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Edebiri O, Ní Áinle F. Risk factors, diagnosis and management of venous thromboembolic disease in pregnancy. Breathe (Sheff) 2022; 18:220018. [PMID: 36337136 PMCID: PMC9584596 DOI: 10.1183/20734735.0018-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022] Open
Abstract
Venous thromboembolism (VTE) in pregnancy is a leading cause of maternal morbidity and mortality. However, despite the significant associated clinical burden and potentially devastating societal impact, there is still a paucity of data surrounding its prevention and management. Consequently, international guideline recommendations vary widely. Exclusion of pregnant women from clinical trials in the past has contributed to knowledge gaps. However, recently published and ongoing studies demonstrate that excellent clinical trials in pregnancy are achievable. This review will discuss prevention, diagnosis and treatment of VTE in pregnancy, and will also explore priorities for future research. Venous thromboembolism in pregnancy is a leading cause of maternal morbidity and mortality. However, individualised clinical risk assessment and recent advances in clinical prediction rules for pulmonary embolism have the potential to improve management.https://bit.ly/3mjtHg2
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Pregnancy Complications Can Foreshadow Future Disease—Long-Term Outcomes of a Complicated Pregnancy. Medicina (B Aires) 2021; 57:medicina57121320. [PMID: 34946265 PMCID: PMC8704070 DOI: 10.3390/medicina57121320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/25/2021] [Accepted: 11/29/2021] [Indexed: 01/22/2023] Open
Abstract
During gestation, the maternal body should increase its activity to fulfil the demands of the developing fetus as pregnancy progresses. Each maternal organ adapts in a unique manner and at a different time during pregnancy. In an organ or system that was already vulnerable before pregnancy, the burden of pregnancy can trigger overt clinical manifestations. After delivery, symptoms usually reside; however, in time, because of the age-related metabolic and pro-atherogenic changes, they reappear. Therefore, it is believed that pregnancy acts as a medical stress test for mothers. Pregnancy complications such as gestational hypertension, preeclampsia and gestational diabetes mellitus foreshadow cardiovascular disease and/or diabetes later in life. Affected women are encouraged to modify their lifestyle after birth by adjusting their diet and exercise habits. Blood pressure and plasmatic glucose level checking are recommended so that early therapeutic intervention can reduce long-term morbidity. Currently, the knowledge of the long-term consequences in women who have had pregnancy-related syndromes is still incomplete. A past obstetric history may, however, be useful in determining the risk of diseases later in life and allow timely intervention.
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O'Shaughnessy F, O'Reilly D, Ní Áinle F. Current opinion and emerging trends on the treatment, diagnosis, and prevention of pregnancy-associated venous thromboembolic disease: a review. Transl Res 2020; 225:20-32. [PMID: 32554071 DOI: 10.1016/j.trsl.2020.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/10/2020] [Accepted: 06/09/2020] [Indexed: 12/23/2022]
Abstract
Pregnancy associated venous thromboembolism (PA-VTE) is a leading cause of maternal morbidity and mortality worldwide. Despite the availability of international guidance on the prevention, diagnosis and treatment, practice differs between countries and clinical institutions. The evidence base in this area is limited due to the vulnerable population who are affected, with the majority of guidelines deriving their recommendations from experience in surgical and medical venous thromboembolic disease. This review includes best evidence in PA-VTE management, highlighting specific literature which supports current diagnosis, prevention, and treatment strategies. Additionally, we hope to demonstrate emerging trends in the field through discussion of ongoing trials designed to progress towards evidence-based practice in the context of PA-VTE.
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Affiliation(s)
- Fergal O'Shaughnessy
- Pharmacy Department, Rotunda Hospital, Dublin 1, Ireland; Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland; Department of Haematology, Mater University Hospital, Dublin 7, Ireland
| | - Daniel O'Reilly
- Department of Paediatrics, Children's Health Ireland at Tallaght, Dublin 24, Ireland; SPHERE research group, Conway Institute, University College Dublin, Dublin 4, Ireland; Department of Haematology, Mater University Hospital, Dublin 7, Ireland.
| | - Fionnuala Ní Áinle
- SPHERE research group, Conway Institute, University College Dublin, Dublin 4, Ireland; School of Medicine, University College Dublin, Dublin 4, Ireland; Department of Haematology, Rotunda Hospital, Dublin 1, Ireland; Department of Haematology, Mater University Hospital, Dublin 7, Ireland
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O'Shaughnessy F, Donnelly JC, Bennett K, Damkier P, Áinle FN, Cleary BJ. Prevalence of postpartum venous thromboembolism risk factors in an Irish urban obstetric population. J Thromb Haemost 2019; 17:1875-1885. [PMID: 31309719 DOI: 10.1111/jth.14568] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/18/2019] [Accepted: 07/02/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Obstetric venous thromboembolism (VTE) is a leading cause of maternal morbidity and mortality. A clear understanding of the burden of VTE risk at a population level is a prerequisite to effective prevention; however, existing data are limited. OBJECTIVES Describe the prevalence and patterns of VTE risk factors among postpartum women and consider the implications for VTE prevention practices. METHOD We undertook a cross-sectional study of prospectively collected data from sequential postpartum VTE risk assessments completed between January 2015 and December 2017 in the Rotunda Hospital, Dublin. RESULTS We analyzed postpartum VTE risk factors in a large unselected Irish urban obstetric cohort of 21 019 consecutively sampled women. This represents more than 90% of all women giving birth in a single institution over a 3-year period. The most common VTE risk factors related to maternal characteristics and delivery characteristics, including overweight and obesity (36%), age ≥35 (35%) and cesarean delivery (32%). More than three-quarters of women had at least 1 VTE risk factor (78%) and more than 40% had multiple (2 or more) VTE risk factors. One-fifth of women had no VTE risk factors before delivery, yet went on to develop VTE risk factors during delivery or in the postpartum period. Reflecting the differences in thromboprophylaxis thresholds internationally, the proportion of women who would have received a recommendation for postpartum thromboprophylaxis ranged from 7% to 37% under various clinical guidelines. CONCLUSION This study demonstrates the high prevalence of VTE risk factors among postpartum women. Postpartum VTE risk is highly individualized and complex.
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Affiliation(s)
- Fergal O'Shaughnessy
- Pharmacy Department, Rotunda Hospital, Dublin 1, Ireland
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Jennifer C Donnelly
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin 1, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Per Damkier
- Department of Clinical Chemistry and Pharmacology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Fionnuala Ní Áinle
- School of Medicine, University College Dublin, and SPHERE Research Group, University College Dublin Conway Institute, Dublin 4, Ireland
- Department of Haematology, Mater Misericordiae University Hospital, Dublin 7, Ireland
- Department of Haematology, Rotunda Hospital, Dublin 1, Ireland
| | - Brian J Cleary
- Pharmacy Department, Rotunda Hospital, Dublin 1, Ireland
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Abstract
Outcomes research on obstetric venous thromboembolism (VTE) involves a number of major challenges. While obstetric VTE, including deep vein thrombosis and pulmonary embolism, is relatively common on a population basis, diagnoses during pregnancy are relatively rare in comparison to high-risk scenarios such as orthopedic surgery. This review characterizes outcomes research on obstetric VTE with a focus on strengths, limitations, and appropriate inferences from existing research. It is divided into four sections. First, evidence regarding validity of diagnosis codes for VTE in administrative data is reviewed. Second, limitations of both clinical research and administrative-data study models are analyzed. Third, examples of high-quality obstetric VTE research from the literature and opportunities for improved research in the future are reviewed. Fourth, future directions for research are explored.
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Affiliation(s)
- Cassandra R Duffy
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, USA.
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Montgomery D, Friedman AM. Optimizing obstetric venous thromboembolism protocol adherence: The experience of a hospital system. Semin Perinatol 2019; 43:234-237. [PMID: 30935755 DOI: 10.1053/j.semperi.2019.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this review is to explore the role of hospital systems in reliably providing high quality obstetric venous thromboembolism (VTE) prophylaxis focusing on the example of the Kaiser Permanente Southern California hospital system. While providers ultimately administer thromboprophylaxis on a patient-by-patient basis, hospital-level protocols, practices, and resources may be the most important determinants of whether a patient receives appropriate care. In comparison to the complex maternal and fetal emergencies that obstetricians are routinely called on to manage, VTE prophylaxis can often be simplified and integrated into the workflow, making decision-making time efficient and straightforward for the provider. Not having protocols (i.e. the provider being on their own) is associated with desired management occurring in only 40% of cases. Enhanced VTE protocols with complementary strategies to encourage use and identification of oversights addressed in real time can result in appropriate care in >90% of cases.
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Affiliation(s)
- Douglas Montgomery
- California Maternal Quality Care Collaborative Maternal Venous Thromboembolism Task Force, Kaiser Permanente Riverside Medical Center, Riverside, CA, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, 622 West 168th Street, PH 16-66, New York, NY 10032, USA.
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Sun M, Liu C, Zhao N, Meng K, Zhang Z. Predictive value of platelet aggregation rate in postpartum deep venous thrombosis and its possible mechanism. Exp Ther Med 2018; 15:5215-5220. [PMID: 29904405 PMCID: PMC5996703 DOI: 10.3892/etm.2018.6116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 02/26/2018] [Indexed: 11/06/2022] Open
Abstract
The present study investigated the predictive value of the platelet aggregation rate in postpartum deep venous thrombosis and its possible mechanism. From January 2014 to January 2016, 23 patients with postpartum deep vein thrombosis of lower extremity treated in the Department of Obstetrics of Beijing Chaoyang Hospital were as assigned as the observation group. At the same time, 25 cases with normal recovery were assigned as the control group. Blood samples were collected from all the subjects. The platelet aggregation rate was measured using a platelet aggregation apparatus. Plasma platelet activating factor (PAF) levels were measured by ELISA. The positive rate of platelet P-selectin (CD62p) and lysosomal membrane glycoprotein (CD63) was measured by flow cytometry. PI3K expression and AKt phosphorylation levels were measured by western blot analysis. The ROC curve was used to evaluate the value of the platelet aggregation rate in predicting postpartum deep vein thrombosis of lower extremity. The correlation between the platelet aggregation rate and PAF and PI3K/AKt expression was also analyzed. The cesarean section rate, platelet 5-min maximum aggregation rate, PAF level and the positive rate of CD62p and CD63 were significantly higher in the control than those in the observation group (P<0.05). Furthermore, the platelet aggregation rate was positively correlated with the expression of PAF, CD62p and CD63 (r=0.389, 0.451, and 0.452; all P<0.05). The platelet 5-min maximum aggregation rate for predicting postpartum deep vein thrombosis of lower extremity was reflected by the area under the ROC curve (AUC=0.797, P=0.000). The PI3Kp110β/β-actin and p-AKt/AKt ratio was significantly higher in the observation compared with the control group (P<0.05). In addition, the platelet aggregation rate was positively correlated with the expression of PI3K and phosphorylation level of AKt (r=0.441, 0.430; all P<0.05). The results suggested that platelet aggregation activity is elevated in postpartum deep vein thrombosis patients. It has a certain predictive value for the occurrence of postpartum deep vein thrombosis of lower extremity. Thuss, the PI3K/AKt signaling pathway may be one of the mechanisms of platelet aggregation.
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Affiliation(s)
- Mingxia Sun
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Beijing 100043, P.R. China
| | - Chongdong Liu
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Beijing 100043, P.R. China
| | - Na Zhao
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Beijing 100043, P.R. China
| | - Kaikai Meng
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Beijing 100043, P.R. China
| | - Zhenyu Zhang
- Department of Obstetrics and Gynecology, Beijing Chaoyang Hospital, Beijing 100043, P.R. China
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Fístula arteriovenosa posterior a trombosis venosa profunda persistente en ilíaca pimitiva posparto. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2017. [DOI: 10.1016/j.gine.2016.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Dueppers P, Grabitz K, Li Y, Schelzig H, Wagenhäuser MU, Duran M. Surgical management of iliofemoral vein thrombosis during pregnancy and the puerperium. J Vasc Surg Venous Lymphat Disord 2016; 4:392-9. [PMID: 27638991 DOI: 10.1016/j.jvsv.2016.06.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/30/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The risk of deep venous thrombosis is elevated during pregnancy and the puerperium. Therapy is usually limited to conservative measures as invasive thrombus removal is feared because of possible complications. However, leg- or life-threatening situations require fast thrombus removal, and the long-term rate of post-thrombotic syndrome (PTS) may be reduced by venous recanalization. Our center's experience may give support to surgical venous thrombectomy (VT). METHODS Between 1996 and 2016, all women who received VT for pregnancy-related deep venous thrombosis in our department were included. Retrospective data were combined with a current follow-up. RESULTS The study included 82 women with a mean age of 29 years (17-38 years). An additional arteriovenous fistula was performed in 79 and planned simultaneous cesarean section in 13 patients. Neither pulmonary emboli nor fetal complications occurred during surgery, and perioperative and postoperative mortality was 0%. Operative revision was required in 38% mainly for rethrombosis (24%) and bleeding (12%). One fetus died 2 months after VT of unrelated causes. After a mean of 83 months, complete venous recanalization was seen in 88%, venous valve sufficiency in 90%, and PTS in 31% without any ulcers. At 10 years, PTS incidence rose to reach 50% with limited statistical significance because of the number of patients reaching long-term follow-up. CONCLUSIONS Iliofemoral venous recanalization during pregnancy can be performed safely in a specialized center, with lower PTS rates than in historical controls.
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Affiliation(s)
- Philip Dueppers
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Klaus Grabitz
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - You Li
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Hubert Schelzig
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Markus Udo Wagenhäuser
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Mansur Duran
- Department of Vascular and Endovascular Surgery, University Hospital Duesseldorf, Duesseldorf, Germany.
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