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Wang X, Chen S, Xu H, Zhang R, Zhan T. Trend, clinical characteristics, and pregnancy outcomes of pregnancy associated venous thromboembolism: a retrospective analysis of nearly 10 years. J Matern Fetal Neonatal Med 2025; 38:2448504. [PMID: 39809475 DOI: 10.1080/14767058.2024.2448504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 12/05/2024] [Accepted: 12/26/2024] [Indexed: 01/16/2025]
Abstract
BACKGROUND Pregnancy-associated venous thromboembolism (PA-VTE) seriously threatens maternal health. We aimed to investigate the clinical characteristics, risk factors, treatments, and pregnancy outcomes to better prevent and treat PA-VTE. METHODS PA-VTE patients were selected from 171,898 women who were registered in the Department of Obstetrics of Fujian Maternity and Child Health Hospital from January 2014 to August 2023 and delivered to calculate the incidence. Clinical data were collected to retrospectively analyze the clinical characteristics, risk factors, treatments, and pregnancy outcomes of PA-VTE. Descriptive statistical analysis was used. RESULTS There were 122 cases of PA-VTE with an incidence of 0.71 per 1000 pregnancies; the incidence showed an upward trend and peaked in 2022 (1.24‰). Pregnant women accounted for 28.69% (35/122), the onset were 5-39+6 weeks and incidence increased with the increase of trimester, reaching the highest level in puerperium with 87 cases (71.31%). VTE was mainly found in the lower extremities (112/122); a few were found in cranial venous sinus (4/122), pelvic vein (1/122), and pulmonary embolism (PE) in five cases. 78.68% (96/122) had clinical manifestations. By Royal College of Obstetricians and Gynaecologists (RCOG) risk assessment scale, 45.71% (16/35) of antepartum patients had risk score ≥3 with a maximum of 9, distributed in eight cases in the first trimester, four cases in the second trimester, and four cases in the third trimester. Patients with risk score <3 all occurred in the second and third trimester. Primary risk factors included advanced maternal age (AMA), thrombophilia. All patients received anticoagulant therapy, and seven patients were placed inferior vena cava (IVC) filter in antepartum period. Except one case of abortion in PPROM, the rest continued pregnancy to 29+1 to 40 weeks, only one case of postpartum hemorrhage and one case of severe neonatal asphyxia. The onset time in puerperium was three hours to 28 days after delivery; 62.07% (54/87) patients were scored ≥2. The main risk factors included elective cesarean section, AMA, and preterm birth. Anticoagulant therapy was given after diagnosis; two cases were placed with IVC filter, one case was placed with left iliac vein stent and thrombolysis. CONCLUSIONS The incidence of PA-VTE showed an increasing trend over the past decade, predominantly occurring postpartum. Main risk factors included AMA, thrombophilia, preterm birth, and elective cesarean section. Higher risk scores correlated with earlier onset. Early risk assessment, appropriate prophylaxis, and standardized anticoagulation therapy resulted in favorable maternal and fetal outcomes, with temporary IVC filter placement being beneficial in selected cases.
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Affiliation(s)
- Xiaomei Wang
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shouzhen Chen
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Haihua Xu
- Department of Obstetrics, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Rong Zhang
- Department of Vascular Surgery & Interventional Therapy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Tenghui Zhan
- Department of Vascular Surgery & Interventional Therapy, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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2
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Andrew L, Garven A, Taylor TS, Bates SM, Duffett L, Dubois S, Malinowski AK, El-Chaâr D, Chan WS, Donnelly J, Chauleur C, Ganzevoort W, McCarthy C, Wiegers H, Ní Áinle F, Buchmuller A, Gibson PS, Middeldorp S, Rodger MA, Skeith L. Patient and healthcare providers' perspectives on participation in a postpartum pilot trial of venous thromboembolism prophylaxis: a qualitative study. J Thromb Haemost 2025; 23:1927-1937. [PMID: 40086753 DOI: 10.1016/j.jtha.2025.02.039] [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: 11/06/2024] [Revised: 01/28/2025] [Accepted: 02/25/2025] [Indexed: 03/16/2025]
Abstract
BACKGROUND There is a need to better understand barriers to recruitment and participation in randomized controlled trials evaluating postpartum thromboprophylaxis, as previous trials had low recruitment and were not feasible. OBJECTIVES In a qualitative interview study of a feasibility trial of low-dose aspirin vs placebo for 6 weeks postpartum (pilot PARTUM (Postpartum Aspirin to Reduce Thromboembolism Undue Morbidity) trial), we explored the facilitators and barriers to trial involvement. METHODS Patients eligible for the pilot PARTUM trial, including those who declined to join the trial, were invited to participate in a qualitative study. Physicians whose clinical practice included caring for eligible patients were also invited to participate. Thirty-minute semistructured interviews were conducted by 2 researchers. Data were analyzed iteratively using reflexive thematic analysis. RESULTS There were 19 patients and 13 physician interviews conducted at a single Canadian center. Nine pilot PARTUM participants and 10 nonparticipants were included. Patients identified the simple study design and familiar oral medication ("Participating as an Easy Ask") and helping other parents ("Helping Other Parents by Providing Knowledge") as facilitators to participate in the trial. Most patients invoked altruism; however, their decision to participate in the trial was influenced by their perception of venous thromboembolism risk ("Venous Thromboembolism Risk Perception and Communication"), their birth experience ("Birth Experience Informs Perspective"), and their opinion of their obstetrical care provider ("Engaging Trusted Care Providers"). CONCLUSION Trial participation is uniquely affected by experiences during pregnancy, delivery, and new parenthood. Improved understanding of the factors most important to patients will inform the design and conduct of future patient-focused clinical trials.
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Affiliation(s)
- Lauren Andrew
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Alexandra Garven
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Taryn S Taylor
- Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada
| | - Shannon M Bates
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lisa Duffett
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Suzanne Dubois
- Canadian Venous Thromboembolism Research Network (CanVECTOR) Research Network, University of Ottawa, Ontario, Canada
| | - A Kinga Malinowski
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Lunenfeld-Tanenbaum Research Institute, Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | - Darine El-Chaâr
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada
| | - Wee-Shian Chan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jennifer Donnelly
- Department of Obstetrics and Gynecology, School of Medicine, Rotunda Hospital, University of College Dublin, Dublin, Ireland; Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Céline Chauleur
- Department of Obstetrics and Gynecology, Université Jean Monnet Saint-Étienne, University Hospital, Sainboise U1059, Saint-Étienne, France
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Claire McCarthy
- Department of Obstetrics and Gynecology, Cork University Maternity Hospital, Cork, Ireland
| | - Hanke Wiegers
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Fionnuala Ní Áinle
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Andrea Buchmuller
- Centre d'Investigation Clinique 1408, Centre Hospitalier Universitaire, Saint-Étienne, France
| | - Paul S Gibson
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada; Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Leslie Skeith
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.
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3
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Bruno AM, Allshouse AA, Warrick CM, Metz TD. Single Center Implementation of a Postpartum Pharmacologic Thromboprophylaxis Protocol. Am J Perinatol 2025. [PMID: 40311623 DOI: 10.1055/a-2597-8735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2025]
Abstract
This study aimed to evaluate trends in the frequency of pharmacologic prophylaxis following the implementation of a postpartum venous thromboembolism (VTE) prevention protocol. Secondarily, to evaluate the association between protocol implementation and incidence of VTE and complications.Retrospective cohort of patients delivering from 2015 to 2022 at a single academic institution. Those with an antepartum VTE or receiving therapeutic anticoagulation were excluded. An inpatient thromboprophylaxis protocol was implemented in January 2017 and further updated in July 2020 to expand risk factors to qualify for prophylaxis and extend the length of therapy to the outpatient setting (total 14 days). The cohort was divided into three time periods: preimplementation (January 1, 2025-December 31, 2016), initial protocol (January 1, 2017-June 30, 2020), and updated (July 1, 2020-December 31, 2022) protocol. The primary outcome was the receipt of inpatient heparin-based pharmacologic prophylaxis. Secondary outcomes included filling an outpatient pharmacologic prophylaxis prescription, VTE, and wound complications observed through 6 weeks postpartum. Baseline characteristics and outcomes were compared across the three protocol periods. Logistic regression modeling estimated the association between outcomes and the updated protocol period compared with prior periods.Overall, 22.6% (95% confidence interval [CI]: 22.1-23.0) of 34,217 included deliveries received inpatient pharmacologic prophylaxis: 7.7% (7.1-8.2%) preimplementation, 15.8% (15.2-16.4%) initial protocol, and 41.2% (40.4-42.1%) during the updated protocol period. The rates of inpatient and outpatient prophylaxis increased significantly over time (p < 0.001 test of trend). Delivery in the updated protocol period was not associated with differences in VTE (pre: 0.1%, initial: 0.2%, and updated: 0.1%) nor wound complications (pre: 3.4%, initial: 2.7%, and updated: 2.7%).Single-center implementation of a postpartum prophylaxis protocol resulted in increased use of inpatient and outpatient pharmacologic prophylaxis without changes in rates of VTE or wound complications. · Implementation of a postpartum thromboprophylaxis protocol resulted in increased rates of pharmacologic prophylaxis.. · No differences in wound complications were observed by the protocol period.. · Rates of VTE did not change over time..
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Affiliation(s)
- Ann M Bruno
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Amanda A Allshouse
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Christine M Warrick
- Division of Obstetric Anesthesia, Department of Anesthesiology, University of Utah Health, Salt Lake City, Utah
| | - Torr D Metz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
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4
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Simard C, Cantara R, Bastrash MP, Antinora C, Plourde M, Trahan MJ, Do A, Koolian M, Suarthana E, Wou K, Malhamé I. An audit of postpartum thromboprophylaxis practices and outcomes following caesarean delivery. Thromb Res 2025; 251:109353. [PMID: 40408923 DOI: 10.1016/j.thromres.2025.109353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2025] [Revised: 05/02/2025] [Accepted: 05/15/2025] [Indexed: 05/25/2025]
Affiliation(s)
- C Simard
- Department of Medicine, Jewish General Hospital, Montreal, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - R Cantara
- Faculty of Medicine, Université de Montréal, Montreal, Canada
| | - M P Bastrash
- Department of Obstetrics and Gynecology, LaSalle Hospital and Jewish General Hospital, Montreal, Canada
| | - C Antinora
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - M Plourde
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - M J Trahan
- Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal, Canada
| | - A Do
- Department of Pharmacy, McGill University Health Centre, Montreal, Canada
| | - M Koolian
- Department of Medicine, Jewish General Hospital, Montreal, Canada
| | - E Suarthana
- Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal, Canada
| | - K Wou
- Department of Obstetrics and Gynecology, McGill University Health Centre, Montreal, Canada
| | - I Malhamé
- Department of Medicine, McGill University Health Centre, Montreal, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada.
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5
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Mao J, Sun H, Shen Q, Zou C, Yang Y, Du Q. Association between perinatal complications and venous thromboembolism in postpartum women. J Glob Health 2025; 15:04153. [PMID: 40375726 DOI: 10.7189/jogh.15.04153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2025] Open
Abstract
Background Several studies have been conducted on the risk factors for but there is a lack of research on the relationship between perinatal complications and venous thromboembolism (VTE) in large samples of Asian populations. This study aimed to systematically investigate the relationship between perinatal complications and VTE in Asian populations. Methods This retrospective study included 40 213 women delivering singleton pregnancies. We compared the perinatal complications between the two groups, including hypertensive disorder complicating pregnancy (HDCP), preeclampsia, maternal fever before delivery, preterm birth, intrahepatic cholestasis of pregnancy, gestational diabetes mellitus, meconium-stained amniotic fluid, postpartum hemorrhage, and premature rupture of membranes. Furthermore, we conducted a logistic regression analysis to explore the relationship between VTE and the risk of adverse perinatal outcomes. Results We observed that mothers in the VTE group were significantly more likely to have been aged 35 years or older (28.79 vs. 17.23%, P = 0.013) and to have undergone cesarean delivery (89.39 vs. 48.19%, P < 0.000) compared to the non-VTE group. Further logistic regression analysis revealed that, regardless of adjustment for confounding factors, the VTE group was significantly associated with HDCP, preeclampsia, maternal fever before delivery, preterm birth, and intrahepatic cholestasis of pregnancy, with statistically significant differences. Conclusions Compared to the non-VTE group, the VTE group was more likely to be older (≥35 years) and exhibited a higher cesarean section rate. Additionally, the VTE group was significantly associated with increased odds of HDCP, preeclampsia, maternal fever before delivery, premature delivery and intrahepatic cholestasis of pregnancy compared to the non-VTE group, regardless of whether the confounding factors were adjusted.
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6
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Marzo C, Solanich T, Tassies D, Pina E, Rebollo MA, Gallardo E, Serradell S, Merino M, Carrasco M, Tugues A. Consensus on the Management of the Clinical Challenges of Venous Thromboembolism in Special Situations. Thromb Haemost 2025. [PMID: 40359988 DOI: 10.1055/a-2595-1811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2025]
Abstract
Venous thromboembolism (VTE) can present different challenging situations for which high-quality evidence to guide optimal preventive and therapeutic management is lacking and for which clinical practice guidelines have not established solid recommendations. The aim of this article is to achieve consensus on a proposal of action for the clinical management of complex, clinically relevant situations with a low level of evidence which generate great uncertainty-the duration of VTE treatment and the role of thrombus recanalization, the prevention of VTE within the context of pregnancy, management of anticoagulant treatment in patients with VTE and special characteristics, such as renal insufficiency and obesity, the therapeutic management of pluripathological and polymedicated older patients with VTE, and finally, primary ambulatory thromboembolic prevention in cancer patients. This consensus article arose from a collaboration of experts in VTE from different medical specialties.
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Affiliation(s)
- Cristina Marzo
- Hematology and Hemotherapy Department, Hospital Universitari Arnau de Vilanova, Lleida, Catalunya, Spain
| | - Teresa Solanich
- Vascular Surgery Department, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - Dolors Tassies
- Hemotherapy and Hemostasis Department, Hospital Clinic Barcelona, Barcelona, Catalunya, Spain
| | - Elena Pina
- Thrombosis and Haemostasis Department, Hospital Universitari Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | | | - Enrique Gallardo
- Oncology, Parc Taulí Hospital Universitari, Sabadell, Barcelona, Spain
- Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Sonia Serradell
- Medical Oncology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Marta Merino
- Medical Affairs Thrombosis, LEO Pharma Spain, Barcelona, Spain
| | - Marina Carrasco
- Unitat d'Hemostasia i Trombosi, Servei d'Hematologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Albert Tugues
- Hematology and Hemotherapy Department, Hospital Universitario Arnau de Vilanova de Lleida, Barcelona, Spain
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7
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Hodgson NR, Lindor RA, Monas J, Heller K, Kishi P, Thomas A, Petrie C, Querin LB, Urumov A, Majdalany DS. Pregnancy-Related Heart Disease in the Emergency Department. J Pers Med 2025; 15:148. [PMID: 40278327 PMCID: PMC12028907 DOI: 10.3390/jpm15040148] [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: 03/17/2025] [Revised: 04/01/2025] [Accepted: 04/05/2025] [Indexed: 04/26/2025] Open
Abstract
Pregnancy induces significant physiologic changes that impact the cardiovascular system, potentially exacerbating pre-existing cardiac conditions or precipitating new illnesses. Pregnant patients with cardiac emergencies pose unique challenges, as standard interventions may pose risks to the developing fetus. This article aims to enhance emergency physicians' confidence in managing pregnancy-related cardiac emergencies by providing a structured approach to initial evaluation and stabilization. We review eight common categories of pregnancy-associated cardiac illness: gestational hypertension and pre-eclampsia, cardiomyopathy, arrhythmias, valvular disease, aortopathies, congenital heart disease and pulmonary hypertension, coronary disease, and anticoagulation-related complications. For each condition, we summarize relevant pregnancy-specific pathophysiology and outline evidence-based, personalized emergency management strategies.
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Affiliation(s)
- Nicole R. Hodgson
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Rachel A. Lindor
- Mayo Clinic Department of Emergency Medicine, Rochester, MN 55905, USA;
| | - Jessica Monas
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Kimberly Heller
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Patrick Kishi
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Aaron Thomas
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Cody Petrie
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Lauren B. Querin
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - Andrej Urumov
- Mayo Clinic Department of Emergency Medicine, Phoenix, AZ 85054, USA; (J.M.); (K.H.); (P.K.); (A.T.); (C.P.); (L.B.Q.); (A.U.)
| | - David S. Majdalany
- Mayo Clinic Department of Cardiovascular Diseases, Phoeniz, AZ 85054, USA
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8
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Xu Y, Xiao F, He J, Xue X, Li Y, Zhu S. Analysis on the causes of unsatisfactory prevention effect of postpartum VTE in Chinese women. Sci Rep 2025; 15:11029. [PMID: 40164739 PMCID: PMC11958802 DOI: 10.1038/s41598-025-95790-5] [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: 12/20/2024] [Accepted: 03/24/2025] [Indexed: 04/02/2025] Open
Abstract
Preventing venous thromboembolism (VTE) in obstetrics remains challenging, with cases still occurring despite preventive measures. The aim of this study is to investigate the underlying causes by analyzing potential issues in current postpartum VTE prevention strategies in China. This retrospective study was conducted in our hospital from May 2021 to August 2024. VTE risk was assessed using the Chinese Expert Consensus on VTE Prevention and Treatment during Pregnancy and Puerperium (Chinese Consensus), and preventive measures were implemented accordingly. Clinical variables, timing of prophylaxis, and the predictive accuracy of the Chinese Consensus were analyzed. The VTE group had higher D-dimer levels and longer hospital stays and shorter gestational ages (P < 0.05). Significant differences were observed in postpartum hemorrhage (PPH), premature birth, autoimmune diseases, and cesarean delivery (P < 0.05). Despite 65.4% receiving thromboprophylaxis, 25.2% developed VTE, with higher incidences in those without prophylaxis. Pneumatic therapy and LMWH were effective in high-risk patients (P < 0.05). Early VTE occurred 6 h postpartum, with 41.8% within 48 h. Most preventive measures were initiated at 24-48 h postpartum, potentially delaying optimal protection. The ROC analysis showed an AUC of 0.497 (P = 0.937), indicating limited predictive efficacy of the Chinese Consensus. Current postpartum VTE prevention is inadequate, as some at-risk patients still miss the opportunity for pneumatic therapy and LMWH anticoagulation after delivery. Initiating LMWH prophylaxis 24 h postpartum appears to be delayed. The predictive ability of the Chinese Consensus for assessing VTE risk is limited. Future research is essential to optimize prevention strategies and reduce the incidence of postpartum VTE.
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Affiliation(s)
- Yonghui Xu
- Department of Obstetrics and Gynecology Intensive Care Unit, West China Women's and Children's Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Fei Xiao
- Department of Obstetrics and Gynecology Intensive Care Unit, West China Women's and Children's Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Ji He
- Department of Obstetrics and Gynecology Intensive Care Unit, West China Women's and Children's Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu, China
| | - XingSheng Xue
- Department of Obstetrics and Gynecology Intensive Care Unit, West China Women's and Children's Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu, China
| | - Yangting Li
- Department of Obstetrics and Gynecology Intensive Care Unit, West China Women's and Children's Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu, China
| | - Sha Zhu
- Department of Obstetrics and Gynecology Intensive Care Unit, West China Women's and Children's Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China.
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9
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Cox C, Roberts LN. Basics of diagnosis and treatment of venous thromboembolism. J Thromb Haemost 2025; 23:1185-1202. [PMID: 39938684 DOI: 10.1016/j.jtha.2025.01.009] [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: 08/23/2024] [Revised: 01/14/2025] [Accepted: 01/27/2025] [Indexed: 02/14/2025]
Abstract
Venous thromboembolism (VTE), comprising deep vein thrombosis and pulmonary embolism (PE), is common and associated with significant morbidity and mortality. The symptoms and signs of VTE are nonspecific. Well-established integrated diagnostic strategies combining clinical probability scores and D-dimer are used to identify patients with a low probability of VTE, where the diagnosis can be safely excluded without imaging. In patients with confirmed VTE, anticoagulation is the mainstay of treatment. However, patients with high-risk features at presentation may benefit from advanced reperfusion therapies such as thrombolysis and/or interventional approaches to reduce early mortality and/or long-term morbidity. The advent of direct oral anticoagulants has greatly simplified the treatment of VTE for most patients, with a persisting role for low molecular weight heparin and vitamin K antagonists in select patient groups. Following an initial 3 to 6 months of anticoagulation, those with major transient provoking factors can safely discontinue anticoagulation. Balancing the risk of recurrent VTE and bleeding risk is central to decisions regarding long-term anticoagulation, and patients should be included in shared decision-making. Assessment and recognition of common long-term complications such as postthrombotic syndrome and post-PE syndrome are also essential, given they are associated with significant adverse impact on long-term quality of life, with a significant risk of mortality associated with the less frequent complication of chronic thromboembolic pulmonary hypertension. This review provides a basic overview and framework for the diagnostic approach to deep vein thrombosis and PE, risk stratification of confirmed diagnoses, and management.
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Affiliation(s)
- Catrin Cox
- Thrombosis and Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Institute of Pharmaceutical Sciences, King's College London, London, UK.
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10
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Patel PB, Patel N, Hedges MA, Benson AE, Tomer A, Lo JO, Shatzel JJ. Hematologic Complications of Pregnancy. Eur J Haematol 2025; 114:596-614. [PMID: 39790057 PMCID: PMC11882378 DOI: 10.1111/ejh.14372] [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: 10/30/2024] [Revised: 12/16/2024] [Accepted: 12/17/2024] [Indexed: 01/12/2025]
Abstract
Hematologic complications are common in pregnancy and can significantly impact both maternal and fetal health. Recognizing and treating these complications can be challenging due to the limited evidence available to guide clinical consultants. Iron deficiency anemia is the most prevalent hematologic issue in pregnancy and often occurs due to increased maternal blood volume and the nutritional demands of the growing fetus. Thrombocytopenia is the second most commonly occurring hematologic issue in pregnancy and can be associated with increased blood loss and complications during childbirth. However, the most common type of thrombocytopenia in pregnancy is gestational thrombocytopenia, which does not typically require clinical management. Thus, it is important to distinguish gestational thrombocytopenia from other etiologies of thrombocytopenia in pregnancy that require immediate treatment, including immune thrombocytopenia, thrombotic thrombocytopenic purpura, preeclampsia, and HELLP (hemolysis, elevated liver enzyme levels, and low platelet levels) syndrome. Other important hematologic conditions in pregnancy include non-inherited anemias, such as autoimmune hemolytic anemia and aplastic anemia, as well as inherited anemias, such as sickle cell disease and thalassemia, which may require specialized management to optimize maternal and fetal outcomes. Additionally, bleeding disorders, such as von Willebrand disease and hemophilia, pose unique challenges in pregnancy, especially around the time of delivery, due to the risk of excessive bleeding. Lastly, thromboembolic disorders, such as venous thromboembolism (VTE), remain the leading cause of mortality in pregnancy in developed countries. Pregnancy-related hormonal changes, venous stasis, and hypercoagulability contribute to an increased thromboembolic risk, further exacerbated by additional risk factors such as obesity or a prior personal or family history of VTE. This review aims to summarize current guidelines and management of the most common hematologic disorders in pregnancy.
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Affiliation(s)
| | - Nidhi Patel
- Department of Medicine, Providence Medical Center, Portland, Oregon, USA
| | - Madeline A Hedges
- Department of Pediatrics, Division of Neonatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Ashley E Benson
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Arjun Tomer
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Jamie O Lo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Oregon Health & Science University, Portland, Oregon, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
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Chairat P, Niprapan P, Hantrakun N, Tantiworawit A, Punnachet T, Piriyakhuntorn P, Rattanathammethee T, Hantrakool S, Rattarittamrong E, Norasetthada L, Chai-Adisaksopha C. Randomized controlled trial evaluating the benefit of the app-based clinical decision support system for the management of venous thromboembolism. BMC MEDICAL EDUCATION 2025; 25:460. [PMID: 40159474 PMCID: PMC11956210 DOI: 10.1186/s12909-025-07014-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2024] [Accepted: 03/13/2025] [Indexed: 04/02/2025]
Abstract
INTRODUCTION Anticoagulant prescription and management are crucial steps of management of venous thromboembolism (VTE). The Clinical decision support systems (CDSS) are designed and developed to aid healthcare professionals in making informed decisions. OBJECTIVES To develop and assess the efficacy the mobile app-based CDSS for the management of VTE. METHODS A randomized controlled trial was conducted, enrolling participants aged ≥ 20 years who were one of the following categories: medical student, intern, internal medicine resident, or hematology fellow. Participants were randomly assigned to either app-based CDSS (DECIDE-COAG®) or control groups. Participants were tasked with prescribing or planning the management of 15 clinical vignettes covering four domains: anticoagulant dosing, perioperative management, management of anticoagulant associated bleeding and diagnosis of VTE. The primary outcome was the mean percentage of accuracy score. RESULTS From September 2023 through November 2023, a total of 126 participants were enrolled. The mean percentage of accuracy score was significantly higher (95.6%) in participants using app-based CDSS compared with those in control group (41.3%), a mean difference of 54.5%, 95% CI 49.8-59.2, p < 0.001. The satisfaction mean score was 4.57 ± 0.49 for accessibility, 4.73 ± 0.45 for app stability, 4.94 ± 0.25 for user interface, 4.78 ± 0.42 for simplicity, 4.98 ± 0.13 for assistance in decision-making and 4.90 ± 0.30 for overall satisfaction. CONCLUSIONS App-based CDSS (DECIDE-COAG®) demonstrates a significant improvement in the accuracy of anticoagulant prescriptions and VTE management. Further studies that specifically investigate the clinical benefits of app-based CDSS in real-world clinical practice are warranted. CLINICAL TRIAL NUMBER TCTR20241117004.
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Affiliation(s)
- Pajaree Chairat
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Piangrawee Niprapan
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Nonthakorn Hantrakun
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Adisak Tantiworawit
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Teerachat Punnachet
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Pokpong Piriyakhuntorn
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Thanawat Rattanathammethee
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Sasinee Hantrakool
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Ekarat Rattarittamrong
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Lalita Norasetthada
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Chatree Chai-Adisaksopha
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, 110 Intawarorot road, Sriphum, Muang, Chiang Mai, 50200, Thailand.
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12
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Philipson J, Thunström E, Svanvik T, Norrsell H, Hellgren M, Westerlund E, Glise Sandblad K. Incidence and time trends of pregnancy-related first-time venous thromboembolism: a 33-year Swedish birth registry study. J Thromb Haemost 2025:S1538-7836(25)00183-7. [PMID: 40234144 DOI: 10.1016/j.jtha.2025.03.009] [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: 09/05/2024] [Revised: 01/20/2025] [Accepted: 03/03/2025] [Indexed: 04/17/2025]
Abstract
BACKGROUND It is unknown whether changes in thromboprophylaxis recommendations are associated with decreasing incidence of pregnancy-related venous thromboembolism (VTE). OBJECTIVES To investigate time trends in the incidence of pregnancy-related first-time VTE and fatal pulmonary embolism (PE) and to describe thromboprophylaxis use. METHODS A nationwide register-based cohort study included all women who delivered a live or stillborn infant in Sweden from 1987 to 2019. Joinpoint analysis, featuring annual percent change (APC), was employed for time trend analysis in VTE incidence. RESULTS The study included 3 449 885 deliveries, with 5202 women experiencing pregnancy-related first-time VTE and 18 fatal PEs. Incidence rates of first-time VTE, PE, and deep vein thrombosis (DVT) were 150.8/100 000 deliveries, 49.3/100 000 deliveries, and 101.5/100 000 deliveries, respectively. Time trend analysis showed an increase in pregnancy-related PE from 1987 to 2019 (APC, 4.9% [95% CI, 4.1%-5.9%]). DVT incidence increased from 1987 to 1993 (APC, 6.2% [95% CI, 0.9%-25.4%]), then decreased from 1993 to 2019 (APC, -0.5% [95% CI, -2.1% to -0.0%]). VTE incidence increased from 1987 to 1993 (APC, 5.5% [95% CI, 1.7%-22.3%]) and remained relatively stable thereafter (APC, 1.2% [95% CI, -4.3% to 1.7%]). Fatal PE varied between 0 and 2 annual cases. Prescriptions of low-molecular-weight heparins during pregnancy and postpartum increased from 2007 to 2018. CONCLUSION During the study period, pregnancy-related PE increased, while DVT decreased from 1993 to 2019. Despite demographic shifts that might elevate VTE risk, the overall incidence of VTE remained stable, possibly because of the increased prescription of low-molecular-weight heparins.
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Affiliation(s)
- Jacob Philipson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital/Östra, Region Västra Götaland, Gothenburg, Sweden.
| | - Erik Thunström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital/Östra, Region Västra Götaland, Gothenburg, Sweden
| | - Teresia Svanvik
- Department of Obstetrics, Sahlgrenska University Hospital/Östra, Region Västra Götaland, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Henrik Norrsell
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital/Östra, Region Västra Götaland, Gothenburg, Sweden
| | - Margareta Hellgren
- Department of Obstetrics, Sahlgrenska University Hospital/Östra, Region Västra Götaland, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Gothenburg, Sweden
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Katarina Glise Sandblad
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medicine, Geriatrics and Emergency Medicine, Sahlgrenska University Hospital/Östra, Region Västra Götaland, Gothenburg, Sweden
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13
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Liu HR, Sun K, Zeng T, Wang XL. Low-molecular-weight heparins utilization in pregnant and postpartum women: a real-world analysis in China (2016-2021). Front Pharmacol 2025; 16:1519051. [PMID: 40196365 PMCID: PMC11973347 DOI: 10.3389/fphar.2025.1519051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Accepted: 03/07/2025] [Indexed: 04/09/2025] Open
Abstract
Objectives This study aimed to examine trends in low-molecular-weight heparin (LMWH) use for managing pregnancy-associated venous thromboembolism (VTE) and to explore the correlation between pregnancy-related VTE risk factors and LMWH prescription rates. Methods This was a cross-sectional study that analyzed prescription data from pregnant and postpartum women using LMWH to manage VTE, collected during 2016-2021. Risk factors associated with VTE were analyzed. Separately comparing the number of prescriptions, prescription cost, defined daily doses (DDDs), and defined daily cost (DDC) of seven LMWH. Results This study included 41,885 prescriptions, with the average age of patients being 32 ± 4.69 years old. The most common risk factors for VTE during pregnancy and the postpartum period in this study included advanced age (>35 years old), cesarean section, diabetes, miscarriage, and preterm birth, accounting for 28.61%, 25.60%, 18.34%, 17.31%, and 13.63% respectively. There was a 173% increase in LMWH prescription costs during the study period. In terms of number of prescriptions, prescription cost, and DDDs, enoxaparin sodium, nadroparin calcium, and low-molecular-weight heparin calcium consistently ranked in the top three from 2019 to 2021. In terms of DDC, low-molecular-weight heparin sodium, dalteparin sodium, and enoxaparin sodium were the lowest. Conclusion From 2016 to 2021, both the number of prescriptions and the total prescription costs for the management of VTE during pregnancy and the postpartum period increased. Enoxaparin sodium, nadroparin calcium, and low-molecular-weight heparin calcium were the most common LMWH. Advanced age (>35 years old), cesarean section, diabetes, miscarriage, and preterm birth were the most common pregnancy-related VTE risk factors linked to LMWH prescription.
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Affiliation(s)
| | | | - Tao Zeng
- Department of Pharmacy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xian-Li Wang
- Department of Pharmacy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
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14
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Rath W, Tsikouras P, Pecks U. Pharmacologic thromboprophylaxis following cesarean delivery-what is the evidence? A critical reappraisal. J Perinat Med 2025:jpm-2025-0041. [PMID: 40123282 DOI: 10.1515/jpm-2025-0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2025] [Accepted: 02/21/2025] [Indexed: 03/25/2025]
Abstract
Venous thromboembolism (VTE) is a severe complication associated with cesarean delivery (c.d.). The risk of VTE has been estimated to be 2-4-fold higher compared to vaginal delivery and appears independent of other risk factors. Pharmacologic thromboprophylaxis after c.d. represents a daily challenge for obstetricians and is a common practice in many countries such as in Germany. However, the evidence of thromboprophylaxis efficacy is based on only four randomized controlled trials and one prospective cohort study. Risk assessment models to predict VTE after c.d. have not adequately been validated. According to meta-analyses pharmacologic thromboprophylaxis was not associated with a significant reduction in the risk of VTE but is associated with an increased risk of bleeding and hematomas compared to placebo. Due to the lack of evidence current guidelines differ markedly regarding recommendations on post-cesarean pharmacologic thromboprophylaxis. Most guidelines recommend no pharmacologic thromboprophylaxis after elective c.d. in the absence of additional VTE risk factors. In case of additional risk factors associated with elective c.d. as well as in case of emergency c.d. pharmacologic prophylaxis is advised for 7-10 days after delivery, and for at least 6 weeks after c.d. in high-risk patients. In view of the great number of various risk factors, the challenge not recognizing all risk factors timely and the low incidence of serious complications associated with the use of low molecular weight heparin (LMWH), we consent with others to suggest universal LMWH prophylaxis following c.d. rather than a selective being aware that universal LMWH prophylaxis is associated with significantly higher costs.
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Affiliation(s)
- Werner Rath
- Department of Obstetrics, RWTH Aachen, University Hospital, Aachen, Germany
| | - Panagiotis Tsikouras
- Department of Obstetrics, Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ulrich Pecks
- Department of Obstetrics, Würzburg University hospital, Würzburg, Germany
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15
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Kruijt M, Cobbaert CM, Ruhaak LR. Antithrombin: Deficiency, Diversity, and the Future of Diagnostics. MASS SPECTROMETRY REVIEWS 2025. [PMID: 40088190 DOI: 10.1002/mas.21929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 02/12/2025] [Accepted: 02/28/2025] [Indexed: 03/17/2025]
Abstract
Our healthcare system provides reactive sick-care, treating patients after symptoms have appeared by prescription of generic and often suboptimal therapy. This strategy brings along high costs and high pressure which is not sustainable. Alternatively, P5 healthcare is proposed focusing on five key elements: prevention, personalization, prediction, participation, psychocognition, however, changes in current clinical care pathways are required, for which antithrombin deficiency is a prime example. Hereditary antithrombin deficiency (ATD) is a genetic disorder, for which screening is instigated after a thrombotic episode. Current diagnostic tests for ATD lack sensitivity and refinement to correctly classify patients, and generic treatments are prescribed. A molecular understanding of ATD through a molecular diagnostic test that analyzes all clinically relevant features of antithrombin is required. Here, clinically relevant molecular characteristics of antithrombin, the diversity of antithrombin (deficiency) in heath and disease, and the strengths and weaknesses of antithrombin tests are reviewed. A mass spectrometry test that molecularly characterizes a patients antithrombin proteoforms harbors the highest potential to improve the clinical pathway for ATD. Application of this MS-based test in a future enhanced clinical pathway will improve patient management and outcome through molecular characterization of antithrombin and enables the promise of P5 healthcare for ATD.
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Affiliation(s)
- Mirjam Kruijt
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Christa M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - L Renee Ruhaak
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
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16
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Kola O, Huang Y, D'Alton ME, Wright JD, Friedman AM. Trends in Antepartum, Delivery, and Postpartum Venous Thromboembolism. Obstet Gynecol 2025; 145:e98-e106. [PMID: 39746204 DOI: 10.1097/aog.0000000000005818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 08/29/2024] [Indexed: 01/04/2025]
Abstract
OBJECTIVE To assess trends in risk for obstetric venous thromboembolism (VTE). METHODS This retrospective cohort study analyzed data from the 2008-2019 Merative MarketScan Commercial Claims and Encounters and Medicaid Multi-State databases. Women aged 15-54 years with a delivery hospitalization and health care enrollment from 1 year before pregnancy to 60 days after delivery were identified. Risk for VTE during pregnancy from 2009 to 2019 was analyzed with joinpoint regression, with trends reported as the average annual percent change (APC). Venous thromboembolism events were identified with diagnosis codes along with pharmacy receipt of anticoagulants. Additionally, the association between risk factors for VTE and VTE events was evaluated with log-Poisson regression models with unadjusted and adjusted risk ratios (aRR) with 95% CIs as measures of association. RESULTS Among 1,970,971 pregnancies, there were 5,270 VTE events, of which 35.5% (n=1,871) included a pulmonary embolism diagnosis and 64.5% (3,399) included a deep vein thrombosis diagnosis, alone. Risk for VTE increased significantly during pregnancy over the study period, with an APC of 9.2% (95% CI, 5.7-12.9%). Rates of VTE also increased individually during the antenatal period (APC 8.2%, 95% CI, 3.7-12.9%), during delivery hospitalizations (APC 12.2%, 95% CI, 7.4-17.3%), during the postpartum period (APC 8.4%, 95% CI, 5.9-11.0%), and individually for vaginal and cesarean delivery hospitalizations. Trends analyses individually for pulmonary embolism (APC 12.4%, 95% CI, 8.6-16.4%) and deep vein thrombosis (APC 7.6%, 95% CI, 4.0-11.3%) also demonstrated significant increases. In adjusted analyses for VTE, obesity (aRR 1.91, 95% CI, 1.78-2.05), chronic heart disease (aRR 3.14, 95% CI, 2.93-3.37), tobacco use (aRR 1.61, 95% CI, 1.34-1.95), asthma (aRR 1.46, 95% CI, 1.33-1.60), and preeclampsia (aRR 1.44, 95% CI, 1.31-1.58) were the factors associated the greatest increased adjusted relative risk. CONCLUSION Risk for obstetric VTE increased significantly over the study period. Risk increased during the antenatal, delivery, and postpartum periods and for both cesarean and vaginal delivery.
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Affiliation(s)
- Olivia Kola
- Rutgers New Jersey Medical School, Newark, New Jersey; the Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York; and the Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, California
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Vinson DR, Somers MJ, Qiao E, Campbell AR, Heringer GV, Florio CJ, Zekar L, Middleton CE, Woldemariam ST, Gupta N, Poth LS, Reed ME, Roubinian NH, Raja AS, Sperling JD. Consent to advanced imaging in antenatal pulmonary embolism diagnostics: Prevalence, outcomes of nonconsent and opportunities to mitigate delayed diagnosis risk. Acad Emerg Med 2025; 32:260-273. [PMID: 39552252 DOI: 10.1111/acem.15045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2024] [Revised: 10/15/2024] [Accepted: 10/18/2024] [Indexed: 11/19/2024]
Abstract
BACKGROUND Nonconsent to pulmonary vascular (or advanced) imaging for suspected pulmonary embolism (PE) in pregnancy can delay diagnosis and treatment, increasing risk of adverse outcomes. We sought to understand factors associated with consent and understand outcomes after nonconsent. METHODS This retrospective cohort study was undertaken across 21 community hospitals from October 1, 2021, through March 31, 2023. We included gravid patients undergoing diagnostics for suspected PE who were recommended advanced imaging. The primary outcome was verbal consent to advanced imaging. Diagnostic settings were nonobstetric (99% emergency departments [EDs]) and obstetrics (labor and delivery and outpatient clinics). Using quasi-Poisson regression, we calculated adjusted relative risks (aRRs) of consenting with 95% confidence intervals (CIs). We also reported symptom resolution and delayed imaging at follow-up and 90-day PE outcomes. RESULTS Imaging was recommended for 405 outpatients: median age was 30.5 years; 50% were in the third trimester. Evaluation was more common in nonobstetric (83%) than obstetric settings (17%). Overall, 314 (78%) agreed to imaging and 91 (22%) declined imaging. Consenting was more prevalent in obstetric settings compared with nonobstetric settings: 99% versus 73% (p < 0.001). When adjusted for demographic and clinical variables, including pretest probability, only obstetric setting was independently associated with consenting: aRR 1.26 (95% CI 1.09-1.44). Seventy-nine (87%) patients declining imaging had 30-day follow-up. Eight of 12 who reported persistent or worsening symptoms on follow-up were again recommended advanced imaging and consented. Imaging was negative. None who initially declined imaging were diagnosed with PE or died within 90 days. CONCLUSIONS One in five gravid patients suspected of PE declined advanced imaging, more commonly in nonobstetric (principally ED) settings than obstetric settings. Patients symptomatic on follow-up responded favorably to subsequent imaging recommendations without 90-day outcomes. Improving the communication and documentation of informed consent and securing close follow-up for nonconsenters may mitigate risks of missed and delayed PE diagnosis.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Pleasanton, California, USA
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | - Madeline J Somers
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
| | - Edward Qiao
- California Northstate University College of Medicine, Elk Grove, California, USA
| | - Aidan R Campbell
- Department of Biology, New York University, New York, New York, USA
| | - Grace V Heringer
- Department of Neurobiology, Physiology and Behavior, University of California, Davis, California, USA
| | - Cole J Florio
- Department of Microbiology and Molecular Genetics, University of California, Davis, California, USA
| | - Lara Zekar
- Department of Emergency Medicine, UC Davis Health, Sacramento, California, USA
| | - Cydney E Middleton
- Department of Emergency Medicine, UC Davis Health, Sacramento, California, USA
| | - Sara T Woldemariam
- Department of Obstetrics and Gynecology, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Nachiketa Gupta
- The Permanente Medical Group, Pleasanton, California, USA
- Department of Emergency Medicine, Kaiser Permanente Redwood City Medical Center, Redwood City, California, USA
| | - Luke S Poth
- The Permanente Medical Group, Pleasanton, California, USA
- Department of Emergency Medicine, Kaiser Permanente South San Francisco Medical Center, San Francisco, California, USA
| | - Mary E Reed
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
| | - Nareg H Roubinian
- The Permanente Medical Group, Pleasanton, California, USA
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
- Department of Pulmonary and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Ali S Raja
- Departments of Emergency Medicine and Radiology, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Jeffrey D Sperling
- The Permanente Medical Group, Pleasanton, California, USA
- Department of Maternal and Fetal Medicine, Kaiser Permanente Modesto Medical Center, Modesto, California, USA
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Santagata D, Tamborini Permurian E, Caiano LM, Squizzato A, Ageno W, Donadini MP. Pharmacotherapeutic management of venous thromboembolism during pregnancy and cesarean section. Expert Opin Pharmacother 2025; 26:433-445. [PMID: 39921666 DOI: 10.1080/14656566.2025.2464100] [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: 10/26/2024] [Revised: 01/30/2025] [Accepted: 02/04/2025] [Indexed: 02/10/2025]
Abstract
INTRODUCTION Venous thromboembolism (VTE) pharmacological management during pregnancy can be challenging due to concerns for both maternal and fetal safety. AREAS COVERED We performed a narrative review to evaluate the most updated therapeutic options for pregnancy-related VTE treatment, also assessing peri-partum management in the case of cesarean section. EXPERT OPINION The correct management of acute VTE in pregnancy starts with an accurate diagnosis followed by anticoagulant therapy, with low-molecular-weight heparin (LMWH) at therapeutic dose being the preferred option. Similar to the non-pregnant population, thrombolytic therapy is reserved to life-threatening pulmonary embolism. Secondary prophylaxis with LMWH at a prophylactic dose during pregnancy is recommended in women with a history of unprovoked or hormone-associated VTE, while postpartum prophylaxis is recommended for all women with a previous VTE. Primary prophylaxis remains more controversial. Peripartum management of women receiving anticoagulants requires collaboration among multiple specialists, especially in cases of unscheduled cesarean section, where both thrombotic and hemorrhagic risks are elevated.
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Affiliation(s)
- Davide Santagata
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Eleonora Tamborini Permurian
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Lucia Maria Caiano
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Marco Paolo Donadini
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
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Federspiel JJ. Inpatient pharmacological thromboprophylaxis in the antepartum period: an argument for risk-based thromboprophylaxis. Am J Obstet Gynecol MFM 2025; 7:101567. [PMID: 39586470 PMCID: PMC11955298 DOI: 10.1016/j.ajogmf.2024.101567] [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: 09/05/2024] [Revised: 10/29/2024] [Accepted: 10/31/2024] [Indexed: 11/27/2024]
Abstract
Venous thromboembolism (VTE) is a significant cause of maternal morbidity and mortality in the United States. People hospitalized during pregnancy for reasons other than routine birth (ie, during antepartum admissions) are at increased risk of VTE compared with nonhospitalized obstetric patients, but there is no consensus regarding which patients should receive thromboprophylaxis during antepartum hospitalizations as the absolute event rates are low and anticoagulation can complicate antepartum management. We argue that an approach informed by individualized patient risk assessment is likely to produce the greatest net benefit for patients. Such an approach would avoid the pitfalls of universal pharmacologic prophylaxis (potential to interfere with unplanned delivery or receipt of neuraxial anesthesia) among patients for whom the absolute risk of VTE is low. In contrast, approaches that withhold pharmacologic prophylaxis from all antepartum patients likely place some at significant risk of VTE. We outline the arguments against universal pharmacologic thromboprophylaxis and against universal avoidance of pharmacologic thromboprophylaxis and discuss a risk-based approach proposed at our institution. Finally, we outline a research agenda for identification of optimal antepartum anticoagulation strategies.
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Affiliation(s)
- Jerome J Federspiel
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke University School of Medicine, Durham, NC (Federspiel); Department of Medicine, Duke University School of Medicine, Durham, NC (Federspiel); Department of Population Health Sciences, Duke University School of Medicine, Durham, NC (Federspiel).
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20
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Xu Y, Federspiel JJ. Pregnancy-associated venous thromboembolism: a window into future health. J Thromb Haemost 2025; 23:817-819. [PMID: 40057371 PMCID: PMC11964127 DOI: 10.1016/j.jtha.2024.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2024] [Revised: 12/05/2024] [Accepted: 12/11/2024] [Indexed: 04/04/2025]
Affiliation(s)
- Yan Xu
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jerome J Federspiel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.
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21
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Kapoor S, Ortel TL. Postpartum Thromboprophylaxis: Balancing Efficacy and Safety. Obstet Gynecol 2025; 145:262-264. [PMID: 39977863 DOI: 10.1097/aog.0000000000005842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2025]
Affiliation(s)
- Sargam Kapoor
- Sargam Kapoor is from the Division of Hematology, Department of Medicine, at Duke University, and Thomas L. Ortel is from the Division of Hematology, Department of Medicine, and the Department of Pathology at Duke University, Durham, North Carolina;
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22
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Mauricio R, Sharma G, Lewey J, Tompkins R, Plowden T, Rexrode K, Canobbio M, Skowronski J, Hameed A, Silversides C, Reynolds H, Vaught A. Assessing and Addressing Cardiovascular and Obstetric Risks in Patients Undergoing Assisted Reproductive Technology: A Scientific Statement From the American Heart Association. Circulation 2025; 151:e661-e676. [PMID: 39811953 DOI: 10.1161/cir.0000000000001292] [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] [Indexed: 01/16/2025]
Abstract
The use of assisted reproductive technology (ART) is growing, both to assist individuals with infertility and for fertility preservation. Individuals with cardiovascular disease (CVD), or risk factors for CVD, are increasingly using ART. Thus, knowing how to care for patients undergoing ART is important for the cardiovascular clinician. In this scientific statement, we review the ART process and known short-term and long-term risks associated with ART that can adversely affect patients with CVD. We review current knowledge on risks from ART for specific cardiac conditions and provide a suggested approach to evaluating and counseling patients with CVD contemplating ART as well as suggested management before and during the ART process. Individuals with CVD are at increased risk for pregnancy complications, and management of this unique population has been discussed previously. The focus of this scientific statement is on ART. Therefore, discussions on risk assessment, counseling, and management of individuals with CVD during pregnancy are limited, and established guidelines are referenced.
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23
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Hrymak CS, Labib A, Akkanti B, Antonini MV, Bruggeman B, Griffee MJ, Heinsar S, Jacobs JP, Larzelere M, Naoum E, O'Neil E, Roussos-Ross D, Zaaqoq AM, Peek GJ, Arora RC. ECMO for the pregnant and peripartum patient: A practical review of indications, unique management considerations, and an approach framework. Perfusion 2025:2676591251321070. [PMID: 39988458 DOI: 10.1177/02676591251321070] [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: 02/25/2025]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) to support the pregnant patient and fetus requires a complex decision-making process. Peripartum ECMO requires coordinated and informed decision-making between an interdisciplinary team of experts, incorporating the unique considerations and, at times, competing physiologic priorities of the pregnant patient. It is often confounded by a scarcity of local relevant experience engendered by its rare occurrence. No event has made the need for an organized approach to the utilization of ECMO in pregnant patients more pressing than the COVID pandemic. The conditions affecting pregnant patients that warrant ECMO consideration are high stakes and, at times, ethically challenging, although outcomes are favourable compared to the general population. This review provides background information and context, followed by a practical approach to the care and specific medical management of patients who are facing life-threatening conditions warranting ECMO while pregnant.
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Affiliation(s)
- Carmen S Hrymak
- Department of Emergency Medicine and Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada
| | - Ahmed Labib
- Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar
- Weill Cornell Medicine, Doha, Qatar
| | - Bindu Akkanti
- Division of Critical Care Medicine and Advanced Cardiopulmonary Therapeutics and Transplantation, UT Health- Houston, Houston, TX, USA
| | | | - Bradley Bruggeman
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Matthew J Griffee
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Silver Heinsar
- Critical Care Research Group, The University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care, North Estonia Medical, Tallinn, Estonia
| | - Jeffrey P Jacobs
- University of Florida Congenital Heart Center, Gainesville, FL, USA
| | - Michelle Larzelere
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Emily Naoum
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Erika O'Neil
- Department of Pediatrics, United States Air Force, Brooke Army Medical Center, San Antonio, TX, USA
| | - Dikea Roussos-Ross
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Akram M Zaaqoq
- Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Giles J Peek
- University of Florida Congenital Heart Center, Gainesville, FL, USA
| | - Rakesh C Arora
- Department of Surgery, Division of Cardiac Surgery, University Hospitals - Harrington Heart Vascular Institute, Cleveland, OH, USA
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24
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Merz LE, Bassa B, Ní Áinle F, Fogerty AE. Thrombotic complications in pregnancy: a case-based review of the evidence. J Thromb Haemost 2025; 23:417-428. [PMID: 39395543 DOI: 10.1016/j.jtha.2024.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 08/27/2024] [Accepted: 09/25/2024] [Indexed: 10/14/2024]
Abstract
Pregnancy is a prothrombotic state due to an estrogen-driven shift in the coagulation system, increased venous stasis, and external restriction of blood flow caused by the gravid uterus. Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in pregnancy. Preventing, recognizing, and treating thrombosis in pregnancy, as well as the postpartum period, often challenges decision making in the clinical setting. In early pregnancy, guidance with respects to thrombophilia testing and anticoagulation in increasing the likelihood of live birth among patients with recurrent miscarriages is evolving. This review explores emerging data that support clinical decision making in thrombosis care in women with common thrombotic complications in pregnancy. The first case outlines VTE diagnosis in pregnancy, initial anticoagulation management, management around delivery and postpartum, and subsequent long-term anticoagulation treatment. The second case examines testing for inherited and acquired thrombophilia in the setting of recurrent miscarriage and the management of obstetric antiphospholipid syndrome. Lastly, the third case reviews VTE risk assessment and prevention in pregnancy and the postpartum period, as well as duration and dose of postpartum thromboprophylaxis. Review of these common clinical scenarios surrounding thrombotic complications in pregnancy demonstrates recent advances in high-quality data, current gaps in knowledge, and variation in expert opinion. Ultimately, multidisciplinary discussion and teamwork remain key to optimal, safe care. Clinicians must prioritize collaborative, high-quality trials and prospective clinical management studies to better understand and define best practice in this population.
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Affiliation(s)
- Lauren E Merz
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Division of Hematology/Oncology, Department of Medicine, Mass General Brigham, Boston, Massachusetts, USA.
| | - Bibi Bassa
- Royal College of Surgeons in Ireland, Dublin, Ireland; Division of Trauma and Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Royal College of Surgeons in Ireland, Dublin, Ireland; Rotunda Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Annemarie E Fogerty
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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25
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Mojaddedi S, Jamil J, Abraham A, Jamil D, Mansoor H, Elgendy IY. Venous thromboembolism during pregnancy and postpartum period: an updated review. Minerva Med 2025; 116:62-74. [PMID: 39392291 DOI: 10.23736/s0026-4806.24.09242-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Abstract
Venous thromboembolism (VTE) is a leading cause of maternal mortality. The risk of VTE in pregnant and postpartum women is ~ five times higher compared with non-pregnant women. There is a physiological tendency to a hypercoagulable state, from conception to the postpartum period. Several non-obstetric risk factors independently increase the risk of VTE. Since most signs and symptoms of VTE might mimic those of a normal pregnancy, a high index of suspicion is warranted to establish the diagnosis. D-dimer, ultrasonography and computed tomography pulmonary angiography are the primary tools for VTE diagnosis. Management mainly revolves around systemic anticoagulation with heparin. Advanced therapy options exist, but these can be considered for selected high-risk cases.
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Affiliation(s)
- Sanaullah Mojaddedi
- Graduate Medical Education, University of Central Florida College of Medicine, Orlando, FL, USA
- Internal Medicine Residency Program, HCA Florida North Florida Hospital, Gainesville, FL, USA
| | - Javairia Jamil
- College of Medicine, Gulf Medical University, Ajman, United Arab Emirates
| | - Andrew Abraham
- Graduate Medical Education, University of Central Florida College of Medicine, Orlando, FL, USA
- Internal Medicine Residency Program, HCA Florida North Florida Hospital, Gainesville, FL, USA
| | - Dawood Jamil
- Internal Medicine Residency Program, Henry Ford Hospital, Detroit, MI, USA
| | - Hend Mansoor
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA -
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26
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Li S, Jiang M, Guan Y, Cao X, Shao Z, Deng J, Hao X. Association between genetic risk and adherence to the Dietary Approaches to Stop Hypertension diet for developing venous thromboembolism. Res Pract Thromb Haemost 2025; 9:102731. [PMID: 40236289 PMCID: PMC11999685 DOI: 10.1016/j.rpth.2025.102731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 01/23/2025] [Accepted: 02/25/2025] [Indexed: 04/17/2025] Open
Abstract
Background The relationship between diet and venous thromboembolism (VTE) remains unclear, and the joint effects of diet patterns and genetic susceptibility on VTE risk are unknown. Objectives Investigate the independent and joint effects of Dietary Approaches to Stop Hypertension (DASH) diet adherence and polygenic risk scores (PRS) on VTE risk. Methods A total of 411,539 UK Biobank participants were included. DASH scores were calculated using Food Frequency Questionnaires, and PRS quantified genetic risk. Cox proportional hazard models estimated hazard ratios (HRs) for VTE, assessing interactions between the DASH diet and genetic susceptibility. Results During a median follow-up of 13.4 years, 10,543 participants were diagnosed with VTE. Higher DASH scores were associated with a lower VTE risk (HR, 0.87; 95% CI, 0.82-0.92). A low-adherent DASH diet combined with high-genetic risk had the highest VTE risk (HR, 2.78; 95% CI, 2.47-3.14). High DASH scores reduced VTE risk in high-genetic-risk individuals (HR, 0.84; 95% CI, 0.76-0.92). Sex-specific associations were detected in the joint effect and interaction of DASH scores and PRS. Notably, high DASH scores can offset moderate genetic risk among men (HR, 0.79; 95% CI, 0.67-0.94). There were additive interactions between DASH scores and high genetic risk in total subjects and men, while not observed in women. Conclusion The DASH diet is associated with reduced VTE risk and can partially offset genetic predisposition. Low adherence to the DASH diet increases VTE risk, particularly in high-genetic-risk individuals. The protective effect of high DASH scores against genetic risks for VTE is more pronounced in males. Precision medicine should consider both diet and genetics for VTE prevention.
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Affiliation(s)
- Si Li
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Minghui Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yunlong Guan
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xi Cao
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhonghe Shao
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jun Deng
- Institute of Hematology, Union Hospital, Tongii Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xingjie Hao
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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27
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Skeith L, Malinowski AK, El-Chaâr D, Chan WS, Donnelly J, Chauleur C, Ganzevoort W, Wood S, Dubois S, McCarthy C, Buchmuller A, Wiegers H, Gibson PS, Ní Áinle F, Middeldorp S, Duffett L, Bates SM, Garven A, Baxter J, Lethebe BC, Rodger MA. Low-dose aspirin versus placebo in postpartum venous thromboembolism: a multi-national, pilot, randomised, placebo-controlled trial. Lancet Haematol 2025; 12:e109-e119. [PMID: 39827892 DOI: 10.1016/s2352-3026(24)00338-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2024] [Revised: 10/16/2024] [Accepted: 10/18/2024] [Indexed: 01/22/2025]
Abstract
BACKGROUND Despite the morbidity and mortality of venous thromboembolism, there is little evidence to guide postpartum thromboprophylaxis in patients at moderate risk. We aimed to assess the feasibility of conducting a double-blind, randomised trial of aspirin versus placebo in postpartum individuals with two or more venous thromboembolism risk factors, mild-to-moderate thrombophilia, or both. METHODS The pilot PARTUM trial, a multi-national, randomised, double-blind, placebo-controlled trial, was conducted in seven centres across Canada, France, Ireland, and the Netherlands. Postpartum individuals aged 18 years or older with venous thromboembolism risk factors, including mild-moderate inherited thrombophilia, antepartum immobilisation, pre-pregnancy BMI of 30 kg/m2 or higher, pre-pregnancy smoking, previous superficial vein thrombosis, and other pregnancy-related conditions, were eligible. Participants were randomly assigned (1:1) within 48 h of delivery to aspirin 81 mg (80 mg in Europe) orally daily (low-dose aspirin group) or placebo orally once daily (placebo group) for 42 days. Follow-up visits occurred at 6 weeks and 90 days postpartum. The primary outcome was the mean recruitment rate (participants per site per month). Additional feasibility metrics were reported, and clinical outcomes were analysed by intention to treat. This study is registered with ClinicalTrials.gov, NCT04153760, and EudraCT, 2020-000619-58, and is completed. FINDINGS Between Nov 2, 2020, and June 19, 2023, 10 040 patients were assessed for eligibility and 808 met all eligibility criteria, of whom 257 (32%) provided consent and were enrolled. 127 were randomly assigned to the low-dose aspirin group and 130 to the placebo group. The median follow-up was 91 days (IQR 89-96). The median age was 34·0 years (IQR 30·0-37·0), and 161 (63%) of participants were White. The mean recruitment rate was 6·3 (95% CI 5·5 to 7·2) patients per site per month. No venous thromboembolism events occurred in the low-dose aspirin group, and one participant had distal deep vein thrombosis in the placebo group (-0·82 [95% CI -2·42 to 0·78]). No major bleeds occurred. Three (2%) participants in the low-dose aspirin group versus one (1%) in the placebo group had clinically relevant non-major bleeds (absolute risk difference 1·66 [95% CI -1·54 to 4·86]). Ten serious adverse events occurred in nine (4%) of 257 participants, and 11 serious adverse events occurred in ten (4%) of 271 infants of participants. No treatment-related death occurred. INTERPRETATION A global postpartum thromboprophylaxis trial evaluating low-dose aspirin is possible and needed to provide high-quality data. FUNDING Canadian Institutes of Health Research and the INVENT-VTE Network.
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Affiliation(s)
- Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, Calgary, AB, Canada.
| | - A Kinga Malinowski
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Lunenfeld-Tanenbaum Research Institute, Sinai Health, University of Toronto, Toronto, ON, Canada
| | - Darine El-Chaâr
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada
| | - Wee-Shian Chan
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Donnelly
- Rotunda Hospital, Dublin, Ireland; Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland; School of Medicine, University of College Dublin, Dublin, Ireland
| | - Céline Chauleur
- Department of Obstetrics and Gynecology, Université Jean Monnet Saint-Étienne, University Hospital, INSERM, SAINBOISE U1059, Saint-Étienne, France
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Stephen Wood
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada
| | - Suzanne Dubois
- CanVECTOR Research Network, The Ottawa Hospital, Ottawa, ON, Canada
| | - Claire McCarthy
- Department of Obstetrics and Gynecology, Cork University Maternity Hospital, Cork, Ireland
| | - Andrea Buchmuller
- Centre d'Investigation Clinique 1408, INSERM, Centre Hospitalier Universitaire, Saint-Étienne, France
| | - Hanke Wiegers
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Paul S Gibson
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada; Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Fionnuala Ní Áinle
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland; School of Medicine, University of College Dublin, Dublin, Ireland
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lisa Duffett
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Shannon M Bates
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Jill Baxter
- Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, QC, Canada
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Chen K, Zhang Y, Zhang L, Zhang W, Chen Y. Machine learning models for risk prediction of cancer-associated thrombosis: a systematic review and meta-analysis. J Thromb Haemost 2025; 23:610-626. [PMID: 39549838 DOI: 10.1016/j.jtha.2024.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 10/16/2024] [Accepted: 11/01/2024] [Indexed: 11/18/2024]
Abstract
BACKGROUND Although the number of models for predicting the risk of cancer-associated thrombosis has been rising, there is still a lack of comprehensive assessment for machine learning prediction models. OBJECTIVES This study aimed to critically appraise and quantify the performance studies using machine learning to predict cancer-associated thrombosis. METHODS We conducted searches on PubMed, Embase, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and other related databases for the related publications (from inception to December 1, 2023). The Prediction Model Risk of Bias Assessment Tool checklist was employed to evaluate the risk of bias and applicability. The Grading of Recommendations Assessment, Development and Evaluation system was used to evaluate the quality of evidence in systematic reviews. Meta-analyses were conducted using R (version 4.3.2). RESULTS A total of 32 studies were included. Mostly included literature exhibited a high risk of bias, and the applicability of the prediction models was deemed acceptable. The 21 included studies in the meta-analysis demonstrated the high predictive capacity of the machine learning models for cancer-associated thrombosis. CONCLUSION Most of the prediction models included in the study showed good applicability and excellent prediction performance, but there was a high risk of bias.
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Affiliation(s)
- Keya Chen
- The First School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ying Zhang
- School of Nursing, Wenzhou Medical University, University Town, Chashan, Wenzhou, Zhejiang, China; Cixi Biomedical Research Institute, Wenzhou Medical University, Cixi, China
| | - Lufang Zhang
- The First School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Zhang
- The First School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yu Chen
- Nursing Department, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, Zhejiang, China.
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Vojjala N, Peshin S, Kattamuri LPV, Iqbal R, Dharia A, Jayakumar J, Iftekhar R, Singh S, Balla M, Villa Celi CS, Ramachandran R, Prabhu R, Yadav SK, Krishnamoorthy G, Singh V, Seegobin K. Direct-Acting Oral Anticoagulants in the Management of Cerebral Venous Sinus Thrombosis-Where Do We Stand? Biomedicines 2025; 13:189. [PMID: 39857772 PMCID: PMC11759824 DOI: 10.3390/biomedicines13010189] [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: 11/26/2024] [Revised: 12/16/2024] [Accepted: 12/26/2024] [Indexed: 01/27/2025] Open
Abstract
BACKGROUND Cerebral venous sinus thrombosis (CVT) is a rare cause of stroke, constituting 0.5-3% of all strokes with an extremely varied spectrum of presentation, predisposing factors, neuroimaging findings, and eventual outcomes. A high index of suspicion is needed because timely diagnosis can significantly alter the natural course of the disease, reduce acute complications, and improve long-term outcomes. Due to its myriad causative factors, protean presentation, and association with several systemic diseases, CVT is encountered not only by neurologists but also by emergency care practitioners, internists, hematologists, obstetricians, and pediatricians. DISCUSSION Anticoagulation remains the mainstay of treatment for CVT. Heparin and warfarin previously had been the anticoagulation of choice. Recently there has been an increased interest in utilizing direct-acting oral anticoagulants in the treatment of CVT given comparable safety and efficacy with ease of utilization. However recent clinical guidelines given by multiple societies including the American Stroke guidelines and European guidelines do not include these agents so far in their treatment recommendations. Ongoing multicentric clinical trials are currently reviewing the role of these agents in both short-term as well as long-term. Our review of the literature supports the safety and reinforces the efficacy of DOAC in the treatment of CVT. Additionally, patient satisfaction has been shown to be better with the use of DOAC. In conclusion, DOAC continues to have a valid role in the management of CVT.
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Affiliation(s)
- Nikhil Vojjala
- Department of Internal Medicine, Trinity Health Oakland Hospital, Pontiac, MI 48341, USA; (N.V.); (R.P.); (G.K.)
| | - Supriya Peshin
- Department of Internal Medicine, Norton Community Hospital, Norton, VA 24273, USA;
| | | | - Rabia Iqbal
- Internal Medicine, Brooklyn Hospital Center, Brooklyn, NY 11201, USA; (R.I.); (J.J.)
| | - Adit Dharia
- HCA Florida Oak Hill Hospital, Brooksville, FL 34613, USA;
| | - Jayalekshmi Jayakumar
- Internal Medicine, Brooklyn Hospital Center, Brooklyn, NY 11201, USA; (R.I.); (J.J.)
| | - Rafi Iftekhar
- Department of Internal Medicine, Norton Community Hospital, Norton, VA 24273, USA;
| | - Shagun Singh
- Department of Internal Medicine, Banner Health, University of Arizona, Tucson, AZ 85719, USA; (S.S.); (R.R.)
| | - Mamtha Balla
- MD Anderson Cancer Center, Department of Infectious Disease Transplant, University of Texas, Houston, TX 77030, USA;
| | | | - Ramya Ramachandran
- Department of Internal Medicine, Banner Health, University of Arizona, Tucson, AZ 85719, USA; (S.S.); (R.R.)
| | - Rishab Prabhu
- Department of Internal Medicine, Trinity Health Oakland Hospital, Pontiac, MI 48341, USA; (N.V.); (R.P.); (G.K.)
| | - Sumeet K. Yadav
- Department of Hospital Internal Medicine, Mayo Clinic Health System, Mankato, MN 56001, USA;
| | - Geetha Krishnamoorthy
- Department of Internal Medicine, Trinity Health Oakland Hospital, Pontiac, MI 48341, USA; (N.V.); (R.P.); (G.K.)
| | - Vijendra Singh
- Department of Hematology-Oncology, Karmanos Cancer Center, Wayne State University School of Medicine, Detroit, MI 48201, USA;
| | - Karan Seegobin
- Department of Medical Oncology, Mayo Clinic Health System, Mankato, MN 56001, USA;
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Takahashi Y, Deshpande GA, Mine Y, Saita M, Naito T. A 27-Year-Old Japanese Woman Presenting with Left Chest Wall Pain Due to Palpable and Visible Sclerosing Superficial Thrombophlebitis (Mondor's Disease). AMERICAN JOURNAL OF CASE REPORTS 2025; 26:e945901. [PMID: 39763158 PMCID: PMC11725653 DOI: 10.12659/ajcr.945901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Revised: 11/29/2024] [Accepted: 11/20/2024] [Indexed: 01/15/2025]
Abstract
BACKGROUND Mondor's disease (MD), or sclerosing superficial thrombophlebitis of the veins of the anterior thoracic wall, is a rare condition of unknown cause that usually involves the superior epigastric vein, producing a visible and palpable Mondor cord. This report describes a 27-year-old Japanese woman presenting with left chest wall pain due to palpable and visible sclerosing superficial thrombophlebitis. CASE REPORT We present the case of a 27-year-old Japanese woman who presented with 8 days of left chest wall and upper abdominal pain. Physical examination revealed a firm, palpable cord in the painful area. Chest wall ultrasound revealed a tubular and anechoic superficial cord. Doppler imaging demonstrated normal blood flow surrounding the cord, with no blood flow within. Computed tomography (CT) revealed a subtle structure beneath the lower left breast skin and without breast or lung involvement. We diagnosed her as having MD, and she was treated with non-steroidal anti-inflammatory drugs (NSAIDs). Her pain gradually improved in 3 weeks and the cord disappeared after approximately 2 months. CONCLUSIONS Mondor's disease can be distressing and painful for patients. Clinicians should be aware of this rare and benign disease when a longitudinal painful cord is found in the torso wall. Pain relief and reassurance are typically adequate until resolution. In addition to ultrasonography, CT is also important for diagnosing MD. This report of a rare diagnosis of MD highlights the importance of accurate and timely diagnosis and investigating the patient to exclude superficial and deep venous thrombotic disease.
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Campbell AR, Florio CJ, Heringer GV, Woldemariam ST, Casey SD, Stubblefield WB, Westafer LM, Qiao E, Middleton CE, Zekar L, Gupta N, Somers MJ, Reed ME, Roubinian NH, Pai AP, Sperling JD, Vinson DR. Preemptive anticoagulation during antenatal pulmonary embolism diagnostics in a community setting: retrospective cohort study. Res Pract Thromb Haemost 2025; 9:102695. [PMID: 40104811 PMCID: PMC11914514 DOI: 10.1016/j.rpth.2025.102695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Revised: 12/27/2024] [Accepted: 01/24/2025] [Indexed: 03/20/2025] Open
Abstract
Background Society recommendations for preemptive (or empiric) anticoagulation during antenatal pulmonary embolism (PE) diagnostics rely on expert opinion, which varies widely across guidelines. The American College of Chest Physicians (CHEST), for example, recommends preemptive anticoagulation when PE is highly suspected or when a delay in imaging is anticipated. The American College of Obstetricians and Gynecologists, however, makes no mention of preemptive anticoagulation for suspected PE in their practice bulletin on thromboembolism in pregnancy. Patterns of preemptive anticoagulation in pregnancy are unknown. Objectives To describe the prevalence of and CHEST-based eligibility for preemptive anticoagulation in pregnancy. Methods This retrospective cohort study was undertaken across 21 United States community hospitals from October 1, 2021 through March 30, 2023. We included pregnant adults without COVID-19 undergoing definitive diagnostic PE imaging. We used pregnancy-adapted Geneva scores to calculate pretest probability as a proxy for suspicion. Results We included 326 patients: median age, 31.0 years; 51% were in the third trimester. Diagnostic settings included emergency departments (n = 254; 78%), Labor & Delivery (n = 65; 20%), and outpatient clinics (n = 7; 2%). Median time from emergency department computed tomography order to results was 1.40 hours (IQR: 0.78, 2.06). Prevalence of confirmed or presumed PE was low (n = 8; 2.5%). Only 2 patients (0.6%) received preemptive anticoagulation, whereas by CHEST criteria, 34 patients (10.4%) were eligible. Conclusion We found rare use of preemptive anticoagulation during antenatal PE diagnostics in this imaged cohort with low PE prevalence and rapid access to diagnostic imaging. More research is needed to explore setting-specific variation in preemptive anticoagulation use.
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Affiliation(s)
| | - Cole J Florio
- Kaiser Permanente CREST Network, Pleasanton, California, USA
- Department of Microbiology and Molecular Genetics, University of California, Davis, California, USA
| | - Grace V Heringer
- Kaiser Permanente CREST Network, Pleasanton, California, USA
- Department of Neurobiology, Physiology and Behavior, University of California, Davis, California, USA
| | - Sara T Woldemariam
- Department of Obstetrics and Gynecology, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Scott D Casey
- Kaiser Permanente CREST Network, Pleasanton, California, USA
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
- Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, California, USA
- The Permanente Medical Group, Pleasanton, California, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lauren M Westafer
- Department of Emergency Medicine and Department of Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - Edward Qiao
- Kaiser Permanente CREST Network, Pleasanton, California, USA
- California Northstate University College of Medicine, Elk Grove, California, USA
| | - Cydney E Middleton
- Department of Emergency Medicine, UC Davis Health, Sacramento, California, USA
| | - Lara Zekar
- Department of Emergency Medicine, UC Davis Health, Sacramento, California, USA
| | - Nachiketa Gupta
- The Permanente Medical Group, Pleasanton, California, USA
- Department of Emergency Medicine, Kaiser Permanente Redwood City Medical Center, Redwood City, California, USA
| | - Madeline J Somers
- Kaiser Permanente CREST Network, Pleasanton, California, USA
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
| | - Mary E Reed
- Kaiser Permanente CREST Network, Pleasanton, California, USA
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
| | - Nareg H Roubinian
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
- The Permanente Medical Group, Pleasanton, California, USA
- Department of Pulmonary and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Ashok P Pai
- The Permanente Medical Group, Pleasanton, California, USA
- Department of Hematology and Oncology, Kaiser Permanente Oakland Medical Center, Oakland, California, USA
| | - Jeffrey D Sperling
- The Permanente Medical Group, Pleasanton, California, USA
- Department of Maternal and Fetal Medicine, Kaiser Permanente Modesto Medical Center, Modesto, California, USA
| | - David R Vinson
- Kaiser Permanente CREST Network, Pleasanton, California, USA
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
- The Permanente Medical Group, Pleasanton, California, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
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32
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Turner ME, Jones T, Bauser-Heaton H. Considerations for Women with Congenital Heart Disease Undergoing Percutaneous Cardiovascular Procedures. Interv Cardiol Clin 2025; 14:97-107. [PMID: 39537293 DOI: 10.1016/j.iccl.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
The catheterization of women with congenital heart disease has unique considerations that must be taken into account. Hemodynamic changes secondary to pregnancy, anticoagulation strategies of women in child bearing years, and protection of a fetus during pregnancy require interventions and evidence of current therapies in the treatment of women continues to have more questions than answers in our current era. This review highlights some challenges in the catheterization of women with congenital heart disease.
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Affiliation(s)
- Mariel E Turner
- Columbia University Irving Medical Center, Morgan Stanley Children's Hospital of New York-Presbyterian, 3959 Broadway, 2 North, Room 253, New York, NY 10032, USA
| | - Tara Jones
- Division of Cardiovascular Medicine, University of Utah, 50 Medical Drive N, Salt Lake City, UT 84132, USA
| | - Holly Bauser-Heaton
- Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University, 2220 North Druid Hills Road, Brookhaven, GA 30329, USA.
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Shard A, Prodger C, Pavord S. Venous thromboembolism still leads on maternal death. Res Pract Thromb Haemost 2025; 9:102675. [PMID: 40226429 PMCID: PMC11992579 DOI: 10.1016/j.rpth.2024.102675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2024] [Revised: 12/28/2024] [Accepted: 12/30/2024] [Indexed: 04/15/2025] Open
Affiliation(s)
- Amelia Shard
- Department of Obstetrics, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Catherine Prodger
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Sue Pavord
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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34
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Zachariah KA, Yuan S, DeSancho MT, Landres IV, Singh HS. Role of Antiplatelets and Anticoagulation Therapies in Pregnancy. J Clin Med 2024; 13:7757. [PMID: 39768679 PMCID: PMC11678094 DOI: 10.3390/jcm13247757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Revised: 12/08/2024] [Accepted: 12/11/2024] [Indexed: 01/11/2025] Open
Abstract
Thrombosis is an important cause of morbidity and mortality worldwide. Pregnancy is a hypercoagulable state, and thrombotic complications in pregnancy are a major cause of maternal and fetal morbidity and mortality. Current guidelines support the selective use of aspirin, heparin, and warfarin in pregnant women. The decision to treat with antiplatelets and anticoagulants during pregnancy can be challenging, as these agents have numerous indications and contraindications, potential teratogenicity, and dosing considerations. Their use requires thoughtful discussion between patient and provider that balances therapeutic benefit versus maternal and fetal risks, while accounting for a safe delivery plan. Our aim is to provide a narrative review of the established and emerging indications of antiplatelets and anticoagulants, discuss their appropriate timing of administration, and consider their associated adverse fetal and maternal risks.
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Affiliation(s)
- Krista A. Zachariah
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY 10021, USA; (K.A.Z.); (S.Y.)
| | - Su Yuan
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY 10021, USA; (K.A.Z.); (S.Y.)
| | - Maria T. DeSancho
- Division of Hematology and Medical Oncology, Department of Medicine, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY 10021, USA;
| | - Inna V. Landres
- Department of Obstetrics and Gynecology, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY 10021, USA;
| | - Harsimran S. Singh
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital-Weill Cornell Medicine, New York, NY 10021, USA; (K.A.Z.); (S.Y.)
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35
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Orrin M, Barber E, Grainge MJ. Pre-Existing and Gestational Diabetes and Risk of Maternal Venous Thromboembolism: A Systematic Review and Meta-Analysis of Observational Studies. BJOG 2024. [PMID: 39686826 DOI: 10.1111/1471-0528.18043] [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: 08/01/2024] [Revised: 11/28/2024] [Accepted: 12/04/2024] [Indexed: 12/18/2024]
Abstract
BACKGROUND Women who are pregnant are at increased risk of venous thromboembolism (VTE), which persists for up to 3 months following childbirth. Diabetes is known to increase the risk of serious cardiovascular outcomes. OBJECTIVE To comprehensively review literature on the extent to which pre-existing or gestational diabetes influences the risk of VTE in both pregnancy and postpartum. SEARCH STRATEGY We used Medline, Embase and Google Scholar to identify observational studies published up to 2 November 2023. SELECTION CRITERIA Studies which quantified the relationship between diabetes on antepartum and/or postpartum VTE, and which provide separate data for pre-existing and gestational diabetes. DATA COLLECTION AND ANALYSIS Results were pooled, where appropriate, using random-effects meta-analysis. MAIN RESULTS Twenty one studies from Europe, the United States and Asia were included. There was an increased risk of antepartum VTE in women with gestational diabetes (RR = 2.48, 95% CI 1.47 - 4.16, I2= 45%, 4 studies) but not pre-existing diabetes (RR = 1.71, 0.43 - 6.77, I2= 68%, 2 studies). For postpartum VTE, there was no clear association with either pre-existing (RR = 1.28, 0.73 - 2.24, I2= 73%, 6 studies) or gestational (RR = 1.39, 0.77 - 2.51, I2= 70%, 10 studies) diabetes. CONCLUSIONS Our results will provide some reassurance for pregnant women with pre-existing or gestational diabetes, owing to no clear evidence of an increased risk of maternal VTE. While some studies report a raised risk of VTE during antepartum specifically, results must be interpreted in light of high levels of heterogeneity.
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Affiliation(s)
- Molly Orrin
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Emilia Barber
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Matthew J Grainge
- Academic Unit of Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, UK
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Scheres LJJ, Middeldorp S. Hormone-related thrombosis: duration of anticoagulation, risk of recurrence, and the role of hypercoagulability testing. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2024; 2024:664-671. [PMID: 39644057 DOI: 10.1182/hematology.2024000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2024]
Abstract
Hormone-related venous thromboembolism (VTE) is common and entails scenarios in which VTE occurs during exposure to exogenous or endogenous female sex hormones, typically estrogen and progestogen. For the management of hormone-related VTE, it is important to realize that many patients use these hormones for a vital purpose often strongly related to the patient's well-being and quality of life. In this review we discuss clinical cases of VTE related to hormonal contraceptive use and pregnancy to illustrate key considerations for clinical practice. We cover practice points for primary VTE treatment and detail the evidence on the risk of recurrent VTE and bleeding in this population. The potential value of thrombophilia testing is described, including "who, why, when, what, and how." We also discuss key aspects of shared decision-making for anticoagulant duration, including a reduced-dose anticoagulant strategy in hormone-related VTE.
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Affiliation(s)
- Luuk J J Scheres
- Department of Internal Medicine, Radboud university medical center, Nijmegen, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud university medical center, Nijmegen, the Netherlands
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37
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Mittal P, Sayar Z, Cohen H. Warfarin and heparin monitoring in antiphospholipid syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2024; 2024:192-199. [PMID: 39644000 DOI: 10.1182/hematology.2024000547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2024]
Abstract
Anticoagulation is central to the management of antiphospholipid syndrome (APS), an acquired thrombo-inflammatory disorder characterized by thrombosis (venous, arterial, or microvascular) or pregnancy morbidity, in association with persistent antiphospholipid antibodies (aPL; ie, 1 or more of lupus anticoagulant [LA], anticardiolipin, anti-beta-2- glycoprotein I, IgG, or IgM antibodies). The mainstay of anticoagulation in patients with thrombotic APS is warfarin or an alternative vitamin K antagonist (VKA) and, in certain situations, low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). Accurate assessment of anticoagulation intensity underpins optimal anticoagulant dosing for thrombus treatment or primary/secondary prevention. In patients with APS on warfarin, the international normalized ratio (INR) may not be representative of anticoagulation intensity due to an interaction between LA and the thromboplastin reagent used in the INR determination. In this review, we summarize the use of warfarin/VKA in patients with APS, along with venous and point-of-care INR monitoring. We also discuss the role and monitoring of LMWH/UFH, including in the anticoagulant refractory setting and during pregnancy.
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Affiliation(s)
- Prabal Mittal
- Department of Haematology, University College London Hospitals, London, United Kingdom
- Department of Haematology, Whittington Health NHS Trust, London, United Kingdom
| | - Zara Sayar
- Department of Haematology, University College London Hospitals, London, United Kingdom
- Department of Haematology, Whittington Health NHS Trust, London, United Kingdom
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals, London, United Kingdom
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38
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Padrnos L, Gangaraju R. Inherited thrombophilia and recurrent miscarriage: is there a role for anticoagulation during pregnancy? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2024; 2024:672-677. [PMID: 39643996 DOI: 10.1182/hematology.2024000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2024]
Affiliation(s)
- Leslie Padrnos
- Division of Hematology-Oncology, Mayo Clinic, Phoenix, AZ
| | - Radhika Gangaraju
- Division of Hematology-Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
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39
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How J, Hobbs G. Pregnancy: MPN management before, during, and after pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2024; 2024:541-546. [PMID: 39644040 DOI: 10.1182/hematology.2024000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2024]
Abstract
The aging obstetric population, combined with more frequent myeloproliferative neoplasm (MPN) diagnoses in younger patients, will result in hematologic providers increasingly caring for MPN patients in pregnancy. There are special considerations that pertain to management of pregnancy in MPN patients. This includes increased risks of thrombosis and hemorrhage as well as pregnancy complications that are likely related to placental dysfunction associated with an MPN diagnosis, including preeclampsia, preterm delivery, and intrauterine growth restriction. Complicating these outcomes is the uncertainty of the safety of many commonly used drugs in MPNs in pregnancy and breastfeeding. Given the overall low incidence of pregnancy in MPNs, many guidelines are based on expert opinions and extrapolation from other high-risk pregnancy populations. In this case-based review, we summarize the literature on MPN pregnancy outcomes and synthesize recommendations to provide guidance on the antepartum and postpartum management of MPN patients. Special attention is also made to issues relevant to preconception, including fertility and the use of assisted reproductive technology.
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Affiliation(s)
- Joan How
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Gabriela Hobbs
- Division of Oncology, Massachusetts General Hospital, Boston, MA
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40
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Chen Q, van Rein N, Broeders L, Middeldorp S, Bloemenkamp KWM, Cannegieter SC, Scheres LJJ. Time trends in antithrombotic therapy during pregnancy and maternal and perinatal outcomes in the Netherlands (2013-19): a nationwide cohort study. Lancet Haematol 2024; 11:e905-e915. [PMID: 39638541 DOI: 10.1016/s2352-3026(24)00313-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Revised: 09/27/2024] [Accepted: 10/02/2024] [Indexed: 12/07/2024]
Abstract
BACKGROUND Considering the paucity of data, we aimed to describe nationwide time trends in antithrombotic therapy during pregnancy and risks of maternal and perinatal outcomes in the Netherlands. METHODS In this nationwide cohort study, all female individuals aged 16-45 years with delivery records in the Dutch perinatal registry between Jan 1, 2013, and Dec 31, 2019, and their infants, were included. Individually linked data from Statistics Netherlands on outpatient medication prescriptions, in-hospital diagnoses, and mortality were used to evaluate time trends in antithrombotic therapy during pregnancy, and risks of maternal and perinatal outcomes (including thromboembolism, bleeding, preeclampsia and eclampsia, and low birthweight). FINDINGS A total of 1 122 711 pregnancies and 1 139 116 infants were included (median maternal age 30·5 years [IQR 27·3-33·7]; 886 085 [78·9%] White; median gravidity 2 (IQR 1-3); and median gestational age at delivery 39 weeks [IQR 38-40]). Low-molecular-weight heparin (LMWH) was the most commonly (more than 99%) prescribed anticoagulants during pregnancy, which slightly increased from 0·7% (1063 of 163 479) in 2013 to 0·9% (1352 of 158 654) in 2019. LMWH was generally started at 5-8 weeks' gestation when oral anticoagulant prescriptions dropped. Antiplatelet drug prescriptions increased from 0·7% (1129 of 163 479) to 4·8% (7671 of 158 654), which primarily initiated around week 12. Maternal risks of venous and arterial thromboembolism and bleeding remained constant from 2013 to 2019; the risk of preeclampsia and eclampsia gradually increased from 1·70% (95% CI 1·63-1·76) in 2013 to 2·05% (1·98-2·13) in 2017, after which it decreased to 1·83% (1·77-1·90) in 2019. There was a significant decrease (2019 vs 2013) in low birthweight (adjusted odds ratio 0·92 [0·90-0·94]; p<0·0001), whereas 28-day neonatal bleeding risk remained unchanged. INTERPRETATION Exposure to anticoagulants during pregnancy is not uncommon, and health-care providers and female individuals of reproductive age should be mindful of this to avoid unintended oral anticoagulant exposure. Adhering to guidelines for aspirin use to prevent preeclampsia might lead to a population-level reduction in disease burden and potential improvement in neonatal prognosis. FUNDING None. TRANSLATION For the Dutch translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Qingui Chen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Nienke van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands; Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kitty W M Bloemenkamp
- Department of Obstetrics, Birth Centre Wilhelmina Children's Hospital, Division Woman and Baby, University Medical Center Utrecht, Utrecht, Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands; Department of Medicine, Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Luuk J J Scheres
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, Netherlands.
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41
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Oza P, McGevna M, Ratner M, Garg K. Mechanical thrombectomy for the management of iliofemoral deep venous thrombosis in the second trimester of pregnancy secondary to May-Thurner syndrome. J Vasc Surg Cases Innov Tech 2024; 10:101609. [PMID: 39319079 PMCID: PMC11420508 DOI: 10.1016/j.jvscit.2024.101609] [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: 05/14/2024] [Accepted: 08/09/2024] [Indexed: 09/26/2024] Open
Abstract
Treatment of pregnancy-related venous thromboembolism is limited by considerations of the health risks to both the patient and fetus. Anticoagulation is the cornerstone treatment for pregnancy-related venous thromboembolism; however, early thrombus removal may be preferred for prompt symptom resolution and to decrease the risk of post-thrombotic syndrome. We report the successful treatment of a patient in the second trimester of pregnancy with symptomatic iliofemoral deep venous thrombosis and May-Thurner syndrome using percutaneous mechanical thrombectomy.
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Affiliation(s)
- Palak Oza
- Sophie Davis Biomedical Education Program, CUNY School of Medicine, New York, NY
| | - Moira McGevna
- New York University Grossman School of Medicine, New York, NY
| | - Molly Ratner
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY
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42
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Bikdeli B, Bates SM. Knowledge and raising awareness are the CURES for alleviating sex disparities in PE care. Thromb Res 2024; 243:109147. [PMID: 39277905 DOI: 10.1016/j.thromres.2024.109147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Accepted: 09/04/2024] [Indexed: 09/17/2024]
Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA.
| | - Shannon M Bates
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada
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DeSancho MT, Suvar E, Roberts JC, Tarantino MD, Schwartz J, Callis J, Recht M. Hereditary antithrombin deficiency pilot project registry from the American Thrombosis and Hemostasis Network. J Thromb Haemost 2024; 22:3183-3190. [PMID: 39151704 DOI: 10.1016/j.jtha.2024.07.026] [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: 03/06/2024] [Revised: 07/21/2024] [Accepted: 07/24/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Patients with hereditary antithrombin deficiency (HAD) have an increased risk of venous thromboembolism (VTE). The American Thrombosis and Hemostasis Network (ATHN) 12: HAD Pilot Project established a registry to collect data on patients with HAD. OBJECTIVES To inform current practice and serve as a platform to design a multicenter global registry for patients with HAD. METHODS The HAD registry was designed in 2020 to identify 100 patients with HAD receiving care at ATHN-affiliated centers. Demographics, type of HAD, thrombotic events, risk factors, anticoagulants, and antithrombin (AT) concentrate administration were recorded. RESULTS Ninety-four patients were included; 65% were females; 51% had type 1 HAD. Mean age at diagnosis was 26 years (SD, 18 years); 61% had VTE: 55% deep vein thrombosis and 27% pulmonary embolisms. Eight patients had arterial thrombosis. Recurrent thrombosis occurred in 58.6% of patients (44.8%) despite anticoagulation. The main risk factor for thrombosis in females was estrogen. Direct oral anticoagulants were prescribed in 30%, heparin in 34%, and warfarin in 32%. There were 139 pregnancies. Low-molecular-weight heparin was administered in 33% and AT concentrate in 19% and 11% prior to and after delivery, respectively. Twelve patients developed thrombosis in pregnancy. Seventy-nine patients underwent 239 surgeries or procedures, mainly gastrointestinal and vascular. Overall, 35% of participants received AT concentrate without adverse events. CONCLUSION In ATHN 12, VTE was the predominant manifestation, frequently recurrent. There was a trend toward using direct oral anticoagulants. Low-molecular-weight heparin was administered in one-third of pregnancies and AT concentrate in one-fifth without adverse events. These data should encourage prospective studies to optimize the management of these patients.
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Affiliation(s)
- Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York, USA.
| | - Erin Suvar
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, New York, New York, USA
| | - Jonathan C Roberts
- Bleeding & Clotting Disorders Institute, Dills Family Foundation Center for Research at BCDI, Peoria, Illinois, USA; Departments of Pediatrics and Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - Michael D Tarantino
- Bleeding & Clotting Disorders Institute, Dills Family Foundation Center for Research at BCDI, Peoria, Illinois, USA; Departments of Pediatrics and Medicine, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | | | - Jessica Callis
- American Thrombosis and Hemostasis Network, Cornwall, New York, USA
| | - Michael Recht
- Department of Pediatric Hematology & Oncology, Yale University School of Medicine, New Haven, Connecticut, USA; National Bleeding Disorders Foundation, New York, New York, USA
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Zuin M, Bikdeli B, Ballard-Hernandez J, Barco S, Battinelli EM, Giannakoulas G, Jimenez D, Klok FA, Krishnathasan D, Lang IM, Moores L, Sylvester KW, Weitz JI, Piazza G. International Clinical Practice Guideline Recommendations for Acute Pulmonary Embolism: Harmony, Dissonance, and Silence. J Am Coll Cardiol 2024; 84:1561-1577. [PMID: 39384264 DOI: 10.1016/j.jacc.2024.07.044] [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: 03/08/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 10/11/2024]
Abstract
Despite abundant clinical innovation and burgeoning scientific investigation, pulmonary embolism (PE) has continued to pose a diagnostic and management challenge worldwide. Aging populations, patients living with a mounting number of chronic medical conditions, particularly cancer, and increasingly prevalent health care disparities herald a growing burden of PE. In the meantime, navigating expanding strategies for immediate and long-term anticoagulation, as well as advanced therapies, including catheter-based interventions for patients with more severe PE, has become progressively daunting. Accordingly, clinicians frequently turn to evidence-based clinical practice guidelines for diagnostic and management recommendations. However, numerous international guidelines, heterogeneity in recommendations, as well as areas of uncertainty or omission may leave the readers and clinicians without a clear management pathway. In this review of international PE guidelines, we highlight key areas of consistency, difference, and lack of recommendations (silence) with an emphasis on critical clinical and research needs.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy; Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy.
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA
| | - Jennifer Ballard-Hernandez
- Cardiology Division, Department of Medicine, Department of Veterans Affairs, VA Long Beach Healthcare System, Long Beach, California, USA; Sue and Bill Gross School of Nursing University of California-Irvine, Irvine, California, USA
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Elisabeth M Battinelli
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, LUMC, Leiden, the Netherlands
| | - Darsiya Krishnathasan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Lisa Moores
- The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Katelyn W Sylvester
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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45
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Konstantinides SV. Shifting Priorities in the Prevention of Venous Thromboembolism: Time to Focus on Overall Cardiovascular Health. Thromb Haemost 2024; 124:958-961. [PMID: 39134035 DOI: 10.1055/s-0044-1788926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Affiliation(s)
- Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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46
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Vlachodimitropoulou E, Carrier M, Malinowski K, Cuker A, Kaplovitch E, Shehata N. Examining postpartum anticoagulation practices: An international survey of healthcare providers. Thromb Res 2024; 242:109113. [PMID: 39154384 DOI: 10.1016/j.thromres.2024.109113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 07/21/2024] [Accepted: 07/31/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) is 15 to 35-fold higher in the postpartum period compared to non-pregnant individuals. Clinical practice guidelines recommend the use of postpartum thromboprophylaxis with low molecular weight heparin (LMWH) for 6 weeks in individuals at high risk of developing VTE. However, a marked reduction in the risk of VTE risk occurs beyond the third week of the postpartum period. OBJECTIVE We sought to characterize practice patterns of clinicians who manage postpartum individuals at high risk of VTE. METHODS We conducted a cross-sectional study using a self-administered electronic questionnaire. The survey explored the use of postpartum thromboprophylaxis in high-risk individuals. Descriptive statistics were used to summarize survey responses. RESULTS Of the 113 participants that responded to the initial invitation, 78 completed the survey (Europe (53.9 %); North America (23.2 %); Australia and New Zealand (19.0 %)). For individuals with a prior unprovoked or provoked deep venous thrombosis or pulmonary embolism, cerebral vein thrombosis and splanchnic vein thrombosis, 97.4 %, 93.5 %, 91.0 % and 88.5 % of the respondents recommended six weeks of postpartum thromboprophylaxis using LMWH, respectively. The recommendation for 6 weeks of thromboprophylaxis in patients with sickle cell disease and obstetric APS was comparatively lower (70.5 and 78.2 % respectively). Respondents with higher practice volumes and more years of experience in clinical practice were more likely to recommend a shorter duration of thromboprophylaxis. CONCLUSION Our study highlights the variability in clinician recommendations and the acceptability of treatment durations for postpartum thromboprophylaxis in high-risk conditions. Prospective studies are needed to determine optimal duration and establish evidence-based management.
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Affiliation(s)
- Evangelia Vlachodimitropoulou
- Department of Maternal and Fetal Medicine, Mount Sinai Hospital, Toronto, Canada; Department of Obstetrics & Gynaecology, University of Toronto, Canada.
| | - Marc Carrier
- Division of Hematology, Ottawa Hospital, Ottawa, Canada
| | - Kinga Malinowski
- Department of Maternal and Fetal Medicine, Mount Sinai Hospital, Toronto, Canada
| | - Adam Cuker
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Eric Kaplovitch
- Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Canada
| | - Nadine Shehata
- Division of Hematology, Mount Sinai Hospital, Toronto, Canada; Division of Medical Oncology and Hematology, University Health Network, Canada; Departments of Medicine, Laboratory Medicine and Pathobiology, University of Toronto, Canada
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47
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Klaserner EL, Popova KJ, Gaudet RL. Venous Thromboembolism Prophylaxis in Obstetric Patients. J Pharm Pract 2024; 37:1183-1196. [PMID: 38621760 DOI: 10.1177/08971900241247628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Venous thromboembolism (VTE), including both pulmonary embolism (PE) and deep vein thrombosis (DVT), is the leading cause of maternal death in developed countries. Pregnancy is associated with an increased risk of VTE due to physiologic changes during the obstetric period that promote a hypercoagulable state. Appropriate use of prophylactic anticoagulants can decrease the event rate of thrombus formation in at-risk patients. In the United States, there is not a validated risk-assessment tool for VTE in obstetric patients or a clear consensus on initiation and optimal dosing strategy for the prophylactic use of anticoagulants. This article reviews the mechanism of coagulation disturbance that leads to an increased risk of VTE in obstetric patients, as well as the available literature surrounding pharmacologic prophylaxis.
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Affiliation(s)
- Emma L Klaserner
- Department of Pharmacy, University of Michigan Health Department of Pharmacy Services, Ann Arbor, MI, USA
| | - Kayla J Popova
- Department of Pharmacy, University of Michigan Health Department of Pharmacy Services, Ann Arbor, MI, USA
| | - Rikki-Leigh Gaudet
- Department of Pharmacy, University of Michigan Health Department of Pharmacy Services, Ann Arbor, MI, USA
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48
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Wan B, Fu D, Chen S, Tao F, Jiang J, Tian Y. Effect of Nurse-Assisted Early Warning Intervention for Prevention of Venous Thromboembolism Following Cesarean Delivery. MATERNAL-FETAL MEDICINE 2024; 6:225-231. [PMID: 40406174 PMCID: PMC12094333 DOI: 10.1097/fm9.0000000000000245] [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: 11/21/2023] [Accepted: 03/14/2024] [Indexed: 05/24/2025] Open
Abstract
Objective To assess the role of a nurse-assisted early warning intervention in improving prophylaxis against obstetric venous thromboembolism (VTE) and preventing VTE following cesarean delivery (CD). Methods A prospective cohort study conducted between January 1, 2020, and December 30, 2022, enrolled pregnant women who underwent CD in the obstetric unit of Women's Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital. The patients were assigned to a control group (routine nursing care) or the intervention group (nurse-assisted early warning intervention) depending on whether or not the nurse-assisted early warning intervention had been implemented. The χ 2 test and Student's t-test were used for statistical analysis. The primary outcome was the incidence of systemic VTE following CD, and secondary outcomes were the rates of mechanical or pharmacologic prophylaxis receipts for VTE and the frequency and severity of adverse events related to pharmacologic prophylaxis. Results A total of 27,074 cases were enrolled. The incidence of symptomatic VTE following CD was significantly lower in the intervention group (0.29 per 1000 deliveries) than in the control group (2.4 per 1000 deliveries) (P < 0.001). Significantly more cases received mechanical and pharmacological VTE prophylaxis in the intervention group than in the control group (respectively, 19.8% vs. 12.6% receiving mechanical prophylaxis and 0.9% vs. 0.2% receiving pharmacological prophylaxis). No cases of life-threatening bleeding occurred in either group. Conclusion The application of nurse-assisted early warning intervention may be an effective method for preventing VTE following CD.
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Affiliation(s)
| | | | | | | | - Jianan Jiang
- Department of Operating Room Nurses, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing 210004, China
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Dereme J, Goodyer M, Baud D, Alberio L, Grandoni F, Gavillet M. Targeted management of coexistent severe thrombophilias-A case report of a successful pregnancy despite paroxysmal nocturnal hemoglobinuria and hereditary protein C deficiency. EJHAEM 2024; 5:1048-1052. [PMID: 39415927 PMCID: PMC11474299 DOI: 10.1002/jha2.972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/17/2024] [Accepted: 06/07/2024] [Indexed: 10/19/2024]
Abstract
Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematological disorder characterized by the absence of complement regulatory proteins on the surface of erythrocytes, leading to intravascular hemolysis and thrombosis. Managing PNH during pregnancy poses significant challenges due to increased risks of morbidity and mortality. This case report describes the detailed obstetric course of a 44-year-old woman with PNH and additional hereditary protein C deficiency who had previously experienced multiple thrombotic events and adverse pregnancy outcomes (two early miscarriages and one stillbirth at 25 weeks gestation [WG]), treated with eculizumab (terminal C5 inhibitor) and optimal anticoagulation management. Close monitoring of hemolysis and hemostasis parameters was conducted throughout the gestation period together with increased obstetrical surveillance. The pregnancy progressed without thrombotic complications or breakthrough hemolysis, and the patient delivered a healthy newborn at 36 WG after induction of labor due to restricted fetal growth. To the best of our knowledge, this is the first reported case of a positive pregnancy outcome despite PNH in conjunction with hereditary thrombophilia. This case report highlights the importance of a multidisciplinary approach involving hematologists and obstetricians in the management of pregnant women with PNH. Tailored therapy, close monitoring, and comprehensive care are crucial to minimize risks and optimize outcomes.
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Affiliation(s)
- Julien Dereme
- Service and Central Laboratory of HaematologyDepartment of Oncology and Department of Laboratories and PathologyLausanne University Hospital (CHUV) and University of Lausanne (UNIL)LausanneSwitzerland
- Interregional Blood Transfusion SRCEpalingesSwitzerland
| | | | - David Baud
- Department Woman‐Mother‐ChildLausanne University HospitalUniversity of LausanneLausanneSwitzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of HaematologyDepartment of Oncology and Department of Laboratories and PathologyLausanne University Hospital (CHUV) and University of Lausanne (UNIL)LausanneSwitzerland
| | - Francesco Grandoni
- Service and Central Laboratory of HaematologyDepartment of Oncology and Department of Laboratories and PathologyLausanne University Hospital (CHUV) and University of Lausanne (UNIL)LausanneSwitzerland
| | - Mathilde Gavillet
- Service and Central Laboratory of HaematologyDepartment of Oncology and Department of Laboratories and PathologyLausanne University Hospital (CHUV) and University of Lausanne (UNIL)LausanneSwitzerland
- Interregional Blood Transfusion SRCEpalingesSwitzerland
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50
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Blondon M, Lansiaux M, Bryan S, Dongala A, Pavoncello R, Chatellier G, Claver M, Azria E, Martinez de Tejada B, Hugon-Rodin J. Preferences of pregnant women for postpartum thromboprophylaxis: the bicentric PREFER-PostPartum study. J Thromb Haemost 2024; 22:2834-2843. [PMID: 38972385 DOI: 10.1016/j.jtha.2024.06.019] [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: 01/18/2024] [Revised: 06/19/2024] [Accepted: 06/24/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Clinical guidelines for postpartum thromboprophylaxis differ due to its uncertain effect and varying preferences of experts. Women's preferences for postpartum thromboprophylaxis are unknown, although they may inform practices and future research. OBJECTIVES Our aim was to elicit the pregnant women's preferences for postpartum thromboprophylaxis according to different risks of venous thromboembolism (VTE) and bleeding. METHODS In 2 Swiss and French maternity hospitals, we conducted structured interviews of pregnant or postpartum women. Participants were instructed on pulmonary embolism, deep vein thrombosis, postpartum hemorrhage, and subcutaneous injections of low-molecular-weight heparin (LMWH). First, we randomized women to either standard gamble or time trade-off (2 different validated methods) to estimate the utilities (quality of life, from 0 to 1) of these health states. Second, we elicited the preference for the use of short-term postpartum thromboprophylaxis with LMWH vs none across different risks of postpartum VTE and bleeding through direct-choice exercises. RESULTS Among 122 participants, median (IQR) health state utilities were 0.725 (0.30-0.925) for pulmonary embolism, 0.75 (0.40-0.97) for postpartum hemorrhage, 0.85 (0.60-0.97) for deep vein thrombosis, and 0.96 (0.96-0.999) for LMWH injections. The median risk of postpartum VTE for preference of the use of postpartum thromboprophylaxis over no treatment was 0.1% (IQR, 0.01%-0.50%) without LMWH-associated bleeding risk and 0.2% (IQR, 0.1%-5%) with a 1% bleeding risk. CONCLUSION European pregnant women appear to have a high willingness for 10-day postpartum thromboprophylaxis, preferred over no treatment even for low risks of postpartum VTE. This perspective from patients supports the urgent need for a randomized trial evaluating the efficacy and safety of postpartum thromboprophylaxis.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland.
| | - Maud Lansiaux
- Gynecology Department, Gynaecological Endocrinology Unit, Hospital Saint Joseph, Paris, France
| | - Saskia Bryan
- Faculty of Medicine, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Amélie Dongala
- Gynecology Department, Gynaecological Endocrinology Unit, Hospital Saint Joseph, Paris, France
| | - Romain Pavoncello
- Faculty of Medicine, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | | | - Marine Claver
- Division of Obstetrics, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Elie Azria
- Maternity Unit, Paris Saint Joseph Hospital, Fédération Hospitalo-Universitaire Combattre la prématurité, Paris, France; Université de Paris Cité, Centre de Recherche en Epidémiologie et Statistiques, Obstetrical Perinatal and Pediatric Epidemiology Research Team, Equipe de recherche en épidémiologie obstétricale périnatale et pédiatrique, Institut national de la santé et de la recherche médicale, Paris, France
| | | | - Justine Hugon-Rodin
- Gynecology Department, Gynaecological Endocrinology Unit, Hospital Saint Joseph, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, Paris, France; Division of Gynecology, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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