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Frank AK, Samuelson Bannow B. Venous thromboembolism in pregnancy and postpartum: an illustrated review. Res Pract Thromb Haemost 2024; 8:102446. [PMID: 39045339 PMCID: PMC11263788 DOI: 10.1016/j.rpth.2024.102446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 07/25/2024] Open
Abstract
The topic of this review is venous thromboembolism (VTE) during pregnancy and postpartum. The following topics will be addressed: epidemiology and pathophysiology of VTE in pregnancy and postpartum, diagnostic considerations for VTE in pregnancy, indications for prophylactic and therapeutic anticoagulation in pregnancy and postpartum, choice of anticoagulation in pregnancy and breastfeeding, anticoagulation management during labor and delivery, and anticoagulation considerations for assisted reproductive technology.
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Affiliation(s)
- Annabel K. Frank
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, California, USA
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2
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Ortel TL. Introduction to a How I Treat series on hematologic complications in pregnancy. Blood 2024; 143:739-740. [PMID: 38421816 DOI: 10.1182/blood.2023020730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Edited by Associate Editor Thomas Ortel, this How I Treat series on hematologic complications of pregnancy uses illustrative cases to discuss the management of thrombocytopenia, antiphospholipid syndrome, sickle cell disease, and myeloid proliferative neoplasms in the setting of pregnancy.
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Eiland LS, Harris JB, Holmes AP. Considerations for Treating Nonobstetric Diseases in Pregnant Patients in the Emergency Department Setting. Ann Pharmacother 2023; 57:1415-1424. [PMID: 37076990 DOI: 10.1177/10600280231167775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
OBJECTIVE To provide nonobstetric practitioners with an overview of key concepts for the pregnant patient and review treatment of 3 common acute nonobstetric diseases encountered in the emergency department setting. DATA SOURCES A literature search of PubMed was performed (1997-February 2023) using key search terms related to pregnancy, pain, urinary tract infection (UTI), venous thromboembolism (VTE), and anticoagulants. STUDY SELECTION AND DATA EXTRACTION Relevant articles in English and humans were considered. DATA SYNTHESIS When caring for a pregnant patient, it is important to utilize appropriate assessments, understand terms used in this population, and recognize how the physiological and pharmacokinetic changes that occur in pregnancy can influence medication use. Pain, UTIs, and VTE are common in this population. Acetaminophen is the most widely used medication for the management of pain during pregnancy and the drug of choice for mild pain in pregnancy not responsive to nonpharmacologic treatment. Pyelonephritis is the most common nonobstetric cause of hospitalization for pregnant patients. Antimicrobial treatment should consider maternal-fetal safety and local resistance patterns. Pregnant and postpartum patients have a 4- to 5-fold increased risk of developing a VTE compared with nonpregnant patients. Low-molecular-weight heparin is the preferred treatment. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Pregnant patients often seek acute care in the emergency department setting for nonobstetric needs. Pharmacists in this setting should understand appropriate assessment questions and terms used within this population, the basics of physiological and pharmacokinetic changes in pregnancy that can impact treatment, and which resources are best to utilize for drug information of the pregnant patient. CONCLUSION Practitioners in the acute care setting commonly encounter pregnant patients seeking care for nonobstetric concerns. This article covers key pregnancy-related information for the nonobstetric practitioner and focuses on the management of acute pain, UTI, and VTE during pregnancy.
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Affiliation(s)
- Lea S Eiland
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - John Brock Harris
- Education and Pharmaceutical Sciences Department, Wingate University School of Pharmacy, Wingate, NC, USA
| | - Amy P Holmes
- Department of Pharmacy, Atrium Wake Forest Baptist Health, Winston-Salem, NC, USA
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Cueto-Robledo G, Cervantes-Naranjo FD, Gonzalez-Hermosillo LM, Roldan-Valadez E, Graniel-Palafox LE, Castro-Escalante KY, Orozco-Zuñiga B. Pulmonary embolism during pregnancy: an updated review with case series description. Curr Probl Cardiol 2023; 48:101683. [PMID: 36898596 DOI: 10.1016/j.cpcardiol.2023.101683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/02/2023] [Indexed: 03/12/2023]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that can occur during pregnancy and pose a significant risk to the mother and the developing fetus. It is a major contributor to pregnancy-related morbidity and mortality in any trimester. It is estimated that the incidence of PE during pregnancy is approximately 1 in 1000 pregnancies. The mortality rate for pregnant women with PE is about 3%, significantly higher than that for non-pregnant women with PE. Overall, the topic of PE and pregnancy is essential for healthcare professionals to be aware of the risks, signs, and treatment options to improve outcomes and ensure the best possible care for both the mother and the developing fetus. To prevent the fatal condition, the physician is encouraged when there is a suspicion of the pathology. This report presents an updated comprehensive review of PE during pregnancy, discussing critical aspects of the clinical and imaging diagnosis, use of heparin, thrombolysis, and prevention. We believe this article will be helpful for cardiologists, obstetricians, and other health-related professionals.
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Affiliation(s)
- Guillermo Cueto-Robledo
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", 06720, Mexico City, Mexico; Pulmonary Circulation Clinic, Hospital General de México "Dr. Eduardo Liceaga", 06720, Mexico City, Mexico; Faculty of Medicine, National Autonomous University of Mexico, 04510, Mexico City, Mexico.
| | | | | | - Ernesto Roldan-Valadez
- Directorate of Research, Hospital General de Mexico "Dr. Eduardo Liceaga," 06720, Mexico City, Mexico; I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
| | | | | | - Benjamin Orozco-Zuñiga
- Ginecology Department, Hospital General de México ¨Dr. Eduardo Liceaga¨, Mexico City, Mexico.
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Legardeur H, Cuenoud A, Panchaud A, Grandoni F, Mesquita Sauvage AB, Alberio L, Baud D, Gavillet M. Shall we rethink the timing of epidural anesthesia in anticoagulated obstetrical patients? Am J Obstet Gynecol 2023; 228:257-260. [PMID: 36402599 DOI: 10.1016/j.ajog.2022.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 09/13/2022] [Accepted: 10/19/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Hélène Legardeur
- Woman-Mother-Child Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Alexia Cuenoud
- Department of Anesthesia, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Alice Panchaud
- Service of Pharmacy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Francesco Grandoni
- Service and Central Laboratory of Hematology, Departments of Oncology and Laboratories and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Ana Batista Mesquita Sauvage
- Service and Central Laboratory of Hematology, Departments of Oncology and Laboratories and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Departments of Oncology and Laboratories and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - David Baud
- Woman-Mother-Child Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Mathilde Gavillet
- Service and Central Laboratory of Hematology, Departments of Oncology and Laboratories and Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland; Interregional Blood Transfusion SRC, Epalinges, Switzerland.
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6
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Bistervels IM, Wiegers HMG, Áinle FN, Bleker SM, Chauleur C, Donnelly J, Jacobsen AF, Rodger MA, DeSancho MT, Verhamme P, Hansen AT, Shmakov RG, Ganzevoort W, Buchmüller A, Middeldorp S. Onset of labor and use of analgesia in women using thromboprophylaxis with 2 doses of low-molecular-weight heparin: insights from the Highlow study. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:57-67. [PMID: 36695396 DOI: 10.1016/j.jtha.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Peripartum management of women using low-molecular-weight heparin (LMWH) varies widely. Minimum time intervals are required between LMWH injection and neuraxial procedure, and they differ by dose. OBJECTIVES The objective of this study was to describe the onset of labor and use of analgesia in women using LMWH and to compare practices between intermediate-dose and low-dose LMWH. METHODS In the Highlow study (NCT01828697), 1110 women were randomized to intermediate-dose or low-dose LMWH and were instructed to discontinue LMWH when labor commenced unplanned or 24 hours prior to planned delivery. The required time interval since last injection to receive a neuraxial procedure was ≥24 hours for intermediate-dose LMWH or ≥12 hours for low-dose LMWH. RESULTS In total, 1018 women had an ongoing pregnancy for ≥24 weeks. Onset of labor was spontaneous in 198 of 509 (39%) women on intermediate-dose LMWH and in 246 of 509 (49%) on low-dose LMWH. With unplanned onset, a neuraxial procedure was performed in 37% on intermediate-dose and in 48% on low-dose LMWH (risk difference -11%, 95% CI -20% to -2%). Based on time interval, 61% on intermediate-dose and 82% on low-dose LMWH were eligible for a neuraxial procedure. With planned onset, 68% on intermediate-dose and 66% on low-dose LMWH received a neuraxial procedure, whereas 81% and 93%, respectively, were eligible for a neuraxial procedure (risk difference -13%, 95% CI -18% to -8%). CONCLUSION With spontaneous onset of labor, neuraxial procedures were performed less often in women using intermediate-dose LMWH. Irrespective of onset, fewer women on intermediate-dose LMWH than those on low-dose LMWH were eligible for neuraxial procedures based on required time intervals since the last LMWH injection.
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Affiliation(s)
- Ingrid M Bistervels
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - Hanke M G Wiegers
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Fionnuala Ní Áinle
- Department of Hematology, Rotunda Hospital and Mater Misericordiae University Hospital, Dublin, Ireland; Irish Network for Venous Thromboembolism Research, Dublin, Ireland; School of Medicine University College Dublin, Dublin, Ireland
| | - Suzanne M Bleker
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Céline Chauleur
- INSERM, Clinical Investigator Center 1408 - F Crin, INNOVTE, Centre Hospitalier Universitaire de Saint-Etienne, Hôpital Nord, Service Médecine Vasculaire et Thérapeutique, France; Department of Obstetrics & Gynaecology, Centre Hospitalier Universitaire de Saint-Etienne, Hôpital Nord, Saint-Etienne, France; INSERM, SAINBIOSE, U1059, Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
| | - Jennifer Donnelly
- Department of Obstetrics and Gynaecology, Rotunda Hospital and Mater Misericordiae University Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Anne F Jacobsen
- Department of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Hospital, Oslo, Norway
| | - Marc A Rodger
- Department of Hematology, The Ottawa Hospital, Ottawa, Canada
| | - Maria T DeSancho
- Department of Medicine, Division of Hematology-Oncology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Vascular Medicine and Haemostasis, KU Leuven, Leuven, Belgium
| | - Anette T Hansen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Roman G Shmakov
- Institute of Obstetrics, National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Andrea Buchmüller
- INSERM, Clinical Investigator Center 1408 - F Crin, INNOVTE, Centre Hospitalier Universitaire de Saint-Etienne, Hôpital Nord, Service Médecine Vasculaire et Thérapeutique, France; Department of Vascular Medicine/Service Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire de Saint-Etienne, Hôpital Nord, Saint-Etienne, France
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Internal Medicine & Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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Algahtani H, Bazaid A, Shirah B, Bouges RN. Cerebral venous sinus thrombosis in pregnancy and puerperium: A comprehensive review. Brain Circ 2022; 8:180-187. [PMID: 37181848 PMCID: PMC10167849 DOI: 10.4103/bc.bc_50_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/03/2022] [Accepted: 09/15/2022] [Indexed: 12/14/2022] Open
Abstract
Cerebral venous sinus thrombosis (CVST) is a distinct neurological emergency caused by occlusion, either partial or complete, of the dural venous sinus and/or the cerebral veins. It occurs more frequently in women during pregnancy and puerperium as compared to the general population. The clinical diagnosis is difficult in some cases due to its variable clinical presentation with numerous causes and risk factors. The diagnosis can be made at an early stage if clinical suspicion is high with the help of advanced neuroimaging techniques that were developed recently. Early therapeutic intervention using anticoagulants allows for preventing complications and improving outcomes. In this article, we review the topic of CVST in pregnancy and the postpartum period with an emphasis on its epidemiology, pathophysiology, clinical presentation, and treatment. We also elaborate on several practical points that are important to the treating team. This review will help obstetricians, neurologists, and emergency physicians diagnose affected pregnant women as early as possible to provide prompt treatment and avoid adverse outcomes.
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Affiliation(s)
- Hussein Algahtani
- Department of Medicine, Neurology Section, King Abdulaziz Medical City, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Abdulrahman Bazaid
- Department of Obstetrics and Gynecology, King Salman Medical City, Madinah, Saudi Arabia
| | - Bader Shirah
- Department of Neuroscience, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Raghad N Bouges
- College of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Schapkaitz E, Jacobson BF, Libhaber E. Pregnancy Related Venous Thromboembolism-Associated with HIV Infection and Antiretroviral Therapy. Semin Thromb Hemost 2022; 49:355-363. [PMID: 36055274 DOI: 10.1055/s-0042-1754391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Human immunodeficiency virus (HIV) infection in pregnancy is associated with substantial morbidity and mortality. Improved access to effective antiretroviral therapy (ART) has shifted the spectrum of pregnancy-related complications among HIV-infected pregnant women. In addition to placental vascular complications and preterm delivery, increased rates of venous thromboembolism (VTE) have been described. HIV infection is characterized by immune activation, inflammation, and endothelial dysfunction, which contribute to the activation of coagulation and its prothrombotic consequences. Indeed, activated coagulation factors have been reported to be increased and natural anticoagulants reduced in HIV. Several mechanisms for this persistent prothrombotic balance on ART have been identified. These may include: co-infections, immune recovery, and loss of the gastrointestinal mucosal integrity with microbial translocation. In addition to the direct effects of HIV and ART, traditional venous and obstetric risk factors also contribute to the risk of VTE. A research priority has been to understand the mechanisms of VTE in HIV-infected pregnant women receiving suppressive ART and to translate this into HIV-specific thromboprophylaxis recommendations. Management requires a multidisciplinary approach and further studies are indicated to guide the prevention and management of pregnancy-associated VTE in this population. The current review describes the epidemiology, mechanisms, and management of VTE in HIV-infected women in pregnancy and the postpartum period.
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Affiliation(s)
- Elise Schapkaitz
- Department of Molecular Medicine and Hematology, University of Witwatersrand, Johannesburg, South Africa
| | - Barry F Jacobson
- Department of Molecular Medicine and Hematology, University of Witwatersrand, Johannesburg, South Africa
| | - Elena Libhaber
- Department of Research Methodology and Statistics, University of Witwatersrand, Johannesburg, South Africa
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Simard C, Gerstein L, Cafaro T, Filion KB, Douros A, Malhamé I, Tagalakis V. Bleeding in women with venous thromboembolism during pregnancy: A systematic review of the literature. Res Pract Thromb Haemost 2022; 6:e12801. [PMID: 36051542 PMCID: PMC9424506 DOI: 10.1002/rth2.12801] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/01/2022] [Accepted: 08/05/2022] [Indexed: 11/19/2022] Open
Abstract
Objectives Venous thromboembolism (VTE) represents an important cause of maternal morbidity and mortality. Estimates of bleeding associated with therapeutic‐dose anticoagulation are variable. We describe the frequency of bleeding in pregnant women receiving therapeutic anticoagulation for VTE by means of a systematic review of the literature. Data Sources Medical Literature Analysis and Retrieval System, Embase, Scopus, Web of Science, and ClinicalTrials.gov were searched. Databases were searched from inception to February 27, 2022. There was no language or geographic location restriction. Methods of Study Selection The search yielded 2773 articles with 2212 unique citations. Studies were included if they described pregnant women treated for an acute VTE with therapeutic‐dose anticoagulation and a defined bleeding outcome was reported. Tabulation, Integration, and Results Five studies met inclusion criteria. Included studies were judged to have a serious to critical risk of bias using the Risk of Bias in Nonrandomized Studies of Intervention tool. The rate of bleeding, as defined by respective studies, ranged between 2.9% and 30.0%. Two studies included control groups, one of which found no significant difference in the risk of bleeding between groups, while the other found a significantly increased bleeding risk associated with therapeutic anticoagulation. Conclusion Among pregnant women anticoagulated for VTE, the reported bleeding risk is variable. The ability to draw definite conclusions is limited by the scarcity and low quality of the studies, the small number of included patients, and the heterogeneity of bleeding definitions used. Large‐scale studies with standardized bleeding definitions are required to provide acute bleeding estimates and optimize the care of these patients. Systematic Review Registration PROSPERO, CRD42021276771.
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Affiliation(s)
- Camille Simard
- Division of General Internal Medicine Department of Medicine Jewish General Hospital McGill University Montreal Quebec Canada
| | | | - Teresa Cafaro
- Division of General Internal Medicine Department of Medicine Jewish General Hospital McGill University Montreal Quebec Canada
| | - Kris B Filion
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research Jewish General Hospital Montreal Quebec Canada
| | - Antonios Douros
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research Jewish General Hospital Montreal Quebec Canada
| | - Isabelle Malhamé
- Division of General Internal Medicine Department of Medicine McGill University Health Centre McGill University Montreal Quebec Canada.,Research Institute of the McGill University Health Centre Montreal Quebec Canada
| | - Vicky Tagalakis
- Division of General Internal Medicine Department of Medicine Jewish General Hospital McGill University Montreal Quebec Canada.,Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research Jewish General Hospital Montreal Quebec Canada
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Direct Oral Anticoagulants in Sickle Cell Disease: A Systematic Review and Meta-Analysis. Blood Adv 2022; 6:5061-5066. [PMID: 35728061 PMCID: PMC9631619 DOI: 10.1182/bloodadvances.2022007308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 06/02/2022] [Indexed: 11/20/2022] Open
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Simard C, Malhamé I, Skeith L, Carson MP, Rey E, Tagalakis V. Management of anticoagulation in pregnant women with venous thromboembolism: An international survey of clinical practice. Thromb Res 2021; 210:20-25. [PMID: 34968851 DOI: 10.1016/j.thromres.2021.12.016] [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: 09/27/2021] [Revised: 11/25/2021] [Accepted: 12/16/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is an important cause of maternal morbidity and mortality. During pregnancy, VTE is treated with low-molecular-weight-heparin (LMWH). Studies assessing the optimal duration and peripartum management of therapeutic anticoagulation are lacking. This survey aimed to assess clinician practices for the management of anticoagulation in pregnant women with acute VTE. METHODS An electronic survey consisting of clinical scenarios addressing anticoagulation management for VTE in pregnancy was created. The target sample was clinicians likely to be involved in the management of pregnant women with acute VTE. The survey completion rate and proportion of individuals selecting a response were determined. RESULTS 96 respondents completed the survey including general internists (56.3%), hematologists (21.9%), and obstetricians (6.3%). In the management of a VTE in first or second trimester, most respondents preferred therapeutic LMWH until 6 weeks postpartum. In the first and second trimester, 48.0% and 37.5% of respondents, respectively, opted to reduce the dose of anticoagulation after 3 or 6 months. 29.2% of physicians opted for bridging with intravenous heparin around delivery when treating a VTE in the third trimester. 73.0% perceived an increased risk of clinically relevant non-major bleeding associated with the use of therapeutic anticoagulation in the peripartum and postpartum periods. CONCLUSIONS The survey highlights a wide variability of practice in the management of therapeutic anticoagulation in pregnancy. Larger scale studies with relevant clinical outcomes including thrombosis and bleeding risks are needed to inform clinical practice.
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Affiliation(s)
- C Simard
- Department of Medicine, McGill University, Montreal, Canada.
| | - I Malhamé
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, McGill University, Montreal, Canada; Research Institute of the McGill University Health Centre, Montreal, Canada
| | - L Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, Calgary, Canada; Department of Community Health Sciences, University of Calgary, Canada
| | - M P Carson
- Department of Medicine, Hackensack Meridian School of Medicine at Seton Hall University, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - E Rey
- Departments of Medicine and Obstetrics and Gynecology, CHU Sainte-Justine, University of Montreal, Montreal, Canada
| | - V Tagalakis
- Division of General Internal Medicine, Department of Medicine, Jewish General Hospital, McGill University, Montreal, Canada; Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada.
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Khryshchanovich VY, Skobeleva NY. Prophylaxis and management of venous thromboembolism during pregnancy and postpartum period. OBSTETRICS, GYNECOLOGY AND REPRODUCTION 2021. [DOI: 10.17749/2313-7347/ob.gyn.rep.2021.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction. Venous thromboembolism (VTE) is one of the lead causes for maternal mortality and morbidity during pregnancy in the majority of developed countries. The incidence rate of VTE per pregnancy-year increases during pregnancy and postpartum period about by 4-fold and at least 14-fold, respectively.Aim: to analyze and summarize current view on risk factors of thrombotic events during gestation and to discuss recent guidelines for the management of venous thromboembolic complications during pregnancy and postpartum, by taking into account a balance between risks and benefits of using anticoagulants.Materials and Methods. The literature search covering the last 10 years was carried out in the electronic scientific databases RSCI, PubMed/MEDLINE, and Embase. While formulating a search strategy for evidence-based information, the PICO method (P = Patient; I = Intervention; C = Comparison; O = Outcome) and the key terms “venous thromboembolism” and “pregnancy” were used.Results. Risk factors were found to include a personal history of VTE, verified inherited or acquired thrombophilia, a family history of VTE and general medical conditions, such as immobilization, overweight, varicose veins, some hematological diseases and autoimmune disorders. VTE is considered being potentially preventable upon prophylactic administration of anticoagulants, but no high confidence randomized clinical trials comparing diverse strategies of thromboprophylaxis in pregnant women have been proposed so far. Because heparins do not cross the placenta, weight-adjusted therapeutic-dose low molecular weight heparins (LMWH) represent the anticoagulant treatment of choice for VTE during pregnancy. Once- and twice-daily dosing regimens are acceptable. However, no evidence suggesting benefits for measurement of factor Xa activities and consecutive LMWH dose adjustments to improve clinical outcomes are available. In case of uncomplicated pregnancy-related VTE, no routine administration of vitamin K antagonists, direct thrombin or factor Xa inhibitors, fondaparinux, or danaparoid is recommended. Lactating women may switch from applying LMWH to warfarin. Anticoagulation therapy should be continued for 6 weeks postpartum with total duration lasting at least for 3 months.Conclusion. VTE is a challenging task in pregnant women expecting to apply a multi-faceted approach for its efficient solution by taking into account updated recommendations and personalized patient-oriented features.
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Affiliation(s)
| | - N. Ya. Skobeleva
- Belarussian State Medical University;
Clinical Maternity Hospital of Minsk Region
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13
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Wiegers H, Hamulyák EN, Damhuis SE, van Duuren JR, Darwish Murad S, Scheres L, Gordijn SJ, Leentjens J, Duvekot JJ, Lauw MN, Hutten BA, Middeldorp S, Ganzevoort W. Pregnancy outcomes in women with Budd-Chiari syndrome or portal vein thrombosis - a multicentre retrospective cohort study. BJOG 2021; 129:608-617. [PMID: 34520620 PMCID: PMC9293458 DOI: 10.1111/1471-0528.16915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 08/25/2021] [Accepted: 08/29/2021] [Indexed: 11/29/2022]
Abstract
Objective To evaluate current practice and outcomes of pregnancy in women previously diagnosed with Budd–Chiari syndrome and/or portal vein thrombosis, with and without concomitant portal hypertension. Design and setting Multicentre retrospective cohort study between 2008 and 2021. Population Women who conceived in the predefined period after the diagnosis of Budd–Chiari syndrome and/or portal vein thrombosis. Methods and main outcome measures We collected data on diagnosis and clinical features. The primary outcomes were maternal mortality and live birth rate. Secondary outcomes included maternal, neonatal and obstetric complications. Results Forty‐five women (12 Budd–Chiari syndrome, 33 portal vein thrombosis; 76 pregnancies) were included. Underlying prothrombotic disorders were present in 23 of the 45 women (51%). Thirty‐eight women (84%) received low‐molecular‐weight heparin during pregnancy. Of 45 first pregnancies, 11 (24%) ended in pregnancy loss and 34 (76%) resulted in live birth of which 27 were at term (79% of live births and 60% of pregnancies). No maternal deaths were observed; one woman developed pulmonary embolism during pregnancy and two women (4%) had variceal bleeding requiring intervention. Conclusions The high number of term live births (79%) and lower than expected risk of pregnancy‐related maternal and neonatal morbidity in our cohort suggest that Budd–Chiari syndrome and/or portal vein thrombosis should not be considered as an absolute contraindication for pregnancy. Individualised, nuanced counselling and a multidisciplinary pregnancy surveillance approach are essential in this patient population. Tweetable abstract Budd–Chiari syndrome and/or portal vein thrombosis should not be considered as an absolute contraindication for pregnancy. Budd–Chiari syndrome and/or portal vein thrombosis should not be considered as an absolute contraindication for pregnancy. Linked article This article is commented on by YY Chung & MA Heneghan pp. 618 in this issue. To view this minicommentary visit https://doi.org/10.1111/1471-0528.17002.
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Affiliation(s)
- Hmg Wiegers
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - E N Hamulyák
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - S E Damhuis
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J R van Duuren
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - S Darwish Murad
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Ljj Scheres
- Department of Internal Medicine &, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S J Gordijn
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - J Leentjens
- Department of Internal Medicine &, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M N Lauw
- Deparment of Haematology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B A Hutten
- Departmentof Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - S Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Internal Medicine &, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
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14
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Blondon M, Martinez de Tejada B, Glauser F, Righini M, Robert-Ebadi H. Management of high-risk pulmonary embolism in pregnancy. Thromb Res 2021; 204:57-65. [PMID: 34146979 DOI: 10.1016/j.thromres.2021.05.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 12/30/2022]
Abstract
Pregnancy-associated high-risk pulmonary embolism (PE) is among the most frequent causes of maternal mortality in the Western world, by causing hemodynamic instability and circulatory failure through a large thrombotic pulmonary obstruction. The very challenging management of these dramatic situations comprises the need to quickly select a therapy of pulmonary reperfusion or hemodynamic replacement, while taking into account both maternal and fetal risks. In this review, we discuss the role of risk stratification in pregnancy-associated PE and the available evidence to support the use of thrombolysis, catheter-directed thrombectomy/thrombolysis, surgical embolectomy and extracorporeal membrane oxygenation. Despite the lack of comparative studies and solid evidence, most reported cases of high-risk pregnancy-associated PE have been treated with thrombolysis, with high maternal and fetal survivals, and thrombolysis is suggested by guidelines in life-threatening PE. For women in the peripartum and early post-partum period, non-fibrinolytic treatments may be preferred as a first-line treatment, if available, because of the particularly high bleeding risk. In all cases, pregnancy-associated high-risk PE requires a multidisciplinary approach involving PE response teams and obstetricians.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Frederic Glauser
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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15
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Dempfle CE, Koscielny J, Lindhoff-Last E, Linnemann B, Bux-Gewehr I, Kappert G, Scholz U, Kropff S, Eberle S, Bramlage P, Heinken A. Fondaparinux Pre-, Peri-, and/or Postpartum for the Prophylaxis/Treatment of Venous Thromboembolism (FondaPPP). Clin Appl Thromb Hemost 2021; 27:10760296211014575. [PMID: 33942675 PMCID: PMC8114740 DOI: 10.1177/10760296211014575] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We analyzed data for women who received fondaparinux for ≥7 days during pregnancy. The study retrospectively included women who received fondaparinux pre-, peri- and/or postpartum for ≥7 days for prophylaxis/venous thromboembolism (VTE) treatment at German specialist centers (2004-2010). Data on pregnancy, VTE risk factors, anticoagulant treatment, pregnancy outcome and adverse events were extracted from medical records. 120 women (mean age 31.5 years) were included. Among 84 women with prior pregnancies, 41.0% had ≥1 abortion. Anticoagulation was indicated for prophylaxis in 92.5% cases, including 82.5% women with an elevated VTE risk (82.8% thrombophilia, 34.2% VTE history). All women received low-molecular-weight heparin (LMWH) as first-line therapy; 3 also unfractionated heparin. Treatment changed to fondaparinux, due to heparin allergy (41.7%) or heparin-induced thrombocytopenia (10.0%). Fondaparinux was generally well tolerated. Adverse events included bleeding events (n = 5), abortion (n = 2), premature births (n = 2), stillbirth (n = 1), arrested labors (n = 2), injection site erythema (n = 4) and unspecified drug hypersensitivity (n = 6). No VTE events or increased liver enzymes occurred during treatment. In this retrospective study, fondaparinux was effective and well tolerated. Trial registration: ClinicalTrials.gov NCT01004939.
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Affiliation(s)
| | - Jürgen Koscielny
- Institut für Transfusionsmedizin, 14903Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | | | - Ute Scholz
- Zentrum für Gerinnungsstörungen, Leipzig, Germany
| | | | | | - Peter Bramlage
- 566322Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
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16
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Abstract
Congenital dysfibrinogenemia (CD) is caused by structural changes in fibrinogen that modify its function. Diagnosis is based on discrepancy between decreased fibrinogen activity and normal fibrinogen antigen levels and is confirmed by genetic testing. CD results from monoallelic mutations in fibrinogen genes leading to clinically heterogenous disorders. Most patients with CD are asymptomatic at time of diagnosis but the clinical course may be complicated by a tendency to bleeding and/or thrombosis. Patients with a thrombotic-related fibrinogen variant are particularly at risk and in such patients long-term anticoagulation should be considered. Management of surgery and pregnancy raise important and difficult issues. The mainstay of CD treatment remains fibrinogen supplementation. Antifibrinolytic agents are part of the treatment in some specific clinical settings. In this article, we discuss five clinical scenarios to highlight common clinical challenges. We detail our approach to establish a diagnosis of CD and discuss strategies for the management of bleeding, thrombosis, surgery and pregnancy.
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