OPtimal TIming of antenatal COrticosteroid administration in pregnancies complicated by early-onset fetal growth REstriction (OPTICORE): study protocol of a multicentre, retrospective cohort study

INTRODUCTION

Early-onset fetal growth restriction (FGR) requires timely, often preterm, delivery to prevent fetal hypoxia causing stillbirth or neurologic impairment. Antenatal corticosteroids (CCS) administration reduces neonatal morbidity and mortality following preterm birth, most effectively when administered within 1 week preceding delivery. Optimal timing of CCS administration is challenging in early-onset FGR, as the exact onset and course of fetal hypoxia are unpredictable. International guidelines do not provide a directive on this topic. In the Netherlands, two timing strategies are commonly practiced: administration of CCS when the umbilical artery shows (A) a pulsatility index above the 95th^h centile and (B) absent or reversed end-diastolic velocity (a more progressed disease state). This study aims to (1) use practice variation to compare CCS timing strategies in early-onset FGR on fetal and neonatal outcomes and (2) develop a dynamic tool to predict the time interval in days until delivery, as a novel timing strategy for antenatal CCS in early-onset FGR.

METHODS AND ANALYSIS

A multicentre, retrospective cohort study will be performed including pregnancies complicated by early-onset FGR in six tertiary hospitals in the Netherlands in the period between 2012 and 2021 (estimated sample size n=1800). Main exclusion criteria are multiple pregnancies and fetal congenital or genetic abnormalities. Routinely collected data will be extracted from medical charts. Primary outcome for the comparison of the two CCS timing strategies is a composite of perinatal, neonatal and in-hospital mortality. Secondary outcomes include the COSGROVE core outcome set for FGR. A multivariable, mixed-effects model will be used to compare timing strategies on study outcomes. Primary outcome for the dynamic prediction tool is 'days until birth'.

ETHICS AND DISSEMINATION

The need for ethical approval was waived by the Ethics Committee (University Medical Center Utrecht). Results will be published in open-access, peer-reviewed journals and disseminated by presentations at scientific conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT05606497.

[A pregnant woman with gastric cancer and placental involvement]

BACKGROUND

About 200 pregnant women in the Netherlands are yearly diagnosed with cancer. Pregnant women with cancer are often diagnosed later than non-pregnant women because symptoms of cancer are common during pregnancy and may elude suspicion. We report a patient with gastric carcinoma masquerading as hyperemesis gravidarum.

CASE DESCRIPTION

A 39-year-old pregnant woman was admitted at 25 weeks' gestation for the evaluation of persistent nausea, vomiting and weight loss (29 kg) since the beginning of her pregnancy. A presumptive diagnosis of hyperemesis gravidarum was made. Endoscopic examination was not performed. At 28 weeks' gestation caesarean was performed due to fetal distress and revealed a gastric tumour with abnormalities of the omentum. Microscopic examination of the omentum and placental specimen demonstrated poorly differentiated adenocarcinoma cells.

CONCLUSION

This case illustrates that endoscopic examination should be conducted in pregnant patients presenting with persistent gastrointestinal symptoms for the differential diagnosis of hyperemesis gravidarum.

No increased systemic fibrinolysis in women with heavy menstrual bleeding

BACKGROUND

Bleeding disorders have been recognized as important etiologic or contributory factors in women with heavy menstrual bleeding. Fibrinolysis in the endometrium plays a role in heavy menstrual bleeding. It is unknown whether increased systemic fibrinolysis might also increase the risk of heavy menstrual bleeding.

OBJECTIVE

To investigate fibrinolytic parameters, including clot lysis time, in women with heavy menstrual bleeding.

METHODS

We included 102 patients referred for heavy menstrual bleeding (Pictorial Bleeding Assessment Chart score of > 100) in our cohort. Patients and controls (28 healthy volunteers without heavy menstrual bleeding) underwent hemostatic testing in the first week after menstruation. For 79 patients and all controls, fibrinolytic parameters (thrombin-activatable fibrinolysis inhibitor activity, and plasminogen activator inhibitor-1, tissue-type plasminogen activator and plasmin inhibitor levels) and clot lysis time were available.

RESULTS

Fibrinolytic parameters were similar between patients and controls, except for thrombin-activatable fibrinolysis inhibitor (89.4% vs. 82.5%) and plasmin inhibitor (106% vs. 96%), the levels of which which were significantly higher in patients. In women with menorrhagia without gynecologic abnormalities, we found lower thrombin-activatable fibrinolysis inhibitor and plasminogen activator inhibitor-1 levels than in women with gynecologic abnormalities (thrombin-activatable fibrinolysis inhibitor, 85.4% vs. 94.8%; plasminogen activator inhibitor-1, 16.0 μg L(-1) vs. 24.5 μg L(-1) ).

CONCLUSION

Systemic fibrinolytic capacity is not increased in women with heavy menstrual bleeding. Overall, levels of the fibrinolytic inhibitors thrombin-activatable fibrinolysis inhibitor and plasmin inhibitor were even higher in patients than in controls. However, in a subgroup of women without gynecologic abnormalities, relatively lower levels of inhibitors may contribute to the heavy menstrual bleeding.

Incidence of hypersensitivity skin reactions in patients on full-dose low-molecular-weight heparins during pregnancy

BACKGROUND

Low-molecular-weight heparins (LMWH) are the most commonly used anticoagulants for the treatment and prophylaxis of venous thromboembolism in pregnancy. Hypersensitivity skin reactions associated with the use of LMWH are frequently seen, but are probably underreported.

OBJECTIVE

To evaluate the incidence of hypersensitivity skin reactions due to the use of LMWH in pregnancy, and the subsequent management of anticoagulation.

PATIENTS/METHODS

From 1999 to 2009, we followed consecutive women who used therapeutic anticoagulation for venous indications. Women visited a combined obstetric/coagulation clinic and were seen by a thrombosis specialist every two months until six weeks postpartum. All women were started on nadroparin.

RESULTS

We included 135 pregnancies in 88 women. Overall, in 52 of 135 pregnancies (39%), women switched at least once to another anticoagulant because of the development of hypersensitivity skin reactions. Switching to another preparation of LMWH was effective in 77% of the cases. In 23% of the cases skin reactions recurred and another switch had to be made.

CONCLUSION

In almost half of the pregnancies, women had to switch at least once to another anticoagulant preparation due to the development of hypersensitivity skin reactions on LMWH. In most cases, skin reactions did not recur on the second preparation of LMWH used.

The prevalence of underlying bleeding disorders in patients with heavy menstrual bleeding with and without gynecologic abnormalities

OBJECTIVE

The purpose of this study was to assess the prevalence of underlying bleeding disorders in women with heavy menstrual bleeding (HMB) with and without gynecologic abnormalities.

STUDY DESIGN

We performed a single-center prospective cohort study of 112 consecutive patients who were referred for heavy menstrual bleeding. Control subjects were 28 healthy volunteers who reported no HMB. Patients and control subjects had hemostatic testing in the first week after menstruation. Patients underwent gynecologic evaluation.

RESULTS

The median age was 42.5 years (range, 17-55 years) in patients and 40.0 years (range, 25-55 years) in control subjects. Forty-six percent of patients had anemia; the median pictorial bleeding assessment chart score was 271. Seven percent of the control subjects with a subjectively normal menstruation had anemia. Twenty-six percent of patients had gynecologic abnormalities, which was considered to explain HMB. Overall, we found an underlying bleeding disorder in 29% of the patients, which was comparable for unexplained and explained HMB (31% vs 27%; P = .75). We diagnosed 6 cases of Von Willebrand's disease, 4 cases of factor XI deficiency, and 1 case of factor VII deficiency. The only abnormalities that we found in control subjects were platelet aggregation defects (11% in control subjects vs 23% in patients). Patients had a significantly longer activated partial thromboplastin time compared with control subjects (26.5 vs 25.0 seconds; P = .001) that was caused by lower median levels of factor XI (100 vs 124 IU/dL; P < .001).

CONCLUSION

Bleeding disorders play an equally important role in the cause of both unexplained and explained heavy menstrual bleeding. A novel finding is the occurrence of low, but not deficient, levels of factor XI.

The risk of postpartum hemorrhage in women using high dose of low-molecular-weight heparins during pregnancy

BACKGROUND

Low-molecular-weight heparins (LMWH) are the most commonly used anticoagulant during pregnancy for prevention or treatment of VTE. However, the size of the associated risk of postpartum haemorrhage (PPH) is unknown.

OBJECTIVE

To assess the bleeding risk of high dose LMWH, also in relation to time between last dose LMWH and delivery.

MATERIAL AND METHODS

From 1999 to 2009, we followed 88 pregnant women who were started on therapeutic anticoagulation. Controls were pregnant women without LMWH, matched 1:4 for parity, mode of delivery, age, gestational age and delivery date. PPH was defined as >500 ml blood loss for vaginal delivery (severe PPH in vaginal delivery as >1000 ml) and >1000 ml for cesarean section (CS). Women were divided into subgroups by the interval between last dose of anticoagulation and delivery (<12, 12-24 hrs, >24 hrs).

RESULTS

Risk of PPH after vaginal delivery was 30% and 18% for LMWH-users and non-users, respectively (OR 1.9, 95%CI 1.1-3.5). Risk of severe PPH after vaginal delivery was not different (5.6 vs 5.0%; OR 1.1; 0.4-3.6). Risk of PPH after CS was 12% in LMWH-users and 4% in non-users (OR 2.9; 0.5-19.4). Both events of LMWH-users occurred after emergency CS. The risk of PPH associated with delivery within 24 hours after last dose of LMWH was 1.2 fold higher (95%CI 0.4-3.6) compared to a larger interval.

CONCLUSION

High dose LMWH carries an increased risk of more than 500 mL blood loss after vaginal delivery. However, this results not in more clinical relevant severe PPHs. The interval between last dose of LMWH and delivery does not influence the risk of PPH.

Haemostatic variables during normal menstrual cycle. A systematic review

For a number of haemostatic factors menstrual cycle variation has been studied. Such variation could have clinical implications for the timing of haemostatic testing in women. It was our objective to systematically review the literature about evidence for timing of haemostatic testing during menstrual cycle.We searched MEDLINE, EMBASE and the Cochrane library to identify studies that measured haemostatic variables [platelet function, von Willebrand factor (VWF), factor VIII (FVIII), factor IX (FIX), factor XI (FXI), factor XIII (FXIII), D-dimer, plasminogen activator inhibitor-I (PAI-I), tissue plasminogen activator (tPA), urokinase-type plasminogen activator (uPA), α2-antiplasmin and fibrinogen] during normal menstrual cycle without hormonal contraceptives. Two investigators independently selected studies, and abstracted data in duplicate. We identified 1,046 studies of which we included 30 studies (25 longitudinal and 5 cross-sectional studies). All studies reported on haemostatic variables during menstrual cycle. Overall, most of the studies found no cyclic variation in VWF, FVIII, FXI, FXIII, fibrinolytic factors (PAI, t-PA, uPA, D-dimer and α2-antiplasmin) and fibrinogen. However, in studies where these variables showed any variation, they reached the lowest levels during menstrual and early follicular phase, especially for VWF, FVIII and platelet function tests. In conclusion, the optimal timing for haemostatic testing during menstrual cycle seems to be menstrual and early follicular phase.