The use of low-molecular-weight heparins in pregnancy – how safe are they?

Safety comparisons among different subcutaneous anticoagulants for venous thromboembolism using FDA adverse event reporting system

Venous thromboembolism (VTE) remains a significant global health burden, particularly in older adults. While fondaparinux sodium, enoxaparin sodium, and dalteparin sodium are commonly used anticoagulants, their safety profiles require further evaluation. This study analyzes their adverse drug events (ADEs) using data from the FDA Adverse Event Reporting System (FAERS). A retrospective pharmacovigilance study was conducted using FAERS data from Q1 2004 to Q2 2024. Reports identifying fondaparinux sodium, enoxaparin sodium, or dalteparin sodium as the primary suspect drug were extracted. ADEs were classified using MedDRA 23.0 at the System Organ Class (SOC) and Preferred Term (PT) levels. Disproportionality analysis was performed with Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-item Gamma Poisson Shrinker (MGPS). FAERS contained 470 reports for fondaparinux sodium, 1,375 for enoxaparin sodium, and 344 for dalteparin sodium. Most cases involved patients aged ≥ 60, with a female predominance. Hospitalization was the most frequent outcome. Fondaparinux showed the strongest signals for intra-abdominal haematoma (ROR = 374.14, PRR = 371.14), muscle haemorrhage (ROR = 354.91, PRR = 347.04), and retroperitoneal haematoma (ROR = 214.97, PRR = 213.25). Enoxaparin demonstrated notable signals for heparin-induced thrombocytopenia (HIT) (ROR = 149.42, PRR = 147.53) and retroperitoneal haemorrhage (ROR = 287.68, PRR = 284.03). Dalteparin showed notable signals for HIT (ROR = 127.88, PRR = 126.49) and retroperitoneal haemorrhage (ROR = 103.23, PRR = 102.75). Distinct ADE profiles were identified among the three anticoagulants, underscoring the need for individualized risk assessment. These findings highlight the importance of close monitoring, particularly in high-risk patients, to optimize anticoagulation safety.

[Women's experience following prophylactic low molecular weight heparin treatment post-cesarean section]

OBJECTIVE

To assess women's experiences with skin-related side effects following subcutaneous low molecular weight heparin (LMWH) injections after a cesarean section, and to analyze their impact on treatment adherence.

METHOD

A questionnaire was developed in collaboration with Cesarine, a patients' association, to explore various aspects of LMWH administration, including prevention methods, cutaneous side effects, treatment compliance, perceived constraints, apprehension, and understanding of treatment benefits. Additionally, women's opinions on an alternative oral administration approach were solicited, taking into consideration breastfeeding contraindication. The questionnaire was on the Facebook® page and blog of the association.

RESULTS

One hundred and sixty-four women participated in the survey. Among them, 139 women (84.8%) reported bruising, while 117 (71.3%) reported pruritus, erythema, or nodules at the injection site. Treatment discontinuation was observed in 36 cases (22%), decided mostly by the women themselves (77.8%). The main reasons cited for discontinuation were discomfort during injection (71.4%), skin reactions (31.4%), and a perceived lack of effectiveness (54.3%). Furthermore, 88 women (53.7%) wanted to quit the treatment prematurely, citing similar reasons. Thirty-three women (20.1%) reported oversights. For most women, the treatment was perceived as burdensome and caused apprehension. An alternative oral administration method was of interest to 131 women (79.9%). However, only 28 (17.8%) would have accepted if the medication was incompatible with breastfeeding.

CONCLUSION

Cutaneous side effects of LMWH injections, as well as injection process itself, have a negative impact on adherence in the postpartum period following a c-section. These findings highlight the need to explore alternative to improve women's compliance and comfort.

Case Report of Umbilical Artery Thrombosis in a Patient With a History of Heparin-Induced Thrombocytopenia

Women are at increased risk of thromboembolism during pregnancy because of hypercoagulability associated with pregnancy. Heparin-induced thrombocytopenia (HIT) is an uncommon complication of heparin therapy, and patients with histories of HIT cannot receive any heparin-derived medications. Limited data exist regarding the clinical management of pregnant women with histories of HIT. Umbilical artery thrombosis (UAT) is a rare fetal complication with significant fetal morbidity and mortality. Using the CARE guidelines, we report a case of a woman previously diagnosed with HIT who received long-term anticoagulation therapy and whose fetus developed UAT at 27 weeks gestation. The purpose of this case report is to share our successful expectant management plan of care, which centered on the woman, involved multidisciplinary collaboration, and led to a term cesarean birth.

Dialysis in Pregnancy: An Update Review

Chronic kidney disease and end-stage kidney disease (ESKD) are important public health problems with increased rates of morbidity, mortality, and social costs. Pregnancy is rare in patients with ESKD, with reduced fertility rates in women undergoing dialysis. Although current advances have led to an increase in live births in pregnant dialysis patients, this modality still has an increased risk of multiple adverse events in pregnant women. Despite these existing risks, large-scale studies investigating the management of pregnant women on dialysis are lacking, resulting in the absence of consensus guidelines for this patient group. In this review, we aimed to present the effects of dialysis during pregnancy. We first discuss pregnancy outcomes in dialysis patients and the development of acute kidney injury during pregnancy. Then, we discuss our recommendations for the management of pregnant dialysis patients, including the maintenance of pre-dialysis blood urea nitrogen levels, the ideal frequency and duration of hemodialysis sessions, as well as the modality of renal replacement therapies, the difficulty of maintaining peritoneal dialysis in the third trimester of pregnancy, and optimization of prepregnancy modifiable risk factors. Finally, we present our recommendations for future studies investigating dialysis among pregnant patients.

Treatment of CML in pregnancy

Since the introduction of tyrosine kinase inhibitors (TKIs) at the beginning of the millennium, the outlook for patients with chronic myeloid leukemia (CML) has improved remarkably. As such, the question of life expectancy and survival has become less problematic while quality of life and family planning have become more so. While TKIs are the cornerstone of CML management, their teratogenicity renders them contraindicated during pregnancy. In recent years, patients who satisfy standardized criteria can stop TKI therapy altogether, and indeed, in eligible patients who wish to become pregnant, these objectives overlap. However, not all patients satisfy these criteria. Some pregnancies are unplanned, and a number of patients are pregnant when diagnosed with CML. In these patients the way forward is less clear, and there remains a paucity of good evidence available to guide treatment. In this article, we summarize the relevant literature and provide a framework for clinicians faced with the challenge of managing CML and pregnancy.

Management of pregnant patients with pulmonary arterial hypertension

Pregnant individuals with pulmonary arterial hypertension (PAH) have significantly high risks of maternal and perinatal mortality. Profound changes in plasma volume, cardiac output and systemic vascular resistance can all increase the strain being placed on the right ventricle, leading to heart failure and cardiovascular collapse. Given the complex network of opposing physiological changes, strict contraception and reduction of hemodynamic fluctuations during pregnancy are important methods of minimizing the risk of maternal mortality and improving the outcomes following pregnancy. In this review, we discuss the recent research progress into pre-conception management and the various therapeutic strategies for pregnant individuals with PAH.

Management of Chronic Myeloid Leukemia and Pregnancy: A Bibliometric Analysis (2000-2020)

Background

Given the increasing number and survival rates of reproductive-age patients with chronic myeloid leukemia (CML), several studies aimed to elucidate optimum disease management in pregnancy. This study aimed to use bibliometric analysis to assess focus and reported insights, as well as future trends, in CML and pregnancy research.

Methods

We extracted all studies related to CML and pregnancy from the Web of Science database from 2001 to 2020. VOS Viewer, CiteSpace, Python, and R-bibliometrix were used for bibliometric analysis, revealing the leading research countries, institutions, and authors, as well as distribution of keywords (frequency greater than five).

Results

A total of 196 records, published in 137 journals by 1,105 authors from 421 research institutes in 50 countries, were identified for analysis. The United States was the leader in the number of publications. Imperial College London and National Research Center for Hematology were the most influential institutions. In addition, Apperley J, Cortes J, Abruzzese E and Kantarjian H were the leading authors in the field. Keyword analysis identified four research hotspot clusters.

Conclusions

This study systematically analyzed the progress in CML and pregnancy research in the last 20 years. The present findings suggest that the management of planned and unplanned pregnancies in patients with CML will remain a research focus, as further evidence is required for the development of treatment guidelines.

Should pregnant women with anticoagulant prophylaxis benefit from scheduled delivery?

PURPOSE

When vaginal delivery is considered in women with low-molecular-weight heparin (LMWH) treatment, epidural analgesia is contraindicated for 12-24 h after the last injection. We evaluated the proportion of epidural analgesia depending on whether this is scheduled delivery (labor induction after stopping LMWH) or unscheduled delivery (stopping LMWH at labor onset).

METHODS

Retrospective hospital study running from 2015 to 2017. Inclusion criteria for patients with LMWH treatment were: singleton pregnancy, gestational age ≥ 38 weeks of gestation and possible vaginal delivery. The primary endpoint was the epidural analgesia rate. Secondary endpoints included risks for caesarean section, deep vein thrombosis, and postpartum hemorrhage.

RESULTS

Among 129 patients, 54 had scheduled delivery (41.9%). In practice, only 44 of them had labor induction (81.5%) and 54 of the 75 patients in the unscheduled delivery group had spontaneous delivery (72.0%). There was no significant difference in the rate of epidural analgesia between the "scheduled" and "unscheduled" groups (52/54 (96.3%) vs. 66/75 (88.0%) (p = 0.12)), and no difference in the secondary endpoints.

CONCLUSION

High access rates to epidural analgesia are observed in both scheduled and unscheduled deliveries. Scheduled delivery does not appear to be a really advantageous strategy for women with LMWH prophylaxis.

The role of maternal-foetal interface inflammation mediated by NLRP3 inflammasome in the pathogenesis of recurrent spontaneous abortion

INTRODUCTION

Approximately half of the recurrent spontaneous abortions (RSAs) that remain unidentified to date may be closely related to inflammation. Our previous study found excessive NLRP3 inflammasomes in RSA patients. Here, we investigated further the role of inflammasomes in the maternal-foetal interface of RSA patients.

METHODS

Villous and decidual tissues were collected during uterine curettage. The trophoblast cell line TEV-1 was cultured with lipopolysaccharide (LPS) or low molecular weight heparin (LMWH), and then the macrophage cell line RAW264.7 was treated with trophoblast media. The expression and localisation of inflammasomes in tissues and cells were detected, and the migration and proliferation of cells were analysed.

RESULTS

A significantly increased expression of inflammasomes was observed in RSA tissues compared with those in the normal group, and it was more obvious in villous tissues than in decidual tissues. In TEV-1 cells, after LPS stimulation, the expression of inflammasomes was increased, but the cell activity was decreased, whereas in RAW264.7, both expression of inflammasomes and cell activity were increased in the LPS group. In addition, LMWH could inhibit the action of LPS in above cells.

DISCUSSION

In patients experiencing RSA, abnormal inflammatory response might be mediated by NLRP3 inflammasomes on the maternal-foetal interface, which may reduce trophoblast activity and promote macrophage activity, leading to early embryo implantation failure. LMWH is expected to treat RSA patients by blocking this process.

Chronic Myeloid Leukemia, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology

Chronic myeloid leukemia (CML) is defined by the presence of Philadelphia chromosome (Ph) which results from a reciprocal translocation between chromosomes 9 and 22 [t(9;22] that gives rise to a BCR-ABL1 fusion gene. CML occurs in 3 different phases (chronic, accelerated, and blast phase) and is usually diagnosed in the chronic phase. Tyrosine kinase inhibitor therapy is a highly effective first-line treatment option for all patients with newly diagnosed chronic phase CML. This manuscript discusses the recommendations outlined in the NCCN Guidelines for the diagnosis and management of patients with chronic phase CML.

Comparison of international societal guidelines for the diagnosis of suspected pulmonary embolism during pregnancy

Pregnancy-associated pulmonary embolism is one of the leading causes of maternal mortality. Diagnosis of pulmonary embolism in pregnancy is challenging, with symptoms of pulmonary embolism mimicking those of pregnancy. Several key components such as clinical prediction tools, risk stratification, laboratory tests, and imaging widely used for diagnosis of pulmonary embolism in the non-pregnant population show limitations for diagnosis in pregnancy. Further, because of the difficulty of studying pregnant patients, high-quality research evaluating the performance of these diagnostic components in pregnancy is scarce. Seven international medical society guidelines present clinical diagnostic pathways for evaluation of pulmonary embolism in pregnancy that show conflicting recommendations on the use of these diagnostic components. This Review assesses all key components of diagnostic clinical pathways recommended by guidelines for evaluation of pulmonary embolism in pregnancy, reviews current evidence, compares the guideline recommendations with respect to each key component, and provides our preferred diagnostic pathway. It provides the guidelines and available data needed for informed decision making to diagnose pulmonary embolism in pregnancy.

Successful Long-term Anticoagulation with Enoxaparin in a Patient with a Mechanical Heart Valve

Thromboembolism related to a mechanical heart valve (MHV) is a major complication after surgical valve replacement. Warfarin remains as guideline-endorsed thromboprophylaxis in patients with MHVs. Alternative anticoagulation therapy for patients who do not tolerate or who fail warfarin is not adequately covered in the current guidelines. We report a case of successful long-term anticoagulation with enoxaparin in a patient with a mechanical aortic valve who had a contraindication to warfarin. The patient developed a left thigh hematoma requiring surgical evacuation 1 month after initiation of weight-based dosing of enoxaparin. His dose was then titrated based on peak anti-factor Xa levels (goal 0.6-1.0 IU/ml). He remained free of signs and symptoms of thromboembolic events, valve dysfunction, bleeding complications, or major adverse effects from long-term enoxaparin use for the next 13 years. Our case provides promising evidence of the potential role of enoxaparin in patients with MHVs in whom warfarin thromboprophylaxis is not possible. Meticulous monitoring of anti-factor Xa levels and dosage adjustments are crucial to treatment success.

A double dilemma: treatment of stage IV fetal twin-twin transfusion syndrome in the setting of maternal recurrent venous thromoembolism: a case report

Background

Fetal conditions can pose significant challenges in the management of pregnancies complicated by pre-existing maternal medical conditions.

Case presentation

We report a case of a 34-year-old woman with Stage IV Twin Twin Transfusion syndrome in the presence of maternal recurrent complex venous thromboembolic disease. Following a previous pregnancy loss, complicated by a third episode of thromboembolic disease, an inferior vena cava filter was placed. One month later, a pregnancy was confirmed and subsequently identified as a monochorionic twin pregnancy. Twin-Twin Transfusion syndrome was identified at 18 weeks’ gestation and progressed rapidly to Quintero Stage IV. In consultation with a multi-disciplinary international team, fetoscopic laser photocoagulation was performed. The pregnancy progressed to delivery of female infants at 33 weeks gestation, who have achieved all developmental milestones at 2 years of age.

Conclusions

We describe the multi-disciplinary effort to optimise the maternal condition to allow fetoscopic laser photocoagulation and continued management of the maternal and fetal conditions to a successful pregnancy outcome.

Aspirin and heparin for the prevention of pre-eclampsia: protocol for a systematic review and network meta-analysis

INTRODUCTION

Pre-eclampsia is an important cause of death and complication for pregnant women and perinatal infant. Low-dose aspirin has been most commonly used to prevent pre-eclampsia in high-risk pregnant women. Recently, heparins have also been used alone or in combination with aspirin to prevent pre-eclampsia. However, the optimal doses and combination therapy of aspirin and heparins are not well established. Therefore, we aim to compare aspirin, heparins and their combination to prevent pre-eclampsia in a network meta-analysis.

METHODS AND ANALYSIS

We will search the following electronic databases from the date of database establishment to 8 January 2019: PubMed, Embase, Cochrane Library, Web of Science and ProQuest. We will also search additional studies manually. There will be no restriction on the language of publications. Only randomised clinical trials will be eligible in our network meta-analysis. We will include pregnant women who have been recommended for aspirin according to the standard of the American Congress of Obstetricians and Gynecologists, or were designated as high risk in some recent studies. We will include studies comparing the effects of any single or combination of aspirin and heparins with placebo or observation or another intervention in pregnancy. We will include studies that reported one of the following outcomes: pre-eclampsia, severe pre-eclampsia, preterm delivery, perinatal death and full-term pre-eclampsia with delivery at ≥37 weeks. Traditional pairwise meta-analysis will be performed initially, and then network meta-analysis will be performed using frequency analysis method. Subgroup analyses and sensitivity analyses will be conducted to assess the robustness of the findings.

ETHICS AND DISSEMINATION

This network meta-analysis does not require ethical certification. An overview and information on the prevention of pre-eclampsia in high-risk pregnant women will be provided by this network meta-analysis.

PROSPERO REGISTRATION NUMBER

CRD42018084248.

Anticoagulants in frail patients. Seven situations at risk

In the case of venous thromboembolic disease (VTE), physicians are facing more and more difficulties in managing VTE and their treatment in frail patients. These patients could present several risk situations such as: chronic kidney disease (CKD), underweight or malnourished, falls, cognitive impairment, multi-medicated patients, cancer and pregnancy. Guidelines typically recommend anticoagulation. There are multiple challenges in the safe use of anticoagulation in frail patients, including bleeding risk, monitoring and adherence, and polypharmacy. The objective of this review is to explore these at-risk situations and to suggest adequate anticoagulation therapy, when possible, in each of these complex situations.

Placental Drug Transport-on-a-Chip: A Microengineered In Vitro Model of Transporter-Mediated Drug Efflux in the Human Placental Barrier

The current lack of knowledge about the effect of maternally administered drugs on the developing fetus is a major public health concern worldwide. The first critical step toward predicting the safety of medications in pregnancy is to screen drug compounds for their ability to cross the placenta. However, this type of preclinical study has been hampered by the limited capacity of existing in vitro and ex vivo models to mimic physiological drug transport across the maternal-fetal interface in the human placenta. Here the proof-of-principle for utilizing a microengineered model of the human placental barrier to simulate and investigate drug transfer from the maternal to the fetal circulation is demonstrated. Using the gestational diabetes drug glyburide as a model compound, it is shown that the microphysiological system is capable of reconstituting efflux transporter-mediated active transport function of the human placental barrier to limit fetal exposure to maternally administered drugs. The data provide evidence that the placenta-on-a-chip may serve as a new screening platform to enable more accurate prediction of drug transport in the human placenta.

Venous Thromboembolism Risk and Adequacy of Prophylaxis in High Risk Pregnancy in the Arabian Gulf

Objectives: To estimate the prevalence of venous thromboembolism (VTE) risk factors in pregnancy and the proportion of pregnancies at risk of VTE that received the recommended prophylaxis according to the American College of Chest Physicians (ACCP) 2012 published guidelines in antenatal clinics in the Arabian Gulf.

Methods: The evaluation of venous thromboembolism (EVE)-Risk project was a non-interventional, cross-sectional, multi-centre, multi-national study of all eligible pregnant women (≥17 years) screened during antenatal clinics from 7 centres in the Arabian Gulf countries (United Arab Emirates, Kuwait, Bahrain, Qatar and Oman). Pregnant women were recruited during a 3-month period between September and December 2012.

Results: Of 4,131 screened pregnant women, 32% (n=1,337) had ≥1 risk factors for VTE. Common VTE risk factors included obesity (76%), multiparity (33%), recurrent miscarriages (9.1%), varicose veins (6.9%), thrombophilia (2.6%), immobilization (2.0%), sickle cell disease (2.8%) and previous VTE (1.6%). Only 8.3% (n=111) of the high risk patients were on the recommended VTE prophylaxis. Enoxaparin was used in 80% (n=89) of the cases followed by tinzaparin (4%; n=4). Antiplatelet agents were prescribed in 11% (n=149) of pregnant women. Of those on anticoagulants (n=111), 59% (n=66) were also co-prescribed antiplatelet agents. Side effects (mainly local bruising at the injection site) were reported in 12% (n=13) of the cases.

Conclusion: A large proportion of pregnant women in the Arabian Gulf countries have ≥1 VTE risk factor with even a smaller fraction on prophylaxis. VTE risk assessment must be adopted to identify those at risk who would need VTE prophylaxis.

Low-Molecular-Weight Heparin for the Treatment of Unexplained Recurrent Miscarriage With Negative Antiphospholipid Antibodies: A Randomized Controlled Trial

BACKGROUND

Recurrent miscarriage (RM) is one of the most common clinical problems in reproduction with no definite cause in about 50% of the cases. The study aims to evaluate the effect of low-molecular-weight heparin (LMWH) in the treatment of women with RM negatively tested for antiphospholipid antibodies (APAs).

METHODS

An open-labeled registered randomized controlled study (NCT 01608347) included women who attended the outpatient clinic in Assiut Women Health Hospital and Nag-Hamady Central Hospital, Egypt, with 3 or more unexplained RM. Eligible participants were randomly assigned into 2 groups. The study group included 150 patients receiving LMWH (Tinzaparin sodium 4500 IU) subcutaneous daily injection with 500 µg folic acid once daily orally started once positive pregnancy test till the 20th week of gestation. The control group included 150 patients receiving the same dose of folic acid alone. The primary outcome of the study was the rate of continuation of a viable pregnancy after 20 weeks of gestation.

RESULTS

There was no significant difference between both groups as regards age, parity, or number of previous miscarriages. There was a significant increase in women who continued their pregnancy beyond 20 weeks in the study group compared to the control group (73.3% vs 48%, respectively; P = .002). The take-home baby rate was also significantly higher in the LMWH group compared to the control group ( P = .001).

CONCLUSION

Early start of LMWH decreases the incidence of miscarriage in the first 20 weeks of pregnancy in women with unexplained RM negative for APAs.

Birthweight in pregnant women with protein S deficiency treated with low-molecular-weight heparin: a retrospective cohort study

OBJECTIVE

To determine the risk of small-for-gestational-age (SGA) and intrauterine growth retardation (IUGR) in pregnant women with protein S (PS) deficiency who received low-molecular-weight heparin (LMWH).

METHODS

Retrospective cohort study of pregnant women seen from January 2002 to December 2011. The study cohort comprised a total of 328 patients with PS deficiency, who received prophylactic enoxaparin during pregnancy. The control cohort included 11 884 pregnant women without significant past medical history. The risk of SGA and IUGR was calculated as odds ratio. Multivariate regression analysis over the entire reference population was performed determining the risk of both SGA and IUGR by adjusting for maternal age, first delivery, maternal underweight status, pre-eclampsia, other treated thrombophilias or history of recurrent abortion.

RESULTS

The SGA rates in the PS deficiency and control cohorts were 10.7% and 8.5%, respectively (p > 0.05). There was no increased risk of SGA (unadjusted OR = 1.28, 95% confidence interval [CI] 0.9-1.83; adjusted OR = 1.35, 95% CI 0.91-2.01). The IUGR rate was 2.7% in pregnant women with PS deficiency versus 4.1% in the control group (p > 0.05). Also, we did not find a significant risk of IUGR (OR = 0.66; 95% CI 0.34-1.28; adjusted OR = 0.843; 95% CI 0.42-1.70).

CONCLUSIONS

In women with PS deficiency treated with LMWH, the risk of SGA and IUGR is similar to the one found in healthy pregnant women.

Identification of a Monoclonal Antibody That Attenuates Antiphospholipid Syndrome-Related Pregnancy Complications and Thrombosis

In the antiphospholipid syndrome (APS), patients produce antiphospholipid antibodies (aPL) that promote thrombosis and adverse pregnancy outcomes. Current therapy with anticoagulation is only partially effective and associated with multiple complications. We previously discovered that aPL recognition of cell surface β2-glycoprotein I (β2-GPI) initiates apolipoprotein E receptor 2 (apoER2)-dependent signaling in endothelial cells and in placental trophoblasts that ultimately promotes thrombosis and fetal loss, respectively. Here we sought to identify a monoclonal antibody (mAb) to β2-GPI that negates aPL-induced processes in cell culture and APS disease endpoints in mice. In a screen measuring endothelial NO synthase (eNOS) activity in cultured endothelial cells, we found that whereas aPL inhibit eNOS, the mAb 1N11 does not, and instead 1N11 prevents aPL action. Coimmunoprecipitation studies revealed that 1N11 decreases pathogenic antibody binding to β2-GPI, and it blocks aPL-induced complex formation between β2-GPI and apoER2. 1N11 also prevents aPL antagonism of endothelial cell migration, and in mice it reverses the impairment in reendothelialization caused by aPL, which underlies the non-thrombotic vascular occlusion provoked by disease-causing antibodies. In addition, aPL inhibition of trophoblast proliferation and migration is negated by 1N11, and the more than 6-fold increase in fetal resorption caused by aPL in pregnant mice is prevented by 1N11. Furthermore, the promotion of thrombosis by aPL is negated by 1N11. Thus, 1N11 has been identified as an mAb that attenuates APS-related pregnancy complications and thrombosis in mice. 1N11 may provide an efficacious, mechanism-based therapy to combat the often devastating conditions suffered by APS patients.

ApoE Receptor 2 Mediation of Trophoblast Dysfunction and Pregnancy Complications Induced by Antiphospholipid Antibodies in Mice

OBJECTIVE

Pregnancies in women with the antiphospholipid syndrome (APS) are frequently complicated by fetal loss and intrauterine growth restriction (IUGR). How circulating antiphospholipid antibodies (aPL) cause pregnancy complications in APS is poorly understood. We sought to determine whether the low-density lipoprotein receptor family member apolipoprotein E receptor 2 (ApoER2) mediates trophoblast dysfunction and pregnancy complications induced by aPL.

METHODS

Placental and trophoblast ApoER2 expression was evaluated by immunohistochemistry and immunoblotting. Normal human IgG and aPL were purified from healthy individuals and APS patients, respectively. The role of ApoER2 in aPL-induced changes in trophoblast proliferation and migration and in kinase activation was assessed using RNA interference in HTR-8/SVneo cells. The participation of ApoER2 in aPL-induced pregnancy loss and IUGR was evaluated in pregnant ApoER2(+/+) and ApoER2(-/-) mice injected with aPL or normal human IgG.

RESULTS

We found that ApoER2 is abundant in human and mouse placental trophoblasts and in multiple trophoblast-derived cell lines, including HTR-8/SVneo cells. ApoER2 and its interaction with the cell surface protein β2 -glycoprotein I were required for aPL-induced inhibition of cultured trophoblast proliferation and migration. In parallel, aPL antagonism of Akt kinase activation by epidermal growth factor in trophoblasts was mediated by ApoER2. Furthermore, in a murine passive-transfer model of pregnancy complications of APS, ApoER2(-/-) mice were protected from both aPL-induced fetal loss and aPL-induced IUGR.

CONCLUSION

ApoER2 plays a major role in the attenuation of trophoblast function by aPL, and the receptor mediates aPL-induced pregnancy complications in vivo in mice. ApoER2-directed interventions can now potentially be developed to combat the pregnancy complications associated with APS.

Bone status of children born from mothers with autoimmune diseases treated during pregnancy with prednisone and/or low molecular weight heparin

BACKGROUND

To evaluate bone status in children born from mothers followed for autoimmune diseases and treated during pregnancy with low molecular weight heparin (LMVH) and/or prednisone.

FINDINGS

History, physical examination, laboratory tests and phalangeal ultrasonography were performed. Demographic, clinical, and laboratory data were entered into a customized database, and results were analyzed with SPSS software. In children whose mothers were treated with LMWH, we retrieved dried blood spots taken for newborn screening, and analyzed the presence of heparin with tandem mass spectrometry. We enrolled 27 females and 14 males born from 31 mothers with SLE or connective tissue diseases. These women were continuously treated during pregnancy with LMWH (n = 10), prednisone (n = 16), or both (n = 15). Bone ultrasound revealed low values (≤ 3 centile for age) in ten patients. In a multistep regression analysis, age at examination resulted the single predictor of low ultrasound values (p < 0.004). Tandem mass spectroscopy failed to determine traces of heparin in newborn blood.

CONCLUSIONS

Children born from mothers with autoimmune diseases are at risk to develop reduced bone mass. The administration of LMWH and of prednisone seems to be safe with regard to children's bone health.

Outcomes in women receiving low-molecular-weight heparin during pregnancy

To assess the rate and type of maternal and infant complications among pregnant women receiving low-molecular-weight heparin (LMWH). Retrospective study of pregnant women on LMWH referred to two university hematology clinics from January 2001 to December 2010. We recorded the number of pregnancies, indication, dose and dose adjustments for LMWH, pregnancy outcomes (live births, maternal and infant complications) and side effects of LMWH. There were 89 pregnancies in 76 women. The most common indication for LMWH was a history of adverse outcome of pregnancy associated with thrombophilia. LMWH was adjusted in 75 and 45% of pregnancies in women on therapeutic and prophylactic doses, respectively. Live birth rate was 97%. There were 25 maternal and 11 infant complications. Side effects were minimal and included decreased bone mineral density and bleeding. LMWH use among pregnant women is associated with successful pregnancy outcomes. Although side effects were minimal, maternal and infant complications occurred in 28 and 12% of cases, respectively.

Uso de la heparina de bajo peso molecular y aspirina en una paciente con síndrome antifosfolípido y pérdida gestacional recurrente

Introducción: La pérdida gestacional recurrente (PGR) es una patología frecuente, que causa gran impacto en las parejas conllevando frustración, ansiedad, depresión, gastos excesivos y hasta rupturas de la relación de pareja. Su etiología es multicausal  y frecuentemente no se logra determinar. Se presenta el caso de una paciente con PGR quien luego de seis pérdidas gestacionales, en el séptimo embarazo se detectaron anticuerpos antifosfolípidos altos, recibiendo tratamiento de tromboprofilaxis doble hasta la semana 32, obteniéndose un producto pretérmino vivo y sano  que  evolucionó  satisfactoriamente.  Se  discuten dificultades para la precisión diagnóstica y las modalidades de tratamiento descritos. 

[News on antithrombotic therapy and pregnancy]

OBJECTIVES

State of the art of antithrombotics and their use recommendations during pregnancy.

METHODS

A review

RESULTS

Aspirin and heparins remain the safest molecules during pregnancy, and oral anticoagulants are still used for mechanical valves. Heparinoids are the methods of choice in case of heparin-induced thrombopenia but other molecules could find their place: fondaparinux at first and possibly the direct thrombin inhibitors. Thrombolysis may be used in case of life-threatening incident. At present, the new oral forms can not be used during pregnancy

CONCLUSIONS

During pregnancy, all antithrombotics, except the oral forms, can be used, but the low molecular weight heparins replacing the unfractionated ones in the treatment and prevention of venous thromboembolism remain the treatment of choice.

New Insights into the Molecular Basis of the Antiphospholipid Syndrome

Antiphospholipid syndrome is an autoimmune disease characterized by the presence of circulating antiphospholipid antibodies (aPL) that promote thrombosis, pregnancy complications and cardiovascular diseases. Alterations in the function of vascular cells induced by aPL underlie these outcomes. This review will discuss recent findings that indicate a novel mechanism by which aPL antagonize endothelial cell production of nitric oxide and thereby promote thrombosis.

Enoxaparin versus unfractionated heparin in the management of recurrent abortion secondary to antiphospholipid syndrome

OBJECTIVE

To determine whether low molecular weight heparin (LMWH) plus low-dose aspirin (LDA) is comparable in efficacy and safety to unfractionated heparin (UFH) plus LDA in the management of pregnant women with a history of recurrent spontaneous abortion secondary to antiphospholipid syndrome (APS).

METHODS

In a randomized prospective study, 60 women with a history of 3 or more consecutive spontaneous abortions and positive antiphospholipid antibodies were assigned in equal numbers to receive either UFH (5000 units, twice daily) plus LDA, or LMWH (enoxaparin 40 mg, once daily) plus LDA as soon as pregnancy was diagnosed.

RESULTS

Twenty-four women in the LMWH group (80%) and 20 women in the UFH group (66.67%) delivered a viable infant (P = 0.243). There were no significant differences in pregnancy complications or neonatal morbidity between the 2 groups. There were no incidences of excessive bleeding, thrombocytopenia, or osteoporotic fractures in either group.

CONCLUSION

LMWH plus LDA was successfully used as an alternative to UFH plus LDA in the management of recurrent abortion secondary to APS. The results highlight the need for a larger randomized controlled trial to determine whether LMWH plus LDA should be the treatment of choice for recurrent abortion secondary to APS. Clinicaltrials.gov NCT01051778.

Lupus and pregnancy--15 years of experience in a tertiary center

This retrospective study was designed to evaluate the outcome of pregnancies in women diagnosed with systemic lupus erythematosus (SLE) followed in a tertiary fetal-maternal center. Data were collected from clinical charts between January 1993 and December 2007, with a total of 136 pregnancies (107 patients). Mean maternal age was 29 years, with the vast majority of patients being Caucasian. Most patients were in remission 6 months prior to pregnancy (93%) and the most frequently affected organs were the skin and joints. Renal lupus accounted for 14% of all cases. Twenty-nine percent of patients were positive for at least one antiphospholid antibody (aPL) and nearly 50% had positive SSa/SSb antibodies. All patients with positive aPL received low-dosage aspirin and low-molecular-weight heparin (LMWH). There were no pregnancy complications in more than 50% of cases and hypertensive disease and intrauterine growth restriction were the most common adverse events. There were 125 live births, one neonatal death, eight miscarriages, and three medical terminations of pregnancy. Preterm delivery occurred in 25% of pregnancies. Our results are probably the conjoined result of a multidisciplinary approach together with a systematic management of SLE pregnancies, with most patients keeping their prior SLE medication combined with low-dosage aspirin and LMWH in the presence of aPL.

[Drugs during preeclampsia. Fetal risks and pharmacology]

During pregnancy, the maternal, placental and fetal physiological characteristics constantly evolve and thereby constantly alter drug bioavailability in the mother and feto-placental unit. Gastric emptying time is increased and bowel movements are reduced. Distribution in the maternal body is mainly influenced by body mass variations, water content and fat stores. Metabolic capacity of the liver appears unchanged but renal clearance of drugs is gradually increased. The placental transfer of most drugs mainly consists of passive diffusion between the maternal and fetal circulations, along their respective concentration gradients. Only the free, unbound and non-ionized fraction of the drug readily crosses the membranes. Four anti-hypertensive drugs have been granted a license for the treatment of PE since the year 2000: these are Clonidine (Catapressan), Nicardipine (Loxen+), Labetalol (Trandate), Dihydralazine (Nepressol). Dihydralazine, Labetalol and Nicardipine are not contraindicated in the breast feeding mother. The administration of a long acting Benzodiazepine during pregnancy can lead to new born intoxication of variable severity and duration. These symptoms may precede a withdrawal syndrome (hyper-excitability, tremor, gastro-intestinal upset, such as diarrhea or vomiting). Breast feeding by mothers using benzodiazepines (Nitrazepam and Midazolam) is not recommended. In France, the use of low molecular weight heparins is not recommended during pregnancy whereas in the United States, they are recommended as a prophylactic measure. Their high molecular weight prevents their diffusion across the placental membrane and therefore prevents any fetal or neonatal risk. Bromocriptine is used as an inhibitor of lactation. During the post-partum period, serious accidents have been described: these consist of systemic hypertension, fits, infarcts (cardiac and neurological). It is contraindicated in case of systemic hypertension.