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Singh KK, Gupta A, Forstner D, Guettler J, Ahrens MS, Prakasan Sheeja A, Fatima S, Shamkeeva S, Lia M, Dathan-Stumpf A, Hoffmann N, Shahzad K, Stepan H, Gauster M, Isermann B, Kohli S. LMWH prevents thromboinflammation in the placenta via HBEGF-AKT signaling. Blood Adv 2024; 8:4756-4766. [PMID: 38941535 PMCID: PMC11457404 DOI: 10.1182/bloodadvances.2023011895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 05/24/2024] [Accepted: 06/20/2024] [Indexed: 06/30/2024] Open
Abstract
ABSTRACT Low molecular weight heparins (LMWH) are used to prevent or treat thromboembolic events during pregnancy. Although studies suggest an overall protective effect of LMWH in preeclampsia (PE), their use in PE remains controversial. LMWH may convey beneficial effects in PE independent of their anticoagulant activity, possibly by inhibiting inflammation. Here, we evaluated whether LMWH inhibit placental thromboinflammation and trophoblast NLRP3 inflammasome activation. Using an established procoagulant extracellular vesicle-induced and platelet-dependent PE-like mouse model, we show that LMWH reduces pregnancy loss and trophoblast inflammasome activation, restores altered trophoblast differentiation, and improves trophoblast proliferation in vivo and in vitro. Moreover, LMWH inhibits platelet-independent trophoblast NLRP3 (NLR family pyrin domain containing 3) inflammasome activation. Mechanistically, LMWH activates via heparin-binding epidermal growth factor (HBEGF) signaling the PI3-kinase-AKT pathway in trophoblasts, thus preventing inflammasome activation. In human PE placental explants, inflammasome activation and PI3-kinase-AKT signaling events were reduced with LMWH treatment compared with those without LMWH treatment. Thus, LMWH inhibits sterile inflammation via the HBEGF signaling pathway in trophoblasts and ameliorates PE-associated complications. These findings suggest that drugs targeting the inflammasome may be evaluated in PE and identify a signaling mechanism through which LMWH ameliorates PE, thus providing a rationale for the use of LMWH in PE.
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Affiliation(s)
- Kunal Kumar Singh
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostics, University Hospital Leipzig, Leipzig University, Leipzig, Germany
| | - Anubhuti Gupta
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostics, University Hospital Leipzig, Leipzig University, Leipzig, Germany
| | - Désirée Forstner
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Jacqueline Guettler
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Mirjam Susanne Ahrens
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostics, University Hospital Leipzig, Leipzig University, Leipzig, Germany
| | - Akshay Prakasan Sheeja
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostics, University Hospital Leipzig, Leipzig University, Leipzig, Germany
| | - Sameen Fatima
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostics, University Hospital Leipzig, Leipzig University, Leipzig, Germany
| | - Saikal Shamkeeva
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostics, University Hospital Leipzig, Leipzig University, Leipzig, Germany
| | - Massimiliano Lia
- Department of Obstetrics, University of Leipzig Medical Center, Leipzig, Germany
| | - Anne Dathan-Stumpf
- Department of Obstetrics, University of Leipzig Medical Center, Leipzig, Germany
| | - Nikola Hoffmann
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostics, University Hospital Leipzig, Leipzig University, Leipzig, Germany
| | - Khurrum Shahzad
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostics, University Hospital Leipzig, Leipzig University, Leipzig, Germany
| | - Holger Stepan
- Department of Obstetrics, University of Leipzig Medical Center, Leipzig, Germany
| | - Martin Gauster
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Berend Isermann
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostics, University Hospital Leipzig, Leipzig University, Leipzig, Germany
| | - Shrey Kohli
- Institute of Laboratory Medicine, Clinical Chemistry, and Molecular Diagnostics, University Hospital Leipzig, Leipzig University, Leipzig, Germany
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Benefits and risks of low molecular weight heparin use on reproductive outcomes: A retrospective cohort study. Taiwan J Obstet Gynecol 2022; 61:812-817. [PMID: 36088049 DOI: 10.1016/j.tjog.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Low molecular weight heparin (LMWH) has been given to reproductive-age women with various indications. This study aims to assess the benefits and risks of such use. MATERIALS AND METHODS We retrospectively reviewed data (n = 204) between Jan 2016 and May 2019. Logistic regression analysis was conducted to evaluate the correlation between indications and reproductive outcomes. RESULTS LMWH use had higher odds of live birth in women less than 30 years of age (OR: 4.98; 95% CI = 1.13-21.98; p = 0.034) and with protein S deficiency (OR: 3.90; 95% CI = 1.77-8.59; p = 0.001). For the subgroup of recurrent pregnant loss, LMWH use was only advantageous to women with protein S deficiency (OR: 2.45; 95%:1.01-5.97; p = 0.048). Risks such as preterm delivery, small-for-gestational-age, placental abruption, antepartum/postpartum hemorrhage were not significantly increased among subgroups. Women treated with LMWH and who had successful live births (n = 171) had a slightly increased risk of postpartum hemorrhage compared to controls (n = 8058) during this period in our institution (2.9% vs 1.2%, p < 0.001). CONCLUSION LMWH administration produces a higher chance of live-birth to women younger than 30 years of age or with protein S deficiency. However, risk of postpartum hemorrhage is increased.
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Romero-Gonzalez B, Caparros-Gonzalez RA, Cruz-Martinez M, Gonzalez-Perez R, Gallego-Burgos JC, Peralta-Ramirez MI. Neurodevelopment of high and low-risk pregnancy babies at 6 months of age. Midwifery 2020; 89:102791. [PMID: 32645601 DOI: 10.1016/j.midw.2020.102791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 06/06/2020] [Accepted: 07/04/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE to compare neurodevelopment differences between babies born from low-risk pregnancies and babies born from high-risk pregnancies. STUDY DESIGN Longitudinal design SETTING: Spain PARTICIPANTS: A total of 91 women participated in the study, divided into two groups: 49 women in the low-risk pregnancy group and 42 women in the high-risk group. MEASUREMENT AND FINDINGS The average amount of cortisol in pregnant mothers' hair was determined in both groups. Following their birth, the babies' neurodevelopment was evaluated using the Bayley-III instrument at 6 months of age and a new sample of cortisol was obtained from both the baby and the mother. The results showed that pregnancy risk group could predict cognitive, fine motor, gross motor and general motor neurodevelopment. KEY CONCLUSIONS These results seem to show that an appropriate treatment tailored to the needs of individualised pregnancies may favor babies' neurodevelopment, including that of babies born from high-risk pregnancies. IMPLICATIONS FOR RESEARCH It is essential to take special care of pregnant women no matter their medical condition and offer them the best medical care available.
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Affiliation(s)
- Borja Romero-Gonzalez
- Mind, Brain and Behaviour Centre (CIMCYC). Faculty of Psychology, University of Granada, Granada, Spain; Personality, Assessment and Psychological Treatment Department, Faculty of Psychology, University of Granada, Granada, Spain
| | | | - Milagros Cruz-Martinez
- Obstetrics and Gynaecology Department, University Hospital San Cecilio, Granada, Granada, Spain
| | - Raquel Gonzalez-Perez
- Department of Pharmacology, CIBERehd, Faculty of Pharmacy, University of Granada, Granada, Spain
| | | | - Maria Isabel Peralta-Ramirez
- Personality, Assessment and Psychological Treatment Department, Faculty of Psychology, University of Granada, Granada, Spain
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Sucker C. Prophylaxis and Therapy of Venous Thrombotic Events (VTE) in Pregnancy and the Postpartum Period. Geburtshilfe Frauenheilkd 2020; 80:48-59. [PMID: 31949319 PMCID: PMC6957355 DOI: 10.1055/a-1030-4546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 08/21/2019] [Accepted: 10/17/2019] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolisms and pulmonary embolisms are one of the main causes of morbidity and mortality in pregnancy. The increased risk of thrombotic events caused by the physiological changes during pregnancy alone does not justify any medical antithrombotic prophylaxis. However, if there are also other risk factors such as a history of thromboses, hormonal stimulation as part of fertility treatment, thrombophilia, increased age of the pregnant woman, severe obesity or predisposing concomitant illnesses, the risk of thrombosis should be re-evaluated - if possible by a coagulation specialist - and drug prophylaxis should be initiated, where applicable. Low-molecular-weight heparins (LMWH) are the standard medication for the prophylaxis and treatment of thrombotic events in pregnancy and the postpartum period. Medical thrombosis prophylaxis started during pregnancy is generally continued for about six weeks following delivery due to the risk of thrombosis which peaks during the postpartum period. The same applies to therapeutic anticoagulation after the occurrence of a thrombotic event in pregnancy; here, a minimum duration of the therapy of three months should also be adhered to. During breastfeeding, LMWH or the oral anticoagulant warfarin can be considered; neither active substance passes into breast milk.
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Lafalla O, Esteban LM, Lou AC, Cornudella R, Domínguez M, Sanz G, Borque-Fernando Á. Clinical utility of thrombophilia, anticoagulant treatment, and maternal variables as predictors of placenta-mediated pregnancy complications: an extensive analysis. J Matern Fetal Neonatal Med 2019; 34:588-598. [PMID: 31018724 DOI: 10.1080/14767058.2019.1611764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: The objective of this study is to analyze the usefulness of thrombophilia and antithrombotic drugs in combination with materno-fetal characteristics to generate a predictive model of placenta-mediated pregnancy complications (PMPC) for counseling treatment.Methods: A retrospective analysis was performed in women with singleton pregnancy that required a thrombophilia study, including 222 patients with unknown cause PMPC and 151 women with no complications at current pregnancy in Hospital Clínico Universitario, Lozano, Blesa, Zaragoza, Spain. Chi-squared and Mann-Whitney test were applied to analyze univariate risk factors. Multivariate analysis was performed using logistic regression model with candidate variables: maternal characteristics, obstetric history, thrombophilia, and treatment with low-molecular-weight heparin (LMWH) and/or with acid acetylsalicylic (ASA). The calibration, discrimination, and best cutoff point for the clinical application of the model was analyzed.Results: Maternal characteristics showed differences in median body mass index (BMI), odds ratio (OR): 0.4, smoking habit, OR: 8.5, and hypertension, OR: 11.4, appearing all of them as risk factors. In our study, a prior pregnancy that ended in a child alive was a protective factor OR: 0.02-0.4, and having a previous preterm child was a strong risk factor OR: 4.2. Thrombophilia was not a risk factor. Patients under LMWH treatment (15%) and/or ASA (6.2%) had better pregnancy outcomes, showing both as protective factors: ASA OR: 0.32 and LMWH OR: 0.16. The model has an AUC value of 0.847, with good calibration. A nomogram and an app is provided for this adjusted model with high discrimination ability in internal validation (AUC = 0.833). Our clinical utility analysis guide us to choose 40% as the best threshold probability.Conclusions: We found risk and protective factors associated with PMPC, but our data were not conclusive to demonstrate its relation with maternal thrombophilia. However, the challenger finding is the clinical utility of antithrombotic drugs as a protective factors in PMPC prevention. It is possible to identify patients with high risk of PMPC through a combined predictive model, for counseling treatment.
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Affiliation(s)
- Olivia Lafalla
- Department of Obstetrics and Gynecology, Hospital General San Jorge, Huesca, Spain
| | | | - Ana Cristina Lou
- Department of Obstetrics and Gynecology, Hospital Clínico Universitario Lozano Blesa-IIS Aragón, Zaragoza, Spain
| | - Rosa Cornudella
- Department of Haemathology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Manuel Domínguez
- Unit of Gastroenterology and Hepathology, Hospital General San Jorge, Huesca, Spain
| | - Gerardo Sanz
- Department of Statistical methods, Universidad de Zaragoza, Zaragoza, Spain
| | - Ángel Borque-Fernando
- Department of Urology, Hospital Universitario Miguel Servet-IIS Aragón, Zaragoza, Spain
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Ferreira CM, Figueiró-Filho EA, Oliveira VMD, Pereira ÉFDV. Thromboprophylaxis and maternal-fetal outcomes of women with serum markers for hereditary thrombophilia and previous obstetric complications. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2017. [DOI: 10.1590/1806-93042017000400005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abstract Objectives: to evaluate the maternalfetal outcomes of thromboprophylaxis with enoxa parin based on scoring system in women with serum markers for hereditary thrombophilia and previous obstetric complications. Methods: a retrospective study was undertaken based on data collected from clinical records. We included 54 pregnant women with serum markers for hereditary thrombophilia undergoing therapeutic intervention with enoxaparin in the period from November 2009 to December 2013. The initial dose of low molecular weight heparin was guided by a scoring system. The maternalfetal outcomes of previous pregnancies and, subsequently, the treatment were compared using the chisquare (χ2) test with the Yates correction and Fisher's Exact Test; p<0.05 was considered significant. Results: we observed significant reduction in fetal/perinatal deaths (p<0.05) and spontaneous abortions (p<0.001) after intervention. The live births at fullterm delivery (p<0.001) and live births at preterm delivery (p<0.05) increased significantly after intervention. Conclusions: the therapeutic intervention with enoxaparin based on scoring system during pregnancy seems to improve the fetal prognosis.
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Eliassen E, Marci R, Di Luca D, Rizzo R. The use of heparin in infertility and recurrent pregnancy loss: Are its antiviral properties at play? Med Hypotheses 2017; 102:41-47. [DOI: 10.1016/j.mehy.2017.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 03/05/2017] [Indexed: 12/31/2022]
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Abheiden CNH, Blomjous BS, Kroese SJ, Bultink IEM, Fritsch-Stork RDE, Lely AT, de Boer MA, de Vries JIP. Low-molecular-weight heparin and aspirin use in relation to pregnancy outcome in women with systemic lupus erythematosus and antiphospholipid syndrome: A cohort study. Hypertens Pregnancy 2016; 36:8-15. [PMID: 27599157 DOI: 10.1080/10641955.2016.1217337] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To relate anticoagulant use to pregnancy complications in women with systemic lupus erythematosus (SLE) and primary antiphospholipid syndrome (APS). METHODS All ongoing pregnancies, 184, in two Dutch tertiary centers between 2000 and 2015. RESULTS LMWH and aspirin was prescribed in 15/109 SLE women without antiphospholipid antibodies (aPL), 5/14 with aPL, 11/13 with APS, 45/48 with primary APS. Main complications in the four treatment groups (no anticoagulant treatment, aspirin, LMWH, aspirin and LMWH) included hypertensive disorders of pregnancy (9.4%, 23.3%, 50%, 18.4%, respectively, p = 0.12) and preterm birth (16.7%, 34.3%, 75%, 36.8%, respectively, p < 0.001). CONCLUSION Maternal and perinatal complications occurred frequently, despite LMWH and aspirin use.
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Affiliation(s)
- Carolien N H Abheiden
- a Department of Obstetrics and Gynaecology , VU University Medical Center , Amsterdam , The Netherlands
| | - Birgit S Blomjous
- a Department of Obstetrics and Gynaecology , VU University Medical Center , Amsterdam , The Netherlands.,b Department of Rheumatology , Amsterdam Rheumatology and Immunology Center, VU University Medical Center , Amsterdam , The Netherlands
| | - Sylvia J Kroese
- c Department of Rheumatology , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Irene E M Bultink
- b Department of Rheumatology , Amsterdam Rheumatology and Immunology Center, VU University Medical Center , Amsterdam , The Netherlands
| | - Ruth D E Fritsch-Stork
- c Department of Rheumatology , University Medical Center Utrecht , Utrecht , The Netherlands
| | - A Titia Lely
- d Department of Obstetrics and Gynaecology , University Medical Center Utrecht , Utrecht , The Netherlands
| | - Marjon A de Boer
- a Department of Obstetrics and Gynaecology , VU University Medical Center , Amsterdam , The Netherlands
| | - Johanna I P de Vries
- a Department of Obstetrics and Gynaecology , VU University Medical Center , Amsterdam , The Netherlands
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Duffett L, Rodger M. LMWH to prevent placenta-mediated pregnancy complications: an update. Br J Haematol 2014; 168:619-38. [DOI: 10.1111/bjh.13209] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Lisa Duffett
- Thrombosis Program; Division of Hematology; Department of Medicine; University of Ottawa; Ottawa ON Canada
| | - Marc Rodger
- Thrombosis Program; Division of Hematology; Department of Medicine; University of Ottawa; Ottawa ON Canada
- Clinical Epidemiology Program; The Ottawa Hospital Research Institute; Ottawa ON Canada
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Rath W, Thaler CJ. [Hereditary thrombophilias and placental-mediated pregnancy complications in the II./III. trimester]. Hamostaseologie 2013; 33:21-36. [PMID: 23392307 DOI: 10.5482/hamo-12-11-0020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 01/18/2013] [Indexed: 11/05/2022] Open
Abstract
UNLABELLED Placental-mediated pregnancy complications (PmC) like preeclampsia, intrauterine growth restriction and placental abruption are common causes of fetal and maternal morbidity and mortality. The high prevalence of hereditary thrombophilias in case-control studies associated with pathological morphological findings of the placenta in these cases gave evidence for the association between hereditary thrombophilias and PmC. However, data from the literature are inconsistent, since subsequent prospective cohort studies could not demonstrate significant associations between inherited thrombophilia and PmC. Because of the multifactorial aetiology of PmC it may be difficult to prove, that hereditary thrombophilias are independent risk factors for PmC. Current guidelines do not recommend screening for inherited thrombophilias in patients with previous PmC. Evidence from current in vitro studies have shown, that heparin has beneficial non-anticoagulatory effects on trophoblast invasion. Retrospective case-control studies and recently published randomised controlled cohort studies have shown, that prophylactic administration of low-molecular-weight heparin (LWH), started in early pregnancy, may lead to a significant reduction in the incidence of PmC in subsequent pregnancies in patients with and without hereditary thrombophilias and previous PmC. CONCLUSION Large, well-designed multicenter studies are needed to elucidate the role of hereditary thrombophilias in cases of PmC and to confirm the benefit of LWH for subsequent pregnancy outcomes.
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Affiliation(s)
- W Rath
- Gynäkologie und Geburtshilfe, Medizinische Fakultät, Universitätsklinikum, Wendlingweg 2, 52074 Aachen.
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Nauheimer D. Medikamente in der Schwangerschaft – Welche Substanzen eignen sich im Akutfall? ACTA ACUST UNITED AC 2012. [DOI: 10.1055/s-0032-1330932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
ZusammenfassungEine Vielzahl an Medikamenten passiert leicht die Plazenta und stellt während der Schwangerschaft wie auch peripartal ein potenzielles Risiko für Fetus oder Neugeborenen dar. Trotz aller Zurückhaltung lässt es sich nicht immer vermeiden, während der Schwangerschaft Medikamente zu verordnen. Häufig notwendig wird dies im Rahmen von ungeplanten Krankenhausaufenthalten oder zur Geburtshilfe. Neben den geburtshilflichen Eingriffen stellen sich jedes Jahr etwa 0.5–2% der Schwangeren zu nichtgynäkologischen Eingriffen in der Klinik vor. Daher ist das Wissen um die mütterlichen physiologischen Veränderungen während der Schwangerschaft sowie um mögliche negative Einflüsse häufig verwendeter Medikamente im klinischen Alltag auf Mutter und Fetus von besonderer Bedeutung. Dieser Beitrag beschäftigt sich mit den physiologischen Veränderungen in der Schwangerschaft und den Auswirkungen verschiedener Substanzen mit dem Ziel, die Anwendung im akuten Anwendungsbereich für Mutter und Fetus so sicher wie möglich zu gestalten.
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Is thrombophilia a risk factor for placenta-mediated pregnancy complications? Arch Gynecol Obstet 2012; 286:585-9. [DOI: 10.1007/s00404-012-2342-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 04/16/2012] [Indexed: 10/28/2022]
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