Differences in thrombotic risk factors in black and white women with adverse pregnancy outcome

Hypertensive Disorders of Pregnancy and Pre-Pregnancy Hypertension with Subsequent Incident Venous Thromboembolic Events

Hypertensive disorders of pregnancy (HDP) and pre-pregnancy hypertension contribute to maternal morbidity and mortality. We examined the association of HDP and pre-pregnancy hypertension with subsequent venous thromboembolic (VTE) events. The retrospective cohort study included 444,859 women with ≥1 live, singleton birth in South Carolina (2004-2016). Hospital and emergency department visit and death certificate data defined incident VTE, HDP, and pre-pregnancy hypertension. Birth certificate data also defined the exposures. Adjusted Cox proportional hazards methods modeled VTE events risk. Of the cohort, 2.6% of women had pre-pregnancy hypertension, 5.8% had HDP, 2.8% had both pre-pregnancy hypertension and HDP (both conditions), and 88.8% had neither condition. The risk of incident VTE events within one year of delivery was higher in women with HDP (hazard ratio [HR] = 1.62, 95% confidence interval [CI]: 1.15-2.29) and both conditions (HR = 2.32, 95% CI: 1.60-3.35) compared to those with neither condition as was the risk within five years for women with HDP (HR = 1.35, 95% CI: 1.13-1.60) and for women with both conditions (HR = 1.82, 95% CI: 1.50-2.20). One- and five-year risks did not differ in women with pre-pregnancy hypertension compared to women with neither condition. Compared to non-Hispanic White (NHW) women with neither condition, the incident VTE event risk was elevated within five years of delivery for NHW (HR = 1.29, 95% CI: 1.02-1.63; HR = 1.59, 95% CI: 1.16-2.17) and non-Hispanic Black (NHB; HR = 1.51, 95% CI: 1.16-2.96; HR = 2.08, 95% CI: 1.62-2.66) women with HDP and with both conditions, respectively, and for NHB women with pre-pregnancy hypertension (HR = 1.50, 95% CI: 1.09-2.07). VTE event risk was highest in women with HDP, and the event rates were higher in NHB women than in NHW women in the same exposure group.

A Longitudinal Study of Thrombosis and Bleeding Outcomes With Thromboprophylaxis in Pregnant Women at Intermediate and High Risk of VTE

BACKGROUND

The efficacy and safety of thromboprophylaxis in pregnancy at intermediate to high risk of venous thrombo-embolism (VTE) is an area of ongoing research.

AIM

This study aimed to assess thrombosis and bleeding outcomes associated with thromboprophylaxis in women at risk of VTE.

METHODS

A cohort of 129 pregnancies, who received thromboprophylaxis for the prevention of VTE, were identified from a specialist obstetric clinic in Johannesburg, South Africa. Intermediate-risk pregnancies, with medical comorbidities or multiple low risks, were managed with fixed low-dose enoxaparin antepartum and for a median (interquartile range) of 4 (4) weeks postpartum. High-risk pregnancies, with a history of previous VTE, were managed with anti-Xa adjusted enoxaparin antepartum and for a median of 6 (0) weeks postpartum. Pregnancy-related VTE was objectively confirmed. Major bleeding, clinically relevant nonmajor bleeding (CRNMB) and minor bleeding were defined according to the International Society on Thrombosis and Hemostasis Scientific Subcommittee.

RESULTS

Venous thrombo-embolism occurred antepartum in 1.4% (95% CI: 0.04-7.7) of intermediate and 3.4% (95% CI: 0.4-11.7) of high-risk pregnancies. Bleeding events occurred in 7.1% (95% CI: 2.4-15.9) of intermediate and 8.5% (95% CI: 2.8-18.7) of high-risk pregnancies. Of these bleeding events, 3.1% (95% CI: 1.0-8.0) were classified as major bleeding. On univariate analysis, no independent predictors of bleeding were identified.

CONCLUSION

The rates of thrombosis and bleeding in this predominantly African population were consistent with similar studies and can be used to inform pregnant women of the benefits of anticoagulation and the risks of potential bleeding.

Changing Incidence and Mechanism of Pregnancy-Associated Myocardial Infarction in the State of California

Background The objective of this study was to evaluate the temporal trends in pregnancy-associated myocardial infarction (PAMI) in the State of California and explore potential risk factors and mechanisms. Methods and Results The California State Inpatient Database was analyzed from 2003 to 2011 for patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for acute myocardial infarction and pregnancy or postpartum admissions; risk factors were analyzed and compared with pregnant patients without myocardial infarction. A total of 341 patients were identified with PAMI from a total of 5 266 380 pregnancies (incidence of 6.5 per 100 000 pregnancies). Inpatient maternal mortality rate was 7%, and infant mortality rate was 3.5% among patients with PAMI. There was a nonsignificant trend toward an increase in PAMI incidence from 2003 to 2011, possibly attributable to higher incidence of spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome. PAMI, when compared with pregnant patients without myocardial infarction, was significant for older age (aged >30 years in 72% versus 37%, P<0.0005), higher preponderance of Black race (12% versus 6%, P<0.00005), lower socioeconomic status (median household income in lowest quartile 26% versus 20%, P=0.04), higher prevalence of hypertension (26% versus 7%, P<0.0005), diabetes (7% versus 1%, P<0.0005), anemia (31% versus 7%, P<0.0001), amphetamine use (1% versus 0%, P<0.00005), cocaine use (2% versus 0.2%, P<0.0001), and smoking (6% versus 1%, P=0.0001). Conclusions There has been a trend toward an increase in PAMI incidence in California over the past decade, with an increasing trend in spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome as mechanisms. These findings warrant further investigation.

Pregnancy outcomes in women with Budd Chiari Syndrome before onset of symptoms and after treatment

BACKGROUND & AIMS

Pregnancy is known to have poor outcomes in women with Budd Chiari syndrome. There are no data on fertility and pregnancy outcomes prior to onset of symptoms or the effect of therapy on these parameters. We therefore evaluated reproductive profile of women with Budd Chiari Syndrome before the onset of symptoms and after therapy.

PATIENTS AND METHODS

Eighty women with Budd Chiari Syndrome (29 years [20-45]) were enrolled over 8 years. Baseline demographic characteristics, disease severity, thrombophilic disorders and treatment were reviewed. Their obstetric history before symptoms and after therapy was noted and compared.

RESULTS

Sixty women conceived at least once (150 pregnancies) before symptom onset and 20 had primary infertility. Eighty-one pregnancies resulted in live births and remaining 69 pregnancies had adverse pregnancy outcomes. Post-intervention, 28 women (15 with primary infertility) attempted conception. Thirteen patients conceived 15 times. More women had live births after successful therapy as compared to presymptomatic period (0/28 vs 5/28 P = .000, Odds ratio5.6; 95% CI: 2.16-14.5). In women with primary infertility, conception (0/15 vs 3/15 P = .007, Odds ratio 5, 95% CI: 1.44-17.27) and proportion of live births (0/15 vs 2/15 P = .002, Odds ratio 7.5, 95% CI: 1.71-32.79) was higher as compared to presymptomatic period.

CONCLUSION

Primary infertility is common and pregnancy outcomes are poor before the onset of symptoms in women with Budd-Chiari syndrome. Effective therapy of Budd-Chiari syndrome may improve fertility and pregnancy outcomes.

Epidemiology of racial/ethnic disparities in severe maternal morbidity and mortality

The literature abounds with examples of racial/ethnic disparities in both obstetric outcomes and care. Disparities in maternal mortality are well documented with non-Hispanic blacks carrying the burden of the highest maternal mortality rates. Maternal deaths likely represent only the "tip of the iceberg" with respect to pregnancy complications, leading many to explore risk factors and disparities in severe maternal morbidity, a more common precursor to maternal mortality. This review article explores commonly cited indicators of severe maternal morbidity and includes a review of the epidemiological literature supporting or refuting disparities among each indicator.

Thrombophilia with an onset symptom of intracranial venous thrombosis: A case report and review of the literature

Thrombophilia may be hereditary or acquired and is associated with a high risk of thrombosis. The diagnosis rate for thrombophilia is low, particularly for patients with non-specific symptoms. The present study describes a patient with thrombophilia, presenting with onset symptoms for intracranial venous thrombosis. The patient had increased serum homocysteine and anticardiolipin immunoglobulin G antibodies and decreased protein S activities. In addition, the patient was obese and had a one-week history of fatigue, immobilization and insufficient water intake. Radiological findings identified multiple venous thrombosis. Since the patient had multiple risk factors for thrombosis, the diagnosis of thrombophilia was made. No mutations with definite clinical significance were identified in the assessments for mutations of the protein S-α (PROS1) gene. The current case highlights the importance of correct diagnosis for thrombophilia in patients who present with the onset symptoms of intracranial venous thrombosis.

Associations between pre-eclampsia and protein C and protein S levels among pregnant Nigerian women

OBJECTIVE

To evaluate levels of protein C and free protein S among women with pre-eclampsia, and determine whether there is a relationship between deficiencies and pre-eclampsia.

METHODS

A cross-sectional study was conducted at a hospital in Nigeria from July 2013 to March 2014 among 90 pregnant women with pre-eclampsia (blood pressure ≥140/90 mm Hg, proteinuria ≥300 mg in 24 hours) and 90 normotensive pregnant women (control group). Plasma levels of protein C and free protein S were analyzed by enzyme-linked immunosorbent assay, and protein C activity by a chromogenic method.

RESULTS

Mean protein C antigen and activity levels did not differ between groups (P=0.639 and P=0.444, respectively). The incidence of protein C antigen and activity deficiency also did not differ (P=0.288 and P>0.99, respectively). The mean free protein S antigen level was higher among women with pre-eclampsia (54.48%±19.58%) than in the control group (47.23%±10.27%; P=0.004). No woman in the control group had protein S deficiency, as compared with 2 (2%) of the women with pre-eclampsia (P=0.497). No association was found between deficiencies of these proteins and pre-eclampsia.

CONCLUSION

Deficiencies of protein C and free protein S are unlikely to be etiopathogenetic for pre-eclampsia; therefore, therapeutic intervention should focus on other potential pathogenetic pathways.

Racial disparity in placental pathology in the collaborative perinatal project

OBJECTIVE

There is substantial disparity in perinatal outcomes between white and African-American women, but the underlying biological mechanisms are poorly understood. The placenta is the principal metabolic, respiratory, excretory, and endocrine organ of the fetus. We studied the association between maternal race and types and severity of placental pathology.

METHODS

Using data from the U.S. Collaborative Perinatal Project (1959-1966), we studied 32,295 African-American and white women with singleton births. CPP pathologists conducted detailed placental examinations following a standard protocol with quality control procedures. Logistic regression modeling was used to test the association between race and placental pathology adjusting for potential confounders.

RESULTS

Compared to white women, African-American women had a higher risk of fetal neutrophilic infiltration (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.0-1.4), and 1.5-fold higher risk of low placental weight (95% CI, 1.3-1.7). However, various placental vascular lesions were significantly less common in African-American women, including infarcts and thrombosis in the cut surface, villous infarcts in the intervillous space, emergence of stromal fibrosis and Langerhans layer in the terminal villi, old hemorrhage in the maternal surface, thrombosis in the intervillous space, and calcification throughout the cut surface (aOR ranging from 0.5 to 0.8). Similar patterns were observed in pregnancies with pregnancy associated hypertension, small-for-gestational-age, and preterm birth.

CONCLUSION

As compared with white women, African-American had higher prevalence of inflammatory lesions but lower prevalence of vascular lesions in placental pathology.

Recurrent cerebral ischaemia in a pregnant woman with patent foramen ovale II° and thrombophilia

This case report concerns a pregnant multipara (age: 27 years) in the 16th gestational week. She developed a sudden onset of paraesthesia in her left lower arm although injecting dalteparin 5000 IU once daily subcutaneously (s. c.) due to a heterozygous factor V Leiden mutation and a prior miscarriage in the first pregnancy and preeclampsia in her third pregnancy. After the miscarriage she delivered two healthy children under prophylactic anticoagulation with low molecular weight heparin (LMWH). Now via magnetic resonance imaging (MRI) she was diagnosed as having multiple cerebral ischaemic lesions. Further workup revealed the presence of a patent foramen ovale (PFO) II° but no venous thrombosis in her legs. She was then treated with dalteparin 5000 IU twice daily by subcutaneous injections. At 19th gestational week she developed paraesthesia in her left lower arm again. The MRI showed a cortical lesion in the territory of the right median cerebral artery. The anticoagulation dose was increased stepwise under surveillance of the anti-FXa-level 3-4 h after subcutaneous injections aiming to achieve the supratherapeutic range of 1.2-1.5 IU/ml anti-Xa-units. No more neurological symptoms appeared under this antithrombotic therapy. The patient delivered by induction of labor at the 38th gestational week.