Evaluation of Complications in Postpartum Women Receiving Therapeutic Anticoagulation

Prevention, diagnosis, and management of PE and DVT in pregnant women

Venous thromboembolism (VTE) is a leading cause of maternal morbidity and mortality worldwide. Despite the impact of VTE on pregnant and postpartum people and on society, guidelines addressing prevention, diagnosis, and management of VTE in pregnant and postpartum people frequently are based on recommendations from expert opinion and are extrapolated from data in nonpregnant populations. Pregnant individuals are frequently excluded from clinical trials, which is a barrier to providing safe, effective care. Anchoring to a case discussion, this review provides an update on recently published and ongoing randomized clinical trials (RCTs), prospective clinical management studies, and other research in this area. It highlights, in particular, the results of the Highlow RCT, which addresses optimal prevention of recurrence during pregnancy in people with prior VTE. Finally, we raise awareness of the impact of national and international clinical trial networks on the conduct of RCTs in pregnancy. We conclude, based on these data, that academic VTE clinical trials in pregnant women can and must be done.

Risk factors, trends of neurological disorders, and outcomes of neonatal periventricular hemorrhages

Periventricular hemorrhage is bleeding from the subependymal germinal matrix, which results in severe motor disorders, mental and speech developmental delay.

Purpose. The study aims to evaluate risk factors, the trends of neurological disorders, and the outcomes of neonatal periventricular hemorrhage in children whose mothers were on gravidary anticoagulant and/or antiplatelet therapy.

Material and methods. The study examined 160 newborns with PVH: Group I — 53 (37.9%) children born from pregnancy on the background of antiplatelet and/or anticoagulant therapy for hypercoagulation syndrome; Group II — 87 (62.1%) children born from pregnancy on the background of antiplatelet and/or anticoagulant therapy to treat degree 1A uteroplacental blood flow disorders; Group III — 20 children born from pregnancy without corticosteroids and antiplatelet and/or anticoagulant therapy. All newborns underwent clinical and neurological examination and neurosonography; data on somatic and obstetric anamnesis were obtained from accompanying medical records.

Results. In children of Groups I and II a more severe condition of newborns with periventricular hemorrhage at birth was noted, a slower dynamics of restoration of muscle-postural tone and the pace of psychomotor development were observed compared to children in Group III. In Groups I and II a high incidence of epilepsy (5.7%) and cerebral palsy (6.4%) by 12 months of corrected age was revealed compared with the population.

Conclusion. Gravidary anticoagulant and antiplatelet therapy might be considered as a risk factor for the development of intracranial hemorrhages and severe neurological disorders: epilepsy, cerebral palsy, mental and motor developmental delays. 

Bleeding in women with venous thromboembolism during pregnancy: A systematic review of the literature

Objectives

Venous thromboembolism (VTE) represents an important cause of maternal morbidity and mortality. Estimates of bleeding associated with therapeutic‐dose anticoagulation are variable. We describe the frequency of bleeding in pregnant women receiving therapeutic anticoagulation for VTE by means of a systematic review of the literature.

Data Sources

Medical Literature Analysis and Retrieval System, Embase, Scopus, Web of Science, and ClinicalTrials.gov were searched. Databases were searched from inception to February 27, 2022. There was no language or geographic location restriction.

Methods of Study Selection

The search yielded 2773 articles with 2212 unique citations. Studies were included if they described pregnant women treated for an acute VTE with therapeutic‐dose anticoagulation and a defined bleeding outcome was reported.

Tabulation, Integration, and Results

Five studies met inclusion criteria. Included studies were judged to have a serious to critical risk of bias using the Risk of Bias in Nonrandomized Studies of Intervention tool. The rate of bleeding, as defined by respective studies, ranged between 2.9% and 30.0%. Two studies included control groups, one of which found no significant difference in the risk of bleeding between groups, while the other found a significantly increased bleeding risk associated with therapeutic anticoagulation.

Conclusion

Among pregnant women anticoagulated for VTE, the reported bleeding risk is variable. The ability to draw definite conclusions is limited by the scarcity and low quality of the studies, the small number of included patients, and the heterogeneity of bleeding definitions used. Large‐scale studies with standardized bleeding definitions are required to provide acute bleeding estimates and optimize the care of these patients.

Systematic Review Registration

PROSPERO, CRD42021276771.

Management of anticoagulation in pregnant women with venous thromboembolism: An international survey of clinical practice

INTRODUCTION

Venous thromboembolism (VTE) is an important cause of maternal morbidity and mortality. During pregnancy, VTE is treated with low-molecular-weight-heparin (LMWH). Studies assessing the optimal duration and peripartum management of therapeutic anticoagulation are lacking. This survey aimed to assess clinician practices for the management of anticoagulation in pregnant women with acute VTE.

METHODS

An electronic survey consisting of clinical scenarios addressing anticoagulation management for VTE in pregnancy was created. The target sample was clinicians likely to be involved in the management of pregnant women with acute VTE. The survey completion rate and proportion of individuals selecting a response were determined.

RESULTS

96 respondents completed the survey including general internists (56.3%), hematologists (21.9%), and obstetricians (6.3%). In the management of a VTE in first or second trimester, most respondents preferred therapeutic LMWH until 6 weeks postpartum. In the first and second trimester, 48.0% and 37.5% of respondents, respectively, opted to reduce the dose of anticoagulation after 3 or 6 months. 29.2% of physicians opted for bridging with intravenous heparin around delivery when treating a VTE in the third trimester. 73.0% perceived an increased risk of clinically relevant non-major bleeding associated with the use of therapeutic anticoagulation in the peripartum and postpartum periods.

CONCLUSIONS

The survey highlights a wide variability of practice in the management of therapeutic anticoagulation in pregnancy. Larger scale studies with relevant clinical outcomes including thrombosis and bleeding risks are needed to inform clinical practice.