Venous thromboembolism during pregnancy and postpartum period

Background D-dimer increases during pregnancy and is problematic to use in the diagnosis of venous thromboembolism. Fibrin monomer represents an alternative biomarker for venous thromboembolism. However, to be useful in pregnancy, the fibrin monomer concentration should be stable throughout pregnancy and during postpartum. Methods To describe the course of fibrin monomer concentration during pregnancy and the postpartum period in healthy pregnant women and to compare their within-subject biological variation (CVI) with non-pregnant women. Blood samples were obtained every fourth week during pregnancy and three samples after delivery in 20 healthy women and every fourth week during a 40-week period in 19 healthy non-pregnant women. Fibrin monomer (STA Liatest FM, Stago) was analysed in duplicates for all samples. Concentrations of fibrin monomer in pregnant and non-pregnant women were compared and the CVI for fibrin monomer was calculated. Results The median fibrin monomer concentration in pregnant women was 6.2 mg/L (2.5 and 97.5 percentiles 3.7–10.8 mg/L) and in non-pregnant women 4.8 mg/L (3.6–8.2) ( P < 0.01). The fibrin monomer concentration was relatively stable during pregnancy, although a few unexplained high fibrin monomer concentrations were found during pregnancy/postpartum. Fibrin monomer CVI in pregnancy and postpartum was 20.6% (95% CI 18.3, 23.5) and in non-pregnant 16.1% (13.7, 18.9). Conclusions For clinical purposes, fibrin monomer concentration can be considered stable during pregnancy, although it is slightly higher than in non-pregnant women. Pregnant and non-pregnant women have the same CVI. The suitability of fibrin monomer in venous thromboembolism diagnosis in pregnant women should be validated in further studies.

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Hypertensive Complications of Pregnancy and Risk of Venous Thromboembolism

Hypertension ◽

10.1161/hypertensionaha.119.14280 ◽

2020 ◽

Vol 75 (3) ◽

pp. 781-787

Author(s):

Luuk J.J. Scheres ◽

Willem M. Lijfering ◽

Norbert F.M. Groenewegen ◽

Sanne Koole ◽

Christianne J.M. de Groot ◽

...

Keyword(s):

Venous Thromboembolism ◽

Postpartum Period ◽

Reference Group ◽

Later Life ◽

Thrombotic Risk ◽

Hazard Ratios ◽

Anticoagulation Clinics ◽

Pregnancy And Postpartum ◽

Cox Proportional Hazard Models

Hypertension during pregnancy and preeclampsia are associated with increased arterial thrombotic risk in later life. Whether these complications are associated with risk of venous thromboembolism (VTE) on the short term after pregnancy and on the long term, that is, outside pregnancy, is largely unknown. We conducted a nationwide cohort study in women with at least 1 pregnancy and their first VTE risk by linking the Dutch perinatal registry (Perined) to anticoagulation clinics. We used Cox proportional hazard models to estimate hazard ratios (HRs) and corresponding 95% CI for VTE risk in women with hypertension during pregnancy, women with preeclampsia, compared with women with uncomplicated pregnancies (reference). A total of 1 919 918 women were followed for a median of 13.7 (interquartile range, 7.6–19.2) years for a total of 24 531 118 person-years in which 5759 first VTEs occurred; incidence rate: 2.3 (95% CI, 2.3–2.4) per 10 000 person-years. In the first pregnancy and 3-month postpartum period, VTE risk was higher in women with hypertension, HR, 2.0 (95% CI, 1.7–2.4), and highest among women with preeclampsia, HR, 7.8 (95% CI, 5.4–11.3), versus the reference group. On the long term, women with hypertension during pregnancy and preeclampsia had a higher VTE risk: HR, 1.5 (95% CI, 1.4–1.6) and HR, 2.1 (95% CI, 1.8–2.4), respectively, versus the reference group. When excluding events during pregnancy and postpartum, these HRs were 1.4 (95% CI, 1.3–1.5) and 1.6 (95% CI, 1.4–2.0), respectively. In conclusion, hypertension during pregnancy and preeclampsia are associated with an increased VTE risk during pregnancy and postpartum period and in the 13 years after.

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Prophylaxis and management of venous thromboembolism during pregnancy and postpartum period

Obstetrics Gynecology and Reproduction ◽

10.17749/2313-7347/ob.gyn.rep.2021.222 ◽

2021 ◽

Vol 15 (5) ◽

pp. 599-616

Author(s):

V. Ya. Khryshchanovich ◽

N. Ya. Skobeleva

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Pregnant Women ◽

Postpartum Period ◽

Anticoagulation Therapy ◽

Total Duration ◽

Factor Xa ◽

Pregnancy And Postpartum ◽

Routine Administration ◽

History Of

Introduction. Venous thromboembolism (VTE) is one of the lead causes for maternal mortality and morbidity during pregnancy in the majority of developed countries. The incidence rate of VTE per pregnancy-year increases during pregnancy and postpartum period about by 4-fold and at least 14-fold, respectively.Aim: to analyze and summarize current view on risk factors of thrombotic events during gestation and to discuss recent guidelines for the management of venous thromboembolic complications during pregnancy and postpartum, by taking into account a balance between risks and benefits of using anticoagulants.Materials and Methods. The literature search covering the last 10 years was carried out in the electronic scientific databases RSCI, PubMed/MEDLINE, and Embase. While formulating a search strategy for evidence-based information, the PICO method (P = Patient; I = Intervention; C = Comparison; O = Outcome) and the key terms “venous thromboembolism” and “pregnancy” were used.Results. Risk factors were found to include a personal history of VTE, verified inherited or acquired thrombophilia, a family history of VTE and general medical conditions, such as immobilization, overweight, varicose veins, some hematological diseases and autoimmune disorders. VTE is considered being potentially preventable upon prophylactic administration of anticoagulants, but no high confidence randomized clinical trials comparing diverse strategies of thromboprophylaxis in pregnant women have been proposed so far. Because heparins do not cross the placenta, weight-adjusted therapeutic-dose low molecular weight heparins (LMWH) represent the anticoagulant treatment of choice for VTE during pregnancy. Once- and twice-daily dosing regimens are acceptable. However, no evidence suggesting benefits for measurement of factor Xa activities and consecutive LMWH dose adjustments to improve clinical outcomes are available. In case of uncomplicated pregnancy-related VTE, no routine administration of vitamin K antagonists, direct thrombin or factor Xa inhibitors, fondaparinux, or danaparoid is recommended. Lactating women may switch from applying LMWH to warfarin. Anticoagulation therapy should be continued for 6 weeks postpartum with total duration lasting at least for 3 months.Conclusion. VTE is a challenging task in pregnant women expecting to apply a multi-faceted approach for its efficient solution by taking into account updated recommendations and personalized patient-oriented features.

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Influence of Sickle Cell Trait on the Risk of Venous Thromboembolism In Pregnancy and the Postpartum

Blood ◽

10.1182/blood.v116.21.1628.1628 ◽

2010 ◽

Vol 116 (21) ◽

pp. 1628-1628 ◽

Cited By ~ 1

Author(s):

Sofya Pintova ◽

Henny Heisler Billett

Keyword(s):

Venous Thromboembolism ◽

Sickle Cell ◽

Postpartum Period ◽

Conflicts Of Interest ◽

Sickle Cell Trait ◽

Pregnancy And Postpartum ◽

Venous Thromboembolic Events ◽

Group A ◽

Group B ◽

In Pregnancy

Abstract Abstract 1628 Background: Evidence suggests a disparity in the incidence of venous thromboembolic events (VTE) amongst racial groups, with blacks purported to have a higher occurrence of VTE than whites. In contrast, Hispanics and Asians have been observed to have a lower occurrence of VTE. Sickle cell anemia is a known prothrombotic state and recent studies contend that sickle cell trait (SCT) may also predispose to VTE. We hypothesized that SCT might play a role in the increased VTE risk for blacks. To this end, we conducted a study to investigate whether pregnant/postpartum women with SCT have a higher VTE incidence than controls without SCT. Methods: Patient information was obtained using our hospital database spanning the eleven years 1998–2008. All pregnant women seen in our large urban medical center had hemoglobin (Hb) electrophoresis screening on their first clinic visit; demographic data was obtained from the patient at registration. Using prospectively-collected data, three patient cohorts were identified. Group A included women with SCT as identified by %HbS of 30–45% on Hb electrophoresis. To ensure exclusion of patients with sickle cell disease who were post-transfusion, subjects who at any time in their medical record had %HbS >45% were excluded from analysis. HbAA black (Group B) and white (Group C) cohorts were included if %HbA was ≥95.5%. Women who self-identified themselves as Hispanic, multiracial, “declined”, “not available” or “not applicable” were also excluded. VTE cases were identified using ICD-9 codes from hospital, ER or outpatient visit discharges during the pregnancy or postpartum period (294 days before delivery or 56 days after delivery). All charts of VTE indexed cases were reviewed (by SP) to ensure accuracy of reporting. Results: The prevalence of SCT was found to be high (11.1%) in our Group A population as compared to 8.3% in the general pregnant/postpartum non-white population that included Hispanics, multiracial and unavailable individuals. We identified 679 black subjects with SCT, 5465 black subjects with HbAA and 1162 white subjects with HbAA. VTE incidence was 0.44% in Group A (SCT), in 0.49% in Group B (Black AA) and in 0.26% in Group C (White AA). The rate of VTE did not significantly differ between these groups. When patients were included who had been thromboprophylaxed secondary to previous VTEs, the incidence of VTE in Black AA was 0.6%, still not significantly different from the white AA group (p=0.13). Age was a more important factor: patients with VTE were significantly older than non-VTE pregnant patients (mean 32.2 vs. 27.6 years, p=0.0002). As expected, the majority of VTE occurred in the postpartum period (61%). Conclusion: Our results suggest that there is a nonsignificant trend toward a higher incidence of VTE in black HbAA (Group B) as compared to white women with HbAA (Group C) in the pregnant/postpartum period. We could not detect a difference in VTE incidence between black SCT (Group A) and black HbAA (Group B). The role of sickle cell trait as an inherited prothrombotic mutation remains unclear. Even a mild increase in age appears to constitute a prothrombotic risk. However, as VTE remains one of the major causes of maternal mortality, further studies will be needed to better identify risk factors of VTE in pregnancy. Prospective studies identifying such patients may help characterize the true impact of sickle cell trait on venous thromboembolism in pregnancy and postpartum. Disclosures: No relevant conflicts of interest to declare.

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Preventing venous thromboembolism during pregnancy and postpartum: crossing the threshold

Hematology ◽

10.1182/asheducation-2017.1.160 ◽

2017 ◽

Vol 2017 (1) ◽

pp. 160-167 ◽

Cited By ~ 8

Author(s):

Leslie Skeith

Keyword(s):

Decision Making ◽

Molecular Weight ◽

Venous Thromboembolism ◽

Postpartum Period ◽

Low Molecular Weight Heparin ◽

Patient Perspectives ◽

Low Molecular Weight ◽

Labor And Delivery ◽

Risk Threshold ◽

Pregnancy And Postpartum

Abstract When should a patient with a known thrombophilia or prior venous thromboembolism (VTE) receive low-molecular-weight heparin (LMWH) prophylaxis during pregnancy and/or the postpartum period? Accurately predicting thrombotic and bleeding risks and knowing what to do with this information is at the heart of decision-making in these challenging scenarios. This article will explore the concept of a risk threshold from clinician and patient perspectives and provide guidance for the use of antepartum and postpartum LMWH prophylaxis in women with a known thrombophilia or prior VTE. Advice for the management of LMWH prophylaxis use around labor and delivery is also reviewed.

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Clinical Characteristics and Outcomes of Women Presenting with Venous Thromboembolism during Pregnancy and Postpartum Period: Findings from the RIETE Registry

Thrombosis and Haemostasis ◽

10.1055/s-0040-1714211 ◽

2020 ◽

Vol 120 (10) ◽

pp. 1454-1462

Author(s):

Islam Y. Elgendy ◽

Annemarie Fogerty ◽

Ángeles Blanco-Molina ◽

Vladimir Rosa ◽

Sebastian Schellong ◽

...

Keyword(s):

Risk Factors ◽

Venous Thromboembolism ◽

Postpartum Period ◽

Vena Cava ◽

Adverse Outcomes ◽

Postpartum Woman ◽

Postpartum Women ◽

Vena Cava Filters ◽

Pregnancy And Postpartum ◽

Using Data

AbstractAlthough venous thromboembolism (VTE) is a leading cause of maternal mortality, there is a paucity of real-world clinical data on clinical presentation and management of VTE during pregnancy and postpartum period. Using data from the international RIETE (Registro Informatizado Enfermedad Trombo Embólica) registry, pregnant and postpartum women with VTE were identified. Baseline characteristics, risk factors, therapies, and outcomes were compared. From March 2001 to July 2019, 596 pregnant and 523 postpartum women had symptomatic, objectively confirmed VTE. Pregnant or postpartum women were less likely to have another risk factor for VTE (i.e., immobility, cancer, recent travel) than nonpregnant women aged < 50 years. The prevalence of thrombophilia was higher among pregnant and postpartum women compared with nonpregnant women (53.2% vs. 46%). Pulmonary embolism (PE) was less commonly diagnosed in pregnant versus postpartum women (27% vs. 42%). Pregnant women with PE were commonly treated with low molecular weight heparin (73% vs. 29%), and received more inferior vena cava filters (6.0% vs. 4.2%) compared with postpartum women. By 90 days, one pregnant and one postpartum woman died after PE, and one died after a deep venous thrombosis. The incidence of recurrent VTE was low. In this largest cohort of pregnant and postpartum women with confirmed VTE, we found that pregnant and postpartum women with VTE were unlikely to present with other risk factors for VTE. Adverse outcomes in our study were uncommon.

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Hormonal contraception in thrombophilic adolescents

Hämostaseologie ◽

10.5482/ha-1177 ◽

2012 ◽

Vol 32 (01) ◽

pp. 15-21 ◽

Cited By ~ 6

Author(s):

H. Rott

Keyword(s):

Venous Thromboembolism ◽

Unintended Pregnancy ◽

Postpartum Period ◽

Hormonal Contraception ◽

Oral Contraception ◽

Coagulation System ◽

Pregnancy And Postpartum

SummaryAbout 3.2 million women in Germany are between 14 and 19 years old representing about 19% of women. 55% of them use combined oral contraception (COC). The risk of venous thromboembolism (VTE) during the use of COC is increased 2–6 times. For thrombophilic patients depending on the kind of thrombophilic defect it is much higher. Pregnancy and postpartum period lead to a much higher increase of VTE than any COC use at all, both in women with and without thrombophilic defect. VTE risk in COC is highly dependent on the content of ethinylestradiol (EE) and the kind of progestagen used in COC. Progestagen-only contraceptives (POC) do not increase the VTE risk, since they do not activate the coagulation system. Conclusion: It is not justified to withhold any hormonal contraception to thrombophilic women, especially considering the much higher VTE risk in (maybe unintended) pregnancy. Adolescents thrombophilic women should rather be informed about the opportunity to use POC.

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