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Kayikci U, Fadiloglu E, Cigdem Bayrak A, Alptug Kir E, Esat Temiz B, Deren O. Guideline-based venous thromboprophylaxis in postpartum women: An in-depth evaluation of ACOG and RCOG recommendations and real-life implementation. Eur J Obstet Gynecol Reprod Biol 2024; 299:272-277. [PMID: 38924871 DOI: 10.1016/j.ejogrb.2024.06.027] [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: 02/07/2024] [Revised: 06/13/2024] [Accepted: 06/16/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES Venous thromboembolism is one of the most serious complications of the postpartum period, and international societies have various thromboprophylaxis guidelines for its prevention. This study compares postpartum venous thromboprophylaxis recommendations from the American College of Obstetrics and Gynecology (ACOG) and the Royal College of Obstetricians and Gynecologists (RCOG) with real-life clinical practices. STUDY DESIGN Data analysis of 1000 postpartum women at a tertiary care center focused on patient demographics, venous thromboembolism risk factors, and clinical thromboprophylaxis practices. Patient-specific risk factors were compared between ACOG and RCOG guidelines, assessing Low-Molecular-Weight-Heparin dosages and durations. Guideline compliance, undertreatment/overtreatment rates, and the required number of prefilled Low-Molecular-Weight-Heparin syringes were evaluated. RESULTS Significant discrepancies were observed between ACOG and RCOG guidelines, particularly in Low Molecular Weight Heparin dosages and durations. Consensus rates with clinical approaches were around 53%, with inconsistencies leaning towards undertreatment (RCOG) and overtreatment (ACOG). The number of required prefilled Low-Molecular-Weight-Heparin syringes was notably higher according to RCOG compared to ACOG guidelines. CONCLUSION Postpartum Venous thromboembolism prophylaxis guidelines from American College of Obstetrics and Gynecology and Royal College of Obstetricians and Gynecologists exhibit substantial differences, leading to variations in clinical practice. Further research on the significance of Venous thromboembolism risk factors is essential for improving risk assessment tools and refining guideline recommendations for pregnancy-related Venous thromboembolism prevention.
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Affiliation(s)
- Umutcan Kayikci
- Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine and Perinatology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Erdem Fadiloglu
- Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine and Perinatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ayse Cigdem Bayrak
- Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine and Perinatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Edip Alptug Kir
- Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine and Perinatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Bilal Esat Temiz
- Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ozgur Deren
- Department of Obstetrics and Gynaecology, Division of Maternal Fetal Medicine and Perinatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Vuong ADB, Pham TH, Bui VH, Nguyen XT, Trinh NB, Nguyen YON, Le DKT, Nguyen PN. Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review. Int J Emerg Med 2024; 17:14. [PMID: 38287235 PMCID: PMC10823749 DOI: 10.1186/s12245-024-00587-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 01/12/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Cardiopulmonary collapse is a catastrophic event in cesarean section, which leads to adverse outcomes for both the mother and the fetus. Pulmonary embolism is one of the rare etiologies of this entity. We herein reported the successful management of acute embolism pulmonary associated with cesarean delivery on a healthy pregnant woman at our tertiary referral hospital. CASE PRESENTATION A full-term pregnant woman hospitalized for planned cesarean delivery due to placenta previa without cardiorespiratory diseases. She was scheduled uneventfully for a planned cesarean section. After placental delivery, the patient spontaneously fell into cardiopulmonary collapse and her vital signs deteriorated rapidly. The obstetricians promptly completed the cesarean section and performed all procedures to prevent the PPH and preserve the uterus. At the same time, the anesthesiologists continued to carry out advanced heart-lung resuscitation in order to control her vital signs. After surgery, the multidisciplinary team assessed the patient and found a thrombus in her pulmonary circulation. Therefore, the patient was managed with therapeutic anticoagulation. The patient recovered in good clinical condition and was discharged after 2 weeks without any complications. CONCLUSIONS The diagnosis of acute pulmonary embolism is extremely difficult due to uncommon occurrence, sudden onset, and non-specific presentation. Awareness of this life-threatening pathology during cesarean delivery should be raised. Interdisciplinary assessment must be essentially established in this life-threatening condition. After the whole conventional management, uterine conservation may be acceptable where applicable. Further data is required to encourage this finding.
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Affiliation(s)
- Anh Dinh Bao Vuong
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Thanh Hai Pham
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Van Hoang Bui
- Integrated Planning Room, Tu Du Hospital, Ho Chi Minh City, Vietnam
| | - Xuan Trang Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Ngoc Bich Trinh
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Yen Oanh Ngoc Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Dang Khoa Tran Le
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam
| | - Phuc Nhon Nguyen
- Department of High-Risk Pregnancy, Tu Du Hospital, 284 Cong Quynh, Pham Ngu Lao Ward, District 1, Ho Chi Minh City, 71012, Vietnam.
- Tu Du Clinical Research Unit (TD-CRU), Tu Du Hospital, Ho Chi Minh City, Vietnam.
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Fatokun TB, Swartz SE, Ebeid A, Cordes SA, Gimovsky AC, Sparks AD, Amdur RL, Ahmadzia HK. Venous Thromboembolism Risk Factors in Women With Obesity Who Undergo Cesarean Delivery. Clin Appl Thromb Hemost 2024; 30:10760296241247203. [PMID: 38619922 PMCID: PMC11020749 DOI: 10.1177/10760296241247203] [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: 11/01/2023] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 04/17/2024] Open
Abstract
Venous thromboembolism (VTE) is a leading cause of maternal mortality. Obesity and cesarean delivery are established risk factors for pregnancy-related VTE. We identified additional risk factors among patients with obesity who underwent a cesarean delivery to identify those who need VTE prophylaxis. We conducted a secondary analysis of data from the Maternal-Fetal Medicine Units Network (MFMU) Cesarean Registry Database using a case-control design. Cases were identified as women with obesity having a pre-pregnancy body mass index of >30 kg/m2, who underwent cesarean delivery and subsequently developed deep venous thrombosis (DVT) or pulmonary embolism (PE). These women were compared to a control group of women with obesity who underwent cesarean delivery but did not develop DVT or PE. Analysis of risk factors associated with VTE was performed using Chi-Square test and Fisher's exact test. We identified 43 VTE cases and 172 controls in the MFMU database. Increased risk of VTE was noted in women with endometritis (OR of 4.58 [95% CI: 1.86-11.2, P = .0004]), receiving a blood transfusion (OR 17.07 [95% CI: 4.46-65.3, P = .0001]), having a coagulopathy (OR 27.73 [95% CI: 3.24-237.25, P = .0003]), and urinary tract infection (OR 2.39 [95% CI: 1.08-5.28, P = .03]). Important risk factors for VTE in women with obesity who undergo cesarean delivery include endometritis, intra- or post-operative transfusion, coagulopathy, and urinary tract infection. The presence of one or more of these factors may help guide provider decision-making regarding whether to administer thromboprophylaxis.
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Affiliation(s)
- Tolulope B. Fatokun
- Department of Obstetrics and Gynecology, Cumberland Regional Hospital, Somerset, KY, USA
| | - Sarah E. Swartz
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ahmed Ebeid
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Sophia A. Cordes
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Alexis C. Gimovsky
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brown University, Providence, RI, USA
| | - Andrew D. Sparks
- Department of Biomedical Statistics, University of Vermont, Burlington, VT, USA
| | - Richard L. Amdur
- Department of Surgery, Medical Faculty Associate, Washington, DC, USA
| | - Homa K. Ahmadzia
- Department of Obstetrics and Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Francis AP, Alshowaikh K, Napoleon M, Al-Khan A, Kayaalp E. Venous Thromboembolism Risk Assessment Models in Obstetrics: A Review of Current Practices and Future Directions. Am J Perinatol 2023; 40:1509-1514. [PMID: 35235956 DOI: 10.1055/a-1785-8948] [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: 11/01/2022]
Abstract
Pregnancy is a major risk factor for venous thromboembolism (VTE) and its associated complications. The hypercoagulable state in both the antenatal and postnatal periods contributes to thromboembolism and continues to be a leading cause of maternal morbidity and mortality worldwide. The non-specific signs and symptoms of VTE in pregnancy and the lack of specific Risk Assessment Models (RAMs) propose a diagnostic challenge in the obstetric population. This review aims to discuss and compare existing RAMs and highlights the important challenges of using established RAMs in obstetric patients. It also emphasizes the importance of enhancing and individualizing RAMs in obstetrics to improve maternal healthcare. KEY POINTS: · VTE is a major complication of pregnancy, associated with increased maternal morbidity and mortality.. · VTE RAMs lack sensitivity and specificity in stratifying VTE risk in pregnancy.. · Validating VTE RAMs in the obstetric population aims to improve maternal outcomes..
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Affiliation(s)
- Antonia P Francis
- Department of Obstetrics and Gynecology, Hackensack Meridian Health, Hackensack, New Jersey
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Khadija Alshowaikh
- Department of Obstetrics and Gynecology, Hackensack Meridian Health, Hackensack, New Jersey
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Melissa Napoleon
- Department of Obstetrics and Gynecology, Hackensack Meridian Health, Hackensack, New Jersey
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Abdulla Al-Khan
- Department of Obstetrics and Gynecology, Hackensack Meridian Health, Hackensack, New Jersey
- Hackensack Meridian School of Medicine, Nutley, New Jersey
| | - Emre Kayaalp
- Department of Obstetrics and Gynecology, Hackensack Meridian Health, Hackensack, New Jersey
- Hackensack Meridian School of Medicine, Nutley, New Jersey
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5
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Delgado García DR, Real Valdés R, Serrano Rodríguez ML, Molina Mendoza CR, Quílez Caballero E, García Del Valle Manzano S. Massive deep vein thrombosis in pregnant women: The importance of individualizing the action plan. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:497-501. [PMID: 36088272 DOI: 10.1016/j.redare.2021.07.005] [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: 02/07/2021] [Accepted: 07/06/2021] [Indexed: 06/15/2023]
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially lethal condition to be taken into account in pregnant women, where the situation is favored by the characteristic physiological changes of the pregnancy, childbirth and the puerperium. The management of this pathology in this type of patient is based on anticoagulation, with the benefits and drawbacks that this implies. We present the case of a pregnant woman with massive DVT and the issues are discussed, such as the method of delivery (vaginal vs. cesarean section) or the management of treatment (LMWH vs. UFH) in order to obtain the safest situation for the patient.
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Affiliation(s)
- D R Delgado García
- Servicio de Anestesiología y Reanimación, Hospital Universitario Fundación, Madrid, Spain.
| | - R Real Valdés
- Servicio de Anestesiología y Reanimación, Hospital Universitario Fundación, Madrid, Spain
| | - M L Serrano Rodríguez
- Servicio de Anestesiología y Reanimación, Hospital Universitario Fundación, Madrid, Spain
| | - C R Molina Mendoza
- Servicio de Anestesiología y Reanimación, Hospital Universitario Fundación, Madrid, Spain
| | - E Quílez Caballero
- Servicio de Radiodiagnóstico, Hospital Universitario Rey Juan Carlos, Madrid, Spain
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Muhamad N, Abu MA, Kalok AH, Shafiee MN, Shah SA, Ismail NAM. Safety and effectiveness of fondaparinux as a postpartum thromboprophylaxis during puerperium among muslim women: A single centre prospective study. Front Pharmacol 2022; 13:887020. [PMID: 36210844 PMCID: PMC9540499 DOI: 10.3389/fphar.2022.887020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/24/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Venous thromboembolism (VTE) remains one of the leading causes of maternal morbidity and mortality, with postpartum period carrying the greatest risk. Perinatal thromboprophylaxis is often administered based on risk-factor assessment. Low molecular weight heparin has a proven safety profile in the obstetrics population, however, its porcine-derived content may lead to reduced uptake amongst certain religious groups. We aimed to evaluate the safety of fondaparinux as an alternative postpartum thromboprophylaxis. Methods: We conducted a prospective, single arm, open label study from September 2017 until March 2018. Women who fulfilled the criteria for post natal thromboprophylaxis based on the 2015 RCOG guidelines were recruited. Each patient received subcutaneous injection of Fondaparinux, 2.5 mg daily for 10 days. A telephone interview was conducted on day 10 post delivery. Each woman was subsequently reviewed in the outpatient clinic 6 weeks postpartum. The primary outcome measure was occurrence of pulmonary embolism or deep vein thrombosis suggestive by clinical symptoms and assessment. Secondary outcome measures were allergic reaction and bleeding tendency such as secondary post-partum haemorrhage, spinal site bleeding and wound haematoma. Allergic reaction and bleeding tendency in neonates were also recorded. Results: Sixty women were included in the analysis. There were no VTE cases amongst our cohort. No major bleeding was recorded. Two patients (3.3%) had wound haematoma, one of which occurred 3 weeks post delivery. No adverse effect in neonates was noted. Conclusion: Fondaparinux is a safe alternative thromboprophylaxis for postpartum women.
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Affiliation(s)
- Normaliza Muhamad
- Department of Obstetrics and Gynecology, UKM Medical Centre, Kuala Lumpur, Malaysia
| | - Muhammad Azrai Abu
- Department of Obstetrics and Gynecology, UKM Medical Centre, Kuala Lumpur, Malaysia
- *Correspondence: Muhammad Azrai Abu,
| | - Aida Hani Kalok
- Department of Obstetrics and Gynecology, UKM Medical Centre, Kuala Lumpur, Malaysia
| | - Mohd Nasir Shafiee
- Department of Obstetrics and Gynecology, UKM Medical Centre, Kuala Lumpur, Malaysia
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7
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Obata-Yasuoka M, Ohara R, Hosokawa Y, Nishida K, Abe H, Mayumi M, Ishizu T, Endo-Kawamura N, Hamada H, Satoh T. Obstetric venous thromboembolism: Evaluation of prophylactic approach based on risk scores, D-dimer levels, and ultrasonography findings in a tertiary hospital in Japan. J Obstet Gynaecol Res 2022; 48:2334-2344. [PMID: 35732592 DOI: 10.1111/jog.15332] [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: 02/12/2022] [Revised: 04/22/2022] [Accepted: 06/01/2022] [Indexed: 12/01/2022]
Abstract
AIM Pulmonary embolism remains a leading cause of maternal mortality in developed countries despite developments in venous thromboembolism prophylaxis strategies. This study aimed to evaluate the effectiveness of our approach involving risk-scoring, D-dimer level assessment, and ultrasonography for obstetric venous thromboembolism. METHODS This retrospective cohort study included women who delivered at 22-41 weeks of gestation in The University of Tsukuba Hospital, Japan between January and December 2020. Venous thromboembolism risk (determined according to Japanese guidelines) and D-dimer levels were evaluated within 20 weeks of gestation, 30-34 weeks of gestation, and during the pre-delivery period (36 weeks of gestation or any time before preterm delivery). Compression and color Doppler ultrasonography for lower extremity deep vein thrombosis were performed if D-dimer levels were ≥3.2 μg/mL (for those undergoing cesarean delivery, 1.0 μg/mL). RESULTS Of 1026 women, 6 women had deep vein thrombosis during pregnancy and 1 during the puerperium period. Pulmonary embolism was not observed. The D-dimer screening result was positive for 8 women (2%) within 20 weeks of gestation (deep vein thrombosis was confirmed in 3 of them), 87 women (10%) (no deep vein thrombosis) at 30-34 weeks of gestation, and 367 women (36%) during the pre-delivery period (asymptomatic deep vein thrombosis in one). Based on the Japanese guidelines, 1%, 11%, 33%, and 55% of women had high, intermediate, low, and no postpartum risk factors, respectively. CONCLUSIONS Our approach appears useful for antenatal venous thromboembolism screening in the first trimester. For postpartum prophylaxis, more cost-effective strategies are needed.
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Affiliation(s)
- Mana Obata-Yasuoka
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Rena Ohara
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yoshihiko Hosokawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Keiko Nishida
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Haruna Abe
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Miyuki Mayumi
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Naho Endo-Kawamura
- Department of Anesthesiology, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Hiromi Hamada
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Toyomi Satoh
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Khryshchanovich VY, Skobeleva NY. Prophylaxis and management of venous thromboembolism during pregnancy and postpartum period. OBSTETRICS, GYNECOLOGY AND REPRODUCTION 2021. [DOI: 10.17749/2313-7347/ob.gyn.rep.2021.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction. Venous thromboembolism (VTE) is one of the lead causes for maternal mortality and morbidity during pregnancy in the majority of developed countries. The incidence rate of VTE per pregnancy-year increases during pregnancy and postpartum period about by 4-fold and at least 14-fold, respectively.Aim: to analyze and summarize current view on risk factors of thrombotic events during gestation and to discuss recent guidelines for the management of venous thromboembolic complications during pregnancy and postpartum, by taking into account a balance between risks and benefits of using anticoagulants.Materials and Methods. The literature search covering the last 10 years was carried out in the electronic scientific databases RSCI, PubMed/MEDLINE, and Embase. While formulating a search strategy for evidence-based information, the PICO method (P = Patient; I = Intervention; C = Comparison; O = Outcome) and the key terms “venous thromboembolism” and “pregnancy” were used.Results. Risk factors were found to include a personal history of VTE, verified inherited or acquired thrombophilia, a family history of VTE and general medical conditions, such as immobilization, overweight, varicose veins, some hematological diseases and autoimmune disorders. VTE is considered being potentially preventable upon prophylactic administration of anticoagulants, but no high confidence randomized clinical trials comparing diverse strategies of thromboprophylaxis in pregnant women have been proposed so far. Because heparins do not cross the placenta, weight-adjusted therapeutic-dose low molecular weight heparins (LMWH) represent the anticoagulant treatment of choice for VTE during pregnancy. Once- and twice-daily dosing regimens are acceptable. However, no evidence suggesting benefits for measurement of factor Xa activities and consecutive LMWH dose adjustments to improve clinical outcomes are available. In case of uncomplicated pregnancy-related VTE, no routine administration of vitamin K antagonists, direct thrombin or factor Xa inhibitors, fondaparinux, or danaparoid is recommended. Lactating women may switch from applying LMWH to warfarin. Anticoagulation therapy should be continued for 6 weeks postpartum with total duration lasting at least for 3 months.Conclusion. VTE is a challenging task in pregnant women expecting to apply a multi-faceted approach for its efficient solution by taking into account updated recommendations and personalized patient-oriented features.
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Affiliation(s)
| | - N. Ya. Skobeleva
- Belarussian State Medical University;
Clinical Maternity Hospital of Minsk Region
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Low Molecular Weight Heparins (LMWH) and Implications along Pregnancy: a Focus on the Placenta. Reprod Sci 2021; 29:1414-1423. [PMID: 34231172 DOI: 10.1007/s43032-021-00678-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
Low molecular weight heparins (LMWH) have been largely studied for their use during pregnancy. The biology and the pharmacology of these molecules are well known and may be summarized in three main mechanisms of action: anti-coagulant, anti-inflammatory, and immunomodulant. The clinical implications of these drugs during pregnancy are mainly related to their action on the placenta, because of the presence of specific molecular and cellular targets, particularly at the trophoblast-endometrial interface. As well as for the prevention and treatment of thromboembolism, LMWH have been largely investigated for the improvement of embryo implantation and for the prevention of placenta-related complications such as preeclampsia, fetal growth restriction, and intrauterine fetal death. However, data on this topic are still unclear. The present review discusses the biological features, the mechanisms of action, and the possible contribution of LMWH to the success of placentation along pregnancy, pointing out the need for future basic science and clinical researches in this important field with the final aim to improve clinical practice in high-risk pregnancies.
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10
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Kjaergaard AB, Fuglsang J, Hvas AM. Anti-Xa Monitoring of Low-Molecular-Weight Heparin during Pregnancy: A Systematic Review. Semin Thromb Hemost 2021; 47:824-842. [PMID: 34130342 DOI: 10.1055/s-0041-1726374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Low-molecular-weight heparin (LMWH) is commonly used for preventing or treating venous thromboembolic disease (VTE) during pregnancy. The physiological changes in maternal metabolism have led to discussions on optimal LMWH dosing strategy and possible need for monitoring. The aim of this systematic review is to summarize and discuss whether LMWH dose adjustment according to anti-Xa provides superior effectiveness and safety compared with weight adjusted or fixed dosed LMWH in pregnant women. A systematic literature search was performed in PubMed, Embase, and Scopus on September 26, 2020. The study is reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Effectiveness was defined as episodes of thrombosis and safety as bleeding episodes. In total, 33 studies were included: 4 randomized controlled studies and 29 cohort studies. Prophylactic dosing strategies employing weight dosed, fixed dosed, or anti-Xa adjusted LMWH dosing performed equal in effectiveness and safety. In pregnant women with VTE or high thromboembolic risk, therapeutic weight-adjusted LMWH and weight plus anti-Xa-adjusted LMWH provided equal results in terms of effectiveness and safety. Pregnant women with mechanical heart valves (MHVs) received therapeutic anti-Xa-adjusted LMWH with four out of seven studies presenting mean peak anti-Xa within target ranges. Still, pregnant women with MHV experienced both thrombosis and bleeding with anti-Xa in target. Based on the results of this systematic review, current evidence does not support the need for anti-Xa monitoring when using LMWH as thromboprophylaxis or treatment during pregnancy. Nonetheless, the need for anti-Xa monitoring in pregnant women with MHV may need further scrutiny.
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Affiliation(s)
| | - Jens Fuglsang
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Rappold JF, Sheppard FR, Carmichael Ii SP, Cuschieri J, Ley E, Rangel E, Seshadri AJ, Michetti CP. Venous thromboembolism prophylaxis in the trauma intensive care unit: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2021; 6:e000643. [PMID: 33718615 PMCID: PMC7908288 DOI: 10.1136/tsaco-2020-000643] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/27/2021] [Accepted: 02/06/2021] [Indexed: 02/06/2023] Open
Abstract
Venous thromboembolism (VTE) is a potential sequela of injury, surgery, and critical illness. Patients in the Trauma Intensive Care Unit are at risk for this condition, prompting daily discussions during patient care rounds and routine use of mechanical and/or pharmacologic prophylaxis measures. While VTE rightfully garners much attention in clinical patient care and in the medical literature, optimal strategies for VTE prevention are still evolving. Furthermore, trauma and surgical patients often have real or perceived contraindications to prophylaxis that affect the timing of preventive measures and the consistency with which they can be applied. In this Clinical Consensus Document, the American Association for the Surgery of Trauma Critical Care Committee addresses several practical clinical questions pertaining to specific or unique aspects of VTE prophylaxis in critically ill and injured patients.
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Affiliation(s)
| | | | | | - Joseph Cuschieri
- Surgery, University of Washington Seattle Campus, Seattle, Washington, USA
| | - Eric Ley
- Surgery, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Erika Rangel
- Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anupamaa J Seshadri
- Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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12
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Updated guidelines to reduce venous thromboembolism in trauma patients: A Western Trauma Association critical decisions algorithm. J Trauma Acute Care Surg 2021; 89:971-981. [PMID: 32590563 PMCID: PMC7587238 DOI: 10.1097/ta.0000000000002830] [Citation(s) in RCA: 123] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Barba Martín R, Joya Seijo D. Prophylaxis of venous thromboembolism during pregnancy. Rev Clin Esp 2020; 220:S0014-2565(20)30176-4. [PMID: 32646756 DOI: 10.1016/j.rce.2020.06.006] [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: 01/24/2020] [Revised: 05/19/2020] [Accepted: 06/16/2020] [Indexed: 11/28/2022]
Abstract
The purpose of this guide is to suggest, based on the available clinical evidence, the prevention measures for venous thromboembolism during pregnancy, childbirth and postpartum in expert recommendations and international guidelines. Venous thromboembolism is a cause of maternal death, and it is therefore important to consider those situations in which the risk is greater and for which women should undergo preventive treatment. Personal and family history, the presence of acquired or hereditary thrombophilia, patient-related factors and those related to pregnancy or childbirth have a relative weight that determines the start of treatment and its duration. Low-molecular-weight heparin is the treatment of choice for these women. Prophylaxis might be necessary during the antenatal or postnatal period, and the duration and indication will vary depending on the risks and benefits.
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Affiliation(s)
- R Barba Martín
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Madrid, España.
| | - D Joya Seijo
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Madrid, España
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