1
|
Nekooghadam SM, Ebrahimi‐Dehkordi S, Paraandavaji E, Pishgahi M, Ghadirzadeh E, Charkazi E, Ghorbani P. Heparin induced thrombocytopenia in pregnancy: A therapeutic challenge case report and literature review. Clin Case Rep 2023; 11:e7839. [PMID: 37614288 PMCID: PMC10442474 DOI: 10.1002/ccr3.7839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/12/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023] Open
Abstract
The anticoagulants of choice for the prevention and treatment of venous thromboembolic disease during pregnancy are unfractionated heparin and low-molecular-weight heparin. Heparin-induced thrombocytopenia (HIT) is introduced as a rare but critical side effect of heparin products raising the thromboembolic event paradoxically. Here, we present a case of HIT in pregnancy with challenging management due to coincidence of lupus anticoagulant (LA) and limited anticoagulant options in the pharmaceutical market of our country of residence. We describe a 6-week pregnant patient with deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE), which developed HIT during antenatal care. Therapeutic anticoagulation was initiated with argatroban, then switched to apixaban due to limited access to argatroban. Another therapeutic challenge was the concurrent incidence of LA. The interdisciplinary care team decided on adding up warfarin and scheduled termination at 12 weeks regarding the hazardous condition of the patient. We also reviewed related case literature to convey a new insight into managing pregnancy-related HIT. HIT is a pro-coagulatory and lethal complication associated with heparin therapy that can be diagnosed by clinical suspicion, the 4T score system, and confirmatory laboratory analyses. Alternative anticoagulation is the cornerstone of the treatment and an interdisciplinary plan will be worthwhile to make the best clinical decision regarding the critical situation and least the thromboembolic events mortality during pregnancy.
Collapse
Affiliation(s)
- Seyyed Mojtaba Nekooghadam
- Department of Internal MedicineSchool of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | | | - Elham Paraandavaji
- Skull Base Research CenterLoghman Hakim HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Mehdi Pishgahi
- Department of CardiologySchool of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | - Erfan Ghadirzadeh
- Cardiovascular Research CenterMazandaran University of Medical SciencesSariIran
| | | | - Parastoo Ghorbani
- Cardiovascular Research CenterMazandaran University of Medical SciencesSariIran
| |
Collapse
|
2
|
Hart C, Bauersachs R, Scholz U, Zotz R, Bergmann F, Rott H, Linnemann B. Prevention of Venous Thromboembolism during Pregnancy and the Puerperium with a Special Focus on Women with Hereditary Thrombophilia or Prior VTE-Position Paper of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH). Hamostaseologie 2020; 40:572-590. [PMID: 32590872 DOI: 10.1055/a-1132-0750] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Venous thromboembolism (VTE) is a major cause of maternal morbidity during pregnancy and the postpartum period. Because there is a lack of adequate study data, management strategies for the prevention of VTE during pregnancy have mainly been deduced from case-control and observational studies and extrapolated from recommendations for non-pregnant patients. The decision for or against pharmacologic thromboprophylaxis must be made on an individual basis weighing the risk of VTE against the risk of adverse side effects such as severe bleeding complications. A comprehensive, multidisciplinary approach is often essential as the clinical scenario is made more complex by the specific obstetric context, especially in the peripartum period. As members of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH), we summarize the evidence from the available literature and aim to establish a more uniform strategy for VTE risk assessment and thromboprophylaxis in pregnancy and the puerperium. In this document, we focus on women with hereditary thrombophilia, prior VTE and the use of anticoagulants that can safely be applied during pregnancy and the lactation period.
Collapse
Affiliation(s)
- Christina Hart
- Department of Hematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt, Germany.,Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Ute Scholz
- MVZ Labor Dr. Reising-Ackermann und Kollegen, Zentrum für Blutgerinnungsstörungen, Leipzig, Germany
| | - Rainer Zotz
- Centrum für Blutgerinnungsstörungen und Transfusionsmedizin, Düsseldorf, Germany
| | - Frauke Bergmann
- MVZ Wagnerstibbe, Amedes-Gruppe, Hannover, Lower Saxony, Germany
| | | | - Birgit Linnemann
- Division of Angiology, University Center of Vascular Medicine, University Hospital Regensburg, Regensburg, Germany
| |
Collapse
|
3
|
Sucker C. Prophylaxis and Therapy of Venous Thrombotic Events (VTE) in Pregnancy and the Postpartum Period. Geburtshilfe Frauenheilkd 2020; 80:48-59. [PMID: 31949319 PMCID: PMC6957355 DOI: 10.1055/a-1030-4546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 08/21/2019] [Accepted: 10/17/2019] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolisms and pulmonary embolisms are one of the main causes of morbidity and mortality in pregnancy. The increased risk of thrombotic events caused by the physiological changes during pregnancy alone does not justify any medical antithrombotic prophylaxis. However, if there are also other risk factors such as a history of thromboses, hormonal stimulation as part of fertility treatment, thrombophilia, increased age of the pregnant woman, severe obesity or predisposing concomitant illnesses, the risk of thrombosis should be re-evaluated - if possible by a coagulation specialist - and drug prophylaxis should be initiated, where applicable. Low-molecular-weight heparins (LMWH) are the standard medication for the prophylaxis and treatment of thrombotic events in pregnancy and the postpartum period. Medical thrombosis prophylaxis started during pregnancy is generally continued for about six weeks following delivery due to the risk of thrombosis which peaks during the postpartum period. The same applies to therapeutic anticoagulation after the occurrence of a thrombotic event in pregnancy; here, a minimum duration of the therapy of three months should also be adhered to. During breastfeeding, LMWH or the oral anticoagulant warfarin can be considered; neither active substance passes into breast milk.
Collapse
|
4
|
Efficacy and safety of venous thromboembolism prophylaxis with fondaparinux in women at risk after cesarean section. Obstet Gynecol Sci 2017; 60:535-541. [PMID: 29184861 PMCID: PMC5694727 DOI: 10.5468/ogs.2017.60.6.535] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/23/2017] [Accepted: 06/08/2017] [Indexed: 02/07/2023] Open
Abstract
Objectives Cesarean section is associated with an increased risk for venous thromboembolism (VTE). The safety and efficacy of primary prophylaxis of fondaparinux, a synthetic sulfated pentasaccharide heparin analog, in women at risk after cesarean section is uncertain. Methods This was a retrospective study of 295 cases of pregnant women presenting to a tertiary referral center of Nara, Japan, to evaluate the usefulness of thromboprophylaxis with fondaparinux after cesarean delivery between 2011 and 2012. Patients were initially received unfractionated heparin (once 5,000 IU subcutaneously, twice a day), starting 6 hours after cesarean section for 24 hours, and then treated with fondaparinux (once 2.5 mg daily, subcutaneously) for 5 days. The primary efficacy end-point was an improvement in the incidence of symptomatic VTE or fatal post-cesarean pulmonary thromboembolism. The primary safety end-point was major bleeding during treatment. Results There were neither any episodes of symptomatic VTE cases nor maternal deaths. A total of 10 patients had a bleeding event. Major bleeding complication was observed in 2 (0.68%) of 295 patients receiving fondaparinux. Non-major bleeding into critical sites was observed in 8 patients, often at surgical sites, and recovery was not delayed. Conclusion This study demonstrates the safety and efficacy of fondaparinux in women at high risk of VTE after cesarean section. Large phase trials comparing clinical outcomes with fondaparinux across a wide spectrum of patients are needed to confirm these observations.
Collapse
|
5
|
Fondaparinux in pregnancy: Could it be a safe option? A review of the literature. Thromb Res 2015; 135:1049-51. [DOI: 10.1016/j.thromres.2015.04.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 04/01/2015] [Accepted: 04/06/2015] [Indexed: 11/20/2022]
|
6
|
Marshall AL. Diagnosis, Treatment, and Prevention of Venous Thromboembolism in Pregnancy. Postgrad Med 2015; 126:25-34. [DOI: 10.3810/pgm.2014.11.2830] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
7
|
Elsaigh E, Thachil J, Nash MJ, Tower C, Hay CRM, Bullough S, Byrd L. The use of fondaparinux in pregnancy. Br J Haematol 2014; 168:762-4. [PMID: 25270038 DOI: 10.1111/bjh.13147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Esra Elsaigh
- Manchester Medical School, University of Manchester, Manchester, UK
| | | | | | | | | | | | | |
Collapse
|
8
|
Demerouti E, Manginas A, Leontiadis E, Hatzis T, Athanassopoulos G, Mihas K, Pavlides G. A 53-year-old woman with thrombocytosis and pulmonary embolism. Arch Med Sci 2014; 10:191-4. [PMID: 24701233 PMCID: PMC3953987 DOI: 10.5114/aoms.2014.40745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 07/24/2011] [Accepted: 09/04/2011] [Indexed: 11/17/2022] Open
|
9
|
Tang AW, Greer I. A systematic review on the use of new anticoagulants in pregnancy. Obstet Med 2013; 6:64-71. [PMID: 27757159 DOI: 10.1177/1753495x12472642] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2012] [Indexed: 12/17/2022] Open
Abstract
New anticoagulants such as direct factor Xa inhibitors and direct thrombin inhibitors have been recently developed, but their experience in pregnancy is limited. This review therefore aims to systematically search for studies on the use of these newer anticoagulants in pregnancy and the puerperal period. Searches were performed on electronic databases MEDLINE (from 1966), EMBASE (from 1974) and the Cochrane Library, until October 2011 using terms of 'pregnancy', 'puerperium', 'breastfeeding' and names of specific anticoagulants. The search yielded 561 citations and 11 studies (10 on fondaparinux, 1 on ximelagatran) were included. Newer anticoagulants (fondaparinux, hirudin and argatroban) on the limited evidence appear not to have adverse pregnancy outcomes, but there is currently no experience of new oral anticoagulants (rivaroxaban, apixaban, betrixaban or dabigatran) use in pregnancy. There is a need for reporting on new oral anticoagulation use in pregnancy to provide more information about the safety and risks to the fetus in utero.
Collapse
Affiliation(s)
- Ai-Wei Tang
- Fetal Medicine Unit, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool L8 7SS, UK
| | - Ian Greer
- Faculty of Health & Life Sciences, University of Liverpool, Foundation Building, Liverpool L69 7ZX, UK
| |
Collapse
|
10
|
Lin TY, Chang CC, Chang CC, Yuan JY, Chen HH. Cyclophosphamide-rescued plasmapheresis-unresponsive secondary thrombotic thrombocytopenic purpura caused by Sjögren's syndrome. Arch Med Sci 2012. [PMID: 23185207 PMCID: PMC3506224 DOI: 10.5114/aoms.2012.30788] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Ting-Yun Lin
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Cheng Chang
- Department of Neurology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chun-Chao Chang
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Jui-Yu Yuan
- Department of Neurology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hsi-Hsien Chen
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of General Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Primary Care Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| |
Collapse
|
11
|
Myers B. Diagnosis and management of maternal thrombocytopenia in pregnancy. Br J Haematol 2012; 158:3-15. [PMID: 22551110 DOI: 10.1111/j.1365-2141.2012.09135.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 03/14/2012] [Indexed: 12/27/2022]
Abstract
Thrombocytopenia is a common finding in pregnancy, occurring in approximately 7-10% of pregnancies. It may be a diagnostic and management problem, and has many causes, some of which are specific to pregnancy. Although most cases of thrombocytopenia in pregnancy are mild, and have no adverse outcome for either mother or baby, occasionally a low platelet count may be part of a more complex disorder with significant morbidity and may be life-threatening. Overall, about 75% of cases are due to gestational thrombocytopenia, 15-20% secondary to hypertensive disorders; 3-4% due to an immune process, and the remaining 1-2% made up of rare constitutional thrombocytopenias, infections and malignancies. In this review, a diagnostic approach to investigating thrombocytopenia in pregnancy is presented, together with antenatal, anaesthetic and peri-natal management issues for mother and baby, followed by a detailed discussion on the specific causes of thrombocytopenia and the management options in each case.
Collapse
Affiliation(s)
- Bethan Myers
- Department of Haematology, Lincoln County Hospital, Lincoln, UK.
| |
Collapse
|
12
|
Spezielle Arzneimitteltherapie in der Schwangerschaft. ARZNEIMITTEL IN SCHWANGERSCHAFT UND STILLZEIT 2012. [PMCID: PMC7271212 DOI: 10.1016/b978-3-437-21203-1.10002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
13
|
Fondaparinux - data on efficacy and safety in special situations. Thromb Res 2011; 129:407-17. [PMID: 22133273 DOI: 10.1016/j.thromres.2011.10.037] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 10/27/2011] [Accepted: 10/28/2011] [Indexed: 12/20/2022]
Abstract
New anticoagulants promise to have better efficacy, more safety and/or a better manageability than traditional anticoagulants. However, knowledge is limited regarding special situations such as renal insufficiency, obesity, pregnancy, long-term therapy, heparin-induced thrombocytopenia, treatment in patients with mechanical heart valves, use for children, and in patients with a high risk of thromboembolic complications. These situations have rarely or even never been the objective of randomised controlled trials. The purpose of the present article is to summarize and discuss available data on efficacy and safety in these special situations for one of the first new anticoagulants, the indirect factor-Xa inhibitor fondaparinux. Furthermore, we discuss safety in licensed indications and management of bleeding complications and comment on measuring of drug concentration in plasma.
Collapse
|