The role of thrombophilia in pregnancy. Thrombosis. 2013;2013:516420. [PMID: 24455235 PMCID: PMC3880751 DOI: 10.1155/2013/516420]

Pituitary Apoplexy: An Updated Review

Pituitary apoplexy (PA) is an acute, life-threatening clinical syndrome caused by hemorrhage and/or infarction of the pituitary gland. It is clinically characterized by the sudden onset of headache. Depending on the severity, it may also be accompanied by nausea, vomiting, visual disturbances, varying degrees of adenohypophyseal hormone deficiency, and decreased level of consciousness. Corticotropic axis involvement may result in severe hypotension and contribute to impaired level of consciousness. Precipitating factors are present in up to 30% of cases. PA may occur at any age and sometimes develops during pregnancy or the immediate postpartum period. PA occurs more frequently in men aged 50-60, being rare in children and adolescents. It can develop in healthy pituitary glands or those affected by inflammation, infection, or tumor. The main cause of PA is usually spontaneous hemorrhage or infarction of a pituitary adenoma (pituitary neuroendocrine tumor, PitNET). It is a medical emergency requiring immediate attention and, in many cases, urgent surgical intervention and long-term follow-up. Although the majority of patients (70%) require surgery, about one-third can be treated conservatively, mainly by monitoring fluid and electrolyte levels and using intravenous glucocorticoids. There are scoring systems for PA with implications for management and therapeutic outcomes that can help guide therapeutic decisions. Management of PA requires proper evaluation and long-term follow-up by a multidisciplinary team with expertise in pituitary pathology. The aim of the review is to summarize and update the most relevant aspects of the epidemiology, etiopathogenesis, pathophysiology, clinical presentation and clinical forms, diagnosis, therapeutic strategies, and prognosis of PA.

Novel nucleotide variations in the thrombomodulin (THBD) gene involved in coagulation pathways can increase the risk of recurrent pregnancy loss (RPL)

Recurrent pregnancy loss (RPL) is a common but complex complication in fertility conditions, affecting about 15-20% of couples. Although several causes have been proposed for RPL, it occurs in about 35-60% of cases without a known explanation. A strong assumption is that genetic factors play a role in the etiology and pathophysiology of PRL. Therefore, several genes are proposed as candidates in the pathogenesis of RPL. The current study aimed to investigate the effects of nucleotide changes in the THBD (thrombomodulin) gene as an RPL-related candidate gene. This gene encodes a cell receptor for thrombin and is involved in reproductive loss in RPL cases. Its involvement in the natural anticoagulant system has been extensively studied. By genetic screening of the entire coding and noncoding regions of the THBD gene, we found twenty-seven heterozygous and homozygous nucleotide changes. Ten of them led to amino acid substitutions, seven variants were identified in the promoter region, and eight of them occurred in 3'UTR. Potentially, the pathogenicity effects of these variations on THBD protein were evaluated by several prediction tools. The numerous genomic variations prompted noticeable modifications of the protein's structural and functional properties. Furthermore, in-silico scores were consistent with deleterious effects for these mutations. The results of this study provide genetic information that will be useful in the future for clinicians, scientists, and students to understand the unknown causes of RPL better. It may also pave the way for developing diagnostic/prognostic approaches to help treat PRL patients.

Successful Caesarean Section on Ticagrelor Treatment One Day after Primary Percutaneous Coronary Intervention

Caesarean section is a challenging intervention in patients treated with dual antiplatelet therapy. We present a case of a 32-year-old pregnant woman experiencing large acute myocardial infarction (MI) of the anterolateral wall, complicated by cardiogenic shock in the 38th week of pregnancy, and treated with drug-eluting stent implantation and dual antiplatelet therapy (DAPT) consisting of aspirin and ticagrelor. Less than 24 h after the MI delivery started, an urgent Caesarean section was indicated. As multiplate aggregometry testing showed a relatively insufficient level of ticagrelor platelet inhibition and a moderate level of aspirin platelet inhibition, a Caesarean section was performed without discontinuation of ticagrelor, which was decided due to the need for emergency surgery. Local hemostatic measures including administration of tranexamic acid were applied. The patient did not experience excessive bleeding. A healthy male baby was born. To the best of our knowledge, this is the first reported case of surgery in pregnant women treated with DAPT without ticagrelor discontinuation.

Adoption of a National Prophylactic Anticoagulation Guideline for Hospitalized Pregnant Women With COVID-19: Retrospective Cohort Study

BACKGROUND

Both COVID-19 and pregnancy are associated with hypercoagulability. Due to the increased risk for thrombosis, the United States National Institute of Health's recommendation for prophylactic anticoagulant use for pregnant patients has expanded from patients hospitalized for severe COVID-19 manifestation to all patients hospitalized for the manifestation of COVID-19 (no guideline: before December 26, 2020; first update: December 27, 2022; second update: February 24, 2022-present). However, no study has evaluated this recommendation.

OBJECTIVE

The objective of this study was to characterize prophylactic anticoagulant use among hospitalized pregnant people with COVID-19 from March 20, 2020, to October 19, 2022.

METHODS

This was a retrospective cohort study in large US health care systems across 7 states. The cohort of interest was pregnant patients who were hospitalized with COVID-19, without previous coagulopathy or contraindication to anticoagulants (n=2767). The treatment group consisted of patients prescribed prophylactic dose anticoagulation between 2 days before and 14 days after COVID-19 treatment onset (n=191). The control group was patients with no anticoagulant exposure between 14 days before and 60 days after COVID-19 treatment onset (n=2534). We ascertained the use of prophylactic anticoagulants with attention to the updates in guidelines and emerging SARS-CoV-2 variants. We propensity score matched the treatment and control group 1:1 on the most important features contributing to the prophylactic anticoagulant administration status classification. Outcome measures included coagulopathy, bleeding, COVID-19-related complications, and maternal-fetal health outcomes. Additionally, the inpatient anticoagulant administration rate was validated in a nationwide population from Truveta, a collective of 700 hospitals across the United States.

RESULTS

The overall administration rate of prophylactic anticoagulants was 7% (191/2725). It was lowest after the second guideline update (no guideline: 27/262, 10%; first update: 145/1663, 8.72%; second update: 19/811, 2.3%; P<.001) and during the omicron-dominant period (Wild type: 45/549, 8.2%; Alpha: 18/129, 14%; Delta: 81/507, 16%; and Omicron: 47/1551, 3%; P<.001). Models developed on retrospective data showed that the variable most associated with the administration of inpatient prophylactic anticoagulant was comorbidities prior to SARS-CoV-2 infection. The patients who were administered prophylactic anticoagulant were also more likely to receive supplementary oxygen (57/191, 30% vs 9/188, 5%; P<.001). There was no statistical difference in a new diagnosis of coagulopathy, bleeding, or maternal-fetal health outcomes between those who received treatment and the matched control group.

CONCLUSIONS

Most hospitalized pregnant patients with COVID-19 did not receive prophylactic anticoagulants across health care systems as recommended by guidelines. Guideline-recommended treatment was administered more frequently to patients with greater COVID-19 illness severity. Given the low rate of administration and differences between treated and untreated cohorts, efficacy could not be assessed.

Evaluation of platelet parameters, coagulation markers, antiphospholipid syndrome, and thyroid function in palestinian women with recurrent pregnancy loss

BACKGROUND

Multiple etiologies contribute to recurrent pregnancy loss (RPL) including immunological, endocrine, anatomical, genetic and infection but more than 50% of cases remain unexplained. Evidences of thrombotic and inflammatory processes were observed at maternal-fetal interface and considered pathological findings in most RPL cases including unexplained cases. This study aimed to evaluate the association between RPL and several risk factors: platelet parameters, coagulation factors, antiphospholipid syndrome, and thyroid function.

METHODS

This is an unmatched case-control study that included 100 RPL and 100 control women. Anthropometric and health data were collected and a gynecologist examined participants to assure fitting the inclusion criteria. Platelet parameters [including Mean Platelet Mass (MPM), Concentration (MPC) and Volume (MPV)] and ratios (MPV/Platelet, MPC/Platelet, MPM/Platelet, Platelet/Mononuclear cells), coagulation markers [Protein C (PC), Protein S (PS), Antithrombin III, D-dimer], antiphospholipid antibodies [Anti-phospholipid (APA), Anti-cardiolipin (ACA) and anti-B2-glycoprotein 1], Lupus anticoagulant, Antinuclear antibodies, and thyroid function (Thyroid stimulating hormone and anti-thyroid peroxidase) were measured.

RESULTS

Mean ages of cases and controls at marriage were 22.5 years for both, and their current ages were 29.4 and 33.0, respectively. 92% of cases and 99% of controls aged blow 30 years at marriage. 75% of cases have 3-4 miscarriages and 9% have ≥ 7 miscarriages. Our results indicated significantly lower male/female age ratio (p = .019), PC (p = .036) and PS (p = .025) in cases compared to controls. Plasma D-dimer (p = .020) and antiphospholipid antibodies [ACA (IgM and IgG), APA (IgM)] were significantly higher in cases compared to controls. No significant differences were observed between cases and controls concerning APA (IgG), anti-B2-glycoprotein 1 (IgM and IgG), Lupus anticoagulant, Antinuclear antibodies, platelet parameters, thyroid markers, family history of miscarriage, consanguineous marriage, and other health data.

CONCLUSIONS

This is the first study that investigated the association between platelet, coagulation, antiphospholipid, autoimmune and thyroid parameters, and RPL in Palestinian women. Significant associations between male/female age ratio, PC, PS, D-dimer, ACA (IgM, IgG), APA (IgM) and RPL were observed. These markers could be used in evaluating RPL. These findings confirm the heterogeneous nature of RPL and emphasize the need for further studies to find out risk factors for RPL.

Accurate diagnosis of isolated iliac vein thrombosis in third trimester pregnancy with clues on great saphenous vein reflux: a case report and review of literature

BACKGROUND

Pregnancy is known to be a risk factor for venous thromboembolism (VTE). We report the case of a pregnant patient with difficult to diagnose iliac vein thrombosis, establishing a definite diagnosis by clues of great saphenous vein reflux.

CASE PRESENTATION

A 37-year-old G1P0 woman at 35 weeks of assisted twin gestation presented with a complaint of persistent left lower limb edema and tenderness. A vascular ultrasound was used to examine the bilateral lower limb. Doppler of left lower extremity revealed continuous great saphenous vein reflux. Right saphenofemoral veins demonstrated venous stasis and no reflux. Unilateral continuous great saphenous vein reflux suggested left iliac veins obstruction or extrinsic compression. Anterograde venography showed a completely occlusive filling defect of the left external iliac vein, which is the definitive diagnosis of acute deep venous thrombosis. The patient underwent a cesarean delivery following inferior vena cava filter (IVCF) placement, and no signs of deep venous thrombosis (DVT) or pulmonary embolism (PE) were reported after delivery.

CONCLUSION

In pregnant women with suspected deep vein thrombosis, it is imperative to assess the presence of unilateral continuous great saphenous vein reflux.

Maternal exposure to heparin products and risk of birth defects in the National Birth Defects Prevention Study

BACKGROUND

Heparin and low-molecular-weight heparin are the preferred anticoagulants during pregnancy as they do not cross the placenta. Although research on the safety of heparin products has been reassuring, previous studies have considered birth defects as a single outcome or by larger organ system and have not examined associations with specific birth defects.

METHODS

We analyzed data from the National Birth Defects Prevention Study, a multisite, population-based case-control study from 1997 to 2011. We used unconditional logistic regression with Firth's penalized likelihood to calculate adjusted odds ratios (ORs) and profile likelihood 95% confidence intervals (CIs) for defects with at least five exposed cases. For defects with 3-4 exposed cases, we estimated crude ORs and exact 95% CIs.

RESULTS

Of the 42,743 women in our analysis, 117 (0.4%) case and 44 (0.4%) control mothers reported using a heparin product in early pregnancy. The adjusted ORs ranged from 0.9 to 3.9 and were elevated for anorectal atresia (OR = 2.0, 95% CI = 0.8-4.3), longitudinal limb deficiency (3.5, 1.3-7.8), transverse limb deficiency (1.8, 0.6-4.3), atrioventricular septal defect (3.9, 1.4-9.0), and secundum atrial septal defect (2.2, 1.2-3.8).

CONCLUSIONS

We observed elevated associations for some birth defects, although heparin is a rare exposure, which limited our ability to evaluate many associations. Future studies that can explore specific birth defects and adequately control for confounding by indication are needed. Given that women with an indication for heparin products during pregnancy often need to take medication, one must remain mindful of the underlying risk of a birth defect that exists regardless of medication use.

A Retrospective Assessment of Thrombophilia in Pregnant Women with First and Second Trimester Pregnancy Loss

Recurrent Pregnancy Loss (RPL) affects between 1% to 5% of women of reproductive age. It is widely believed that RPL is a complex disorder that is influenced by chromosomal abnormalities, genetic mutations, uterine anatomic deformity, endocrine dysfunction, immunologic factors, infections, and the environment. Thrombotic disorders are a frequent cause of RPL, accounting for almost half of all cases; however, in the rest of the cases, the cause of RPL remains unclear. Therefore, in this study, it was planned to determine the genetic mutations involved in RPL during the first and second trimester of pregnancy. An observational retrospective cohort study was conducted in 2021, collecting data from 157 first trimester miscarriages and 54 s trimester pregnancies. All patients with a panel of laboratory and genetic analysis for thrombophilia were included for data analysis. It was observed that four factors were significantly more prevalent in one of the groups. Factor V Leiden (FVL) homozygosity and antiphospholipid syndrome (APS) antibodies were statistically significantly more common in pregnant women who suffered first trimester pregnancy losses. On the other hand, Protein C deficiency and Glycoprotein Ia polymorphism were statistically significantly more frequent in the second trimester group. The strongest independent risk factors for first trimester pregnancy loss were FVL and prothrombin (PT) compound mutations (OR = 3.11), followed by FVL homozygous mutation (OR = 3.66), and APS antibodies (OR = 4.47). Regarding second trimester pregnancy loss risk factors, the strongest were FVL and PT compound (OR = 3.24), followed by Glycoprotein Ia polymorphism (OR = 3.61), and respectively, APS antibodies (OR = 3.85). Numerous thrombophilic risk factors for early and late pregnancy loss have been found, including several mutations that seem to occur more often either during the first or the second trimester. Even though we are aware of risk-free and efficient diagnostics for thrombophilia abnormalities, no intervention has been proved to be clearly successful after the detection of these variables.

Thrombophilia and Pregnancy

Leading cause of death in pregnant women still remains venous thromboembolism, with an incidence of 1.4 to 4.9 per 100,000 pregnancies. A special group of inherited and acquired coagulation disorders associated with a susceptibility to thrombosis is thrombophilia. Physiological changes during the pregnancy also contribute to the occurrence thromboembolic diseases (VTE) in pregnancy. Total rate of venous thromboembolism is 100 per 100,000 pregnancies and 200 per 100,000 births. Etiopathogenesis of obstetric complications in thrombophilia is not clearly defined, which is one of the reasons for the occasional failure of therapy. In pregnancies with hereditary thrombophilia the oxidative stress is considered to be a cause of complications, similar to preeclampsia. Based on the findings so far, additional research should clarify questions regarding the anticoagulants role in pregnancy loss prevention. In this paper, we analyze the effect of the screening on pregnancy outcomes, consider the justification for the use of anticoagulation therapy in difficult situations, discuss about previous knowledge in the field and argue the use of new specific protocols. In short, we address the justification for prescribing anticoagulants and evaluation of their effect within thrombophilia therapeutic strategies.

Frequency of Leiden Mutation in Newborns with Birth Weight below 1500 g

It has been hypothesized that fetal prematurity or Intrauterine Growth Restriction (IUGR) could be related to the presence of factor V of Leiden mutation. This mutation is associated with a higher incidence of pregnancy difficulties that can result in preterm birth. The frequency of Leiden mutation was investigated in the group of newborns with a low birth weight below 1500 g over a six-year period from 2015 to 2020. During this period, 339 newborns were tested, of which 42 newborns with V Leiden mutation (12.4%) were detected. The average of its occurrence frequency in the Czech population was determined as 5.0% based on published studies. In our research, the occurrence of the V Leiden mutation was found significantly higher in newborns under 1500 g. At the same time, we did not demonstrate an increased frequency of births at lower gestational weeks, lower birth weight, or an association with sex in newborns with a positive diagnosis of the Leiden V factor.

Detection of factor V G1691A, Prothrombin G20210A and Methylene tetra hydro folate reductase deficiency C677T Gene mutations among Sudanese Women with recurrent spontaneous abortion

The current study is a prospective analytical case control study designed to investigate the relationship between Factor V Leiden G1691A, methylenetetrahydrofolate reductase (MTHFR) C677T and to the prothrombin G20210A mutation variant and adverse pregnancy outcomes. Material and Method: The study included hundred Sudanese women who experienced three or more of the adverse pregnancy loss as case group during their reproductive in the Omdurman Maternity Hospital (Sudan) these compared with ninety-four control group healthy women with at least more than two normal pregnancies and without any history of adverse pregnancy outcome or recurrent miscarriages. The study group data collected using structure questionnaire which was used to collect information about age, parity, medical and obstetric history, smoking, family medical and obstetric history, residency and relative marriage. Blood samples were collected from participants and total genomic DNA was isolated from blood leukocytes and the frequency of these gene mutations in the patients and controls were determined using PCR-restriction fragment length. Results the mutation was detected in 8 out of 100 cases (8.0%) and in 6 out of 94 controls (6.4%) (P- Value > 0.05).

Nanomaterial-Based Label-Free Electrochemical Aptasensors for the Detection of Thrombin

Thrombin plays a central role in hemostasis and its imbalances in coagulation can lead to various pathologies. It is of clinical significance to develop a fast and accurate method for the quantitative detection of thrombin. Electrochemical aptasensors have the capability of combining the specific selectivity from aptamers with the extraordinary sensitivity from electrochemical techniques and thus have attracted considerable attention for the trace-level detection of thrombin. Nanomaterials and nanostructures can further enhance the performance of thrombin aptasensors to achieve high sensitivity, selectivity, and antifouling functions. In highlighting these material merits and their impacts on sensor performance, this paper reviews the most recent advances in label-free electrochemical aptasensors for thrombin detection, with an emphasis on nanomaterials and nanostructures utilized in sensor design and fabrication. The performance, advantages, and limitations of those aptasensors are summarized and compared according to their material structures and compositions.

Examination of in Factor V Leiden and Prothrombin II Thrombophilic Mutations in Czech Young Women Using ddPCR-Prevalence and Cost-Benefit Analysis

BACKGROUND

Thrombophilic mutations in genes for factor V Leiden and factor II prothrombin are among the most important risk factors for developing the thromboembolic disease (TED), along with the use of oral contraceptives (OCs) or smoking.

AIM

This study aimed to investigate the occurrence of risk factors in young women using droplet digital PCR (ddPCR) and, based on the results of this investigation, to perform a cost-benefit analysis of ddPCR-based screening in young women starting to take OCs compared to the treatment costs of patients who develop preventable TED in the Czech Republic.

METHODS

In this cross-sectional study, female university students filled in a questionnaire and provided a blood sample for DNA isolation and ddPCR analysis of both aforementioned genetic risk factors. The results, along with data from literature and web search, were used for cost-benefit analysis valid for the Czech Republic.

RESULTS

Out of 148 participants, 30 (20%) were smokers and 49 (33%) took OCs. A mutation was confirmed in 6 women (4.1%) in the factor V gene and in 3 women (2%) in the factor II gene, respectively. A model calculation on a cohort of 50,000 women starting to use contraceptives in the Czech Republic every year showed that at maximum compliance, (i.e., non-use of OC and smoking cessation), screening could prevent 68 cases of TED over the course of the mean period of OC use (5.7 years). Economically, the costs of testing in this cohort (2.25 mil. USD) would be significantly lower than prevented treatment costs (16 mil. USD at maximum compliance); the cost-benefit break-even point would be at 14.1% compliance.

CONCLUSION

The cost-benefit analysis based on our results indicates that screening for factor V Leiden and factor II prothrombin in young women before starting to use OCs would, in the conditions of the Czech Republic, likely be highly economically effective.

Placental Thrombus After Maternal COVID-19 Infection: A Case Study

A 34-year-old patient developed an area of thrombus within her placenta. This resulted in severe fetal growth restriction which physicians felt was due to contracting and recovering from the coronavirus disease (COVID-19), during her pregnancy. Serial sonograms demonstrated a slowing of fetal growth and an area of thrombosis within the placenta. This was confirmed by pathologic examination of the placenta after delivery. Since COVID-19 and pregnancy are both known hypercoagulable states, it is vital for the ultrasonographer to recognize thrombosis in the placenta. It is also important to understand the possible pregnancy outcomes, based on the location and appearance of a nonvascular placental lesion.

Factor V Leiden G1691A and Prothrombin Gene G20210A Mutations on Pregnancy Outcome

Factor V Leiden (FVL) G1619A mutation and prothrombin gene (PTG) G20210A are the most common inherited thrombophilias. They have been associated with various obstetric complications such as venous thromboembolism, recurrent pregnancy loss, preeclampsia, abruptio placentae, and small for gestational age fetus. The prevalence of these two mutations is 3-15% in Caucasians and is assumed to be far less common in other ethnic populations. However, there have been several controversies regarding advising routine screening of these thrombophilias because of a widely variable strength of association between different ethnic groups, as well as contradictory conclusions by different studies in regards to the association. In this study, the literature was analyzed thoroughly for the effect of FVL G1619A and PTG G20210A mutations on various obstetric outcomes. A review of multiple case-control and prospective studies suggests that despite the availability of robust data on this subject the results remain inconclusive and insubstantial. Further superior quality research, preferably prospective studies, is warranted to conclusively establish this relationship and to enable practitioners to follow a definitive protocol in the screening of various populations for these mutations to achieve an improved pregnancy outcome.

Management and Perspective of Coronavirus Disease 2019 (COVID-19), Pregnancy, and Hypercoagulability

The modern-day pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has spread rapidly. There is limited data about the effects of the virus on pregnant women, even in women who were infected by other strains of coronavirus such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). After reviewing numerous articles published in the peer-reviewed journals and other authentic sources, in this mini-review, we evaluated various key clinical and laboratory aspects of coronavirus disease 2019 (COVID-19) in relation to pregnancy. Eligibility criteria included the patient being pregnant upon admission to the hospital, clinically diagnosed, and/or laboratory-confirmed COVID-19. Taking a comprehensive approach by reviewing numerous studies, it is safe to say that there is no concrete evidence of intrauterine transmission. With adequate infection control measures, breastfeeding in neonates of mothers with COVID-19 is safe postpartum. A disruption of Virchow’s triad by COVID-19 and the normal physiologic changes of pregnancy put the expectant mothers at great risk of arterial, venous, and placental thrombus formation, which can be managed by antithrombotic and related pharmacologic agents including antiviral and anti-inflammatory drugs.

Pulmonary thromboembolism during pregnancy and puerperium: Comparison of survival and death cases

AIM

In Japan, the frequency of maternal deaths due to obstetric hemorrhage has been decreasing in the last decade, while that resulting from other causes such as pulmonary thromboembolism (PTE) was consistent. To help reduce maternal deaths due to PTE, we investigated PTE during pregnancy and puerperium and compared the survival and death cases, and aimed to find out life and death factors.

METHODS

This study was a retrospective analysis based on a clinical chart review in 407 maternal and perinatal centers. We compared the survival and death cases of PTE during pregnancy and puerperium from 2013 to 2017.

RESULTS

In PTE during pregnancy, the survival cases underwent significantly earlier diagnoses than the death cases, and thromboprophylaxis was performed in most of both the survival and death cases of PTE during puerperium according to the existing Japanese guidelines; however, only one fourth of the total cases underwent anticoagulation to prevent venous thromboembolism (VTE).

CONCLUSIONS

Early diagnosis of PTE in suspected cases was associated with better survival during pregnancy.

Pregnancy-Associated Myocardial Infarction: Prevalence, Causes, and Interventional Management

Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.

Valvular Heart Disease in Pregnancy: Anticoagulation and the Role of Percutaneous Treatment

Valvular heart disease is present in about 1% of pregnancies, and it poses a management challenge as both fetal and maternal lives are at risk of complications. Pregnancy is associated with significant hemodynamic changes, which can compromise the cardiac status in women with underlying valvular disorders. Management of valvular heart diseases has undergone considerable innovation and advancement with newer techniques, approaches and devices being employed. The decision regarding the management of anticoagulation, especially in patients with prosthetic valves, raises distinct questions and challenges. In this review, we describe the management of common valvular heart diseases encountered during pregnancy, role of percutaneous catheter based therapeutic interventions, the importance of a team-based approach, and the challenges given existing gaps in the literature.

Advances in the Diagnosis of Venous Thromboembolism: A Literature Review

The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.

Management of reproductive health in patients with pulmonary hypertension

Pulmonary hypertension is characterized by elevated pulmonary artery pressure caused by several clinical conditions that affect pulmonary vasculature. Morbidity and death in this condition are related to the development of right ventricular failure. Normal physiologic changes that occur in pregnancy to support the growing fetus can pose hemodynamic challenges to the pregnant patient with pulmonary hypertension that results in increased morbidity and mortality rates. Current guidelines recommend that patients with known pulmonary hypertension be counseled against pregnancy. This review aims to provide clinicians with guidelines for preconception counseling, medication management, and delivery planning.

Aspirin, low molecular weight heparin, or both in preventing pregnancy complications in women with recurrent pregnancy loss and factor V Leiden mutation

Objective: The aim of this study was to compare the effects of low molecular weight heparin (LMWH), LMWH plus low dose aspirin, or low dose aspirin only on pregnancy outcomes in recurrent pregnancy loss (RPL) patients with factor V Leiden mutation (FVLM).Materials and methods: A total of 2764 RPL patients were evaluated in for the etiology of RPL. Mutations in factor V Leiden homozygous and heterozygous were determined. Subsequently, 196 of these patients were diagnosed with FVLM and included in the study; of these 174 completed the study. At the sixth week of gestation of subsequent pregnancy participants were randomly distributed into three groups. Group A (n = 61) was composed of patients with an oral dose of 100 mg aspirin daily, Group B (n = 59) consisted of patients using 40 mg enoxaparin and 100 mg orally aspirin daily, and Group C (n = 54) included patients using 40 mg enoxaparin daily during pregnancy.Results: Among the 174 patients who completed the study, the live birth and miscarriage rates were similar for the three groups (p = .843 and p = .694, respectively). There was no significant difference among the groups in rates of eclampsia, placental abruption, intrauterine fetal growth restriction and gestational diabetes mellitus. The number of preeclamptic patients was significantly higher in Group A than Groups B and C. The levels of preterm birth was significantly higher in Group A than Groups B and C.Conclusion: Using low dose aspirin, LMWH plus aspirin, or LMWH alone yielded comparable live birth rates in RPL patients with FVLM. However, LMWH decreased the risk of preeclampsia in this group of patients. LMWH might therefore have a preventive role regarding preeclampsia.

C-Reactive Protein Predicts Risk of Venous Thromboembolism in Pediatric Musculoskeletal Infection

BACKGROUND

The rate of venous thromboembolism in children with musculoskeletal infections (MSKIs) is markedly elevated compared with hospitalized children in general. Predictive biomarkers to identify high-risk patients are needed to prevent the significant morbidity and rare mortality associated with thrombotic complications. We hypothesize that overactivation of the acute phase response is associated with the development of pathologic thrombi and we aim to determine whether elevations in C-reactive protein (CRP) are associated with increased rates of thrombosis in pediatric patients with MSKI.

METHODS

A retrospective cohort study measuring CRP in pediatric MSKI patients with or without thrombotic complications.

RESULTS

The magnitude and duration of elevation in CRP values correlated with the severity of infection and the development of pathologic thrombosis. In multivariable logistic regression, every 20 mg/L increase in peak CRP was associated with a 29% increased risk of thrombosis (P<0.001). Peak and total CRP were strong predictors of thrombosis with area under the receiver-operator curves of 0.90 and 0.92, respectively.

CONCLUSIONS

Future prospective studies are warranted to further define the discriminatory power of CRP in predicting infection-provoked thrombosis. Pharmacologic prophylaxis and increased surveillance should be strongly considered in patients with MSKI, particularly those with disseminated disease and marked elevation of CRP.

LEVEL OF EVIDENCE

Level III.

Thrombophilia: Women-Specific Reference Ranges Can Prevent Misdiagnosis in Women

BACKGROUND

Thrombophilia is a state where abnormalities of the hemostatic system predispose a patient to thrombosis. Some coagulation factors are generally lower in women than in men. Therefore, the use of routine reference ranges (RRRs) based on male or mixed-sex groups may be misleading in the diagnosis of thrombophilia in women. We hypothesize that this affects the analysis of thrombophilia after pregnancy complications. Therefore, the aim of our study was to investigate the effect of women-specific reference ranges (WRRs) on the interpretation of hemostatic variables in postpartum women.

METHODS

Coagulant and anticoagulant variables were measured 3 months postpartum in 61 healthy women with an uncomplicated pregnancy and in 197 women who experienced preeclampsia (PE). In 55 of the healthy women, these variables were also measured at least 6 months after an uncomplicated pregnancy and used to calculate WRR.

RESULTS

In total, 48% of healthy women had normal results when using routine reference ranges compared with 89% when using WRRs (P < 0.05). In the women with PE, there were normal results in 26% of women when using routine reference ranges compared with 66% when using WRRs (P < 0.05).

CONCLUSION

When using WRRs, fewer abnormalities were seen in healthy women as well as in women with a history of PE, which may prevent misdiagnosis of thrombophilia.

Portal vein thrombosis after cesarean section in a patient on prolonged bed rest due to threatened preterm labor

Portal vein thrombosis is a rare but life-threatening complication during pregnancy and postpartum period. Color Doppler ultrasound is useful for prompt diagnosis. Although the risk of complications should be considered, successful pregnancy with comorbid portal vein thrombosis is possible with appropriate anticoagulation therapy and close monitoring.

Mesenteric vein thrombosis following impregnation via in vitro fertilization-embryo transfer

Pregnancy is an acquired hypercoagulable state. Most patients with thrombosis that develops during pregnancy present with deep vein leg thrombosis and/or pulmonary embolism, whereas the development of mesenteric vein thrombosis (MVT) in pregnant patients is rare. We report a case of MVT in a 34-year-old woman who had achieved pregnancy via in vitro fertilization-embryo transfer (IVF-ET). At 7 wk of gestation, the patient was referred to us due to abdominal pain accompanied by vomiting and hematochezia, and she was diagnosed with superior MVT. Following resection of the gangrenous portion of the small intestine, anticoagulation therapy with unfractionated heparin and thrombolysis therapy via a catheter placed in the superior mesenteric artery were performed, and the patient underwent an artificial abortion. Oral estrogen had been administered for hormone replacement as part of the IVF-ET procedure, and additional precipitating factors related to thrombosis were not found. Pregnancy itself, in addition to the administered estrogen, may have caused MVT in this case. We believe that MVT should be included in the differential diagnosis of a pregnant patient who presents with an acute abdomen.

Low-molecular-weight-heparin can benefit women with recurrent pregnancy loss and sole protein S deficiency: a historical control cohort study from Taiwan

BACKGROUND

Heritable thrombophilias are assumed important etiologies for recurrent pregnancy loss. Unlike in the Caucasian populations, protein S and protein C deficiencies, instead of Factor V Lieden and Prothrombin mutations, are relatively common in the Han Chinese population. In this study we aimed to investigate the therapeutic effect of low molecular weight heparin upon women with recurrent pregnancy loss and documented protein S deficiency.

METHODS

During 2011-2016, 68 women with recurrent pregnancy loss (RPL) and protein S deficiency (both the free antigen and function of protein S were reduced) were initially enrolled. All the women must have experienced at least three recurrent miscarriages. After excluding those carrying balanced translocation, medical condition such as diabetes mellitus, chronic hypertension, and autoimmune disorders (including systemic lupus erythematosus and anti-phospholipid syndrome), coexisting thrombophilias other than persistent protein S deficiency (including transient low protein S level, protein C deficiency, and antithrombin III), only 51 women with RPL and sole protein S deficiency were enrolled. Initially they were prescribed low dose Aspirin (ASA: 100 mg/day) and unfortunately there were still 39 women ended up again with early pregnancy loss (12 livebirths were achieved though). Low-molecular-weight-heparin (LMWH) was given for the 39 women in a dose of 1 mg/Kg every 12 h from the day when the next clinical pregnancy was confirmed to the timing at least 24 h before delivery. The perinatal outcomes were assessed.

RESULTS

Of 50 treatment subjects performed for the 39 women (i.e. 11 women enrolled twice for two pregnancies), 46 singletons and one twin achieved livebirths. The successful live-birth rate in the whole series was 94 % (47/50). Nineteen livebirths delivered vaginally whereas 28 delivered by cesarean section. The cesarean delivery rate is thus 59.57 %. Emergent deliveries occurred in 3 but no postpartum hemorrhage had been noted.

CONCLUSIONS

Our pilot study in Taiwan, an East Asian population, indicated anti-coagulation therapy is of benefit to women with recurrent pregnancy loss who had documented sole protein S deficiency.

TRIAL REGISTRATION

ISRCTN64574169. Retrospectively registered 29 Jun 2016.

The Role of Anticoagulants in the Prevention of Pregnancy Complications

The role of anticoagulants in the prevention of pregnancy complications, including recurrent miscarriage, late fetal loss, and preeclampsia, continues to be an area of active research and debate. Although prophylactic anticoagulation with heparin and aspirin is considered the standard of care in some conditions, such as obstetric antiphospholipid antibody syndrome, the optimal management of pregnant women with factor V Leiden mutation, prothrombin G20210A mutation, and other inherited thrombophilias without a history of thrombosis remains unknown. Some studies suggest a benefit of heparins in preventing late-term losses but not earlier miscarriages in the inherited thrombophilias. In the following review, we will discuss the recent literature regarding anticoagulation and pregnancy complications and conclude with our suggested approach to the management of these challenging patients.

Prevalence and role of antithrombin III, protein C and protein S deficiencies and activated protein C resistance in Kosovo women with recurrent pregnancy loss during the first trimester of pregnancy

CONTEXT

Several studies have reported that thrombophilia is responsible for recurrent pregnancy loss (RPL).

AIMS

The aim of this study was to evaluate the prevalence and role of inherited thrombophilia in early pregnancy loss, specifically in the first trimester.

MATERIALS AND METHODS

A total of 104 women (patients) with a history of two or more miscarriages during the first trimester of pregnancy and 110 women (controls) who had experienced two or more births without a miscarriage were included in this study. In both groups, we determined the biological activities of antithrombin III (ATIII) and protein C (PC) using the chromogenic method and the biological activity of protein S (PS) and the activated protein C resistance (APCR) were examined using a clotting method.

RESULTS

In the patient group, deficiencies of ATIII, PC, and PS were detected in 3 (2.88%), 4 (3.85%), and 6 (5.77%) cases, respectively. In the control group, ATIII (0%) deficiencies were not detected, and deficiencies for PC (0.9%) and PS (0.9%) were each detected in 1 patient. APCR was detected in 9 patients (8.65%) and 4 control subjects (3.63%).

CONCLUSION

Based on our results, we can conclude that thrombophilia is a causal factor for miscarriages in the first trimester of pregnancy, although there are the conflicting data in the literature.

A Dormant Microbial Component in the Development of Preeclampsia

Preeclampsia (PE) is a complex, multisystem disorder that remains a leading cause of morbidity and mortality in pregnancy. Four main classes of dysregulation accompany PE and are widely considered to contribute to its severity. These are abnormal trophoblast invasion of the placenta, anti-angiogenic responses, oxidative stress, and inflammation. What is lacking, however, is an explanation of how these themselves are caused. We here develop the unifying idea, and the considerable evidence for it, that the originating cause of PE (and of the four classes of dysregulation) is, in fact, microbial infection, that most such microbes are dormant and hence resist detection by conventional (replication-dependent) microbiology, and that by occasional resuscitation and growth it is they that are responsible for all the observable sequelae, including the continuing, chronic inflammation. In particular, bacterial products such as lipopolysaccharide (LPS), also known as endotoxin, are well known as highly inflammagenic and stimulate an innate (and possibly trained) immune response that exacerbates the inflammation further. The known need of microbes for free iron can explain the iron dysregulation that accompanies PE. We describe the main routes of infection (gut, oral, and urinary tract infection) and the regularly observed presence of microbes in placental and other tissues in PE. Every known proteomic biomarker of "preeclampsia" that we assessed has, in fact, also been shown to be raised in response to infection. An infectious component to PE fulfills the Bradford Hill criteria for ascribing a disease to an environmental cause and suggests a number of treatments, some of which have, in fact, been shown to be successful. PE was classically referred to as endotoxemia or toxemia of pregnancy, and it is ironic that it seems that LPS and other microbial endotoxins really are involved. Overall, the recognition of an infectious component in the etiology of PE mirrors that for ulcers and other diseases that were previously considered to lack one.

Increase in maternal death-related venous thromboembolism during pregnancy in Japan (2010-2013)

BACKGROUND

The aim of the present work was to understand the current circumstances of maternal-death-related venous thromboembolism (MD-VTE) in Japan. We retrospectively investigated the characteristics of cases of MD-VTE, and compared past and present rates of occurrence.

METHODS AND RESULTS

We examined the Japanese data for MD-VTE in 2010-2013, and compared it with that from 1991-1992. MD-VTE occurred in 17 women in 1991-1992, and in 13 women in 2010-2013. The maternal mortality ratio of MD-VTE was 0.7 per 100,000 in 1991-1992 and 0.4 per 100,000 in 2010-2013. Both the maternal mortality ratio and rate of MD-VTE in 2010-2013 deceased significantly compared with 1991-1992 (P<0.05). However, the number of cases of MD-VTE during pregnancy was 6 among 13 women (41%) in 2010-2013, but 1 in 17 women (6%) in 1991-1992, showing an increase (P<0.05). In the present study, cesarean delivery was more frequently associated with MD-VTE.

CONCLUSIONS

MD-VTE overall has decreased within the past 20 years in Japan. But, MD-VTE during pregnancy in 2010-2013 increased relative to 1991-1992. Future guidelines for prevention of VTE may need to extend beyond the perioperative period to decrease the incidence of MD-VTE.