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Kilkenny K, Frishman W. Venous Thromboembolism in Pregnancy: A Review of Diagnosis, Management, and Prevention. Cardiol Rev 2024:00045415-990000000-00306. [PMID: 39051770 DOI: 10.1097/crd.0000000000000756] [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: 07/27/2024]
Abstract
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism, is a leading cause of maternal morbidity and mortality worldwide. Physiological changes that occur in a normal pregnancy increase the risk for VTE by 4-5-fold in the antepartum period and 30-60-fold in the immediate postpartum period. Compressive ultrasonography is the diagnostic test of choice for deep vein thrombosis. Both ventilation/perfusion scanning and computed tomography pulmonary angiography can reliably diagnose pulmonary embolism. Anticoagulation for a minimum of 3 months, typically with low molecular weight heparin, is the treatment of choice for pregnancy-associated VTE (PA-VTE). Despite the significant societal burden and potentially devastating consequences, there is a paucity of data surrounding the prevention of PA-VTE, resulting in major variations between international guidelines. This review will summarize the current recommendations for diagnosis, management, and prevention of PA-VTE.
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Affiliation(s)
- Katherine Kilkenny
- From the Department of Medicine, New York Presbyterian-Weill Cornell Medicine, New York, NY
- Department of Medicine, New York Medical College, School of Medicine, Valhalla, NY
| | - William Frishman
- Department of Medicine, New York Medical College, School of Medicine, Valhalla, NY
- Department of Medicine, Westchester Medical Center, Valhalla, NY
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Girma S, Abdureshid N, Ayele K, Dagne I, Mekonnen BA, Abate S, Hamza A, Solomon M, Oumer A. Burden and determinants of anemia among lactating women in Ethiopia: evidence from demographic health survey. Sci Rep 2024; 14:14816. [PMID: 38937545 PMCID: PMC11211342 DOI: 10.1038/s41598-024-65583-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 06/21/2024] [Indexed: 06/29/2024] Open
Abstract
Globally one-third of global population are victims of anemia, significantly impacting maternal and infant health and linked to poor cognition, productivity, and mortality risks. We used randomly selected 4040 lactating mothers' record from nationally representative survey. Descriptive statistics were weighted, and the standard hemoglobin cutoff point (below 12 g/dl) was used. Bivariable and multivariable multilevel binary logistic regression model considering the individual and community-level factors associated with anemia was employed. Crude and adjusted odds ratios with a 95% confidence interval were reported. In Ethiopia, 32.3% (95% CI 30.9-33.7%) of lactating women were anemic, with 23.4% having mild, 7.3% moderate, and 1.2% severe anemia. Pastoral regions (Afar, Somalia, and Oromia region) had higher burden of anemia than the others. The advanced age of the mother above 45 years (AOR = 1.43 (1.11-1.82), unemployment (AOR = 1.19; 95% CI 1.08-1.32), household wealth index (AOR = 0.56; 95% CI 0.50-0.63), extended family size (AOR = 1.20; 95% CI 1.04-1.46), and not using family planning (AOR = 1.70; 95% CI 1.49-1.93) were significant factors associated with anemia. Anemia is a moderate public health problem and associated with location and other factors to be addressed via effective interventions.
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Affiliation(s)
- Selamawit Girma
- Department of Public Health, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Neil Abdureshid
- Department of Midwifery, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Ketema Ayele
- Department of Public Health, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Imam Dagne
- Department of Public Health, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Berhanu Abebaw Mekonnen
- Department of Nutrition and Dietetics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
| | - Shambel Abate
- Department of Public Health, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Aragaw Hamza
- Department of Anesthesia, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Milkias Solomon
- Department of Public Health, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia
| | - Abdu Oumer
- Department of Public Health, College of Medicine and Health Sciences, Dire Dawa University, Dire Dawa, Ethiopia.
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Davila J, O'Brien SH, Mitchell WB, Manwani D. Evaluating thromboprophylaxis in the sickle cell disease population: Navigating the evidence gap. Br J Haematol 2024; 204:2184-2193. [PMID: 38578212 DOI: 10.1111/bjh.19428] [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: 10/02/2023] [Revised: 02/08/2024] [Accepted: 03/14/2024] [Indexed: 04/06/2024]
Abstract
Sickle cell disease (SCD) arises from beta-globin gene mutations, with global estimates indicating around 500 000 affected neonates in 2021. In the United States, it is considered rare, impacting fewer than 200 000 individuals. The key pathogenic flaw lies in mutant haemoglobin S, prone to polymerization under low oxygen conditions, causing erythrocytes to adopt a sickled shape. This leads to complications like vascular occlusion, haemolytic anaemia, inflammation and organ damage. Beyond erythrocyte abnormalities however, there is a body of literature highlighting the hypercoagulable state that is likely a contributor to many of the complications we see in SCD. The persistent activation of the coagulation cascade results in thromboembolic events, notably venous thromboembolism (VTE) which is independently associated with increased mortality in both adults and children with SCD. While the increased risk of VTE in the SCD population seems well established, there is a lack of guidelines for thromboprophylaxis in this population. This Wider Perspective will describe the hypercoagulable state and increased thrombosis risk in the SCD population, as well as advocate for the development of evidence-based guidelines to aid in the prevention of VTE in SCD.
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Affiliation(s)
- Jennifer Davila
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio, USA
| | - William B Mitchell
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York, USA
| | - Deepa Manwani
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Albert Einstein College of Medicine, Children's Hospital at Montefiore, Bronx, New York, USA
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Hu M, Blanchard CT, Seasely AR, Lu M, Szychowski JM, Casey B, Tita AT, Saade G, Subramaniam A. Postpartum Outcomes in Patients Receiving Venous Thromboembolism Prophylaxis during Antepartum Admission. Am J Perinatol 2024. [PMID: 38608670 DOI: 10.1055/s-0044-1785672] [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: 04/14/2024]
Abstract
OBJECTIVE We evaluated if venous thromboembolism (VTE) prophylaxis in the inpatient antepartum period was associated with wound hematomas, VTE occurrence, and other adverse outcomes. STUDY DESIGN This study is a secondary analysis of a retrospective cohort of patients who delivered at University of Alabama at Birmingham (UAB). Patients receiving outpatient anticoagulation (AC) were excluded. We grouped patients into those who received inpatient antepartum prophylactic AC and those who did not. The primary outcome was wound hematomas from delivery to 6 weeks postpartum (PP). Secondary outcomes included VTE occurrence and select adverse outcomes, including other wound complications, unplanned procedures, mode of anesthesia, and intensive care unit (ICU) admission. Analyses were performed with no AC group as the reference. A sensitivity analysis excluding those who received inpatient PP AC was performed. RESULTS Of 1,035 included patients, only 169 patients received inpatient prophylactic AC. They were older, had higher body mass indices, and more comorbidities. Patients receiving inpatient antepartum AC had higher wound hematomas (adjusted odds ratio [aOR] 23.81; 95% confidence interval [CI] 7.04-80.47). They had similar risk for developing VTE as the control group (aOR 2.68; 95% CI 0.19-37.49) but were more likely to have wound complications (aOR 2.36; 95% CI 1.24-4.47), maternal deaths (p < 0.05), and require PP ICU admission (aOR 13.38; 95% CI 4.79-37.35). When excluding those receiving any PP AC, there was no difference in bleeding complications between the two groups and VTE rates remained unchanged. Rates of maternal deaths and PP ICU admissions remained higher in those who received inpatient antepartum AC prophylaxis. CONCLUSION In this small cohort study, increased wound hematomas were found in those who received inpatient antepartum AC prophylaxis with no difference in VTE occurrence. While adverse events were increased in the inpatient AC group, this was mostly associated with PP AC prophylaxis. Larger studies should be conducted to describe the true benefits and risks of antepartum AC prophylaxis and determine efficacy of this widely used practice. KEY POINTS · Peripartum chemoprophylaxis is associated with increased wound hematomas.. · VTE is rare, despite its association with significant peripartum morbidity/mortality.. · Large studies are needed to guide practices that optimize the risk/benefit ratio of chemoprophylaxis..
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Affiliation(s)
- Muhan Hu
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christina T Blanchard
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Angela R Seasely
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle Lu
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeff M Szychowski
- Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brian Casey
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alan T Tita
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - George Saade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Akila Subramaniam
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
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Brenner A, Shakur-Still H, Chaudhri R, Muganyizi P, Olayemi O, Arribas M, Kayani A, Javid K, Bello A, Roberts I. Tranexamic acid by the intramuscular or intravenous route for the prevention of postpartum haemorrhage in women at increased risk: a randomised placebo-controlled trial (I'M WOMAN). Trials 2023; 24:782. [PMID: 38044460 PMCID: PMC10694937 DOI: 10.1186/s13063-023-07687-1] [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: 08/14/2023] [Accepted: 09/28/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Postpartum haemorrhage (PPH) causes about 70,000 maternal deaths every year. Tranexamic acid (TXA) is a life-saving treatment for women with PPH. Intravenous (IV) TXA reduces deaths due to PPH by one-third when given within 3 h of childbirth. Because TXA is more effective when given early and PPH usually occurs soon after childbirth, giving TXA just before childbirth might prevent PPH. Although several randomised trials have examined TXA for PPH prevention, the results are inconclusive. Because PPH only affects a small proportion of births, we need good evidence on the balance of benefits and harms before using TXA to prevent PPH. TXA is usually given by slow IV injection. However, recent research shows that TXA is well tolerated and rapidly absorbed after intramuscular (IM) injection, achieving therapeutic blood levels within minutes of injection. METHODS The I'M WOMAN trial is an international, multicentre, three-arm, randomised, double-blind, placebo-controlled trial to assess the effects of IM and IV TXA for the prevention of PPH in women with one or more risk factors for PPH giving birth vaginally or by caesarean section. DISCUSSION The trial will provide evidence of the benefits and harms of TXA for PPH prevention and the effects of the IM and IV routes of administration. The IM route should be as effective as the IV route for preventing bleeding. There may be fewer side effects with IM TXA because peak blood concentrations are lower than with the IV route. IM TXA also has practical advantages as it is quicker and simpler to administer. By avoiding the need for IV line insertion and a slow IV injection, IM administration would free up overstretched midwives and doctors to focus on looking after the mother and baby and expand access to timely TXA treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT05562609. Registered on 3 October 2022. ISRCTN Registry ISRCTN12590098. Registered on 20 January 2023. Pan African Clinical Trial Registry PACTR202305473136570. Registered on 18 May 2023.
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Affiliation(s)
- Amy Brenner
- London School of Hygiene & Tropical Medicine, London, United Kingdom.
| | | | | | | | | | - Monica Arribas
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Aasia Kayani
- Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | - Kiran Javid
- Shifa Tameer-E-Millat University, Islamabad, Pakistan
| | | | - Ian Roberts
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Cate JJM, Sundermann AC, Campbell AIK, Sugrue R, Dotters-Katz SK, James AH, Myers ER, Federspiel JJ. High rates of venous thromboembolism among deliveries complicated by cancer. J Thromb Haemost 2023; 21:2854-2862. [PMID: 37353083 PMCID: PMC10560586 DOI: 10.1016/j.jtha.2023.06.015] [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: 02/16/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) risk is increased independently by both cancer and pregnancy. OBJECTIVES To estimate VTE risk in the postpartum period among patients delivering with a cancer diagnosis, stratified by cancer type and delivery route. METHODS We performed a retrospective cohort study utilizing the large, all-payer Nationwide Readmissions Database from October 2015 through December 2020. We identified delivery hospitalizations, cancer diagnoses, and VTE using patient demographics and diagnosis codes. The primary outcome was VTE incidence at 42 and 330 days from delivery admission date, comparing patients with and without cancer diagnoses. A secondary analysis included VTE risk stratified by cancer diagnosis and delivery route. Outcomes were compared using inverse probability-weighted survival curves. RESULTS The study population included 9 793 503 delivery hospitalizations (weighted estimate, 18 207 346), with a weighted estimate of 10 428 (0.06%) pregnant patients with cancer. Individuals with cancer were older, with higher rates of comorbid conditions, than those without cancer. VTE incidence in individuals with cancer at 42 and 330 days was 1.11% and 2.19%, respectively, vs 0.11% and 0.14%, respectively, in those without cancer. At 330 days, this finding was significant in both unadjusted (relative risk, 15.52; 95% CI, 11.54-19.51) and adjusted (relative risk, 9.68; 95% CI, 7.18-12.18) models. Stratification by cancer type and delivery route demonstrated elevated VTE risk across cancer types, with cesarean delivery conferring a greater risk. CONCLUSION Cancer in pregnancy confers excess thromboembolic risk extending beyond the immediate postpartum period. Further study is needed to identify optimal VTE prophylactic strategies for this population.
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Affiliation(s)
- Jennifer J M Cate
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA. https://twitter.com/healthyhappydoc
| | - Alexandra C Sundermann
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Ronan Sugrue
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah K Dotters-Katz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Evan R Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jerome J Federspiel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, 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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Chen X, Peng W, Zhang Y, Zhou H, Zhang M. Development and validation of a facile rapid assessment scale for perinatal venous thromboembolism in puerperium in Chinese women. BMC Pregnancy Childbirth 2023; 23:607. [PMID: 37620792 PMCID: PMC10464158 DOI: 10.1186/s12884-023-05901-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 08/06/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND It is still urgent and challenge to develop a simple risk assessment scale for venous thromboembolism (VTE) in puerperium in Chinese women. METHODS The study, a retrospective case-control study, was conducted in 12 hospitals in different cities in China. A total of 1152 pregnant women were selected, including 384 cases with VTE and 768 cases without VTE. A logistic regression method was conducted to determine the risk factors of VTE. RESULTS Age, BMI before delivery, gestational diabetes mellitus, family history (thrombosis, diabetes, cardiovascular disease), and assisted reproductive technology were independent risk factors (P<0.05). The difference between the high-risk group and the low-risk group was statistically significant(P<0.001) with a sensitivity of 0.578, specificity of 0.756, Yuden index o.334, and area under the ROC curve of 0.878. CONCLUSIONS The age (≥ 35 years), BMI before delivery (≥ 30 kg/m2), gestational diabetes mellitus, family history of related diseases and assisted reproductive technology are more likely to cause VTE after full-time delivery. The simple and rapid assessment scale of VTE in women after full-term delivery has perfect discrimination (P < 0.001), which can be applied to predict the risk of VTE in Chinese full-term postpartum women.
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Affiliation(s)
- Xiujuan Chen
- Nursing Department, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Wei Peng
- Department of Obstetrics, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yan Zhang
- Department of Obstetrics, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Huansheng Zhou
- Department of Obstetrics, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meng Zhang
- Department of Obstetrics, the Affiliated Hospital of Qingdao University, Qingdao, China.
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Neumann I, Izcovich A, Aguilar R, Basantes GL, Casais P, Colorio CC, Guillermo Esposito MC, García Lázaro PP, Pereira J, Meillon García LA, Rezende SM, Serrano JC, Tejerina Valle ML, Altuna D, Zúñiga P, Vera F, Karzulovic L, Schünemann HJ. American Society of Hematology, ABHH, ACHO, Grupo CAHT, Grupo CLAHT, SAH, SBHH, SHU, SOCHIHEM, SOMETH, Sociedad Panamena de Hematología, Sociedad Peruana de Hematología, and SVH 2023 guidelines for diagnosis of venous thromboembolism and for its management in special populations in Latin America. Blood Adv 2023; 7:3005-3021. [PMID: 36929813 PMCID: PMC10320207 DOI: 10.1182/bloodadvances.2021006534] [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: 02/03/2023] [Revised: 02/28/2023] [Accepted: 02/28/2023] [Indexed: 03/18/2023] Open
Abstract
Implementation of international guidelines in Latin American settings requires additional considerations (ie, values and preferences, resources, accessibility, feasibility, and impact on health equity). The purpose of this guideline is to provide evidence-based recommendations about the diagnosis of venous thromboembolism (VTE) and its management in children and during pregnancy. We used the GRADE ADOLOPMENT method to adapt recommendations from 3 American Society of Hematology (ASH) VTE guidelines (diagnosis of VTE, VTE in pregnancy, and VTE in the pediatric population). ASH and 12 local hematology societies formed a guideline panel comprising medical professionals from 10 countries in Latin America. Panelists prioritized 10 questions about the diagnosis of VTE and 18 questions about its management in special populations that were relevant for the Latin American context. A knowledge synthesis team updated evidence reviews of health effects conducted for the original ASH guidelines and summarized information about factors specific to the Latin American context. In comparison with the original guideline, there were significant changes in 2 of 10 diagnostic recommendations (changes in the diagnostic algorithms) and in 9 of 18 management recommendations (4 changed direction and 5 changed strength). This guideline ADOLOPMENT project highlighted the importance of contextualizing recommendations in other settings based on differences in values, resources, feasibility, and health equity impact.
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Affiliation(s)
- Ignacio Neumann
- School of Medicine, Universidad San Sebastian, Santiago, Chile
| | | | - Ricardo Aguilar
- Servicio de Hematología, Complejo Hospitalario Dr. Arnulfo Arias Madrid, Panama City, Panama
| | | | - Patricia Casais
- Epidemiología Clínica y Evidencia, Instituto de Investigaciones en Salud Pública, Universidad de Buenos Aires, Buenos Aires, Argentina
- Centro de Hematología Pavlovsky, Buenos Aires, Argentina
| | | | | | - Pedro P. García Lázaro
- Faculty of Medicine, Universidad Privada Antenor Orrego, Trujillo, Peru
- Hospital Especializado Víctor Lazarte Echegaray, Trujillo, Peru
| | - Jaime Pereira
- Department of Hematology and Oncology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Suely Meireles Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Diana Altuna
- Pediatric Oncology and Hematology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Pamela Zúñiga
- Department of Hematology and Oncology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Felipe Vera
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Lorena Karzulovic
- Department of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Holger J. Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Rath WH, Stelzl P. Strategies for the prevention of maternal death from venous thromboembolism clinical recommendations based on current literature. J Perinat Med 2023; 51:213-218. [PMID: 35585683 DOI: 10.1515/jpm-2022-0069] [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: 02/07/2022] [Accepted: 04/14/2022] [Indexed: 11/15/2022]
Abstract
Venous thromboembolism (VTE) is one of the leading causes of direct maternal deaths. It has been estimated that approximately 50% of these deaths are potentially preventable. The UK Confidential Enquiries into Maternal Deaths and the National Partnership for Maternal Safety have proposed strategies for the prevention of maternal deaths from VTE based on current guideline recommendations. The main strategies include: - Early recognition and comprehensive assessment of risk factors for VTE at different times from the beginning of pregnancy until patient's discharge from hospital. - Appropriate risk stratification using standardized VTE risk assessment tools (e.g. the Royal College Scoring System). - Risk-based antenatal and postnatal heparin thromboprophylaxis adjusting the heparin dosage and the duration of prophylaxis to the individual patient's risk. - Adequate management of heparin prophylaxis before and after delivery. - Preference of universal rather than selective post-cesarean heparin thromboprophylaxis and application of perioperative mechanical prophylaxis. - Avoidance of gaps in the postpartum prescription of heparin. - Good communication and cooperation between primary and secondary care including community midwifery staff in the postpartum period. - Immediate intravenous administration of (unfractionated) heparin, if pulmonary embolism is suspected. - Critical analysis of all thromboembolic events, particularly in association with maternal death to learn from failures and to realize, if and where improvement is needed. Adequate pharmacological thromboprophylaxis has the potential to reduce the risk of VTE by 60-70% in pregnant women at increased risk.
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Affiliation(s)
- Werner H Rath
- Department of Obstetrics and Gynecology, University of Kiel, Kiel, Germany
| | - Patrick Stelzl
- Department for Gynecology, Obstetrics and Gynecological Endocrinology, Kepler University Hospital Linz, Johannes Kepler University Linz, Linz, Austria
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Walker RF, Zakai NA, Mason SM, MacLehose RF, Norby FL, Evensen LH, Alonso A, Lutsey PL. Autoimmune disease and risk of postpartum venous thromboembolism. Res Pract Thromb Haemost 2023; 7:100091. [PMID: 36970127 PMCID: PMC10031534 DOI: 10.1016/j.rpth.2023.100091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/20/2022] [Accepted: 01/25/2023] [Indexed: 02/25/2023] Open
Abstract
Background The risk of pregnancy-related mortality in the United States has nearly doubled since 1990, with venous thromboembolism (VTE) accounting for approximately 10% of these deaths. Objectives The objective of this study was to assess whether preexisting autoimmune disease is a risk factor for postpartum VTE. Methods Using the MarketScan Commercial and Medicare Supplemental administrative databases, a retrospective cohort study analyzed whether postpartum persons with autoimmune disease had a higher risk of postpartum VTE incidence than postpartum persons without autoimmune disease. Using International Classification of Diseases codes, we identified 757,303 individuals of childbearing age who had a valid delivery date with at least 12 weeks of follow-up. Results Individuals were, on average, 30.7 years old (SD, 5.4), and 3.7% (N = 27,997 of 757,303) of them had evidence of preexisting autoimmune disease. In covariate-adjusted models, postpartum persons with preexisting autoimmune disease had higher rates of postpartum VTE than postpartum persons without autoimmune disease (hazard ratio [HR], 1.33; 95% CI, 1.07-1.64). When analyzed by individual autoimmune disease, those with systemic lupus erythematosus (HR, 2.49; 95% CI, 1.47-4.21) and Crohn's disease (HR, 2.49; 95% CI, 1.34-4.64) were at an elevated risk of postpartum VTE compared with those without autoimmune disease. Conclusion Autoimmune disease was associated with a higher rate of postpartum VTE, with evidence that the association was most pronounced among individuals with systemic lupus erythematosus and Crohn's disease. These findings suggest that postpartum persons of childbearing age with autoimmune disease may require more monitoring and prophylactic care after delivery to prevent potentially fatal VTE events.
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Affiliation(s)
- Rob F. Walker
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Neil A. Zakai
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
- Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Susan M. Mason
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Richard F. MacLehose
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
| | - Faye L. Norby
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Health System, Los Angeles, California, USA
| | - Line H. Evensen
- K.G. Jebsen - Thrombosis Research and Expertise Center, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Pamela L. Lutsey
- School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota, USA
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Bambo GM, Kebede SS, Sitotaw C, Shiferaw E, Melku M. Postpartum anemia and its determinant factors among postnatal women in two selected health institutes in Gondar, Northwest Ethiopia: A facility-based, cross-sectional study. Front Med (Lausanne) 2023; 10:1105307. [PMID: 37153091 PMCID: PMC10157165 DOI: 10.3389/fmed.2023.1105307] [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: 11/22/2022] [Accepted: 03/15/2023] [Indexed: 05/09/2023] Open
Abstract
Background Anemia is highly prevalent globally and disproportionately affects postnatal women. It is a significant cause of maternal mortality and morbidity globally. Objective The main aim of this study was to determine the extent of postpartum anemia and associated factors among postnatal women in two selected health facilities in Gondar, Northwest Ethiopia. Methods A facility-based, cross-sectional study was conducted among 282 postnatal women from March to May 2021. A systematic sampling technique was used to recruit study participants from each institute. Sociodemographic, obstetric, and clinical data were collected through a semi-structured questionnaire. A venous blood sample was collected to determine the red blood cell parameters. A thin blood smear preparation was performed to examine blood morphology. In addition, direct wet mount and formalin-ether sedimentation techniques were used for stool examination to identify intestinal parasites. Data were entered into EpiData and exported to Stata 14 for statistical analysis. Descriptive statistics were presented in text, tables, and figures. A binary logistic regression model was used to identify factors associated with postpartum anemia. A p-value <0.05 was considered statistically significant. Results The proportion of postpartum anemia was 47.16%; 95% CI; 41.30-53.03 with moderate, mild, and severe anemia accounting for 45.11, 42.86, and 12.03%, respectively. The majority of the anemia (94%) was of the normocytic normochromic type. It was associated with postpartum hemorrhage (AOR = 2.23; 95% CI: 1.24-4.01), cesarean section (AOR = 4.10; 95% CI: 2.11-7.78), lack of iron and folate supplementation during pregnancy (AOR = 2.12; 95% CI: 1.17-4.02), and low diet diversity level (AOR = 1.83; 95% CI: 1.05-3.18). Conclusion The prevalence of anemia was found to be a major public health concern. Iron and folate supplementation during pregnancy, improved management of PPH, an effective cesarean section with post-operative care, and taking a diversified diet will reduce the burden. Therefore, identified factors should be considered to prevent and control postpartum anemia.
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Affiliation(s)
- Getachew Mesfin Bambo
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, University of Gondar, Gondar, Ethiopia
- Department of Medical Laboratory Science, College of Health Sciences, Mizan-Tepi University, Mizan, Ethiopia
- *Correspondence: Getachew Mesfin Bambo,;
| | - Samuel Sahile Kebede
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, University of Gondar, Gondar, Ethiopia
- Department of Medical Laboratory Science, College of Health Sciences, Mizan-Tepi University, Mizan, Ethiopia
| | - Chomaw Sitotaw
- University of Gondar Comprehensive Specialized Hospital Laboratory, Gondar, Ethiopia
| | - Elias Shiferaw
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, University of Gondar, Gondar, Ethiopia
| | - Mulugeta Melku
- Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, University of Gondar, Gondar, Ethiopia
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Schapkaitz E, Libhaber E, Gerber A, Rhemtula H, Zamparini J, Jacobson BF, Büller HR. A Longitudinal Study of Thrombosis and Bleeding Outcomes With Thromboprophylaxis in Pregnant Women at Intermediate and High Risk of VTE. Clin Appl Thromb Hemost 2023; 29:10760296231160748. [PMID: 36972476 PMCID: PMC10052495 DOI: 10.1177/10760296231160748] [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: 03/29/2023] Open
Abstract
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.
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Affiliation(s)
- E Schapkaitz
- Department of Molecular Medicine and Hematology, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - E Libhaber
- Department of Research Methodology and Statistics, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - A Gerber
- Department of Obstetrics, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - H Rhemtula
- Department of Obstetrics, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - J Zamparini
- Department of Internal Medicine, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - B F Jacobson
- Department of Molecular Medicine and Hematology, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - H R Büller
- Department of Vascular Medicine, 1234University of Amsterdam, Amsterdam, the Netherlands
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13
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Page MR, Cozzi GD, Blanchard CT, Lu MY, Ausbeck EB, Casey BM, Tita AT, Kim DJ, Szychowski JM, Subramaniam A. Venous thromboembolism and adverse outcomes in highest thromboembolism risk patients compared with those at lower risk. Am J Obstet Gynecol MFM 2022; 4:100720. [PMID: 35977704 DOI: 10.1016/j.ajogmf.2022.100720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND A risk-based institutional protocol for inpatient heparin-based venous thromboembolism prophylaxis in a general obstetrical population previously demonstrated a greater than 2-fold increase in wound hematomas with no change in the frequency of thromboembolism. OBJECTIVE We sought to compare the rates of thromboembolism and bleeding outcomes in patients at the highest risk for thromboembolism (eg, those with a history of thromboembolism or thrombophilia who require anticoagulation prophylaxis or therapy throughout pregnancy) than low-risk patients. STUDY DESIGN We performed a retrospective cohort study of all deliveries >20 weeks at a single center from 2013-2018. Patients were categorized as high-risk (received outpatient heparin-based prophylaxis or treatment) or low-risk (no outpatient anticoagulation). The primary outcome was newly diagnosed postpartum thromboembolism; the main secondary outcome was wound/perineal hematoma. The outcomes were compared between the high- and low-risk cohorts. Adjusted odds ratios (with 95% confidence intervals) were calculated with the low-risk group as reference. RESULTS Of 24,303 total deliveries, 395 (1.7%) were high-risk and 23,905 (98.3%) were low-risk. Among the low-risk patients, 8.6% received anticoagulation prophylaxis in accordance with our risk-based inpatient thromboembolism prophylaxis protocol. High-risk patients were more likely to be older and have a higher body mass index, earlier delivery gestational age, medical comorbidities, and pregnancy complications, eg, preeclampsia. Despite outpatient antepartum anticoagulation, high-risk patients had an 11-fold increased risk of thromboembolism (adjusted odds ratio, 11.1 [4.7-26.2]) than low-risk patients. High-risk patients also had significantly more wound/perineal hematomas (adjusted odds ratio, 4.8 [2.7-8.4]), overall wound complications (adjusted odds ratio, 3.0 [2.0-4.4]), blood transfusions, intensive care unit admissions, maternal deaths, and longer maternal lengths of stay. CONCLUSION Patients at the highest risk of obstetrical thromboembolism had an 11-fold increased risk of thromboembolism with a more moderate increase (∼5-fold) in postpartum wound and bleeding complications than low-risk patients. This more favorable risk or benefit profile supports current anticoagulation recommendations in high-risk patients.
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Affiliation(s)
- Margaret R Page
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam); Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam).
| | - Gabriella D Cozzi
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam); Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Christina T Blanchard
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam); Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Michelle Y Lu
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam); Wildflower Obstetrics and Gynecology, Austin, TX (Dr Lu)
| | | | - Brian M Casey
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam); Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Alan T Tita
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam); Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Dhong-Jin Kim
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam); Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
| | - Jeff M Szychowski
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam); Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam); Department of Biostatistics, The University of Alabama at Birmingham, Birmingham AL (Dr Szychowski)
| | - Akila Subramaniam
- Center for Women's Reproductive Health, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Lu, Casey, and Tita, Mr Kim, and Drs Szychowski and Subramaniam); Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Drs Page and Cozzi, Ms Blanchard, Drs Casey and Tita, Mr Kim, and Drs Szychowski and Subramaniam)
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14
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Jeong Y, Jung YJ, Noh E, Ha S, Hwang J, Cho GJ, Oh MJ, Kim YH. The risk for future cerebrovascular disease in pregnant women with Moyamoya disease: a nationwide population-based study in South Korea. BMC Pregnancy Childbirth 2022; 22:433. [PMID: 35610618 PMCID: PMC9128146 DOI: 10.1186/s12884-022-04718-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 04/22/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Physiologic changes during pregnancy affect the development of postpartum cerebrovascular disease (CVD) in women with Moyamoya disease. Due to the rare prevalence of Moyamoya disease and its large regional variations, large-scale based studies on the risk of CVD after delivery have not been conducted. This study aimed to evaluate whether women with Moyamoya disease have an increased risk of CVD after delivery. METHODS Research data was collected from the National Health Insurance Claims Database of the Health Insurance Review and Assessment Service. Patients who delivered in Korea from 2007 to 2014 were enrolled in this study. We classified women as having CVD if they were diagnosed with any of the following conditions between delivery and December 31, 2016; cerebral infarction (I63.X in the International Classification of Diseases-10th Revision [ICD-10]) and/or intracranial hemorrhage (I61.X, I62.X in ICD-10) and/or subarachnoid hemorrhage (I60.X in ICD-10). Women with Moyamoya disease were identified as having I67.5 in ICD-10. We matched the study cohort by the ratio of 1:10 to analyze the risk CVD occurrence. The matching technique applied in this study was based on the variables of age and parity. To evaluate the adjusted hazard ratio (HR) for CVD in women with Moyamoya disease, we used multivariate Cox proportional hazard regression. RESULTS Among a total of 3,611,216 Korean women who underwent delivered, we identified 412 women with Moyamoya disease diagnosis and 1420 age- and parity-matched women without Moyamoya disease (control). Compared to the control group, women with Moyamoya disease had a significantly higher rate of Cesarean section, overt DM, and essential hypertension (all p < 0.0001). Among women with Moyamoya disease, 55 (13.35%) women developed CVD within the follow-up postpartum period. The presence of Moyamoya disease was associated with an increased risk of CVD after delivery (adjusted HR 37.42; 95% confidence interval (CI) 17.50-80.02 within 2.3 years) after adjusting for pregnancy-induced hypertension, gestational diabetes mellitus, pregestational diabetes, chronic hypertension. CONCLUSION This population based study showed that the occurrence rate of CVD after delivery was higher in women with Moyamoya disease than in those without. Therefore, careful and long-term postpartum surveillance is required for women with Moyamoya disease.
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Affiliation(s)
- Yeonseong Jeong
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Yun Ji Jung
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Eunjin Noh
- Korea University Guro Hospital Smart Healthcare Center, Seoul, Republic of Korea
| | - Sungyeon Ha
- Graduate School of Statistics, Sungkyunkwan University, Seoul, Republic of Korea
| | - Jeongeun Hwang
- Department of Biomedical Research Center, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Geum Joon Cho
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Min-Jeong Oh
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young-Han Kim
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea.
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15
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Dol J, Hughes B, Bonet M, Dorey R, Dorling J, Grant A, Langlois EV, Monaghan J, Ollivier R, Parker R, Roos N, Scott H, Shin HD, Curran J. Timing of maternal mortality and severe morbidity during the postpartum period. JBI Evid Synth 2022; 20:2119-2194. [PMID: 35916004 PMCID: PMC9594153 DOI: 10.11124/jbies-20-00578] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: The objective of this review was to determine the timing of overall and cause-specific maternal mortality and severe morbidity during the postpartum period. Introduction: Many women continue to die or experience adverse health outcomes in the postpartum period; however, limited work has explored the timing of when women die or present complications during this period globally. Inclusion criteria: This review considered studies that reported on women after birth up to 6 weeks postpartum and included data on mortality and/or morbidity on the first day, days 2–7, and days 8–42. Studies that reported solely on high-risk women (eg, those with antenatal or intrapartum complications) were excluded, but mixed population samples were included (eg, low-risk and high-risk women). Methods: MEDLINE, Embase, Web of Science, and CINAHL were searched for published studies on December 20, 2019, and searches were updated on May 11, 2021. Critical appraisal was undertaken by 2 independent reviewers using standardized critical appraisal instruments from JBI. Quantitative data were extracted from included studies independently by at least 2 reviewers using a study-specific data extraction form. Quantitative data were pooled, where possible. Identified studies were used to obtain the summary estimate (proportion) for each time point. Maternal mortality was calculated as the maternal deaths during a given period over the total number of maternal deaths known during the postpartum period. For cause-specific analysis, number of deaths due to a specific cause was the numerator, while the total number of women who died due to the same cause in that period was the denominator. Random effects models were run to pool incidence proportion for relative risk of overall maternal deaths. Subgroup analysis was conducted according to country income classification and by date (ie, data collection before or after 2010). Where statistical pooling was not possible, the findings were reported narratively. Results: A total of 32 studies reported on maternal outcomes from 17 reports, all reporting on mixed populations. Most maternal deaths occurred on the first day (48.9%), with 24.5% of deaths occurring between days 2 and 7, and 24.9% occurring between days 8 and 42. Maternal mortality due to postpartum hemorrhage and embolism occurred predominantly on the first day (79.1% and 58.2%, respectively). Most deaths due to postpartum eclampsia and hypertensive disorders occurred within the first week (44.3% on day 1 and 37.1% on days 2–7). Most deaths due to infection occurred between days 8 and 42 (61.3%). Due to heterogeneity, maternal morbidity data are described narratively, with morbidity predominantly occurring within the first 2 weeks. The mean critical appraisal score across all included studies was 85.9% (standard deviation = 13.6%). Conclusion: Women experience mortality throughout the entire postpartum period, with the highest mortality rate on the first day. Access to high-quality care during the postpartum period, including enhanced frequency and quality of postpartum assessments during the first 42 days after birth, is essential to improving maternal outcomes and to continue reducing maternal mortality and morbidity worldwide. Systematic review registration number: PROSPERO CRD42020187341
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Affiliation(s)
- Justine Dol
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
- Aligning Health Needs and Evidence for Transformative Change (AH_NET-C): A JBI Centre of Excellence, Dalhousie University, Halifax, NS, Canada
| | - Brianna Hughes
- Aligning Health Needs and Evidence for Transformative Change (AH_NET-C): A JBI Centre of Excellence, Dalhousie University, Halifax, NS, Canada
- School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Mercedes Bonet
- UNDP/UNFPA/ UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Rachel Dorey
- School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Jon Dorling
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Faculty of Medicine, Dalhousie University and IWK Health Centre, Halifax, NS, Canada
| | - Amy Grant
- Maritime SPOR Support Unit, Halifax, NS, Canada
| | - Etienne V. Langlois
- Partnership for Maternal, Newborn and Child Health, World Health Organization, Geneva, Switzerland
| | - Joelle Monaghan
- Centre for Research in Family Health, IWK Health Centre, Halifax, NS, Canada
| | - Rachel Ollivier
- School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Robin Parker
- W.K. Kellogg Health Sciences Library, Dalhousie Libraries, Dalhousie University, Halifax, NS, Canada
| | - Nathalie Roos
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Heather Scott
- Department of Obstetrics and Gynecology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Hwayeon Danielle Shin
- Aligning Health Needs and Evidence for Transformative Change (AH_NET-C): A JBI Centre of Excellence, Dalhousie University, Halifax, NS, Canada
- School of Nursing, Dalhousie University, Halifax, NS, Canada
| | - Janet Curran
- Aligning Health Needs and Evidence for Transformative Change (AH_NET-C): A JBI Centre of Excellence, Dalhousie University, Halifax, NS, Canada
- School of Nursing, Dalhousie University, Halifax, NS, Canada
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Abstract
PURPOSE OF REVIEW Risk factors for obstetric venous thromboembolism (VTE), a leading cause of maternal mortality in the United States, are increasing on a population basis. This review provides the obstetrician with an update of current issues related to obstetric VTE risk, prophylaxis, outcomes, anaesthesia considerations and future research opportunities. RECENT FINDINGS Obstetric VTE affects approximately 1 per 1000 pregnancies and accounts consistently for 9-10% of maternal deaths in the United States. In industrialized countries, risk factors for VTE, including overweight/obesity, caesarean delivery and obstetrical complications such postpartum haemorrhage and infection continue to increase. VTE prophylaxis is central to reducing maternal mortality. However, recommendations for prophylaxis from leadership societies vary widely. In the UK, maternal mortality risk from VTE has decreased significantly in the setting of broader heparin prophylaxis. In the United States where mechanical VTE prophylaxis is used more commonly, mortality risk has remained constant. SUMMARY Obstetric VTE is a leading cause of maternal mortality in the United States. The incidence of risk factors for obstetric VTE continues to increase. Currently, recommendations for obstetric VTE prophylaxis vary substantially. Opportunities for research in this area exist to optimize prophylaxis and improve maternal outcomes.
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Affiliation(s)
- Alexander M Friedman
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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17
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Friedman AM, D'Alton ME. Expert review: prevention of obstetrical venous thromboembolism. Am J Obstet Gynecol 2021; 225:228-236. [PMID: 33974905 DOI: 10.1016/j.ajog.2021.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 12/24/2022]
Abstract
Venous thromboembolism represents a persistent proportionate cause of maternal mortality in the United States accounting for 9% to 10% of maternal deaths. Given that overall maternal mortality rose >40% since the late 1990s, it is likely that absolute venous thromboembolism mortality risk increased as well. This persistent risk may be secondary to increases in broad population-based risk factors for venous thromboembolism such as obesity and cesarean delivery. Widespread adoption of perioperative cesarean mechanical thromboprophylaxis is associated with reduced risk for venous thromboembolism events but has not been sufficient to reduce mortality. Experts agree that improved clinical care is required to reduce risk as it is unlikely that trends in venous thromboembolism risk factors will reverse course anytime soon. Experts further agree that improving prophylaxis and prevention may provide the largest benefit. However, how to best improve prophylaxis is highly controversial with both experts and guidelines in disagreement. In the United Kingdom, mortality risk decreased substantially following the 2004 recommendations for broader heparin prophylaxis without evidence of increased mortality risk from hemorrhage. A key clinical question in the United States is whether heparin prophylaxis should be expanded to patients hospitalized for cesarean delivery or an antepartum indication. Some experts, including us, support expanded heparin prophylaxis. Evidence supporting heparin prophylaxis includes (1) demonstration of safety and efficacy in the United Kingdom, (2) that mechanical prophylaxis-the primary alternative to heparin-has major limitations outside the immediate perioperative setting, and (3) that hospitalized cesarean and antepartum patients are at high relative risk of events. Experts against broader heparin prophylaxis cite concerns related to safety, efficacy, and cost. This expert review focused on whether heparin prophylaxis should be routinely used during antepartum hospitalizations and after cesarean delivery. First, we review the differences in major society guidelines. Second, we review arguments for and against broader heparin prophylaxis. Third, we discuss what future research may be most likely to further inform best practices. Fourth, we review practical clinical considerations with heparin prophylaxis, including access to neuraxial anesthesia. Given the best available data, we concluded that expanding heparin prophylaxis represents a modest intervention with the potential to meaningfully reduce venous thromboembolism mortality.
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Affiliation(s)
- Alexander M Friedman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY.
| | - Mary E D'Alton
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY
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Sano N, Motoie R, Yamashita T, Nakajima Y, Kitahara T, Torikoshi S, Hayase M, Nishimura M. A peripartum major cerebral infarction in a patient with moyamoya disease following previous bilateral STA-MCA anastomosis: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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19
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Grünewald M, Häge E, Lehnert S, Maier C, Schimke A, Bramlage P, Güth M. Prophylactic Anticoagulation With Intermediate-Dose Certoparin in Vascular-Risk Pregnancies-The PACER-VARP Registry. Clin Appl Thromb Hemost 2021; 27:10760296211016550. [PMID: 34027682 PMCID: PMC8150601 DOI: 10.1177/10760296211016550] [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] [Indexed: 12/03/2022] Open
Abstract
The management of pregnant women at increased risk of thromboembolic/other vascular events is still a matter of debate. In a single-center, retrospective, observational trial, we analyzed the safety and efficacy of prophylactic anticoagulation with certoparin in pregnant women at intermediate- or high-risk by EThIG criteria of thromboembolic/other vascular events. Subcutaneous certoparin 8,000 IU once daily was administered immediately after pregnancy confirmation and continued for 6 weeks postpartum. We investigated 74 pregnancies (49 women; mean age 31.8 years; weight 77.3 kg). Most prevalent risk factors were factor V Leiden mutation (40.5%), thrombogenic factor II mutation (12.2%) and protein S deficiency (8.1%). In 76 control pregnancies prior to registry inclusion/without anticoagulation there were 14 cases [18.4%] of venous thromboembolism (between week 7 gestation and week 8 postpartum); 63.2% pregnancies resulted in abortion (median week 8.6 gestation). With certoparin anticoagulation, thromboembolism was 1.4%, exclusively non-major bleeding was 4.1% and abortion was 10.8%. One case of pre-eclampsia necessitating obstetric intervention occurred. Prophylactic anticoagulation with intermediate-dose certoparin throughout pregnancies at increased venous vascular risk was safe and effective.
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Affiliation(s)
- Martin Grünewald
- Department of Medicine I, Klinikum Heidenheim, Heidenheim, Germany
| | - Esther Häge
- Department of Medicine I, Klinikum Heidenheim, Heidenheim, Germany
| | | | | | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Martina Güth
- Department of Medicine I, Klinikum Heidenheim, Heidenheim, Germany
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Schapkaitz E, Libhaber E, Rhemtula H, Gerber A, Jacobson BF, Chauke L, Büller HR. Pregnancy-related venous thromboembolism and HIV infection. Int J Gynaecol Obstet 2021; 155:110-118. [PMID: 33448037 DOI: 10.1002/ijgo.13596] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/15/2020] [Accepted: 01/11/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess risk factors for venous thromboembolism (VTE) in African women in order to guide thromboprophylaxis. METHODS A case-control study was performed at a specialist obstetric unit in South Africa from July 1, 2017 to June 30, 2020. We identified 128 cases with VTE and 640 controls, matched for gestation. RESULTS Prepartum risk factors associated with VTE included; medical comorbidities (odds ratios [OR] 5.32, 95% confidence intervals [CI] 1.82-15.56), human immunodeficiency virus (HIV) (OR 2.84, 95% CI 1.50-5.41), and hospital admission or immobility (OR 5.33, 95% CI 1.17-24.22). Postpartum, the following were identified as significant risk factors; medical comorbidities (OR 23.72, 95% CI 8.75-64.27), hospital admission or immobility (OR 13.18, 95% CI 5.04-34.49), systemic infection (OR 4.48, 95% CI 1.28-15.68), HIV (OR 3.20, 95% CI 1.49-6.87), pre-eclampsia and fetal growth restriction (OR 2.74, 95% CI 1.18-6.36), and postpartum hemorrhage (OR 4.38, 95% CI 1.75-10.97). Antiretroviral therapy, opportunistic infections, and viral load >50 copies/ml, however, were not associated with VTE risk among HIV-infected participants. CONCLUSION HIV was a significant risk factor for pregnancy-related thrombosis. This was independent of traditional HIV risk factors. As such, future studies are recommended to explore the mechanisms of thrombosis associated with HIV infection.
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Affiliation(s)
- Elise Schapkaitz
- Department of Molecular Medicine and Hematology, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Elena Libhaber
- HS Research Office and School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Haroun Rhemtula
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Annika Gerber
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Barry F Jacobson
- Department of Molecular Medicine and Hematology, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Lawrence Chauke
- Department of Obstetrics, Faculty of Health Sciences, University of Witwatersrand Medical School, Johannesburg, South Africa
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Park JE, Park Y, Yuk JS. Incidence of and risk factors for thromboembolism during pregnancy and postpartum: A 10-year nationwide population-based study. Taiwan J Obstet Gynecol 2021; 60:103-110. [PMID: 33494981 DOI: 10.1016/j.tjog.2020.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Knowledge of the incidence of pregnancy-related thromboembolism and its risk factors is clinically important because thromboembolism is the leading cause of maternal death. However, there are insufficient large population-based studies on this topic. The purpose of this study was to estimate the incidence of and identify the risk factors for thromboembolism during pregnancy and puerperium. MATERIALS AND METHODS We analyzed data from 2007 to 2016 using the Health Insurance Review and Assessment Service (HIRA) database. Women who gave birth in the Republic of Korea were identified. Thromboembolism was defined as the simultaneous presence of both the diagnostic and test codes. Risk factors for thromboembolism were identified using logistic regression. RESULTS A total of 1,188 delivery episodes with thromboembolism were extracted from 4,243,393 delivery episodes. The incidence of thromboembolism was 0.28 per 1,000 deliveries, and it increased over the 10-year period. The incidence of antepartum thromboembolism was 0.1 per 1,000 deliveries (418 cases), and the incidence of postpartum thromboembolism was 0.18 per 1,000 deliveries (770 cases). Thromboembolism was associated with ovarian hyperstimulation syndrome, low socioeconomic status, multiple birth, cesarean birth, preeclampsia, postpartum hemorrhage, placenta previa, advanced maternal age, hyperemesis and primiparity. The factors associated with mortality from thromboembolism were cesarean birth and preterm premature rupture of membranes. CONCLUSION The incidence of pregnancy-related thromboembolism increased over the 10-year study period. Low socioeconomic status, ovarian hyperstimulation syndrome, cesarean delivery and premature rupture of membranes were high-risk factors. This study provides an important reference for thromboprophylaxis for pregnancy-related thromboembolism.
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Affiliation(s)
- Ji Eun Park
- Department of Obstetrics and Gynecology, College of Medicine, Gyeongsang National University, Gyeongsang National University Changwon Hospital, Republic of Korea
| | - Yongwhi Park
- Division of Cardiology, Department of Internal Medicine, College of Medicine, Gyeongsang National University, Gyeongsang National University Changwon Hospital, Republic of Korea
| | - Jin-Sung Yuk
- Department of Obstetrics and Gynecology, College of Medicine, Inje University, Sanggye Paik Hospital, Republic of Korea.
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Khryshchanovich V, Skobeleva N. Medical prevention and management of varicose vein disease during pregnancy. ROSSIISKII VESTNIK AKUSHERA-GINEKOLOGA 2021. [DOI: 10.17116/rosakush20212104127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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23
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Menezes MO, Takemoto MLS, Nakamura‐Pereira M, Katz L, Amorim MMR, Salgado HO, Melo A, Diniz CSG, de Sousa LAR, Magalhaes CG, Knobel R, Andreucci CB. Risk factors for adverse outcomes among pregnant and postpartum women with acute respiratory distress syndrome due to COVID-19 in Brazil. Int J Gynaecol Obstet 2020; 151:415-423. [PMID: 33011966 PMCID: PMC9087686 DOI: 10.1002/ijgo.13407] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/04/2020] [Accepted: 09/29/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate whether clinical and social risk factors are associated with negative outcomes for COVID-19 disease among Brazilian pregnant and postpartum women. METHODS A secondary analysis was conducted of the official Acute Respiratory Syndrome Surveillance System database. Pregnant and postpartum women diagnosed with COVID-19 ARDS until July 14, 2020, were included. Adverse outcomes were a composite endpoint of either death, admission to the intensive care unit (ICU), or mechanical ventilation. Risk factors were examined by multiple logistic regression. RESULTS There were 2475 cases of COVID-19 ARDS. Among them, 23.8% of women had the composite endpoint and 8.2% died. Of those who died, 5.9% were not hospitalized, 39.7% were not admitted to the ICU, 42.6% did not receive mechanical ventilation, and 25.5% did not have access to respiratory support. Multivariate analysis showed that postpartum period, age over 35 years, obesity, diabetes, black ethnicity, living in a peri-urban area, no access to Family Health Strategy, or living more than 100 km from the notification hospital were associated with an increased risk of adverse outcomes. CONCLUSION Clinical and social risk factors and barriers to access health care are associated with adverse outcomes among maternal cases of COVID-19 ARDS in Brazil.
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Affiliation(s)
| | | | - Marcos Nakamura‐Pereira
- Instituto Nacional de Saúde da Mulherda Criança e do Adolescente Fernandes FigueiraFundação Oswaldo CruzRio de JaneiroRJBrazil
| | - Leila Katz
- Instituto de Medicina Integral Prof. Fernando Figueira (IMIP)RecifePEBrazil
| | | | - Heloisa O. Salgado
- Departamento de Medicina SocialFaculdade de Medicina de Ribeirão PretoUniversidade de São Paulo (USP)Ribeirão PretoSPBrazil
| | - Adriana Melo
- Universidade Federal de Campina Grande (UFCG)Campina GrandePBBrazil
| | - Carmen S. G. Diniz
- Department of HealthLife Cycles and SocietySchool of Public HealthUniversity of São Paulo (USP)São PauloSPBrazil
| | | | | | - Roxana Knobel
- Department of Gynecology and ObstetricsUniversidade Federal de Santa Catarina (UFSC)FlorianópolisSCBrazil
| | - Carla B. Andreucci
- Department of MedicineUniversidade Federal de São Carlos (UFSCAR)São CarlosSPBrazil
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The freeze-all strategy after IVF: which indications? Reprod Biomed Online 2020; 42:529-545. [PMID: 33384269 DOI: 10.1016/j.rbmo.2020.11.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/09/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022]
Abstract
The freeze-all strategy is gaining popularity worldwide as an alternative to the conventional fresh embryo transfer. It consists of cryopreservation of the entire embryo cohort and the embryo transfer in a subsequent cycle that takes place separately from ovarian stimulation. The freeze-all strategy was initially a 'rescue' strategy for women at high risk of ovarian hyperstimulation syndrome; however, this approach has been extended to other indications as a scheduled strategy to improve implantation rates. This assumes that ovarian stimulation can alter endometrial receptivity in fresh cycles owing to the effect of supraphysiological levels of steroids on endometrial maturation. The procedure, however, has not been associated with increased live birth rates in all infertile couples, and concerns have been raised about the occurrence of several adverse perinatal outcomes. It is, therefore, crucial to identify in which subgroups of patients a freeze-all strategy could be beneficial. The aim of this review is to summarize current scientific research in this field to highlight potential indications for this strategy and to guide clinicians in their daily practice.
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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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Hu W, Wang Y, Li J, Huang J, Pu Y, Jiang Y, Xu D, Ding Z, Zhao B, Luo Q. The Predictive Value of d-Dimer Test for Venous Thromboembolism During Puerperium: A Prospective Cohort Study. Clin Appl Thromb Hemost 2020; 26:1076029620901786. [PMID: 32090610 PMCID: PMC7288823 DOI: 10.1177/1076029620901786] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The aim of this study was to investigate the d-dimer for prediction of
venous thromboembolism (VTE) events in puerperium and to identify other risk
factors associated with the occurrence of VTE. This was a prospective
observational cohort study, which included 16 127 women who gave birth after 28
weeks of gestation at Women’s Hospital of Zhejiang University, School of
Medicine, from January 2016 to December 2016. Data including basic maternal and
fetal characteristics, pregnancy complications, and predictive biomarkers within
postpartum 24 hours including d-dimer, platelet, and fibrinogen were
collected for analyses. In the cohort study, 19 (0.12%) women were identified as
VTE, including 1 pulmonary embolism event and 18 deep venous thrombosis events.
The receiver operating characteristic curve analysis suggested the best cutoff
point for d-dimer level within postpartum 24 hours was 3.695 mg/L, with
a specificity of 75.5% and a sensitivity of 73.7%, and there was no statistical
correlation between fibrinogen and VTE, as well as between platelets and VTE. On
multivariate analysis, age ≥35 years (odds ratio [OR] = 2.895, 95% confidence
interval [CI]: 1.079-7.773), scarred uterus (OR = 3.894, 95% CI: 1.234-12.282),
intrauterine infection (OR = 7.214, 95% CI: 1.519-34.262), antiphospholipid
syndrome (OR = 199.530, 95% CI: 15.152-2627.529), d-dimer ≥3.70 mg/L
(OR = 7.573, 95% CI: 2.699-21.247), and emergency cesarean delivery (OR =
23.357, 95% CI: 2.819-193.508) were independently associated with VTE in
puerperium. We concluded that d-dimer ≥3.70 mg/L was an independent
predictor of VTE during puerperium and d-dimer testing was necessary
for perinatal women.
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Affiliation(s)
- Wen Hu
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Yali Wang
- Department of Obstetrics & Gynecology, Changxing Maternal and Child Health Hospital, Huzhou, Zhejiang, China
| | - Juan Li
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Jian Huang
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Yuqun Pu
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Jiang
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Dong Xu
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Zhiming Ding
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Baihui Zhao
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Qiong Luo
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
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Hu W, Xu D, Li J, Chen C, Chen Y, Xi F, Zhou F, Guo X, Zhao B, Luo Q. The predictive value of D-dimer test for venous thromboembolism during puerperium in women age 35 or older: a prospective cohort study. Thromb J 2020; 18:26. [PMID: 33088222 PMCID: PMC7566136 DOI: 10.1186/s12959-020-00241-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 10/12/2020] [Indexed: 12/04/2022] Open
Abstract
Background This study aimed to investigate the predictive value of the D-dimer level for venous thromboembolism (VTE) events during puerperium of women age at 35 years or older, as well as to identify other risk factors associated with the occurrence of VTE. Methods It was a prospective observational cohort study, from January 2014 to December 2018, which involved 12,451 women age 35 or older who delivered at least 28 weeks of gestation at Women’s Hospital of Zhejiang University, School of Medicine. The maternal and fetal demographic characteristics, pregnancy complications, imaging finding and results of laboratory test within postpartum 24 h including D-dimer level, platelet counts and fibrinogen level were collected for analyses. Results 30(2.4‰) women were identified as VTE, including 1 pulmonary embolism event and 29 deep venous thrombosis events. The receiver operating characteristic (ROC) curve analysis suggested the best cutoff point for D-dimer level within postpartum 24 h of women age 35 or older was 5.545 mg/L, with a specificity of 70.0% and a sensitivity of 75.4%. Besides, there was no statistical correlation between platelet counts and VTE, as well as between fibrinogen level and VTE. On multivariate analysis, D-dimer≥5.50 mg/L (OR = 5.874, 95%CI: 2.678–12.886) and emergency cesarean section (OR = 11.965, 95%CI: 2.732–52.401) were independently associated with VTE in puerperium of women age 35 or older. Conclusions We concluded that D-dimer≥5.50 mg/L was an independent predictor of VTE in puerperium with maternal age 35 or older and D-dimer testing was a necessary examination for perinatal women.
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Affiliation(s)
- Wen Hu
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Dong Xu
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Juan Li
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Cheng Chen
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Yuan Chen
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Fangfang Xi
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Feifei Zhou
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Xiaohan Guo
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Baihui Zhao
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
| | - Qiong Luo
- Department of Obstetrics, Women's Hospital, Zhejiang University, School of Medicine, 1st Xueshi Road, Hangzhou, 310006 Zhejiang China
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Abstract
Women who are pregnant or in the postpartum period have a fourfold to fivefold increased risk of thromboembolism compared with nonpregnant women (). Approximately 80% of thromboembolic events in pregnancy are venous (), with a prevalence of 0.5-2.0 per 1,000 pregnant women (). Venous thromboembolism (VTE) is one of the leading causes of maternal mortality in the United States, accounting for 9.3% of all maternal deaths ().The prevalence and severity of this condition during pregnancy and the peripartum period warrant special consideration of management and therapy. Such therapy includes the treatment of acute thrombotic events and prophylaxis for those at increased risk of thrombotic events. The purpose of this document is to provide information regarding the risk factors, diagnosis, management, and prevention of thromboembolism, particularly VTE in pregnancy. This Practice Bulletin has been revised to reflect updated guidance regarding screening for thromboembolism risk and management of anticoagulation around the time of delivery.
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Selvaraj R, Ramakrishnan J, Sahu SK, Kar SS, Laksham KB, Premarajan KC, Roy G. High prevalence of anemia among postnatal mothers in Urban Puducherry: A community-based study. J Family Med Prim Care 2019; 8:2703-2707. [PMID: 31548960 PMCID: PMC6753800 DOI: 10.4103/jfmpc.jfmpc_386_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 05/13/2019] [Accepted: 06/17/2019] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Anemia is a common problem across all life stages and ages with a higher burden among women. The postnatal period is an often-neglected period for the provision of effective care to the mothers. Anemia burden is also high during this period, which leads to many morbidities and poor quality of life. METHODS A community-based cross-sectional study was done in the field practice area of two Urban Primary Health Centres (PHCs) in Puducherry between March 2015 and February 2016. A total of 227 postnatal mothers were selected by simple random sampling from the list of mothers delivered from the field practice area. House visit was done within 4 weeks of completion of their postnatal period. Socio-demographic details and third-trimester hemoglobin levels were collected using a pretested questionnaire. Hemoglobin level during post-partum was measured using Sahli's Hemoglobinometer. Paired t-test is done to assess the difference in hemoglobin antepartum and post-partum. Multiple Logistic Regression is done to identify factors associated with postpartum anemia. RESULTS The mean (SD) hemoglobin during postpartum was 10.95 (1.1) gm% ranging from 7.4 gm% to 13.8 gm%. The prevalence of anemia among postnatal mothers is 76.2% (n = 173, 95% CI: 70.4%-81.4%). Around 26% (59) had mild anemia, 49.8% (113) had moderate anemia and 0.4% (1) had severe anemia. One-fourth of the mothers who had a normal hemoglobin level in their third trimester had developed anemia in the postnatal period. There was a significant difference in mean hemoglobin during postpartum and that of third trimester (10.95 vs 10.69 gm%, t = 3.4, df 226, P = 0.001). Birth order of two or more is significantly associated with postpartum anemia (aOR 2.2, 95% CI: 1.07-4.39). CONCLUSIONS The prevalence of anemia among postnatal mothers is high. Routine hemoglobin estimation, advice on consumption of iron-rich foods and Iron and Folic Acid (IFA) supplementation have to be provided to postnatal mothers to improve this situation.
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Affiliation(s)
- Ramya Selvaraj
- Department of Community Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Karaikal, Puducherry, India
| | - Jayalakshmy Ramakrishnan
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Swaroop Kumar Sahu
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sitanshu Sekhar Kar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Karthik Balajee Laksham
- Department of Community Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Karaikal, Puducherry, India
| | - K. C. Premarajan
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Gautam Roy
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Goecke T, Voigt F, Rath W. Thromboprophylaxis following cesarean section - a nation-wide survey from Germany. J Matern Fetal Neonatal Med 2019; 33:2359-2365. [PMID: 30606064 DOI: 10.1080/14767058.2018.1550064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective: Our study aimed to assess current practice related to thromboprophylaxis following cesarean section (c.s.) among obstetricians in Germany taking account of the German and international guidelines.Study design: A nation-wide survey using a structured 22-item questionnaire was conducted in Germany. The questionnaire was sent to head of all registered departments of obstetrics and gynecology in Germany, followed by a single reminder followed 3 weeks after the first return deadline. The respondents' answers were related to the different levels of care (1-4) of German perinatal centers.Results: In total 726 obstetric departments were invited to participate. Questionnaires were returned by 389 (54%) of departments. Of the respondents 162 (41%) stated to undertake risk assessment for venous thromboembolism (VTE) using a structured checklist or interview. Compared to level 4 centers risk assessment was significantly more often performed by perinatal centers level 1 (47 versus 35%, p = .05). The majority of responding hospitals preferred universal heparin thromboprophylaxis following elective and emergency caesarean section, regardless of additional risk factors (n = 362; 93%). The "usual" prophylactic dose of heparin was given by the majority of hospitals (n = 280, 72%), while 98 (25%) hospitals used heparin doses adjusted to patients' body weight. In women at increased risk for VTE (e.g. previous VTE) there was a considerable variation in the recommended doses; 140 responding hospitals (36%) used 50-75% of the therapeutic heparin dose, 139 hospitals (36%) the "usual" prophylactic dose, and 97 hospitals (25%) preferred a therapeutic dose. In women at low risk for VTE 64% (n = 248) of hospitals recommended heparin thromboprophylaxis only during the hospital stay, 16% (n = 62) for at least 7 days after c.s., 4% (n = 15) for 10 days, 6% (n = 23) for 2-5 weeks, and 3% (n = 14) for 6 weeks postpartum. In women at increased risk level 1 centers prescribed heparin for VTE prophylaxis significantly more often for 6-8-week postpartum compared to level 4 centers (p = .02) whereas Level 4 centers used prophylactic heparin significantly more often <6 weeks (p = .01).Conclusion: Our survey reveals that the vast majority of hospitals (93%) used heparin prophylaxis after any c.s., irrespective of individual risk factors and the mode of c.s. (elective or emergency). This is in remarkable contrast to the recommendations from the German and other international guidelines. As well, we found a wide variation among respondents in dosing and duration of heparin related to the risk profile of VTE. This demonstrates, that there is little awareness and/or adherence to the German and other guideline recommendations which mirrors the inconsistencies between current guidelines. There is an urgent need to clarify optimal prophylaxis strategies after c.s. and the true magnitudes of benefits and harms associated with heparin prophylaxis by randomized controlled trials with sufficient statistical power.
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Affiliation(s)
- Tamme Goecke
- Department of Obstetrics and Gynecology, University Hospital RWTH Aachen, Aachen, Germany
| | - Franziska Voigt
- Department of Obstetrics and Gynecology, University Hospital RWTH Aachen, Aachen, Germany
| | - Werner Rath
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitatsklinikum Schleswig-Holstein, Kiel, Germany
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FSRH Guideline (January 2019) Combined Hormonal Contraception (Revision due by January 2024). BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:1-93. [PMID: 30665985 DOI: 10.1136/bmjsrh-2018-chc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Ker K, Roberts I, Chaudhri R, Fawole B, Beaumont D, Balogun E, Prowse D, Pepple T, Javaid K, Kayani A, Arulkumaran S, Bates I, Shakur-Still H. Tranexamic acid for the prevention of postpartum bleeding in women with anaemia: study protocol for an international, randomised, double-blind, placebo-controlled trial. Trials 2018; 19:712. [PMID: 30594227 PMCID: PMC6311062 DOI: 10.1186/s13063-018-3081-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 11/27/2018] [Indexed: 01/10/2023] Open
Abstract
Background Postpartum haemorrhage (PPH) is responsible for about 100,000 maternal deaths every year, most of which occur in low- and middle-income countries. Tranexamic acid (TXA) reduces bleeding by inhibiting the enzymatic breakdown of fibrin blood clots. TXA decreases blood loss in surgery and reduces death due to bleeding after trauma. When given within 3 h of birth, TXA reduces deaths due to bleeding in women with PPH. However, for many women, treatment of PPH is too late to prevent death. Over one third of pregnant women in the world are anaemic and many are severely anaemic. These women have an increased risk of PPH and suffer more severe outcomes if PPH occurs. There is an urgent need to identify a safe and effective way to reduce postpartum bleeding in anaemic women. Methods/design The WOMAN-2 trial is an international, multicentre, randomised, double-blind, placebo-controlled trial to quantify the effects of TXA on postpartum bleeding in women with moderate or severe anaemia. Ten thousand women with moderate or severe anaemia who have given birth vaginally will be randomised to receive 1 g of TXA or matching placebo by intravenous injection immediately (within 15 min) after the umbilical cord is cut or clamped. The primary outcome is the proportion of women with a clinical diagnosis of primary PPH. The cause of PPH will be described. Data on maternal health and wellbeing, maternal blood loss and its consequences, and other health outcomes will be collected as secondary outcomes. The main analyses will be on an ‘intention-to-treat’ basis, irrespective of whether the allocated treatment was received. Results will be presented as appropriate effect estimates with a measure of precision (95% confidence intervals). Subgroup analyses will be based on the severity of anaemia (moderate versus severe) and type of labour (induced or augmented versus spontaneous). A study with 10,000 patients will have over 90% power to detect a 25% relative reduction from 10 to 7.5% in PPH. The trial will be conducted in hospitals in Africa and Asia. Discussion The WOMAN-2 trial should provide reliable evidence for the effects of TXA for preventing postpartum bleeding in women with anaemia. Trial registration ISRCTN, ISRCTN62396133. Registered on 7 December 2017; ClincalTrials.gov, ID: NCT03475342. Registered on 23 March 2018. Electronic supplementary material The online version of this article (10.1186/s13063-018-3081-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Katharine Ker
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Danielle Beaumont
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Eni Balogun
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Danielle Prowse
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Tracey Pepple
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Kiran Javaid
- Pakistan Regional Trials Coordinating Centre, Rawalpindi Medical College, Rawalpindi,, Pakistan
| | - Aasia Kayani
- Pakistan Regional Trials Coordinating Centre, Rawalpindi Medical College, Rawalpindi,, Pakistan
| | | | - Imelda Bates
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Haleema Shakur-Still
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, UK.
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Zhao Y, Ding A, Arya R, Patel JP. Factors influencing the recruitment of lactating women in a clinical trial involving direct oral anticoagulants: a qualitative study. Int J Clin Pharm 2018; 40:1511-1518. [PMID: 30306454 PMCID: PMC6280865 DOI: 10.1007/s11096-018-0734-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 10/04/2018] [Indexed: 12/26/2022]
Abstract
Background Robust human data on medication use during lactation is scarce. With increasing medication use in postpartum women, it is important to conduct clinical lactation studies measuring the excretion of drugs in human milk and generate evidence. We plan to conduct a clinical lactation study, involving the direct oral anticoagulants (DOACs). Objective This study aimed to identify factors influencing lactating women's clinical trial participation and to improve the design of a proposed DOACs clinical lactation study. Setting Lactating women in London, UK. Methods Three focus groups were conducted in lactating women with differing experiences of being prescribed anticoagulants during puerperium. Main outcome measures Thematic framework approach was used to analyse and identify key themes, using NVivo version 11. Results Eight breastfeeding mothers participated. Women's decision-making on clinical trial participation was largely influenced by the lactation stage and previous breastfeeding experience. The concern of harm to their infant caused by the test medication or interruption of lactation were the predominant barriers to potential participation. Around 6 months following the birth of their infant and second-time mothers appeared to be more amenable to clinical trial participation. The provision of home visits for the execution of the study was highly recommended. Conclusion Our findings suggest that lactating women would participate in a clinical trial during the breastfeeding period, if the timing is right and if the woman is an experienced mother. Home visits will be provided in our proposed DOACs clinical lactation study.
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Affiliation(s)
- Yating Zhao
- Institute of Pharmaceutical Science, King's College London, 5th Floor Franklin-Wilkins Building, 150 Stamford Street, London, SE1 9NH, UK.
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK.
| | - Amally Ding
- Institute of Pharmaceutical Science, King's College London, 5th Floor Franklin-Wilkins Building, 150 Stamford Street, London, SE1 9NH, UK
| | - Roopen Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Jignesh P Patel
- Institute of Pharmaceutical Science, King's College London, 5th Floor Franklin-Wilkins Building, 150 Stamford Street, London, SE1 9NH, UK
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
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Inayama Y, Kondoh E, Chigusa Y, Io S, Funaki T, Matsumura N, Miyamoto S, Mandai M. Moyamoya Disease in Pregnancy: A 20-Year Single-Center Experience and Literature Review. World Neurosurg 2018; 122:684-691.e2. [PMID: 30347298 DOI: 10.1016/j.wneu.2018.10.071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/08/2018] [Accepted: 10/09/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Pregnancy is a potential risk factor for stroke in women with Moyamoya disease. However, the rarity of the disease has limited clinical expertise to ensure a healthy pregnancy. The aim of the present study was to explore the possible risk factors for hemorrhagic and ischemic stroke in pregnant women with Moyamoya disease. METHODS A retrospective review of cases in our hospital during a 20-year period and a review of the reported data were conducted to investigate pregnancy-related cerebrovascular events in women with Moyamoya disease. RESULTS Thirty pregnancies in 20 women with Moyamoya disease were identified in the case review of our hospital. All were previously diagnosed cases, and no stroke had occurred during the study period. In the reported data review, pregnancy-related stroke in women with Moyamoya disease was identified in 54 (44 intracranial hemorrhage and 10 cerebral infarction). Intracranial hemorrhage occurred most commonly during the antepartum period (n = 39; 88.6%), with most events occurring at ≥24 weeks. Of the intracranial hemorrhage cases, 7 (15.9%) were complicated by hypertensive disorders of pregnancy, and 8 patients (18.2%) died of stroke. The onset of cerebral infarction was either in the antepartum (n = 4; 40.0%) or postpartum (n = 6; 60.0%) period. All postpartum cases occurred within 3-7 days after delivery. CONCLUSION Pregnancy-related stroke in patients with Moyamoya disease might be susceptible to gestational age. Intracranial hemorrhage is prone to occur during the antepartum period, especially at ≥24 weeks, and cerebral infarction tends to occur postpartum.
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Affiliation(s)
- Yoshihide Inayama
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Eiji Kondoh
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Yoshitsugu Chigusa
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shingo Io
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Funaki
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Noriomi Matsumura
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Susumu Miyamoto
- Department of Neurosurgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masaki Mandai
- Department of Gynecology and Obstetrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
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35
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Rodríguez-Nora B, Álvarez-Silvares E. [An update on the treatment of venous insufficiency in pregnancy]. Semergen 2017; 44:262-269. [PMID: 29249567 DOI: 10.1016/j.semerg.2017.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 10/16/2017] [Accepted: 11/03/2017] [Indexed: 11/18/2022]
Abstract
Chronic venous insufficiency is a long-term pathological condition resulting from anatomical or functional alterations of the venous system. This leads to the appearance of symptoms and physical signs that affect a large part of the population and particularly pregnant women, due to the physiology of pregnancy. The few published studies on the use of pharmacological treatments of venous insufficiency in this group of the population, often makes the management of this condition difficult in routine clinical practice. A review is presented in this article, with all the latest updates in the treatment of this condition during pregnancy. There are numerous general, and some pharmacological, recommendations, that we can safely offer the pregnant patient.
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Affiliation(s)
- B Rodríguez-Nora
- Medicina de Familia y Comunitaria, Complexo Hospitalario Universitario de Ourense, Ourense, España
| | - E Álvarez-Silvares
- Servicio de Obstetricia y Ginecología, Complexo Hospitalario Universitario de Ourense, Ourense, España.
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Melov SJ, Hitos K. Venous thromboembolism risk and postpartum lying-in: Acculturation of Indian and Chinese women. Midwifery 2017; 58:13-18. [PMID: 29275264 DOI: 10.1016/j.midw.2017.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 11/15/2017] [Accepted: 11/28/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE many cultures have a set time of traditional rest in the postpartum period. There is limited information on how this activity may potentially increase the risk of venous thromboembolism (VTE). We aimed to investigate VTE risk by determining the prevalence of the cultural practice of postpartum "lying-in", quantifying activity and determining the factors that influence this tradition in women from China and the Indian subcontinent (India, Bangladesh, Pakistan and Sri Lanka) at an Australian tertiary referral hospital. DESIGN we surveyed a prospective cohort of 150 women aged ≥ 18 years who self-identified culturally as from the Indian subcontinent or Chinese, at baseline (≥ 32 weeks gestation) and at follow-up (six to eight weeks postpartum). Demographic details collected included VTE risk factors such as caesarean section, lack of graduated compression stockings (GCS), postpartum haemorrhage greater than 1000mL, comorbidities and immobility. We quantified postpartum activities and investigated factors that might influence inactivity. RESULTS there were 100 women identifying as from the Indian subcontinent and 50 women identifying as Chinese recruited at the baseline of over 32 weeks' gestation. Most of the study participants (85%) rested in the postpartum period for cultural reasons. Of the women surveyed, 51% rested in bed as much as possible in the postpartum period. We found a significant correlation between increased number of children and decreased overall immobility or rest (P = 0.03). Overall, 91% of participants had relative live-in help, and this significantly increased the risk of immobility by more than six-fold (odds ratio [OR], 6.17; 95% CI, 1.6-23.5; P = 0.008). Furthermore, a vaginal compared to a caesarean birth increased immobility risk by almost 3.5 times (OR, 3.4; 95% CI, 1.20-9.4; P = 0.021). CONCLUSIONS acculturation is highly individualised, however postpartum rest remains prevalent in women who identify themselves culturally as from the Indian subcontinent or as Chinese. Inactivity and comorbidities compounded the impact of cultural postpartum rest, and put women at increased risk for VTE. IMPLICATIONS FOR PRACTICE targeted, culturally appropriate, postnatal education should include VTE-prevention information to women who intend to practise postpartum rest.
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Affiliation(s)
- Sarah J Melov
- Westmead Institute for Maternal and Fetal Medicine, Westmead Hospital, Australia.
| | - Kerry Hitos
- Westmead Research Centre for Evaluation of Surgical Outcomes, Department of Surgery, Westmead Hospital, The University of Sydney, Australia
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