosing antiphospholipid syndrome (APS) in women with recurrent miscarriage usually leads to treatment with aspirin and low-molecular-weight heparin (LMWH), although the evidence to support this treatment is limited. Because testing for thrombophilia serves a limited purpose, this test should not be performed on a routine basis.
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Abstract
Abstract
Venous thromboembolism (VTE) complicates ∼ 1 to 2 of 1000 pregnancies, with pulmonary embolism being a leading cause of maternal mortality and deep vein thrombosis an important cause of maternal morbidity, also on the long term. However, a strong evidence base for the management of pregnancy-related VTE is missing. Management is not standardized between physicians, centers, and countries. The management of pregnancy-related VTE is based on extrapolation from the nonpregnant population, and clinical trial data for the optimal treatment are not available. Low-molecular-weight heparin (LMWH) in therapeutic doses is the treatment of choice during pregnancy, and anticoagulation (LMWH or vitamin K antagonists postpartum) should be continued until 6 weeks after delivery with a minimum total duration of 3 months. Use of LMWH or vitamin K antagonists does not preclude breastfeeding. Whether dosing should be based on weight or anti-Xa levels is unknown, and practices differ between centers. Management of delivery, including the type of anesthesia if deemed necessary, requires a multidisciplinary approach, and several options are possible, depending on local preferences and patient-specific conditions.
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Abstract
Thrombophilia can be identified in about half of all patients presenting with VTE. Testing has increased tremendously for various indications, but whether the results of such tests help in the clinical management of patients has not been settled. I use evidence from observational studies to conclude that testing for hereditary thrombophilia generally does not alter the clinical management of patients with VTE, with occasional exceptions for women at fertile age. Because testing for thrombophilia only serves limited purpose this should not be performed on a routine basis.
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Affiliation(s)
- Saskia Middeldorp
- Academic Medical Centre, Department of Vascular Medicine, F4-276, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
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Roeters van Lennep JE, Meijer E, Klumper FJCM, Middeldorp JM, Bloemenkamp KWM, Middeldorp S. Prophylaxis with low-dose low-molecular-weight heparin during pregnancy and postpartum: is it effective? J Thromb Haemost 2011; 9:473-80. [PMID: 21232006 DOI: 10.1111/j.1538-7836.2011.04186.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The optimal approach for venous thrombosis (VTE) prophylaxis during pregnancy and postpartum in women with an increased risk of VTE is not established. OBJECTIVES To evaluate the effectiveness, represented as the incidence of pregnancy-related VTE, and safety, represented as incidence of postpartum hemorrhage (PPH), of a protocol recommending prophylaxis with low-dose low-molecular-weight heparin (LMWH) in women at intermediate to high risk of VTE. PATIENTS/METHODS In this retrospective cohort study, we analyzed 34 women (44 pregnancies) with intermediate risk of VTE who received low-dose LMWH for 6 weeks postpartum and 57 women (82 pregnancies) with high risk of VTE who received low-dose LMWH during pregnancy and for 6 weeks postpartum. Pregnancy-related VTE was defined as VTE during pregnancy or ≤ 3 months postpartum. PPH was defined as blood loss >500 mL and severe PPH as blood loss > 1000 mL. RESULTS The incidence of pregnancy-related VTE was 5.5% (95% CI, 2.4-12.3) despite prophylaxis with low-dose LMWH. All events occurred in women at high risk, with a postpartum incidence of 7.0% (95% CI, 2.9-16.7) and antepartum incidence of 1.8% (95% CI, 0.4-9.2). The risk of PPH was 21.6% (95% CI, 14.3-31.3) and severe PPH 9.1% (95% CI, 4.7-16.9), which was not different in women who started LMWH postpartum and those who used LMWH during pregnancy. CONCLUSIONS Although prophylaxis with low-dose LMWH during pregnancy and postpartum proved to be safe, the risk of pregnancy-related VTE is considerable in women with a high risk of VTE. VTE prophylaxis with low-dose LMWH may not be sufficiently effective in these women.
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Abstract
In Western nations, venous thromboembolism (VTE) is an important cause of morbidity and the most common cause of maternal death during pregnancy and the puerperium. Pregnancy is a hypercoagulable state in which coagulation is activated and thrombolysis inhibited. This prothrombotic risk is compounded when hereditary and acquired thrombophilias and other prothrombotic risk factors are present. The risk of venous thrombotic events is increased fivefold during pregnancy and 60-fold in the first 3 months after delivery (postpartum period) compared with nonpregnant women. Many of the signs and symptoms of VTE overlap those of a normal pregnancy, which complicates the diagnosis. Patients with history of previous VTE should use graduated compression stockings throughout pregnancy and the puerperium, and should receive postpartum anticoagulant prophylaxis. The indications for antepartum anticoagulant prophylaxis are somewhat controversial. This article reviews the management of VTE during pregnancy and in the postpartum period.
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Schindewolf M, Scheuermann J, Kroll H, Garbaraviciene J, Hecking C, Marzi I, Wolter M, Kaufmann R, Boehncke WH, Lindhoff-Last E, Ludwig RJ. Low allergenic potential with fondaparinux: results of a prospective investigation. Mayo Clin Proc 2010; 85:913-9. [PMID: 20843983 PMCID: PMC2947963 DOI: 10.4065/mcp.2010.0346] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the incidence and causes of skin reactions to the synthetic pentasaccharide fondaparinux. PATIENTS AND METHODS Patients who received prophylactic/therapeutic subcutaneous fondaparinux treatment for more than 7 days were prospectively examined for cutaneous adverse effects between September 1, 2008, and April 30, 2009. When indicated, other procedures, such as skin biopsy, allergy testing, and clinical/laboratory assessment for thrombosis and heparin-induced thrombocytopenia, were performed. RESULTS Overall, 231 patients were enrolled. No patient developed typical delayed type IV hypersensitivity (DTH) erythematous skin lesions. However, one female patient experienced abdominal pruritus at sites of injection. Histology revealed a mild lymphohistiocytic infiltrate, confirming a DTH reaction. Heparin-induced thrombocytopenia, as another possible underlying pathomechanism for cutaneous lesions, was ruled out clinically and serologically. Hence, the overall incidence of fondaparinux-induced allergic skin lesions was 0.4% (95% confidence interval, 0.01%-2.4%). No cross-allergies were observed in patients with DTH reaction to heparins. CONCLUSION Fondaparinux has a low allergenic potential. The incidence of allergic cutaneous DTH reactions is almost 20 times lower compared to that with commonly used heparins. These results, together with the known low prevalence of secondary thrombotic events or heparin-induced thrombocytopenia during fondaparinux therapy, suggest that in selected patients fondaparinux might substantially improve patient care, therapeutic safety, and cost-effectiveness of anticoagulant therapy. TRIAL REGISTRATION clinicaltrials.gov identifier: NCT00510432.
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Affiliation(s)
- Marc Schindewolf
- Department of Internal Medicine, J. W. Goethe University Hospital, Theodor-Stern-Kai 7, Bldg. 13A, 60590 Frankfurt am Main, Germany.
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Knol HM, Schultinge L, Erwich JJHM, Meijer K. Fondaparinux as an alternative anticoagulant therapy during pregnancy. J Thromb Haemost 2010; 8:1876-9. [PMID: 20492464 DOI: 10.1111/j.1538-7836.2010.03926.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Schindewolf M, Kroll H, Ackermann H, Garbaraviciene J, Kaufmann R, Boehncke WH, Ludwig RJ, Lindhoff-Last E. Heparin-induced non-necrotizing skin lesions: rarely associated with heparin-induced thrombocytopenia. J Thromb Haemost 2010; 8:1486-91. [PMID: 20128858 DOI: 10.1111/j.1538-7836.2010.03795.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
SUMMARY BACKGROUND Recently, there has been an increasing number of reports regarding adverse skin reactions to subcutaneous heparin administration. Case series have implied that heparin-induced skin lesions are predominantly associated with life-threatening heparin-induced thrombocytopenia (HIT) in at least 22% of patients. Skin lesions, therefore, have been included in clinical scores for HIT. OBJECTIVES To determine the association of heparin-induced skin lesions with HIT. This would have a pivotal impact on further anticoagulatory management in patients with heparin-induced skin lesions. PATIENTS/METHODS In our observational cohort study, 87 consecutive patients with heparin-induced skin lesions (85 occurring during low-molecular-weight heparin administration) were evaluated using a standardized internal protocol, including HIT diagnostics (heparin-platelet factor 4-ELISA, heparin-induced platelet activation assay), platelet count monitoring, clinical/sonographical screening for thrombosis, skin allergy testing and, if necessary, histology. RESULTS None of the observed heparin-induced skin lesions was due to HIT; all lesions were caused by delayed-type IV-hypersensitivity reactions (DTH) instead. Even the cutaneous reaction in one patient with concomitant HIT could be classified histologically as DTH reaction, amounting to an association of heparin-induced skin lesions and HIT in 1.2% (1/87; 95% confidence interval, 0.00-0.06). CONCLUSION Heparin-induced skin lesions associated with use of low-molecular-weight heparins do not seem to be strongly associated with a systemic immunologic reaction in terms of HIT and might rather be due to DTH reactions than due to microvascular thrombosis. Hence, we propose refining existing pretest probability scores for HIT, unless underlying causes have been clarified.
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Affiliation(s)
- M Schindewolf
- Division of Vascular Medicine and Hemostaseology, Department of Medicine, JW Goethe University Hospital, Frankfurt/M, Germany.
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Schindewolf M, Schwaner S, Wolter M, Kroll H, Recke A, Kaufmann R, Boehncke WH, Lindhoff-Last E, Ludwig RJ. Incidence and causes of heparin-induced skin lesions. CMAJ 2009; 181:477-81. [PMID: 19786468 DOI: 10.1503/cmaj.081729] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Little is known about the incidence and causes of heparin-induced skin lesions. The 2 most commonly reported causes of heparin-induced skin lesions are immune-mediated heparin-induced thrombocytopenia and delayed-type hypersensitivity reactions. METHODS We prospectively examined consecutive patients who received subcutaneous heparin (most often enoxaparin or nadroparin) for the presence of heparin-induced skin lesions. If such lesions were identified, we performed a skin biopsy, platelet count measurements, and antiplatelet-factor 4 antibody and allergy testing. RESULTS We enrolled 320 patients. In total, 24 patients (7.5%, 95% confidence interval [CI] 4.7%-10.6%) had heparin-induced skin lesions. Delayed-type hypersensitivity reactions were identified as the cause in all 24 patients. One patient with histopathologic evidence of delayed-type hypersensitivity tested positive for antiplatelet-factor 4 antibodies. We identified the following risk factors for heparin-induced skin lesions: a body mass index greater than 25 (odds ratio [OR] 4.6, 95% CI 1.7-15.3), duration of heparin therapy longer than 9 days (OR 5.9, 95% CI 1.9-26.3) and female sex (OR 3.0, 95% CI 1.1-8.8). INTERPRETATION Heparin-induced skin lesions are relatively common, have identifiable risk factors and are commonly caused by a delayed-type hypersensitivity reaction (type IV allergic response).
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Affiliation(s)
- Marc Schindewolf
- Department of Internal Medicine, Division of Angiology, Hospital of the Johann Wolfgang Goethe University, Frankfurt am Main, Germany
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Magnani HN. An analysis of clinical outcomes of 91 pregnancies in 83 women treated with danaparoid (Orgaran). Thromb Res 2009; 125:297-302. [PMID: 19656552 DOI: 10.1016/j.thromres.2009.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2009] [Revised: 05/07/2009] [Accepted: 06/02/2009] [Indexed: 10/20/2022]
Abstract
UNLABELLED Danaparoid case reports of 91 pregnancies in 83 patients with a history of thrombophilia and/or intra-uterine growth retardation have been analysed. All had intolerance to the heparins including HIT and acute or past thromboses or a history of repeated pregnancy loss (RPL). Danaparoid was started in the first, second and third trimesters in 60.2%, 19.3% and 20.5% pregnancies respectively at a dosing intensity of 1000 to 7500 U/day. Subcutaneous and/or intravenous administration was continued for a median 105 days (range 1-252) during pregnancy and 7 days (range 2 to 56) post-partum. The live birth rate was 90.4% (75/81) and danaparoid was restarted after 37 deliveries. Maternal adverse events in 46.2% of the pregnancies included 2 post cesarean deaths (a failed post-operative resuscitation and a major bleed in a patient refusing transfusion), 3 non-fatal major bleeds (associated with cesarean section and faulty placental implantation), 3 thrombo-embolic events unresponsive to danaparoid dose increase and 10 recurrent rashes. Seven early miscarriages, 1 therapeutic termination and 1 neonatal death occurred. In 13 reports a maternal, but no fetal, adverse event was attributed to danaparoid. Anti-Xa activity levels in maternal plasma were between 0.1 and 1.2 U/mL, absent from 6 fetal cord blood samples and 0 - 0.07 U/mL in the 5 maternal breast milk samples tested. CONCLUSION The successful birth rate and adverse event profile indicates that danaparoid can be an effective and safe alternative anti-thrombotic in pregnancies complicated by HIT or intolerance or resistance to (LMW)heparins.
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Rodger MA. Thrombophilia and placenta-mediated pregnancy complications: from the bench to bedside to policy. Thromb Res 2009; 123 Suppl 2:S100-4. [DOI: 10.1016/s0049-3848(09)70021-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Middeldorp S, van Hylckama Vlieg A. Does thrombophilia testing help in the clinical management of patients? Br J Haematol 2008; 143:321-35. [PMID: 18710381 DOI: 10.1111/j.1365-2141.2008.07339.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Saskia Middeldorp
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
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Nelson SM, Greer IA. Thromboembolic events in pregnancy: pharmacological prophylaxis and treatment. Expert Opin Pharmacother 2007; 8:2917-31. [DOI: 10.1517/14656566.8.17.2917] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Schulman S, Lindmarker P, Holmström M, Lärfars G, Carlsson A, Nicol P, Svensson E, Ljungberg B, Viering S, Nordlander S, Leijd B, Jahed K, Hjorth M, Linder O, Beckman M. Post-thrombotic syndrome, recurrence, and death 10 years after the first episode of venous thromboembolism treated with warfarin for 6 weeks or 6 months. J Thromb Haemost 2006; 4:734-42. [PMID: 16634738 DOI: 10.1111/j.1538-7836.2006.01795.x] [Citation(s) in RCA: 316] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The influence of the duration of anticoagulant therapy after venous thromboembolism (VTE) on the long-term morbidity and mortality is unclear. AIM To investigate the long-term sequelae of VTE in patients randomized to different duration of secondary prophylaxis. METHODS In a multicenter trial comparing secondary prophylaxis with vitamin K antagonists for 6 weeks or 6 months, we extended the originally planned 2 years follow-up to 10 years. The patients had annual visits and at the last visit clinical assessment of the post-thrombotic syndrome (PTS) was performed. Recurrent thromboembolism was adjudicated by a radiologist, blinded to treatment allocation. Causes of death were obtained from the Swedish Death Registry. RESULTS Of the 897 patients randomized, 545 could be evaluated at the 10 years follow-up. The probability of developing severe PTS was 6% and any sign of PTS was seen in 56.3% of the evaluated patients. In multivariate analysis, old age and signs of impaired circulation at discharge from the hospital were independent risk factors at baseline for development of PTS after 10 years. Recurrent thromboembolism occurred in 29.1% of the patients with a higher rate among males, older patients, those with permanent triggering risk factor - especially with venous insufficiency at baseline - signs of impaired venous circulation at discharge, proximal deep vein thrombosis, or pulmonary embolism. Death occurred in 28.5%, which was a higher mortality than expected with a standardized incidence ratio (SIR) of 1.43 (95% CI 1.28-1.58), mainly because of a higher mortality than expected from cancer (SIR 1.83; 95% CI 1.44-2.23) or from myocardial infarction or stroke (SIR 1.28; 95% CI 1.00-1.56). The duration of anticoagulation did not have a statistically significant effect on any of the long-term outcomes. CONCLUSION The morbidity and mortality during 10 years after the first episode of VTE is high and not reduced by extension of secondary prophylaxis from 6 weeks to 6 months. A strategy to reduce recurrence of VTE as well as mortality from arterial disease is needed.
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Affiliation(s)
- S Schulman
- Department of Hematology, Coagulation Unit, Karolinska University Hospital, Stockholm, Sweden.
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Greer IA, Nelson-Piercy C. Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood 2005; 106:401-7. [PMID: 15811953 DOI: 10.1182/blood-2005-02-0626] [Citation(s) in RCA: 458] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
To assess the safety and efficacy of low-molecular-weight heparins (LMWHs) for thromboprophylaxis and treatment of venous thromboembolism (VTE) in pregnancy, a systematic review of studies to the end of 2003 was undertaken. Data on VTE recurrence and side effects were extracted and cumulative incidences of VTE and adverse effects calculated. Of 81 reports identified, 64 reporting 2777 pregnancies were included. In 15 studies (174 patients) the indication for LMWH was treatment of acute VTE, and in 61 studies (2603 pregnancies) it was thromboprophylaxis or adverse pregnancy outcome. There were no maternal deaths. VTE and arterial thrombosis (associated with anti-phospholipid syndrome) were reported in 0.86% (95% confidence interval [CI], 0.55%-1.28%) and 0.50% (95% CI, 0.28%-0.84%) of pregnancies, respectively. Significant bleeding, generally associated with primary obstetric causes, occurred in 1.98% (95% CI, 1.50%-2.57%), allergic skin reactions in 1.80% (95% CI, 1.34%-2.37%), heparin-induced thrombocytopenia in 0%, thrombocytopenia (unrelated to LMWH) in 0.11% (95% CI, 0.02%-0.32%), and osteoporotic fracture in 0.04% (95% CI, < 0.01%-0.20%) of pregnancies. Overall, live births were reported in 94.7% of pregnancies, including 85.4% in those receiving LMWH for recurrent pregnancy loss. LMWH is both safe and effective to prevent or treat VTE in pregnancy.
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Affiliation(s)
- Ian A Greer
- Department of Obstetrics and Gynaecology, University of Glasgow, Glasgow Royal Infirmary, 10 Alexandra Parade, Glasgow, G31 2ER, United Kingdom.
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