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Does fetal sex influence the risk of venous thrombosis in pregnancy? A cohort study. J Thromb Haemost 2023; 21:599-605. [PMID: 36696192 DOI: 10.1016/j.jtha.2022.11.024] [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: 12/20/2021] [Revised: 10/18/2022] [Accepted: 11/15/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Venous thromboembolism is a prominent cause of maternal death. OBJECTIVE As inflammation is a well-known risk factor for venous thromboembolism and several studies have found a higher grade of inflammation in pregnancies bearing a male compared with female fetuses, we investigated the risk of pregnancy-related venous thromboembolism associated with sex of the fetus. METHODS This cohort study linked data from national registries and compared event rates and hazard ratios of venous thrombosis for pregnancies bearing a male fetus with those bearing a female fetus during pregnancy and in the first 3 months postpartum. National data from 1995 to 2017 were used. All Danish women aged 15 to 49 years with a live or stillbirth were eligible for inclusion; 1 370 583 pregnancies were included. Women with venous thrombosis, ischemic heart disease, cerebrovascular disease, thrombophilia, or cancer before conception were excluded. RESULTS The event rate for a venous thrombosis was 8.0 per 10.000 pregnancy years with a male fetus compared with 6.8 for a female fetus. The adjusted hazard ratio for venous thrombosis during pregnancies bearing a male was 1.2 (95% CI, 1.1-1.4), whereas in the postpartum period, it was 0.9 (95% CI, 0.7-1.0). The risk was elevated until week 30. CONCLUSION These findings indicate a slightly greater risk of venous thrombosis during pregnancies bearing a male fetus than during pregnancies bearing a female fetus. There was no increased risk associated with fetal male sex in the postpartum period.
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Castro CN, Lopes PPM, Mayrink J. Dyspnea and COVID-19: A Review of Confounding Diagnoses during the Postpartum Period. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:862-869. [PMID: 34872145 PMCID: PMC10183873 DOI: 10.1055/s-0041-1736304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
The puerperium is a complex period that begins with placental delivery and lasts for 6 weeks, during which readaptation of the female organism and redistribution of blood volume occur. This period is conducive to the occurrence of thromboembolic events. In the context of the SARS-CoV-2 pandemic, the virus responsible for COVID-19, the attention of the scientific community and health professionals has been focused on obtaining insights on different aspects of this disease, including etiology, transmission, diagnosis, and treatment. Regarding the pregnancy-postpartum cycle, it is opportune to review the clinical conditions that can occur during this period and to investigate dyspnea as a postpartum symptom in order to avoid its immediate association with COVID-19 without further investigation, which can lead to overlooking the diagnosis of other important and occasionally fatal conditions.
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Affiliation(s)
- Clara Nunes Castro
- Department of Gynecology and Obstetrics, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Pedro Paulo Machado Lopes
- Department of Gynecology and Obstetrics, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Jussara Mayrink
- Department of Gynecology and Obstetrics, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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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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Lamont MC, McDermott C, Thomson AJ, Greer IA. United Kingdom recommendations for obstetric venous thromboembolism prophylaxis: Evidence and rationale. Semin Perinatol 2019; 43:222-228. [PMID: 30935752 DOI: 10.1053/j.semperi.2019.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of maternal death in the United Kingdom. To address this problem guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) has been developed that recommends the assessment of a woman's risk of thrombosis at specific time-points during pregnancy and postnatally at the time of delivery. The RCOG guidelines provide clinicians with a framework to inform decision-making on the use of thromboprophylaxis and are based on the premise that the higher risk a woman has for VTE, the more likely she is to benefit from prophylaxis - determining her level of risk is based on the number and characteristics of the risk factors that she has. This article will address the pathophysiology of VTE in pregnancy, evidence behind the risk factors for VTE and the use of thromboprophylactic agents. Further, it will reflect on the rationale behind the RCOG guidance.
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Affiliation(s)
- M Christy Lamont
- Department of Obstetrics & Gynaecology, NHS Greater Glasgow & Clyde, Scotland
| | | | - Andrew J Thomson
- Department of Obstetrics & Gynaecology, NHS Greater Glasgow & Clyde, Scotland.
| | - Ian A Greer
- President and Vice Chancellor, Queen's University Belfast, Northern Ireland
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Creanga AA. Maternal Mortality in the United States: A Review of Contemporary Data and Their Limitations. Clin Obstet Gynecol 2019; 61:296-306. [PMID: 29561285 DOI: 10.1097/grf.0000000000000362] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article provides a review of maternal mortality data and their limitations in the United States. National maternal mortality data, which rely heavily on vital statistics, document that the risk of death from pregnancy-related causes has not declined for >25 years and that striking racial disparities persist. State-based maternal mortality reviews, functional in many states, obtain detailed information on medical and nonmedical factors contributing to maternal deaths. Without this detailed knowledge from state-level data and without addressing recognized quality problems with vital statistics data at the national-level, we will have difficulty understanding maternal death trends and preventing future such deaths.
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Affiliation(s)
- Andreea A Creanga
- Departments of International Health.,Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
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Oh J, Bae JY. Postpartum spontaneous renal blood vessel rupture followed by pulmonary artery thromboembolism associated with protein C deficiency. J OBSTET GYNAECOL 2018; 39:403-405. [PMID: 29884108 DOI: 10.1080/01443615.2018.1460745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Jinju Oh
- a Department of Obstetrics and Gynecology, School of Medicine , Catholic University of Daegu , Gyeongsan , South Korea
| | - Jin Young Bae
- a Department of Obstetrics and Gynecology, School of Medicine , Catholic University of Daegu , Gyeongsan , South Korea
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Leovic MP, Robbins HN, Starikov RS, Foley MR. Multidisciplinary obstetric critical care delivery: The concept of the "virtual" intensive care unit. Semin Perinatol 2018; 42:3-8. [PMID: 29310986 DOI: 10.1053/j.semperi.2017.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
With an increasing prevalence of chronic medical conditions and the associated potential for decompensation to critical illness among modern day parturients, we present here the concept of the "virtual" intensive care unit. We challenge the traditional association of the word "unit" to extend beyond a fixed physical setting to portray an individualized, predetermined patient care team capable of managing these complex patients in a variety of settings. In this model, obstetric critical care is provided through a multidisciplinary patient care team, with emphasis on early identification of complicated pregnancies, detailed antepartum planning, anticipation of complications, and retrospective review of clinical outcomes aimed at continued quality improvement. This structured approach in the provision of care to the critically ill pregnant patient will serve as a foundation for future attempts at reduction in rates of maternal morbidity and mortality.
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Affiliation(s)
- Michael P Leovic
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ; Department of Obstetrics and Gynecology, Banner University Medical Center-Phoenix, 1111 E. McDowell Road, Phoenix, AZ 85006.
| | - Hailey N Robbins
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ; Department of Obstetrics and Gynecology, Banner University Medical Center-Phoenix, 1111 E. McDowell Road, Phoenix, AZ 85006
| | - Roman S Starikov
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ; Department of Obstetrics and Gynecology, Banner University Medical Center-Phoenix, 1111 E. McDowell Road, Phoenix, AZ 85006; Division of Maternal-Fetal Medicine, Phoenix Perinatal Associates, Phoenix, AZ
| | - Michael R Foley
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ; Department of Obstetrics and Gynecology, Banner University Medical Center-Phoenix, 1111 E. McDowell Road, Phoenix, AZ 85006
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Compliance with the 2009 Royal College of Obstetricians and Gynaecologists guidelines for venous thromboembolic disease prophylaxis in pregnancy and postpartum period in Uruguay. Blood Coagul Fibrinolysis 2018; 29:252-256. [PMID: 29369082 DOI: 10.1097/mbc.0000000000000708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Venous thromboembolism remains as one of the leading causes of maternal death. Prevention of venous thromboembolism in the obstetric population is challenging as recommendations for prophylaxis have low grade of evidence. Risk factors and prophylaxis guidelines have been highlighted by Royal College of Obstetricians and Gynaecologists. In 2014, we developed a written alert following this guidelines to guide thromboprophylaxis. The aim of this study is to assess recommendations compliance. This study was conducted at University-Hospital in Uruguay from January 2014 to December 2016. A total of 1035 women were enrolled and stratified in high, intermediate or low risk based on Royal College of Obstetricians and Gynaecologists guidelines. Thromboprophylaxis was recommended for women at intermediate and high risk. Women were followed up to assess symptomatic thromboembolism or haemorrhagic complications. A total of 309 were pregnant and 731 puerperal. Median age was 24 (19-29) years old. Of them, 3.0% (n = 31) were at high risk and 35.4% (n = 366) at intermediate risk. All high-risk women received prophylaxis with low-molecular-weight heparin. Of the 366 intermediate-risk women, 52.7% received prophylaxis. Venous thromboembolism was developed in only one woman of the intermediate group, who had received prophylaxis. Bleeding complications were not observed. Awareness of the thrombotic risk, as conferred by an easy and suitable risk assessment, has the potential to improve venous thromboembolism prophylaxis in pregnant and puerperal women. We have a good guidelines compliance with the written alert in the high-risk women group. However, we have to improve low-molecular-weight heparin indication in intermediate-risk group, especially in postcaesarean women.
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O'Shaughnessy F, Donnelly JC, Cooley SM, Deering M, Raman A, Gannon G, Hickey J, Holland A, Hayes N, Bennett K, Ní Áinle F, Cleary BJ. Thrombocalc: implementation and uptake of personalized postpartum venous thromboembolism risk assessment in a high-throughput obstetric environment. Acta Obstet Gynecol Scand 2017; 96:1382-1390. [PMID: 28832906 DOI: 10.1111/aogs.13206] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/06/2017] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Venous thromboembolism risk assessment (VTERA) is recommended in all pregnant and postpartum women. Our objective was to develop, pilot and implement a user-friendly electronic VTERA tool. MATERIAL AND METHODS We developed "Thrombocalc", an electronic VTERA tool using Microsoft EXCEL™ . Thrombocalc was designed as a score-based tool to facilitate rapid assessment of all women after childbirth. Calculation of a total score estimated risk of venous thromboembolism in line with consensus guidelines. Recommendations for thromboprophylaxis were included in the VTERA output. Implementation was phased. Uptake of the VTERA tool was assessed prospectively by monitoring the proportion of women who gave birth in our institution and had a completed risk assessment. Factors affecting completion and accuracy of risk assessments were also assessed. RESULTS Thrombocalc was used prospectively to risk-assess 8380 women between September 2014 and December 2015. Compliance with this tool increased dramatically throughout the study period; over 92% of women were risk-assessed in the last quarter of data collection. Compliance was not adversely affected if delivery took place out of working hours [adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 0.93-1.14]. Risk assessment was less likely in the case of cesarean deliveries (aOR 0.66, 95% CI 0.60-0.73) and stillborn infants (aOR 0.48, 95% CI 0.29-0.79). Misclassification of risk factors led to approximately 207 (2.5%) inaccurate thromboprophylaxis recommendations. CONCLUSIONS Our electronic, score-based VTERA tool provides a highly effective mechanism for rapid assessment of individual postpartum venous thromboembolism risk in a high-throughput environment.
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Affiliation(s)
- Fergal O'Shaughnessy
- Pharmacy Department, Rotunda Hospital, Dublin, Ireland.,Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jennifer C Donnelly
- Department of Obstetrics and Gynecology, Rotunda Hospital, Dublin, Ireland.,Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sharon M Cooley
- Department of Obstetrics and Gynecology, Rotunda Hospital, Dublin, Ireland
| | - Mary Deering
- Department of Midwifery, Rotunda Hospital, Dublin, Ireland
| | - Ajita Raman
- Department of Midwifery, Rotunda Hospital, Dublin, Ireland
| | | | - Jane Hickey
- Department of Midwifery, Rotunda Hospital, Dublin, Ireland
| | - Alan Holland
- Department of Finance, Rotunda Hospital, Dublin, Ireland
| | - Niamh Hayes
- Department of Anesthesia, Rotunda Hospital, Dublin, Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Department of Hamatology, Rotunda Hospital, Dublin, Ireland.,School of Medicine and SPHERE Research Group, University College Dublin, Conway Institute, Dublin, Ireland.,Department of Hematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Brian J Cleary
- Pharmacy Department, Rotunda Hospital, Dublin, Ireland.,School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
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Drife J. Deep venous thrombosis and pulmonary embolism in obese women. Best Pract Res Clin Obstet Gynaecol 2015; 29:365-76. [PMID: 25457857 DOI: 10.1016/j.bpobgyn.2014.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 08/05/2014] [Indexed: 11/18/2022]
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Hordern CE, Bircher CW, Prosser-Snelling EC, Fraser FK, Smith RP. Patient compliance with postnatal thromboprophylaxis: An observational study. J OBSTET GYNAECOL 2015; 35:793-6. [PMID: 25692872 DOI: 10.3109/01443615.2015.1009878] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Prescription of postnatal thromboprophylaxis has increased with the Royal College of Obstetricians and Gynaecologists and the National Institute for Health and Care Excellence guidance. Our study of postnatal women meeting the criteria for thromboprophylaxis aimed to ascertain compliance with low-molecular-weight heparin and barriers to completion of a full course. Women were recruited from the antenatal clinic or postnatal wards. Those who agreed were contacted by telephone 14 days after delivery and asked about their compliance with and experience of thromboprophylaxis. 111 women were followed up. We found reported compliance with postnatal thromboprophylaxis to be high (83% taking the full course); most women self-injected (54%) but a significant number relied on family members (39%). Most would be prepared to take the course in a future pregnancy (94%); however, some felt that they needed more information. Reported compliance with postnatal thromboprophylaxis is high. This may be down to the motivation of the new mother, appropriate information giving and access to health care professionals for advice.
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Affiliation(s)
- C E Hordern
- a Department of Obstetrics and Gynaecology , Norfolk and Norwich University Hospital NHS Foundation Trust , Norwich , UK
| | - C W Bircher
- a Department of Obstetrics and Gynaecology , Norfolk and Norwich University Hospital NHS Foundation Trust , Norwich , UK
| | - E C Prosser-Snelling
- a Department of Obstetrics and Gynaecology , Norfolk and Norwich University Hospital NHS Foundation Trust , Norwich , UK
| | - F K Fraser
- a Department of Obstetrics and Gynaecology , Norfolk and Norwich University Hospital NHS Foundation Trust , Norwich , UK
| | - R P Smith
- a Department of Obstetrics and Gynaecology , Norfolk and Norwich University Hospital NHS Foundation Trust , Norwich , UK
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Guimicheva B, Czuprynska J, Arya R. The prevention of pregnancy-related venous thromboembolism. Br J Haematol 2014; 168:163-74. [DOI: 10.1111/bjh.13159] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Boriana Guimicheva
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
| | - Julia Czuprynska
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
| | - Roopen Arya
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
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Wu P, Poole TC, Pickett JA, Bhat A, Lees CC. Current obstetric guidelines on thromboprophylaxis in the United Kingdom: evidence based medicine? Eur J Obstet Gynecol Reprod Biol 2013; 168:7-11. [DOI: 10.1016/j.ejogrb.2012.12.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 12/03/2012] [Accepted: 12/24/2012] [Indexed: 10/27/2022]
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