1
|
Mok T, Nguyen AV, Kwan L, Steinberg I, Vallera C, Silverman NS, Rao R. Prophylactic Unfractionated Heparin in Antepartum Hospitalizations: A Randomized Controlled Trial. Obstet Gynecol 2024; 144:118-125. [PMID: 38743958 DOI: 10.1097/aog.0000000000005599] [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: 01/31/2024] [Accepted: 03/14/2024] [Indexed: 05/16/2024]
Abstract
OBJECTIVE To assess the effect of gestational age-based dosing of unfractionated heparin (UFH) compared with standard dosing of UFH for thromboprophylaxis on an elevated serum activated partial thromboplastin time (aPTT) during prolonged antepartum hospitalizations. METHODS This was a randomized trial of pregnant persons who were admitted in the antepartum period for at least 72 hours. Participants were randomly allocated to the standard dose of UFH (5,000 units subcutaneously every 12 hours) or the gestational age-based dose of UFH (first trimester [less than 14 weeks]: 5,000 units subcutaneously every 12 hours; second trimester [14-27 6/7 weeks]: 7,500 units subcutaneously every 12 hours; third trimester (28 weeks or more): 10,000 units subcutaneously every 12 hours). The primary outcome was the proportion of antepartum patients who had an elevated serum aPTT value above the normal range (more than 36.2 seconds) 6 hours after an UFH dose. Secondary outcomes included the development of venous thromboembolism (VTE) and reported side effects of heparin administration. RESULTS Between December 15, 2020, and April 1, 2022, 97 patients with antepartum hospitalizations were screened and 46 were randomized: 22 allocated to standard dosing and 24 allocated to gestational age-based dosing of UFH. A significantly greater proportion of antepartum patients who received gestational age-based dosing had an abnormal elevation in aPTT compared with those who received standard dosing (33.3% vs 4.8%, P =.02). Gestational age-based dosing resulted in higher maximum [interquartile range] aPTT (30.4 [27.4, 37.5] vs 26.6 [23.0, 29.6], P =.01) and anti-Xa levels (0.09 [0.09, 0.11] vs 0.09 [0.09, 0.09], P =.04). There was no significant difference in VTE between groups ( P =.47). CONCLUSION Gestational age-based dosing of UFH for thromboprophylaxis of antepartum hospitalizations was associated with significantly increased rates of elevated coagulation parameters compared with standard fixed dosing. This study suggests a need for close monitoring if higher doses of UFH during pregnancy are used later in gestation. The efficacy of gestational age-based dosing compared with standard dosing for UFH to prevent thromboembolic events remains an area for future investigation. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov , NCT04635839.
Collapse
Affiliation(s)
- Thalia Mok
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, the Department of Urology, and the Department of Anesthesiology, University of California, Los Angeles, and the Department of Clinical Pharmacy and Pediatrics, University of Southern California School of Pharmacy, Los Angeles, California
| | | | | | | | | | | | | |
Collapse
|
2
|
Chirumbole DL, Gandhi M, Clark SL, Tolcher MC. Pharmacologic venous thromboembolism prophylaxis for preterm prelabor rupture of membranes. Am J Obstet Gynecol MFM 2024; 6:101393. [PMID: 38821180 DOI: 10.1016/j.ajogmf.2024.101393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/24/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Pregnant patients with preterm prelabor rupture of membranes (PPROM) may experience prolonged hospitalization, which is an indication for pharmacologic venous thromboembolism (VTE) prophylaxis according to certain international guidelines. The proportion of patients who deliver unexpectedly and within a period during which pharmacologic prophylaxis would be expected to impact coagulation is unknown. OBJECTIVE To estimate the proportion of patients with PPROM who would deliver within 12 hours of typical dosing of pharmacologic VTE prophylaxis if administered routinely for antepartum admissions >72 hours. STUDY DESIGN This is a retrospective cohort study from a database including patients admitted for expectant management of PPROM January 2011 to September 2020. The outcome of the study was the proportion of patients who remained undelivered 72 hours after admission and experienced an unplanned delivery potentially within 12 hours of enoxaparin administration. We evaluated patients undelivered after 72 hours due to international recommendations to initiate VTE prophylaxis in hospitalized patients after 72 hours. Unplanned delivery was defined as onset of spontaneous labor or other indication for immediate delivery. Timing of delivery was analyzed based on usual timing of enoxaparin administration daily at approximately 8 am and the recommendation to withhold regional anesthesia until 12 hours after a prophylactic dose. RESULTS 1381 deliveries were identified as PPROM out of the 49,322 deliveries in our database. 139 cases were included after the following exclusions: delivery >35 weeks (N=641), rupture of membranes >34 weeks (N=145), delivery <72 hours after admission (N=409), insufficient data (N=35), and duplicates (N=12). Sixty of the 139 (43%) had an unplanned delivery, while 33 of these (24% of total) occurred within 12 hours of enoxaparin administration. CONCLUSION A quarter of patients admitted for PPROM had an unplanned delivery within 12 hours of typical enoxaparin dosing. This cohort may experience harm (ineligibility for regional anesthesia, risks of general anesthesia, increased risk of bleeding) if given routine pharmacologic VTE prophylaxis. Risk/benefit considerations should be discussed with patients in considering pharmacologic versus mechanical prophylaxis during prolonged hospitalization for PPROM.
Collapse
Affiliation(s)
- Danielle L Chirumbole
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX.
| | - Manisha Gandhi
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX
| | - Steven L Clark
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX
| | - Mary C Tolcher
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX
| |
Collapse
|
3
|
Stančiaková L, Brisudová K, Škorňová I, Bolek T, Samoš M, Biringer K, Staško J, Sokol J. Evaluating Thromboprophylaxis Strategies for High-Risk Pregnancy: A Current Perspective. Pharmaceuticals (Basel) 2024; 17:773. [PMID: 38931440 PMCID: PMC11207010 DOI: 10.3390/ph17060773] [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: 03/04/2024] [Revised: 05/27/2024] [Accepted: 05/30/2024] [Indexed: 06/28/2024] Open
Abstract
Venous thromboembolism (VTE) represents one of the leading causes of death during pregnancy. The greatest risk for it is the presence of medical or family history of VTE, stillbirth, cesarean section and selected thrombophilia. Appropriate thromboprophylaxis has the potential to decrease the risk of VTE in at-risk pregnant patients by 60-70%. Based on this, the authors reviewed the PubMed, Web of Science and Scopus databases to identify the possibilities of thromboprophylaxis in pregnant patients with a high risk of VTE. Moreover, they summarized its management in specific situations, such as cesarean delivery or neuraxial blockade. Currently, low-molecular-weight heparins (LMWH) are the preferred drugs for anticoagulant thromboprophylaxis in the course of pregnancy and postpartum due to easy administration and a lower rate of adverse events.
Collapse
Affiliation(s)
- Lucia Stančiaková
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Martin University Hospital, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 01 Martin, Slovakia; (I.Š.); (J.S.); (J.S.)
| | - Kristína Brisudová
- Department of Internal Medicine I., Martin University Hospital, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 01 Martin, Slovakia; (K.B.); (T.B.)
| | - Ingrid Škorňová
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Martin University Hospital, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 01 Martin, Slovakia; (I.Š.); (J.S.); (J.S.)
| | - Tomáš Bolek
- Department of Internal Medicine I., Martin University Hospital, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 01 Martin, Slovakia; (K.B.); (T.B.)
| | - Matej Samoš
- Department of Internal Medicine I., Martin University Hospital, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 01 Martin, Slovakia; (K.B.); (T.B.)
| | - Kamil Biringer
- Department of Gynecology and Obstetrics, Martin University Hospital, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 01 Martin, Slovakia;
| | - Ján Staško
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Martin University Hospital, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 01 Martin, Slovakia; (I.Š.); (J.S.); (J.S.)
| | - Juraj Sokol
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusion Medicine, Martin University Hospital, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 01 Martin, Slovakia; (I.Š.); (J.S.); (J.S.)
| |
Collapse
|
4
|
Shams D, Sachse K, Statzer N, Gupta RK. Regional Anesthesia Complications and Contraindications. Anesthesiol Clin 2024; 42:329-344. [PMID: 38705680 DOI: 10.1016/j.anclin.2023.11.013] [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: 05/07/2024]
Abstract
Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low. While a variety of different regional anesthesia techniques exist, complications tend to fall within 4 broad categories: block failure, bleeding/hematoma, neurological injury, and local anesthetic toxicity.
Collapse
Affiliation(s)
- Danial Shams
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Kaylyn Sachse
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Nicholas Statzer
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Rajnish K Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA.
| |
Collapse
|
5
|
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.
Collapse
Affiliation(s)
- Annabel K. Frank
- Division of Hematology/Oncology, Department of Medicine, University of California, San Francisco, California, USA
| | | |
Collapse
|
6
|
Aase TA, Rosseland LA. Response to: reply to: regional anaesthesia in patients on antithrombotic drugs. Eur J Anaesthesiol 2024; 41:392-393. [PMID: 38567681 DOI: 10.1097/eja.0000000000001963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Torger Aarstad Aase
- From Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway (TAA, LAR), and University of Oslo, Oslo, Norway (LAR)
| | | |
Collapse
|
7
|
Lau ES, Aggarwal NR, Briller JE, Crousillat DR, Economy KE, Harrington CM, Lindley KJ, Malhamé I, Mattina DJ, Meng ML, Mohammed SF, Quesada O, Scott NS. Recommendations for the Management of High-Risk Cardiac Delivery: ACC Cardiovascular Disease in Women Committee Panel. JACC. ADVANCES 2024; 3:100901. [PMID: 38939671 PMCID: PMC11198580 DOI: 10.1016/j.jacadv.2024.100901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/28/2023] [Accepted: 01/30/2024] [Indexed: 06/29/2024]
Abstract
Maternal mortality is a major public health crisis in the United States. Cardiovascular disease (CVD) is a leading cause of maternal mortality and morbidity. Labor and delivery is a vulnerable time for pregnant individuals with CVD but there is significant heterogeneity in the management of labor and delivery in high-risk patients due in part to paucity of high-quality randomized data. The authors have convened a multidisciplinary panel of cardio-obstetrics experts including cardiologists, obstetricians and maternal fetal medicine physicians, critical care physicians, and anesthesiologists to provide a practical approach to the management of labor and delivery in high-risk individuals with CVD. This expert panel will review key elements of management from mode, timing, and location of delivery to use of invasive monitoring, cardiac devices, and mechanical circulatory support.
Collapse
Affiliation(s)
- Emily S. Lau
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Niti R. Aggarwal
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
| | - Joan E. Briller
- Division of Cardiology, Department of Medicine, Obstetrics, and Gynecology, University of Illinois Chicago, Chicago, Illinois, USA
| | - Daniela R. Crousillat
- Division of Cardiovascular Sciences, Department of Medicine, Obstetrics, and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Katherine E. Economy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Colleen M. Harrington
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathryn J. Lindley
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Deirdre J. Mattina
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Selma F. Mohammed
- Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Odayme Quesada
- Women’s Heart Center, The Carl and Edyth Lindner Center for Research & Education, The Christ Hospital Network Heart & Vascular Institute, Cincinnati, Ohio, USA
| | - Nandita S. Scott
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - ACC Cardiovascular Disease in Women Committee
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
- Division of Cardiology, Department of Medicine, Obstetrics, and Gynecology, University of Illinois Chicago, Chicago, Illinois, USA
- Division of Cardiovascular Sciences, Department of Medicine, Obstetrics, and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska, USA
- Women’s Heart Center, The Carl and Edyth Lindner Center for Research & Education, The Christ Hospital Network Heart & Vascular Institute, Cincinnati, Ohio, USA
| |
Collapse
|
8
|
Barnes KN, Leader LD, Cieri-Hutcherson NE, Kelsey J, Hebert MF, Karaoui LR, McBane S. Peripartum Pharmacotherapy: A Pharmacist's Guide. J Pharm Pract 2024; 37:467-477. [PMID: 36427222 DOI: 10.1177/08971900221142681] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Complications throughout the peripartum period may be caused by preexisting conditions or pregnancy-induced conditions and may alter pharmacotherapy management. Pharmacotherapy management during late pregnancy and delivery requires careful consideration due to changing hormones, hemodynamic status, and pharmacokinetics, and concerns for potential maternal and/or fetal morbidity. Increased maternal and fetal monitoring are often required and may lead to therapy changes. Pharmacists, as key members of the interprofessional team, can contribute essential perspective to the management of postpartum pharmacotherapy through assessment and recommendation of appropriate and judicious use of medications.
Collapse
Affiliation(s)
- Kylie N Barnes
- Kansas City School of Pharmacy, University of Missouri, Kansas City, MO, USA
| | - Lauren D Leader
- Obstetrics and Gynecology, Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Nicole E Cieri-Hutcherson
- Pharmacy Practice, University at Buffalo School of Pharmacy and Pharmaceutical Sciences, Buffalo, NY, USA
| | | | - Mary F Hebert
- Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Lamis R Karaoui
- Department of Pharmacy Practice, Lebanese American University School of Pharmacy, Byblos, Lebanon
| | - Sarah McBane
- School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, CA, USA
| |
Collapse
|
9
|
Katz D, Farber M, Getrajdman C, Hamburger J, Reale S, Butwick A. The role of viscoelastic hemostatic assays for postpartum hemorrhage management and bedside intrapartum care. Am J Obstet Gynecol 2024; 230:S1089-S1106. [PMID: 38462250 DOI: 10.1016/j.ajog.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 03/12/2024]
Abstract
Viscoelastic hemostatic assays are point-of-care devices that assess coagulation and fibrinolysis in whole blood samples. These technologies provide numeric and visual information of clot initiation, clot strength, and clot lysis under low-shear conditions, and have been used in a variety of clinical settings and subpopulations, including trauma, cardiac surgery, and obstetrics. Emerging data indicate that these devices are useful for detecting important coagulation defects during major postpartum hemorrhage (especially low plasma fibrinogen concentration [hypofibrinogenemia]) and informing clinical decision-making for blood product use. Data from observational studies suggest that, compared with traditional formulaic approaches to transfusion management, targeted or goal-directed transfusion approaches using data from viscoelastic hemostatic assays are associated with reduced hemorrhage-related morbidity and lower blood product requirement. Viscoelastic hemostatic assays can also be used to identify and treat coagulation defects in patients with inherited or acquired coagulation disorders, such as factor XI deficiency or immune-mediated thrombocytopenia, and to assess hemostatic profiles of patients prescribed anticoagulant medications to mitigate the risk of epidural hematoma after neuraxial anesthesia and postpartum hemorrhage after delivery.
Collapse
Affiliation(s)
- Daniel Katz
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Michaela Farber
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Chloe Getrajdman
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joshua Hamburger
- Department of Anesthesiology, Perioperative, and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sharon Reale
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Alexander Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| |
Collapse
|
10
|
Scarpelli EM, Park CH, Jeng CL. Regional anesthesia and anticoagulation: a narrative review of current considerations. Int Anesthesiol Clin 2024; 62:1-9. [PMID: 38063032 DOI: 10.1097/aia.0000000000000420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Enrico M Scarpelli
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, New York, New York
| | - Chang H Park
- Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai Hospital, New York, New York
| | - Christina L Jeng
- Department of Anesthesiology, Perioperative and Pain Medicine; Orthopaedics; and Medical Education, Mount Sinai Hospital, New York, New York
| |
Collapse
|
11
|
Kevane B, Áinle FN. Prevention, diagnosis, and management of PE and DVT in pregnant women. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:237-247. [PMID: 38066865 PMCID: PMC10727078 DOI: 10.1182/hematology.2023000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Venous thromboembolism (VTE) is a leading cause of maternal morbidity and mortality worldwide. Despite the impact of VTE on pregnant and postpartum people and on society, guidelines addressing prevention, diagnosis, and management of VTE in pregnant and postpartum people frequently are based on recommendations from expert opinion and are extrapolated from data in nonpregnant populations. Pregnant individuals are frequently excluded from clinical trials, which is a barrier to providing safe, effective care. Anchoring to a case discussion, this review provides an update on recently published and ongoing randomized clinical trials (RCTs), prospective clinical management studies, and other research in this area. It highlights, in particular, the results of the Highlow RCT, which addresses optimal prevention of recurrence during pregnancy in people with prior VTE. Finally, we raise awareness of the impact of national and international clinical trial networks on the conduct of RCTs in pregnancy. We conclude, based on these data, that academic VTE clinical trials in pregnant women can and must be done.
Collapse
Affiliation(s)
- Barry Kevane
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- Department of Hematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- Department of Hematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| |
Collapse
|
12
|
Vinsard PA, Arendt KW, Sharpe EE. Care for the Obstetric Patient with Complex Cardiac Disease. Adv Anesth 2023; 41:53-69. [PMID: 38251622 DOI: 10.1016/j.aan.2023.05.004] [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: 01/23/2024]
Abstract
The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.
Collapse
Affiliation(s)
- Patrice A Vinsard
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| |
Collapse
|
13
|
Aase TA, Rosseland LA. Regional anaesthesia in patients on antithrombotic drugs. Eur J Anaesthesiol 2023; 40:959. [PMID: 37909158 DOI: 10.1097/eja.0000000000001871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Affiliation(s)
- Torger Aa Aase
- From the Division of Emergencies and Critical Care, Department of Anaesthesiology and Intensive Care Medicine (TAA), Division of Emergencies and Critical Care, Department of Research and Development, Oslo University Hospital (LAR) and Institute of Clinical Medicine, University of Oslo, Oslo, Norway (LAR)
| | | |
Collapse
|
14
|
Jones Pullins M, Boggess K, Porter TF. Aspirin in Pregnancy. Obstet Gynecol 2023; 142:1333-1340. [PMID: 37917941 DOI: 10.1097/aog.0000000000005429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/31/2023] [Indexed: 11/04/2023]
Abstract
Preeclampsia is associated with significant perinatal morbidity and mortality. Aspirin has been long purported and extensively studied for prevention of preeclampsia. For this reason, the U.S. Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine recommend its use in pregnancy for preeclampsia prevention in those at high risk. Yet, much controversy exists regarding optimal use in pregnancy with guidelines across global organizations varying. In this narrative review, we summarize the published literature related to the safety, optimal dose, and timing and duration of use of aspirin, as well as other indications for which aspirin has been studied in pregnancy.
Collapse
Affiliation(s)
- Maura Jones Pullins
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and the Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, Utah
| | | | | |
Collapse
|
15
|
Mauny L, Peyronnet V, Peynaud-Debayle E, Picone O, Nebout S, Mandelbrot L. Induction or spontaneous labor for pregnant patients on anticoagulants? J Gynecol Obstet Hum Reprod 2023; 52:102623. [PMID: 37308038 DOI: 10.1016/j.jogoh.2023.102623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/08/2023] [Accepted: 06/09/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE There are two approaches to peripartum management for pregnant patients undergoing anticoagulation treatments: spontaneous labor or scheduling an induction. A long interval without anticoagulation is a thrombosis risk factor, while a short interval leads to risks of delivery without epidural analgesia or post partum hemorrhage. Our objective was to evaluate the impact of planned induction versus spontaneous labor on obtaining neuraxial analgesia. MATERIALS AND METHODS A retrospective single-center study was conducted from 2012 to 2020 including all patients on preventive or curative low molecular-weight heparin at the time of delivery, excluding planned cesarean sections. The rates of neuraxial analgesia were compared between two groups: spontaneous labor and induction, as well as the intervals without anticoagulants. RESULTS 127 patients were included. In the spontaneous labor group, 78% (44/56) received neuraxial analgesia versus 88% (37/42) in the induction group (p = 0.29). For curative dose treatment, the rate of neuraxial analgesia was 45,5% in the spontaneous group versus 78,6% (p = 0.12). The median time without anticoagulation was 34 h [26-46] in the spontaneous labor group and 43 h [34-54] in the induction group (p = 0.01), without an increased incidence of thrombosis. The rate of postpartum hemorrhage did not differ between the two groups. CONCLUSION Planned induction tended to increase the rate of neuraxial analgesia, without reaching significance, and most women in spontaneous labor accessed analgesia. Peripartum management should be a shared decision with the patient considering the obstetrical and thrombosis risk context for each patient.
Collapse
Affiliation(s)
- Lea Mauny
- Assistance Publique des Hôpitaux de Paris Department of Obstetrics and Gynecology, Hôpital Louis Mourier, Colombes, France; Université Paris Cité, Paris, France
| | - Violaine Peyronnet
- Assistance Publique des Hôpitaux de Paris Department of Obstetrics and Gynecology, Hôpital Louis Mourier, Colombes, France; Fédération Hospital-universitaire PREMA, Paris, France.
| | - Edith Peynaud-Debayle
- Assistance Publique des Hôpitaux de Paris Department of Hematology, Hôpital Louis Mourier, Colombes, France
| | - Olivier Picone
- Assistance Publique des Hôpitaux de Paris Department of Obstetrics and Gynecology, Hôpital Louis Mourier, Colombes, France; Université Paris Cité, Paris, France; Fédération Hospital-universitaire PREMA, Paris, France; Inserm IAME, Paris, France
| | - Sophie Nebout
- Assistance Publique des Hôpitaux de Paris Department of Anethesiology, Hôpital Louis Mourier, Colombes, France
| | - Laurent Mandelbrot
- Assistance Publique des Hôpitaux de Paris Department of Obstetrics and Gynecology, Hôpital Louis Mourier, Colombes, France; Université Paris Cité, Paris, France; Fédération Hospital-universitaire PREMA, Paris, France; Inserm IAME, Paris, France
| |
Collapse
|
16
|
Benhamou D, Mercier FJ, Van de Velde M, Lucas N, Sng BL, Gaiser R. Education in obstetric anesthesiology: an international approach. Int J Obstet Anesth 2023; 55:103896. [PMID: 37270857 DOI: 10.1016/j.ijoa.2023.103896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/26/2023] [Accepted: 04/24/2023] [Indexed: 06/06/2023]
Abstract
Competency-based training and active teaching methods are increasingly becoming accepted and utilized in medical schools and hospitals, and obstetric anesthesiology training is expected to follow this process. This article summarizes current modalities of obstetric anesthesiology training in five countries from various parts of the world. Analysis of these curricula shows that implementation of new educational methods is variable, incomplete, and lacking in data related to patient outcomes. Research in assessments and practical applications are required to avoid wide ranges of educational strategies.
Collapse
Affiliation(s)
- D Benhamou
- Service d'Anesthésie Réanimation Médecine Péri Opératoire, AP-HP.Université Paris Saclay, Hôpital Bicêtre, Le Kremlin Bicêtre Cedex, France.
| | - F J Mercier
- Service d'Anesthésie Réanimation Médecine Péri Opératoire, AP-HP.Université Paris Saclay, Hôpital Antoine Béclère, Clamart Cedex, France
| | - M Van de Velde
- Department of Cardiovascular Sciences, KU Leuven, and Department of Anaesthesiology, UZ Leuven, Leuven, Belgium
| | - N Lucas
- London North West Healthcare NHS Trust, United Kingdom
| | - B L Sng
- Anesthesiology and Perioperative Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore and Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
| | - R Gaiser
- Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
17
|
Smiley RM, Chen CJ. Use of protamine to reverse therapeutic heparin infusion in a post-cesarean patient with postoperative hemorrhage. Int J Obstet Anesth 2023; 55:103879. [PMID: 37024394 DOI: 10.1016/j.ijoa.2023.103879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/01/2023] [Accepted: 03/16/2023] [Indexed: 03/28/2023]
Affiliation(s)
- R M Smiley
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA.
| | - C-J Chen
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| |
Collapse
|
18
|
Warrick CM, Sutton CD, Farber MM, Hess PE, Butwick A, Markley JC. Anesthesia Considerations for Placenta Accreta Spectrum. Am J Perinatol 2023; 40:980-987. [PMID: 37336215 DOI: 10.1055/s-0043-1761637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Anesthesiologists are critical members of the multidisciplinary team managing patients with suspected placenta accreta spectrum (PAS). Preoperatively, anesthesiologists provide predelivery consultation for patients with suspected PAS where anesthetic modality and invasive monitor placement is discussed. Additionally, anesthesiologists carefully assess patient and surgical risk factors to choose an anesthetic plan and to prepare for massive intraoperative hemorrhage. Postoperatively, the obstetric anesthesiologist hold unique skills to assist with postoperative pain management for cesarean hysterectomy. We review the unique aspects of peripartum care for patients with PAS who undergo cesarean hysterectomy and explain why these responsibilities are critical for achieving successful outcomes for patients with PAS. KEY POINTS: · Anesthesiologists are critical members of the multidisciplinary team planning for patients with suspected placenta accreta spectrum.. · Intraoperative preparation for massive hemorrhage is a key component of anesthetic care for patients with PAS.. · Obstetric anesthesiologists have a unique skill set to manage postpartum pain and postoperative disposition for patients with PAS who undergo cesarean hysterectomy..
Collapse
Affiliation(s)
- Christine M Warrick
- Department of Anesthesiology, School of Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - Caitlin D Sutton
- Department of Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Michaela M Farber
- Department of Anesthesiology, Perioperative, and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Philip E Hess
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Alexander Butwick
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University Medical Center, Palo Alto, California
| | - John C Markley
- Department of Anesthesia and Perioperative Care, University of California San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
| |
Collapse
|
19
|
Webster LA, Bishay V. Venous Thromboembolism Management in Pregnant Patients. Tech Vasc Interv Radiol 2023; 26:100901. [PMID: 37865451 DOI: 10.1016/j.tvir.2023.100901] [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: 10/23/2023]
Abstract
Pulmonary embolism (PE) in pregnancy accounts for 10% of maternal deaths in the United States. As maternal morbidity and mortality continue to increase, it is imperative for all specialties interfacing with pregnant patients to understand the current research and guidelines surrounding risk stratification, diagnosis, and treatments of PE in pregnancy. Given the complexity of high-risk pregnancy-associated PE (PA-PE), that is, which is associated with hemodynamic instability or collapse, and the rising popularity of new technologies to treat high-risk PA-PE in the nonpregnant population, this review aims to emphasize the differences in diagnosis, risk stratification, and management of the pregnant and nonpregnant PE patients. Furthermore, this review will cover treatment paradigms that include anticoagulation versus advanced therapies such as systemic thrombolysis, surgical embolectomy, extracorporeal membrane oxygenation, and inferior vena cava disruption as well as the more novel therapies which fall under the umbrella term of catheter-based treatments. Finally, this review will include a case-based review of 2 patients with PA-PE requiring catheter-based therapies and their ultimate clinical outcomes.
Collapse
Affiliation(s)
- Linzi A Webster
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular & Interventional Radiology, Mount Sinai Health System, New York, NY
| | - Vivian Bishay
- Division of Vascular and Interventional Radiology, Department of Diagnostic, Molecular & Interventional Radiology, Mount Sinai Health System, New York, NY.
| |
Collapse
|
20
|
Samuelson Bannow B, Federspiel JJ, Abel DE, Mauney L, Rosovsky RP, Bates SM. Multidisciplinary care of the pregnant patient with or at risk for venous thromboembolism: a recommended toolkit from the Foundation for Women and Girls with Blood Disorders Thrombosis Subcommittee. J Thromb Haemost 2023; 21:1432-1440. [PMID: 36972785 PMCID: PMC10192106 DOI: 10.1016/j.jtha.2023.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/28/2023] [Accepted: 03/05/2023] [Indexed: 03/29/2023]
Abstract
The care of pregnant persons with/at risk of venous thromboembolism is complex and often challenging. Although guidelines have been published regarding the use of specific therapies, such as anticoagulants; in this population, none have provided guidance on how to coordinate multidisciplinary care of these patients. Here we provide an expert consensus on the role of various providers in the care of this patient population, as well as necessary resources and suggestions for best practices.
Collapse
Affiliation(s)
| | - Jerome J Federspiel
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, USA
| | - David E Abel
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Logan Mauney
- Department of Obstetrics and Gynecology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel P Rosovsky
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shannon M Bates
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
21
|
Meng ML, Arendt KW, Banayan JM, Bradley EA, Vaught AJ, Hameed AB, Harris J, Bryner B, Mehta LS. Anesthetic Care of the Pregnant Patient With Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e657-e673. [PMID: 36780370 DOI: 10.1161/cir.0000000000001121] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location, and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.
Collapse
|
22
|
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.
| |
Collapse
|
23
|
Saad A, Safarzadeh M, Shepherd M. Anticoagulation Regimens in Pregnancy. Obstet Gynecol Clin North Am 2023; 50:241-249. [PMID: 36822707 DOI: 10.1016/j.ogc.2022.10.010] [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: 02/23/2023]
Abstract
This article explores current recommendations for anticoagulation therapy in pregnancy, including antepartum, intrapartum, and postpartum guidelines. The authors review various screening strategies used to assess whether a patient is an appropriate candidate for anticoagulation during pregnancy and the postpartum period. The article includes dosing regimens, optimal surveillance, and medication reversal. The authors also address the challenges of transitioning between low-molecular-weight heparin and unfractionated heparin. Finally, there is a discussion of intrapartum anticoagulation management, especially as it relates to the administration of regional anesthesia, and the indications for and timing of thromboprophylaxis following delivery.
Collapse
Affiliation(s)
- Antonio Saad
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77555, USA.
| | - Melody Safarzadeh
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77555, USA
| | - Megan Shepherd
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch at Galveston, 301 University Boulevard, Galveston, TX 77555, USA
| |
Collapse
|
24
|
Nicholas A, Countouris M, Jeyabalan A, Lim G. A Case Series of Parturients With Mechanical Mitral Valves: Anticoagulation Management During Labor and Delivery. JACC Case Rep 2023; 9:101741. [PMID: 36909263 PMCID: PMC9998718 DOI: 10.1016/j.jaccas.2023.101741] [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: 12/20/2022] [Accepted: 12/27/2022] [Indexed: 03/05/2023]
Abstract
More women with mechanical mitral valves (MMVs) are pursuing pregnancy. Guidelines exist for pregnancy anticoagulation, but they do not address individualized anticoagulation during delivery-a period of risk for bleeding, thrombosis, and anesthetic complications. This case series of parturients with MMVs highlights the challenges in, and the evidence and strategies for, treating these patients. (Level of Difficulty: Advanced.).
Collapse
Affiliation(s)
- Alexandra Nicholas
- Division of Obstetric and Women's Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, UPMC Magee Women's Hospital, Pittsburgh, Pennsylvania, USA.,Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Malamo Countouris
- Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arun Jeyabalan
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Grace Lim
- Division of Obstetric and Women's Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, UPMC Magee Women's Hospital, Pittsburgh, Pennsylvania, USA.,Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
25
|
Surgical Emergencies in the Pregnant Patient. Curr Probl Surg 2023; 60:101304. [PMID: 37169419 DOI: 10.1016/j.cpsurg.2023.101304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
|
26
|
Albright CM, Steiner J, Sienas L, Delgado C, Buber J. Main operating room deliveries for patients with high-risk cardiovascular disease. Open Heart 2023; 10:openhrt-2022-002213. [PMID: 36787936 PMCID: PMC9930549 DOI: 10.1136/openhrt-2022-002213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/27/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND High-risk cardiovascular disease (CVD) prevalence in pregnant patients is increasing. Management of this complex population is not well studied, and little guidance is available regarding labour and delivery planning for optimal outcomes. OBJECTIVE We aimed to describe the process for and outcomes of our centre's experience with the main operating room (OR) caesarean deliveries for patients with high-risk CVD, including procedural and postpartum considerations. STUDY DESIGN We performed a retrospective evaluation of pregnant patients with high-risk CVD who delivered in the main OR at a large academic centre between January 2010 and March 2021. Patients were classified by CVD type: adult congenital heart disease, cardiac arrest, connective tissue disease with aortopathy, ischaemic cardiomyopathy, non-ischaemic cardiomyopathy or valve disease. We examined demographic, anaesthetic and procedure-related variables and in-hospital maternal and fetal outcomes. Multidisciplinary delivery planning was evaluated before and after formalising a cardio-obstetrics programme. RESULTS Of 25 deliveries, connective tissue disease (n=9, 36%) was the most common CVD type, followed by non-ischaemic cardiomyopathy (n=5, 20%). Scheduled deliveries that went as initially planned occurred for six patients (24%). Fourteen (56%) were unscheduled and urgent or emergent. Patients in modified WHO Class IV frequently underwent unscheduled, urgent deliveries (64%). Most deliveries were safely achieved with neuraxial regional anaesthesia (80%) and haemodynamic monitoring via arterial lines (88%). Postdelivery intensive care unit stays were common (n=18, 72%), but none required mechanical circulatory support. There were no in-hospital maternal or perinatal deaths; 60-day readmission rate was 16%. Some delivery planning was achieved for most patients (n=21, 84%); more planning was evident after establishing a cardio-obstetrics programme. Outcomes did not differ significantly by CVD group or delivery era. CONCLUSIONS Our experience suggests that short-term outcomes of pregnant patients with high-risk CVD undergoing main OR delivery are favourable. Multidisciplinary planning may support the success of these complex cases.
Collapse
Affiliation(s)
- Catherine M Albright
- Department of Obstetrics and Gynecology, University of Washington Medical Center, Seattle, Washington, USA
| | - Jill Steiner
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Laura Sienas
- Women’s Healthcare Associates, Northwest Perinatal Center, Portland, Oregon, USA
| | - Carlos Delgado
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, Washington, USA
| | - Jonathan Buber
- Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA
| |
Collapse
|
27
|
Hale J, Galanti G, Langer A, Lassey S, Reiff E, Camann W. A Case Report of Rotational Thromboelastometry-Assisted Decision Analysis for Two Pregnant Patients With Platelet Storage Pool Disorder. A A Pract 2023; 17:e01658. [PMID: 36800513 DOI: 10.1213/xaa.0000000000001658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Platelet storage pool disorders (PSPDs) constitute a diverse group of hematologic abnormalities, which share the common feature of a deficiency in the ability of platelets to aggregate. Parturients with PSPD can present management challenges to their care team when they present for childbirth, especially with regard to neuraxial anesthesia. We report a series of 2 deliveries from unrelated patients affected by PSPD. In particular, we highlight the utility of rotational thromboelastometry (ROTEM) and the need for a multidisciplinary approach to the care of patients with this hematologic abnormality.
Collapse
Affiliation(s)
- John Hale
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
| | - Gregory Galanti
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
| | | | - Sarah Lassey
- Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily Reiff
- Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William Camann
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
| |
Collapse
|
28
|
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. J Thromb Haemost 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] [MESH Headings] [Track Full Text] [Journal Information] [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.
Collapse
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
| |
Collapse
|
29
|
Yurashevich M, Taylor CR, Dominguez JE, Habib AS. Anesthesia and Analgesia for the Obese Parturient. Adv Anesth 2022; 40:185-200. [PMID: 36333047 DOI: 10.1016/j.aan.2022.07.004] [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: 11/07/2022]
Abstract
Obesity is a worldwide epidemic and is associated with an increased risk of hypertension, diabetes, and obstructive sleep apnea. Pregnant patients with obesity experience a higher risk of maternal and fetal complications. Anesthesia also poses higher risks for obese parturients and may be more technically challenging due to body habitus. Safe anesthesia practice for these patients must take into consideration the unique challenges associated with the combination of pregnancy and obesity.
Collapse
Affiliation(s)
- Mary Yurashevich
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University School of Medicine, Durham, NC 27710, USA
| | - Cameron R Taylor
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University School of Medicine, Durham, NC 27710, USA
| | - Jennifer E Dominguez
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University School of Medicine, Durham, NC 27710, USA
| | - Ashraf S Habib
- Department of Anesthesiology, Division of Women's Anesthesia, Duke University School of Medicine, Durham, NC 27710, USA.
| |
Collapse
|
30
|
Schrufer-Poland TL, Florio K, Grodzinsky A, Borsa JJ, Schmidt L. Management of May Thurner Syndrome in Pregnant Patients. J Cardiovasc Dev Dis 2022; 9:jcdd9120410. [PMID: 36547407 PMCID: PMC9784684 DOI: 10.3390/jcdd9120410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/12/2022] [Accepted: 11/14/2022] [Indexed: 11/24/2022] Open
Abstract
May Thurner Syndrome contributes to thromboembolic disease and can cause significant morbidity in pregnant patients secondary to exaggerated anatomic relationships and physiologic changes in the hematologic system favoring thrombogenesis. Because this condition is both underrecognized and underreported, management in pregnant and postpartum patients is based on expert opinion without any formal evidence-based guidance. Herein, we review five pregnancies in four patients with May Thurner Syndrome and general management strategies. Through collaborative and multidisciplinary care, patients with May Thurner Syndrome can be safely and successfully managed during pregnancy and the postpartum period with appropriate anticoagulation.
Collapse
Affiliation(s)
- Tabitha L. Schrufer-Poland
- Maternal and Fetal Medicine, Saint Luke’s Health System, Kansas City, MO 64111, USA
- Cardiovascular Outcomes Research Department, Saint Luke’s Health System, Kansas City, MO 64111, USA
- Correspondence:
| | - Karen Florio
- Maternal and Fetal Medicine, Saint Luke’s Health System, Kansas City, MO 64111, USA
- Cardiovascular Outcomes Research Department, Saint Luke’s Health System, Kansas City, MO 64111, USA
| | - Anna Grodzinsky
- Cardiovascular Outcomes Research Department, Saint Luke’s Health System, Kansas City, MO 64111, USA
| | - John J. Borsa
- Department of Radiology, Saint Luke’s Health System, Kansas City, MO 64111, USA
- Department of Radiology, University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Laura Schmidt
- Cardiovascular Outcomes Research Department, Saint Luke’s Health System, Kansas City, MO 64111, USA
| |
Collapse
|
31
|
Sun P, Liang XQ, Hong T, Zhang H. Perioperative management of acute myocardial infarction in the 31st week of pregnancy: A case report and literature review. Front Surg 2022; 9:1023551. [DOI: 10.3389/fsurg.2022.1023551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
Pregnancy-related acute myocardial infarction (PAMI) is rare but life-threatening. The incidence of PAMI is growing over time for multiple reasons, and the management of parturients with acute myocardial infarction is challenging in terms of diagnosis and treatment. To date, there are still no clear guidelines on the best practice for PAMI. We present a case of a 41-year-old woman with PAMI at 31 weeks of pregnancy. Through multidisciplinary collaboration, successful outcomes were achieved for both the mother and fetus.
Collapse
|
32
|
Mohammad-Akbari A, Mohazzab A, Tavakoli M, Karimi A, Zafardoust S, Zolghadri Z, Shahali S, Tokhmechi R, Ansaripour S. The effect of low-molecular-weight heparin on live birth rate of patients with unexplained early recurrent pregnancy loss: A two-arm randomized clinical trial. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2022; 27:78. [PMID: 36438075 PMCID: PMC9693726 DOI: 10.4103/jrms.jrms_81_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/26/2022] [Accepted: 05/30/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND The effect of anticoagulant medication in unexplained early recurrent pregnancy loss (RPL) patients is controversial. This clinical trial evaluated the effect of low-molecular-weight heparin (LMWH) on pregnancy outcomes in these patients. MATERIALS AND METHODS The study was performed as a single-blind randomized clinical trial between 2016 and 2018. Samples were selected from patients who were referred to Avicenna RPL clinic with a history of at least two previously happened early unexplained miscarriages. The eligibility was defined strictly to select unexplained RPL patients homogenously. One hundred and seventy-three patients who got pregnant recently were allocated randomly into two groups LMWH plus low-dose aspirin treatment (Group A = 85) and low-dose aspirin treatment only (Group B = 88)) and were followed up till their pregnancy termination (delivery/abortion). A per-protocol analysis was carried out and all statistical tests were two-sided with a P < 0.05 significance level. RESULTS The live birth rates (LBRs) in Groups A and B were 78% and 77.1%, respectively, which did not show any statistically significant difference between the two groups, neither in rates nor in time of abortion. In subgroup analysis for polycystic ovary syndrome (PCOS) patients, the odds ratio for study outcome (intervention/control) was 2.25 (95% confidence interval: 0.65-7.73). There was no major adverse event whereas minor bleeding was observed in 18% of patients in Group A. CONCLUSION LMWH does not improve the LBR in unexplained RPL patients, however, it is recommended to evaluate its effect separately in PCOS patients.
Collapse
Affiliation(s)
- Azam Mohammad-Akbari
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran,Avicenna Fertility Center, Tehran, Iran
| | - Arash Mohazzab
- Department of Epidemiology, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Tavakoli
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran
| | - Atousa Karimi
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran,Avicenna Fertility Center, Tehran, Iran
| | - Simin Zafardoust
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran,Avicenna Fertility Center, Tehran, Iran
| | - Zhaleh Zolghadri
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran,Avicenna Fertility Center, Tehran, Iran
| | - Shadab Shahali
- Department of Reproductive Health and Midwifery, Tarbiat Modares University, Tehran, Iran
| | | | - Soheila Ansaripour
- Reproductive Biotechnology Research Center, ACECR, Avicenna Research Institute, Tehran, Iran,Avicenna Fertility Center, Tehran, Iran,Address for correspondence: Prof. Soheila Ansaripour, Avicenna Research Institute, Evin, Daneshjoo Blvd, Chamran Exp.Way, Tehran 1936773493, Iran. E-mail:
| |
Collapse
|
33
|
León-García M, Humphries B, Maraboto A, Rabassa M, Boehmer KR, Perestelo-Perez L, Xie F, Pelayo I, Eckman M, Bates S, Selva A, Alonso-Coello P. Women's values and preferences on low-molecular-weight heparin and pregnancy: a mixed-methods systematic review. BMC Pregnancy Childbirth 2022; 22:747. [PMID: 36199014 PMCID: PMC9533610 DOI: 10.1186/s12884-022-05042-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/09/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) in pregnancy is an important cause of maternal morbidity and mortality. Low-molecular-weight heparin (LMWH) is the cornerstone of prophylaxis and treatment of thrombotic events during pregnancy. LMWH has fewer adverse effects than other anticoagulants, does not cross the placenta, and is safe for the fetus. However, the use of LMWH during pregnancy is sensitive to womens' underlying preferences. The objective of this review is to systematically assess women's values and preferences research evidence on this topic. METHODS We searched four electronic databases from inception to March 2022, and included studies examining values and preferences of using LMWH among pregnant women at risk of VTE. We followed a convergent integrated mixed-methods design to compare and contrast quantitative outcomes (utility and non-utility measures) and qualitative findings. We assessed the certainty of the values and preferences evidence with the GRADE approach for quantitative findings, and with GRADE-CERqual for qualitative evidence. Results were presented in a conjoint display. RESULTS We screened 3,393 references and identified seven eligible studies. The mixed methods analysis resulted in four themes. Datasets confirmed each other in that: 1) the majority of women consider that benefits of treatment outweigh the inconveniences of daily injections; and 2) main concerns around medication are safety and injections administration. Quantitative outcomes expanded on the qualitative findings in that: 3) participants who perceived a higher risk of VTE were more willing to take LMWH. Finally, we found a discrepancy between the datasets around: 4) the amount of information preferred to make the decision; however, qualitative data expanded to clarify that women prefer making informed decisions and receive support from their clinician in their decision-making process. CONCLUSIONS We are moderately confident that in the context of pregnancy, using LMWH is preferred by women given its net beneficial balance. Integrating data from different sources of evidence, and representing them in a jointly manner helps to identify patient's values and preferences. Our results may inform clinical practice guidelines and support shared decision-making process in the clinical encounter for the management of VTE in the context of pregnancy.
Collapse
Affiliation(s)
- Montserrat León-García
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain.
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain.
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Brittany Humphries
- Cytel Inc, Toronto, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Andrea Maraboto
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Kasey R Boehmer
- Knowledge and Evaluation Research Unit, Department of Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Lilisbeth Perestelo-Perez
- Evaluation Unit (SESCS), Canary Islands Health Service (SCS), Tenerife, Spain
- Research Network On Health Services in Chronic Diseases (REDISSEC), Tenerife, Spain
- Network for Research On Chronicity, Primary Care, and Health Promotion (RICAPPS), Tenerife, Spain
| | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Irene Pelayo
- Department of Obstetrics and Gynecology, Ramón y Cajal Hospital, Madrid, Spain
- Faculty of Medicine, Alcalá de Henares University, Madrid, Spain
| | - Mark Eckman
- Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Shannon Bates
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Anna Selva
- Department of Pediatrics, Obstetrics, Gynaecology and Preventive Medicine, Universidad Autónoma de Barcelona, Barcelona, Spain
- Clinical Epidemiology and Cancer Screening, Corporació Sanitaria Parc Taulí, Sabadell, Barcelona, Spain
| | - Pablo Alonso-Coello
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- CIBER of Epidemiology and Public Health, CIBERESP, Madrid, Spain
| |
Collapse
|
34
|
Barnes C, Mignacca E, Mabbott K, Officer K, Hauck Y, Bradfield Z. Using a scheduled caesarean birth plan: A cross-sectional exploration of women's perspectives. Women Birth 2022; 36:264-270. [PMID: 36137931 DOI: 10.1016/j.wombi.2022.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/02/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022]
Abstract
PROBLEM There is minimal evidence regarding the role or impact of birth plans from the perspective of women experiencing scheduled caesarean birth. BACKGROUND Quality maternity care requires respect for women's preferences. Evidence suggests birth plans enable communication of women's preferences and may enhance agency when vaginal birth is intended, however there is limited evidence of how this translates in the perioperative environment where caesarean birth is the intended outcome. AIM Explore the experiences and perspectives of women who had utilised a scheduled caesarean birth plan at an Australian tertiary maternity hospital. METHODS A cross-sectional design was used; 294 participants completed the survey within two weeks post-birth. Descriptive statistics were used to analyse quantitative data, qualitative responses were analysed using content analysis. FINDINGS Over half of the women requested lowering of the surgical-screen at birth, most requested immediate skin-to-skin with their babies; around two-thirds of these preferences were met. Use of a birth plan for scheduled caesarean section supported women's ability to communicate their desires and choices, enhancing agency and reinforcing the significance of the caesarean birth experience. Qualitative data revealed two main categories: Perceptions and experiences; and Recommendations for improvement, with corresponding sub-categories. DISCUSSION Findings provide unique opportunities to consider the provision of woman-centred care within the highly technocratic perioperative environment. CONCLUSION All women, regardless of birth mode, have a right to respectful maternity care that prioritises their wishes and agency. This study provides evidence for the positive utility of birth plans in caesarean birth, local adaptation is encouraged.
Collapse
Affiliation(s)
| | - Emily Mignacca
- King Edward Memorial Hospital, Western Australia, Australia
| | - Kelly Mabbott
- King Edward Memorial Hospital, Western Australia, Australia
| | - Kirsty Officer
- King Edward Memorial Hospital, Western Australia, Australia
| | - Yvonne Hauck
- School of Nursing, Curtin University, Western Australia, Australia; King Edward Memorial Hospital, Western Australia, Australia
| | - Zoe Bradfield
- School of Nursing, Curtin University, Western Australia, Australia; King Edward Memorial Hospital, Western Australia, Australia.
| |
Collapse
|
35
|
Clark KJ, Arendt KW, Rehfeldt KH, Sviggum HP, Kauss ML, Ammash NM, Rose CH, Sharpe EE. Peripartum anesthetic management in patients with left ventricular noncompaction: a case series and review of the literature. Int J Obstet Anesth 2022; 52:103575. [PMID: 35905687 DOI: 10.1016/j.ijoa.2022.103575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 06/18/2022] [Accepted: 06/29/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND This retrospective review focuses on peripartum anesthetic management and outcome of a series of five pregnant women with left ventricular noncompaction (LVNC). METHODS The Mayo Clinic Advanced Cohort Explorer medical database was utilized to identify women diagnosed with LVNC who had been admitted for delivery at the Mayo Clinic in Rochester, Minnesota between January 2001 and September 2021. Echocardiograms were independently reviewed by two board-certified echocardiographers, and those determined by both to meet the Jenni criteria and/or having compatible findings on magnetic resonance imaging (MRI) were included. Electronic medical records were reviewed for information pertaining to cardiac function, labor, delivery, and postpartum management. RESULTS We identified 44 patients whose medical record included the term "noncompaction" or "hypertrabeculation" and who had delivered at our institution during the study period. Upon detailed review of the medical records, 36 did not meet criteria for LVNC, and three additional patients did not receive the diagnosis until after delivery, leaving five patients with confirmed LVNC who had undergone six deliveries during the study interval. All five patients had a history of arrhythmias or had developed arrhythmias during pregnancy. One patient underwent emergency cesarean delivery due to sustained ventricular tachycardia requiring three intra-operative cardioversions. CONCLUSIONS This case series adds new evidence to that already available about pregnancies among women with LVNC. Favorable obstetrical outcomes were achievable when multidisciplinary teams were prepared to manage the maternal and fetal consequences of intrapartum cardiac arrhythmias and hemodynamic instability.
Collapse
Affiliation(s)
- K J Clark
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - K W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - K H Rehfeldt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - H P Sviggum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - M L Kauss
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - N M Ammash
- Department of Cardiovascular Disease, Sheikh Shakhbout Medical City in Partnership with Mayo Clinic, Ghweifast International Highway, Abu Dhabi, United Arab Emirates
| | - C H Rose
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Mayo Clinic, Rochester, MN, USA
| | - E E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
36
|
Katz D, Leffert L, Getrajdman C, Sison M, Shin DW, Lin HM, Butwick A. The relationship between INTEM/HEPTEM coagulation time ratio and heparin plasma concentration in obstetric patients: an exploratory in vitro investigation. Can J Anaesth 2022; 69:597-604. [PMID: 35102496 DOI: 10.1007/s12630-022-02193-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Unfractionated heparin continues to be one of the main agents used for thromboprophylaxis in obstetrics, which can complicate the placement of neuraxial anesthetics. In this study, we explored the relationship between a point-of-care coagulation test (thromboelastometry) and plasma heparin concentrations in vitro. METHODS We obtained blood from consenting obstetric patients with uncomplicated pregnancies in their third trimester who were not in labour and had a specific hematocrit range. Blood was processed and analyzed. We added increasing amounts of unfractionated heparin to samples from 0 to 0.3 U·mL-1 in 0.05 U·mL-1 increments to simulate increasing doses of unfractionated heparin. We performed INTEM and HEPTEM testing in parallel with activated partial thromboplastin time (aPTT) testing. We created a model of the relationship between heparin concentration and the INTEM/HEPTEM coagulation time (IH CT) ratio using nonlinear regression. A similar model for aPTT was also created. RESULTS Seventy-seven patients were included in the study. Only one concentration of heparin was added to blood samples of each patient. At a concentration of 0.05 U·mL-1, the IH CT ratio was less than or equal to 1.1 in 9/11 (82%) samples. Activated partial thromboplastin time was not prolonged (> 35 sec) until a concentration of 0.1 U·mL-1 heparin was added. In all samples, the IH CT ratio was prolonged at a concentration ≥ 0.2 U·mL-1 as measured by thromboelastometry; however, at no concentration of heparin was aPTT prolonged in all samples. CONCLUSION The point-of-care IH CT ratio may be useful in identifying the presence of little to no heparin activity. Further research is needed to determine if this ratio can predict heparin activity in vivo.
Collapse
Affiliation(s)
- Daniel Katz
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA
| | - Lisa Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Chloe Getrajdman
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA.
| | - Matthew Sison
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA
| | - Da Wi Shin
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA
| | - Hung-Mo Lin
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA
| | - Alex Butwick
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
37
|
Pacheco LD, Saade G, Shrivastava V, Shree R, Elkayam U. Society for Maternal-Fetal Medicine Consult Series #61: Anticoagulation in pregnant patients with cardiac disease. Am J Obstet Gynecol 2022; 227:B28-B43. [PMID: 35337804 DOI: 10.1016/j.ajog.2022.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pregnancy in individuals with a mechanical heart valve has been classified as very high risk because of a substantially increased risk of maternal mortality or severe morbidity. Lifelong therapeutic anticoagulation is a principal component of the medical management of mechanical heart valves to prevent valve thrombosis. Anticoagulation regimens indicated outside of pregnancy for patients with mechanical valves should be continued during pregnancy with the possibility of modifications based on the type of valve, the trimester of pregnancy, individual risk tolerance, and circumstances around the time of delivery. The purpose of this document is to provide recommendations regarding the management of anticoagulation for common cardiac conditions complicating pregnancy, including mechanical heart valves, atrial fibrillation, systolic heart failure, and congenital heart disease.
Collapse
Affiliation(s)
- Luis D Pacheco
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - George Saade
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Vineet Shrivastava
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Raj Shree
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Uri Elkayam
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| |
Collapse
|
38
|
Shams D, Sachse K, Statzer N, Gupta RK. Regional Anesthesia Complications and Contraindications. Clin Sports Med 2022; 41:329-343. [PMID: 35300844 DOI: 10.1016/j.csm.2021.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low. While a variety of different regional anesthesia techniques exist, complications tend to fall within 4 broad categories: block failure, bleeding/hematoma, neurological injury, and local anesthetic toxicity.
Collapse
Affiliation(s)
- Danial Shams
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Kaylyn Sachse
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Nicholas Statzer
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Rajnish K Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA.
| |
Collapse
|
39
|
Bhatia K, Shehata N, D'Souza R. Anaesthetic considerations and anticoagulation in pregnant patients with mechanical heart valves. BJA Educ 2022; 22:273-281. [DOI: 10.1016/j.bjae.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
40
|
Lumbreras-Marquez MI, Villela-Franyutti D, Reale SC, Farber MK. Coagulation Management in Obstetric Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-022-00517-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
41
|
Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
Collapse
Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Reale S, Farber M. Management of patients with suspected placenta accreta spectrum. BJA Educ 2022; 22:43-51. [PMID: 35035992 PMCID: PMC8749385 DOI: 10.1016/j.bjae.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 02/03/2023] Open
|
43
|
Elmofty DH, Tucker A, Wuenstel AM, Cheng PK, Fox E, Knoebel R, Liao C, Scavone B. Varying Dosages of Subcutaneous Unfractionated Heparin and Activated Partial Thromboplastin Time in Hospitalized Antepartum Patients: A Retrospective Cohort Analysis. Anesth Analg 2022; 134:1028-1034. [PMID: 35020621 DOI: 10.1213/ane.0000000000005866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a leading cause of maternal morbidity and mortality in the United States. Subcutanous unfractionated heparin (UFH) has been used for decades for VTE prophylaxis and under many obstetric quality of care initiatives, hospitalized antepartum patients now receive doses as high as 10,000 units every 12 hours. This practice increases the likelihood of UFH administration around the time that epidural labor analgesia is requested or neuraxial analgesia for cesarean delivery is needed. To clarify the effect of UFH on coagulation, we reviewed the care of hospitalized antepartum patients receiving VTE prophylaxis with UFH to determine the incidence of concurrent abnormal activated partial thromboplastin time (aPTT) values and associated risk factors. METHODS This retrospective cohort study used data from the University of Chicago Pharmacy database to identify hospitalized antepartum patients receiving subcutaneous UFH from June 1, 2016 to July 1, 2019. Our institutional protocol states that all patients hospitalized for antepartum conditions should receive pharmacologic prophylaxis empirically unless contraindicated. For patients receiving UFH, dosing was based on gestational age: 5000 units every 12 hours for first trimester antepartum patients, 7500 units every 12 hours for second trimester patients, and 10,000 units every 12 hours for patients in the third trimester. As per protocol, aPTT values were obtained 2 hours after the third dose of heparin, and platelet counts after 4 days. Data collection included demographics, comorbidities, heparin doses, aPTT values, platelet counts, creatinine if available, and anesthetic type and complications. Logistic regression was performed to determine the association between elevated aPTT >40 seconds and study variables. RESULTS Of the 321 antepartum patients who received subcutaneous UFH, 33 (10.3%) had an aPTT >40 seconds, 4 of those 33 patients (12.1%) received 5000 units every 12 hours, 14 (42.2%) received 7500 units every 12 hours, and 15 (45.5%) received 10,000 units every 12 hours. The likelihood of a patient having aPTT >40 seconds was 2.8% with 5000 units every 12 hours, 18.9% with 7500 units every 12 hours, and 14.6% with 10,000 units every 12 hours. CONCLUSIONS Elevated aPTT values are likely with total daily doses of 15,000 or 20,000 units subcutaneous UFH in hospitalized antepartum patients.
Collapse
Affiliation(s)
- Dalia H Elmofty
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Andrew Tucker
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Andrew M Wuenstel
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Paul K Cheng
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Edward Fox
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
| | - Randall Knoebel
- Department of Pharmacy, University of Chicago, Chicago, Illinois
| | - Chuanghong Liao
- Department of Public Health Sciences,University of Chicago, Chicago, Illinois
| | - Barbara Scavone
- From the Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois.,Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| |
Collapse
|
44
|
Lee MS, Fenstermaker MA, Naoum EE, Chong S, Van de Ven CJ, Bauer ME, Kountanis JA, Ellis JH, Shields J, Ambani S, Krambeck AE, Roberts WW, Ghani KR. Management of Nephrolithiasis in Pregnancy: Multi-Disciplinary Guidelines From an Academic Medical Center. Front Surg 2021; 8:796876. [PMID: 35028309 PMCID: PMC8751485 DOI: 10.3389/fsurg.2021.796876] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The management of nephrolithiasis during pregnancy can be stressful for urologists due to concerns for investigations and treatments that may pose risk of fetal harm, and unfamiliarity with optimal management of these complex patients. In response, we created multi-disciplinary evidence-based guidelines to standardize the care for obstetric patients presenting with flank pain and suspicion for nephrolithiasis. Methods: A multi-disciplinary team involving Urology, Obstetric Anesthesiology, Obstetrics and Gynecology, Diagnostic Radiology, and Interventional Radiology from a single academic medical center was assembled. A PubMed search was performed using keywords of pregnancy/antepartum, nephrolithiasis/calculi/kidney stones, ureteroscopy, non-obstetric surgery, complications, preterm delivery, MRI, computerized tomography, renal bladder ultrasound (RBUS), and anesthesia to identify relevant articles. Team members reviewed their respective areas to create a comprehensive set of guidelines. One invited external expert reviewed the guidelines for validation purposes. Results: A total of 54 articles were reviewed for evidence synthesis. Four guideline statements were constructed to guide diagnosis and imaging, and seven statements to guide intervention. Guidelines were then used to create a diagnostic and intervention flowchart for ease of use. In summary, RBUS should be the initial diagnostic study. If diagnostic uncertainty still exists, a non-contrast CT scan should be obtained. For obstetric patients presenting with a septic obstructing stone, urgent decompression should be achieved. We recommend ureteral stent placement as the preferred intervention if local factors allow. Conclusions: We present a standardized care pathway for the management of nephrolithiasis during pregnancy. Our aim is to standardize and simplify the clinical management of these complex scenarios for urologists.
Collapse
Affiliation(s)
- Matthew S. Lee
- Department of Urology, University of Michigan, Ann Arbor, MI, United States
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Michael A. Fenstermaker
- Department of Urology, University of Michigan, Ann Arbor, MI, United States
- Kaiser Permanente Group, Department of Urology, Washington, DC, United States
| | - Emily E. Naoum
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Suzanne Chong
- Department of Radiology, Indiana University, Indianapolis, IN, United States
| | - Cosmas J. Van de Ven
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Melissa E. Bauer
- Department of Anesthesiology, Duke University, Durham, NC, United States
| | - Joanna A. Kountanis
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, United States
| | - James H. Ellis
- Department of Radiology, University of Michigan, Ann Arbor, MI, United States
| | - James Shields
- Department of Interventional Radiology, University of Michigan, Ann Arbor, MI, United States
| | - Sapan Ambani
- Department of Urology, University of Michigan, Ann Arbor, MI, United States
| | - Amy E. Krambeck
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - William W. Roberts
- Department of Urology, University of Michigan, Ann Arbor, MI, United States
| | - Khurshid R. Ghani
- Department of Urology, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|
45
|
Skeith L. Prevention and management of venous thromboembolism in pregnancy: cutting through the practice variation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:559-569. [PMID: 34889418 PMCID: PMC8791179 DOI: 10.1182/hematology.2021000291] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
There is clinical practice variation in the area of prevention and management of venous thromboembolism (VTE) in pregnancy. There are limited data and differing recommendations across major clinical practice guidelines, especially relating to the role of postpartum low-molecular-weight heparin (LMWH) for patients with mild inherited thrombophilia and those with pregnancy-related VTE risk factors. This chapter explores the issues of practice variation and related data for postpartum VTE prevention. Controversial topics of VTE management in pregnancy are also reviewed and include LMWH dosing and the role of anti-Xa level monitoring, as well as peripartum anticoagulation management around labor and delivery.
Collapse
Affiliation(s)
- Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, Foothills Medical Centre, University of Calgary, Calgary, Canada
| |
Collapse
|
46
|
Galvan JM, Nixon HC. Neuraxial Techniques for Parturients with Thromboprophylaxis or Thrombocytopenia. Anesthesiol Clin 2021; 39:727-742. [PMID: 34776106 DOI: 10.1016/j.anclin.2021.08.011] [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: 10/19/2022]
Abstract
Pharmacologic thromboprophylaxis from venous thromboembolism (VTE) and thrombocytopenia in pregnancy results in conditions that may preclude the use of neuraxial anesthesia due to a perceived risk of spinal/epidural hematoma. Spinal epidural hematoma is a recognized complication in patients who are hypocoagulable and may lead patients to undergo general anesthesia for delivery or other procedures, which carries numerous complications in obstetric care. A robust understanding of maternal physiologic changes in coagulation status, review of consensus statements, and safety bundles may help to maximize the use of neuraxial anesthesia in obstetric patients who might otherwise be denied these anesthetic techniques.
Collapse
Affiliation(s)
- Jacqueline M Galvan
- Department of Anesthesiology, University of Illinois at Chicago, 1740 West Taylor Street MW 3200W, Chicago, IL 60612, USA.
| | - Heather C Nixon
- Department of Anesthesiology, University of Illinois at Chicago, 1740 West Taylor Street MW 3200W, Chicago, IL 60612, USA
| |
Collapse
|
47
|
Warner LL, Arendt KW, Theiler RN, Sharpe EE. Analgesic considerations for induction of labor. Best Pract Res Clin Obstet Gynaecol 2021; 77:76-89. [PMID: 34627722 DOI: 10.1016/j.bpobgyn.2021.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 12/13/2022]
Abstract
Induction of labor may be indicated to minimize maternal and fetal risks. The rate of induction is likely to increase as recent evidence supports elective induction at 39 weeks gestation. We review methods of induction and then analgesic options as they relate to indications and methods to induce labor. We specifically focus on parturients at high risk for anesthetic complications including those requiring anticoagulation, and those with cardiac disease, obesity, chorioamnionitis, prior spinal instrumentation, elevated intracranial pressure, known or anticipated difficult airway, thrombocytopenia, and preeclampsia. Guidelines regarding timing of anticoagulation dosing with neuraxial anesthetic techniques have been defined through consensus statements. Early epidural placement may be beneficial in patients with cardiac disease, obesity, anticipated difficult airway, and HELLP syndrome. Questions remain regarding how early is too early for epidural placement, what options are safest for patients with bacteremia, and what pain relief should be offered to those unable to tolerate cervical exams in early labor.
Collapse
Affiliation(s)
- Lindsay L Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st, St SW, Rochester, MN, United States.
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st, St SW, Rochester, MN, United States
| | - Regan N Theiler
- Department of Obstetrics and Gynecology, Mayo Clinic, 200 1st, St SW, Rochester, MN, United States
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st, St SW, Rochester, MN, United States
| |
Collapse
|
48
|
Anticoagulation of women with congenital heart disease during pregnancy. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
49
|
Abstract
PURPOSE OF REVIEW Risk factors for obstetric venous thromboembolism (VTE), a leading cause of maternal mortality in the United States, are increasing on a population basis. This review provides the obstetrician with an update of current issues related to obstetric VTE risk, prophylaxis, outcomes, anaesthesia considerations and future research opportunities. RECENT FINDINGS Obstetric VTE affects approximately 1 per 1000 pregnancies and accounts consistently for 9-10% of maternal deaths in the United States. In industrialized countries, risk factors for VTE, including overweight/obesity, caesarean delivery and obstetrical complications such postpartum haemorrhage and infection continue to increase. VTE prophylaxis is central to reducing maternal mortality. However, recommendations for prophylaxis from leadership societies vary widely. In the UK, maternal mortality risk from VTE has decreased significantly in the setting of broader heparin prophylaxis. In the United States where mechanical VTE prophylaxis is used more commonly, mortality risk has remained constant. SUMMARY Obstetric VTE is a leading cause of maternal mortality in the United States. The incidence of risk factors for obstetric VTE continues to increase. Currently, recommendations for obstetric VTE prophylaxis vary substantially. Opportunities for research in this area exist to optimize prophylaxis and improve maternal outcomes.
Collapse
Affiliation(s)
- Alexander M Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| |
Collapse
|
50
|
McNeil A, Chen J, Meng M. Pulmonary hypertension in pregnancy-the Anesthesiologist's perspective. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|