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Beilin Y, Liu H, Hyers BM, Mijovic V, Katz D. Is There an Association between Platelet Count and Blood Loss in the Parturient? A Retrospective Study. Am J Perinatol 2024; 41:1567-1576. [PMID: 38141621 DOI: 10.1055/s-0043-1778009] [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: 12/25/2023]
Abstract
OBJECTIVE The influence of thrombocytopenia on blood loss and postpartum hemorrhage (PPH) has been conflicting. Our aim was to determine if there is an association between predelivery platelet count and quantitative blood loss (QBL) and PPH in both vaginal (VD) and cesarean deliveries (CD). STUDY DESIGN We conducted a retrospective database study at a single institution from April 1, 2017 to September 9, 2020. The platelet count closest to time of delivery and the QBL was assessed separately for VD and CD. RESULTS A total of 22,479 records were reviewed, of which 16,822 (75%) were VD and 5,657 (25%) were CD. A total of 2,600 (12%) patients had thrombocytopenia, defined as a platelet count <150,000/mm3. Of these, 1,980 (76%) had a VD and 620 (24%) had CD. We found a statistically significant difference in QBL between parturients with thrombocytopenia compared with those without, with a median estimated difference in QBL of 25 (95% confidence interval [CI]: 16-32) and 57 mL (95% CI: 31-87) in VD and CD patients, respectively. We also found a statistically significant difference in QBL when comparing patients among all the platelet count ranges except in the lowest platelet count range of 50,000 to 69,999/mm3 with a mean difference of 52 (95% CI: 25-81) and 107 mL (95% CI: 39-180) in the VD and CD patients, respectively in the platelet count range of 70,000 to 99,999/mm3 . We also found the incidence of PPH was greater in those with thrombocytopenia, p < 0.001, but the median difference in QBL in all platelet groups was small. CONCLUSION We found a statistically significant association between lower predelivery platelet counts and QBL and PPH. The clinical significance of these results is debatable, because at all platelet count ranges, differences in blood loss were small. KEY POINTS · Hemorrhage is etiology of morbidity and mortality in obstetric parturients.. · We found a small increase in blood loss in those with thrombocytopenia.. · The clinical relevance of these findings is debatable since the increased blood loss was small..
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Affiliation(s)
- Yaakov Beilin
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Obstetrics Gynecology and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Helen Liu
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Benjamin M Hyers
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Vasilije Mijovic
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Daniel Katz
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Obstetrics Gynecology and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, New York
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David J, Desmurs-Clavel H, Mechtouff L, Long A, Dargaud Y, Catella J. The obstetrical consequences of ischemic stroke in women of childbearing age. Arch Gynecol Obstet 2024; 310:405-412. [PMID: 38679658 DOI: 10.1007/s00404-024-07498-y] [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: 02/21/2024] [Accepted: 03/25/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE Although recurrence risk is a major concern for women having had an ischemic stroke (IS) and who are planning a pregnancy, studies on recurrence risk and pregnancy outcomes are scarce and heterogeneous. METHODS This retrospective study assessed women aged 15-44 years with a diagnosis of ischemic stroke admitted in the Lyon Stroke Centre, France, between January 2009 and December 2013. The primary outcome was stroke recurrence during pregnancy or the post-partum period. Secondary outcomes were pregnancy complications. RESULTS Overall, 104 women with a prior ischemic stroke were included. Mean age at the time of the stroke was 36 ± 6.7 years old. Stroke etiology was large-artery atherosclerosis for 1 woman, cardioembolism for 23 women, and undetermined for 55 women. No antiphospholipid syndrome was found. Among them, 29 women had 58 subsequent pregnancies. Overall, there were three IS recurrence (2.9%), but none occurred during pregnancy. There were 27 miscarriages (47% of pregnancies), two pre-eclampsia (3%), and one stillbirth (1.7%). CONCLUSIONS We observed no recurrence of IS during pregnancy. The study also highlighted that the risk of miscarriages was higher than general population and that of stillbirth should be further studied.
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Affiliation(s)
- Jeremy David
- Service de Médecine Interne, Unité Médecine Vasculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, France
| | - Helene Desmurs-Clavel
- Service de Médecine Interne, Unité Médecine Vasculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, France
- Unité d'hémostase Clinique, Hôpital Cardiologique Louis Pradel, 5 Place d'Arsonval, 69003, Lyon, France
| | - Laura Mechtouff
- Stroke Department, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Lyon, France
| | - Anne Long
- Service de Médecine Interne, Unité Médecine Vasculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, France
- Interuniversity Laboratory of Human Movement Biology, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France
| | - Yesim Dargaud
- Unité d'hémostase Clinique, Hôpital Cardiologique Louis Pradel, 5 Place d'Arsonval, 69003, Lyon, France
- EA, UFR Laennec, Université Claude Bernard, 4609-Hémostase et CancerLyon 1, Lyon, France
| | - Judith Catella
- Service de Médecine Interne, Unité Médecine Vasculaire, Hôpital Edouard Herriot, Hospices Civils de Lyon, France.
- Interuniversity Laboratory of Human Movement Biology, Université Claude Bernard Lyon 1, Université de Lyon, Lyon, France.
- Laboratoire d'Excellence du Globule Rouge (Labex GR-Ex), Paris, France.
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Na MJ, Kim JK. Characteristics of factor V and protein C based on results from Korean testing centers. Blood Coagul Fibrinolysis 2024; 35:173-179. [PMID: 38477838 PMCID: PMC11064905 DOI: 10.1097/mbc.0000000000001296] [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: 02/05/2024] [Accepted: 03/01/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVE The global incidence of thrombosis is increasing. However, research on thrombosis in the context of Korea is scarce. We aimed to analyze the relationship between factor V and protein C test results and thrombosis in Koreans through a domestic commissioned testing institution conducting mass examinations. METHODS Results of factor V and protein C tests of 1386 individuals referred simultaneously to EONE Laboratories (Incheon, Republic of Korea) from January 2017 to July 2023 were analyzed retrospectively to identify the association with thrombotic disease. The tests were performed using a STAR MAX (Diagnostica Stago, Asnieres, France) automatic blood coagulation analyzer. The results were analyzed by age and sex. RESULTS The inspection rate increased gradually from 2017 to 2022. Women (70.0%) demonstrated a higher test rate than did men (30.0%). Young women reported high test rates; the test rate and age distribution differed by sex. Women aged between 20 and 49 years reported lower factor V and higher protein C concentrations than did men between 20 and 49 years of age. CONCLUSIONS The tests were more commonly performed in women than in men. Women aged between 20 and 49 years reported lower factor V concentrations and higher protein C concentrations than men between 20 and 49 years of age. This study will facilitate recognizing and preventing thrombotic diseases in women.
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Affiliation(s)
- Min Ji Na
- Department of Biomedical Laboratory Science, Dankook University College of Health Sciences, Chungnam, Republic of Korea
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Flaujac C, Faille D, Lavenu-Bombled C, Drillaud N, Lasne D, Billoir P, Desconclois C, Touzet L, Lebreton A, Diaz-Cau I, d’Oiron R, Giansily-Blaizot M, Wibaut B, Beurrier P, Volot F, Rugeri L, Roussel-Robert V, de Raucourt E. Perioperative management and neuraxial analgesia in women with factor XI deficiency (<60 IU/dL): a French multicenter observational study of 314 pregnancies. Res Pract Thromb Haemost 2024; 8:102462. [PMID: 39006229 PMCID: PMC11245963 DOI: 10.1016/j.rpth.2024.102462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/05/2024] [Accepted: 05/16/2024] [Indexed: 07/16/2024] Open
Abstract
Background Factor (F)XI deficiency is a rare bleeding disorder with a poor correlation between bleeding tendency and FXI level. Management of pregnant women with FXI deficiency is not clearly established, especially regarding neuraxial analgesia (NA). Objectives A retrospective multicenter observational study was conducted in French hemostasis centers on pregnant women with FXI of <60 IU/dL. Methods Data to report were (i) FXI levels before pregnancy and at time of delivery, (ii) type of NA and delivery management modalities, and (iii) possible complications related to NA and bleeding complications. Results Three hundred fourteen pregnancies in patients with FXI deficiency of <60 IU/dL were reported (from 20 centers); among them, 199 NA procedures have been completed (137 epidurals and 61 spinals, 1 had both). The period of childbirth was mostly from 2014 to 2020 (281/314; 89.5%). Congenital FXI deficiency was established with certainty by investigators in 32.8% patients (n = 103). Previous bleedings were described in 20.4% of the patients (64/314; 45.3% cutaneous, 31.3% gynecologic, and 15.6% postsurgical). Thirteen deliveries had an NA procedure with FXI of <30 IU/dL, 42 with FXI of 30-40 IU/dL, and 118 with FXI of 40-60 IU/dL. Median FXI levels at delivery in the epidural and spinal groups were not significantly different but were significantly lower in the group without NA by medical staff contraindications. There were no complications related to NA. A 17.5% postpartum hemorrhage or excessive postpartum bleeding incidence was reported, which is consistent with previous data. Conclusion Our data support the use of a 30 IU/dL FXI threshold for NA, as suggested by the French proposals published in August 2023.
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Affiliation(s)
- C. Flaujac
- Laboratoire de biologie médicale, Secteur hémostase, Centre hospitalier de Versailles (André Mignot), Le Chesnay-Rocquencourt, France
| | - D. Faille
- Service d’hématologie biologique, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, hôpital Bichat, Paris, France
| | - C. Lavenu-Bombled
- Service d’hématologie biologique, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - N. Drillaud
- Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles rares, Centre hospitalier Universitaire, Nantes, France
| | - D. Lasne
- Service d’hématologie biologique, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Hôpital Necker Enfants Malades, Paris, France
| | - P. Billoir
- Service d’hématologie biologique, Centre hospitalier universitaire de Rouen, Rouen, France
| | - C. Desconclois
- Service d’hématologie biologique, Assistance Publique Hôpitaux de Paris, Hôpital Antoine Béclère, Université Paris-Saclay, Clamart, France
| | - L. Touzet
- Laboratoire de biologie médicale, Centre hospitalier de Valencienne, Valencienne, France
| | - A. Lebreton
- Service d’hématologie biologique, Centre hospitalier universitaire de Clermont Ferrand, Université Clermont Auvergne, Clermont-Ferrand, France
| | - I. Diaz-Cau
- Service d’hématologie biologique, Centre hospitalier universitaire de Montpellier, Montpellier, France
| | - R. d’Oiron
- Centre de Référence de l’Hémophilie et des Maladies Hémorragiques Constitutionnelles rares, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - M. Giansily-Blaizot
- Service d’hématologie biologique, Centre hospitalier universitaire de Montpellier, Montpellier, France
| | - B. Wibaut
- Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles rares et Centre de Référence maladie de Willebrand, Centre hospitalier régional universitaire de Lille, Lille, France
| | - P. Beurrier
- Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles rares, Centre hospitalier universitaire d’Angers, Angers, France
| | - F. Volot
- Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles rares, Centre hospitalier universitaire de Dijon, Dijon, France
| | - L. Rugeri
- Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles rares, Hospices Civils de Lyon, Lyon, France
| | - V. Roussel-Robert
- Centre de Ressources et de Compétences des Maladies Hémorragiques Constitutionnelles rares, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Hôpital Cochin, Paris, France
| | - E. de Raucourt
- Centre de Ressources et Compétences des Maladies Hémorragiques Constitutionnelles rares, centre hospitalier de Versailles (André Mignot), Le Chesnay, France
- Service d’hématologie biologique, Assistance Publique Hôpitaux de Paris, Nord Université de Paris Centre, Hôpital Beaujon, Clichy, France
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Frimat M, Gnemmi V, Stichelbout M, Provôt F, Fakhouri F. Pregnancy as a susceptible state for thrombotic microangiopathies. Front Med (Lausanne) 2024; 11:1343060. [PMID: 38476448 PMCID: PMC10927739 DOI: 10.3389/fmed.2024.1343060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/12/2024] [Indexed: 03/14/2024] Open
Abstract
Pregnancy and the postpartum period represent phases of heightened vulnerability to thrombotic microangiopathies (TMAs), as evidenced by distinct patterns of pregnancy-specific TMAs (e.g., preeclampsia, HELLP syndrome), as well as a higher incidence of nonspecific TMAs, such as thrombotic thrombocytopenic purpura or hemolytic uremic syndrome, during pregnancy. Significant strides have been taken in understanding the underlying mechanisms of these disorders in the past 40 years. This progress has involved the identification of pivotal factors contributing to TMAs, such as the complement system, ADAMTS13, and the soluble VEGF receptor Flt1. Regardless of the specific causal factor (which is not generally unique in relation to the usual multifactorial origin of TMAs), the endothelial cell stands as a central player in the pathophysiology of TMAs. Pregnancy has a major impact on the physiology of the endothelium. Besides to the development of placenta and its vascular consequences, pregnancy modifies the characteristics of the women's microvascular endothelium and tends to render it more prone to thrombosis. This review aims to delineate the distinct features of pregnancy-related TMAs and explore the contributing mechanisms that lead to this increased susceptibility, particularly influenced by the "gravid endothelium." Furthermore, we will discuss the potential contribution of histopathological studies in facilitating the etiological diagnosis of pregnancy-related TMAs.
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Affiliation(s)
- Marie Frimat
- CHU Lille, Nephrology Department, Univ. Lille, Lille, France
- Inserm, Institut Pasteur de Lille, Univ. Lille, Lille, France
| | | | | | - François Provôt
- CHU Lille, Nephrology Department, Univ. Lille, Lille, France
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, CHUV and University of Lausanne, Lausanne, Switzerland
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Liu Y, Li S, Liu B, Zhang J, Wang C, Feng L. Maternal urban particulate matter (SRM 1648a) exposure disrupted the cellular immune homeostasis during early life: The potential attribution of altered placental transcriptome profile. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 912:169432. [PMID: 38135080 DOI: 10.1016/j.scitotenv.2023.169432] [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: 10/10/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
Ambient fine particular matter (PM2.5) exposure has been associated with numerous adverse effects including triggering functional disorders of the placenta and inducing immune imbalance in offspring. However, how maternal PM2.5 exposure impacts immune development during early life is not fully understood. In the current study, we exposed mice with low-, middle-, and high-dose PM2.5 during pregnancy to investigate the potential link between the transcriptional changes in the placenta and immune imbalance in mice offspring induced by PM2.5 exposures. Using flow cytometry, we found that the proportions of B cells, CD3+CD4+ T cells, CD3+CD8+ T cells, and macrophage (Mφ) cells were altered in the blood of PM2.5-exposed mice pups but not dendritic cells (DCs) and natural killer cells (NKs). Using bulk RNA sequencing, we found that PM2.5 exposure altered the transcriptional profile which indicated an inhibition of the complement and coagulation cascades in the placenta. Weighted gene co-expression network analysis (WGCNA) revealed the potential crosstalk between the perturbation of placental gene expression and the changes of immune cell subsets in pups on postnatal day 10 (PND10). Specifically, WGCNA identified a cluster of genes including Defb15, Defb20, Defb25, Cst8, Cst12, and Adam7 that might regulate the core immune cell types in PND10 pups. Although the underlying mechanisms of how maternal PM2.5 exposure induces peripheral lymphocyte disturbance in offspring still remain much unknown, our findings here shed light on the potential role of placental dysfunction in these adverse effects.
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Affiliation(s)
- Yongjie Liu
- Ministry of Education and Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, PR China
| | - Shuman Li
- Ministry of Education and Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, PR China
| | - Bin Liu
- Ministry of Education and Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, PR China
| | - Jun Zhang
- Ministry of Education and Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, PR China
| | - Cuiping Wang
- Ministry of Education and Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, PR China; Department of Maternal and Child Health, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan 250012, PR China.
| | - Liping Feng
- Ministry of Education and Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200092, PR China; Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, USA.
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Osborne B, Mitra S, Karol D, Azzi P, Ou K, Alibhai KM, Murphy MSQ, El-Chaâr D. Etiology of stillbirth in a tertiary care center: a retrospective cohort study assessing ultrasound, laboratory, and pathology investigations. J Matern Fetal Neonatal Med 2023; 36:2277131. [PMID: 37926910 DOI: 10.1080/14767058.2023.2277131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Canadian stillbirth data are limited, and a significant proportion of pregnancies resulting in stillbirth have no attributable cause. The objective of this study was to characterize stillbirth case investigations and management at a tertiary care hospital in Ontario, Canada. METHODS This was a retrospective chart review study of all cases of singleton stillbirth at The Ottawa Hospital between 1 January 2012 and 31 December 2017. Terminations and multiples stillbirths were excluded. Chart reviews were conducted to extract maternal sociodemographic, obstetrical, and fetal characteristics, including results from antenatal ultrasounds, autopsy, placenta pathology, and laboratory investigations. RESULTS A total of 155 eligible cases of stillbirth were identified, resulting in a 6-year stillbirth rate of 4.2 per 1000 total births. The median maternal age was 31.0 years (IQR: 29.0, 35.0) and the median gestational age at delivery was 28 weeks (IQR: 24, 35). A total of 9 (5.8%) pregnant individuals had a history of previous stillbirth. Of the 155 stillbirths, 35% underwent the full suite of post-loss laboratory, placental, and fetal autopsy investigations. 63.2% of cases had post-loss laboratory investigations completed. 76% and 71% of cases had fetal autopsy and placenta pathology evaluations completed, respectively. Antenatal characteristics associated with stillbirth included fetal anomalies/genetic markers (27.1%), umbilical cord and placental anomalies (24.5%), fetal growth abnormalities (27.7%), cervical/uterine abnormalities (11.6%), and amniotic fluid abnormalities (25.1%). The most common autopsy findings included evidence of infection (22.7%), fetal anomalies (12.6%), and fetal hypoxia (10%). The most common placental pathology findings included features of placental insufficiency (21.8%), retroplacental abnormalities (16.3%), and umbilical cord accident/infarct (15.4%). CONCLUSIONS Our findings demonstrate that as many as two-thirds of singleton stillbirth cases at our center did not receive the post-perinatal loss investigations recommended by clinical practice guidelines. More thorough collection of post-stillbirth data at all levels (institutional, provincial, national) is warranted to improve our understanding of stillbirth epidemiology, etiology, and management in Canada.
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Affiliation(s)
- Brenden Osborne
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Medicine, University of Galway, Galway, Ireland
| | - Sohini Mitra
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
| | - Dalia Karol
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada
| | - Pierre Azzi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Faculty of Science, University of Ottawa, Ottawa, Canada
| | - Kelsie Ou
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Kameela M Alibhai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Malia S Q Murphy
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Darine El-Chaâr
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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Brennan KA, Angelidis IK. Resuscitation in obstetric care. Int Anesthesiol Clin 2023; 61:55-61. [PMID: 37622314 DOI: 10.1097/aia.0000000000000413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Kaitlyn A Brennan
- Department of Anesthesiology & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennesse
| | - Ioannis K Angelidis
- New York University, Grossman School of Medicine, New York, New York
- Department of Anesthesiology, Perioperative Care & Pain Medicine, NYU Langone Health, New York, New York
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Theodoraki K, Hadzilia S, Valsamidis D, Kalopita K, Stamatakis E. Reply to Akça, B.; Bilotta, F. Time and Type of Administered Fluids during Cesarean Section Might Not Matter for Hemodynamic Outcomes, but There Are Significant Patient Safety Concerns Regarding Colloid Use in Parturients. Comment on "Theodoraki et al. Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter. J. Clin. Med. 2023, 12, 1333 ". J Clin Med 2023; 12:4754. [PMID: 37510868 PMCID: PMC10381518 DOI: 10.3390/jcm12144754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
We would like to take this opportunity to thank Drs Akça and Bilotta for their interest and their insightful comments [...].
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Affiliation(s)
- Kassiani Theodoraki
- Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Sofia Hadzilia
- Department of Anesthesiology, Alexandra General Hospital of Athens, 11528 Athens, Greece
| | - Dimitrios Valsamidis
- Department of Anesthesiology, Alexandra General Hospital of Athens, 11528 Athens, Greece
| | - Konstantina Kalopita
- Department of Anesthesiology, Alexandra General Hospital of Athens, 11528 Athens, Greece
| | - Emmanouil Stamatakis
- Department of Anesthesiology, Alexandra General Hospital of Athens, 11528 Athens, Greece
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Akça B, Bilotta F. Time and Type of Administered Fluids during Cesarean Section Might Not Matter for Hemodynamic Outcomes, but There Are Significant Patient Safety Concerns Regarding Colloid Use in Parturients. Comment on Theodoraki et al. Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter. J. Clin. Med. 2023, 12, 1333. J Clin Med 2023; 12:4753. [PMID: 37510867 PMCID: PMC10381353 DOI: 10.3390/jcm12144753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/20/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
We read the article by Theodoraki K and colleagues entitled 'Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter' with interest [...].
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Affiliation(s)
- Başak Akça
- Hacettepe University, School of Medicine, Department of Anaesthesiology and Reanimation, Ankara 06100, Turkey
| | - Federico Bilotta
- Department of Anaesthesiology and Reanimation, School of Medicine, Sapienza University of Rome, 00185 Rome, Italy
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Lv Y, Zhang X, Xu Q, Wu J. Factors associated with poorer childbirth outcomes in pregnant women diagnosed with placenta previa. Taiwan J Obstet Gynecol 2023; 62:423-428. [PMID: 37188447 DOI: 10.1016/j.tjog.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE Placenta previa is a health issue during pregnancy when the placenta wholly or partially covers the opening of the uterus. It can result in bleeding during pregnancy or after delivery, and preterm delivery. This study aimed to investigate the risk factors correlated with poorer childbirth outcomes of placenta previa. MATERIALS AND METHODS Between May 2019 and January 2021, pregnant women diagnosed with placenta previa in our hospital were enrolled. Outcomes were postpartum hemorrhage after childbirth, and lower Apgar score and preterm delivery of the neonate. Laboratory blood examination data preoperatively were collected from medical records. RESULTS A total of 131 subjects were included, with a median age 31 years. Multivariate analysis showed that fibrinogen reduced risk for postpartum hemorrhage (adjusted odds ratio (aOR): 0.45, 95% confidence interval (CI): 0.26-0.79, p = 0.005). Homocysteine (aOR: 0.73, 95% CI: 0.54-0.99, p = 0.04) reduced the risk while D-dimer (aOR: 1.19, 95% CI: 1.02-1.37, p = 0.02) increased the risk for low Apgar score. Age (aOR: 0.86, 95% CI: 0.77-0.96, p = 0.005) decreased the risk but history of full-term pregnancy more than twice (aOR: 8.58, 95% CI: 2.32-31.71, p = 0.001) increased the risk for preterm delivery. CONCLUSION The findings suggest that poorer childbirth outcomes in pregnant women with placenta previa are associated with young age, history of full-term pregnancy, and preoperative concentrations of low fibrinogen, low homocysteine and high D-dimer. This provides obstetricians adjunctive information for early screening of high-risk population and relevant treatment arrangement in advance.
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Affiliation(s)
- Yuqiong Lv
- Department of Obstetrics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, 362000, China
| | - Xueya Zhang
- Department of Hematology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, 362000, China
| | - Qiuxia Xu
- Department of Pharmacy, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, 362000, China
| | - Jingjing Wu
- Department of Obstetrics, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, 362000, China.
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12
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Nguyen KP, Aqui TLB, Milestone H. Factor VII Deficiency and Second Trimester Abortion: A Case Report. Cureus 2023; 15:e37039. [PMID: 37143638 PMCID: PMC10153760 DOI: 10.7759/cureus.37039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2023] [Indexed: 04/04/2023] Open
Abstract
The prevalence of factor VII deficiency (F7D) is 1 in 500,000. Due to its rarity, the management of bleeding disorders in pregnancy is not well established. We examine a case of an 18-year-old (gravida 1, para 0) woman at approximately 19 weeks gestation with a known history of F7D who presents after a motor vehicle accident. Fetal demise was confirmed necessitating a medical induction. She also had multiple fractures requiring surgical intervention. A multidisciplinary team consisting of orthopedic surgery, obstetrics and gynecology, and hematology/oncology was consulted for optimal timing of factor VII replacement prior to procedures. The patient underwent successful left tibial intramedullary nailing with minimal bleeding. She received factor VII and tolerated an uncomplicated vaginal delivery. Her postpartum and postoperative courses were uncomplicated, requiring one unit of packed red blood cells. The patient was discharged on postpartum day three. Management of this second-trimester abortion with a history of F7D was possible with effective communication and the organization of a multidisciplinary team to account for the risk of thrombosis versus hemorrhage and the availability of factor VII replacement therapy.
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13
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Hilali C, Aboulaghras S, Lamalmi N. Pathophysiological, immunogenetic, anatomopathological profile of thrombophilia in pregnancy. Transfus Clin Biol 2023:S1246-7820(23)00043-5. [PMID: 37028589 DOI: 10.1016/j.tracli.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/24/2023] [Accepted: 03/31/2023] [Indexed: 04/08/2023]
Abstract
Thrombophilic states have been associated with early and/or late pregnancy loss and possibly other severe obstetrical complications. Pregnancy-induced hypercoagulability, increased stasis, and the consequences of inherited and acquired thrombophilia are just a few of the factors that contribute to the development of thrombosis in pregnancy. In this review, we illustrate the impact that these factors have on the development of thrombophilia during pregnancy. We also explore how thrombophilia impact pregnancy outcomes. Next, we discuss how human leukocyte antigen G plays a part in thrombophilia during pregnancy by regulating cytokine release to prevent trophoblastic cell invasion and maintain local immunotolerance constant. Human leukocyte antigen class E is briefly explored with thrombophilia in pregnancy. Regarding the anatomopathologic aspect, we describe the different histopathological lesions of the placenta found in women with thrombophilia.
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14
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Lukic A, Cmelak L, Draženović D, Kojundzic H, Lukic IK, Gluncic V. Pulmonary Arteriovenous Malformation Unmasked by Pregnancy: A Review of Pulmonary Arteriovenous Malformations and Cardiovascular and Respiratory Changes in Pregnancy. Case Rep Pulmonol 2023; 2023:5469592. [PMID: 37026089 PMCID: PMC10072959 DOI: 10.1155/2023/5469592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/05/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Pulmonary arteriovenous malformations are abnormal, direct communications between the branches of the pulmonary artery and pulmonary veins, but without pulmonary capillaries between them. During pregnancy, PAVMs can enlarge and become symptomatic, causing even serious complications like haematothorax. To recognize the PAVM that becomes symptomatic in pregnancy, one must be able to distinguish the patient’s symptoms caused by developing complications of PAVM, as in the case we present, from physiological changes accompanying a healthy pregnancy, including their degree in relation to the stage of pregnancy. The modified early obstetric warning score charts are a very helpful tool in the assessment of (ab)normal signs and symptoms in pregnant women, especially for physicians who rarely manage pregnant women.
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15
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Collis R, Bell S. The Role of Thromboelastography during the Management of Postpartum Hemorrhage: Background, Evidence, and Practical Application. Semin Thromb Hemost 2023; 49:145-161. [PMID: 36318958 DOI: 10.1055/s-0042-1757895] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Postpartum hemorrhage (PPH) is a common cause of significant maternal morbidity and mortality that can be associated with coagulopathy, especially hypofibrinogenemia. There is interest in point-of-care viscoelastic hemostatic assays (POC-VHA) in PPH because prompt knowledge of coagulation status can aid diagnosis, identify cases of severe coagulopathy, and allow ongoing monitoring during rapid bleeding. The incidence of coagulopathy in most cases of PPH is low because of the procoagulant state of pregnancy, including raised fibrinogen levels of around 4 to 6 g/L. A Clauss fibrinogen of >2 g/L or POC-VHA equivalent has been found to be adequate for hemostasis during PPH. POC-VHA has been used successfully to diagnose hypofibrinogenemia (Clauss fibrinogen of ≤2 g/L) and guide fibrinogen treatment which has reduced bleed size and complications of massive transfusion. There are uncertainties about the use of POC-VHA to direct fresh frozen plasma and platelet administration during PPH. Several POC-VHA algorithms have been used successfully incorporated in the management of many thousands of PPHs and clinicians report that they are easy to use, interpret, and aid decision making. Due to the relative cost of POC-VHA and lack of definitive data on improving outcomes, these devices have not been universally adopted during PPH.
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Affiliation(s)
- Rachel Collis
- Department of Anaesthetics, University Hospital of Wales, Cardiff, United Kingdom
| | - Sarah Bell
- Department of Anaesthetics, University Hospital of Wales, Cardiff, United Kingdom
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16
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Surgical Emergencies in the Pregnant Patient. Curr Probl Surg 2023; 60:101304. [PMID: 37169419 DOI: 10.1016/j.cpsurg.2023.101304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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17
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Yamashita Y, Morimoto T, Kadota K, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Inoko M, Tada T, Chen PM, Murata K, Tsuyuki Y, Nishimoto Y, Sakamoto J, Togi K, Mabuchi H, Takabayashi K, Kato T, Ono K, Kimura T. Clinical characteristics, management strategies and outcomes of patients with recurrent venous thromboembolism in the real world. Sci Rep 2022; 12:22437. [PMID: 36575292 PMCID: PMC9794688 DOI: 10.1038/s41598-022-26947-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
There is a paucity of data on management strategies and clinical outcomes after recurrent venous thromboembolism (VTE). In a multicenter registry enrolling 3027 patients with acute symptomatic VTE, the current study population was divided into the following 3 groups: (1) First recurrent VTE during anticoagulation therapy (N = 110); (2) First recurrent VTE after discontinuation of anticoagulation therapy (N = 116); and (3) No recurrent VTE (N = 2801). Patients with first recurrent VTE during anticoagulation therapy more often had active cancer (45, 25 and 22%, P < 0.001). Among 110 patients with first recurrent VTE during anticoagulation therapy, 84 patients (76%) received warfarin at recurrent VTE with the median prothrombin time-international normalized ratio (PT-INR) value at recurrent VTE of 1.6, although patients with active cancer had a significantly higher median PT-INR value at recurrent VTE compared with those without active cancer (2.0 versus 1.4, P < 0.001). Within 90 days after recurrent VTE, 23 patients (20.9%) during anticoagulation therapy and 24 patients (20.7%) after discontinuation of anticoagulation therapy died. Active cancer was a major cause of recurrent VTE during anticoagulation therapy as a patient-related factor, while sub-optimal intensity of anticoagulation therapy was a major cause of recurrent VTE during anticoagulation therapy as a treatment-related factor, particularly in patients without active cancer.
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Affiliation(s)
- Yugo Yamashita
- grid.258799.80000 0004 0372 2033Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Takeshi Morimoto
- grid.272264.70000 0000 9142 153XDepartment of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazushige Kadota
- grid.415565.60000 0001 0688 6269Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- grid.413111.70000 0004 0466 7515Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- grid.415432.50000 0004 0377 9814Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- grid.410843.a0000 0004 0466 8016Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- grid.410835.bDepartment of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- grid.417000.20000 0004 1764 7409Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- grid.414936.d0000 0004 0418 6412Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Moriaki Inoko
- grid.415392.80000 0004 0378 7849Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomohisa Tada
- grid.415804.c0000 0004 1763 9927Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- grid.415800.80000 0004 1763 9863Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- grid.415744.70000 0004 0377 9726Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Yuji Nishimoto
- grid.413697.e0000 0004 0378 7558Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Jiro Sakamoto
- grid.416952.d0000 0004 0378 4277Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Kiyonori Togi
- grid.258622.90000 0004 1936 9967Division of Cardiology, Faculty of Medicine, Nara Hospital, Kinki University, Ikoma, Japan
| | - Hiroshi Mabuchi
- grid.513109.fDepartment of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Takao Kato
- grid.258799.80000 0004 0372 2033Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Koh Ono
- grid.258799.80000 0004 0372 2033Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Takeshi Kimura
- grid.258799.80000 0004 0372 2033Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
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18
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COVID-19: Impact of Original, Gamma, Delta, and Omicron Variants of SARS-CoV-2 in Vaccinated and Unvaccinated Pregnant and Postpartum Women. Vaccines (Basel) 2022; 10:vaccines10122172. [PMID: 36560582 PMCID: PMC9786095 DOI: 10.3390/vaccines10122172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/09/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
This study compares the clinical characteristics and disease progression among vaccinated and unvaccinated pregnant and postpartum women who tested positive for different variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using the Brazilian epidemiological data. Data of pregnant or postpartum patients testing positive for SARS-CoV-2 and presenting with coronavirus disease 2019 (COVID-19) from February 2020 to July 2022 were extracted from Brazilian national database. The patients were grouped based on vaccination status and viral variant (original, Gamma, Delta, and Omicron variants), and their demographics, clinical characteristics, comorbidities, symptoms, and outcomes were compared retrospectively. Data of 10,003 pregnant and 2361 postpartum women were extracted from the database. For unvaccinated postpartum women, intensive care unit (ICU) admission was more likely; invasive ventilation need was more probable if they tested positive for the original, Gamma, and Omicron variants; and chances of death were higher when infected with the original and Gamma variants than when infected with other variants. Vaccinated patients had reduced adverse outcome probability, including ICU admission, invasive ventilation requirement, and death. Postpartum women showed worse outcomes, particularly when unvaccinated, than pregnant women. Hence, vaccination of pregnant and postpartum women should be given top priority.
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19
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Johnsen JM, MacKinnon HJ. JTH in Clinic - Obstetric bleeding: VWD and other inherited bleeding disorders. J Thromb Haemost 2022; 20:1568-1575. [PMID: 35621921 DOI: 10.1111/jth.15770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 01/19/2023]
Abstract
Individuals with inherited bleeding disorders (IBDs) have higher bleeding risk during pregnancy, childbirth, and the postpartum period. Clinical management requires recognition of the IBD as high risk for postpartum hemorrhage and a personalized multidisciplinary approach that includes the patient in decision making. When the fetus is known or at risk to inherit a bleeding disorder, fetal and neonatal bleeding risk also need to be considered. In pregnant IBD patients, it is common for providers to need to make decisions in the absence of high level of certainty evidence. We here present the case of a pregnant von Willebrand disease patient that reached multiple decision points where there is currently clinical ambiguity due to a lack of high level of certainty evidence. For each stage of her care, from diagnosis to the postpartum period, we discuss current literature and describe our approach. This is followed by a brief overview of considerations in other IBDs and pregnancy.
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Affiliation(s)
- Jill M Johnsen
- Bloodworks Research Institute, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Washington Center for Bleeding Disorders, Seattle, Washington, USA
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20
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Lumbreras-Marquez MI, Villela-Franyutti D, Reale SC, Farber MK. Coagulation Management in Obstetric Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00517-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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21
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Dias JD, Butwick AJ, Hartmann J, Waters JH. Viscoelastic haemostatic point-of-care assays in the management of postpartum haemorrhage: a narrative review. Anaesthesia 2022; 77:700-711. [PMID: 35194779 DOI: 10.1111/anae.15662] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2021] [Indexed: 01/29/2023]
Abstract
Viscoelastic haemostatic assays provide rapid testing at the bed-side that identify all phases of haemostasis, from initial fibrin formation to clot lysis. In obstetric patients, altered haemostasis is common as pregnancy is associated with coagulation changes that may contribute to bleeding events such as postpartum haemorrhage, as well as thrombosis events. In this narrative review, we examine the potential clinical utility of viscoelastic haemostatic assays in postpartum haemorrhage and consider the current recommendations for their use in obstetric patients. We discuss the clinical benefits associated with the use of viscoelastic haemostatic assays due to the provision of (near) real-time readouts with a short turnaround, coupled with the identification of coagulation defects such as hypofibrinogenaemia. The use of viscoelastic haemostatic assay-guided algorithms may be beneficial to diagnose coagulopathy, predict postpartum haemorrhage, reduce transfusion requirements and monitor fibrinolysis in women with obstetric haemorrhage. Further studies are required to assess whether viscoelastic haemostatic assay-guided treatment improves clinical outcomes, and to confirm the utility of prepartum viscoelastic haemostatic assay measurements for identifying patients at risk of postpartum haemorrhage.
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Affiliation(s)
- J D Dias
- Haemonetics Corporation, Boston, MA, USA
| | - A J Butwick
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA
| | - J Hartmann
- Haemonetics Corporation, Boston, MA, USA
| | - J H Waters
- Department of Anesthesiology and Bioengineering, University of Pittsburgh and McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
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22
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Lithgow KV, Buchholz VCH, Ku E, Konschuh S, D'Aubeterre A, Sycuro LK. Protease activities of vaginal Porphyromonas species disrupt coagulation and extracellular matrix in the cervicovaginal niche. NPJ Biofilms Microbiomes 2022; 8:8. [PMID: 35190575 PMCID: PMC8861167 DOI: 10.1038/s41522-022-00270-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 01/14/2022] [Indexed: 12/14/2022] Open
Abstract
Porphyromonas asaccharolytica and Porphyromonas uenonis are common inhabitants of the vaginal microbiome, but their presence has been linked to adverse health outcomes for women, including bacterial vaginosis and preterm birth. However, little is known about the pathogenesis mechanisms of these bacteria. The related oral opportunistic pathogen, Porphyromonas gingivalis, is comparatively well-studied and known to secrete numerous extracellular matrix-targeting proteases. Among these are the gingipain family of cysteine proteases that drive periodontal disease progression and hematogenic transmission to the placenta. In this study, we demonstrate that vaginal Porphyromonas species secrete broad-acting proteases capable of freely diffusing within the cervicovaginal niche. These proteases degrade collagens that are enriched within the cervix (type I) and chorioamniotic membranes (type IV), as well as fibrinogen, which inhibits clot formation. Bioinformatic queries confirmed the absence of gingipain orthologs and identified five serine, cysteine, and metalloprotease candidates in each species. Inhibition assays revealed that each species' proteolytic activity can be partially attributed to a secreted metalloprotease with broad substrate specificity that is distantly related to the P. gingivalis endopeptidase PepO. This characterization of virulence activities in vaginal Porphyromonas species highlights their potential to alter the homeostasis of reproductive tissues and harm human pregnancy through clotting disruption, fetal membrane weakening, and premature cervical remodeling.
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Affiliation(s)
- Karen V Lithgow
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Vienna C H Buchholz
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Emily Ku
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Shaelen Konschuh
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
| | - Ana D'Aubeterre
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada
- Department of Biological Sciences, University of Alberta, Edmonton, AB, Canada
| | - Laura K Sycuro
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, AB, Canada.
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada.
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
- International Microbiome Centre, University of Calgary, Calgary, AB, Canada.
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23
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Viscoelastic Hemostatic Assays: A Primer on Legacy and New Generation Devices. J Clin Med 2022; 11:jcm11030860. [PMID: 35160311 PMCID: PMC8836477 DOI: 10.3390/jcm11030860] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 02/06/2023] Open
Abstract
Viscoelastic hemostatic assay (VHAs) are whole blood point-of-care tests that have become an essential method for assaying hemostatic competence in liver transplantation, cardiac surgery, and most recently, trauma surgery involving hemorrhagic shock. It has taken more than three-quarters of a century of research and clinical application for this technology to become mainstream in these three clinical areas. Within the last decade, the cup and pin legacy devices, such as thromboelastography (TEG® 5000) and rotational thromboelastometry (ROTEM® delta), have been supplanted not only by cartridge systems (TEG® 6S and ROTEM® sigma), but also by more portable point-of-care bedside testing iterations of these legacy devices (e.g., Sonoclot®, Quantra®, and ClotPro®). Here, the legacy and new generation VHAs are compared on the basis of their unique hemostatic parameters that define contributions of coagulation factors, fibrinogen/fibrin, platelets, and clot lysis as related to the lifespan of a clot. In conclusion, we offer a brief discussion on the meteoric adoption of VHAs across the medical and surgical specialties to address COVID-19-associated coagulopathy.
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24
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Lee J, Eley VA, Wyssusek KH, Kimble RMN, Way M, van Zundert AA. Rotational thromboelastometry (ROTEM ® ) in gestational diabetes mellitus and coagulation in healthy term pregnancy: A prospective observational study in Australia. Aust N Z J Obstet Gynaecol 2022; 62:389-394. [PMID: 34994402 DOI: 10.1111/ajo.13474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rotational thromboelastometry (ROTEM® ) is a point-of-care test of coagulation. ROTEM® -defined hypercoagulability has been identified in pregnant women and in non-pregnant patients with diabetes mellitus. Pregnancy is known to be a hypercoagulable state, but the influence of gestational diabetes mellitus (GDM) on coagulation is unknown. AIM The aim of this study was to assess the combined effect of pregnancy and GDM on coagulation using ROTEM® and to compare this to healthy pregnant women presenting for elective caesarean delivery. MATERIALS AND METHODS Ethics approval was granted for recruitment of women presenting for elective caesarean delivery. Women with pre-existing conditions affecting coagulation were excluded. Group N included health pregnant women at term and Group G included pregnant women at term with GDM. Data regarding GDM management and glycaemic control were collected. Poor glycaemic control was defined by markers of accelerated fetal growth and elevated fasting or postprandial blood glucose levels. The ROTEM® parameters (extrinsically activated thromboelastometric test (EXTEM) / fibrin polymerisation test (FIBTEM) amplitude at five minutes, coagulation time, maximum clot firmness and clot formation time) were compared between the two groups using Student's t-test. RESULTS There were 75 women in Group N and 21 women in Group G. Mean age and median body mass index values were comparable for both groups. There were no statistical differences found between the EXTEM and FIBTEM parameters analysed for the two groups. CONCLUSIONS There was no association between GDM and increased hypercoagulability as demonstrated by ROTEM® parameters in healthy pregnant women presenting for elective caesarean delivery at term.
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Affiliation(s)
- Julie Lee
- Department of Anaesthesia and Perioperative Services, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
| | - Victoria A Eley
- Department of Anaesthesia and Perioperative Services, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
| | - Kerstin H Wyssusek
- Department of Anaesthesia and Perioperative Services, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
| | - Rebecca M N Kimble
- The University of Queensland, Brisbane, Queensland, Australia.,Department of Obstetrics, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Mandy Way
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Andre A van Zundert
- Department of Anaesthesia and Perioperative Services, The Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,The University of Queensland, Brisbane, Queensland, Australia
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25
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Nair M, Chhabra S, Choudhury SS, Deka D, Deka G, Kakoty SD, Kumar P, Mahanta P, Medhi R, Rani A, Rao S, Roy I, Solomi V C, Talukdar RK, Zahir F, Kansal N, Arora A, Opondo C, Armitage J, Laffan M, Stanworth S, Quigley M, Baigent C, Knight M, Kurinczuk JJ. Relationship between anaemia, coagulation parameters during pregnancy and postpartum haemorrhage at childbirth: a prospective cohort study. BMJ Open 2021; 11:e050815. [PMID: 34607867 PMCID: PMC8491293 DOI: 10.1136/bmjopen-2021-050815] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 09/17/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To investigate the association between coagulation parameters and severity of anaemia (moderate anaemia: haemoglobin (Hb) 7-9.9 g/dL and severe anaemia: Hb <7 g/dL) during pregnancy and relate these to postpartum haemorrhage (PPH) at childbirth. DESIGN A prospective cohort study of pregnant women recruited in the third trimester and followed-up after childbirth. SETTING Ten hospitals across four states in India. PARTICIPANTS 1342 pregnant women. INTERVENTION Not applicable. METHODS Hb and coagulation parameters: fibrinogen, D-dimer, D-dimer/fibrinogen ratio, platelets and international normalised ratio (INR) were measured at baseline. Participants were followed-up to measure blood loss within 2 hours after childbirth and PPH was defined based on blood loss and clinical assessment. Associations between coagulation parameters, Hb, anaemia and PPH were examined using multivariable logistic regression models. OUTCOMES MEASURES Adjusted OR with 95% CI. RESULTS In women with severe anaemia during the third trimester, the D-dimer was 27% higher, mean fibrinogen 117 mg/dL lower, D-dimer/fibrinogen ratio 69% higher and INR 12% higher compared with women with no/mild anaemia. Mean platelets in severe anaemia was 37.8×109/L lower compared with women with moderate anaemia. Similar relationships with smaller effect sizes were identified for women with moderate anaemia compared with women with no/mild anaemia. Low Hb and high INR at third trimester of pregnancy independently increased the odds of PPH at childbirth, but the other coagulation parameters were not found to be significantly associated with PPH. CONCLUSION Altered blood coagulation profile in pregnant women with severe anaemia could be a risk factor for PPH and requires further evaluation.
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Affiliation(s)
- Manisha Nair
- NPEU, Nuffield Department of Population Health, Oxford University, Oxford, Oxfordshire, UK
| | - Shakuntala Chhabra
- Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | - Saswati Sanyal Choudhury
- Department of Obstetrics and Gynaecology, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Dipika Deka
- Srimanta Sankaradeva University of Health Sciences, Guwahati, Assam, India
| | - Gitanjali Deka
- Department of Obstetrics and Gynaecology, Tezpur Medical College, Tezpur, India
| | - Swapna D Kakoty
- Department of Obstetrics and Gynaecology, Fakhruddin Ali Ahmed Medical College and Hospital, Barpeta, Assam, India
| | - Pramod Kumar
- Department of Obstetrics and Gynaecology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | - Pranabika Mahanta
- Department of Obstetrics and Gynaecology, Jorhat Medical College and Hospital, Jorhat, Assam, India
| | - Robin Medhi
- Department of Obstetrics and Gynaecology, Fakhruddin Ali Ahmed Medical College and Hospital, Barpeta, Assam, India
| | - Anjali Rani
- Department of Obstetrics and Gynaecology, Banaras Hindu University Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | - Seeresha Rao
- Department of Obstetrics and Gynaecology, Silchar Medical College and Hospital, Silchar, Assam, India
| | - Indrani Roy
- Department of Obstetrics and Gynaecology, Nazareth Hospital, Shillong, Meghalaya, India
| | - Carolin Solomi V
- Department of Obstetrics and Gynaecology, Makunda Christian Leprosy and General Hospital, Karimganj, Assam, India
| | - Ratna Kanta Talukdar
- Department of Obstetrics and Gynaecology, Jorhat Medical College and Hospital, Jorhat, Assam, India
| | - Farzana Zahir
- Department of Obstetrics and Gynaecology, Assam Medical College, Dibrugarh, Assam, India
| | - Nimmi Kansal
- National Reference Laboratory, Dr Lal Pathlabs, New Delhi, India
| | - Anil Arora
- National Reference Laboratory, Dr Lal Pathlabs, New Delhi, India
| | - Charles Opondo
- Nuffield Department of Population Health, Oxford University, Oxford, Oxfordshire, UK
| | - Jane Armitage
- Nuffield Department of Population Health, Oxford University, Oxford, Oxfordshire, UK
| | - Michael Laffan
- Haemostasis and Thrombosis, Imperial College London Faculty of Medicine, London, UK
| | - Simon Stanworth
- Department of Haematology/Transfusion Medicine, Oxford University, Oxford, Oxfordshire, UK
| | - Maria Quigley
- National Perinatal Epidemiology Unit, Oxford University, Oxford, Oxfordshire, UK
| | - Colin Baigent
- Nuffield Department of Population Health, Oxford University, Oxford, Oxfordshire, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Oxford University, Oxford, Oxfordshire, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Oxford University, Oxford, Oxfordshire, UK
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Getrajdman C, Shin DW, Sison M, Katz D. Baseline parameters for non-activated rotational thromboelastometry tests with and without heparinase in healthy pregnant women at term gestation. J Clin Anesth 2021; 75:110484. [PMID: 34500406 DOI: 10.1016/j.jclinane.2021.110484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 08/05/2021] [Accepted: 08/11/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To determine the normal values for non-activated thromboelastometry parameters among pregnant women. DESIGN Prospective, observational study. SETTING Tertiary care hospital. PATIENTS Non-laboring women at term gestation without history of bleeding or clotting disorder or anticoagulation use. INTERVENTIONS Venous blood samples were collected and ROTEM® was performed using NATEM and NaHEPTEM assays. MEASUREMENTS Reference ranges were derived by calculating 2.5 and 97.5 percentiles for the following parameters: clotting time (CT), clot formation time (CFT), amplitude at 10 (A10) and 20 min (A20), alpha angle, maximum clot firmness (MCF), and lysis index at 30 (LI30) and 60 min (LI60). The NATEM/NaHEPTEM CT ratio was calculated to determine the baseline ratio in term pregnant women. MAIN RESULTS 146 women were screened and 120 were enrolled. The median age was 34 years [31-36], median gestational age was 39.1 weeks [38.3-39.3], and median parity was 1 [0-2]. Median pre-delivery platelet and hematocrit levels were within the normal ranges. The reference ranges for NATEM parameters were: CT (232-759 (s)), CFT (69-243 (s)), alpha angle (50-77 (°)), A10 (44-69 (mm)), A20 (54-75 (mm)), MCF (57-77 (mm)), LI30 (100-100 (%)), LI60 (90-100 (%)). The reference ranges for NaHEPTEM parameters were: CT (224-717 (s)), CFT (66-210 (s)), alpha angle (53-77 (°)), A10 (44-67 (mm)), A20 (55-73 (mm)), MCF (58-74 (mm)), LI30 (99-100 (%)), LI60 (90-100 (%)). The NATEM to NaHEPTEM CT ratio reference range was 0.73-1.3. CONCLUSIONS This study is the first to our knowledge to report reference ranges for non-activated ROTEM® tests with and without heparinase in non-laboring term pregnant women. These reference ranges may serve as a baseline comparison and may be useful for future research on anticoagulation management in pregnancy.
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Affiliation(s)
- Chloe Getrajdman
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Da Wi Shin
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Matthew Sison
- Department of Anesthesiology, Pain, and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Daniel Katz
- Department of Anesthesiology, Pain, and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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Liew-Spilger AE, Sorg NR, Brenner TJ, Langford JH, Berquist M, Mark NM, Moore SH, Mark J, Baumgartner S, Abernathy MP. Viscoelastic Hemostatic Assays for Postpartum Hemorrhage. J Clin Med 2021; 10:3946. [PMID: 34501395 PMCID: PMC8432102 DOI: 10.3390/jcm10173946] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/26/2021] [Accepted: 08/29/2021] [Indexed: 12/15/2022] Open
Abstract
This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.
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Affiliation(s)
- Alyson E. Liew-Spilger
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73104, USA;
| | - Nikki R. Sorg
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Toby J. Brenner
- Division of Natural Sciences, Indiana Wesleyan University, Marion, IN 46953, USA;
| | - Jack H. Langford
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN 46208, USA;
| | - Margaret Berquist
- College of Science, University of Notre Dame, Notre Dame, IN 46556, USA;
| | - Natalie M. Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Spencer H. Moore
- Marian University College of Osteopathic Medicine, Indianapolis, IN 46222, USA;
| | - Julie Mark
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN 46617, USA; (N.R.S.); (N.M.M.); (J.M.)
| | - Sara Baumgartner
- Department of Obstetrics and Gynecology, Saint Joseph Regional Medical Center, Mishawaka, IN 46545, USA
| | - Mary P. Abernathy
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
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Metzger L, Teitelbaum M, Weber G, Kumaraswami S. Complex Pathology and Management in the Obstetric Patient: A Narrative Review for the Anesthesiologist. Cureus 2021; 13:e17196. [PMID: 34540424 PMCID: PMC8439398 DOI: 10.7759/cureus.17196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2021] [Indexed: 11/20/2022] Open
Abstract
Pregnant patients may present with multiple complex comorbidities that can affect peripartum management and anesthetic care. The preanesthesia clinic is the ideal setting for early evaluation of high-risk pregnant patients. Comorbidities may include cardiovascular pathology such as valvular abnormalities, septal defects, aortopathies, arrythmias and cardiomyopathies. Additional comorbidities include pulmonary conditions such as obstructive sleep apnea as well as preexisting neuromuscular and skeletal disorders that may impact anesthetic management. Hematologic conditions involving both bleeding diathesis and thrombophilias may present unique challenges for the anesthesiologist. Patients may also present with endocrinopathies including diabetes and obesity. While not as common, high-risk patients may also have preexisting gastrointestinal conditions such as liver dysfunction, renal failure, and even post-transplant status. Ongoing and prior substance abuse, obstetric conditions such as placenta accreta spectrum disorders, and fetal conditions needing ex utero Intrapartum treatment also require advanced planning. Preanesthesia evaluations also help address important ethical and cultural considerations. Counseling patients regarding anesthetic considerations as well as addressing concerns will play a role in reducing racial and ethnic disparities. Anticipatory guidance by means of pre-anesthetic planning can facilitate multidisciplinary communication and planning. This can allow for an impactful and meaningful role in the care provided, allowing for safe maternal care and optimal outcomes.
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Affiliation(s)
- Lia Metzger
- Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | | | - Garret Weber
- Anesthesiology, New York Medical College, Valhalla, USA
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29
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Knobel R, Takemoto MLS, Nakamura-Pereira M, Menezes MO, Borges VK, Katz L, Amorim MMR, Andreucci CB. COVID-19-related deaths among women of reproductive age in Brazil: The burden of postpartum. Int J Gynaecol Obstet 2021; 155:101-109. [PMID: 34213771 PMCID: PMC9087613 DOI: 10.1002/ijgo.13811] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/01/2021] [Indexed: 12/18/2022]
Abstract
Objective To compare risk of death due to COVID‐19 among pregnant, postpartum, and non‐pregnant women of reproductive age in Brazil, using the severe acute respiratory syndrome surveillance system (SARS‐SS). Methods A secondary analysis was performed of the Brazilian official SARS‐SS, with data retrieved up to August 17, 2020. Cases were stratified by pregnancy status, risk factors or co‐morbidities, and outcome (death or recovery). Multiple logistic regression was employed to examine associations between independent variables and risk of death. Results A total of 24 805 cases were included, with 3129 deaths (12.6%), including 271 maternal deaths. Postpartum was associated with increased risk of death, admission to the intensive care unit (ICU), and mechanical ventilation. Co‐morbidities with higher impact on case fatality rate among non‐obstetric cases were cancer and neurological and kidney diseases. Among pregnant women, cancer, diabetes mellitus, obesity, and rheumatology diseases were associated with risk of death. In the postpartum subgroup, age over 35 years and diabetes mellitus were independently associated with higher chance of death. Conclusion Postpartum was associated with worse outcomes among the obstetric population, despite lower risk of dying without accessing ICU care. Non‐pregnant women with cancer, neurological diseases, and kidney diseases have a higher risk of death due to COVID‐19. Postpartum increased the risk of death, admission to the ICU, and mechanical ventilation among reproductive‐age women admitted to hospital due to COVID‐19 severe acute respiratory syndrome.
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Affiliation(s)
- Roxana Knobel
- Department of Gynecology and Obstetrics, Federal University of Santa Catarina (UFSC, Florianopolis, Santa Catarina, Brazil
| | - Maíra L S Takemoto
- São Paulo State University (UNESP, Medical School of Botucatu, Botucatu, São Paulo, Brazil
| | - Marcos Nakamura-Pereira
- National Institute for Women, Children and Adolescents Health Fernandes Figueira, Oswaldo Cruz Foundation, Rio de Janeiro, RJ, Brazil
| | - Mariane O Menezes
- São Paulo State University (UNESP, Medical School of Botucatu, Botucatu, São Paulo, Brazil
| | - Vicente K Borges
- Department of Automation and Systems, Control and Automation Engineering Program, Federal University of Santa Catarina (UFSC, Florianopolis, Santa Catarina, Brazil
| | - Leila Katz
- Professor Fernando Figueira Institute of Integral Medicine (IMIP, Recife, PE, Brazil
| | - Melania M R Amorim
- Professor Fernando Figueira Institute of Integral Medicine (IMIP, Recife, PE, Brazil
| | - Carla B Andreucci
- Department of Medicine, Federal University of Sao Carlos (UFSCAR, Sao Carlos, SP, Brazil
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30
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O.1 Coagulation factor levels during severe postpartum haemorrhage. Int J Obstet Anesth 2021. [DOI: 10.1016/j.ijoa.2021.102989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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31
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Gunaratne MDSK, Thorsteinsdottir B, Garovic VD. Combined Oral Contraceptive Pill-Induced Hypertension and Hypertensive Disorders of Pregnancy: Shared Mechanisms and Clinical Similarities. Curr Hypertens Rep 2021; 23:29. [PMID: 33982185 DOI: 10.1007/s11906-021-01147-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Oral contraceptive pill-induced hypertension (OCPIH) and hypertensive disorders in pregnancy (HDP) share common risk factors and pathophysiological mechanisms, yet the bidirectional relationship between these two conditions is not well-established. We review and describe OCPIH and HDP to better understand how hormonal and metabolic imbalances affect hypertension. RECENT FINDINGS Oral contraceptive pills continue to be a popular method of contraception, with an incidence of OCPIH ranging from 1-8.5% among OCP users. HDP have an incidence of 5-10% of all pregnancies in the USA and have been shown to be a powerful predictor of lifetime adverse cardiovascular outcomes, including future hypertension. OCPIH and HDP share common risk factors such as age, BMI, past personal and family history of hypertension, as well as pathogenic mechanisms, including alterations in hormonal metabolism and the renin angiotensin aldosterone system; imbalance of vasodilator-vasoconstrictor compounds; and changes in the cardiovascular system. Future research should address additional potential mechanisms that underlie hypertension in these two conditions where endocrine changes, either physiological (pregnancy) or iatrogenic (use of OCP), play a role. This may lead to novel, targeted treatment options to improve hypertension management and overall cardiovascular risk profile management in this subset of young female patients.
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Affiliation(s)
- Madugodaralalage D S K Gunaratne
- Division of Nephrology and Hypertension, Department of Internal Medicine, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, USA
| | - Bjorg Thorsteinsdottir
- Mayo Clinic KERN Center for the Science of Health Care Delivery and the Knowledge Evaluation and Research Unit, Division of Community Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Mayo Clinic, 200 First Street, SW, Rochester, MN, USA.
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Tasca C, Rossi RS, Corti S, Anelli GM, Savasi V, Brunetti F, Cardellicchio M, Caselli E, Tonello C, Vergani P, Nebuloni M, Cetin I. Placental pathology in COVID-19 affected pregnant women: A prospective case-control study. Placenta 2021; 110:9-15. [PMID: 34058611 PMCID: PMC8096756 DOI: 10.1016/j.placenta.2021.04.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 01/23/2023]
Abstract
Introduction During pregnancy, SARS-CoV-2 infection may cause an abnormal development of the placenta, thus influencing maternal and fetal outcomes. Few studies have reported data on placental morphology and histology in infected pregnant patients, although not compared with carefully matched controls. The aim of this study is to compare placental morphology and histology of pregnant women affected by SARS-CoV-2 to non-infected controls. Methods This is a prospective multicenter case-control study on 64 pregnant women affected by SARS-CoV-2 who delivered at term or late-preterm. Data were collected about pregnancy course, maternal and fetal outcomes, placental biometry and macro- and microscopical morphology. 64 not-infected women were identified as controls, matched by age, body mass index and ethnicity. Results Cases and controls had similar fetal and maternal outcomes. No significant differences were observed in placental macro- or microscopical morphology between the two groups. In the cases treated with antivirals, chloroquine, LMWH or antibiotics, placentas were heavier but not more efficient than the non-treated, since the fetal/placental weight ratio did not differ. Moreover, delayed villous maturation was more frequent in treated women, although not significantly. The newborns whose mothers received oxygen therapy as treatment had higher levels of umbilical cord pO₂ at birth. Discussion In this prospective case-control study, SARS-CoV-2 infection during the third trimester did not influence placental histological pattern. Pharmacological and oxygen therapy administered to women affected by this viral infection could impact maternal and fetal outcomes and be associated to placental histological alterations.
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Affiliation(s)
- Chiara Tasca
- Department of Obstetrics and Gynecology, Vittore Buzzi Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milano, Italy
| | - Roberta Simona Rossi
- Pathology Unit, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milan, Italy
| | - Silvia Corti
- Department of Obstetrics and Gynecology, Vittore Buzzi Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milano, Italy
| | - Gaia Maria Anelli
- Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milano, Italy
| | - Valeria Savasi
- Unit of Obstetrics and Gynecology, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milano, Italy
| | - Federica Brunetti
- Pathology Unit, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milan, Italy
| | - Manuela Cardellicchio
- Unit of Obstetrics and Gynecology, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milano, Italy
| | - Emilio Caselli
- Pathology Unit, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milan, Italy
| | - Cristina Tonello
- Pathology Unit, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milan, Italy
| | - Patrizia Vergani
- Department of Obstetrics and Gynecology, MBBM Foundation at San Gerardo Hospital, School of Medicine and Surgery, University of Milano-Bicocca, Italy
| | - Manuela Nebuloni
- Pathology Unit, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milan, Italy
| | - Irene Cetin
- Department of Obstetrics and Gynecology, Vittore Buzzi Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco", Università Degli Studi di Milano, Milano, Italy.
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Peterson W, Tse B, Martin R, Fralick M, Sholzberg M. Evaluating hemostatic thresholds for neuraxial anesthesia in adults with hemorrhagic disorders and tendencies: A scoping review. Res Pract Thromb Haemost 2021; 5:e12491. [PMID: 33977207 PMCID: PMC8105160 DOI: 10.1002/rth2.12491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/29/2020] [Accepted: 01/01/2021] [Indexed: 11/08/2022] Open
Abstract
Neuraxial anesthesia can be complicated by spinal or epidural hematoma and may result in permanent neurologic injury. There is a paucity of literature characterizing this serious complication in patients with congenital and acquired hemorrhagic disorders or tendencies. The objective of this scoping review was to describe the hemostatic laboratory parameters where neuraxial anesthesia has been administered with and without spinal and epidural hematoma in patients with preexisting hemorrhagic disorders and tendencies, including immune thrombocytopenia, gestational thrombocytopenia, thrombocytopenia associated with hypertensive disorders of pregnancy, platelet function disorders, von Willebrand disease, coagulation factor deficiencies, and fibrinogen disorders. A systematic search of Ovid MEDLINE, CINAHL, Embase, Scopus, and Web of Science was performed. Two authors independently reviewed all titles, abstracts, and full texts to determine study eligibility and extract data. Qualitative synthesis of 91 studies revealed significant gaps in our understanding of the risk of spinal and epidural hematoma in patients with hemorrhagic disorders and tendencies, including few studies of males and in nonobstetric settings. Most reviewed articles were small, retrospective studies at high risk for potential bias. With such low-quality data, we were unable to provide any true estimates of the risk of spinal or epidural hematoma for these patients, nor could we attribute any specific hemostatic or laboratory values to increased risk of hematoma. There is a need both for larger and more rigorously designed and reported studies on this subject and for structured, comprehensive recommendations for safe administration and removal of neuraxial anesthesia in patients with hemorrhagic disorders and tendencies.
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Affiliation(s)
- Wynn Peterson
- Division of Medicine University of Toronto Toronto ON Canada
| | - Brandon Tse
- Faculty of Medicine University of Toronto Toronto ON Canada
| | - Rachel Martin
- Department of Anesthesia St. Michael's Hospital Toronto ON Canada
| | - Michael Fralick
- Sinai Health System and the Department of Medicine University of Toronto Toronto ON Canada
| | - Michelle Sholzberg
- Division of Hematology Department of Medicine and Department of Laboratory Medicine and Pathobiology St. Michael's Hospital Toronto ON Canada
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Oluwaseyi BE, Michael OA, Oluwafemi AE, David AB. Pregnancy associated coagulopathies in selected community hospitals in Southwest Nigeria. J Family Med Prim Care 2021; 10:1614-1620. [PMID: 34123901 PMCID: PMC8144756 DOI: 10.4103/jfmpc.jfmpc_1381_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/12/2020] [Accepted: 01/15/2021] [Indexed: 12/02/2022] Open
Abstract
Background and Aim: Pregnancy is characterized by multiple changes in the coagulation system which occurs at different stages of the condition, representing one of the major triggers of maternal and foetal morbidity/mortality in the world during complicated incidences. This study determined the prevalence of coagulation disorders among pregnant women in Southwest Nigeria to buttress the need for prompt and accurate routine diagnosis of these disorders. Methods: Four hundred and five participants (405) attending some selected tertiary health facilities in Southwestern Nigeria were randomly recruited for the study, comprising two hundred and seventy (270) pregnant subjects and one hundred and thirty-five (135) apparently healthy age- and socio-economic status-matched non-pregnant women as controls. The platelet count was assessed; prothrombin time and activated partial thromboplastin time were assessed. Immunoturbidimetric and chromogenic techniques were also used to assess the level of D-dimer and activated protein C resistance. Results: Platelet count, PT and INR in all three trimesters were significantly (p < 0.05) reduced when compared to the non-pregnant control subjects. However, the level of circulating D-dimer was significantly (p < 0.05) increased in all three trimesters when compared with the control group, with observable steady increase in the second and third trimesters. Also, 13% of respondents had thrombotic predisposition and 14.8% with tendencies for consumption coagulopathy while 1.1% are APCr positive individuals. Conclusion: The study affirms the hypercoagulable state of pregnancy coupled with mild gestational thrombocytopenia which could be pointers to onset of coagulation disorders in some participants, subjects with coagulation profiles indicative of thrombotic tendencies and possible onset of consumption coagulopathy and the presence of activated protein C resistant in the region. A review of the coagulation monitoring strategies for pregnant women from primary care to include more definite assays and its proper implementation will immensely contribute to early diagnosis along with intervention for pregnancy associated coagulopathies in resource-limited settings.
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Affiliation(s)
- Bamisaye E Oluwaseyi
- Department of Biomedical Laboratory Science, Faculty of Basic Medical Sciences, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | - Okungbowa A Michael
- Department of Medical Laboratory Science, Faculty of Basic Medical Sciences, University of Benin, Benin City, Edo State, Nigeria
| | - Akanni E Oluwafemi
- Department of Medical Laboratory Science, Faculty of Basic Medical Sciences, College of Medicine and Health Sciences, Ladoke Akintola University of Technology, Osogbo, Osun State, Nigeria
| | - Akinbo B David
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Ekiti State, Nigeria
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35
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Collis RE, Kenyon C, Roberts TCD, McNamara H. When does obstetric coagulopathy occur and how do I manage it? Int J Obstet Anesth 2021; 46:102979. [PMID: 33906823 DOI: 10.1016/j.ijoa.2021.102979] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/20/2021] [Accepted: 03/08/2021] [Indexed: 01/22/2023]
Abstract
Anticipating obstetric coagulopathy is important when obstetric anaesthetists are involved in the clinical management of women with postpartum haemorrhage. Although the incidence of coagulopathy in women with postpartum haemorrhage is low, significant hypofibrinogenaemia is associated with major haemorrhage-related morbidity and thus early identification and treatment is essential to improve outcomes. Point-of-care viscoelastic haemostatic assays, including thromboelastography and rotational thromboelastometry, provide granular information about alterations in clot formation and hypofibrinogenaemia, allow near-patient interpretation of coagulopathy, and can guide goal-directed treatment. If these assays are not available, anaesthetists should closely monitor the maternal coagulation profile with standard laboratory testing during the active phase of postpartum bleeding in order to rule coagulopathy 'in or out', decide if pro-haemostatic therapies are indicated, and assess the response to haemostatic support.
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Affiliation(s)
- R E Collis
- University Hospital of Wales, Cardiff, UK.
| | - C Kenyon
- Liverpool Women's Hospital NHS Trust, Liverpool, UK
| | | | - H McNamara
- Liverpool Women's Hospital NHS Trust, Liverpool, UK
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36
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Togioka BM, Burwick RM, Kujovich JL. Delivery and neuraxial technique outcomes in patients with hemophilia and in hemophilia carriers: a systematic review. J Anesth 2021; 35:288-302. [PMID: 33682038 DOI: 10.1007/s00540-021-02911-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/22/2021] [Indexed: 12/22/2022]
Abstract
Female carriers are more common than males with hemophilia and unrecognized factor VIII or IX deficiency is associated with intrauterine growth retardation, epidural hematomas, blood transfusion, and peripartum hemorrhage. A review was conducted to assess the evidence for professional society recommendations for > 50% factor levels during labor. Two searches of Pubmed, CINAHL, Cochrane, and Google Scholar were completed in October 2019. The first for case reports and series described neuraxial techniques in patients with hemophilia-regardless of sex, age, or pregnant status. The second for case reports and series described bleeding outcomes of parturients with hemophilia. Primary outcomes were diagnosis of neuraxial hematoma (first search) and postpartum bleeding complications (second search). Thirteen articles (n = 134) described neuraxial techniques in patients with hemophilia. Neuraxial hematoma with paraplegia occurred in 3/134 patients-all had a factor level of 1%. Nineteen articles (2712 deliveries in 2657 women) described bleeding outcomes. Postpartum hemorrhage occurred in 7.1% (193/2712) of deliveries, of which 60% necessitated blood transfusion. Postpartum bleeding complications were twice as likely (51.0% [25/49] vs. 25.6% [52/203], P < 0.001) with factor activity < 50%. Therefore, factor levels should be assessed and increased above 50% prior to neuraxial technique and delivery.Trial registration: PROSPERO 2018 CRD42018110215.
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Affiliation(s)
- Brandon M Togioka
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code UHN-2, Portland, OR, 97239, USA.
| | - Richard M Burwick
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jody L Kujovich
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
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37
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Zhou J, Wang Y, Zhao J, Gu L, Yang C, Wang J, Zhang H, Tian Y, Tuo H, Li D, Wei M, He B. The metabolic and immunological characteristics of pregnant women with COVID-19 and their neonates. Eur J Clin Microbiol Infect Dis 2021; 40:565-574. [PMID: 33006691 PMCID: PMC7530551 DOI: 10.1007/s10096-020-04033-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
Abstract
Our aim was to investigate whether SARS-CoV-2 infection raised high risks of late pregnancy complications, and posed health problems in fetuses and neonates. We analyzed the data of COVID-19 pregnant women with COVID-19 during late pregnancy and their neonates. Eleven out of 16 (69%) pregnant women with COVID-19 had ++ or +++ of ketone body in urine. The blood uric acid of pregnant patients was 334 μmol/L (IQR, 269-452). D-dimer and FDP in pregnant patients were 3.32 mg/L (IQR, 2.18-4.21) and 9.6 mg/L (IQR, 5.9-12.4). Results of blood samples collected at birth showed that 16 neonates had leukocytes (15.7 × 109/L (IQR, 13.7-17.2)), neutrophils (11.1 × 109/L (IQR, 9.2-13.2)), CK (401 U/L (IQR, 382-647)), and LDH (445 U/L (IQR, 417-559)). Twenty-four hours after birth, a neonate from COVID-19 woman had fever and positive of SARS-CoV-2 gene. Another woman had strongly positive for SARS-CoV-2 gene (+++) for 4 weeks, and delivered one neonate who had SARS-CoV-2 IgM (46 AU/mL) and IgG (140 AU/mL) on day 1 after birth. In the third trimester, COVID-19 infection in pregnant patients raised high risks of ketonuria, hypercoagulable state, and hyperfibrinolysis, which may lead to severe complications. COVID-19 increased the inflammatory responses of placenta, and fetuses and neonates had potential organ dysregulation and coagulation disorders. There was a potential intrauterine transmission while pregnant women had high titer of SARS-CoV-2, but it is necessary to detect SARS-CoV-2 in the blood cord, placenta, and amniotic fluid to further confirm intrauterine infection of fetuses.
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Affiliation(s)
- Jingjiao Zhou
- Department of Biology and Genetics, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
- Institute of Biology and Medicine, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, 430065, Hubei, China
| | - Yudie Wang
- Department of Biology and Genetics, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
- Institute of Biology and Medicine, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, 430065, Hubei, China
| | - Juan Zhao
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, 430065, Hubei, China
| | - Lixing Gu
- Department of Biology and Genetics, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
- Institute of Biology and Medicine, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, 430065, Hubei, China
| | - Cheng Yang
- Department of Biology and Genetics, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
- Institute of Biology and Medicine, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, 430065, Hubei, China
| | - Jun Wang
- Department of Biology and Genetics, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
- Institute of Biology and Medicine, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, 430065, Hubei, China
| | - Heng Zhang
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, 430065, Hubei, China
| | - Yu Tian
- Department of Biology and Genetics, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
- Institute of Biology and Medicine, College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, 430065, Hubei, China
| | - Hu Tuo
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, 430065, Hubei, China
| | - Dan Li
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, 430065, Hubei, China
| | - Min Wei
- Department of Obstetrics, Renmin Hospital of Wuhan University, Wuhan, 430065, Hubei, China
| | - Bing He
- Department of Pediatrics, Renmin Hospital of Wuhan University, Wuhan, 430065, Hubei, China.
- Department of Pediatrics, Renmin Hospital of Wuhan University, 99 Zhangzhidong Road, Wuhan, 430060, China.
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38
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Agarwala R, Millar CM, Campbell JP. Haemostatic disorders in pregnancy. BJA Educ 2021; 20:150-157. [PMID: 33456944 DOI: 10.1016/j.bjae.2020.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- R Agarwala
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - C M Millar
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Imperial College London, London, UK
| | - J P Campbell
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
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39
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Opaskar A, Massaquoi R, Sila C. Stroke in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:283-293. [PMID: 33632448 DOI: 10.1016/b978-0-12-819814-8.00032-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Stroke in pregnancy is rare and has a wide range of etiologies and implications on stroke management that differ from nonpregnant individuals. The highest risk of stroke is during the third trimester and puerperium period, where hypertensive disorders of pregnancy occur; however, stroke can occur at any point during pregnancy. In this chapter, we will provide an overview of the epidemiology of stroke in pregnancy and then review the specific etiologies of ischemic and hemorrhagic stroke as they relate to pregnant women. Finally, we discuss the process of acute stroke evaluation in pregnancy and the management of women after stroke with regard to long-term risk factors, medications, and implications in future pregnancies. Throughout the chapter, we highlight relevant guidelines from the American Heart Association and American Stroke Association and key literature on stroke in pregnancy.
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Affiliation(s)
- Amanda Opaskar
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Reyanna Massaquoi
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Cathy Sila
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States.
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40
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Acquired Factor XI Deficiency with Lupus Anticoagulant in a Pregnant Woman Diagnosed by the Eruptions and Pain in Fingers. Case Rep Obstet Gynecol 2020; 2020:8854676. [PMID: 33489393 PMCID: PMC7803157 DOI: 10.1155/2020/8854676] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 12/17/2022] Open
Abstract
We report a case of acquired factor XI deficiency with lupus anticoagulant (LA) in a 28-year-old primigravida who presented with finger pain and eruptions on her palms and fingers during the 3rd trimester of pregnancy. The patient complained of pain and reddening of the fingers at 30 weeks of gestation. She was referred to our tertiary center with a diagnosis of preeclampsia and suspected collagen disease at 35 weeks of gestation. Erythema was seen on the fingers and palms, and she presented with pain and cryesthesia on the fingers. Laboratory investigations revealed an activated partial thromboplastin time of 51 s (normal, 23–40 s), although it was normal during the 30th and 34th gestational weeks, LA with an anticardiolipin-beta2-glycoprotein I complex antibody, and low level of clotting XI activity (25 U/mL). On week 37 day 0 of gestation, the patient presented with severe hypertension. An urgent Cesarean section was performed after transfusion of two units of fresh frozen plasma. There was no excessive bleeding during the surgery or the postpartum period. The symptoms on her fingers and palms gradually improved after surgery. Our case indicates that dermatoses of pregnancy may become a starting point for the diagnosis of autoimmune diseases and coagulation abnormalities. When a patient presents with an atypical symptom, as in our case, the possibility of various diseases should be considered.
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41
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Altendahl M, Afshar Y, de St Maurice A, Fajardo V, Chu A. Perinatal Maternal-Fetal/Neonatal Transmission of COVID-19: A Guide to Safe Maternal and Neonatal Care in the Era of COVID-19 and Physical Distancing. Neoreviews 2020; 21:e783-e794. [PMID: 33262205 DOI: 10.1542/neo.21-12-e783] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19), is highly contagious and can cause serious respiratory illness and other clinical manifestations. The aim of this review is to summarize the clinical presentation, diagnosis, and outcomes of COVID-19 in pregnant women and neonates, who may be especially vulnerable to the effects of COVID-19, and to discuss what is known about potential maternal-fetal and maternal-neonatal transmission of SARS-CoV-2.
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Affiliation(s)
- Marie Altendahl
- Department of Pediatrics, Division of Neonatology and Developmental Biology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Yalda Afshar
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Annabelle de St Maurice
- Department of Pediatrics, Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Viviana Fajardo
- Department of Pediatrics, Division of Neonatology and Developmental Biology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Alison Chu
- Department of Pediatrics, Division of Neonatology and Developmental Biology, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Venous malformation of the foot: Spontaneous regression postpartum on MRI. Radiol Case Rep 2020; 16:62-65. [PMID: 33193930 PMCID: PMC7642758 DOI: 10.1016/j.radcr.2020.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022] Open
Abstract
Venous malformations (VMs) are present at birth, grow proportionally during childhood, and usually do not regress. We report the imaging appearance of a VM of the foot found during pregnancy, which regressed spontaneously postpartum. A 35-year-old, 8-month-pregnant woman presented with a 6-month history of painful swelling of the left foot. MRI demonstrated a well-defined, intricate-shaped mass measuring 38 × 36 × 28 mm between the muscles and tendons of the third, fourth, and fifth toes with subcutaneous extension. Dynamic CT taken a month after delivery revealed gradual enhancement of the lesion. Gray-scale ultrasonography (US) showed a heterogenic hypoechoic mass containing thrombi with venous waveforms on Doppler US. A second MRI obtained 15 months after delivery showed a remarkable reduction of the lesion size (16 × 20 × 15 mm). Symptomatic VMs found during pregnancy can be observed conservatively without treatment.
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43
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Takayama W, Endo A, Yoshii J, Arai H, Oi K, Nagaoka E, Toyama S, Yamamoto H, Uchida T, Otomo Y. Severe COVID-19 Pneumonia in a 30-Year-Old Woman in the 36th Week of Pregnancy Treated with Postpartum Extracorporeal Membrane Oxygenation. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e927521. [PMID: 33110055 PMCID: PMC7603798 DOI: 10.12659/ajcr.927521] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patient: Female, 30-year-old Final Diagnosis: Severe COVID-19 pneumonia Symptoms: Dyspena Medication: — Clinical Procedure: Extracorporeal membrane oxygenation Specialty: Critical Care Medicine • Infectious Diseases
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Affiliation(s)
- Watatu Takayama
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Akira Endo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Junichiro Yoshii
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Keiji Oi
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eiki Nagaoka
- Department of Cardiovascular Surgery, Tokyo Medical and Dental University Hospital of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Toyama
- Department of Anesthesiology, Tokyo Medical and Dental University Hospital of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroto Yamamoto
- Department of Anesthesiology, Tokyo Medical and Dental University Hospital of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tokujiro Uchida
- Department of Anesthesiology, Tokyo Medical and Dental University Hospital of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
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44
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Stanca HT, Tăbăcaru B, Baltă F, Mălăescu M, Stanca S, Munteanu M, Dărăbuș DM, Roșca C, Teodoru AC. Cumulative visual impact of two coagulability disorders: A case report. Exp Ther Med 2020; 20:218. [PMID: 33149782 PMCID: PMC7604761 DOI: 10.3892/etm.2020.9348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/05/2020] [Indexed: 12/22/2022] Open
Abstract
Cumulative visual impact of two coagulability disorders were reviewed by presenting a case of a young female patient with a spontaneous abortion and two thromboembolic events in 8 years, whose visual function was severely affected. The particularities of her genetic constellation regarding the retinal circulation are also discussed. The patient developed a central retinal artery occlusion in the right eye during pregnancy in 2010, which led to an extended hematological workup that revealed presence of MTHFR C677T and MTHFR A1298C heterozygote mutations. The screening for myeloproliferative disorders showed JAK2 V617F gene mutation. Test results confirmed the diagnosis of thrombophilia and essential thrombocythemia and she was recommended permanent treatment with low molecular weight heparin, platelet antiaggregant, peripheral vasodilator and neuroprotectors. Despite the treatment, the patient developed central retinal vein occlusion in the fellow eye 8 years after the first thromboembolic event. The visual acuity for the right eye (0.9 logMAR) remained poor and the visual acuity for the left eye recovered completely (from 0.3 logMAR to 0 logMAR). However, new retinal artery or vein occlusions could occur in the future and there is also a risk of thrombosis in other areas, such as cerebral, pulmonary or renal, due to the general coagulability imbalance.
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Affiliation(s)
- Horia T Stanca
- Department of Ophthalmology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Bogdana Tăbăcaru
- Department of Ophthalmology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Florian Baltă
- Department of Ophthalmology, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Monica Mălăescu
- Department of Ophthalmology, Faculty of Medicine, 'Lucian Blaga' University, 550159 Sibiu, Romania
| | - Simona Stanca
- Department of Pediatrics, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Mihnea Munteanu
- Department of Ophthalmology, 'Victor Babe?' University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Diana-Maria Dărăbuș
- Department of Ophthalmology, 'Victor Babe?' University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Cosmin Roșca
- Department of Ophthalmology, Oculens Clinic, 400501 Cluj-Napoca, Romania
| | - Adrian Cosmin Teodoru
- Department of Ophthalmology, Faculty of Medicine, 'Lucian Blaga' University, 550159 Sibiu, Romania
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Abstract
Postpartum hemorrhage is a leading cause of severe maternal morbidity and mortality worldwide and the United States. While the rates of maternal mortality attributable to hemorrhage are declining, severe maternal morbidity continues to be a growing problem. Efforts in recent years to more appropriately identify patients at risk, define significant hemorrhage, quantify blood loss, and standardize approaches to care in pregnancy and postpartum have led to an increasing preventability of PPH. We aim to review the most current recommendation for the prevention and effective management of obstetric hemorrhage.
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Affiliation(s)
- Veronica Gonzalez-Brown
- Division Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Patrick Schneider
- Division Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA.
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46
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Prior C, Sims K, Seligman K, Jackson S, Chau A. Peripartum management of a parturient with type 1C (clearance) von Willebrand disease. Int J Obstet Anesth 2020; 44:112-115. [PMID: 32942216 DOI: 10.1016/j.ijoa.2020.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/30/2020] [Accepted: 08/17/2020] [Indexed: 11/25/2022]
Abstract
Peripartum replacement of factor VIII and von Willebrand factor is not usually required in type 1 von Willebrand disease, as the levels of endogenous factors tend to increase to within the normal range as a physiological change of pregnancy. However, there is wide heterogeneity of genotypes and phenotypes associated with type 1 von Willebrand disease. Here, we describe the anesthetic management of a parturient with type 1C von Willebrand disease, a subtype characterized by decreased plasma von Willebrand factor survival.
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Affiliation(s)
- C Prior
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada.
| | - K Sims
- Adult Bleeding Disorders Program of British Columbia, St Paul's Hospital, Vancouver, BC, Canada
| | - K Seligman
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - S Jackson
- Adult Bleeding Disorders Program of British Columbia, St Paul's Hospital, Vancouver, BC, Canada; Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - A Chau
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
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47
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To Clot or Not: HELLP Syndrome and Disseminated Intravascular Coagulation in an Eclamptic Patient with Intrauterine Fetal Demise. Case Rep Anesthesiol 2020; 2020:9642438. [PMID: 32724681 PMCID: PMC7364204 DOI: 10.1155/2020/9642438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 06/17/2020] [Indexed: 11/17/2022] Open
Abstract
A 39-year-old G2P1001 female presented from an outside hospital following an eclamptic seizure in the setting of HELLP syndrome. This condition was complicated by intrauterine fetal demise and disseminated intravascular coagulation, which required an emergent cesarean section. We report the work-up and intraoperative and postoperative management of this complex patient with multiple medical needs. We focus on the hemostatic abnormalities in this patient and describe how our management would differ from that of a similar, nonpregnant patient.
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48
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Pulmonary Thromboembolism in a Pregnant Patient with Severe COVID19: A Novel Case Report and Review of Literature. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2020. [DOI: 10.5812/archcid.104394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Introduction: The novel coronavirus has been shown to infect many bodily organs. Recent studies have suggested that the virus may be capable of causing inappropriate thrombosis formation. In the present case study, we present a pregnant patient who had severe pneumonia caused by the virus; and subsequently developed pulmonary thromboembolism. Case Presentation: A 39-year-old primi-gravid pregnant woman presented to the emergency department with moderate to severe respiratory symptoms and tested positive for SARS-CoV-2. The patient was hospitalized and received routine treatment. The patient had a rapid deterioration of clinical signs and symptoms, coupled with sensations of palpitations and chest discomfort. The patient had an echocardiogram, which was suggestive of right ventricular strain. D-dimer tested positive, and the patient had a CT angiography, showing filling defects in branches of the pulmonary arteries. Conclusions: Pulmonary thromboembolism may be a complicating factor in patients with severe viral pneumonia. In patients with underlying procoagulant conditions, such as pregnancy, the occurrence of Pulmonary Thromboembolism (PTE) should be strongly considered.
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49
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Wang R, Su Q, Yan Z. Treatment of slow transit constipation-induced ileus during pregnancy by colectomy with ileorectal anastomosis: A case report. Medicine (Baltimore) 2020; 99:e19944. [PMID: 32358366 PMCID: PMC7440070 DOI: 10.1097/md.0000000000019944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Slow transit constipation is a major cause of chronic constipation. During pregnancy, changes in hormone levels and the physical effects of an enlarged uterus could cause new onset slow transit constipation or aggravate a pre-existing constipation. The management of slow transit constipation-induced ileus during pregnancy is a medical dilemma. PATIENT CONCERNS A 28-year-old pregnant woman presented to the emergency department with a 7-day history of worsening bloating and abdominal colic. The patient was in her third trimester (27 weeks). She had a 5-year history of constipation which had worsened with her pregnancy, and neither flatus nor stool could be passed. DIAGNOSIS Based on the constipation history and computed tomography, a slow transit constipation-induced ileus was confirmed. INTERVENTIONS As medications for the management of constipation and endoscopic efforts to remove the blockage were ineffective and the patient's symptoms worsened, Cesarean section and colectomy with ileorectal anastomosis were performed. OUTCOMES After the procedure, the patient recovered and defecated well. At the 6-month follow-up, the patient reported that she defecated two to three times per day without difficulty. CONCLUSION Pregnancy can worsen pre-existing constipation and cause ileus. In cases where drug treatment is unsuccessful, colectomy, and ileorectal anastomosis may be necessary.
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Affiliation(s)
- Rui Wang
- Department of Critical Care Medicine
| | - Qi Su
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhaopeng Yan
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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Mulvey JJ, Magro CM, Ma LX, Nuovo GJ, Baergen RN. WITHDRAWN: A mechanistic analysis placental intravascular thrombus formation in COVID-19 patients. Ann Diagn Pathol 2020; 46:151529. [PMID: 32361635 PMCID: PMC7195270 DOI: 10.1016/j.anndiagpath.2020.151529] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/21/2020] [Indexed: 02/06/2023]
Affiliation(s)
- J Justin Mulvey
- Department of Laboratory Medicine, Memorial Sloan-Kettering Cancer Center, United States of America
| | - Cynthia M Magro
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, United States of America
| | - Lucy X Ma
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, United States of America
| | - Gerard J Nuovo
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States of America; Discovery Life Sciences, Powell, OH, United States of America
| | - Rebecca N Baergen
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, United States of America
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