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Nasich LL, Hoffman R, Keren-Politansky A, Jabareen A, Kalish Y, Schliamser L, Brenner B, Nadir Y. Effects of anti-Xa activity monitoring on the outcome of high-risk pregnancies treated with a prophylactic dose of low-molecular-weight heparin. Eur J Haematol 2023; 111:655-661. [PMID: 37533300 DOI: 10.1111/ejh.14060] [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: 03/23/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVE To evaluate if anti-Xa level monitoring and dose adjustment in women using a prophylactic dose of enoxaparin can decrease placenta-mediated pregnancy complications. METHODS This retrospective observational cohort study included pregnant women receiving enoxaparin prophylaxis, who were followed at the Thrombosis and Hemostasis Outpatient clinic between 2010 and 2017. The dose was adjusted according to enoxaparin anti-Xa levels in the study group or the weight of individuals in the control group. RESULTS Of 585 women surveyed, 110 met the inclusion criteria; 63 of them were included in the study group and 47 in the control group. Mean starting dose was 46 versus 43 mg (p = .25), mean final dose was 52 mg versus 45 mg (p = .03) and dose adjustment was required in 37% versus 11% (p = .002) in the study and control groups, respectively. Twenty-eight percent of anti-Xa measurements in the second trimester were beneath the prophylactic threshold, compared to 11% and 16% in the first and third trimesters, respectively (p = .02). Labors ended with live birth in 91% versus 94% of cases (p = .5), 85% versus 68% of pregnancies were term (p = .05), 11% versus 23% of newborns were low birth weight (p = .1) and placenta-mediated pregnancy complications were documented in 9% versus 19%, (p = .17) in the study group relative to controls, respectively. CONCLUSIONS The most prominent decrease in anti-Xa levels was observed in the second trimester. Monitored women had significantly more term deliveries and demonstrated a trend toward higher birth weight and fewer placenta-mediated pregnancy complications. Larger studies are needed to confirm improved pregnancy outcome in monitored women.
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Affiliation(s)
- Lea Liat Nasich
- Thrombosis and Hemostasis Unit, Rambam Health Care Campus, Haifa, Israel
| | - Ron Hoffman
- Thrombosis and Hemostasis Unit, Rambam Health Care Campus, Haifa, Israel
| | | | - Amal Jabareen
- Thrombosis and Hemostasis Unit, Rambam Health Care Campus, Haifa, Israel
| | - Yosef Kalish
- Thrombosis and Hemostasis Unit, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Benjamin Brenner
- Thrombosis and Hemostasis Unit, Rambam Health Care Campus, Haifa, Israel
| | - Yona Nadir
- Thrombosis and Hemostasis Unit, Rambam Health Care Campus, Haifa, Israel
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2
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de Moreuil C, Pan-Petesch B, Trémouilhac C, Dupré PF, Merviel P, Anouilh F, Bellot C, Müller M, Drugmanne G, Nowak E, Coadic J, Bihan L, Gourhant L, Lemarié C, Robin S, Couturaud F, Moigne EL. Clinical risk factors for vasculo-placental disorders: results from a prospective case-control study nested in HEMOTHEPP French cohort study. J Gynecol Obstet Hum Reprod 2023; 52:102511. [PMID: 36417979 DOI: 10.1016/j.jogoh.2022.102511] [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: 09/08/2022] [Revised: 11/18/2022] [Accepted: 11/18/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Determine clinical risk factors for vasculo-placental disorders in singleton pregnancies. DESIGN Prospective case-control study nested in HEMOTHEPP French cohort. SETTING Women delivered between June, 2015 and January, 2019 in any maternity ward of Finistère. POPULATION Cases were women with vasculo-placental disorders (pre-eclampsia, intrauterine growth restriction (IUGR), placental abruption or stillbirth). Controls were women matched for age at delivery and parity. METHODS Clinical data were collected by obstetricians or midwives during antenatal care visits and delivery, and recorded by trained research assistants. MAIN OUTCOME MEASURES Occurrence of a vasculo-placental disorder. RESULTS 505 women with vasculo-placental disorder (299 pre-eclampsia, 253 IUGR, 44 placental abruptions, 11 stillbirths) and 1515 matched controls were selected out of 20,075 participants. In multivariable analysis, four clinical parameters were associated with pre-eclampsia: obesity (Odd ratio (OR) = 3.11, 95%CI 2.11-4.58), French overseas origin (OR = 4.41, 95%CI 1.87-10.42), previous vasculo-placental disorder (OR = 5.14, 95%CI 2.72-9.70), aspirin during pregnancy (OR = 10.10, 95%CI 1.99-51.08). Three clinical parameters were associated with IUGR: auto-immune/inflammatory disorder (OR = 3.75, 95%CI 1.83-7.68), previous vasculo-placental disorder (OR = 3.63, 95%CI 2.06-6.41), smoking during pregnancy (OR = 2.66, 95%CI 1.91- 3.71). A previous venous thromboembolism (VTE) was associated with IUGR in univariable but not in multivariable analysis (OR = 3.72, 95%CI 0.82-17.00, p = 0.09). CONCLUSIONS Clinical risk factors differ between IUGR and pre-eclampsia, the later, but not the former, being associated with cardiovascular risk factors.
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Affiliation(s)
- Claire de Moreuil
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest (France), Boulevard Tanguy Prigent, F-29609 Brest Cedex, France.
| | - Brigitte Pan-Petesch
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Centre de traitement de l'hémophilie, Hématologie, CHU Brest - Brest (France), France
| | - Christophe Trémouilhac
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Service de Gynécologie Obstétrique, CHU Brest - Brest (France), France
| | - Pierre-François Dupré
- Service de Gynécologie Obstétrique, CHU Brest - Brest (France), France; INSERM 1078, équipe GTCA, France
| | - Philippe Merviel
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Service de Gynécologie Obstétrique, CHU Brest - Brest (France), France
| | - François Anouilh
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Ecole de Sage-femmes, UFR Santé - Brest (France), France
| | - Charles Bellot
- Service de Gynécologie Obstétrique, CHIC de Quimper - Quimper (France), France
| | - Matthieu Müller
- Service de Gynécologie Obstétrique, CH des Pays de Morlaix - Morlaix (France), France
| | | | | | | | - Line Bihan
- CIC1412, INSERM - Brest (France), France
| | - Lénaick Gourhant
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France
| | - Catherine Lemarié
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France
| | - Sara Robin
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest (France), Boulevard Tanguy Prigent, F-29609 Brest Cedex, France
| | - Francis Couturaud
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest (France), Boulevard Tanguy Prigent, F-29609 Brest Cedex, France
| | - Emmanuelle Le Moigne
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest (France), Boulevard Tanguy Prigent, F-29609 Brest Cedex, France
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3
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Cornish EF, McDonnell T, Williams DJ. Chronic Inflammatory Placental Disorders Associated With Recurrent Adverse Pregnancy Outcome. Front Immunol 2022; 13:825075. [PMID: 35529853 PMCID: PMC9072631 DOI: 10.3389/fimmu.2022.825075] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/29/2022] [Indexed: 12/11/2022] Open
Abstract
Chronic inflammatory placental disorders are a group of rare but devastating gestational syndromes associated with adverse pregnancy outcome. This review focuses on three related conditions: villitis of unknown etiology (VUE), chronic histiocytic intervillositis (CHI) and massive perivillous fibrin deposition (MPFD). The hallmark of these disorders is infiltration of the placental architecture by maternal immune cells and disruption of the intervillous space, where gas exchange between the mother and fetus occurs. Currently, they can only be detected through histopathological examination of the placenta after a pregnancy has ended. All three are associated with a significant risk of recurrence in subsequent pregnancies. Villitis of unknown etiology is characterised by a destructive infiltrate of maternal CD8+ T lymphocytes invading into the chorionic villi, combined with activation of fetal villous macrophages. The diagnosis can only be made when an infectious aetiology has been excluded. VUE becomes more common as pregnancy progresses and is frequently seen with normal pregnancy outcome. However, severe early-onset villitis is usually associated with fetal growth restriction and recurrent pregnancy loss. Chronic histiocytic intervillositis is characterised by excessive accumulation of maternal CD68+ histiocytes in the intervillous space. It is associated with a wide spectrum of adverse pregnancy outcomes including high rates of first-trimester miscarriage, severe fetal growth restriction and late intrauterine fetal death. Intervillous histiocytes can also accumulate due to infection, including SARS-CoV-2, although this infection-induced intervillositis does not appear to recur. As with VUE, the diagnosis of CHI requires exclusion of an infectious cause. Women with recurrent CHI and their families are predisposed to autoimmune diseases, suggesting CHI may have an alloimmune pathology. This observation has driven attempts to prevent CHI with a wide range of maternal immunosuppression. Massive perivillous fibrin deposition is diagnosed when >25% of the intervillous space is occupied by fibrin, and is associated with fetal growth restriction and late intrauterine fetal death. Although not an inflammatory disorder per se, MPFD is frequently seen in association with both VUE and CHI. This review summarises current understanding of the prevalence, diagnostic features, clinical consequences, immune pathology and potential prophylaxis against recurrence in these three chronic inflammatory placental syndromes.
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Affiliation(s)
- Emily F. Cornish
- Elizabeth Garrett Anderson Institute for Women’s Health, Department of Maternal and Fetal Medicine, University College London, London, United Kingdom,*Correspondence: Emily F. Cornish,
| | - Thomas McDonnell
- Faculty of Engineering Science, Department of Biochemical Engineering, University College London, London, United Kingdom
| | - David J. Williams
- Elizabeth Garrett Anderson Institute for Women’s Health, Department of Maternal and Fetal Medicine, University College London, London, United Kingdom
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4
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Low Molecular Weight Heparins (LMWH) and Implications along Pregnancy: a Focus on the Placenta. Reprod Sci 2021; 29:1414-1423. [PMID: 34231172 DOI: 10.1007/s43032-021-00678-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
Low molecular weight heparins (LMWH) have been largely studied for their use during pregnancy. The biology and the pharmacology of these molecules are well known and may be summarized in three main mechanisms of action: anti-coagulant, anti-inflammatory, and immunomodulant. The clinical implications of these drugs during pregnancy are mainly related to their action on the placenta, because of the presence of specific molecular and cellular targets, particularly at the trophoblast-endometrial interface. As well as for the prevention and treatment of thromboembolism, LMWH have been largely investigated for the improvement of embryo implantation and for the prevention of placenta-related complications such as preeclampsia, fetal growth restriction, and intrauterine fetal death. However, data on this topic are still unclear. The present review discusses the biological features, the mechanisms of action, and the possible contribution of LMWH to the success of placentation along pregnancy, pointing out the need for future basic science and clinical researches in this important field with the final aim to improve clinical practice in high-risk pregnancies.
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5
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Bettiol A, Avagliano L, Lombardi N, Crescioli G, Emmi G, Urban ML, Virgili G, Ravaldi C, Vannacci A. Pharmacological Interventions for the Prevention of Fetal Growth Restriction: A Systematic Review and Network Meta-Analysis. Clin Pharmacol Ther 2021; 110:189-199. [PMID: 33423282 DOI: 10.1002/cpt.2164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/04/2020] [Indexed: 11/08/2022]
Abstract
The prevention of fetal growth restriction (FGR) is challenging in clinical practice. To date, no meta-analysis summarized evidence on the relative benefits and harms of pharmacological interventions for FGR prevention. We performed a systematic review and network meta-analysis (NetMA), searching PubMed, Embase, Cochrane Library, and ClinicalTrials.gov from inception until November 2019. We included clinical trials and observational studies on singleton gestating women evaluating antiplatelet, anticoagulant, or other treatments, compared between each other or with controls (placebo or no treatment), and considering the pregnancy outcome FGR (primary outcome of the NetMA). Secondary efficacy outcomes included preterm birth, placental abruption, and fetal or neonatal death. Safety outcomes included bleeding and thrombocytopenia. Network meta-analyses using a frequentist framework were conducted to derive odds ratios (ORs) and 95% confidence intervals (CIs). Of 18,780 citations, we included 30 studies on 4,326 patients. Low molecular weight heparin (LMWH), alone or associated with low-dose aspirin (LDA), appeared more efficacious than controls in preventing FGR (OR 2.00, 95% CI 1.27-3.16 and OR 2.67, 95% CI 1.21-5.89 for controls vs. LMWH and LDA + LMWH, respectively). No difference between active treatments emerged in terms of FGR prevention, but estimates for treatments other than LMWH +/- LDA were imprecise. Only the confidence in the evidence regarding LMWH vs. controls was judged as moderate, according to the Confidence in Network Meta-Analysis framework. No treatment was associated with an increased risk of bleeding, although estimates were precise enough only for LMWH. These results should inform clinicians on the benefits of active pharmacological prophylaxis for FGR prevention.
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Affiliation(s)
- Alessandra Bettiol
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Laura Avagliano
- Department of Health Sciences, San Paolo Hospital Medical School, University of Milan, Milan, Italy
| | - Niccolò Lombardi
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Giada Crescioli
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.,PeaRL Perinatal Research Laboratory, University of Florence, CiaoLapo Foundation for Perinatal Health, Prato, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Letizia Urban
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.,Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Claudia Ravaldi
- PeaRL Perinatal Research Laboratory, University of Florence, CiaoLapo Foundation for Perinatal Health, Prato, Italy.,Department of Health Sciences, University of Florence, Florence, Italy
| | - Alfredo Vannacci
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.,PeaRL Perinatal Research Laboratory, University of Florence, CiaoLapo Foundation for Perinatal Health, Prato, Italy
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6
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Rasheedy R, El Bishry G, Tarek R. Maternal low molecular weight heparin versus sildenafil citrate for fetal growth restriction: a randomized, parallel groups, open-label clinical trial. J Perinatol 2020; 40:715-723. [PMID: 31695136 DOI: 10.1038/s41372-019-0544-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 10/09/2019] [Accepted: 10/28/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To compare the effect of sildenafil citrate (SC) and low molecular weight heparin (LMWH) on neonatal birth weight (BW) and the fetoplacental blood flow in pregnancies with FGR. STUDY DESIGN A parallel groups, randomized clinical trial was conducted at a university hospital, between June 2017 and September 2018, involving 100 pregnant women with placental mediated FGR between 28 and 35 weeks of gestation who were randomly assigned to receive either SC or LMWH started at FGR diagnosis till delivery. RESULTS The neonatal BW in LMWH group was higher than SC group (p < 0.000) with a longer time from randomization till delivery, LMWH group had significant improvement in Ut A PI, UA PI, and MCA PI compared with SC treated group with p values 0.005, <0.000001, and 0.014, respectively. CONCLUSION The neonatal BW, time from randomization to delivery, and fetoplacental blood flow indices were significantly better with LMWH use compared with SC.
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Affiliation(s)
- R Rasheedy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - G El Bishry
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - R Tarek
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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7
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Jawad AK, Alalaf SK, Ali MS, Bawadikji AA. Bemiparin as a Prophylaxis After an Unexplained Stillbirth: Open-Label Interventional Prospective Study. Clin Appl Thromb Hemost 2019; 25:1076029619896629. [PMID: 31880168 PMCID: PMC7019397 DOI: 10.1177/1076029619896629] [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] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/11/2019] [Accepted: 11/26/2019] [Indexed: 11/18/2022] Open
Abstract
Stillbirth is a devastating event to the parents, relatives, friends, and families. The role of anticoagulants in the prevention of unexplained stillbirths is uncertain. An open-label interventional prospective cohort study was conducted on 144 women with a history of unexplained stillbirths. The intervention group had a high umbilical artery resistance index (RI) and received bemiparin. The nonintervention group had a normal RI and did not receive any intervention. We measured the adjusted odds ratio (OR) and 95% confidence interval (CI) of the main outcome for these variables using logistic regression analysis. Fresh stillbirth and early neonatal death rates were lower (P = .005, OR = 11.949 and 95% CI = 2.099-68.014) and newborn weight was higher (P = .015, OR = 0.048, 95% CI = 0.004-0.549) in the group that received bemiparin. Bemiparin is effective in decreasing the rate of stillbirth in women with a history of previous unexplained stillbirths.
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Affiliation(s)
- Ariana Khalis Jawad
- Department of Obstetrics and Gynecology, Kurdistan Board of Medical
Specialty, Erbil, Kurdistan, Iraq
| | - Shahla Kareem Alalaf
- Department of Obstetrics and Gynecology, College of Medicine, Hawler Medical
University, Erbil, Kurdistan, Iraq
| | - Mahabad Salih Ali
- Department of Obstetrics and Gynecology, Ministry of Health, Maternity
Teaching Hospital, Erbil, Kurdistan, Iraq
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8
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Abstract
Preeclampsia continues to afflict 5% to 8% of all pregnancies throughout the world and is associated with significant morbidity and mortality to the mother and the fetus. Although the pathogenesis of the disorder has not yet been fully elucidated, current evidence suggests that imbalance in angiogenic factors is responsible for the clinical manifestations of the disorder, and may explain why certain populations are risk. In this review, we begin by demonstrating the roles that angiogenic factors play in pathogenesis of preeclampsia and its complications in the mother and the fetus. We then continue to report on the use of angiogenic markers as biomarkers to predict and risk-stratify disease. Strategies to treat preeclampsia by correcting the angiogenic balance, either by promoting proangiogenic factors or by removing antiangiogenic factors in both animal and human studies, are discussed. We end the review by summarizing status of the current preventive strategies and the long-term cardiovascular outcomes of women afflicted with preeclampsia.
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Affiliation(s)
- Belinda Jim
- Division of Nephrology, Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY.
| | - S Ananth Karumanchi
- Departments of Medicine, Obstetrics, and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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9
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McLaughlin K, Scholten RR, Parker JD, Ferrazzi E, Kingdom JCP. Low molecular weight heparin for the prevention of severe preeclampsia: where next? Br J Clin Pharmacol 2018; 84:673-678. [PMID: 29226532 DOI: 10.1111/bcp.13483] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 11/29/2017] [Indexed: 12/14/2022] Open
Abstract
Low molecular weight heparin has been extensively evaluated for the prevention of preeclampsia in high-risk pregnant women; however, the results from these trials have been conflicting. This review discusses the potential mechanisms of action of low molecular weight heparin for the prevention of severe preeclampsia, how to optimize the selection of high-risk women for participation in future trials, and the importance of trial standardization.
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Affiliation(s)
- Kelsey McLaughlin
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Canada.,Department of Medicine, Division of Cardiology, Sinai Health System, University of Toronto, Canada
| | - Ralph R Scholten
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, Sinai Health System, University of Toronto, Canada
| | - John D Parker
- Department of Medicine, Division of Cardiology, Sinai Health System, University of Toronto, Canada
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynaecology, Buzzi Children's Hospital, University of Milan, Italy
| | - John C P Kingdom
- The Centre for Women's and Infant's Health at the Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Canada.,Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, Sinai Health System, University of Toronto, Canada
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10
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Mastrolia SA, Mazor M, Holcberg G, Leron E, Beharier O, Loverro G, Erez O. The physiologic anticoagulant and anti-inflammatory role of heparins and their utility in the prevention of pregnancy complications. Thromb Haemost 2017; 113:1236-46. [DOI: 10.1160/th14-10-0848] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 01/14/2015] [Indexed: 01/13/2023]
Abstract
SummaryAccumulating evidence supports the concept of increased thrombin generation, placental vascular lesions, and inflammation as crucial points in the development of the great obstetrical syndromes [preeclampsia, intrauterine growth restriction (IUGR), preterm labor (PTL), preterm prelabor rupture of membranes (PROM), fetal demise and recurrent abortions]. In light of this, the role of heparins for primary or secondary prevention of these syndromes is becoming more and more apparent, mainly due to the antithrombotic and anti-inflammatory effects of heparins. There is agreement regarding the use of heparin in the prevention of gestational complications in patients with antiphospholipid syndrome, while its use for other obstetrical complications is under debate. In the present review we will describe the physiologic role of heparins on coagulation and inflammation and we will discuss current evidence regarding the use of heparins for the prevention/ treatment of obstetrical syndromes.
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11
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Vardi L, Paterson H, Hung NA. Successful pregnancy following treatment of recurrent chronic histiocytic intervillositis. BMJ Case Rep 2017; 2017:bcr-2016-217886. [PMID: 28073874 DOI: 10.1136/bcr-2016-217886] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Chronic histiocytic intervillositis (CHI) is a rare placental lesion associated with adverse obstetric outcomes and high recurrence rate. We report a case of six consecutive pregnancies in one woman, where CHI was detected following an intrauterine death in the fifth pregnancy, after being missed in four earlier losses. The successful sixth pregnancy was treated with a combination of immunosuppressive and antithrombotic agents. While low-molecular-weight heparin (LMWH) and aspirin had been shown to improve pregnancy outcome in recurrent pregnancy loss, there was limited evidence of improved outcome in CHI. It has been suggested that CHI may result from a maternal immunological process and there have been a few reports of the use of corticosteroids because of this possibility, though without convincing evidence of efficacy. We too tried a corticosteroid, in combination with LMWH and aspirin. Comparative histopathological analysis of the placentae supported post-treatment effectiveness of our intervention strategy.
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Affiliation(s)
- Leehe Vardi
- Department of Women's Health, Dunedin Public Hospital, Dunedin, New Zealand.,Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Helen Paterson
- Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Noelyn Anne Hung
- Department of Pathology, University of Otago, Dunedin School of Medicine, Dunedin, New Zealand
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12
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Fernández-Alba JJ, González-Macías C, Vilar Sánchez A, Tajada Cepero P, Garrido Teruel R, García-Cabanillas MJ, Moreno-Corral LJ, Torrejón Cardoso R. Birthweight in pregnant women with protein S deficiency treated with low-molecular-weight heparin: a retrospective cohort study. J Matern Fetal Neonatal Med 2016; 30:2193-2197. [PMID: 27677928 DOI: 10.1080/14767058.2016.1242126] [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: 10/20/2022]
Abstract
OBJECTIVE To determine the risk of small-for-gestational-age (SGA) and intrauterine growth retardation (IUGR) in pregnant women with protein S (PS) deficiency who received low-molecular-weight heparin (LMWH). METHODS Retrospective cohort study of pregnant women seen from January 2002 to December 2011. The study cohort comprised a total of 328 patients with PS deficiency, who received prophylactic enoxaparin during pregnancy. The control cohort included 11 884 pregnant women without significant past medical history. The risk of SGA and IUGR was calculated as odds ratio. Multivariate regression analysis over the entire reference population was performed determining the risk of both SGA and IUGR by adjusting for maternal age, first delivery, maternal underweight status, pre-eclampsia, other treated thrombophilias or history of recurrent abortion. RESULTS The SGA rates in the PS deficiency and control cohorts were 10.7% and 8.5%, respectively (p > 0.05). There was no increased risk of SGA (unadjusted OR = 1.28, 95% confidence interval [CI] 0.9-1.83; adjusted OR = 1.35, 95% CI 0.91-2.01). The IUGR rate was 2.7% in pregnant women with PS deficiency versus 4.1% in the control group (p > 0.05). Also, we did not find a significant risk of IUGR (OR = 0.66; 95% CI 0.34-1.28; adjusted OR = 0.843; 95% CI 0.42-1.70). CONCLUSIONS In women with PS deficiency treated with LMWH, the risk of SGA and IUGR is similar to the one found in healthy pregnant women.
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Affiliation(s)
| | - Carmen González-Macías
- a Department of Obstetrics and Gynecology , University Hospital of Puerto Real , Cádiz , Spain
| | - Angel Vilar Sánchez
- a Department of Obstetrics and Gynecology , University Hospital of Puerto Real , Cádiz , Spain
| | - Pilar Tajada Cepero
- a Department of Obstetrics and Gynecology , University Hospital of Puerto Real , Cádiz , Spain
| | - Raquel Garrido Teruel
- b Department of Hematology , University Hospital of Puerto Real , Cádiz , Spain , and
| | | | | | - Rafael Torrejón Cardoso
- a Department of Obstetrics and Gynecology , University Hospital of Puerto Real , Cádiz , Spain
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13
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McLaughlin K, Drewlo S, Parker JD, Kingdom JC. Current Theories on the Prevention of Severe Preeclampsia With Low-Molecular Weight Heparin. Hypertension 2015; 66:1098-103. [DOI: 10.1161/hypertensionaha.115.05770] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 09/02/2015] [Indexed: 01/17/2023]
Affiliation(s)
- Kelsey McLaughlin
- From the Division of Cardiology, Department of Medicine, Mount Sinai Hospital (K.M., J.D.P.), Department of Pharmacology and Toxicology (K.M., J.D.P.), and Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (J.C.P.K.), University of Toronto, Toronto, Canada; The Centre for Women’s and Infant’s Health at the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada (K.M., J.C.P.K.); and Department of Obstetrics and Gynecology, Wayne State University
| | - Sascha Drewlo
- From the Division of Cardiology, Department of Medicine, Mount Sinai Hospital (K.M., J.D.P.), Department of Pharmacology and Toxicology (K.M., J.D.P.), and Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (J.C.P.K.), University of Toronto, Toronto, Canada; The Centre for Women’s and Infant’s Health at the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada (K.M., J.C.P.K.); and Department of Obstetrics and Gynecology, Wayne State University
| | - John D. Parker
- From the Division of Cardiology, Department of Medicine, Mount Sinai Hospital (K.M., J.D.P.), Department of Pharmacology and Toxicology (K.M., J.D.P.), and Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (J.C.P.K.), University of Toronto, Toronto, Canada; The Centre for Women’s and Infant’s Health at the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada (K.M., J.C.P.K.); and Department of Obstetrics and Gynecology, Wayne State University
| | - John C.P. Kingdom
- From the Division of Cardiology, Department of Medicine, Mount Sinai Hospital (K.M., J.D.P.), Department of Pharmacology and Toxicology (K.M., J.D.P.), and Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology (J.C.P.K.), University of Toronto, Toronto, Canada; The Centre for Women’s and Infant’s Health at the Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada (K.M., J.C.P.K.); and Department of Obstetrics and Gynecology, Wayne State University
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Oyston CJ, Stanley JL, Baker PN. Potential targets for the treatment of preeclampsia. Expert Opin Ther Targets 2015; 19:1517-30. [DOI: 10.1517/14728222.2015.1088004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Singh S, Sinha R, Kaushik M. Prophylactic Low Molecular Weight Heparin Improving Perinatal Outcome in Non-thrombophilic Placental-Mediated Complications. J Obstet Gynaecol India 2015; 66:436-440. [PMID: 27821984 DOI: 10.1007/s13224-015-0728-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 06/04/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To study the role of low molecular weight heparin (LMWH) in perinatal outcome. METHODS A randomized, case control study was conducted at Safdarjang hospital, New Delhi. Patients were recruited from Sept. 2011 to May 2013 and were followed up till delivery. Thirty cases and controls were enrolled which comprised non-thrombophilic patients with previous history of preeclampsia, fetal growth restriction, abruption, and stillbirth (>20 weeks). Study group received daily single dose of LMWH depending upon the weight, subcutaneously; it was started before 15 weeks of gestation and continued up to 36 weeks. Nursery/NICU admission, APGAR score at 0 and 5 min, birth weight, gestational age at delivery, mode of delivery were observed among the interventional and control groups. RESULT There was substantial reduction (80 %) in nursery/NICU admission. The mean gestational age and birth weight of the cases were observed to be higher as compared to those of control (38.05 ± 2.02 vs. 37.58 ± 2.06 weeks and 2770 ± 400 vs. 2530 ± 0.533 g). CONCLUSION Prophylactic LMWH before 15 weeks of gestation improved the perinatal outcome in non-thrombophilic pregnant women.
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Affiliation(s)
- Shweta Singh
- Obstetrics and Gynaecology Department, V.M.M.C. & Safdarjang Hospital, New Delhi, India ; D.D.U Hospital, New Delhi, India ; 108, New Gandhi Nagar, Ghaziabad, U.P India
| | - Renuka Sinha
- Unit Head Department of Obstetrics and Gynaecology, V.M.M.C. & Safdarjang Hospital, D II/172, West Kidwai Nagar, New Delhi, 110023 India ; Rama Medical College, Ghaziabad, U.P India
| | - Mayank Kaushik
- 108, New Gandhi Nagar, Ghaziabad, U.P India ; Department of Dermatology, E.S.I.C. Basaidarapur, Delhi, India
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Regal JF, Gilbert JS, Burwick RM. The complement system and adverse pregnancy outcomes. Mol Immunol 2015; 67:56-70. [PMID: 25802092 DOI: 10.1016/j.molimm.2015.02.030] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 02/20/2015] [Accepted: 02/24/2015] [Indexed: 02/08/2023]
Abstract
Adverse pregnancy outcomes significantly contribute to morbidity and mortality for mother and child, with lifelong health consequences for both. The innate and adaptive immune system must be regulated to insure survival of the fetal allograft, and the complement system is no exception. An intact complement system optimizes placental development and function and is essential to maintain host defense and fetal survival. Complement regulation is apparent at the placental interface from early pregnancy with some degree of complement activation occurring normally throughout gestation. However, a number of pregnancy complications including early pregnancy loss, fetal growth restriction, hypertensive disorders of pregnancy and preterm birth are associated with excessive or misdirected complement activation, and are more frequent in women with inherited or acquired complement system disorders or complement gene mutations. Clinical studies employing complement biomarkers in plasma and urine implicate dysregulated complement activation in components of each of the adverse pregnancy outcomes. In addition, mechanistic studies in rat and mouse models of adverse pregnancy outcomes address the complement pathways or activation products of importance and allow critical analysis of the pathophysiology. Targeted complement therapeutics are already in use to control adverse pregnancy outcomes in select situations. A clearer understanding of the role of the complement system in both normal pregnancy and complicated or failed pregnancy will allow a rational approach to future therapeutic strategies for manipulating complement with the goal of mitigating adverse pregnancy outcomes, preserving host defense, and improving long term outcomes for both mother and child.
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Affiliation(s)
- Jean F Regal
- Department of Biomedical Sciences, University of Minnesota Medical School, 1035 University Drive, Duluth, MN 55812, USA.
| | - Jeffrey S Gilbert
- Department of Biomedical Sciences, University of Minnesota Medical School, 1035 University Drive, Duluth, MN 55812, USA.
| | - Richard M Burwick
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Oregon Health & Science University, Mail Code: L-458, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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IFPA Gábor Than Award Lecture: Recognition of placental failure is key to saving babies' lives. Placenta 2014; 36 Suppl 1:S20-8. [PMID: 25582276 DOI: 10.1016/j.placenta.2014.12.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 12/04/2014] [Accepted: 12/17/2014] [Indexed: 11/21/2022]
Abstract
In high-income countries, placental failure is implicated in up to 65% of cases of stillbirth. Placental failure describes the situation where the placenta cannot meet the fetus' needs and may be the end-result of a variety of underlying pathological processes evident in the placental disc, membranes and umbilical cord. These include lesions with genetic, environmental, infectious, inflammatory, mechanical, metabolic, traumatic or vascular origin. Investigation of placental tissue from stillbirths and from pregnancies at an increased risk of stillbirth has demonstrated changes in macroscopic and microscopic structure which are themselves related to abnormal placental function. A better understanding and identification of placental failure may improve the management of pregnancy complications and of pregnancies after stillbirth (which have a 5-fold increased risk of stillbirth). The majority of current antenatal tests focus on the fetus and its response to the intrauterine environment; few of these investigations reduce stillbirths in low-risk pregnancies. However, some currently used investigations reflect placental development, structure and vascular function, while other investigations employed in clinical research settings such as the evaluation of placental structure and shape have a good predictive value for adverse fetal outcome. In addition, recent studies suggest that biomarkers of placental inflammation and deteriorating placental function can be detected in maternal blood suggesting that holistic evaluation of placental structure and function is possible. We anticipate that development of reliable tests of placental structure and function, coupled to assessment of fetal wellbeing offer a new opportunity to identify pregnancies at risk of stillbirth and to direct novel therapeutic strategies to prevent it.
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Low molecular weight heparin therapy during pregnancy is associated with elevated circulatory levels of placental growth factor. Placenta 2014; 36:121-4. [PMID: 25555501 DOI: 10.1016/j.placenta.2014.12.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 12/06/2014] [Accepted: 12/12/2014] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Low molecular weight heparin (LMWH) has been shown to be effective in decreasing the recurrence of placenta-mediated complications of pregnant women. The aim of this study was to determine the effect of LMWH on circulating levels of soluble fms-like tyrosine kinase-1 (sFlt-1), soluble endoglin (sEng) and placental growth factor (PLGF) in pregnant women who required anticoagulation therapy. METHODS A longitudinal prospective cohort study was performed including pregnant women in whom anticoagulation therapy by LMWH during pregnancy was clinically indicated (n = 33). Healthy pregnant women, matched for gestational age, who did not require thromboprophylaxis served as controls (n = 29). Maternal plasma samples were obtained throughout gestation every 4 weeks and stored at -70 °C. Maternal plasma concentrations of sFlt-1, sEng and PLGF were determined by ELISA and compared between the two groups. RESULTS Patients treated with LMWH had significantly increased circulatory levels of PLGF during the third trimester compared with controls (28-34 weeks: 719.2 pg/ml vs 558.6 pg/ml at, p < 0.01; 35-40 weeks: 975.6 pg/ml vs 511.2 pg/ml, p < 0.01, respectively). In contrast, circulatory levels of sFlt-1 and sEng were similar between the LMWH treatment group and controls throughout gestation. Consistent with these findings, the ratio of sFlt-1/PLGF was lower in patients treated with LMWH compared to controls (28-34 weeks: 1.9 vs 7.2, p < 0.05; 35-40 weeks: 5 vs 12.9, p < 0.05, respectively). DISCUSSION Anticoagulation treatment of pregnant women with LMWH is associated with a pro-angiogenic state. These findings may explain the effectiveness of LMWH in the prevention of placenta-mediated complications of pregnancy.
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Luley L, Schumacher A, Mulla MJ, Franke D, Löttge M, Fill Malfertheiner S, Tchaikovski SN, Costa SD, Hoppe B, Abrahams VM, Zenclussen AC. Low molecular weight heparin modulates maternal immune response in pregnant women and mice with thrombophilia. Am J Reprod Immunol 2014; 73:417-27. [PMID: 25496123 DOI: 10.1111/aji.12348] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 11/18/2014] [Indexed: 12/12/2022] Open
Abstract
PROBLEM Thrombophilia is associated with pregnancy complications. Treatment with low molecular weight heparin (LMWH) improves pregnancy outcome, but the underlying mechanisms are not clear. METHODS OF STUDY We analyzed Treg frequency in blood from thrombophilic pregnancies treated with LMWH (n = 32) or untreated (n = 33) and from healthy pregnancies (n = 39) at all trimesters. Additionally, we treated pregnant wild-type, heterozygous and homozygous factor-V-Leiden (FVL) mice with LMWH or PBS and determined Treg frequency, pro-/anti-inflammatory cytokine levels and Caspase-3-activity in placenta and decidua. RESULTS Treg frequencies were increased in second and third trimester in LMWH-treated thrombophilic pregnancies compared to controls. Treg levels were comparable to those of normal pregnancies. Homozygous FVL mice had decreased decidual Tregs compared to wild-type mice. LMWH treatment normalized Tregs and was associated with increased decidual IL-10 mRNA. LMWH diminished Caspase-3-activity in mice of all genotypes. CONCLUSION We demonstrated anti-apoptotic and anti-inflammatory effects of LMWH in pregnant FVL mice. LMWH increased Treg levels in mice and humans, which suggests benefits of LMWH treatment for thrombophilic women during pregnancy.
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Affiliation(s)
- Lydia Luley
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke-University, Magdeburg, Germany; Department of Gynecology and Obstetrics, Medical Faculty, Otto-von-Guericke-University, Magdeburg, Germany
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Duffett L, Rodger M. LMWH to prevent placenta-mediated pregnancy complications: an update. Br J Haematol 2014; 168:619-38. [DOI: 10.1111/bjh.13209] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Lisa Duffett
- Thrombosis Program; Division of Hematology; Department of Medicine; University of Ottawa; Ottawa ON Canada
| | - Marc Rodger
- Thrombosis Program; Division of Hematology; Department of Medicine; University of Ottawa; Ottawa ON Canada
- Clinical Epidemiology Program; The Ottawa Hospital Research Institute; Ottawa ON Canada
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Ferrazzi E, Muggiasca M, Gervasi MT. Low molecular weight heparin: does it represent a clinical opportunity for preventing preeclampisa associated with fetal growth restriction? J Matern Fetal Neonatal Med 2014; 28:1525-9. [PMID: 25228276 DOI: 10.3109/14767058.2014.963045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Enrico Ferrazzi
- a Department of Woman, Mother and Neonate , Biomedical and Clinical School of Medicine, University of Milan Medical School , via Castelvetro 32 , Milan 20154 Italy
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Unfractionated heparin and placental pathology in high-risk pregnancies: secondary analysis of a pilot randomized controlled trial. Placenta 2014; 35:816-23. [PMID: 25128485 DOI: 10.1016/j.placenta.2014.07.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 06/17/2014] [Accepted: 07/15/2014] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Heparin is often prescribed during pregnancy with the intention of improving perinatal outcomes on the basis that it exerts an anticoagulant action in the inter-villous space. Accumulating in-vitro and in-vivo evidence indicates that heparin's beneficial effects in pregnancy may result from 'non-anticoagulant' effects including the promotion of angiogenesis. METHODS To study the effect of heparin within the placenta, we performed secondary analyses on a pilot trial where 32 women with negative thrombophilia screens and second-trimester evidence of placental insufficiency were randomized to standard care or antenatal self-administration of unfractionated heparin (UFH) 7500 IU twice-daily. Serial placental ultrasound images were reviewed and compared with histo-pathologic findings following delivery. RESULTS There were no differences between the two arms in either the evolution of abnormal placental lesions on ultrasound (p = 0.75) or evidence of maternal vascular under-perfusion on histopathology (p = 0.89). In pregnancies considered at increased risk for adverse pregnancy outcomes based on previous history or abnormal serum marker screen, early (second-trimester) placental ultrasound, reflecting developmental pathology had better test characteristics (sensitivity 77.8%; positive predictive value 80.8%) for predicting adverse pregnancy outcomes than third-trimester ultrasound that is reflective of placental thrombotic injury. CONCLUSIONS Administration of UFH did not prevent the development or evolution of abnormal placental lesions on placental ultrasound or evidence of maternal vascular underperfusion on placental histo-pathology. Second-trimester placental ultrasound may be of value in predicting those at greatest risk of adverse outcomes.
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Ghidini A. Overview of low molecular weight heparin for preventative treatment of adverse obstetric outcomes related to abnormal placentation. Prenat Diagn 2014; 34:649-54. [PMID: 24752745 DOI: 10.1002/pd.4385] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/07/2014] [Accepted: 04/09/2014] [Indexed: 11/10/2022]
Abstract
Different proportions of cases of preterm and severe preeclampsia, placental abruption, fetal growth restriction, and fetal death share a common causal pathway of abnormal placental implantation. Documentation of an association between the risk of such adverse pregnancy outcomes (APOs) and inherited thrombophilias prompted initial studies to evaluate the benefit of anticoagulants for the prevention of recurrences both in patients with and without inherited thrombophilias. Prenatal administration of low molecular weight heparin (LMWH) has been evaluated in case control, cohort and randomized clinical trials. The evidence suggests a benefit of LMWH in the reduction of recurrences of APOs, with a number needed to treat of 6 (95% confidence interval: 4-10) to prevent one case of recurrent APOs. Such benefit is independent of the presence of inherited thrombophilias or the administration of low dose aspirin. Further studies are needed to establish the optimal duration for the prophylaxis, to better delineate the mechanism of action of LMWH and to explore the role, if any, of maternal serum markers and uterine artery Doppler findings in the modulation of the LMWH prophylaxis.
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Affiliation(s)
- Alessandro Ghidini
- Perinatal Diagnostic Center, Inova Alexandria Hospital, Alexandria, VA, USA
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Low-molecular weight heparin increases circulating sFlt-1 levels and enhances urinary elimination. PLoS One 2014; 9:e85258. [PMID: 24465515 PMCID: PMC3897409 DOI: 10.1371/journal.pone.0085258] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 11/25/2013] [Indexed: 12/03/2022] Open
Abstract
Rationale Preeclampsia is a devastating medical complication of pregnancy which leads to maternal and fetal morbidity and mortality. While the etiology of preeclampsia is unclear, human and animal studies suggest that excessive circulating levels of soluble fms-like tyrosine-kinase-1 (sFlt-1), an alternatively spliced variant of VEGF-receptor1, contribute to the signs and symptoms of preeclampsia. Since sFlt-1 binds to heparin and heparan sulfate proteoglycans, we hypothesized that the anticoagulant heparin, which is often used in pregnancy, may interfere with the levels, distribution and elimination of sFlt-1 in vivo. Objective We systematically determined serum and urine levels of angiogenic factors in preeclamptic women before and after administration of low molecular weight heparin and further characterized the interaction with heparin in biochemical studies. Methods and Results Serum and urine samples were used to measure sFlt-1 levels before and after heparin administration. Serum levels of sFlt-1 increased by 25% after heparin administration in pregnant women. The magnitude of the increase in circulating sFlt-1 correlated with initial sFlt-1 serum levels. Urinary sFlt-1 levels were also elevated following heparin administration and levels of elimination were dependent on the underlying integrity of the glomerular filtration barrier. Biochemical binding studies employing cation exchange chromatography revealed that heparin bound sFlt-1 had decreased affinity to negatively charged surfaces when compared to sFlt-1 alone. Conclusion Low molecular weight heparin administration increased circulating sFlt1 levels and enhanced renal elimination. We provide evidence that both effects may be due to heparin binding to sFlt1 and masking the positive charges on sFlt1 protein.
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Becker R, Keller T, Kiesewetter H, Fangerau H, Bittner U. Individual risk assessment of adverse pregnancy outcome by multivariate regression analysis may serve as basis for drug intervention studies: retrospective analysis of 426 high-risk patients including ethical aspects. Arch Gynecol Obstet 2013; 288:41-8. [PMID: 23389246 PMCID: PMC3682099 DOI: 10.1007/s00404-013-2723-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Accepted: 01/15/2013] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To identify patients at very high risk for adverse pregnancy outcome (APO) at the 20- to 23-week scan and to assess the effectiveness of Aspirin (ASS) and low molecular weight heparin (LMWH) starting after this examination. PATIENTS AND METHODS By applying an algorithm based on multivariate logistic regression analysis using the parameters maternal age, parity, body mass index (BMI), mean pulsatility index of both uterine arteries (meanPI), presence of uni- or bilateral notch, and depth of notch (mean notch index (meanNI), we retrospectively calculated the individual risk for APO of 21,302 singleton pregnancies. We isolated a subgroup of 426 patients with the highest calculated probability for APO (cpAPO > 27.8 %). 147 had been treated with ASS; 73 with LMWH, 15 patients with a combination of ASS and LMWH, and 191 patients had not received anticoagulants. RESULTS Administration of ASS starting after 20 gestational weeks in comparison to non-treated patients significantly reduced the frequency of intrauterine/neonatal death (IUD/NND), preeclampsia <33 weeks (PE < 33), and preterm delivery <33 weeks (PD < 33), while the frequency of IUGR showed a tendency to be elevated (P = 0.061). The subgroup of high-risk patients treated with LMWH was characterised by a higher a priori risk for APO and showed no significant reduction of any form of APO but an increased frequency of PE. CONCLUSION Individual assessment of risk for APO by applying a simple algorithm based on biometrical/biographical as well as sonographic parameters may serve as basis for drug intervention studies. The administration of ASS in high-risk patients starting after 20 gestational weeks reduced the frequency of most of the severe forms of adverse pregnancy outcome in high-risk patients. A complication-reducing effect of LMWH starting after 20 weeks of gestation in patients could not be proven. From an ethical point of view, it may not be justified any more to preclude high-risk patients from administration of ASS or to perform studies of ASS against placebo.
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Affiliation(s)
- Rolf Becker
- Center for Prenatal Diagnosis and Human Genetics, Free University of Berlin, Kurfuerstendamm 199, 10719 Berlin, Germany.
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Hossain N, Paidas MJ. Inherited thrombophilia: diagnosis and anticoagulation treatment in pregnancy. Clin Lab Med 2013; 33:377-90. [PMID: 23702125 DOI: 10.1016/j.cll.2013.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The association between inherited thrombophilia and deep vein thrombosis is well established. Adverse pregnancy outcomes, sometimes called placenta-mediated complications, have been attributed to excessive thrombosis and inflammation at the uteroplacental interface. This linkage resulted in widespread screening for thrombophilia in women with adverse pregnancy outcome. Anticoagulant therapy was initially liberally administered for prevention of adverse pregnancy outcome. Well-designed randomized trials were initiated and the results of some of these randomized trials have provided critical evidence-based data to serve as a guide for clinicians faced with managing patients with one or more of the common obstetric complications.
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Affiliation(s)
- Nazli Hossain
- Department of Obstetrics & Gynecology, Dow University of Health Sciences, Karachi 74200, Pakistan.
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Rath W, Thaler CJ. [Hereditary thrombophilias and placental-mediated pregnancy complications in the II./III. trimester]. Hamostaseologie 2013; 33:21-36. [PMID: 23392307 DOI: 10.5482/hamo-12-11-0020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/18/2013] [Indexed: 11/05/2022] Open
Abstract
UNLABELLED Placental-mediated pregnancy complications (PmC) like preeclampsia, intrauterine growth restriction and placental abruption are common causes of fetal and maternal morbidity and mortality. The high prevalence of hereditary thrombophilias in case-control studies associated with pathological morphological findings of the placenta in these cases gave evidence for the association between hereditary thrombophilias and PmC. However, data from the literature are inconsistent, since subsequent prospective cohort studies could not demonstrate significant associations between inherited thrombophilia and PmC. Because of the multifactorial aetiology of PmC it may be difficult to prove, that hereditary thrombophilias are independent risk factors for PmC. Current guidelines do not recommend screening for inherited thrombophilias in patients with previous PmC. Evidence from current in vitro studies have shown, that heparin has beneficial non-anticoagulatory effects on trophoblast invasion. Retrospective case-control studies and recently published randomised controlled cohort studies have shown, that prophylactic administration of low-molecular-weight heparin (LWH), started in early pregnancy, may lead to a significant reduction in the incidence of PmC in subsequent pregnancies in patients with and without hereditary thrombophilias and previous PmC. CONCLUSION Large, well-designed multicenter studies are needed to elucidate the role of hereditary thrombophilias in cases of PmC and to confirm the benefit of LWH for subsequent pregnancy outcomes.
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Affiliation(s)
- W Rath
- Gynäkologie und Geburtshilfe, Medizinische Fakultät, Universitätsklinikum, Wendlingweg 2, 52074 Aachen.
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Zhao Y, Koga K, Osuga Y, Nagai M, Izumi G, Takamura M, Harada M, Hirota Y, Yoshino O, Taketani Y. Thrombin enhances soluble Fms-like tyrosine kinase 1 expression in trophoblasts; possible involvement in the pathogenesis of preeclampsia. Fertil Steril 2012; 98:917-21. [DOI: 10.1016/j.fertnstert.2012.06.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 06/23/2012] [Accepted: 06/25/2012] [Indexed: 10/28/2022]
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Characterization of negatively charged phospholipids and cell origin of microparticles in women with gestational vascular complications. Thromb Res 2012; 130:479-84. [DOI: 10.1016/j.thromres.2012.03.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 03/27/2012] [Accepted: 03/28/2012] [Indexed: 01/05/2023]
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30
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Is thrombophilia a risk factor for placenta-mediated pregnancy complications? Arch Gynecol Obstet 2012; 286:585-9. [DOI: 10.1007/s00404-012-2342-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 04/16/2012] [Indexed: 10/28/2022]
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Gris JC, Marès P. Heparin promotes soluble vascular enothelial growth factor receptor expression in human placental villi: a rebuttal. J Thromb Haemost 2012; 10:499-500. [PMID: 22244055 DOI: 10.1111/j.1538-7836.2012.04625.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tersigni C, Marana R, Santamarìa A, Castellani R, Scambia G, Simone ND. In Vitro Evidences of Heparin's Effects on Embryo Implantation and Trophoblast Development. Reprod Sci 2012; 19:454-62. [DOI: 10.1177/1933719111430994] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Chiara Tersigni
- Department of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Riccardo Marana
- Department of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Amparo Santamarìa
- Haematology Department, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Roberta Castellani
- Department of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicoletta Di Simone
- Department of Obstetrics and Gynecology, Università Cattolica del Sacro Cuore, Rome, Italy
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Abstract
Randomized control trials show beneficial effects of heparin in high-risk pregnancies to prevent preeclampsia and intrauterine growth restriction. However, the lack of placental pathology data in these trials challenges the assumption that heparin is a placental anticoagulant. Recent data show that placental infarction is probably associated with abnormalities in development of the placenta, characterized by poor maternal perfusion and an abnormal villous trophoblast compartment in contact with maternal blood, than with maternal thrombophilia. At-risk pregnancies may therefore be predicted by noninvasive prenatal testing of placental function in mid-pregnancy. Heparin has diverse cellular functions that include direct actions on the trophoblast. Dissecting the non-anticoagulant actions of heparin may indicate novel and safer therapeutic targets to prevent the major placental complications of pregnancy.
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