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Du Z, Zhu T, Peng P, Liu X, Fu L, Sun Z. A retrospective study of the management and outcomes of pregnancies with inherited antithrombin deficiency. J Obstet Gynaecol Res 2024. [PMID: 38960394 DOI: 10.1111/jog.16005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/10/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Antithrombin (AT) deficiency is a rare but highly thrombogenic inherited thrombophilia. Its association with adverse pregnancy outcomes (APO) is undefined. There is limited guidance on managing AT deficiency in pregnancy. Some significant issues remain controversial, including risk assessment for prophylactic anticoagulation, anticoagulant therapy, and monitoring. Our goal was to examine if the antepartum management of patients with AT deficiency affected their pregnancy outcomes. MATERIALS AND METHODS This retrospective, single-center observational study included pregnant women with inherited AT deficiency in Peking Union Medical College Hospital between 2013 and 2024. RESULTS Seventeen pregnancies in 6 women with AT deficiency were identified. A total of 7 pregnancies received adjusted-dose low-molecular-weight heparin (LMWH) and were monitored by anti-Xa level, AT activity, and D-dimer. There were 5 live births (all received LMWH), 7 second-trimester abortions (1 received LMWH), and 5 early pregnancy losses (1 received LMWH). There were 5 abruptio placentae events (3 received LMWH) and 7 thrombotic events (2 received LMWH). CONCLUSIONS AT deficiency is at least an important partial factor contributing to APO. It is suggested to make a full assessment of AT patients both for venous thrombus embolism and APO risk. We observed a high prevalence of heparin resistance and a positive correlation between adequate anticoagulation and pregnancy outcome based on tight monitoring with anti-Xa level and timely adjustment of the LMWH dosage.
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Affiliation(s)
- Zhe Du
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Tienan Zhu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ping Peng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Xinyan Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Linru Fu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
| | - Zhijing Sun
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, National Clinical Research Center for Obstetric & Gynecologic Diseases, Beijing, China
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Federspiel JJ, Rodriguez W, Spears J, Calloway M, Zhang X, Farrar E, Rajkumar R, Lodaya K, James AH. Antithrombin testing and treatment in pregnancy: Their real-world relationship to clinical outcomes. Thromb Res 2024; 241:109070. [PMID: 38970992 DOI: 10.1016/j.thromres.2024.109070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/28/2024] [Accepted: 06/17/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Antithrombin (AT) deficiency is a severe thrombophilia associated with increased rates of maternal morbidity, mortality, and greater healthcare resource utilization during pregnancy and postpartum. METHODS Two large U.S. healthcare databases were queried for women aged 15-44 with delivery-related encounters: Cerner Real-World Data (CRWD, 01/01/2000-12/31/2021) and Premier Healthcare Database (PHD, 01/01/2016-01/01/2019). Individuals receiving cardiopulmonary bypass were excluded. Three cohorts were created: 1) Individuals who had AT levels tested any time between 9-months pre- through 3-months post-delivery (CRWD Test Cohort); 2) individuals prescribed AT concentrate (ATc) within 1-year pre- or 1-year post-delivery in CRWD (CRWD Medication Cohort); and 3) the same criteria as 2) applied to PHD (PHD Medication Cohort). RESULTS There were 5411 individuals in the CRWD Test Cohort, 13 in the CRWD Medication Cohort and 38 in the PHD Medication Cohort. Demographic and baseline clinical characteristics were similar across cohorts. AT level testing occurred pre-delivery in 47.9 % of the CRWD Test Cohort and 23.1 % of the CRWD Medication Cohort. ATc was administered during the delivery hospitalization to 0.1 %, 23.1 % and 50.0 % of the CRWD Test, CRWD Medication, and PHD Medication Cohorts, respectively. Across cohorts, 5.4-7.9 % of individuals experienced thrombosis during the delivery-related encounter. Mean (SD) total costs for delivery through 1-year post-delivery were $190,894 ($276,893) with $123,763 ($177,122) of total costs related to abnormal coagulation. CONCLUSION Opportunities exist to enhance the care of pregnant individuals with low AT levels throughout pregnancy, aiming for optimal maternal outcomes.
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Affiliation(s)
| | | | | | | | - Xuan Zhang
- Boston Strategic Partners, Inc., Boston, MA, United States
| | - Emily Farrar
- Boston Strategic Partners, Inc., Boston, MA, United States
| | - Rahul Rajkumar
- Boston Strategic Partners, Inc., Boston, MA, United States
| | - Kunal Lodaya
- Boston Strategic Partners, Inc., Boston, MA, United States
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Kruijt M, van der Pol LM, Eikenboom J, Verburg HJ, Cobbaert CM, Ruhaak LR. Unraveling a borderline antithrombin deficiency case with quantitative mass spectrometry. J Thromb Haemost 2022; 20:145-148. [PMID: 34653293 PMCID: PMC9298056 DOI: 10.1111/jth.15553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 11/27/2022]
Abstract
Antithrombin deficiency diagnostics by first-line activity tests suffer from a lack of sensitivity sometimes resulting in diagnostic uncertainty. We here present a case of a woman with recurrent pregnancy loss who was screened for inherited thrombophilia. Antithrombin activity was borderline low, resulting in uncertainty about the correct diagnosis. Using a mass spectrometry-based test, the antithrombin protein of the patient was characterized at the molecular level and a heterozygous p.Pro73Leu mutation was identified. The mutation, also known as antithrombin "Basel," increases the risk of venous thromboembolism and obstetric complications. This case is illustrative of current antithrombin deficiency screening, in which diagnoses may be missed by traditional diagnostics. Next-generation protein diagnostics by mass spectrometry provides molecular insight into the proteoforms present in vivo. This information is essential for laboratory specialists and clinicians to unambiguously diagnose patients and will aid in evolving healthcare from traditional to precision diagnostics.
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Affiliation(s)
- Mirjam Kruijt
- Department of Clinical Chemistry and Laboratory MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - Liselotte M. van der Pol
- Department of Internal MedicineDivision of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Jeroen Eikenboom
- Department of Internal MedicineDivision of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Harjo J. Verburg
- Department of Gynecology and FertilityLeiden University Medical CenterLeidenThe Netherlands
| | - Christa M. Cobbaert
- Department of Clinical Chemistry and Laboratory MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - L. Renee Ruhaak
- Department of Clinical Chemistry and Laboratory MedicineLeiden University Medical CenterLeidenThe Netherlands
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Treatment of Homozygous Type II Antithrombin Heparin-Binding Site Deficiency in Pregnancy. Case Rep Obstet Gynecol 2021; 2021:4393821. [PMID: 34513101 PMCID: PMC8433018 DOI: 10.1155/2021/4393821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/14/2021] [Indexed: 12/02/2022] Open
Abstract
Pregnancy is associated with an increased risk of venous thromboembolism (VTE). Previous VTE and severe thrombophilia are important risk factors. Our case was a 36-year-old woman, gravida 6, para 0, with antithrombin (AT) deficiency caused by a homozygous mutation in the heparin-binding site (HBS). Her history included seven prior VTEs, three early and two late pregnancy losses. She was prophylactically treated with both human plasma-derived AT concentrate (hpATC) and low molecular weight heparin (LMWH), resulting in a successful 6th pregnancy and a healthy live born baby. There is limited evidence and guidance on the management of AT deficiency in pregnancy. Dosing and monitoring of anticoagulants, alone or together with hpATC, must be based on individual risk assessment. The severity of clinical manifestations varies with the type of AT deficiency. Characterization of the AT mutation may aid in the decision-making process and optimize pregnancy outcomes.
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Bravo-Pérez C, Vicente V, Corral J. Management of antithrombin deficiency: an update for clinicians. Expert Rev Hematol 2019; 12:397-405. [PMID: 31116611 DOI: 10.1080/17474086.2019.1611424] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Introduction. Antithrombin is a serpin that inhibits multiple procoagulant serine proteases and acts as an endogenous anticoagulant. Thus, congenital antithrombin deficiency constitutes a major thrombophilic state, the most severe so far. Areas covered. In the present work, we globally review the biology, genetics, diagnosis, and management of congenital antithrombin deficiency, and also discuss puzzling questions and future perspectives regarding this severe inherited thrombophilia. Expert opinion. Although this disorder exerts high clinical heterogeneity, many carriers will need careful and long-term anticoagulation and/or thromboprophylaxis, especially in high-risk situations, such as surgery and pregnancy. Notably, antithrombin concentrates constitute a considerable arsenal for both treatment and prevention of acute venous thrombosis in subjects with antithrombin deficiency. Current evidences are based almost exclusively on retrospective case series, so an integrated functional, biochemical and molecular characterization will be of clinical relevance and guide hematologists' personalized decisions.
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Affiliation(s)
- Carlos Bravo-Pérez
- a Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación , Universidad de Murcia, IMIB-Arrixaca, CIBERER , Murcia , Spain
| | - Vicente Vicente
- a Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación , Universidad de Murcia, IMIB-Arrixaca, CIBERER , Murcia , Spain
| | - Javier Corral
- a Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación , Universidad de Murcia, IMIB-Arrixaca, CIBERER , Murcia , Spain
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Kovac M, Mitic G, Mikovic Z, Mandic V, Miljic P, Mitrovic M, Tomic B, Bereczky Z. The influence of specific mutations in the AT gene (SERPINC1) on the type of pregnancy related complications. Thromb Res 2018; 173:12-19. [PMID: 30458337 DOI: 10.1016/j.thromres.2018.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/17/2018] [Accepted: 11/07/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Inherited antithrombin (AT) deficiency is a rare autosomal dominant disorder, caused by mutations in the SERPINC1 gene. The most common clinical presentation in AT deficient patients includes venous thrombosis and pulmonary embolism, while the association of AT deficiency and its effect on the development of pregnancy complications has been less studied. The aim of our research was to evaluate the effect of AT deficiency types, determined by genotyping, on pregnancy outcomes. METHODS A retrospective cohort study included 28 women with AT deficiency, and their 64 pregnancies were analyzed. RESULTS With regard to live birth rate, a significant difference was observed among women who were carriers of different SERPINC1 mutations, as the rate varied from 100% in cases of type I to the extremely low rate of 8% for women with type II HBS (AT Budapest 3) in the homozygous variant, P = 0.0005. All pregnancies from the type I group, even untreated ones, resulted in live births. In women with AT Budapest 3 in homozygous variant the overall live birth rate increased to 28.5% in the treated pregnancies. In this group the highest incidence of fetal death was observed of 62%; repeated fetal losses in 30%; fetal growth restriction in 22% and placental abruption in 7% of all pregnancies. CONCLUSION Our study results indicate a difference between type I and type II AT deficiency. The risk of pregnancy related VTE was equally present in both groups, except for AT Budapest 3 in the heterozygous variant, while adverse pregnancy outcomes were strictly related to type II, especially AT Budapest 3 in the homozygous variant.
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Affiliation(s)
- Mirjana Kovac
- Faculty of Medicine, University of Belgrade, Serbia; Blood Transfusion Institute of Serbia, Hemostasis Department, Belgrade, Serbia.
| | - Gorana Mitic
- Institute of Laboratory Medicine, Clinical Center of Vojvodina, Faculty of Medicine Novi Sad, University of Novi Sad, Serbia
| | - Zeljko Mikovic
- Faculty of Medicine, University of Belgrade, Serbia; Gynecology and Obstetrics Clinic Narodni Front, Belgrade, Serbia
| | - Vesna Mandic
- Faculty of Medicine, University of Belgrade, Serbia; Gynecology and Obstetrics Clinic Narodni Front, Belgrade, Serbia
| | - Predrag Miljic
- Faculty of Medicine, University of Belgrade, Serbia; Clinic of Hematology, Clinical Center of Serbia, Serbia
| | - Mirjana Mitrovic
- Faculty of Medicine, University of Belgrade, Serbia; Clinic of Hematology, Clinical Center of Serbia, Serbia
| | - Branko Tomic
- Institute of Molecular Genetics and Genetic Engineering, University of Belgrade, Belgrade, Serbia
| | - Zsuzsanna Bereczky
- Division of Clinical Laboratory Research, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Joly BS, Sudrié-Arnaud B, Barbay V, Borg JY, Le Cam Duchez V. Thrombin generation test as a marker for high risk venous thrombosis pregnancies. J Thromb Thrombolysis 2018; 45:114-121. [PMID: 29032523 DOI: 10.1007/s11239-017-1572-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pregnancy is a well-established risk factor for venous thromboembolism and is associated with a state of hypercoagulability. The use of sensitive and specific biological markers to predict risk factors for thrombosis is essential during pregnancy. Our objective was to investigate the usefulness of thrombin generation test (TGT) as a marker to predict the risk of thrombosis in high risk venous thrombosis (HRVT) pregnancies compared to normal pregnancies. This retrospective study enrolled 134 women with HRVT pregnancies, 78 of whom had monozygotic, spontaneous and untreated pregnancies and formed the study group. The control group comprised 106 women with normal pregnancies. Routine assessment of coagulation activation markers: fibrinogen, D-dimer, prothrombin fragments 1 + 2 (F1 + 2), thrombin-antithrombin complexes (TAT) and fibrin monomer complexes (FMC) was performed every 5 weeks in the study group to detect a possible pathological state of hypercoagulability. TGT was performed using platelet-free plasma, 1 and 5 pM tissue factor (TF), supplemented by phospholipids (PL) ± thrombomodulin. Fibrinogen, D-dimer, F1 + 2, and TAT, but not FMC, increased significantly throughout pregnancy in both groups but no difference was shown between the groups. TGT showed an early increase in thrombin generation in both groups, which stabilized during the second month of pregnancy. No correlation was demonstrated between thrombin generation parameters and coagulation activation markers. Based on our results, TGT did not prove conclusive as a marker to predict the risk of thrombosis in HRVT pregnancies. Finding a sensitive and specific biological marker to predict thrombosis risk requires further investigation.
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Affiliation(s)
- Bérangère S Joly
- Department of Biological Hematology, Rouen University Hospital, F 76000, Rouen, France.,Hôpital Lariboisière, Service d'Hématologie Biologique, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Paris, France
| | | | - Virginie Barbay
- Normandie Univ, UNIROUEN, Inserm 1096, Department of Biological Hematology, Rouen University Hospital, F 76000, Rouen, France
| | - Jeanne-Yvonne Borg
- Department of Biological Hematology, Rouen University Hospital, F 76000, Rouen, France
| | - Véronique Le Cam Duchez
- Normandie Univ, UNIROUEN, Inserm 1096, Department of Biological Hematology, Rouen University Hospital, F 76000, Rouen, France.
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Gindele R, Selmeczi A, Oláh Z, Ilonczai P, Pfliegler G, Marján E, Nemes L, Nagy Á, Losonczy H, Mitic G, Kovac M, Balogh G, Komáromi I, Schlammadinger Á, Rázsó K, Boda Z, Muszbek L, Bereczky Z. Clinical and laboratory characteristics of antithrombin deficiencies: A large cohort study from a single diagnostic center. Thromb Res 2017; 160:119-128. [PMID: 29153735 DOI: 10.1016/j.thromres.2017.10.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Inherited antithrombin (AT) deficiency is a heterogeneous disease. Due to low prevalence, only a few studies are available concerning genotype-phenotype associations. The aim was to describe the clinical, laboratory and genetic characteristics of AT deficiency in a large cohort including children and to add further laboratory data on the different sensitivity of functional AT assays. PATIENTS AND METHODS Non-related AT deficient patients (n=156) and their family members (total n=246) were recruited. Clinical and laboratory data were collected, the mutation spectrum of SERPINC1 was described. Three different AT functional assays were explored. RESULTS Thirty-one SERPINC1 mutations including 11 novel ones and high mutation detection rate (98%) were detected. Heparin binding site deficiency (type IIHBS) was the most frequent (75.6%) including AT Budapest3 (ATBp3), AT Padua I and AT Basel (86%, 9% and 4% of type IIHBS, respectively). Clinical and laboratory phenotypes of IIHBS were heterogeneous and dependent on the specific mutation. Arterial thrombosis and pregnancy complications were the most frequent in AT Basel and AT Padua I, respectively. Median age at the time of thrombosis was the lowest in ATBp3 homozygotes. The functional assay with high heparin concentration and pH7.4 as assay conditions had low (44%) sensitivity for ATBp3 and it was insensitive for AT Basel and Padua I. CONCLUSION Type IIHBS deficiencies behave differently in clinical and laboratory phenotypes from each other and from other AT deficiencies. Heparin concentration and pH seem to be the key factors influencing the sensitivity of AT functional assays to IIHBS.
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Affiliation(s)
- Réka Gindele
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anna Selmeczi
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary; National Haemophilia Center and Haemostasis Department, State Health Center, Budapest, Hungary
| | - Zsolt Oláh
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Péter Ilonczai
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - György Pfliegler
- Division of Rare Diseases, Department of Internal Medicine, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Erzsébet Marján
- Department of Pediatrics, A. Jósa Teaching Hospital, Nyíregyháza, Hungary
| | - László Nemes
- National Haemophilia Center and Haemostasis Department, State Health Center, Budapest, Hungary
| | - Ágnes Nagy
- Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Hajna Losonczy
- Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Gorana Mitic
- Institute of Laboratory Medicine, Clinical Centre of Vojvodina, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Mirjana Kovac
- Blood Transfusion Institute of Serbia, Belgrade, Serbia
| | - Gábor Balogh
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - István Komáromi
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ágota Schlammadinger
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Katalin Rázsó
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - Zoltán Boda
- Thrombosis and Haemostasis Center, Clinical Center, University of Debrecen, Debrecen, Hungary
| | - László Muszbek
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsanna Bereczky
- Division of Clinical Laboratory Science, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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Marshall AL, Botero JP, Ashrani AA, Pruthi RK, Heit JA, Chintakuntlawar A, Guenther JC, Patnaik MM. The Impact of Antithrombin Deficiency on Women's Reproductive Health Experiences and Healthcare Decision-Making. J Womens Health (Larchmt) 2017; 26:1350-1355. [PMID: 28933640 DOI: 10.1089/jwh.2017.6333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Women with inherited antithrombin (AT) deficiency are at high risk for venous thromboembolism (VTE), especially during times of estrogen exposure, but little is known about patient-oriented reproductive decision-making in this population. MATERIALS AND METHODS Provider-administered survey of women with AT deficiency. Participants were asked to discuss their diagnosis of AT deficiency and questioned about (1) contraception, (2) pregnancies, and (3) menorrhagia, and the impact of their AT deficiency on each reproductive health experience. RESULTS Of 31 women with inherited AT deficiency, 18 (58%) were surveyed, 8 (26%) were unreachable, and 5 (16%) were deceased. Twelve (67%) had a VTE, including two which occurred during pregnancy and five during oral contraceptive (OCP) use. Women reported using OCPs, intrauterine device (IUD), and condoms for contraception. Of five women diagnosed with AT deficiency while taking OCPs, three switched to an IUD, one to condoms, and one used no alternative method. Eighteen women reported 42 total pregnancies, with 33 (79%) resulting in live term birth, 3 (7%) in live preterm birth, and 6 (14%) in spontaneous abortion at a median of 12 weeks. Four (22%) women reported the use of anticoagulation during pregnancy. Eleven (61%) women reported menorrhagia and 4 (36%), while on anticoagulation for VTE events. Ten of 18 women (56%) reported that the diagnosis of AT had affected their reproductive health in some way. CONCLUSION Women with AT deficiency require careful multidisciplinary management to avoid complications in the setting of contraception and pregnancy. AT deficiency impacts women's reproductive health experiences and patient-oriented reproductive decision-making is key.
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Affiliation(s)
- Ariela L Marshall
- 1 Division of Hematology, Department of Internal Medicine, Mayo Clinic , Rochester, Minnesota
| | - Juliana Perez Botero
- 1 Division of Hematology, Department of Internal Medicine, Mayo Clinic , Rochester, Minnesota
| | - Aneel A Ashrani
- 1 Division of Hematology, Department of Internal Medicine, Mayo Clinic , Rochester, Minnesota.,2 Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota
| | - Rajiv K Pruthi
- 1 Division of Hematology, Department of Internal Medicine, Mayo Clinic , Rochester, Minnesota.,2 Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota
| | - John A Heit
- 1 Division of Hematology, Department of Internal Medicine, Mayo Clinic , Rochester, Minnesota.,2 Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota.,3 Department of Cardiovascular Diseases, Mayo Clinic , Rochester, Minnesota
| | | | - Jennifer C Guenther
- 2 Department of Laboratory Medicine and Pathology, Mayo Clinic , Rochester, Minnesota
| | - Mrinal M Patnaik
- 1 Division of Hematology, Department of Internal Medicine, Mayo Clinic , Rochester, Minnesota
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10
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A case that illustrates the challenges of managing pregnant patients with antithrombin deficiency: More questions than answers. Thromb Res 2017; 157:1-6. [PMID: 28667866 DOI: 10.1016/j.thromres.2017.06.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/17/2017] [Accepted: 06/23/2017] [Indexed: 11/20/2022]
Abstract
Using an illustrative case of a patient with antithrombin (AT) deficiency who developed a recurrent venous thromboembolism (VTE) in pregnancy despite therapeutic low-molecular-weight heparin (LMWH), we highlight what is known in the literature and address areas of controversy through a series of questions around the case. The questions we address include the role of anti-Xa monitoring for patients with past VTE on antepartum LMWH, what treatment regimen is recommended for pregnant patients who develop a recurrent VTE while on therapeutic anticoagulation, the role of antepartum AT concentrate prophylaxis, and the management of labor/delivery, epidural anesthesia and postpartum anticoagulation. We also describe practical considerations for use of AT concentrate, including teaching our patient to self-infuse AT concentrate at home with support of a hemophilia treatment center (HTC), and the direct and indirect costs of AT concentrate for secondary prophylaxis.
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Management of Venous Thromboembolism in Patients with Hereditary Antithrombin Deficiency and Pregnancy: Case Report and Review of the Literature. Case Rep Hematol 2017; 2017:9261351. [PMID: 28168066 PMCID: PMC5259678 DOI: 10.1155/2017/9261351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/14/2016] [Accepted: 11/24/2016] [Indexed: 02/02/2023] Open
Abstract
Background. Hereditary antithrombin deficiency is a thrombogenic disorder associated with a 50–90% lifetime risk of venous thromboembolism (VTE), which is increased during pregnancy and the puerperium in these patients. We present a case of a woman with antithrombin (AT) deficiency who presented with a VTE despite therapeutic low molecular weight heparin (LMWH). Though the pregnancy was deemed unviable, further maternal complications were mitigated through the combined use of therapeutic anticoagulation and plasma-derived antithrombin concentrate infusions to normalize her functional antithrombin levels. Methods. A review of the literature was conducted for studies on prophylaxis and management of VTE in pregnant patients with hereditary AT deficiency. The search involved a number of electronic databases, using combinations of keywords as described in the text. Only English language studies between 1946 and 2015 were included. Conclusion. Antithrombin concentrate is indicated in pregnant women with hereditary AT deficiency who develop VTE despite being on therapeutic dose anticoagulation. Expert opinion suggests AT concentrate should be used concomitantly with therapeutic dose anticoagulation. However, further high-quality studies on the dose and duration of treatment in the postpartum period are required. Use of AT concentrate for prophylaxis is controversial and should be based on individual VTE risk stratification.
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Bauer KA, Nguyen-Cao TM, Spears JB. Issues in the Diagnosis and Management of Hereditary Antithrombin Deficiency. Ann Pharmacother 2016; 50:758-67. [DOI: 10.1177/1060028016651276] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective: To review insights gained in the past several years about hereditary antithrombin (AT) deficiency and to outline approaches to the management of patients with AT deficiency in the acute and chronic settings. Data Sources: An extensive literature search of Scopus (January 2008-April 2016) was performed for the terms congenital antithrombin deficiency, inherited antithrombin deficiency, or hereditary antithrombin deficiency. Additional references were identified by reviewing literature citations. Study Selection: All relevant English-language case reports, reviews, clinical studies, meeting abstracts, and book chapters assessing hereditary AT deficiency were included. Data Synthesis: AT deficiency significantly increases the risk of venous thromboembolism (VTE). The risk of VTE is particularly high during pregnancy, the postpartum period, and following major surgery. Effective clinical management includes determination of the appropriate type and duration of antithrombotic therapy (ie, AT replacement for acute situations) while minimizing the risk of bleeding. For persons newly diagnosed with AT deficiency, age, lifestyle, concurrent medical conditions, family history, and personal treatment preferences can be used to individualize patient management. Patients should be informed of the risks associated with hormonal therapy, pregnancy, surgical procedures, and immobility, which further increase the risk of VTE in patients with AT deficiency. Conclusion: AT deficiency poses the highest risk for VTE among the hereditary thrombophilias, often requiring long-term anticoagulation. Undertaking an evaluation for hereditary thrombophilia is controversial; however, a diagnosis of VTE in association with AT deficiency can have management implications. An important treatment option for patients with this disorder in high-risk situations is AT concentrate.
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