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Hilali C, Aboulaghras S, Lamalmi N. Pathophysiological, immunogenetic, anatomopathological profile of thrombophilia in pregnancy. Transfus Clin Biol 2023:S1246-7820(23)00043-5. [PMID: 37028589 DOI: 10.1016/j.tracli.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/24/2023] [Accepted: 03/31/2023] [Indexed: 04/08/2023]
Abstract
Thrombophilic states have been associated with early and/or late pregnancy loss and possibly other severe obstetrical complications. Pregnancy-induced hypercoagulability, increased stasis, and the consequences of inherited and acquired thrombophilia are just a few of the factors that contribute to the development of thrombosis in pregnancy. In this review, we illustrate the impact that these factors have on the development of thrombophilia during pregnancy. We also explore how thrombophilia impact pregnancy outcomes. Next, we discuss how human leukocyte antigen G plays a part in thrombophilia during pregnancy by regulating cytokine release to prevent trophoblastic cell invasion and maintain local immunotolerance constant. Human leukocyte antigen class E is briefly explored with thrombophilia in pregnancy. Regarding the anatomopathologic aspect, we describe the different histopathological lesions of the placenta found in women with thrombophilia.
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Redox status of pregnant women with thrombophilia. VOJNOSANIT PREGL 2022. [DOI: 10.2298/vsp200908001d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background/Aim. Since the role of oxidative stress in the pathogenesis of thrombophilia in pregnancy has still not been clarified, the aim of the study was to assess the redox status of pregnant women with thrombophilia. Methods. The study involved 120 pregnant women divided into two groups: pregnant women with thrombophilia (n = 60) and women with normal pregnancy (n = 60). Blood samples for biochemical analysis were collected at the end of the first, second, and third trimester of pregnancy. Concentrations of hydrogen peroxide (H2O2), nitrites (NO2-), and the index of lipid peroxidation measured as thiobarbituric acid reactive substances (TBARS) were measured in plasma. Levels of reduced glutathione (GSH), activities of superoxide dismutase (SOD) and catalase (CAT) were measured in erythrocytes. Results. In women with thrombophilia, NO2- values were increased in the first and third trimester compared to healthy pregnant women (p < 0.05). The higher levels of TBARS and H2O2 were noticed in women with thrombophilia in the first trimester compared to healthy pregnant women (p < 0.05). The values of SOD and CAT were lower in women with thrombophilia in the third and GSH in the first trimester compared to the control group (p < 0.05). Conclusion. Our results suggest an increased generation of prooxidants in thrombophilia at the beginning of gestation, which declines as gestation progresses and reaches similar values as in normal pregnancy at the end of pregnancy. Generally viewed, pregnant women with thrombophilia was associated with impaired antioxidant capacity ? activities of SOD and CAT were lower in the third and GSH in the first trimester compared to their values in healthy pregnant women.
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Hamedi B, Feulefack J, Khan A, Sergi C. Association between factor V Leiden mutation and recurrent pregnancy loss in the middle east countries: a Newcastle-Ottawa meta-analysis. Arch Gynecol Obstet 2020; 302:345-354. [PMID: 32472185 DOI: 10.1007/s00404-020-05610-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Heritable thrombophilia is a category of genetic disorders of the coagulation cascade with the increasing risk of thrombus formation and recurrent pregnancy loss (RPL). Factor V Leiden (FVL) (R506Q) mutation is the most common genetic cause of deep venous thrombosis, but its association with RPL has been inconsistent in studies arising from non-Western countries. The present metanalysis was aimed to determine whether an association exists between FVL and RPL in the Middle East. METHODS We searched PubMed, MEDLINE Web of Science, Scopus, and Embase, evaluating the association between the FVL and RPL. The Middle East countries (Bahrain, Cyprus, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, The State of Palestine, Syria, Turkey, The United Arab Emirates, and Yemen) were evaluated in succession. Raw data were extracted, and 19 case-control studies were included in our final analysis. RESULTS Overall, 2513 cases and 1836 controls in the Middle East showed a prevalence of FVL mutation as 12.6% and 4.9% in patients and controls, respectively. To evaluate the relationship between FVL mutation and RPL, we used Forest plot (random effect model) with the overall random OR of 2.37 (CI 95%: 1.50-3.75). FVL mutation was associated with a higher risk of RPL. In Iran, the OR was 1.90 (95% CI 1.04-3.45), and in Turkey, the OR was 3.01 (95% CI 1.10-8.23). CONCLUSION The results of our study support an association between FVL mutation status and RPL in women of the Middle East countries. It is recommended that specific policies include comprehensive testing for FVL mutation as a standard of care in women of the Middle East region with unexplained RPL.
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Affiliation(s)
- Bahareh Hamedi
- Department of Laboratory Medicine and Pathology, University of Alberta, WMC 5B4.09, 8440 112 ST NW, Edmonton, AB, Canada.,Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Joseph Feulefack
- Department of Laboratory Medicine and Pathology, University of Alberta, WMC 5B4.09, 8440 112 ST NW, Edmonton, AB, Canada
| | - Aiza Khan
- Department of Laboratory Medicine and Pathology, University of Alberta, WMC 5B4.09, 8440 112 ST NW, Edmonton, AB, Canada
| | - Consolato Sergi
- Department of Laboratory Medicine and Pathology, University of Alberta, WMC 5B4.09, 8440 112 ST NW, Edmonton, AB, Canada. .,Department of Pediatrics, University of Alberta, Stollery Children's Hospital, Edmonton, AB, Canada.
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Kwang H, Mou E, Richman I, Kumar A, Berube C, Kaimal R, Ahuja N, Harman S, Johnson T, Shah N, Witteles R, Harrington R, Shieh L, Hom J. Thrombophilia testing in the inpatient setting: impact of an educational intervention. BMC Med Inform Decis Mak 2019; 19:167. [PMID: 31429747 PMCID: PMC6701078 DOI: 10.1186/s12911-019-0889-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 08/06/2019] [Indexed: 11/26/2022] Open
Abstract
Background Thrombophilia testing is frequently ordered in the inpatient setting despite its limited impact on clinical decision-making and unreliable results in the setting of acute thrombosis or ongoing anticoagulation. We sought to determine the effect of an educational intervention in reducing inappropriate thrombophilia testing for hospitalized patients. Methods During the 2014 academic year, we implemented an educational intervention with a phase implementation design for Internal Medicine interns at Stanford University Hospital. The educational session covering epidemiology, appropriate thrombophilia evaluation and clinical rationale behind these recommendations. Their ordering behavior was compared with a contemporaneous control (non-medicine and private services) and a historical control (interns from prior academic year). From the analyzed data, we determined the proportion of inappropriate thrombophilia testing of each group. Logistic generalized estimating equations were used to estimate odds ratios for inappropriate thrombophilia testing associated with the intervention. Results Of 2151 orders included, 934 were deemed inappropriate (43.4%). The two intervention groups placed 147 orders. A pooled analysis of ordering practices by intervention groups revealed a trend toward reduction of inappropriate ordering (p = 0.053). By the end of the study, the intervention groups had significantly lower rates of inappropriate testing compared to historical or contemporaneous controls. Conclusion A brief educational intervention was associated with a trend toward reduction in inappropriate thrombophilia testing. These findings suggest that focused education on thrombophilia testing can positively impact inpatient ordering practices. Electronic supplementary material The online version of this article (10.1186/s12911-019-0889-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Henry Kwang
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Eric Mou
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Ilana Richman
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Andre Kumar
- Division of Hospital Medicine, Department of Medicine, Stanford University, 300 Pasteur Drive, HC007, Stanford, CA, 94305, USA
| | - Caroline Berube
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Rajani Kaimal
- Department of Medicine, Quantitative Sciences Unit, Stanford University, Stanford, CA, USA
| | - Neera Ahuja
- Division of Hospital Medicine, Department of Medicine, Stanford University, 300 Pasteur Drive, HC007, Stanford, CA, 94305, USA
| | - Stephanie Harman
- Division of Palliative Care, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Tyler Johnson
- Division of Oncology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Neil Shah
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Ronald Witteles
- Division of Cardiology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Robert Harrington
- Division of Cardiology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Lisa Shieh
- Division of Hospital Medicine, Department of Medicine, Stanford University, 300 Pasteur Drive, HC007, Stanford, CA, 94305, USA.
| | - Jason Hom
- Division of Hospital Medicine, Department of Medicine, Stanford University, 300 Pasteur Drive, HC007, Stanford, CA, 94305, USA.
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Bremme K, Lannemyr A, Tyni L, Chaireti R. Obstetric and neonatal outcomes in pregnant women treated with high-dose thromboprophylaxis: a retrospective, single-center study. J Matern Fetal Neonatal Med 2019; 34:1641-1644. [PMID: 31303074 DOI: 10.1080/14767058.2019.1644312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION It is well established that women with very high risk of developing antenatal thrombosis benefit from high-dose thromboprophylaxis, however data on outcomes and the safety and efficacy of thromboprophylaxis are scarce. The aim of the study was to evaluate the safety and effectiveness of the Swedish guidelines for high-dose thromboprophylaxis and the obstetric outcomes in a single-center patient cohort. PATIENTS AND METHODS Forty-seven women treated at the Department of Obstetrics and Gynecology, Karolinska University Hospital, Solna, Sweden, between 2004 and 2017 were included in this retrospective study. Data on treatment, obstetric, and neonatal outcomes and medical history were collected. Data derived from the Swedish Medical Birth Registry on women giving birth in Stockholm County 2004-2016 were used as controls. The protocol of the study was approved by the Regional Ethics Committee in Stockholm, Sweden. RESULTS The initial thromboprophylaxis dose was 5000 IU dalteparin twice daily. No patient developed ablatio placentae or preeclampsia. One patient suffered antenatal muscle vein thrombosis. Six patients (12.7%) suffered postpartum hemorrhage (PPH); however only one patient had severe PPH. Forty-eight children were born. Three children (6%) were diagnosed with intrauterine growth retardation, five (10%) were born small for gestational age and seven (15%) were born premature, the majority of which (except for two premature) to women with thrombophilia. DISCUSSION High-dose thromboprophylaxis was effective and safe. The incidence of preeclampsia and ablatio was lower than in controls; however, neonatal outcomes were worse, especially among mothers with thrombophilia. Due to the diversity of the thrombophilic traits, no thrombophilia-specific conclusion could be drawn. Stricter adherence to the guidelines could further decrease the risk for bleeding, whereas more frequent antenatal controls could possible improve neonatal outcomes.
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Affiliation(s)
- Katarina Bremme
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Division of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - Amelie Lannemyr
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Lena Tyni
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Roza Chaireti
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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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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Ata B, Urman B. Thrombophilia and assisted reproduction technology-any detrimental impact or unnecessary overuse? J Assist Reprod Genet 2016; 33:1305-1310. [PMID: 27423663 PMCID: PMC5065550 DOI: 10.1007/s10815-016-0771-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 07/01/2016] [Indexed: 12/22/2022] Open
Abstract
PURPOSE The aim of this study is to provide an overview of the studies investigating a possible association between thrombophilia and assisted reproductive technology (ART) outcome. METHODS This is a literature review. RESULTS Congenital thrombophilias (CoT) are reported to be associated with pregnancy loss. However, the association between CoT and early pregnancy loss is weak and does not necessarily support causation. CoT are more likely to be associated with late fetal loss. Even though data pooled from case-control and cohort studies suggest an increased risk of ART failure in women with CoTs, there seems no association when the analysis is confined to better quality cohort studies. The evidence supporting anticoagulation to improve ART outcome in CoT carriers is weak. Likewise, studies on antiphospholipid antibodies (APAs) and ART outcome suffer from multiple methodological limitations and a detrimental impact of APA positivity is controversial. Empirical administration of heparin or low molecular weight heparin to women with recurrent ART failures is supported by weak evidence. Importantly, thrombophilias are likely to increase thrombotic complications after ovarian stimulation for ART. CONCLUSIONS Current evidence does not support routinely testing for or treatment of thrombophilia in the setting of ART nor in couples with implantation failure. A careful personal and family history should be obtained and a risk assessment for thrombotic complications should be made in every woman undergoing ovarian stimulation. If positive, testing for thrombophilia is warranted.
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Affiliation(s)
- Baris Ata
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Davutpasa Caddesi No: 4, Topkapi, Istanbul, 34010, Turkey
| | - Bulent Urman
- Department of Obstetrics and Gynecology, Koc University School of Medicine, Davutpasa Caddesi No: 4, Topkapi, Istanbul, 34010, Turkey.
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Mastrolia SA, Novack L, Thachil J, Rabinovich A, Pikovsky O, Klaitman V, Loverro G, Erez O. LMWH in the prevention of preeclampsia and fetal growth restriction in women without thrombophilia. A systematic review and meta-analysis. Thromb Haemost 2016; 116:868-878. [PMID: 27440387 DOI: 10.1160/th16-02-0169] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/17/2016] [Indexed: 12/18/2022]
Abstract
Placental mediated pregnancy complications such as preeclampsia and fetal growth restriction (FGR) are common, serious, and associated with increased morbidity and mortality. We conducted a systematic review and meta-analysis to determine the effect of treatment with low-molecular-weight heparins (LMWHs) for secondary prevention of these complications in non thrombophilic women. We searched the electronic databases PubMed, Scopus, and Cochrane Library for randomised controlled trials addressing this question. Five studies including 403 patients met the inclusion criteria, 68 developed preeclampsia and 118 FGR. The studies were very heterogeneous in terms of inclusion criteria, LMWH preparation, and dosage. Meta-analyses were performed using random-effect models. The overall use of LMWHs was associated with a risk reduction for preeclampsia (Relative risk (RR) 0.366; 95 % confidence interval (CI), 0.219-0.614) and FGR (RR 0.409; 95 % CI, 0.195-0.932) vs. no treatment. From the data available for analysis it appears that the use of Dalteparin is associated with a risk reduction for preeclampsia (p=0.002) and FGR (p<0.001); while Enoxaparin is associated with risk reduction for preeclampsia (p=0.013) but not for FGR (p=0.3). In spite of the small number of studies addressing the research question, and the high variability among them, our meta-analysis found a modest beneficial effect of LMWH for secondary prevention of preeclampsia and FGR. Further studies are needed to address these questions before a definite conclusion can be reached.
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Affiliation(s)
| | | | | | | | | | | | | | - Offer Erez
- Prof. Offer Erez, MD, Acting Director Maternity Department D and Obstetrical Day care Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, P. O.Box 151, 84101, Beer Sheva, Israel, Tel.: +972 8 6400061, E-mail
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van Hoorn ME, Hague WM, van Pampus MG, Bezemer D, de Vries JI. Low-molecular-weight heparin and aspirin in the prevention of recurrent early-onset pre-eclampsia in women with antiphospholipid antibodies: the FRUIT-RCT. Eur J Obstet Gynecol Reprod Biol 2016; 197:168-73. [DOI: 10.1016/j.ejogrb.2015.12.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 11/26/2015] [Accepted: 12/10/2015] [Indexed: 10/22/2022]
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Zavala-Hernández C, Hernández-Zamora E, Martínez-Murillo C, Majluf-Cruz A, Vela-Ojeda J, García-Chávez J, Reyes-Maldonado E. Risk Factors for Thrombosis Development in Mexican Patients. Ann Vasc Surg 2015; 29:1625-32. [DOI: 10.1016/j.avsg.2015.05.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 05/01/2015] [Accepted: 05/23/2015] [Indexed: 11/17/2022]
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Ziakas PD, Poulou LS, Pavlou M, Zintzaras E. Thrombophilia and venous thromboembolism in pregnancy: a meta-analysis of genetic risk. Eur J Obstet Gynecol Reprod Biol 2015; 191:106-11. [PMID: 26115054 DOI: 10.1016/j.ejogrb.2015.06.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 05/30/2015] [Accepted: 06/03/2015] [Indexed: 01/06/2023]
Abstract
Three common polymorphic variants, namely Factor V Leiden (FVL), Prothrombin G20210A (PT G20210A) and Methylenetetrahydrofolate Reductase (MTHFR) C677T are candidate genes for venous thromboembolism (VTE) in pregnancy. We performed a literature review and meta-analysis of pertinent genetic association studies (GAS) in pregnancy, to quantify the genetic risk of VTE in pregnancy. We used the model-free approach of generalized odds ratio (ORG) to estimate gene-to-disease association and explored the mode of inheritance using the degree of dominance h index. Twelve case-control GAS studies provided the full genotype distributions for at least one candidate gene to assess the genetic risk. FVL was associated with a significant risk of VTE in pregnancy (ORG 7.28; 95% confidence interval 5.53-9.58) and a dominant mode of inheritance (h=0.76), that is the effect of heterozygous carriers will lie close to the homozygous mutant genotype. PT G20210A mutation was also associated with a significant VTE risk (ORG 5.43; 95% CI 3.66-8.03) and had an over-dominant mode of inheritance (h=1.5), suggesting that the effect of heterozygous carriers may exceed that of homozygous mutant. MTHFR C677T had no association with VTE risk in pregnancy (ORG 1.24; 95% CI 0.88-1.73). Our analysis provided robust data on VTE in pregnancy, relative to FVL and PT G20210A status and suggested that the genetic effects of heterozygous over homozygous carriers do not justify stratification of heterozygous as "lower risk" over homozygous mutants. On clinical grounds this may impact decisions to preferentially exclude heterozygous from anticoagulation prophylaxis.
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Affiliation(s)
| | - Loukia S Poulou
- Research Unit in Radiology & Medical Imaging, Medical School, University of Athens, Greece.
| | | | - Elias Zintzaras
- Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Department of Biomathematics, School of Medicine, University of Thessaly, Larissa, Greece
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