1
|
Beltrami-Moreira M, Sharma A, Bussel JB. Immune thrombocytopenia and pregnancy: challenges and opportunities in diagnosis and management. Expert Rev Hematol 2024; 17:595-607. [PMID: 39105265 DOI: 10.1080/17474086.2024.2385481] [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: 03/18/2024] [Revised: 06/13/2024] [Accepted: 07/24/2024] [Indexed: 08/07/2024]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) affecting pregnancy is a diagnostic and often a therapeutic challenge. AREAS COVERED We review the current diagnostic criteria for ITP in pregnancy and the potential utility of laboratory tests. We discuss the impact of ITP on pregnancy outcomes and the effects of pregnancy on patients living with chronic ITP. We describe the criteria for intervention, the evidence supporting first-line treatment approaches and the therapeutic decisions and challenges in cases refractory to steroids and IVIG. We review the evidence supporting the potential use of thrombopoietin receptor agonists for refractory thrombocytopenia. Finally, we describe the diagnostic, prognostic, and treatment approaches to neonatal ITP and considerations regarding breastfeeding. We searched the terms 'immune thrombocytopenia' and 'pregnancy' on PubMed to identify the relevant literature published before 31 December 2023, including within cited references. EXPERT OPINION Decreased platelet production may play a role in pregnancy-related ITP exacerbation. Putative mechanisms include placental hormones, such as inhibin. Although IVIG and prednisone usually suffice to achieve hemostasis for delivery, second-line agents are sometimes required to allow for neuraxial anesthesia. There is growing evidence supporting the use of romiplostim during pregnancy; however, its risk of venous thromboembolism warrants further evaluation.
Collapse
MESH Headings
- Humans
- Pregnancy
- Female
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/therapy
- Pregnancy Complications, Hematologic/diagnosis
- Pregnancy Complications, Hematologic/therapy
- Pregnancy Complications, Hematologic/drug therapy
- Immunoglobulins, Intravenous/therapeutic use
- Disease Management
- Receptors, Thrombopoietin/agonists
- Thrombopoietin/therapeutic use
- Pregnancy Outcome
- Receptors, Fc
- Recombinant Fusion Proteins
Collapse
Affiliation(s)
- Marina Beltrami-Moreira
- Department of Medicine, Division of Hematology, The Ohio State University Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Amy Sharma
- Department of Hematology-Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Division of Hematology, New York, NY, USA
| | - James B Bussel
- NewYork-Presbyterian Hospital/Weill Cornell Medicine, Department of Pediatrics and Department of Medicine, Division of Hematology and Medical Oncology, New York, NY, USA
| |
Collapse
|
2
|
Federspiel JJ, Rodriguez W, Spears J, Calloway M, Zhang X, Farrar E, Rajkumar R, Lodaya K, James AH. Antithrombin testing and treatment in pregnancy: Their real-world relationship to clinical outcomes. Thromb Res 2024; 241:109070. [PMID: 38970992 DOI: 10.1016/j.thromres.2024.109070] [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: 02/18/2024] [Revised: 05/28/2024] [Accepted: 06/17/2024] [Indexed: 07/08/2024]
Abstract
BACKGROUND Antithrombin (AT) deficiency is a severe thrombophilia associated with increased rates of maternal morbidity, mortality, and greater healthcare resource utilization during pregnancy and postpartum. METHODS Two large U.S. healthcare databases were queried for women aged 15-44 with delivery-related encounters: Cerner Real-World Data (CRWD, 01/01/2000-12/31/2021) and Premier Healthcare Database (PHD, 01/01/2016-01/01/2019). Individuals receiving cardiopulmonary bypass were excluded. Three cohorts were created: 1) Individuals who had AT levels tested any time between 9-months pre- through 3-months post-delivery (CRWD Test Cohort); 2) individuals prescribed AT concentrate (ATc) within 1-year pre- or 1-year post-delivery in CRWD (CRWD Medication Cohort); and 3) the same criteria as 2) applied to PHD (PHD Medication Cohort). RESULTS There were 5411 individuals in the CRWD Test Cohort, 13 in the CRWD Medication Cohort and 38 in the PHD Medication Cohort. Demographic and baseline clinical characteristics were similar across cohorts. AT level testing occurred pre-delivery in 47.9 % of the CRWD Test Cohort and 23.1 % of the CRWD Medication Cohort. ATc was administered during the delivery hospitalization to 0.1 %, 23.1 % and 50.0 % of the CRWD Test, CRWD Medication, and PHD Medication Cohorts, respectively. Across cohorts, 5.4-7.9 % of individuals experienced thrombosis during the delivery-related encounter. Mean (SD) total costs for delivery through 1-year post-delivery were $190,894 ($276,893) with $123,763 ($177,122) of total costs related to abnormal coagulation. CONCLUSION Opportunities exist to enhance the care of pregnant individuals with low AT levels throughout pregnancy, aiming for optimal maternal outcomes.
Collapse
Affiliation(s)
| | | | | | | | - Xuan Zhang
- Boston Strategic Partners, Inc., Boston, MA, United States
| | - Emily Farrar
- Boston Strategic Partners, Inc., Boston, MA, United States
| | - Rahul Rajkumar
- Boston Strategic Partners, Inc., Boston, MA, United States
| | - Kunal Lodaya
- Boston Strategic Partners, Inc., Boston, MA, United States
| | | |
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
|
Zhu H, Sang X, Wu H, Shen W, Wang Y, Yu L, Li M, Zhou T. Successful management of postpartum venous thrombosis following splenectomy for traumatic splenic rupture: a case report. J Int Med Res 2024; 52:3000605241255507. [PMID: 38749907 PMCID: PMC11107327 DOI: 10.1177/03000605241255507] [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: 02/21/2023] [Accepted: 05/01/2024] [Indexed: 05/23/2024] Open
Abstract
Traumatic splenic rupture is rare in pregnant women; and multiple venous thromboses of the portal vein system, inferior vena cava and ovarian vein after caesarean section and splenectomy for splenic rupture has not been previously reported. This case report describes a case of multiple venous thromboses after caesarean section and splenectomy for traumatic splenic rupture in late pregnancy. A 34-year-old G3P1 female presented with abdominal trauma at 33+1 weeks of gestation. After diagnosis of splenic rupture, she underwent an emergency caesarean section and splenectomy. Multiple venous thromboses developed during the recovery period. The patient eventually recovered after anticoagulation therapy with low-molecular-weight heparin and warfarin. These findings suggest that in patients that have had a caesarean section and a splenectomy, which together might further increase the risk of venous thrombosis, any abdominal pain should be thoroughly investigated and thrombosis should be ruled out, including the possibility of multiple venous thromboses. Anticoagulant therapy could be extended after the surgery.
Collapse
Affiliation(s)
- Hongdan Zhu
- Department of Obstetrics and Gynaecology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Xia Sang
- Department of Obstetrics and Gynaecology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Heli Wu
- Department of Obstetrics and Gynaecology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Wei Shen
- Department of Obstetrics and Gynaecology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Yanli Wang
- Department of Obstetrics and Gynaecology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Liling Yu
- Department of Obstetrics and Gynaecology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Mengjia Li
- Department of Obstetrics and Gynaecology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Tao Zhou
- Department of Obstetrics and Gynaecology, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| |
Collapse
|
5
|
Horakova L, Kriemler S, Študent V, Pichler Hefti J, Hillebrandt D, Jean D, Mateikaitė-Pipirienė K, Paal P, Rosier A, Andjelkovic M, Beidlemann B, Derstine M, Keyes LE. Hormonal Contraception and Menstrual Cycle Control at High Altitude: A Scoping Review-UIAA Medical Commission Recommendations. High Alt Med Biol 2024. [PMID: 38607652 DOI: 10.1089/ham.2024.0021] [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: 04/13/2024] Open
Abstract
Horakova, Lenka , Susi Kriemler, Vladimír Študent, Jacqueline Pichler Hefti, David Hillebrandt, Dominique Jean, Kastė Mateikaitė-Pipirienė, Peter Paal, Alison Rosier, Marija Andjelkovic, Beth Beidlemann, Mia Derstine, and Linda E. Keyes. Hormonal contraception and menstrual cycle control at high altitude: a scoping review-UIAA Medical Commission recommendations. High Alt Med Biol. 00:00-00, 2024. Background: Women who use hormonal contraception (HC) may have questions about their use during travel to high altitude. This scoping review summarizes current evidence on the efficacy and safety of HC and cycle control during high-altitude travel. Methods: We performed a scoping review for the International Climbing and Mountaineering Federation (UIAA) Medical Commission series on Women's Health in the Mountains. Pertinent literature from PubMed and Cochrane was identified by keyword search combinations (including contraception) with additional publications found by hand search. Results: We identified 17 studies from 7,165 potentially eligible articles. No articles assessed the efficacy of contraception during a short-term high-altitude sojourn. Current data show no advantage or disadvantage in HC users for acclimatization or acute mountain sickness (AMS). Use of HC during high-altitude travel is common and safe for menses suppression. A potential concern of estrogen-containing HC is the increased thrombotic risk, which theoretically could be compounded in hypobaric hypoxia. Conclusions: Evidence is limited for the interaction of HC and high altitude on performance, thrombosis, and contraceptive efficacy. HC does not affect the risk of AMS. The most efficacious and safest method at high altitude is generally the one women are most familiar with and already using.
Collapse
Affiliation(s)
- Lenka Horakova
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University Prague, Kladno, Czech Republic
| | - Susi Kriemler
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Vladimír Študent
- Department of Gynecology and Obstetrics, Prachatice Hospital, Prachatice, Czech Republic
| | | | - David Hillebrandt
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- General Medical Practitioner, Holsorthy, United Kingdom
| | - Dominique Jean
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Pediatrics, Infectious Diseases and Altitude Medicine, Grenoble, France
| | - Kastė Mateikaitė-Pipirienė
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Diaverum Dialysis Clinic, Elektrėnai, Lithuania
| | - Peter Paal
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Alison Rosier
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
| | - Marija Andjelkovic
- Medical Commission of the International Climbing and Mountaineering Federation (UIAA), Bern, Switzerland
- Pharmacy, Singidunum University, Belgrade, Serbia
| | - Beth Beidlemann
- Military Performance Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | - Mia Derstine
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado, USA
| | - Linda E Keyes
- Department of Emergency Medicine, University of Colorado, Aurora, Colorado, USA
| |
Collapse
|
6
|
Davis S, Pandor A, Sampson FC, Hamilton J, Nelson-Piercy C, Hunt BJ, Daru J, Goodacre S. Estimating the value of future research into thromboprophylaxis for women during pregnancy and after delivery: a value of information analysis. J Thromb Haemost 2024; 22:1105-1116. [PMID: 38215911 DOI: 10.1016/j.jtha.2023.12.035] [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: 09/20/2023] [Revised: 12/28/2023] [Accepted: 12/30/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Risk assessment models (RAMs) are used to select women at increased risk of venous thromboembolism (VTE) during pregnancy and the puerperium for thromboprophylaxis. OBJECTIVES To estimate the value of potential future studies that would reduce the decision uncertainty associated with offering thromboprophylaxis according to available RAMs in the following groups: high-risk antepartum women (eg, prior VTE), unselected postpartum women, and postpartum women with risk factors (obesity or cesarean delivery). METHODS A decision-analytic model was developed to simulate clinical outcomes, lifetime costs, and quality-adjusted life-years for different thromboprophylaxis strategies, including thromboprophylaxis for all, thromboprophylaxis for none, and RAM-based thromboprophylaxis. The expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty. The value of future research studies was estimated using expected value of sample information analysis. Costs were assessed from a health and social services perspective. RESULTS The expected value of perfect information analysis identified high decision uncertainty for high-risk antepartum women (£21.8 million) and obese postpartum women (£13.4 million), which was largely attributable to uncertainty regarding the effectiveness of thromboprophylaxis in reducing VTE. A randomized controlled trial of thromboprophylaxis compared with none in obese postpartum women is likely to have substantial value (£2.8 million; 300 participants per arm). A trial in women with previous VTE would have higher value but would be less acceptable. CONCLUSION Future research should focus on estimating the effectiveness of thromboprophylaxis in obese postpartum women with additional risk factors who have not had a previous VTE.
Collapse
Affiliation(s)
- Sarah Davis
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
| | - Abdullah Pandor
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Fiona C Sampson
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Jean Hamilton
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Catherine Nelson-Piercy
- Women's Health Academic Centre, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Jahnavi Daru
- Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Steve Goodacre
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
7
|
Davis S, Pandor A, Sampson FC, Hamilton J, Nelson-Piercy C, Hunt BJ, Daru J, Goodacre S, Carser R, Rooney G, Clowes M. Thromboprophylaxis during pregnancy and the puerperium: a systematic review and economic evaluation to estimate the value of future research. Health Technol Assess 2024; 28:1-176. [PMID: 38476084 PMCID: PMC11017156 DOI: 10.3310/dfwt3873] [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: 03/14/2024] Open
Abstract
Background Pharmacological prophylaxis to prevent venous thromboembolism is currently recommended for women assessed as being at high risk of venous thromboembolism during pregnancy or in the 6 weeks after delivery (the puerperium). The decision to provide thromboprophylaxis involves weighing the benefits, harms and costs, which vary according to the individual's venous thromboembolism risk. It is unclear whether the United Kingdom's current risk stratification approach could be improved by further research. Objectives To quantify the current decision uncertainty associated with selecting women who are pregnant or in the puerperium for thromboprophylaxis and to estimate the value of one or more potential future studies that would reduce that uncertainty, while being feasible and acceptable to patients and clinicians. Methods A decision-analytic model was developed which was informed by a systematic review of risk assessment models to predict venous thromboembolism in women who are pregnant or in the puerperium. Expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty and should be the target of future research. To find out whether future studies would be acceptable and feasible, we held workshops with women who have experienced a blood clot or have been offered blood-thinning drugs and surveyed healthcare professionals. Expected value of sample information analysis was used to estimate the value of potential future research studies. Results The systematic review included 17 studies, comprising 19 unique externally validated risk assessment models and 1 internally validated model. Estimates of sensitivity and specificity were highly variable ranging from 0% to 100% and 5% to 100%, respectively. Most studies had unclear or high risk of bias and applicability concerns. The decision analysis found that there is substantial decision uncertainty regarding the use of risk assessment models to select high-risk women for antepartum prophylaxis and obese postpartum women for postpartum prophylaxis. The main source of decision uncertainty was uncertainty around the effectiveness of thromboprophylaxis for preventing venous thromboembolism in women who are pregnant or in the puerperium. We found that a randomised controlled trial of thromboprophylaxis in obese postpartum women is likely to have substantial value and is more likely to be acceptable and feasible than a trial recruiting women who have had a previous venous thromboembolism. In unselected postpartum women and women following caesarean section, the poor performance of risk assessment models meant that offering prophylaxis based on these models had less favourable cost effectiveness with lower decision uncertainty. Limitations The performance of the risk assessment model for obese postpartum women has not been externally validated. Conclusions Future research should focus on estimating the efficacy of pharmacological thromboprophylaxis in pregnancy and the puerperium, and clinical trials would be more acceptable in women who have not had a previous venous thromboembolism. Study registration This study is registered as PROSPERO CRD42020221094. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR131021) and is published in full in Health Technology Assessment; Vol. 28, No. 9. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona C Sampson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Beverley J Hunt
- Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jahnavi Daru
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rosie Carser
- Patient and Public Involvement, Thrombosis UK, Llanwrda, UK
| | - Gill Rooney
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| |
Collapse
|
8
|
Chatterton CG, Fouad LA, Kline JA. Patient counseling for pulmonary embolism requires an individualized approach. Res Pract Thromb Haemost 2024; 8:102407. [PMID: 38694838 PMCID: PMC11060943 DOI: 10.1016/j.rpth.2024.102407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 05/04/2024] Open
Affiliation(s)
- Carolyn G. Chatterton
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Lina A. Fouad
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Jeffrey A. Kline
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| |
Collapse
|
9
|
Vogel JP, Jung J, Lavin T, Simpson G, Kluwgant D, Abalos E, Diaz V, Downe S, Filippi V, Gallos I, Galadanci H, Katageri G, Homer CSE, Hofmeyr GJ, Liabsuetrakul T, Morhason-Bello IO, Osoti A, Souza JP, Thakar R, Thangaratinam S, Oladapo OT. Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward. Lancet Glob Health 2024; 12:e317-e330. [PMID: 38070535 PMCID: PMC10805007 DOI: 10.1016/s2214-109x(23)00454-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 01/22/2024]
Abstract
Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However, the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth complications that can emerge or persist months or years postnatally. This paper addresses these overlooked conditions, arguing that their absence from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the 6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology, and inherent predispositions that contribute to these complications. We offer actionable recommendations to change the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3. This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.
Collapse
Affiliation(s)
- Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia.
| | - Jenny Jung
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Tina Lavin
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Grace Simpson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Dvora Kluwgant
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - Edgardo Abalos
- Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina
| | - Virginia Diaz
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Soo Downe
- School of Nursing and Midwifery, University of Central Lancashire, Preston, UK
| | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Ioannis Gallos
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Hadiza Galadanci
- Africa Center of Excellence for Population Health and Policy, Bayero University, Kano, Nigeria
| | - Geetanjali Katageri
- S Nijalingappa Medical College and HSK Hospital & Research Centre, Bagalkot, India
| | - Caroline S E Homer
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC, Australia
| | - G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana; University of the Witwatersrand and Walter Sisulu University, East London, South Africa
| | - Tippawan Liabsuetrakul
- Department of Epidemiology and Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Imran O Morhason-Bello
- Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences and Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Alfred Osoti
- Department of Obstetrics and Gynaecology, University of Nairobi, Nairobi, Kenya
| | - João Paulo Souza
- Department of Social Medicine, Ribeirao Preto Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Olufemi T Oladapo
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| |
Collapse
|
10
|
Liu H, Li L, Zhao Z. Values of Caprini Risk Assessment Scale and D-Dimer for Predicting Venous Thromboembolism During Puerperium. Int J Womens Health 2024; 16:47-53. [PMID: 38229588 PMCID: PMC10790585 DOI: 10.2147/ijwh.s443245] [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: 10/25/2023] [Accepted: 12/28/2023] [Indexed: 01/18/2024] Open
Abstract
Purpose To evaluate the predictive value of the combination of the Caprini risk assessment model (RAM) and D-dimer for venous thromboembolism (VTE) during puerperium. Patients and Methods This was a retrospective case-control study. Thirty-one puerperium patients with VTE were included as cases, and 279 puerperium women without VTE were matched to cases according to age, number of fetuses, birth day and delivery mode at the ratio of 9:1. Demographic data, clinical data and laboratory parameters within postpartum 24 h were collected. Multivariate analysis, employing the forward stepwise model, was conducted to identify independent factors associated with VTE during puerperium. The predictive values of Caprini RAM, D-dimer and their combination were evaluated using receiver operating characteristic (ROC) curve, and the area under curve (AUC) was compared using Z test. Results Univariate analysis demonstrated that there were significant differences in D-dimer levels, Caprini score, scarred uterus, adherent placenta, postpartum hemorrhage and intrauterine infection between cases and controls (P<0.05). Multivariate analysis demonstrated that D-dimer levels (OR: 1.754, 95% CI: 1.237-3.182), Caprini score (OR: 1.209, 95% CI: 1.058-2.280), scarred uterus (OR: 1.978, 95% CI: 1.258-3.794), postpartum hemorrhage (OR: 2.276, 95% CI: 1.334-4.347) and intrauterine infection (OR: 2.575, 95% CI: 1.463-4.618) were independently associated with VTE during puerperium with adjustment for adherent placenta and fetal birth weight. The AUCs of D-dimer levels, Caprini score and their combination were 0.748 (SE: 0.030, 95% CI: 0.688-0.807), 0.647 (SE: 0.035, 95% CI: 0.578-0.716) and 0.840 (SE: 0.025, 95% CI: 0.791-0.888). Combination prediction had a higher AUC compared with that of independent prediction (0.840 vs 0.748, Z=2.356, P=0.009; 0.840 vs 0.647, Z=4.487, P<0.001) with a sensitivity of 83.9% and specificity of 80.3%. Conclusion The combination of the Caprini RAM and D-dimer could significantly elevate the predictive value for VTE during puerperium, and this new tool had the potential in the prediction of VTE during puerperium.
Collapse
Affiliation(s)
- Hongmei Liu
- Department of Gynaecology, the First Affiliated Hospital of Shihezi University, Shihezi, 832000, People’s Republic of China
| | - Lamei Li
- Department of Gynaecology and Obstetrics, Shihezi University School of Medicine, Shihezi, 832000, People’s Republic of China
| | - Zhe Zhao
- Department of Gynaecology and Obstetrics, Bingtuan Sishi Hospital, Yining, 835000, People’s Republic of China
| |
Collapse
|
11
|
Villalba L, Vaddavalli VV, Tripathi RK. Iliac vein stenting and pregnancy. J Vasc Surg Venous Lymphat Disord 2023; 11:1276-1284. [PMID: 37572777 DOI: 10.1016/j.jvsv.2023.08.003] [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: 05/21/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/14/2023]
Abstract
Venous stenting is the mainstay treatment of symptomatic iliofemoral venous outflow obstruction. However, because pregnancy and the postpartum period are hypercoagulable, concerns exist regarding stent placement in women of childbearing age. We performed a systematic review up to April 2023 of studies reporting on the performance of venous stents in women who subsequently became pregnant. The data collected included demographics, indication for stenting, stent characteristics, stent-related complications, incidence of venous thromboembolism, medical management during pregnancy, and follow-up. The indications for stenting included acute iliofemoral deep vein thrombosis in 39 patients (51%), nonthrombotic iliac vein lesions in 35 (46%), and post-thrombotic lesions in 2 patients. A total of 76 women with 87 subsequent pregnancies after stenting were included. Of the 76 women, 1 (1.14%) experienced stent occlusion, 2 (2.29%) developed asymptomatic nonocclusive in-stent thrombus, and 2 (2.29%) experienced permanent stent compression. The only patency loss occurred because of inadequate anticoagulation therapy in a patient with antiphospholipid antibodies. The two cases of permanent compression occurred in an arterial stent and a balloon-fenestrated Vici stent (Boston Scientific). Venous stents performed well through pregnancy and can be safely used in women of childbearing age. Given the increased risk of venous thromboembolism and the low bleeding risk, it is prudent to recommend anticoagulation therapy for all stented patients until more data are available.
Collapse
Affiliation(s)
- Laurencia Villalba
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia; Department of Vascular Surgery, The Wollongong Hospital, Wollongong, NSW, Australia; Vascular Care Centre, Wollongong, NSW, Australia.
| | | | | |
Collapse
|
12
|
Luo X, Shan D, Zhang L, Wu Y, Li T, Ren Y, Hu Y. Incidence of maternal venous thromboembolism in China: A systematic review and meta-analysis. Int J Gynaecol Obstet 2023; 163:75-88. [PMID: 37069776 DOI: 10.1002/ijgo.14776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/12/2023] [Accepted: 03/20/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is one of the primary causes of maternal death. Although many studies have reported maternal VTE, no study has estimated the incidence of it in China. OBJECTIVES The aim of this work was to estimate the incidence of maternal VTE in China and to compare the risk factors for it. SEARCH STRATEGY The authors searched eight platforms and databases including PubMed, Embase, and Cochrane Library from inception to April 2022, with the search terms "venous thromboembolism" AND "puerperium (pregnancy)" AND "incidence" AND "China." SELECTION CRITERIA Studies provide data to calculate the incidence of maternal VTE among Chinese patients. DATA COLLECTION AND ANALYSIS The authors made a standardized table to collect data and calculated the incidence and 95% confidence intervals (CIs), founding source of heterogeneity by subgroup analysis and meta-regression and judging publication bias by funnel plot and Egger test. MAIN RESULTS The included 53 papers with a total sample size of 3 813 871 patients had 2539 cases of VTE, and the incidence of maternal VTE in China was 0.13% (95% CI, 0.11-0.16; P < 0.001). CONCLUSIONS The trend in the incidence of maternal VTE in China is stable. Cesarean section and advanced age are associated with a higher incidence of VTE.
Collapse
Affiliation(s)
- Xingrong Luo
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of the Ministry of Education of Birth Defects and Related Maternal and Child Diseases, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dan Shan
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of the Ministry of Education of Birth Defects and Related Maternal and Child Diseases, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lin Zhang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of the Ministry of Education of Birth Defects and Related Maternal and Child Diseases, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuxia Wu
- Key Laboratory of the Ministry of Education of Birth Defects and Related Maternal and Child Diseases, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Tao Li
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of the Ministry of Education of Birth Defects and Related Maternal and Child Diseases, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Ren
- Department of Obstetrics and Gynecology, Zigong Hospital of Woman and Children Healthcare, Zigong, Sichuan, China
| | - Yayi Hu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of the Ministry of Education of Birth Defects and Related Maternal and Child Diseases, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
13
|
Guo J, Li C, Yu P, Xu T, Zhou H, Chen H. The effect of low molecular weight heparin combined with air pressure in the prevention of lower extremity venous thrombosis after cesarean section: A single-center retrospective study. Medicine (Baltimore) 2023; 102:e33475. [PMID: 37058024 PMCID: PMC10101301 DOI: 10.1097/md.0000000000033475] [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: 11/24/2022] [Accepted: 03/17/2023] [Indexed: 04/15/2023] Open
Abstract
In this study, we investigated the effect of low-molecular-weight heparin combined with pneumatic pressure in preventing lower extremity deep vein thrombosis after cesarean section, as well as on the visual analog scale (VAS) score. 120 women who underwent cesarean sections at full term in our hospital from January 2019 to January 2022 were included and divided into a control group (55 cases) and an observation group (65 cases) based on the different treatment methods: the control group was treated with low-molecular-weight heparin and the observation group was treated with pneumatic compression therapy based on the control group. The 2 groups were analyzed for thrombosis, clinical efficacy of the treatment methods, and VAS scores. The incidence of deep vein thrombosis in the observation group were significantly lower than in the control group (4.62% vs 21.82%, P < .05). There were no statistically significant differences in activated partial thromboplastin time, prothrombin time, and thrombin time between the 2 groups (P > .05) before treatment; however, after treatment, activated partial thromboplastin time, prothrombin time, and thrombin time in the observation group were significantly higher than those in the control group (P < .05). The clinical efficacy was significantly higher in the observation group compared with the control group (95.38% vs 78.18%, respectively). The VAS scores in the observation group were significantly lower than those in the control group (P < .05). Hence, low-molecular-weight heparin combined with pneumatic pressure therapy significantly reduces the incidence of lower limb deep vein thrombosis after cesarean section. It also improves the coagulation index and reduces post-operative pain. Therefore, it should be considered for use in clinical practice.
Collapse
Affiliation(s)
- Jian Guo
- Department of Vascular Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chenhao Li
- Department of Vascular Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Peidong Yu
- Department of Vascular Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Tongjie Xu
- Department of Vascular Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Haoge Zhou
- Department of Vascular Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Hao Chen
- Department of Vascular Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| |
Collapse
|
14
|
Sha M, Chen S. Pregnancy-related venous thromboembolism in Wuhan, China 2010-2022: A case-control study. J Obstet Gynaecol Res 2023. [PMID: 37004992 DOI: 10.1111/jog.15648] [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: 01/01/2023] [Accepted: 03/22/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE To explore the time trends and risk factors for pregnancy-related venous thromboembolism (VTE) in the Chinese population. METHODS A case-control study was conducted with 120 652 pregnancies between Jan 2010 and June 2022 in Wuhan, China. Medical records from pregnant patients with VTE and patients without VTE were reviewed and analyzed. RESULTS There were 197 cases of VTE diagnosed during pregnancy or postpartum, with an overall incidence of 1.63 per 1000 pregnancies, and the incidence rate trend of VTE was increasing year by year and then declining. The incidence of deep venous thrombosis (DVT) was 1.24 per 1000 pregnancies (76.1%). Consistent with previous studies, most VTE occurred in the puerperium (1.05 per 1000 pregnancies, 64.5%). Significant risk factors included immobility, previous VTE, systemic infection, BMI over 30, and hypertensive disorders of pregnancy. CONCLUSION Pregnancy-related VTE is not uncommon in China which is consistent with current foreign reports, and the change in incidence trend may be related to greater physicians' understanding of VTE and effective preventive measures after the publication of Chinese guidelines.
Collapse
Affiliation(s)
- Menghan Sha
- Department of Obstetrics and Gynecology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Suhua Chen
- Department of Obstetrics and Gynecology, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| |
Collapse
|
15
|
Cheng X, Zhang M, Xie Y, Xu Y, Du R, Wu B, Guan Z, Wang W, Sun W, Xu T, Zhu S, Wu L, Wang X, Shi H, Sun B, Zhang Y. Bone marrow-derived mesenchymal stem cells accelerate angiogenesis in pregnant experimentally induced deep venous thrombosis rat model via up-regulation of pro-angiogenic secretogranin II. Int Immunopharmacol 2023; 118:110025. [PMID: 36933488 DOI: 10.1016/j.intimp.2023.110025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/24/2023] [Accepted: 03/08/2023] [Indexed: 03/18/2023]
Abstract
The present study investigated whether bone marrow-derived mesenchymal stem cells (BMMSCs) facilitate angiogenesis and improve outcomes of pregnancy with obstetric deep venous thrombosis (DVT) and explored the underlying mechanism. A pregnant DVT rat model was established using a "stenosis" method on the lower segment of the inferior vena cava (IVC). The extent of vascularization in thrombosed IVC was examined by immunohistochemistry. In addition, the effect of BMMSCs on DVT pregnancy outcomes was evaluated. We also characterized the effect of BMMSC-derived conditioned medium (BM-CM) on the impaired human umbilical vein endothelial cells (HUVECs). Thereafter, transcriptome sequencing was employed to identify the differentially expressed genes in thrombosed IVC tissues of DVT and DVT plus BMMSCs (thrice) groups. Lastly, the candidate gene's role in the promotion of angiogenesis was demonstrated in vitro and in vivo. The DVT model was successfully established using IVC stenosis. The injection of three consecutive BMMSC doses into pregnant SD rats with DVT was demonstrated to be the most effective treatment, which significantly reduced the length and weight of the thrombus, induced the highest level of angiogenesis, and ameliorated the embryo absorption rate. In vitro, BM-CM efficiently increased the abilities of impaired endothelial cells to proliferate, migrate, invade, and form vessel-like tubes, while inhibiting their apoptosis. Transcriptome sequencing revealed that BMMSCs induced a prominent upregulation of a variety of pro-angiogenic genes, including secretogranin II (SCG2). When SCG2 expression was knocked down by lentivirus, the BMMSCs' and BM-CM-induced pro-angiogenic effects on pregnant DVT rats and HUVECs were markedly attenuated. In conclusion, the study results suggest that BMMSCs enhance angiogenesis via up-regulation of SCG2, providing an effective alternative regenerative agent and novel target for the therapy of obstetric DVT.
Collapse
Affiliation(s)
- Xi Cheng
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong 226001, Jiangsu, China; Laboratory Animal Center, Nantong University, Nantong 226001, Jiangsu, China
| | - Mu Zhang
- Department of Ophthalmology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong 226001, Jiangsu, China
| | - Yuanyuan Xie
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong 226001, Jiangsu, China; Laboratory Animal Center, Nantong University, Nantong 226001, Jiangsu, China
| | - Yanhua Xu
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong 226001, Jiangsu, China; Laboratory Animal Center, Nantong University, Nantong 226001, Jiangsu, China
| | - Rong Du
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong 226001, Jiangsu, China; Laboratory Animal Center, Nantong University, Nantong 226001, Jiangsu, China
| | - Bowen Wu
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong 226001, Jiangsu, China; Laboratory Animal Center, Nantong University, Nantong 226001, Jiangsu, China
| | - Zongyu Guan
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong 226001, Jiangsu, China
| | - Weina Wang
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong 226001, Jiangsu, China
| | - Weiwei Sun
- Department of Orthopaedics, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, China
| | - Ting Xu
- Department of Pediatrics, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, China
| | - Shunxing Zhu
- Laboratory Animal Center, Nantong University, Nantong 226001, Jiangsu, China
| | - Liucheng Wu
- Laboratory Animal Center, Nantong University, Nantong 226001, Jiangsu, China
| | - Xu Wang
- Laboratory Animal Center, Nantong University, Nantong 226001, Jiangsu, China
| | - Hongyun Shi
- Laboratory Animal Center, Nantong University, Nantong 226001, Jiangsu, China
| | - Baolan Sun
- Department of Laboratory, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, China.
| | - Yuquan Zhang
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong 226001, Jiangsu, China.
| |
Collapse
|
16
|
Cueto-Robledo G, Cervantes-Naranjo FD, Gonzalez-Hermosillo LM, Roldan-Valadez E, Graniel-Palafox LE, Castro-Escalante KY, Orozco-Zuñiga B. Pulmonary embolism during pregnancy: an updated review with case series description. Curr Probl Cardiol 2023; 48:101683. [PMID: 36898596 DOI: 10.1016/j.cpcardiol.2023.101683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/02/2023] [Indexed: 03/12/2023]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that can occur during pregnancy and pose a significant risk to the mother and the developing fetus. It is a major contributor to pregnancy-related morbidity and mortality in any trimester. It is estimated that the incidence of PE during pregnancy is approximately 1 in 1000 pregnancies. The mortality rate for pregnant women with PE is about 3%, significantly higher than that for non-pregnant women with PE. Overall, the topic of PE and pregnancy is essential for healthcare professionals to be aware of the risks, signs, and treatment options to improve outcomes and ensure the best possible care for both the mother and the developing fetus. To prevent the fatal condition, the physician is encouraged when there is a suspicion of the pathology. This report presents an updated comprehensive review of PE during pregnancy, discussing critical aspects of the clinical and imaging diagnosis, use of heparin, thrombolysis, and prevention. We believe this article will be helpful for cardiologists, obstetricians, and other health-related professionals.
Collapse
Affiliation(s)
- Guillermo Cueto-Robledo
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", 06720, Mexico City, Mexico; Pulmonary Circulation Clinic, Hospital General de México "Dr. Eduardo Liceaga", 06720, Mexico City, Mexico; Faculty of Medicine, National Autonomous University of Mexico, 04510, Mexico City, Mexico.
| | | | | | - Ernesto Roldan-Valadez
- Directorate of Research, Hospital General de Mexico "Dr. Eduardo Liceaga," 06720, Mexico City, Mexico; I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
| | | | | | - Benjamin Orozco-Zuñiga
- Ginecology Department, Hospital General de México ¨Dr. Eduardo Liceaga¨, Mexico City, Mexico.
| |
Collapse
|
17
|
Zheng X, Xue M, Zhou Y, Guan Y. Endovascular Thrombus Removal for Treating Post-Partum Iliofemoral Deep Vein Thrombosis: A Single-Centre Retrospective Cohort Study. Clin Appl Thromb Hemost 2023; 29:10760296231200851. [PMID: 37691283 PMCID: PMC10494515 DOI: 10.1177/10760296231200851] [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: 06/07/2023] [Revised: 08/15/2023] [Accepted: 08/26/2023] [Indexed: 09/12/2023] Open
Abstract
OBJECTIVE To evaluate the safety and efficacy of percutaneous thrombectomy for treating postpartum iliofemoral vein thrombosis. METHODS A retrospective analysis was performed on patients with continuous postpartum acute symptomatic iliofemoral deep vein thrombosis who were treated in our center, including all patients who underwent pharmacomechanical thrombolysis (PMT) or only catheter-directed thrombolysis (CDT) (study group), and patients that received simple anticoagulation treatment (control group). We evaluated the incidence of lower extremity postthrombotic syndrome, recanalization rate of lower extremity veins, and complications in the study and control groups. RESULTS Overall, 72 postpartum women were included in this study, including the PMT combined with CDT group (14 cases, 15 limbs), CDT alone group (26 cases, 27 limbs), and anticoagulant therapy alone group (32 cases, 34 limbs). The thrombectomy group completed the treatment with a technical success rate of 100%, and no serious bleeding complications occurred. The patency rate of lower limb veins in the thrombectomy group was 85.09 ± 16.51% after treatment and 82.60 ± 21.45% after 1 year. At the 1-year follow-up, the Villalta score in the study group was lower (1.90 ± 2.45 vs 8.50 ± 5.33, P < .001), and the incidence of postthrombotic syndrome was significantly different between the groups (17.50% in the study group vs 68.75% in the anticoagulant group, P < .001). CONCLUSIONS Lower extremity venous thrombectomy is a safe and effective treatment for postpartum iliofemoral venous thrombosis. It can improve the patency rate of lower extremity veins and reduce the incidence of postthrombotic syndrome compared with anticoagulation alone.
Collapse
Affiliation(s)
- Xuexun Zheng
- Department of Vascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Ming Xue
- Department of Vascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Yadong Zhou
- Department of Vascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Yunbiao Guan
- Department of Vascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| |
Collapse
|
18
|
Bussel JB, Cooper N, Lawrence T, Michel M, Vander Haar E, Wang K, Wang H, Saad H. Romiplostim use in pregnant women with immune thrombocytopenia. Am J Hematol 2023; 98:31-40. [PMID: 36156812 PMCID: PMC10091785 DOI: 10.1002/ajh.26743] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 02/04/2023]
Abstract
Treatment for immune thrombocytopenia (ITP) in pregnancy is hampered by the lack of fetal safety evidence of maternally-administered medications. The Pregnancy Surveillance Program (PSP) collected patient information from 2017-2020 for pregnancy, birth outcomes, and adverse events (AEs) for 186 women exposed to romiplostim from 20 days before pregnancy to the end of pregnancy. Timing of exposure was available in 128 women. Seventy-one mothers (38%) had prepregnancy exposure to romiplostim; intrapartum exposure was known for the first (for many mothers when they discovered their pregnancy), second, and third trimesters for 74 (40%), 22 (12%), and 44 (24%) mothers, respectively, with 15 mothers exposed during >1 trimester. Among the 86 mothers with known pregnancy outcomes, 46 (53%) had at least one pregnancy-related serious AE (SAE); approximately 2/3 of SAEs were due to underlying ITP. Of 92 mothers with known birth outcomes, 60 (65%) had a normal pregnancy and 16 (17%) had complications, with both categories including term and preterm births; there were 12 (14%) spontaneous miscarriages/stillbirths, 3 (3%) ectopic pregnancies, and 1 (1%) molar pregnancy. Most abnormal births resulted from abnormal pregnancies. There were five neonatal/postnatal AEs of note: inguinal hernia, cytomegalovirus infection, trisomy 8 (third trimester single-dose romiplostim exposure), single umbilical artery without known anomalies, and development of autism at age 2 years. Seven of 12 infants with neonatal thrombocytopenia had resolution of thrombocytopenia before discharge; all 12 were discharged. Review of pregnancies in women exposed to romiplostim did not reveal any specific safety concerns for mothers, fetuses, or infants.
Collapse
Affiliation(s)
| | | | | | - Marc Michel
- Henri Mondor University Hospital, Université Paris-Est Créteil, France
| | | | - Kejia Wang
- Amgen Inc., Thousand Oaks, California, USA
| | | | | |
Collapse
|
19
|
[Clinical characteristics of patients with rheumatoid arthritis complicated with venous thrombosis of lower extremities]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022. [PMID: 36533336 PMCID: PMC9761818 DOI: 10.19723/j.issn.1671-167x.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To analyze the clinical characteristics of patients with rheumatoid arthritis (RA) complicated with venous thrombosis of lower extremities, and to improve the awareness of this condition. METHODS The clinical and laboratory data of 502 RA patients hospitalized in Department of Rheumatology and Immunology Peking University Third Hospital from November 1, 2013 to December 31, 2020 were collected, retrospective analysis was made on the RA patients who were diagnosed with lower limb vein thrombosis on discharge but hadn't on admission, the patients in this group were defined as thrombosis group, and the other patients without lower limb vein thrombosis were taken as control group. Single factor analysis was conducted between the two groups. Then multivariate Logistic regression analysis was used to analyze the independent risk factors of RA complicated with lower limb venous thrombosis with statistical significance in univariate analysis. RESULTS There were 34 patients (6.77%) in the thrombosis group and 468 patients (93.23%) in the control group. The age of thrombosis group was 34-86 years (median age was 71 years); 23 were female and 11 were male; there were 20 cases with unilateral lower limb vein thrombosis and 14 cases with bilateral lower limb vein thrombosis; pulmonary embolism in 3 cases (low risk).In the thrombosis group 17 (50.0%) patients were bedridden for more than one week or needed crutches/wheelchairs before admission. 29 cases(85.3%)had large joint involvement of lower extremities, including 22 cases of knee joint involvement, 1 case of hip joint involvement, 2 cases of ankle joint involvement, and 4 cases with both knee and hip joint involvement. In the thrombosis group, the high, middle and low disease activity scores 28(DAS28) were 23 (67.6%), 9 (26.5%) and 2 (5.9%), respectively. There were 21 patients in the thrombosis group had completed thrombosis related examinations, only 4 patients were positive for anti-cardiolipin antibody or anti-β2 glycoprotein 1 antibody or lupus anticoagulant, the rests were all negative. In the thrombosis group, age and platelet (PLT) level were significantly higher than those in the control group [71 (60, 77) years vs. 60 (51, 68) years, Z=-3.873, P < 0.01, (328.53× 109±119.06 × 109) /L vs.(278.68 × 109±104.50 × 109)/L, t=2.660, P < 0.01, respectively]. The proportion of D-Dimer increased in the thrombosis group as well as the positivity rheumatoid factor (RF) was much higher than those in the control group (94.1% vs.66.4%, χ2=11.192, P < 0.01; 85.3% vs.67.1%, χ2=4.852, P < 0.05, respectively). Multivariate Logistic regression analysis showed that age (OR=1.063, 95%CI: 1.026-1.101, P=0.001), D-Dimer increased (OR=4.968, 95%CI: 1.136-21.730, P=0.033) and PLT level (OR=1.004, 95%CI: 1.001-1.007, P=0.022) were the independent risk factors for RA complica-ted with lower extremity venous thrombosis. CONCLUSION RA patients have potential risk of thrombosis of lower extremities. For the older age, D-Dimer and PLT elevated, especially those who were bedridden, RF positive and had high disease activity, should be alert to the risk.
Collapse
|
20
|
Cheng X, Wang W, Du R, Zhang M, Xie Y, Sun W, Ji J, Sun B, Zhang Y. Impact of repeated intravenous infusions of umbilical cord-derived versus bone marrow-derived mesenchymal stem cells on angiogenesis in a pregnant experimentally induced deep venous thrombosis rat model. In Vitro Cell Dev Biol Anim 2022; 58:957-969. [PMID: 36469244 DOI: 10.1007/s11626-022-00733-3] [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: 09/14/2022] [Accepted: 10/22/2022] [Indexed: 12/12/2022]
Abstract
Deep venous thrombosis (DVT) therapy during pregnancy warrants special consideration for the woman and the fetus. This study aimed to evaluate the impact of umbilical cord-derived mesenchymal stem cells (UC-MSCs) and bone marrow-derived mesenchymal stem cells (BM-MSCs) in terms of pro-angiogenic capacity and amelioration of pregnancy outcomes. The pregnant DVT rat model was successfully established by the "stenosis" method. Three consecutive injections of both UC-MSCs and BM-MSCs improved angiogenesis and ameliorated the embryo absorption rate in pregnant SD rats with DVT, in which UC-MSCs promoted angiogenesis more significantly. Furthermore, the levels of serum vascular endothelial growth factor-A (VEGF-A) and epidermal growth factor (EGF) were significantly higher in the UC-MSC group compared to those of the BM-MSC group. Thereafter, differentially expressed genes (DEGs) in thrombosed inferior vena cava tissues in the UC-MSC and BM-MSC groups were identified using transcriptome sequencing and further assessed by RT-qPCR and western blotting. The bioinformatics analysis indicated that the enriched DEG terms occurred in the cytokine activity, and the DEG pathways were significantly enriched in the cytokine-cytokine receptor interaction. In addition, both the mRNA and protein levels of angiogenic genes and their receptors, including VEGF-A, VEGF receptor-1, EGF, and EGF receptor, were significantly higher in the UC-MSC group. In conclusion, the BM-MSCs and UC-MSCs both significantly stimulate angiogenesis and ameliorate the embryo absorption rate in pregnant SD rats with DVT, but the difference in cytokine secretion causes UC-MSCs to have more potent angiogenic effects than BM-MSCs.
Collapse
Affiliation(s)
- Xi Cheng
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, No. 20 Xi-Si Road, Nantong, 226001, Jiangsu, China
| | - Weina Wang
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, No. 20 Xi-Si Road, Nantong, 226001, Jiangsu, China
| | - Rong Du
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, No. 20 Xi-Si Road, Nantong, 226001, Jiangsu, China
| | - Mu Zhang
- Department of Ophthalmology, Affiliated Hospital of Nantong University, Nantong, 226001, Jiangsu, China
| | - Yuanyuan Xie
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, No. 20 Xi-Si Road, Nantong, 226001, Jiangsu, China
| | - Weiwei Sun
- Department of Orthopedics, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, 226001, Jiangsu, China
| | - Jingjing Ji
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, No. 20 Xi-Si Road, Nantong, 226001, Jiangsu, China
| | - Baolan Sun
- Department of Laboratory, Affiliated Hospital of Nantong University, No. 20 Xi-Si Road, Nantong, 226001, Jiangsu, China.
| | - Yuquan Zhang
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Medical School of Nantong University, No. 20 Xi-Si Road, Nantong, 226001, Jiangsu, China.
| |
Collapse
|
21
|
Functionally integrating nanoparticles alleviate deep vein thrombosis in pregnancy and rescue intrauterine growth restriction. Nat Commun 2022; 13:7166. [PMID: 36418325 PMCID: PMC9684510 DOI: 10.1038/s41467-022-34878-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/09/2022] [Indexed: 11/24/2022] Open
Abstract
There is still unmet demand for effective, safe, and patient-friendly anti-thrombotics to treat deep vein thrombosis (DVT) during pregnancy. Here we first engineer a bioactive amphiphile (TLH) by simultaneously conjugating Tempol and linoleic acid onto low molecular weight heparin (LMWH), which can assemble into multifunctional nanoparticles (TLH NP). In pregnant rats with DVT, TLH NP can target and dissolve thrombi, recanalize vessel occlusion, and eradicate the recurrence of thromboembolism, thereby reversing DVT-mediated intrauterine growth restriction and delayed development of fetuses. Mechanistically, therapeutic effects of TLH NP are realized by inhibiting platelet aggregation, facilitating thrombolysis, reducing local inflammation, attenuating oxidative stress, promoting endothelial repair, and increasing bioavailability. By decorating with a fibrin-binding peptide, targeting efficiency and therapeutic benefits of TLH NP are considerably improved. Importantly, LMWH nanotherapies show no toxicities to the mother and fetus at the dose 10-time higher than the examined therapeutic dosage.
Collapse
|
22
|
López García-Franco A, Baeyens Fernández JA, Iglesias Piñeiro MJ, Alonso Coello P, Ruiz Cabello C, Pereira Iglesias A, Landa Goñi J. [Preventive activities in women. PAPPS update 2022]. Aten Primaria 2022; 54 Suppl 1:102471. [PMID: 36435585 PMCID: PMC9705224 DOI: 10.1016/j.aprim.2022.102471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022] Open
Abstract
In the 2022 PAPPS update we present those specific preventive activities for women's health, except those related to cancer prevention (which are included in another document) and those aspects related to differential gender morbidity, a cross-cutting aspect for all working groups. Contraception is an essential preventive activity, considering basic the right to decide both the number of children and the time to have them. We must inform about the possible contraceptive methods, guaranteeing the monitoring of their safety, efficacy and effectiveness (tables are included on changing from one method to another to preserve contraceptive protection). We must inform about emergency contraception and propose it in the event of unprotected intercourse. All this will be done through opportunistic screening without requiring screening for thrombophilia or dyslipidemia, but for arterial hypertension. Pregnancy is an important life experience and the family doctor should not remain oblivious. We must be competent both in the preconception consultation (recommending the intake of folic acid, avoiding exposure to occupational and environmental risks, screening for certain pathologies and assessing the intake of drugs not indicated during pregnancy) and in the monitoring of pregnancy. Whether or not we monitor the pregnancy, we must not disregard its control, taking advantage of this period to promote healthy lifestyles and participating in the intercurrent processes that may occur. Menopause in general and osteoporosis in particular exemplify the strategy of medicalization of vital processes that has been followed from different instances and organizations. In our update we address the prevention and treatment of symptoms secondary to estrogen deprivation. We also propose the prevention of osteoporosis, including carrying out densitometry based on the risk of fracture in the next 10 years, and therefore densitometric screening is not recommended in women under 60 years of age. In risk assessment we recommend the use of the frax tool or better, the calibration of the risk of hip fracture with prevalence data from our setting. We linked the indication for treatment with the Z-Score (bone mineral density compared with women of the same age), as it is a condition associated with aging.
Collapse
Affiliation(s)
| | | | | | - Pablo Alonso Coello
- Medicina Familiar y Comunitaria, Centro Cochrane Iberoamericano (CIBERESP-IIB Sant Pau), Barcelona, España
| | - Cristina Ruiz Cabello
- Medicina Familiar y Comunitaria, Consultorio Castilléjar, zona básica de Benamaurel, Granada, España
| | - Ana Pereira Iglesias
- Medicina Familiar y Comunitaria, Centro de Salud Dr. Mendiguchía Carriche, Leganés, Madrid, España
| | - Jacinta Landa Goñi
- Medicina Familiar y Comunitaria, Centro de Salud Emisora, Pozuelo de Alarcón, Madrid, España
| |
Collapse
|
23
|
Silva-Herrera JL, Polanía-Reyes DP, Aya-Porto AC, Russi-Santamaría AM, Suarez-Pareja N. Agreement between two scales used for assessing risk classification for thromboembolic events and the requirement of postpartum pharmacological prophylaxis. REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGIA 2022; 73:274-282. [PMID: 36331306 PMCID: PMC9674385 DOI: 10.18597/rcog.3831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/01/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To determine agreement in assessing the need for postpartum pharmacological prophylaxis between the scale of the Royal College of Obstetricians and Gynaecologists and the Colombian guideline scale in a Level IV institution in Bogota, Colombia. MATERIAL AND METHODS Diagnostic agreement study assembled on a cross-sectional study. The included population consisted of pregnant women with 24 or more weeks of pregnancy admitted between March 1 and April 30 of 2021 to a high complexity private institution in Bogotá, Colombia, for labor induction, in active labor, for elective cesarean section, or who required urgent cesarean section. Convenience sampling was used. Measured variables included demographics, risk factors, risk classification and pharmacological prophylaxis according to the two scales. The prevalence of risk factors for each scale was estimated and agreement regarding prophylaxis indication between the two scales was measured using the weighted kappa value. RESULTS Overall, 320 patients were included. According to the scale of the Royal College Obstetricians and Gynaecologists, 54.7 % patients were classified as low risk, 42.5 % as intermediate risk and 2.8 % as high risk. The Colombian scale classified 80 % of patients as low risk, 17.2 % as intermediate risk, 2.2 % as high risk, and 0.6 % as very high risk. The weighted kappa value for agreement regarding the indication was 0.47 (95 % CI: 0.38-0.56). CONCLUSIONS Agreement between the two scales to determine the need for postpartum pharmacological prophylaxis is moderate. Risk classification criteria for the Colombian scale should be validated in a second cohort. Moreover, the predictive ability of the Colombian guideline tool should be assessed at different cut-off points in terms of the consequences of false positive and false negative results.
Collapse
|
24
|
Maughan BC, Marin M, Han J, Gibbins KJ, Brixey AG, Caughey AB, Kline JA, Jarman AF. Venous Thromboembolism During Pregnancy and the Postpartum Period: Risk Factors, Diagnostic Testing, and Treatment. Obstet Gynecol Surv 2022; 77:433-444. [PMID: 35792687 PMCID: PMC10042329 DOI: 10.1097/ogx.0000000000001043] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but pulmonary embolism is typically of greater concern as it contributes to far higher morbidity and mortality. Diagnosis and treatment of VTE during pregnancy differ substantially from the general nonpregnant population. Objective This review describes the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of VTE during pregnancy and the postpartum period. Evidence Acquisition First, we reviewed the VTE guidelines from professional societies in obstetrics, cardiology, hematology, emergency medicine, pulmonology, and critical care. Second, we examined references from these documents and used PubMed to identify recent articles that cited the guidelines. Finally, we searched PubMed and Google Scholar for articles published since 2018 that included terms for pregnancy and the epidemiology, risk factors, diagnostic imaging, or treatment of VTE. Results Venous thromboembolism risk increases throughout pregnancy and peaks shortly after delivery. More than half of pregnancy-related VTE are associated with thrombophilia; other major risks include cesarean delivery, postpartum infection, and the combination of obesity with immobilization. Most VTE can be treated with low molecular weight heparin, but cases of limb- or life-threatening VTE require consideration of thrombolysis and other reperfusion therapies. Conclusions and Relevance Venous thromboembolism is far more frequent in antepartum and postpartum women than age-matched controls, and clinical suspicion for VTE in this population should incorporate pregnancy-specific risks. Treatment of limb- or life-threatening antepartum or postpartum VTE requires multispecialty coordination to optimize maternal and fetal outcomes.
Collapse
Affiliation(s)
- Brandon C Maughan
- Assistant Professor, Department of Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, OR
| | - Maria Marin
- Medical Student, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA
| | - Justin Han
- Medical Student, College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Karen J Gibbins
- Assistant Professor, Division of Perinatology, Department of Obstetrics and Gynecology
| | - Anupama G Brixey
- Assistant Professor, Section of Cardiothoracic Imaging, Department of Diagnostic Radiology
| | - Aaron B Caughey
- Professor and Chair, Department of Obstetrics and Gynecology, Oregon Health & Science University School of Medicine, Portland, OR
| | - Jeffrey A Kline
- Professor and Associate Chair of Research, Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Angela F Jarman
- Assistant Professor, Department of Emergency Medicine, University of California Davis, Davis, CA
| |
Collapse
|
25
|
Bikdeli B, Piazza G, Jimenez D, Muriel A, Wang Y, Khairani CD, Rosovsky RP, Mehdipoor G, O'Donoghue ML, Spagnolo P, Dreyer RP, Bertoletti L, López-Jiménez L, Núñez MJ, Blanco-Molina Á, Bates SM, Gerhard-Herman M, Goldhaber SZ, Monreal M, Krumholz HM. Sex Differences in PrEsentation, Risk Factors, Drug and Interventional Therapies, and OUtcomes of Elderly PatientS with Pulmonary Embolism: Rationale and design of the SERIOUS-PE study. Thromb Res 2022; 214:122-131. [DOI: 10.1016/j.thromres.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022]
|
26
|
Gris JC, Guillotin F, Chéa M, Bourguignon C, Bouvier S. The Risk of Thrombosis Around Pregnancy: Where Do We Stand? Front Cardiovasc Med 2022; 9:901869. [PMID: 35722088 PMCID: PMC9205638 DOI: 10.3389/fcvm.2022.901869] [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: 03/22/2022] [Accepted: 04/25/2022] [Indexed: 11/15/2022] Open
Abstract
Pregnancy and puerperium increase the relative risk of venous thromboembolism (VTE) and the absolute risk remains low, around 1 per 1,000, with induced mortality of around 1 per 100,000. Analysis of large databases has helped specify the modes of presentation and risk factors (RF) whose impact is greater after than before childbirth, since VTE during pregnancy and post-partum obey different RFs. The evolution of the population concerned (mostly women over 35, obese, of multi-ethnicity undergoing medically assisted reproduction) affects the frequency of these RFs. Pulmonary embolism (PE) is over-represented after childbirth, but 30% of PE in pregnancy occurs without any RFs. Recommendations for prevention, mainly from expert groups, are heterogeneous and often discordant. Low molecular weight heparins (LMWH) are the mainstay of pharmacological thromboprophylaxis, in a field where randomized controlled studies are definitely lacking. VTE risk assessment in pregnancy must be systematic and repetitive. Risk assessment methods and scores are beginning to emerge to guide thromboprophylaxis and should be used more systematically. In the future, analyzing observational data from huge, nationwide registries and prospective cluster clinical trials may bring to light clinically relevant outcomes likely to feed comprehensive guidelines.
Collapse
Affiliation(s)
- Jean-Christophe Gris
- Department of Hematology, Nîmes University Hospital, Nîmes, France
- Department of Hematology, Faculty of Pharmaceutical and Biological Sciences, Montpellier University, Montpellier, France
- UMR UA11 INSERM-Montpellier University IDESP, Montpellier, France
- Department of Obstetrics and Gynecology, First Ivan Setchenov Medical University, Moscow, Russia
- *Correspondence: Jean-Christophe Gris
| | | | - Mathias Chéa
- Department of Hematology, Nîmes University Hospital, Nîmes, France
| | - Chloé Bourguignon
- Department of Hematology, Nîmes University Hospital, Nîmes, France
- UMR UA11 INSERM-Montpellier University IDESP, Montpellier, France
| | - Sylvie Bouvier
- Department of Hematology, Nîmes University Hospital, Nîmes, France
- Department of Hematology, Faculty of Pharmaceutical and Biological Sciences, Montpellier University, Montpellier, France
- UMR UA11 INSERM-Montpellier University IDESP, Montpellier, France
| |
Collapse
|
27
|
Zhou Q, Zhao Z, Xu J, Xiong Y, Li X. Hospital Variation and Associated Organizational Factors of Pregnancy-Related Venous Thromboembolism in China. Clin Appl Thromb Hemost 2022; 28:10760296221076148. [PMID: 35360953 PMCID: PMC8980411 DOI: 10.1177/10760296221076148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objective Identifying organizational factors affecting venous thromboembolism (VTE) incidence and variations between hospitals. Methods From a 2019 survey of VTE and live births in 113 hospitals, organizational factors: (hospital type, characteristics, live birth number), resource availability: (D-dimer, B-scan ultrasonography of lower extremity veins, computed tomographic pulmonary angiography [CTPA], and competency: [risk assessment, use of anticoagulants and patient education], data were collected and the associations, weighted by live birth number, analyzed. Results Of 113 hospitals in China, 770,828 live births and 526 cases of VTE (68.2 per 100,000 live births) were reported. Nine hospitals lacked B-scan ultrasonography of lower extremity veins and 22 lacked CTPA. Prevalence rates of VTE rates were higher in general hospitals (Odds ratio [OR] = 4.251, 95% CI: 3.373-5.357), hospitals with live births < 10,000 (OR = 1.650-2.193), and hospitals without B-scan ultrasonography (OR = 1.661, 95% CI: 1.096-2.518). Hospitals implementing patient education, had a lower risk of VTE (OR = 0.296-0.374), and VTE rate decreased with the annual increase in live births. Conclusions Improved hospital resource availability and competency, especially patient education, is vital for reducing VTE-related maternal mortality and morbidity risk.
Collapse
Affiliation(s)
- Qiongjie Zhou
- Department of Obstetrics, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Zhekun Zhao
- Department of Obstetrics, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Jinghui Xu
- Department of Obstetrics, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Yu Xiong
- Department of Obstetrics, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Xiaotian Li
- Department of Obstetrics, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
- Institute of Biomedical Sciences, Fudan University, Shanghai, China
| |
Collapse
|
28
|
Barger MK. Current Resources for Evidence-Based Practice, November/December 2021. J Midwifery Womens Health 2021; 66:806-812. [PMID: 34883545 DOI: 10.1111/jmwh.13318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/01/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Mary K Barger
- Hahn School of Nursing and Health Science, Beyster Institute for Nursing Research, University of San Diego, San Diego, California
| |
Collapse
|
29
|
Speranza G, Sadek M, Jacobowitz G. Common iliac vein stenting for May-Thurner syndrome and subsequent pregnancy. J Vasc Surg Venous Lymphat Disord 2021; 10:348-352. [PMID: 34438090 DOI: 10.1016/j.jvsv.2021.07.018] [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: 06/04/2021] [Accepted: 07/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND For women with left common iliac vein compression (ie, May-Thurner syndrome) who undergo venous stenting and subsequently become pregnant, concerns have been raised regarding a possible compromise of stent patency due to compression from the gravid uterus and the hypercoagulability induced by pregnancy. Only a small body of literature exists on this subject, and limited management guidelines are available. The present study was designed to evaluate the safety of iliac vein stenting for May-Thurner syndrome (MTS) with subsequent pregnancy. METHODS Female patients who had undergone common iliac vein stenting at our center who were aged 18 to 45 years and had subsequently become pregnant were identified. A retrospective medical record review of eight eligible patients was conducted, recording the demographics, procedural characteristics, and anticoagulation strategies. The primary outcome evaluated was stent patency. RESULTS All eight patients had undergone left common iliac vein stenting for MTS. A total of eight stents were placed, and all demonstrated duplex ultrasound patency throughout pregnancy and postpartum. Seven patients delivered healthy pregnancies, and one experienced a stillbirth. The clinical CEAP (clinical, etiologic, anatomic, pathophysiologic) class remained unchanged or improved from pregnancy to postpartum for all patients. The average age at stent placement was 31 ± 5 years, and the average interval from stent placement to pregnancy was 28 ± 19 months. One patient developed nonobstructive deep vein thrombosis (DVT) of the left femoral vein during pregnancy and was treated with therapeutic enoxaparin. The nonobstructive DVT did not compromise the iliac vein stent. Two patients received low-dose aspirin and prophylactic doses of enoxaparin, one for a history of DVT and factor V Leiden and one for a recent history of fertility treatment. The five remaining patients received no anticoagulation, three received low-dose aspirin, and two received no antiplatelet therapy. CONCLUSIONS Common iliac vein stent patency was not compromised by subsequent pregnancy in our eight patients with MTS. Furthermore, the stents remained patent throughout pregnancy in patients receiving a wide range of anticoagulation and antiplatelet treatments, suggesting that no uniform therapeutic threshold exists and treatment should be individualized. For most patients, low-dose aspirin alone or no treatment was adequate. This could have implications for counseling women who require intervention for MTS and are of child-bearing age.
Collapse
Affiliation(s)
| | - Mikel Sadek
- Division of Vascular Surgery, New York University Langone Health, New York, NY
| | - Glenn Jacobowitz
- Division of Vascular Surgery, New York University Langone Health, New York, NY.
| |
Collapse
|
30
|
Song J, Nam BD, Yoon SH, Yoo JY, Jeong YJ, Yeo CD, Lim SY, Lee SY, Kim HK, Kim BH, Jin KN, Yong HS. [Korean Clinical Imaging Guidelines for the Appropriate Use of Chest MRI]. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:562-574. [PMID: 36238776 PMCID: PMC9432450 DOI: 10.3348/jksr.2020.0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/15/2021] [Accepted: 02/01/2021] [Indexed: 11/15/2022]
Abstract
MRI has the advantages of having excellent soft-tissue contrast and providing functional information without any harmful ionizing radiation. Although previous technical limitations restricted the use of chest MRI, recent technological advances and expansion of insurance coverage are increasing the demand for chest MRI. Recognizing the need for guidelines on appropriate use of chest MRI in Korean clinical settings, the Korean Society of Radiology has composed a development committee, working committee, and advisory committee to develop Korean chest MRI justification guidelines. Five key questions were selected and recommendations have been made with the evidence-based clinical imaging guideline adaptation methodology. Recommendations are as follows. Chest MRI can be considered in the following circumstances: for patients with incidentally found anterior mediastinal masses to exclude non-neoplastic conditions, for pneumoconiosis patients with lung masses to differentiate progressive massive fibrosis from lung cancer, and when invasion of the chest wall, vertebrae, diaphragm, or major vessels by malignant pleural mesothelioma or non-small cell lung cancer is suspected. Chest MRI without contrast enhancement or with minimal dose low-risk contrast media can be considered for pregnant women with suspected pulmonary embolism. Lastly, chest MRI is recommended for patients with pancoast tumors planned for radical surgery.
Collapse
|
31
|
McGlinn E, Parviz J, Pazderka P. Postpartum fever and radicular low back pain. Am J Emerg Med 2021; 48:378.e3-378.e5. [PMID: 33892941 DOI: 10.1016/j.ajem.2021.04.040] [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: 03/11/2021] [Revised: 04/11/2021] [Accepted: 04/14/2021] [Indexed: 11/17/2022] Open
Abstract
Fever and low back pain with radicular symptoms raise concern for epidural abscess or other neuraxial infection, especially in the context of recent epidural anesthesia. Here we present an unusual case with several confounding factors and an unexpected diagnosis.
Collapse
Affiliation(s)
- Evan McGlinn
- Department of Emergency Medicine, Western Michigan University, Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008-8060, United States of America.
| | - Jason Parviz
- Department of Emergency Medicine, Western Michigan University, Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008-8060, United States of America
| | - Philip Pazderka
- Department of Emergency Medicine, Western Michigan University, Homer Stryker MD School of Medicine, 1000 Oakland Drive, Kalamazoo, MI 49008-8060, United States of America
| |
Collapse
|
32
|
Sahoo DR, Dorairajan G, Palanivel C. Risk stratification for venous thrombosis in post-partum women in a tertiary care setup in south India. Indian J Med Res 2021; 152:523-526. [PMID: 33707396 PMCID: PMC8157891 DOI: 10.4103/ijmr.ijmr_1564_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background & objectives The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines for thromboprophylaxis among post-partum women are recommended across Asia. This study was aimed to find the proportion of post-partum women eligible for thromboprophylaxis based on the RCOG guidelines and how many actually received it in a tertiary care health facility in south India. Methods This cross-sectional study was carried out on 1652 consecutive women who delivered in the setup of tertiary care. Risk stratification for venous thrombosis was done as per the RCOG guidelines. The number of women who received thromboprophylaxis was also noted. Results Among the 1652 women studied, three [0.18%; 95% confidence interval (CI): 0.06-0.53] were in the high-risk, 598 (36.2%; 95% CI: 33.9-38.6) in the intermediate and 254 (15.4%; 95% CI: 13.7-17.2) in the low-risk category for thrombosis. All the three women in the high-risk and only two women in the intermediate-risk category actually received thromboprophylaxis with heparin. Interpretation & conclusions It was seen that the number of women needing prophylaxis in our setup, as per the RCOG guidelines, was as high as 601 (36.4%), but only five (0.8%) received it.
Collapse
Affiliation(s)
- Dripta Ramya Sahoo
- Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Gowri Dorairajan
- Department of Obstetrics & Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - C Palanivel
- Department of Preventive & Social Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| |
Collapse
|
33
|
Jaya-Bodestyne SL, Lee LH, Tan LK, Tan KH, Østbye T, Malhotra R, Allen J, Tan SSX, Tan MSY, Ng LCK, Yong Y, Tan TC. Risk factors for pregnancy-associated venous thromboembolism in Singapore. J Perinat Med 2021; 49:153-158. [PMID: 32889795 DOI: 10.1515/jpm-2020-0298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 08/10/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Pregnancy-associated venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), is associated with increased risk of maternal mortality and morbidity. This study aimed to assess potential risk factors for pregnancy-associated VTE. METHODS In this case-control study, women with pregnancy-associated VTE were identified via International Classification of Diseases codes and included if they had been objectively diagnosed with VTE during pregnancy or within six weeks postpartum, from 2004 to 2016, at KK Women's and Children's Hospital or Singapore General Hospital in Singapore. Controls, i.e. pregnant women without VTE, were selected from a prospective longitudinal study. The odds ratio (OR) for VTE was computed for a range of maternal and obstetric factors. RESULTS AND CONCLUSIONS From 2004 to 2016, 89 cases of pregnancy-associated VTE and 926 controls were identifed and analysed using logistic regression. The most significant risk factors for pregnancy-associated VTE were smoking (OR 5.44, p=0.0002) and preterm delivery (OR 5.06, p=0.023). Malay race, multiparity, non-O blood group and caesarean section, were also identified to be of higher risk. These risk factors should be useful in the development of thromboprophylaxis strategies for pregnancy and the postpartum period, especially in Singapore.
Collapse
Affiliation(s)
| | - Lai Heng Lee
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Lay Kok Tan
- Department of Obstetrics and Gynaecology, Singapore General Hospital, Singapore, Singapore
| | - Kok Hian Tan
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore, Singapore
| | | | | | - John Allen
- Duke-NUS Medical School, Singapore, Singapore
| | - Sophie Seine Xuan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Melinda Si Yun Tan
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | | | - Yang Yong
- Department of Epidemiology, Singapore General Hospital, Singapore, Singapore
| | - Thiam Chye Tan
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore, Singapore
| |
Collapse
|
34
|
Evaluation of Complications in Postpartum Women Receiving Therapeutic Anticoagulation. Obstet Gynecol 2020; 136:394-401. [PMID: 32649504 DOI: 10.1097/aog.0000000000003971] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate complications associated with early postpartum therapeutic anticoagulation. METHODS A multicenter retrospective cohort study was done to evaluate the association between therapeutic anticoagulation postpartum and major complications (hemorrhagic and wound complications). Secondary outcomes included minor complications, risk factors associated with total complications (including the time to therapeutic anticoagulation resumption after delivery) and recurrent thrombotic events within 6 weeks postpartum. RESULTS From 2003 to 2015, 232 consecutive women were treated with therapeutic anticoagulation within 96 hours postpartum; among those treated, 91 received unfractionated heparin, 138 received low-molecular-weight heparin, and three received other anticoagulants. The primary outcome, a composite of major hemorrhagic complications (requiring transfusion, hospitalization, volume resuscitation, transfer to intensive care unit, or surgery) and major wound complications, occurred in 7 of 83 (8.4%) for cesarean deliveries and 9 of 149 (6.0%) for vaginal deliveries (P=.490). Total complications (including major and minor hemorrhagic and wound complications) occurred in 13 of 83 (15.7%) for cesarean deliveries compared with 9 of 149 (6.0%) for vaginal deliveries (P=.016). When comparing cases associated with and without complications, the median delay before resuming anticoagulation was significantly shorter for both cesarean (12 vs 33 hours, P=.033) and vaginal deliveries (6 vs 19 hours, P=.006). For vaginal deliveries, 8 of 51 (15.7%) women had complications when anticoagulation was started before 9.25 hours postpartum, compared with 1 of 98 (1.0%) when started after 9.25 hours. For cesarean deliveries, 7 of 21 (33.3%) of women experienced complications compared with 6 of 62 (9.7%) if anticoagulation was started before or after 15.1 hours, respectively. Two (0.9%) episodes of venous thromboembolism occurred within 6 weeks postpartum. CONCLUSION Among postpartum women who received early therapeutic anticoagulation, major complications occurred in 8.4% for cesarean deliveries and 6.0% for vaginal deliveries. Complications were associated with earlier resumption of therapeutic anticoagulation, particularly before 9.25 hours for vaginal deliveries and before 15.1 hours for cesarean deliveries.
Collapse
|
35
|
Bistervels IM, Scheres LJJ, Spijker R, Middeldorp S, van Mens TE. Diagnostic tests for pregnancy-related deep vein thrombosis. Hippokratia 2020. [DOI: 10.1002/14651858.cd013794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ingrid M Bistervels
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development; Amsterdam Netherlands
| | - Luuk JJ Scheres
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development; Amsterdam Netherlands
- Department of Internal Medicine; Radboud UMC; Nijmegen Netherlands
| | - René Spijker
- Cochrane Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University; Utrecht Netherlands
- Amsterdam UMC, University of Amsterdam, Medical Library, Amsterdam Public Health; Amsterdam Netherlands
| | - Saskia Middeldorp
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development; Amsterdam Netherlands
| | - Thijs E van Mens
- Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development; Amsterdam Netherlands
| |
Collapse
|
36
|
Abstract
IMPORTANCE Incidence rates for lower extremity deep vein thrombosis (DVT) range from 88 to 112 per 100 000 person-years and increase with age. Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event. OBSERVATIONS PubMed and Cochrane databases were searched for English-language studies published from January 2015 through June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies. Risk factors for venous thromboembolism (VTE), such as older age, malignancy (cumulative incidence of 7.4% after a median of 19 months), inflammatory disorders (VTE risk is 4.7% in patients with rheumatoid arthritis and 2.5% in those without), and inherited thrombophilia (factor V Leiden carriers with a 10-year cumulative incidence of 10.9%), are associated with higher risk of VTE. Patients with signs or symptoms of lower extremity DVT, such as swelling (71%) or a cramping or pulling discomfort in the thigh or calf (53%), should undergo assessment of pretest probability followed by D-dimer testing and imaging with venous ultrasonography. A normal D-dimer level (ie, D-dimer <500 ng/mL) excludes acute VTE when combined with a low pretest probability (ie, Wells DVT score ≤1). In patients with a high pretest probability, the negative predictive value of a D-dimer less than 500 ng/mL is 92%. Consequently, D-dimer cannot be used to exclude DVT without an assessment of pretest probability. Postthrombotic syndrome, defined as persistent symptoms, signs of chronic venous insufficiency, or both, occurs in 25% to 50% of patients 3 to 6 months after DVT diagnosis. Catheter-directed fibrinolysis with or without mechanical thrombectomy is appropriate in those with iliofemoral obstruction, severe symptoms, and a low risk of bleeding. The efficacy of direct oral anticoagulants-rivaroxaban, apixaban, dabigatran, and edoxaban-is noninferior to warfarin (absolute rate of recurrent VTE or VTE-related death, 2.0% vs 2.2%). Major bleeding occurs in 1.1% of patients treated with direct oral anticoagulants vs 1.8% treated with warfarin. CONCLUSIONS AND RELEVANCE Greater recognition of VTE risk factors and advances in anticoagulation have facilitated the clinical evaluation and treatment of patients with DVT. Direct oral anticoagulants are noninferior to warfarin with regard to efficacy and are associated with lower rates of bleeding, but costs limit use for some patients.
Collapse
Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
- EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Ida Ehlers Albertsen
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
37
|
López García-Franco A, Baeyens Fernández JA, Bailón Muñoz E, Iglesias Piñeiro MJ, Ortega Del Moral A, Coello PA, Ruiz Cabello C, Landa Goñi J, Arribas Mir L. [Preventive activities in women's care]. Aten Primaria 2020; 52 Suppl 2:125-148. [PMID: 33388112 PMCID: PMC7801221 DOI: 10.1016/j.aprim.2020.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 12/17/2022] Open
Abstract
A review is presented of the scientific evidence on preventive activities in women's care in relation to pregnancy follow-up, preventive activities in the planning and follow-up of contraceptive methods, preventive activities in menopause, and the prevention of osteoporotic fractures.
Collapse
Affiliation(s)
| | | | - Emilia Bailón Muñoz
- Medicina Familiar y Comunitaria, Centro de Salud Universitario de Albaycín, Granada, España
| | | | | | - Pablo Alonso Coello
- Medicina Familiar y Comunitaria, Centro Cochrane Iberoamericano (CIBERESP-IIB Sant Pau), Barcelona, España
| | - Cristina Ruiz Cabello
- Medicina Familiar y Comunitaria, Consultorio Castilléjar, zona básica de Benamaurel, Granada, España
| | - Jacinta Landa Goñi
- Medicina Familiar y Comunitaria, Centro de Salud Emisora, Pozuelo de Alarcón, Madrid, España
| | - Lorenzo Arribas Mir
- Medicina Familiar y Comunitaria, Centro de Salud Universitario La Chana, Granada, España
| |
Collapse
|
38
|
Hu W, Wang Y, Li J, Huang J, Pu Y, Jiang Y, Xu D, Ding Z, Zhao B, Luo Q. The Predictive Value of d-Dimer Test for Venous Thromboembolism During Puerperium: A Prospective Cohort Study. Clin Appl Thromb Hemost 2020; 26:1076029620901786. [PMID: 32090610 PMCID: PMC7288823 DOI: 10.1177/1076029620901786] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The aim of this study was to investigate the d-dimer for prediction of
venous thromboembolism (VTE) events in puerperium and to identify other risk
factors associated with the occurrence of VTE. This was a prospective
observational cohort study, which included 16 127 women who gave birth after 28
weeks of gestation at Women’s Hospital of Zhejiang University, School of
Medicine, from January 2016 to December 2016. Data including basic maternal and
fetal characteristics, pregnancy complications, and predictive biomarkers within
postpartum 24 hours including d-dimer, platelet, and fibrinogen were
collected for analyses. In the cohort study, 19 (0.12%) women were identified as
VTE, including 1 pulmonary embolism event and 18 deep venous thrombosis events.
The receiver operating characteristic curve analysis suggested the best cutoff
point for d-dimer level within postpartum 24 hours was 3.695 mg/L, with
a specificity of 75.5% and a sensitivity of 73.7%, and there was no statistical
correlation between fibrinogen and VTE, as well as between platelets and VTE. On
multivariate analysis, age ≥35 years (odds ratio [OR] = 2.895, 95% confidence
interval [CI]: 1.079-7.773), scarred uterus (OR = 3.894, 95% CI: 1.234-12.282),
intrauterine infection (OR = 7.214, 95% CI: 1.519-34.262), antiphospholipid
syndrome (OR = 199.530, 95% CI: 15.152-2627.529), d-dimer ≥3.70 mg/L
(OR = 7.573, 95% CI: 2.699-21.247), and emergency cesarean delivery (OR =
23.357, 95% CI: 2.819-193.508) were independently associated with VTE in
puerperium. We concluded that d-dimer ≥3.70 mg/L was an independent
predictor of VTE during puerperium and d-dimer testing was necessary
for perinatal women.
Collapse
Affiliation(s)
- Wen Hu
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Yali Wang
- Department of Obstetrics & Gynecology, Changxing Maternal and Child Health Hospital, Huzhou, Zhejiang, China
| | - Juan Li
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Jian Huang
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Yuqun Pu
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Jiang
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Dong Xu
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Zhiming Ding
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Baihui Zhao
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Qiong Luo
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| |
Collapse
|
39
|
Hu W, Xu D, Li J, Chen C, Chen Y, Xi F, Zhou F, Guo X, Zhao B, Luo Q. The predictive value of D-dimer test for venous thromboembolism during puerperium in women age 35 or older: a prospective cohort study. Thromb J 2020; 18:26. [PMID: 33088222 PMCID: PMC7566136 DOI: 10.1186/s12959-020-00241-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 10/12/2020] [Indexed: 12/04/2022] Open
Abstract
Background This study aimed to investigate the predictive value of the D-dimer level for venous thromboembolism (VTE) events during puerperium of women age at 35 years or older, as well as to identify other risk factors associated with the occurrence of VTE. Methods It was a prospective observational cohort study, from January 2014 to December 2018, which involved 12,451 women age 35 or older who delivered at least 28 weeks of gestation at Women’s Hospital of Zhejiang University, School of Medicine. The maternal and fetal demographic characteristics, pregnancy complications, imaging finding and results of laboratory test within postpartum 24 h including D-dimer level, platelet counts and fibrinogen level were collected for analyses. Results 30(2.4‰) women were identified as VTE, including 1 pulmonary embolism event and 29 deep venous thrombosis events. The receiver operating characteristic (ROC) curve analysis suggested the best cutoff point for D-dimer level within postpartum 24 h of women age 35 or older was 5.545 mg/L, with a specificity of 70.0% and a sensitivity of 75.4%. Besides, there was no statistical correlation between platelet counts and VTE, as well as between fibrinogen level and VTE. On multivariate analysis, D-dimer≥5.50 mg/L (OR = 5.874, 95%CI: 2.678–12.886) and emergency cesarean section (OR = 11.965, 95%CI: 2.732–52.401) were independently associated with VTE in puerperium of women age 35 or older. Conclusions We concluded that D-dimer≥5.50 mg/L was an independent predictor of VTE in puerperium with maternal age 35 or older and D-dimer testing was a necessary examination for perinatal women.
Collapse
Affiliation(s)
- Wen Hu
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Dong Xu
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Juan Li
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Cheng Chen
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Yuan Chen
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Fangfang Xi
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Feifei Zhou
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Xiaohan Guo
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Baihui Zhao
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Qiong Luo
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| |
Collapse
|
40
|
Hobohm L, Keller K, Valerio L, Ni Ainle F, Klok FA, Münzel T, Kucher N, Lankeit M, Konstantinides SV, Barco S. Fatality rates and use of systemic thrombolysis in pregnant women with pulmonary embolism. ESC Heart Fail 2020; 7:2365-2372. [PMID: 32567197 PMCID: PMC7524052 DOI: 10.1002/ehf2.12775] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/28/2020] [Accepted: 04/28/2020] [Indexed: 11/11/2022] Open
Abstract
AIMS Data on the early course and use of systemic thrombolysis in pregnant women with pulmonary embolism associated or not with haemodynamic failure are scarce. We investigated these aspects using the information from the German Nationwide Inpatient Registry (years 2005-2016). METHODS AND RESULTS In Germany, all diagnoses referring to hospitalized patients are coded according to the International Classification of Diseases and Related Health Problems, 10th Revision with German Modification. We analysed data of pregnant women aged 18-50 years for whom the following diagnoses were recorded during hospitalization: (i) pulmonary embolism (I26) during pregnancy or peripartum (O09) or (ii) obstetric thromboembolism (O88.2). Haemodynamic failure at any time during the in-hospital stay was defined as need for cardiopulmonary resuscitation (OPS code 8-77) or the presence of shock (International Classification of Diseases and Related Health Problems, 10th Revision with German Modification code R57). The primary study outcome was in-hospital death. A total of 8 271 327 births were registered in Germany from 2005 to 2016. During this 12 year time period, there were 1846 hospitalizations for pregnancy-associated pulmonary embolism in patients aged 18-50, corresponding to 2.2 [95% confidence interval (CI): 2.1-2.3] cases every 10 000 births and 0.2% of all hospitalizations for pulmonary embolism in Germany. The median age was 31 years, and the median length of hospitalization was 8 days. A total of 63 deaths were reported, corresponding to an overall in-hospital fatality rate of 3.4% (95% CI: 2.7-4.4) and a pulmonary embolism-related mortality rate of 0.8 (95% CI: 0.6-1.0) per 100 000 (live) births per year. Pulmonary embolism-related deaths in hospitalized pregnant women represented 14% of all maternal deaths recorded in Germany between 2005 and 2016. A total of 135 (7.3%) women had haemodynamic failure, of whom 51 (37.8%) received systemic thrombolysis and 50 (37.0%) died. CONCLUSIONS Pulmonary embolism-related fatality remains substantial in pregnant women with pulmonary embolism and represents a frequent cause of maternal mortality. The use of systemic thrombolysis was reported in one third of pregnant women with pulmonary embolism and haemodynamic failure. Better preventive and management strategies should be urgently implemented in this vulnerable patient group.
Collapse
Affiliation(s)
- Lukas Hobohm
- Center for Cardiology, Cardiology IUniversity Medical Center MainzMainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
| | - Karsten Keller
- Center for Cardiology, Cardiology IUniversity Medical Center MainzMainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
| | - Fionnuala Ni Ainle
- Department of HaematologyMater Misericordiae University HospitalDublinIreland
- SPHERE Research Group, Conway InstituteUniversity College DublinDublinIreland
- The Rotunda HospitalDublinIreland
- Irish Centre for Vascular BiologyRoyal College of Surgeons in IrelandDublinIreland
- School of MedicineUniversity College DublinDublinIreland
| | - Frederikus A. Klok
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Thomas Münzel
- Center for Cardiology, Cardiology IUniversity Medical Center MainzMainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
| | - Nils Kucher
- Clinic of AngiologyUniversity Hospital ZürichZürichSwitzerland
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK)Charité – University MedicineBerlinGermany
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
- Department of CardiologyDemocritus University of ThraceAlexandroupolisGreece
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
- Clinic of AngiologyUniversity Hospital ZürichZürichSwitzerland
| |
Collapse
|
41
|
Identification of Key mRNAs and lncRNAs in Neonatal Sepsis by Gene Expression Profiling. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2020; 2020:8741739. [PMID: 32908583 PMCID: PMC7469075 DOI: 10.1155/2020/8741739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/02/2020] [Accepted: 04/08/2020] [Indexed: 12/27/2022]
Abstract
Neonatal sepsis is one of the most prevalent causes of death of the neonates. However, the mechanisms underlying neonatal sepsis remained unclear. The present study identified a total of 1128 upregulated mRNAs and 1008 downregulated mRNAs, 28 upregulated lncRNAs, and 61 downregulated lncRNAs in neonatal sepsis. Then, we constructed PPI networks to identify key regulators in neonatal sepsis, including ITGAM, ITGAX, TLR4, ITGB2, SRC, ELANE, RPLP0, RPS28, RPL26, and RPL27. lncRNA coexpression analysis showed HS.294603, LOC391811, C12ORF47, LOC729021, HS.546375, HNRPA1L-2, LOC158345, and HS.495041 played important roles in the progression of neonatal sepsis. Bioinformatics analysis showed DEGs were involved in the regulation cellular extravasation, acute inflammatory response, macrophage activation of NF-kappa B signaling pathway, TNF signaling pathway, HIF-1 signaling pathway, Toll-like receptor signaling pathway, and ribosome, RNA transport, and spliceosome. lncRNAs were involved in regulating ribosome, T cell receptor signaling pathway, RNA degradation, insulin resistance, ribosome biogenesis in eukaryotes, and hematopoietic cell lineage. We thought this study provided useful information for identifying novel therapeutic markers for neonatal sepsis.
Collapse
|
42
|
Hosny M, Maged AM, Reda A, Abdelmeged A, Hassan H, Kamal M. Obstetric venous thromboembolism: a one-year prospective study in a tertiary hospital in Egypt. J Matern Fetal Neonatal Med 2020; 35:2642-2647. [PMID: 32674652 DOI: 10.1080/14767058.2020.1793316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND OBJECTIVE Obstetric venous thromboembolism (VTE) poses a life-threating burden and it is one of the major causes of maternal morbidity and mortality with an increased incidence throughout the last decades. The objectives of this study were to assess the incidence of VTE, types of prophylaxis received, and factors determining prophylaxis in women at VTE risk during pregnancy and puerperium at a tertiary hospital for 1 year. METHODS This is a prospective study that was carried out at Minia maternity university hospital, Egypt during the period from June 2018 to June 2019. The study included women attended the hospital at risk of VTE as per the RCOG guidelines. Full history, patient characteristics, and VTE risk factors were assessed. RESULTS During the study period, a total of 901 women attended the hospital and perceived at risk of VTE (298 cases during pregnancy and 603 cases during puerperium), about half of them were mild in intensity. They comprise 8.22% of the total deliveries during the study period (n = 10,956). About two-thirds of them (71.5%) had a cesarean delivery. Varicose veins were found in 209 cases (23.2%), previous VTE in 189 cases (21.0%), previous superficial vein thrombosis was recorded in 240 cases (26.6%) and previous arterial ischemic events in 83 cases (9.2%). The vast majority of patients (99.6%) received the pharmacological type of prophylaxis (55.6% of them received unfractionated heparin and the rest of them 43.9% received Aspirin). Only six cases developed VTE from the total included cases with an incidence of 0.55/1000 maternities (0.055%). Obesity (BMI >30 kg/m2) and cesarean delivery were significant factors that determine VTE prophylaxis with an odds ratio of 1.68 (95% CI, 1.20-2.35, p < .01) and 2.05 (95% CI, 1.49-2.80, p < .01), respectively. CONCLUSION The incidence of women perceived at VTE risk was 8.22%, about half of them were mild in intensity. The risk of VTE was higher during the postpartum period than that during pregnancy. The incidence of VTE was 0.55/1000 overall maternities (0.055%). The pharmacological type of prophylaxis was the predominant used type. Obesity and cesarean delivery were significant factors determining VTE prophylaxis.
Collapse
Affiliation(s)
- Mahmoud Hosny
- Obstetrics and Gynaecology Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Ahmed M Maged
- Obstetrics and Gynecology Department, Kasr AlAini hospital Cairo University, Cairo, Egypt
| | - Ahmed Reda
- Obstetrics and Gynaecology Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Ayman Abdelmeged
- Obstetrics and Gynaecology Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Hany Hassan
- Obstetrics and Gynaecology Department, Faculty of Medicine, Minia University, Minia, Egypt
| | - Mostafa Kamal
- Obstetrics and Gynaecology Department, Faculty of Medicine, Minia University, Minia, Egypt
| |
Collapse
|
43
|
Mehta LS, Warnes CA, Bradley E, Burton T, Economy K, Mehran R, Safdar B, Sharma G, Wood M, Valente AM, Volgman AS. Cardiovascular Considerations in Caring for Pregnant Patients: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e884-e903. [DOI: 10.1161/cir.0000000000000772] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardio-obstetrics has emerged as an important multidisciplinary field that requires a team approach to the management of cardiovascular disease during pregnancy. Cardiac conditions during pregnancy include hypertensive disorders, hypercholesterolemia, myocardial infarction, cardiomyopathies, arrhythmias, valvular disease, thromboembolic disease, aortic disease, and cerebrovascular diseases. Cardiovascular disease is the primary cause of pregnancy-related mortality in the United States. Advancing maternal age and preexisting comorbid conditions have contributed to the increased rates of maternal mortality. Preconception counseling by the multidisciplinary cardio-obstetrics team is essential for women with preexistent cardiac conditions or history of preeclampsia. Early involvement of the cardio-obstetrics team is critical to prevent maternal morbidity and mortality during the length of the pregnancy and 1 year postpartum. A general understanding of cardiovascular disease during pregnancy should be a core knowledge area for all cardiovascular and primary care clinicians. This scientific statement provides an overview of the diagnosis and management of cardiovascular disease during pregnancy.
Collapse
|
44
|
Makatsariya A, Bitsadze V, Khizroeva J, Vorobev A, Makatsariya N, Egorova E, Mischenko A, Mashkova T, Antonova A. Neonatal thrombosis. J Matern Fetal Neonatal Med 2020; 35:1169-1177. [PMID: 32204642 DOI: 10.1080/14767058.2020.1743668] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Neonatal thromboembolism in pediatric patients is a rare but life-threatening condition mainly caused by combinations of at least 2 prothrombotic triggering risk factors such as the central venous lines, septic condition, and prematurity. Other risk factors include asphyxia, dehydration, liver dysfunction, inflammation, and maternal condition. Neonatal hemostatic system is different from one of the older children and adults. Coagulation proteins do not cross the placenta but are synthesized in the fetus from an early stage. In the term neonate, concentrations of several procoagulant proteins, particularly the vitamin K dependent and contact factors are reduced when compared with adults. Conversely, levels of antithrombin, heparin cofactor II and protein C and S are low at birth and fibrinolysis system is characterized by the decreased level of plasminogen and alpha-1-antiplasmin, increased tissue plasminogen activator. These features all tend to be gestational dependent and are more present in the preterm infant. Primarily in this context neonates appear to be at a higher risk of thrombosis than older children. Thrombotic complications reach their peak in the group of children born at 22-27 weeks. The role of inherited thrombophilic risk factors in neonatal VTE development is poorly defined. The presence of inherited and acquired thrombophilia in mother and newborn is also responsible for the development of thrombosis in neonates and should be considered. Thrombophilia in the mother can lead to increased coagulation potential and prethrombotic conditions during pregnancy, causing thrombotic vasculopathy at the placental level. The benefit of identifying thrombophilia in the sick preterm newborns who are in the group of risk for development of thrombotic complications may facilitate the thromboprophylaxis. Further research regarding assessment of risk factors, diagnostics and treatment strategy is required.
Collapse
Affiliation(s)
- Alexander Makatsariya
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Viktoriya Bitsadze
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Jamilya Khizroeva
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Alexander Vorobev
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Natalya Makatsariya
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Elena Egorova
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Alexander Mischenko
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Tamara Mashkova
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Alexandra Antonova
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| |
Collapse
|
45
|
Sun S, Diaconescu M, Zhe T, Mesurolle B, Semionov A. Outcomes of Multidetector Computed Tomography Pulmonary Angiography in Pregnant and Postpartum Women With Suspected Pulmonary Embolism. Can Assoc Radiol J 2020; 72:512-518. [PMID: 32070114 DOI: 10.1177/0846537119899552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Verify whether there is a difference in likelihood of developing pulmonary embolism (PE) between pregnant women, nonpregnant women of reproductive age, and postpartum (up to 6 weeks) women, by comparing their outcomes on computed tomography pulmonary angiography (CTPA) done for suspicion of PE. MATERIALS AND METHODS Retrospective cohort study of 1463 CTPA done for suspicion of PE in females of reproductive age (18-40 years), nonpregnant, pregnant (antepartum), and postpartum, from 2 tertiary-care academic hospitals between October 2006 and September 2015. Primary outcome was diagnosis of PE on imaging. Additional assessment was made of technical adequacy of the studies and method of delivery for the postpartum cohort (vaginal vs caesarean birth). Twenty-nine technically nondiagnostic studies were excluded. The effect of any potential variable on PE status was tested using univariate logistic regression. Subgroup analysis was performed after excluding patients with independent risk factors for PE. RESULTS The rate of CTPA positive for PE was less among pregnant patients compared to early postpartum and nonpregnant women of similar age, 2.9% vs 11.5% and 10.3%, respectively. Pregnancy was associated with statistically significant decreased odds ratio of developing a PE on CTPA, 0.23 (0.09-0.89), P value = .004. After excluding patients with additional independent risk factors for PE, there was no statistically significant odds ratio association between presence of PE on CTPA and pregnancy 0.41 (0.13-1.34), P value = .14. CONCLUSION Rate of CTPA positive for PE in pregnant women was lower than in nonpregnant and early postpartum women. Pregnancy was statistically significantly less likely to be associated with positive PE on a CTPA study. The common perception that pregnancy (antepartum state) is associated with an increased risk of PE may require a thorough critical reappraisal.
Collapse
Affiliation(s)
- Simon Sun
- Department of Diagnostic Radiology, McGill University Health Centre, 10041Montreal General Hospital, Montréal, Quebec, Canada
| | - Marius Diaconescu
- Department of Diagnostic Radiology, McGill University Health Centre, 10041Montreal General Hospital, Montréal, Quebec, Canada
| | - Tian Zhe
- Cancer Prognostics and Health Outcomes Unit, CRCHUM, 5622University of Montreal Health Center, Montréal, Quebec, Canada
| | - Benoit Mesurolle
- Department of Radiology, 55046Centre République, Elsan, Clermont-Ferrand, France
| | - Alexandre Semionov
- Department of Diagnostic Radiology, McGill University Health Centre, 10041Montreal General Hospital, Montréal, Quebec, Canada
| |
Collapse
|
46
|
Wiegers HMG, Middeldorp S. Contemporary best practice in the management of pulmonary embolism during pregnancy. Ther Adv Respir Dis 2020; 14:1753466620914222. [PMID: 32425105 PMCID: PMC7238314 DOI: 10.1177/1753466620914222] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/25/2020] [Indexed: 12/25/2022] Open
Abstract
Approximately 1-2 per 1000 pregnancies are complicated by venous thromboembolism (VTE). VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE) and the diagnostic management of pregnancy-related VTE is challenging. Current guidelines vary greatly in their approach to diagnosing PE in pregnancy as they base their recommendations on scarce and weak evidence. The pregnancy-adapted YEARS diagnostic algorithm is well tolerated and is the most efficient diagnostic algorithm for pregnant women with suspected PE, with 39% of women not requiring computed tomographic pulmonary angiography. Low-molecular-weight heparin is the first-choice anticoagulant treatment in pregnancy and should be continued until 6 weeks postpartum and for a minimum of 3 months. Direct oral anticoagulants should be avoided in women who want to breastfeed. Management of delivery needs a multidisciplinary approach in order to decide on an optimal delivery plan. Neuraxial analgesia can be given in most patients, provided time windows since last low-molecular-weight heparin dose are respected. Women with a history of VTE are at risk of recurrence during pregnancy and in the postpartum period. Therefore, in most women with a history of VTE, thromboprophylaxis in subsequent pregnancies is indicated. The reviews of this paper are available via the supplemental material section.
Collapse
Affiliation(s)
- Hanke M. G. Wiegers
- Department of Vascular Medicine, Amsterdam UMC,
University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9,
Amsterdam, North Holland 1105 AZ, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC,
University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The
Netherlands
| |
Collapse
|
47
|
Nan J, Tan N, Schaff H, Bell MR, Pislaru S, Best PJM. A Dangerous Dilemma: Thrombus in Transit During Pregnancy. JACC Case Rep 2019; 1:369-371. [PMID: 34316828 PMCID: PMC8288568 DOI: 10.1016/j.jaccas.2019.08.010] [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: 06/17/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 11/15/2022]
Abstract
Pregnancy is associated with venous thromboembolism. Occasionally, thrombus can become entrapped across a patent foramen ovale, with risk of systemic embolism. This report presents a case of a pregnant woman who had thrombus in transit diagnosed by echocardiography, which was successfully removed by surgical thrombectomy. (Level of Difficulty: Intermediate.)
Collapse
Affiliation(s)
- John Nan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Nicholas Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Sorin Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Patricia J M Best
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| |
Collapse
|
48
|
Kim YH, Pfaller B, Marson A, Yim HW, Huang V, Ito S. The risk of venous thromboembolism in women with inflammatory bowel disease during pregnancy and the postpartum period: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e17309. [PMID: 31568016 PMCID: PMC6756775 DOI: 10.1097/md.0000000000017309] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Pregnancy and inflammatory bowel disease (IBD) are independent risk factors for venous thromboembolism (VTE). Nevertheless, the optimal VTE prevention strategy for women with IBD in pregnancy and postpartum period has not been established yet. We assessed VTE risks during pregnancy and the postpartum period in women with IBD through systematic review and meta-analysis.Systematic searches were conducted in MEDLINE (Ovid), Embase (Ovid), CENTRAL (Ovid), and Web of Science (Tomson Reuters) from the database inception till May 2017 to identify relevant studies reporting the risk of VTE during pregnancy and/or the postpartum period in women with IBD. Random effect meta-analyses were performed to compare VTE-related outcomes between women with IBD and without IBD. Our protocol was registered: CRD 42017060199 in the PROSPERO International prospective register of systematic reviews.In the analysis of 5 studies reviewed, IBD population (n = 17,636) had a significantly increased risk of VTE during pregnancy (pooled risk ratio (RR) 2.13, 95% confidence interval (CI) 1.66-2.73) and postpartum (RR 2.61, 95% CI 1.84-3.69), comparing to the non-IBD population (n = 11,251,778). According to the location of VTE, the risk of deep vein thrombosis increased significantly by RR of 2.74 (95% CI 1.73-4.36) during pregnancy, whilst risk increase of pulmonary embolism was not statistically significant. In the subgroup analysis, the degree of VTE risk was higher in both periods in the UC group than in the CD group, as compared to that in the non-IBD population (UC group, during pregnancy: RR 2.24, 95% CI 1.6-3.11; postpartum period: RR 2.85, 95% CI 1.79-4.52).Significantly increased risks of VTE during pregnancy were found in the women with IBD, according to the periods and type of IBD, which might support a detailed strategy regarding administration of prophylactic anticoagulants to women with IBD.
Collapse
Affiliation(s)
- Yeon Hee Kim
- Department of Obstetrics And Gynecology
- Department of Pediatrics, Division of Clinical Pharmacology and Toxicology, Motherisk Program, The Hospital for Sick Children
| | - Birgit Pfaller
- Department of Pediatrics, Division of Clinical Pharmacology and Toxicology, Motherisk Program, The Hospital for Sick Children
- Department of Medicine, University of Toronto
| | | | - Hyeon Woo Yim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Vivian Huang
- Division of Gastroenterology Pregnancy in IBD Program, Mount Sinai Hospital University of Toronto, Toronto, Canada
| | - Shinya Ito
- Department of Pediatrics, Division of Clinical Pharmacology and Toxicology, Motherisk Program, The Hospital for Sick Children
| |
Collapse
|
49
|
Nascimento CMDB, Machado AMN, Guerra JCDC, Zlotnik E, Campêlo DHC, Kauffman P, Waksman H, Wolosker N, Podgaec S, Hamerschlak N. Consensus on the investigation of thrombophilia in women and clinical management. EINSTEIN-SAO PAULO 2019; 17:eAE4510. [PMID: 31432891 PMCID: PMC6707753 DOI: 10.31744/einstein_journal/2019ae4510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 01/21/2019] [Indexed: 12/04/2022] Open
Abstract
Objective To standardize the investigation and clinical management of women with laboratory and/or clinical abnormalities suggestive of thrombophilia, in order to optimize antithrombotic approach and indication of laboratory tests. Methodology A discussion was carried out among 107 physicians (gynecologists/obstetricians, hematologists and vascular surgeons) present at a forum held at the Hospital Israelita Albert Einstein, in São Paulo (SP), Brazil. As a minimum criterion, 80% agreement was established in the voting to each recommendation of conduct in the final document. The cases in which there was agreement below 80% were discussed again, reaching a consensual agreement of conduct for the document writing. Conclusion The standardization of an institutional consensus of suggestions of clinical approach contributes to a better management of the group to be evaluated and minimizes risks of intercurrent events. This was the first national consensus on the investigation of thrombophilia in women.
Collapse
Affiliation(s)
| | | | | | | | | | - Paulo Kauffman
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Hilton Waksman
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | - Sérgio Podgaec
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | |
Collapse
|
50
|
Langlois E, Cusson-Dufour C, Moumneh T, Elias A, Meyer G, Lacut K, Schmidt J, Le Gall C, Chauleur C, Glauser F, Robert-Ebadi H, Righini M, Le Gal G. Could the YEARS algorithm be used to exclude pulmonary embolism during pregnancy? Data from the CT-PE-pregnancy study. J Thromb Haemost 2019; 17:1329-1334. [PMID: 31108013 DOI: 10.1111/jth.14483] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/13/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The recently proposed YEARS algorithm was shown to safely exclude pulmonary embolism (PE) and reduce the use of computed tomography pulmonary angiography (CTPA) among pregnant women with suspected PE. Our aim was to externally validate this finding. METHODS We performed a post hoc analysis of a prospective management outcome study for PE diagnosis in pregnant women. PE was diagnosed with an algorithm that combined the revised Geneva score, D-dimer testing, bilateral lower-limb compression ultrasonography, and CTPA. All women had a 3-month follow-up. All of the items necessary to use the YEARS algorithm were prospectively collected at the time of the study. RESULTS Of the 395 women included in the original study, 371 were available for the present analysis. The PE prevalence was 6.5%. Ninety-one women had no YEARS items, and 280 had one or more items. When the YEARS items were combined with D-dimer levels (<1000 ng/mL in women with no items, and <500 ng/mL in women with one or more items), 77 women (21%) met the criteria for PE exclusion and would not have undergone CTPA as per the YEARS algorithm. None of these 77 women had PE diagnosed during the initial work-up or 3-month follow-up. Therefore, the failure rate of the YEARS algorithm in our pregnant women population was 0/77 (95% confidence interval 0.0-3.9). CONCLUSION In our study, application of the YEARS algorithm would have resulted in safe exclusion of PE in one of five pregnant women without the need for radiation exposure, further supporting the use of the algorithm in this population.
Collapse
Affiliation(s)
- Emilie Langlois
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Camille Cusson-Dufour
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Thomas Moumneh
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Emergency Medicine, University Hospital of Angers, University of Angers, MITOVASC, UMR CNRS 6015, UMR INSERM 1083, Angers, France
| | - Antoine Elias
- Médecine vasculaire, Centre Hospitalier de Toulon, Toulon, France
| | - Guy Meyer
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- INSERM, UMR S 1140, Paris, France
- F-CRIN INNOVTE, St-Etienne, France
| | - Karine Lacut
- EA3878 GETBO, Université de Brest, Brest, France
| | - Jeannot Schmidt
- Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Céline Chauleur
- Department of Gynecology and Obstetrics, University Hospital, Saint-Etienne, France
| | - Frédéric Glauser
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| |
Collapse
|