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Harrison M, Umstad MP, Cui W, Thevathasan I, Price SAL. An audit of the maternal medicine clinic: Cancer and pregnancy. Aust N Z J Obstet Gynaecol 2024; 64:308-313. [PMID: 38265120 DOI: 10.1111/ajo.13796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/11/2024] [Indexed: 01/25/2024]
Abstract
AIMS To explore the incidence and complexity of women presenting for maternity care who require concurrent cancer care, and to report the birth outcomes of these women. MATERIALS AND METHODS A retrospective audit of women attending a 'high risk' maternal medicine clinic at an Australian tertiary maternity hospital between 1 October 2021 and 30 April 2023 was conducted. The inclusion criteria were a diagnosis of cancer and a concurrent pregnancy, or a diagnosis of cancer prior to the current pregnancy. Clinic lists and coding data were screened via the electronic medical record to identify potential subjects. Data were collected from the individual maternity and neonatal records. RESULTS Forty of 705 (5.7%) women attending the maternal medicine clinic met the inclusion criteria, of which ten had a new diagnosis of cancer in pregnancy and 30 presented for maternity care after a previous diagnosis of cancer. Cancer therapy during pregnancy included surgery and chemotherapy. Most pregnancies (92.5%) resulted in term deliveries (≥37 weeks gestation). Four neonates were preterm, and one was small-for-gestational-age. Caesarean section delivery and post-partum haemorrhage were more common than expected, but the rate of other adverse pregnancy outcomes was consistent with the background population. Over half of neonates required neonatal intensive care unit / special care nursery admission but the indications for admission were common, self-limiting conditions, and the length of stay was short (mean <5.0 days). CONCLUSIONS Approximately 6% of women attending the maternal medicine clinic had a current or previous diagnosis of cancer. Most pregnancies resulted in term deliveries and neonatal outcomes were excellent.
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Affiliation(s)
- Mia Harrison
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Mark P Umstad
- Department of Maternal Fetal Medicine, Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Consultative Council on Obstetric and Paediatric Mortality and Morbidity, Safer Care Victoria, Melbourne, Victoria, Australia
| | - Wanda Cui
- Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Iniyaval Thevathasan
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Sarah A L Price
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Department of Obstetric Medicine, Royal Women's Hospital, Melbourne, Victoria, Australia
- Frances Perry House, Melbourne, Victoria, Australia
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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Folkins S, Miller A, Nash CM. Risk of venous thromboembolism in pregnant patients with active malignancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:645-652. [PMID: 37968882 PMCID: PMC10993334 DOI: 10.1111/aogs.14712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION Cancer currently occurs in about 1 in 1000 pregnancies. Both active malignancy and pregnancy are individual risk factors for venous thromboembolism (VTE). The purpose of this systematic review/meta-analysis was to evaluate the rate of VTE in pregnant patients with active malignancy compared with pregnant patients without malignancy. MATERIAL AND METHODS Embase, Medline/PubMed, Cochrane Database, and clinicaltrial.gov were search by a trained librarian from inception until June 2021, and limited to English and French language human studies using keywords related to pregnancy, neoplasm, and thrombosis. This study was prospectively registered with PROSPERO (CRD42021245886). Title, abstract, and full-text review was performed using the Covidence data management system. Two authors reviewed the studies independently. Of the 3821 articles screened, seven cohort studies were included that reported VTE rate in patients with active malignancy in pregnancy. RESULTS A total of 5928 individuals had active malignancy and pregnancy. Active malignancy in pregnancy significantly increased the odds of a VTE (odds ratio [OR] 6.8, 95% confidence interval [CI] 3.8-12.1). Specifically, patients with thyroid (OR 2.7, 95% CI 1.3-6.3), cervix (OR 6.6, 95% CI 2.4-18.0), or other gynecological (OR 10.6, 95% CI 4.4-25.8) cancers; Hodgkin's lymphoma (OR 8.7, 95% CI 3.3-23.4); or acute leukemia (OR 17.1, 95% CI 10.9-26.8) all had increased odds, whereas those with brain cancer (OR 6.1, 95% CI 0.4-98.2), breast cancer (OR 2.5, 95% CI 0.3-17.4), malignant melanoma (OR 5.5, 95% CI 0.3-88.1), or non-Hodgkin's lymphoma (OR 3.2, 95% CI 0.8-12.9) malignancies did not have statistically significant increased odds for VTE. No studies reported whether prophylactic anticoagulation was used during pregnancy in this population; nor did they report timing in pregnancy of the VTE. The absolute risk for VTE in those with active malignancy was 0.9% compared with 0.2% in those without active malignancy in pregnancy. CONCLUSIONS Pregnancy with active malignancy confers a significant increased risk for VTE compared with pregnancy alone. Given this finding, prophylactic anticoagulation during pregnancy and postpartum could be considered in this patient population. Data are underpowered to make firm recommendations per cancer type.
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Affiliation(s)
- Sara Folkins
- Dalhousie University Medical SchoolHalifaxNova ScotiaCanada
| | - Ashley Miller
- Division of General Internal Medicine, Department of MedicineDalhousie UniversityHalifaxNova ScotiaCanada
| | - Christopher M. Nash
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynaecologyDalhousie UniversityHalifaxNova ScotiaCanada
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3
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Walters B, Midwinter I, Chew-Graham CA, Jordan KP, Sharma G, Chappell LC, Crosbie EJ, Parwani P, Mamas MA, Wu P. Pregnancy-Associated Cancer: A Systematic Review and Meta-Analysis. Mayo Clin Proc Innov Qual Outcomes 2024; 8:188-199. [PMID: 38524280 PMCID: PMC10957385 DOI: 10.1016/j.mayocpiqo.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
This study aimed to systematically evaluate and quantify the risk of adverse maternal and neonatal outcomes in patients with pregnancy-associated cancer (PAC). This study was conducted from February 13, 2021, through July 24, 2023. A systematic search of MEDLINE, Embase, Web of Science Core Collection, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials was conducted to identify studies reporting outcomes for patients with PAC. The study was registered on PROSPERO. Two reviewers independently conducted screening, data extraction, and quality assessment. The associations were quantified using random-effects meta-analysis. The initial search produced 29,401 titles and abstracts, after which 147 unique full-text articles were screened, of which 22 articles with 59,190 pregnancies with PAC from 70,097,167 births were included in the meta-analysis. Women with PAC were at significantly increased risk of cesarean deliveries (risk ratio [RR], 1.58; 95% CI, 1.31-1.89), preterm birth (RR, 3.07; 95% CI, 2.37-3.98), venous thromboembolism (RR, 6.76; 95% CI, 5.08-8.99), and maternal death (RR, 41.58; 95% CI, 20.38-84.83). The only outcome with reduced risk was instrumental mode of delivery (RR, 0.67; 95% CI, 0.52-0.87). Pregnancy-associated cancer increases risk of adverse outcomes, including a 7-fold risk of venous thromboembolism and a 42-fold risk of maternal death. Further research is required to better understand the mechanisms leading to these adverse outcomes, especially for women who are not diagnosed until the postpartum period. Affected women should have counseling regarding their increased risk of adverse outcomes.
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Affiliation(s)
- Ben Walters
- Academic Department of Obstetrics and Gynaecology, Royal Stoke Hospital, Stoke-on-Trent, United Kingdom
| | - India Midwinter
- Academic Department of Obstetrics and Gynaecology, Royal Stoke Hospital, Stoke-on-Trent, United Kingdom
| | - Carolyn A. Chew-Graham
- School of Medicine, Faculty of Medicine and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Kelvin P. Jordan
- School of Medicine, Faculty of Medicine and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Garima Sharma
- Division of Cardiology, Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Diseases, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lucy C. Chappell
- School of Life Course Sciences, King’s College London, London, United Kingdom
| | - Emma J. Crosbie
- Department of Obstetrics and Gynaecology, St Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA
| | - Mamas A. Mamas
- School of Medicine, Faculty of Medicine and Health Sciences, Keele University, Staffordshire, United Kingdom
- Keele Cardiovascular Research Group, Centre for Prognosis Research, School of Medicine, Faculty of Medicine and Health Sciences, Keele University, Staffordshire, United Kingdom
| | - Pensée Wu
- Academic Department of Obstetrics and Gynaecology, Royal Stoke Hospital, Stoke-on-Trent, United Kingdom
- Keele Cardiovascular Research Group, Centre for Prognosis Research, School of Medicine, Faculty of Medicine and Health Sciences, Keele University, Staffordshire, United Kingdom
- Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, United Kingdom
- Department of Obstetrics and Gynecology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Storgaard L, Greiber IK, Pedersen BW, Nielsen BB, Karlsen MA. Cancer in pregnancy - The obstetrical management. Acta Obstet Gynecol Scand 2024; 103:630-635. [PMID: 37596726 PMCID: PMC10993351 DOI: 10.1111/aogs.14653] [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: 03/28/2023] [Revised: 07/05/2023] [Accepted: 07/07/2023] [Indexed: 08/20/2023]
Abstract
Cancer in pregnancy, defined as a cancer diagnosed during pregnancy, is a rare but severe condition presenting both clinical and ethical challenges. During the last two decades a paradigm shift has occurred towards recommending similar staging and treatment regimens of pregnant and non-pregnant cancer patients. This strategy is a result of an increasing number of reassuring reports on chemotherapy treatment in pregnancy after the first trimester. The management of cancer in pregnancy should be managed in a multidisciplinary team where staging, oncological treatment, social and mental care, timing of delivery, and follow-up of the infant should be planned. Due to the rarity, centralization is recommended to allow experience accumulation. Furthermore, national and international advisory boards are supportive when there is a lack of expertise.
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Affiliation(s)
- Lone Storgaard
- Obstetric DepartmentCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Iben Katinka Greiber
- Obstetric DepartmentCopenhagen University Hospital RigshospitaletCopenhagenDenmark
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5
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Cate JJM, Sundermann AC, Campbell AIK, Sugrue R, Dotters-Katz SK, James AH, Myers ER, Federspiel JJ. High rates of venous thromboembolism among deliveries complicated by cancer. J Thromb Haemost 2023; 21:2854-2862. [PMID: 37353083 PMCID: PMC10560586 DOI: 10.1016/j.jtha.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) risk is increased independently by both cancer and pregnancy. OBJECTIVES To estimate VTE risk in the postpartum period among patients delivering with a cancer diagnosis, stratified by cancer type and delivery route. METHODS We performed a retrospective cohort study utilizing the large, all-payer Nationwide Readmissions Database from October 2015 through December 2020. We identified delivery hospitalizations, cancer diagnoses, and VTE using patient demographics and diagnosis codes. The primary outcome was VTE incidence at 42 and 330 days from delivery admission date, comparing patients with and without cancer diagnoses. A secondary analysis included VTE risk stratified by cancer diagnosis and delivery route. Outcomes were compared using inverse probability-weighted survival curves. RESULTS The study population included 9 793 503 delivery hospitalizations (weighted estimate, 18 207 346), with a weighted estimate of 10 428 (0.06%) pregnant patients with cancer. Individuals with cancer were older, with higher rates of comorbid conditions, than those without cancer. VTE incidence in individuals with cancer at 42 and 330 days was 1.11% and 2.19%, respectively, vs 0.11% and 0.14%, respectively, in those without cancer. At 330 days, this finding was significant in both unadjusted (relative risk, 15.52; 95% CI, 11.54-19.51) and adjusted (relative risk, 9.68; 95% CI, 7.18-12.18) models. Stratification by cancer type and delivery route demonstrated elevated VTE risk across cancer types, with cesarean delivery conferring a greater risk. CONCLUSION Cancer in pregnancy confers excess thromboembolic risk extending beyond the immediate postpartum period. Further study is needed to identify optimal VTE prophylactic strategies for this population.
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Affiliation(s)
- Jennifer J M Cate
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA. https://twitter.com/healthyhappydoc
| | - Alexandra C Sundermann
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Ronan Sugrue
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah K Dotters-Katz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jerome J Federspiel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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Ram S, Ram HS, Neuhof B, Shperling RB, Chodick G, Yogev Y. Venous thromboembolism during pregnancy: Trends, incidence, and risk patterns in a large cohort population. Int J Gynaecol Obstet 2023; 160:962-968. [PMID: 35979847 DOI: 10.1002/ijgo.14414] [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: 05/27/2022] [Revised: 07/25/2022] [Accepted: 08/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the incidence and risk factors for pregnancy-associated venous thromboembolism (VTE). METHODS An observational retrospective study was conducted using data from 452 176 live births between the years 2010 and 2019. The study group consisted of women who were diagnosed with VTE during pregnancy or the postpartum period. The exclusion criteria included women who purchased anticoagulant drugs during pregnancy or postpartum. The hazard ratios (HRs) of VTE per week of each trimester and the postpartum period were calculated. RESULTS A total of 421 125 live births were included in the study. Among the study population, 302 cases (0.71 cases/1000 pregnancies) were diagnosed with VTE during pregnancy and postpartum. The overall rates of diagnosis did not change significantly during the study period but followed a declining trend in the postpartum period. The highest risk of VTE was found to be during the third trimester (HR 0.002% per week, 95% confidence interval [CI] 0.0016-0.0023), while the lowest rate was during the postpartum period (HR 0.0007% per week, 95% CI 0.0004-0.0011). CONCLUSION Pregnancy and the puerperium are well-established risk factors for VTE. The present study demonstrates a declining trend in the risk and incidence of VTE during the postpartum period, which can be explained by a liberal and effective VTE prevention policy.
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Affiliation(s)
- Shai Ram
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hila S Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | - Bitya Neuhof
- Hebrew University of Jerusalem, Department of statistics and data science
| | - Roza B Shperling
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Chodick
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Maccabi Healthcare Services, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Lis Maternity Hospital, Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Safi N, Li Z, Anazodo A, Remond M, Hayen A, Currow D, Roder D, Hamad N, Nicholl M, Gordon A, Frawley J, Fotheringham P, Sullivan E. Pregnancy associated cancer, timing of birth and clinical decision making-a NSW data linkage study. BMC Pregnancy Childbirth 2023; 23:105. [PMID: 36759774 PMCID: PMC9909861 DOI: 10.1186/s12884-023-05359-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/06/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND The incidence of pregnancy-associated cancer (PAC), comprising cancer diagnosed during pregnancy or within one year postpartum, is increasing. We investigated the obstetric management and outcomes of women with PAC and their babies. METHODS A population-based observational study of all women who gave birth between 1994 and 2013 in New South Wales, Australia. Women were stratified into three groups: those diagnosed during pregnancy (gestational cancer group), those diagnosed within one year of giving birth (postpartum cancer group), and a no-PAC group. Generalized estimating equations were used to examine the association between PAC and adverse maternal and neonatal outcomes. RESULTS One million seven hundred eighty-eight thousand four hundred fifty-onepregnancies were included-601 women (614 babies) were in the gestational cancer group, 1772 women (1816 babies) in the postpartum cancer group, and 1,786,078 women (1,813,292 babies) in the no-PAC group. The overall crude incidence of PAC was 132.7/100,000 women giving birth. The incidence of PAC increased significantly over the twenty-year study period from 93.5/100,000 in 1994 to 162.5/100,000 in 2013 (2.7% increase per year, 95% CI 1.9 - 3.4%, p-value < 0.001). This increase was independent of maternal age. The odds of serious maternal complications (such as acute abdomen, acute renal failure, and hysterectomy) were significantly higher in the gestational cancer group (adjusted odds ratio (AOR) 5.07, 95% CI 3.72 - 6.90) and the postpartum cancer group (AOR 1.55, 95% CI 1.16 - 2.09). There was no increased risk of perinatal mortality in babies born to women with PAC. However, babies of women with gestational cancer (AOR 8.96, 95% CI 6.96 - 11.53) or postpartum cancer (AOR 1.36, 95% CI 1.05 - 1.81) were more likely to be planned preterm birth. Furthermore, babies of women with gestational cancer had increased odds of a severe neonatal adverse outcome (AOR 3.13, 95% CI 2.52 - 4.35). CONCLUSION Women with PAC are more likely to have serious maternal complications. While their babies are not at increased risk of perinatal mortality, they are more likely to experience poorer perinatal outcomes associated with preterm birth. The higher rate of birth intervention among women with gestational cancers reflects the complexity of clinical decision-making in this context.
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Affiliation(s)
- Nadom Safi
- grid.266842.c0000 0000 8831 109XCollege of Health, Medicine and Wellbeing, University of Newcastle, 130 University Drive, Callaghan, NSW 2308 Australia ,grid.413648.cHunter Medical Research Institute, New Lambton Heights, NSW 2305 Australia
| | - Zhuoyang Li
- grid.266842.c0000 0000 8831 109XCollege of Health, Medicine and Wellbeing, University of Newcastle, 130 University Drive, Callaghan, NSW 2308 Australia ,grid.413648.cHunter Medical Research Institute, New Lambton Heights, NSW 2305 Australia
| | - Antoinette Anazodo
- grid.415193.bPrince of Wales Hospital, Nelune Comprehensive Cancer Centre, Randwick, NSW 2031 Australia
| | - Marc Remond
- grid.266842.c0000 0000 8831 109XCollege of Health, Medicine and Wellbeing, University of Newcastle, 130 University Drive, Callaghan, NSW 2308 Australia ,grid.413648.cHunter Medical Research Institute, New Lambton Heights, NSW 2305 Australia
| | - Andrew Hayen
- grid.117476.20000 0004 1936 7611School of Public Health, University of Technology Sydney, Ultimo, NSW 2007 Australia
| | - David Currow
- grid.1007.60000 0004 0486 528XUniversity of Wollongong, the Vice-Chancellor’s Unit, NSW, Wollongong, 2522 Australia
| | - David Roder
- grid.1026.50000 0000 8994 5086University of South Australia, Population Health, Beat Cancer Project, Adelaide, SA Australia
| | - Nada Hamad
- grid.410697.dThe Kinghorn Cancer Centre, Darlinghurst, NSW 2010 Australia
| | - Michael Nicholl
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Camperdown, NSW Australia
| | - Adrienne Gordon
- grid.1013.30000 0004 1936 834XFaculty of Medicine and Health, The University of Sydney, Camperdown, NSW Australia
| | - Jane Frawley
- grid.117476.20000 0004 1936 7611School of Public Health, University of Technology Sydney, Ultimo, NSW 2007 Australia
| | - Penelope Fotheringham
- grid.266842.c0000 0000 8831 109XCollege of Health, Medicine and Wellbeing, University of Newcastle, 130 University Drive, Callaghan, NSW 2308 Australia ,grid.413648.cHunter Medical Research Institute, New Lambton Heights, NSW 2305 Australia
| | - Elizabeth Sullivan
- College of Health, Medicine and Wellbeing, University of Newcastle, 130 University Drive, Callaghan, NSW, 2308, Australia. .,Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.
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Ram S, Shalev-Ram H, Neuhof B, Shlezinger R, Shalev-Rosental Y, Chodick G, Yogev Y. Air travel during pregnancy and the risk of venous thrombosis. Am J Obstet Gynecol MFM 2023; 5:100751. [PMID: 36115570 DOI: 10.1016/j.ajogmf.2022.100751] [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: 07/06/2022] [Revised: 09/06/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pregnancy and air travel independently increase the risk of venous thrombosis. However, there is a lack of data regarding the added risk, if at all, of thrombosis after air travel during pregnancy. OBJECTIVE This study aimed to determine the potential added risk of venous thromboembolism among pregnant women who traveled by air. STUDY DESIGN This was an observational retrospective study using data from 452,663 live births between the years 2010 to 2019. The study group consisted of women who flew during pregnancy. Data of pregnant women who flew during pregnancy were compared with that of pregnant women who did not fly during pregnancy. The primary outcome was venous thromboembolism during pregnancy and in the postpartum period. A case of venous thromboembolism was deemed related to air travel only if it occurred up to 8 weeks after the return flight (exposure time). Propensity score weighting Poisson regression was calculated to assess the effect and to control selection biases. Risk per day was calculated. RESULTS Overall, 421,125 live births were included. Of those cases, 33,674 (8%) had traveled by air during pregnancy (study group), and 387,451 (92%) did not (control group). There were 6 cases of venous thromboembolism after a flight that occurred during the exposure time of 8 weeks and 285 cases of venous thromboembolism in the control group (0.05% vs 0.07%; P=.158). When the propensity weighting Poisson regression was calculated as risk per day, there was a significantly increased risk between the study and control groups (0.00031% vs 0.00022%; hazard ratio, 1.406; P=.005). CONCLUSION The overall risk of venous thromboembolism after air travel is low; however, our study found that the risk of venous thromboembolism during pregnancy is increased by air traveling.
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Affiliation(s)
- Shai Ram
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel (Drs Ram and Yogev); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Ram, Shalev-Ram, Shalev-Rosenthal, Chodick, and Yogev).
| | - Hila Shalev-Ram
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Ram, Shalev-Ram, Shalev-Rosenthal, Chodick, and Yogev); Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel (Dr Shalev-Ram)
| | - Bitya Neuhof
- Department of Statistics and Data Science, Hebrew University of Jerusalem, Jerusalem, Israel (Ms Neuhof and Ms Shlezinger)
| | - Roei Shlezinger
- Department of Statistics and Data Science, Hebrew University of Jerusalem, Jerusalem, Israel (Ms Neuhof and Ms Shlezinger)
| | - Yael Shalev-Rosental
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Ram, Shalev-Ram, Shalev-Rosenthal, Chodick, and Yogev)
| | - Gabriel Chodick
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Ram, Shalev-Ram, Shalev-Rosenthal, Chodick, and Yogev); Maccabi Healthcare Services, Tel Aviv, Israel (Dr Chodick)
| | - Yariv Yogev
- Lis Hospital for Women, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel (Drs Ram and Yogev); Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (Drs Ram, Shalev-Ram, Shalev-Rosenthal, Chodick, and Yogev)
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9
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Boere I, Lok C, Poortmans P, Koppert L, Painter R, Vd Heuvel-Eibrink MM, Amant F. Breast cancer during pregnancy: epidemiology, phenotypes, presentation during pregnancy and therapeutic modalities. Best Pract Res Clin Obstet Gynaecol 2022; 82:46-59. [PMID: 35644793 DOI: 10.1016/j.bpobgyn.2022.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/02/2022] [Accepted: 05/02/2022] [Indexed: 11/02/2022]
Abstract
Although it is uncommon in general, breast cancer is the most commonly diagnosed cancer during pregnancy. While treatment for pregnant patients should adhere to treatment guidelines for non-pregnant patients, there exist specific considerations concerning diagnosis, staging, oncological treatment, and obstetrical care. Imaging and staging are preferably performed using breast ultrasound and mammography. Other ionizing radiation imaging modalities, including computed tomography (CT) and Positron Emission Tomography/ Computed Tomography (PET/CT), can be selectively performed when the estimated benefit for the mother outweighs the risks to the foetus, e.g., when the results will change clinical management. MRI is appropriate to stage for distant disease on the indication. Breast cancer during pregnancy is less often hormone receptor-positive and more frequently triple-negative breast cancer compared to age-matched controls. The basic principle is that women should receive state-of-the-art oncological treatment without delay if possible and that the pregnancy should be maintained as long as possible. Treatment strategy should be multidisciplinary defined, carefully weighing the selection, sequence, and timing of treatment modalities depending on patient-, tumour-, and pregnancy-related characteristics, as well as patient preferences. Initiating cancer treatment during pregnancy often decreases the risks of early delivery and prematurity. Breast cancer surgery is possible during all trimesters. Radiotherapy is possible during pregnancy in the first half of pregnancy. Chemotherapy can be safely administered starting from 12 weeks of gestational age, but endocrine and HER2 targeted therapy are contraindicated throughout the whole pregnancy. Importantly, foetal growth should be monitored and long-term follow-up of the children is encouraged in dedicated centres.
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Affiliation(s)
- Ingrid Boere
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Christianne Lok
- Center for Gynecological Oncology Amsterdam (CGOA), Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Philip Poortmans
- Iridium Network and University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Linetta Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rebecca Painter
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Marry M Vd Heuvel-Eibrink
- Department of Obstetrics and Gynecology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Frederic Amant
- Center for Gynecological Oncology Amsterdam (CGOA), Antoni van Leeuwenhoek - Netherlands Cancer Institute, Amsterdam, the Netherlands; Gynecologic Oncology, UZ Leuven, Belgium
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