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Davis S, Pandor A, Sampson FC, Hamilton J, Nelson-Piercy C, Hunt BJ, Daru J, Goodacre S. Estimating the value of future research into thromboprophylaxis for women during pregnancy and after delivery: a value of information analysis. J Thromb Haemost 2024; 22:1105-1116. [PMID: 38215911 DOI: 10.1016/j.jtha.2023.12.035] [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: 09/20/2023] [Revised: 12/28/2023] [Accepted: 12/30/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Risk assessment models (RAMs) are used to select women at increased risk of venous thromboembolism (VTE) during pregnancy and the puerperium for thromboprophylaxis. OBJECTIVES To estimate the value of potential future studies that would reduce the decision uncertainty associated with offering thromboprophylaxis according to available RAMs in the following groups: high-risk antepartum women (eg, prior VTE), unselected postpartum women, and postpartum women with risk factors (obesity or cesarean delivery). METHODS A decision-analytic model was developed to simulate clinical outcomes, lifetime costs, and quality-adjusted life-years for different thromboprophylaxis strategies, including thromboprophylaxis for all, thromboprophylaxis for none, and RAM-based thromboprophylaxis. The expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty. The value of future research studies was estimated using expected value of sample information analysis. Costs were assessed from a health and social services perspective. RESULTS The expected value of perfect information analysis identified high decision uncertainty for high-risk antepartum women (£21.8 million) and obese postpartum women (£13.4 million), which was largely attributable to uncertainty regarding the effectiveness of thromboprophylaxis in reducing VTE. A randomized controlled trial of thromboprophylaxis compared with none in obese postpartum women is likely to have substantial value (£2.8 million; 300 participants per arm). A trial in women with previous VTE would have higher value but would be less acceptable. CONCLUSION Future research should focus on estimating the effectiveness of thromboprophylaxis in obese postpartum women with additional risk factors who have not had a previous VTE.
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Affiliation(s)
- Sarah Davis
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
| | - Abdullah Pandor
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Fiona C Sampson
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Jean Hamilton
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Catherine Nelson-Piercy
- Women's Health Academic Centre, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Jahnavi Daru
- Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Steve Goodacre
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
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Davis S, Pandor A, Sampson FC, Hamilton J, Nelson-Piercy C, Hunt BJ, Daru J, Goodacre S, Carser R, Rooney G, Clowes M. Thromboprophylaxis during pregnancy and the puerperium: a systematic review and economic evaluation to estimate the value of future research. Health Technol Assess 2024; 28:1-176. [PMID: 38476084 PMCID: PMC11017156 DOI: 10.3310/dfwt3873] [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] [Indexed: 03/14/2024] Open
Abstract
Background Pharmacological prophylaxis to prevent venous thromboembolism is currently recommended for women assessed as being at high risk of venous thromboembolism during pregnancy or in the 6 weeks after delivery (the puerperium). The decision to provide thromboprophylaxis involves weighing the benefits, harms and costs, which vary according to the individual's venous thromboembolism risk. It is unclear whether the United Kingdom's current risk stratification approach could be improved by further research. Objectives To quantify the current decision uncertainty associated with selecting women who are pregnant or in the puerperium for thromboprophylaxis and to estimate the value of one or more potential future studies that would reduce that uncertainty, while being feasible and acceptable to patients and clinicians. Methods A decision-analytic model was developed which was informed by a systematic review of risk assessment models to predict venous thromboembolism in women who are pregnant or in the puerperium. Expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty and should be the target of future research. To find out whether future studies would be acceptable and feasible, we held workshops with women who have experienced a blood clot or have been offered blood-thinning drugs and surveyed healthcare professionals. Expected value of sample information analysis was used to estimate the value of potential future research studies. Results The systematic review included 17 studies, comprising 19 unique externally validated risk assessment models and 1 internally validated model. Estimates of sensitivity and specificity were highly variable ranging from 0% to 100% and 5% to 100%, respectively. Most studies had unclear or high risk of bias and applicability concerns. The decision analysis found that there is substantial decision uncertainty regarding the use of risk assessment models to select high-risk women for antepartum prophylaxis and obese postpartum women for postpartum prophylaxis. The main source of decision uncertainty was uncertainty around the effectiveness of thromboprophylaxis for preventing venous thromboembolism in women who are pregnant or in the puerperium. We found that a randomised controlled trial of thromboprophylaxis in obese postpartum women is likely to have substantial value and is more likely to be acceptable and feasible than a trial recruiting women who have had a previous venous thromboembolism. In unselected postpartum women and women following caesarean section, the poor performance of risk assessment models meant that offering prophylaxis based on these models had less favourable cost effectiveness with lower decision uncertainty. Limitations The performance of the risk assessment model for obese postpartum women has not been externally validated. Conclusions Future research should focus on estimating the efficacy of pharmacological thromboprophylaxis in pregnancy and the puerperium, and clinical trials would be more acceptable in women who have not had a previous venous thromboembolism. Study registration This study is registered as PROSPERO CRD42020221094. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR131021) and is published in full in Health Technology Assessment; Vol. 28, No. 9. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona C Sampson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Beverley J Hunt
- Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jahnavi Daru
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rosie Carser
- Patient and Public Involvement, Thrombosis UK, Llanwrda, UK
| | - Gill Rooney
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Kevane B, Áinle FN. Prevention, diagnosis, and management of PE and DVT in pregnant women. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:237-247. [PMID: 38066865 PMCID: PMC10727078 DOI: 10.1182/hematology.2023000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Venous thromboembolism (VTE) is a leading cause of maternal morbidity and mortality worldwide. Despite the impact of VTE on pregnant and postpartum people and on society, guidelines addressing prevention, diagnosis, and management of VTE in pregnant and postpartum people frequently are based on recommendations from expert opinion and are extrapolated from data in nonpregnant populations. Pregnant individuals are frequently excluded from clinical trials, which is a barrier to providing safe, effective care. Anchoring to a case discussion, this review provides an update on recently published and ongoing randomized clinical trials (RCTs), prospective clinical management studies, and other research in this area. It highlights, in particular, the results of the Highlow RCT, which addresses optimal prevention of recurrence during pregnancy in people with prior VTE. Finally, we raise awareness of the impact of national and international clinical trial networks on the conduct of RCTs in pregnancy. We conclude, based on these data, that academic VTE clinical trials in pregnant women can and must be done.
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Affiliation(s)
- Barry Kevane
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- Department of Hematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- Department of Hematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Schapkaitz E, Libhaber E, Gerber A, Rhemtula H, Zamparini J, Jacobson BF, Büller HR. A Longitudinal Study of Thrombosis and Bleeding Outcomes With Thromboprophylaxis in Pregnant Women at Intermediate and High Risk of VTE. Clin Appl Thromb Hemost 2023; 29:10760296231160748. [PMID: 36972476 PMCID: PMC10052495 DOI: 10.1177/10760296231160748] [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: 03/29/2023] Open
Abstract
BACKGROUND The efficacy and safety of thromboprophylaxis in pregnancy at intermediate to high risk of venous thrombo-embolism (VTE) is an area of ongoing research. AIM This study aimed to assess thrombosis and bleeding outcomes associated with thromboprophylaxis in women at risk of VTE. METHODS A cohort of 129 pregnancies, who received thromboprophylaxis for the prevention of VTE, were identified from a specialist obstetric clinic in Johannesburg, South Africa. Intermediate-risk pregnancies, with medical comorbidities or multiple low risks, were managed with fixed low-dose enoxaparin antepartum and for a median (interquartile range) of 4 (4) weeks postpartum. High-risk pregnancies, with a history of previous VTE, were managed with anti-Xa adjusted enoxaparin antepartum and for a median of 6 (0) weeks postpartum. Pregnancy-related VTE was objectively confirmed. Major bleeding, clinically relevant nonmajor bleeding (CRNMB) and minor bleeding were defined according to the International Society on Thrombosis and Hemostasis Scientific Subcommittee. RESULTS Venous thrombo-embolism occurred antepartum in 1.4% (95% CI: 0.04-7.7) of intermediate and 3.4% (95% CI: 0.4-11.7) of high-risk pregnancies. Bleeding events occurred in 7.1% (95% CI: 2.4-15.9) of intermediate and 8.5% (95% CI: 2.8-18.7) of high-risk pregnancies. Of these bleeding events, 3.1% (95% CI: 1.0-8.0) were classified as major bleeding. On univariate analysis, no independent predictors of bleeding were identified. CONCLUSION The rates of thrombosis and bleeding in this predominantly African population were consistent with similar studies and can be used to inform pregnant women of the benefits of anticoagulation and the risks of potential bleeding.
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Affiliation(s)
- E Schapkaitz
- Department of Molecular Medicine and Hematology, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - E Libhaber
- Department of Research Methodology and Statistics, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - A Gerber
- Department of Obstetrics, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - H Rhemtula
- Department of Obstetrics, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - J Zamparini
- Department of Internal Medicine, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - B F Jacobson
- Department of Molecular Medicine and Hematology, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - H R Büller
- Department of Vascular Medicine, 1234University of Amsterdam, Amsterdam, the Netherlands
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5
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Tardy B, Bertoletti L. Editorial: Venous thromboembolism and pregnancy. Front Cardiovasc Med 2022; 9:1113941. [PMID: 36620628 PMCID: PMC9817018 DOI: 10.3389/fcvm.2022.1113941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 12/25/2022] Open
Affiliation(s)
- Bernard Tardy
- Clinical Investigation Center, Inserm CIC1408, Saint-Étienne, France,*Correspondence: Bernard Tardy ✉
| | - Laurent Bertoletti
- Université Jean Monnet, Department of Médecine Vasculaire et Thérapeutique, University Hospital of Saint-Etienne, Mines Saint-Étienne, INSERM, U 1059, CIC1408, Saint-Étienne, France
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6
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Bistervels IM, Buchmüller A, Wiegers HMG, Ní Áinle F, Tardy B, Donnelly J, Verhamme P, Jacobsen AF, Hansen AT, Rodger MA, DeSancho MT, Shmakov RG, van Es N, Prins MH, Chauleur C, Middeldorp S. Intermediate-dose versus low-dose low-molecular-weight heparin in pregnant and post-partum women with a history of venous thromboembolism (Highlow study): an open-label, multicentre, randomised, controlled trial. Lancet 2022; 400:1777-1787. [PMID: 36354038 DOI: 10.1016/s0140-6736(22)02128-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pregnancy-related venous thromboembolism is a leading cause of maternal morbidity and mortality, and thromboprophylaxis is indicated in pregnant and post-partum women with a history of venous thromboembolism. The optimal dose of low-molecular-weight heparin to prevent recurrent venous thromboembolism in pregnancy and the post-partum period is uncertain. METHODS In this open-label, randomised, controlled trial (Highlow), pregnant women with a history of venous thromboembolism were recruited from 70 hospitals in nine countries (the Netherlands, France, Ireland, Belgium, Norway, Denmark, Canada, the USA, and Russia). Women were eligible if they were aged 18 years or older with a history of objectively confirmed venous thromboembolism, and with a gestational age of 14 weeks or less. Eligible women were randomly assigned (1:1), before 14 weeks of gestational age, using a web-based system and permuted block randomisation (block size of six), stratified by centre, to either weight-adjusted intermediate-dose or fixed low-dose low-molecular-weight heparin subcutaneously once daily until 6 weeks post partum. The primary efficacy outcome was objectively confirmed venous thromboembolism (ie, deep-vein thrombosis, pulmonary embolism, or unusual site venous thrombosis), as determined by an independent central adjudication committee, in the intention-to-treat (ITT) population (ie, all women randomly assigned to treatment). The primary safety outcome was major bleeding which included antepartum, early post-partum (within 24 h after delivery), and late post-partum major bleeding (24 h or longer after delivery until 6 weeks post partum), assessed in all women who received at least one dose of assigned treatment and had a known end of treatment date. This study is registered with ClinicalTrials.gov, NCT01828697, and is now complete. FINDINGS Between April 24, 2013, and Oct 31, 2020, 1339 pregnant women were screened for eligibility, of whom 1110 were randomly assigned to weight-adjusted intermediate-dose (n=555) or fixed low-dose (n=555) low-molecular-weight heparin (ITT population). Venous thromboembolism occurred in 11 (2%) of 555 women in the weight-adjusted intermediate-dose group and in 16 (3%) of 555 in the fixed low-dose group (relative risk [RR] 0·69 [95% CI 0·32-1·47]; p=0·33). Venous thromboembolism occurred antepartum in five (1%) women in the intermediate-dose group and in five (1%) women in the low-dose group, and post partum in six (1%) women and 11 (2%) women. On-treatment major bleeding in the safety population (N=1045) occurred in 23 (4%) of 520 women in the intermediate-dose group and in 20 (4%) of 525 in the low-dose group (RR 1·16 [95% CI 0·65-2·09]). INTERPRETATION In women with a history of venous thromboembolism, weight-adjusted intermediate-dose low-molecular-weight heparin during the combined antepartum and post-partum periods was not associated with a lower risk of recurrence than fixed low-dose low-molecular-weight heparin. These results indicate that low-dose low-molecular-weight heparin for thromboprophylaxis during pregnancy is the appropriate dose for the prevention of pregnancy-related recurrent venous thromboembolism. FUNDING French Ministry of Health, Health Research Board Ireland, GSK/Aspen, and Pfizer.
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Affiliation(s)
- Ingrid M Bistervels
- Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Andrea Buchmüller
- CIC 1408 Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France; FCRIN INNOVTE, CHU de Saint Etienne, Saint-Etienne, France
| | - Hanke M G Wiegers
- Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Fionnuala Ní Áinle
- Rotunda Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Bernard Tardy
- CIC 1408 Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France; FCRIN INNOVTE, CHU de Saint Etienne, Saint-Etienne, France
| | - Jennifer Donnelly
- School of Medicine, University College Dublin, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Anne F Jacobsen
- Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway
| | - Anette T Hansen
- Aalborg University Hospital, Aalborg, Denmark; Aarhus University Hospital, Aarhus, Denmark
| | | | - Maria T DeSancho
- Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Roman G Shmakov
- Institute of Obstetrics, National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Nick van Es
- Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Martin H Prins
- Department of Epidemiology and Technology Assessment, University of Maastricht, Maastricht, Netherlands
| | - Céline Chauleur
- CIC 1408 Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France; University Jean Monnet, University Hospital of Saint-Etienne, Mines Saint-Etienne, INSERM U 1059, Saint-Etienne, France
| | - Saskia Middeldorp
- Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands; Radboud university medical center, Nijmegen, Netherlands.
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7
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Malinowski AK, Abdul-Kadir R. Planning Pregnancy and Birth in Women with Inherited Bleeding Disorders. Semin Thromb Hemost 2022; 49:371-381. [PMID: 36368690 DOI: 10.1055/s-0042-1758117] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AbstractInherited bleeding disorders are characterized by a diverse clinical phenotype within and across specific diagnoses. von Willebrand disease (VWD), hemophilia A, and hemophilia B comprise 95 to 97% of inherited bleeding disorders, with the remaining 3 to 5% attributed to rare bleeding disorders, including congenital fibrinogen disorders, factor deficiencies (affecting FII, FV, FV + FVIII, FVII, FX, FXI, and FXIII), and platelet function defects. The pregnancy, birth, and the puerperium may be adversely influenced in the setting of an inherited bleeding disorder depending on its type and clinical phenotype. Obstetric hemostatic challenges may sometimes also unmask the presence of a previously unknown inherited bleeding disorder. This review aims to address the approach to pregnancy and birth in the context of an inherited bleeding disorder and highlights the significance of multidisciplinary input into the care of these women.
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Affiliation(s)
- A. Kinga Malinowski
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
| | - Rezan Abdul-Kadir
- Department of Obstetrics and Gynaecology and Katharine Dormandy Haemophilia and Thrombosis Centre, The Royal Free NHS Foundation Hospital, London, United Kingdom
- Institute for Women's Health, University College London, London, United Kingdom
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8
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Saeed K, Áinle FN. Standardizing definitions for bleeding events in studies including pregnant women: A call to action. Res Pract Thromb Haemost 2022; 6:e12822. [PMID: 36313985 PMCID: PMC9596607 DOI: 10.1002/rth2.12822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/05/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Khalid Saeed
- Department of HaematologyMater Misericordiae University HospitalDublinIreland
| | - Fionnuala Ní Áinle
- Department of HaematologyMater Misericordiae University HospitalDublinIreland,Department of HaematologyRotunda HospitalDublinIreland,School of MedicineUniversity College Dublin (UCD)DublinIreland
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9
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Novak P, Novak A, Šabović M, Kozak M. Prophylactic Dose of Dalteparin in Pregnant Women With History of Venous Thromboembolisms and/or Thrombophilia: Real-World Data. Angiology 2022:33197221126244. [DOI: 10.1177/00033197221126244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Women with a history of venous thromboembolisms (VTEs) and/or thrombophilia are at increased risk of VTE during pregnancy. We analysed our cohort of such women who were treated with a prophylactic doses of dalteparin. 152 pregnant women with 179 pregnancies were classified into 3 groups: (1) previous VTE without thrombophilia (122 pregnancies); (2) previous VTE with thrombophilia (26 pregnancies) and (3) thrombophilia only (31 pregnancies). They were treated with prophylactic dalteparin in the prepartum and postpartum periods or only in the postpartum period. Occurrences of symptomatic VTE and bleeding episodes were followed, as well as dalteparin discontinuation and anti-Xa activity. Symptomatic deep vein thrombosis occurred in 4 women (2.2%) with 2 episodes in group 1 (in the postpartum period) and 2 episodes in group 2 (one in the prepartum and another in the postpartum period). Seven episodes (3.9%) of minor bleeding occurred. Dalteparin was not stopped in any women. Anti-Xa levels were within the prophylactic range. Our real-world data show a low incidence of thrombosis and minor bleeding in pregnant women treated with prophylactic dalteparin. The incidence of recurrent VTE was lower than that reported in women with similar risk, but without prophylactic anticoagulation.
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Affiliation(s)
- Petra Novak
- Department of Perioperative Medicine, General Hospital Murska Sobota, Ljubljana, Slovenia
| | - Anja Novak
- Department of Anaesthesiology, Perioperative Intensive Care and Pain Management, General Hospital Novo Mesto, Novo Mesto, Slovenia
| | - Mišo Šabović
- Department for Vascular Disorders, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Kozak
- Department for Vascular Disorders, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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10
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Simard C, Gerstein L, Cafaro T, Filion KB, Douros A, Malhamé I, Tagalakis V. Bleeding in women with venous thromboembolism during pregnancy: A systematic review of the literature. Res Pract Thromb Haemost 2022; 6:e12801. [PMID: 36051542 PMCID: PMC9424506 DOI: 10.1002/rth2.12801] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/01/2022] [Accepted: 08/05/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives Venous thromboembolism (VTE) represents an important cause of maternal morbidity and mortality. Estimates of bleeding associated with therapeutic‐dose anticoagulation are variable. We describe the frequency of bleeding in pregnant women receiving therapeutic anticoagulation for VTE by means of a systematic review of the literature. Data Sources Medical Literature Analysis and Retrieval System, Embase, Scopus, Web of Science, and ClinicalTrials.gov were searched. Databases were searched from inception to February 27, 2022. There was no language or geographic location restriction. Methods of Study Selection The search yielded 2773 articles with 2212 unique citations. Studies were included if they described pregnant women treated for an acute VTE with therapeutic‐dose anticoagulation and a defined bleeding outcome was reported. Tabulation, Integration, and Results Five studies met inclusion criteria. Included studies were judged to have a serious to critical risk of bias using the Risk of Bias in Nonrandomized Studies of Intervention tool. The rate of bleeding, as defined by respective studies, ranged between 2.9% and 30.0%. Two studies included control groups, one of which found no significant difference in the risk of bleeding between groups, while the other found a significantly increased bleeding risk associated with therapeutic anticoagulation. Conclusion Among pregnant women anticoagulated for VTE, the reported bleeding risk is variable. The ability to draw definite conclusions is limited by the scarcity and low quality of the studies, the small number of included patients, and the heterogeneity of bleeding definitions used. Large‐scale studies with standardized bleeding definitions are required to provide acute bleeding estimates and optimize the care of these patients. Systematic Review Registration PROSPERO, CRD42021276771.
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Affiliation(s)
- Camille Simard
- Division of General Internal Medicine Department of Medicine Jewish General Hospital McGill University Montreal Quebec Canada
| | | | - Teresa Cafaro
- Division of General Internal Medicine Department of Medicine Jewish General Hospital McGill University Montreal Quebec Canada
| | - Kris B Filion
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research Jewish General Hospital Montreal Quebec Canada
| | - Antonios Douros
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research Jewish General Hospital Montreal Quebec Canada
| | - Isabelle Malhamé
- Division of General Internal Medicine Department of Medicine McGill University Health Centre McGill University Montreal Quebec Canada.,Research Institute of the McGill University Health Centre Montreal Quebec Canada
| | - Vicky Tagalakis
- Division of General Internal Medicine Department of Medicine Jewish General Hospital McGill University Montreal Quebec Canada.,Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research Jewish General Hospital Montreal Quebec Canada
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11
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Edebiri O, Ní Áinle F. Risk factors, diagnosis and management of venous thromboembolic disease in pregnancy. Breathe (Sheff) 2022; 18:220018. [PMID: 36337136 PMCID: PMC9584596 DOI: 10.1183/20734735.0018-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022] Open
Abstract
Venous thromboembolism (VTE) in pregnancy is a leading cause of maternal morbidity and mortality. However, despite the significant associated clinical burden and potentially devastating societal impact, there is still a paucity of data surrounding its prevention and management. Consequently, international guideline recommendations vary widely. Exclusion of pregnant women from clinical trials in the past has contributed to knowledge gaps. However, recently published and ongoing studies demonstrate that excellent clinical trials in pregnancy are achievable. This review will discuss prevention, diagnosis and treatment of VTE in pregnancy, and will also explore priorities for future research. Venous thromboembolism in pregnancy is a leading cause of maternal morbidity and mortality. However, individualised clinical risk assessment and recent advances in clinical prediction rules for pulmonary embolism have the potential to improve management.https://bit.ly/3mjtHg2
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12
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Skeith L. Prevention and management of venous thromboembolism in pregnancy: cutting through the practice variation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:559-569. [PMID: 34889418 PMCID: PMC8791179 DOI: 10.1182/hematology.2021000291] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
There is clinical practice variation in the area of prevention and management of venous thromboembolism (VTE) in pregnancy. There are limited data and differing recommendations across major clinical practice guidelines, especially relating to the role of postpartum low-molecular-weight heparin (LMWH) for patients with mild inherited thrombophilia and those with pregnancy-related VTE risk factors. This chapter explores the issues of practice variation and related data for postpartum VTE prevention. Controversial topics of VTE management in pregnancy are also reviewed and include LMWH dosing and the role of anti-Xa level monitoring, as well as peripartum anticoagulation management around labor and delivery.
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Affiliation(s)
- Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, Foothills Medical Centre, University of Calgary, Calgary, Canada
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Wiegers HMG, Middeldorp S. Contemporary best practice in the management of pulmonary embolism during pregnancy. Ther Adv Respir Dis 2021; 14:1753466620914222. [PMID: 32425105 PMCID: PMC7238314 DOI: 10.1177/1753466620914222] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Approximately 1–2 per 1000 pregnancies are complicated by venous thromboembolism
(VTE). VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE) and
the diagnostic management of pregnancy-related VTE is challenging. Current
guidelines vary greatly in their approach to diagnosing PE in pregnancy as they
base their recommendations on scarce and weak evidence. The pregnancy-adapted
YEARS diagnostic algorithm is well tolerated and is the most efficient
diagnostic algorithm for pregnant women with suspected PE, with 39% of women not
requiring computed tomographic pulmonary angiography. Low-molecular-weight
heparin is the first-choice anticoagulant treatment in pregnancy and should be
continued until 6 weeks postpartum and for a minimum of 3 months. Direct oral
anticoagulants should be avoided in women who want to breastfeed. Management of
delivery needs a multidisciplinary approach in order to decide on an optimal
delivery plan. Neuraxial analgesia can be given in most patients, provided time
windows since last low-molecular-weight heparin dose are respected. Women with a
history of VTE are at risk of recurrence during pregnancy and in the postpartum
period. Therefore, in most women with a history of VTE, thromboprophylaxis in
subsequent pregnancies is indicated. The reviews of this paper are available via the supplemental material
section.
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Affiliation(s)
- Hanke M G Wiegers
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, Amsterdam, North Holland 1105 AZ, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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How I treat venous thromboembolism in pregnancy. Blood 2021; 136:2133-2142. [PMID: 32797192 DOI: 10.1182/blood.2019000963] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/11/2020] [Indexed: 12/11/2022] Open
Abstract
One to 2 pregnant women in 1000 will experience venous thromboembolism (VTE) during pregnancy or postpartum. Pulmonary embolism (PE) is a leading cause of maternal mortality, and deep vein thrombosis leads to maternal morbidity, with postthrombotic syndrome potentially diminishing quality of life for a woman's lifetime. However, the evidence base for pregnancy-related VTE management remains weak. Evidence-based guideline recommendations are often extrapolated from nonpregnant women and thus weak or conditional, resulting in wide variation of practice. In women with suspected PE, the pregnancy-adapted YEARS algorithm is safe and efficient, rendering computed tomographic pulmonary angiography to rule out PE unnecessary in 39%. Low molecular weight heparin (LMWH) in therapeutic doses is the treatment of choice during pregnancy, and anticoagulation (LMWH or vitamin K antagonists [VKAs]) should be continued until 6 weeks after delivery, with a 3-month minimum total duration. LMWH or VKA use does not preclude breastfeeding. Postpartum, direct oral anticoagulants are an option if a woman does not breastfeed and long-term use is intended. Management of delivery, including type of analgesia, requires a multidisciplinary approach and depends on local preferences and patient-specific conditions. Several options are possible, including waiting for spontaneous delivery with temporary LMWH interruption. Prophylaxis for recurrent VTE prevention in subsequent pregnancies is indicated in most women with a history of VTE.
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