Individually Tailored Prophylaxis Using a Risk Score for the Management of Pregnant Women with Increased Risk of Venous Thromboembolism

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 889-889
Author(s):  
Yesim G. Dargaud ◽  
Lucia Rugeri ◽  
Chloe Fleury ◽  
Helene Desmurs Clavel ◽  
Jacques Ninet ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Prospective Study ◽  
Pregnant Women ◽  
Risk Score ◽  
Personal History ◽  
Vein Thrombosis ◽  
Increased Risk ◽  
History Of

Abstract Patients with thrombophilia and/or a history of venous thromboembolism (VTE) exhibit a high risk of thrombosis during pregnancy. A risk score for pregnancies with increased risk of VTE was previously described by our group (1,2). The present work reports the results of a prospective study, evaluating the efficacy and the safety of the prophylaxis strategy based on the same risk score, in 542 pregnancies at high risk of VTE, managed between 2005 and 2015 in Lyon University Hospitals. Among 445 patients included in the study, 26 had several pregnancies during the study period. The mean age of the study population was 33±4.8 years, 132 women (29.7%) were older than 35 years. Fifty three women had a BMI of 30 or over and 61 were smokers. Among these 445 patients, 279 had a personal history of VTE (62.7%), 299 patients (67.2%) had a thrombophilia marker and 131 (29.4%) thrombophilic women had a personal history of VTE. During pregnancy, patients were assigned to one of three prophylaxis strategies according to the risk scoring system. Compression stockings were worn by the majority of the patients throughout the pregnancy and during the postpartum. In antepartum, LMWH prophylaxis was prescribed to 64.5% of patients with high risk of VTE. Among them, 34.4% were treated in the third trimester only and 30.1% were treated throughout pregnancy. In postpartum, all patients received low molecular weight heparin (LMWH) prophylaxis for at least 6 weeks. In this cohort, two antepartum-related VTE (0.37%) and four postpartum-related VTE (0.73%) occurred. One of the ante-partum related VTE was occurred in a patient who was on LMWH prophylaxis with enoxaparin 40mg/day for a personal history of spontaneous pulmonary embolism and homozygous prothrombin G20210A mutation. Despite well conducted LMWH prophylaxis, the patient had a distal deep vein thrombosis (DVT) at week 28. The second VTE was a proximal DVT during a bed resting in the eighth month of pregnancy in a patient with heterozygous FV Leiden mutation and a history of proximal DVT. According to the risk score, LMWH prophylaxis was required during bed-resting but it was not prescribed by the obstetrician. Among four postpartum-related VTE, 3 occurred after the 6 weeks of LMWH prophylaxis, between weeks 8 and 12 of the postpartum period and one was a ovarian vein thrombosis. No case of pulmonary embolism was observed during the study period. The rate of bleeding was 0.37%, no serious bleeding requiring transfusions or surgery was occurred during the study period. There was no evidence of heparin-induced thrombocytopenia or osteoporosis. The use of a risk score may provide a rational decision process to implement safe and effective antepartum thromboprophylaxis in pregnant women at high risk of VTE Dargaud, Y., Rugeri, L., Ninet, J., Negrier, C. & Trzeciak, M.C. Management of pregnant women with increased risk of venous thrombosis. International Journal of Gynaecology and Obstetrics 2005, 90,203-207 Dargaud, Y., Rugeri, L., Vergnes MC, Arnuti B, Miranda P, Negrier, C., Ninet, J., Trzeciak, M.C. A risk score for the management of pregnant women with increased risk of venous thrombomebolism: a multicenter prospective study. Br J Haematol 2009;145:825-35 Disclosures No relevant conflicts of interest to declare.

scholarly journals A risk score for the management of pregnant women with increased risk of venous thromboembolism: a multicentre prospective study

2009 ◽  
Vol 145 (6) ◽  
pp. 825-835 ◽  
Author(s):  
Yesim Dargaud ◽  
Lucia Rugeri ◽  
Marie Christine Vergnes ◽  
Brigitte Arnuti ◽  
Paula Miranda ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Prospective Study ◽  
Pregnant Women ◽  
Risk Score ◽  
Increased Risk ◽  
Multicentre Prospective Study

scholarly journals Modified IMPROVE VTE Risk Score and Elevated D-Dimer Identify a High Venous Thromboembolism Risk in Acutely Ill Medical Population for Extended Thromboprophylaxis

TH Open ◽  
2020 ◽  
Vol 04 (01) ◽  
pp. e59-e65 ◽  
Author(s):  
Alex C. Spyropoulos ◽  
Concetta Lipardi ◽  
Jianfeng Xu ◽  
Colleen Peluso ◽  
Theodore E. Spiro ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
High Risk ◽  
Risk Score ◽  
Lower Risk ◽  
Risk Group ◽  
High Risk Group ◽  
Cutoff Score ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
D Dimer

AbstractAn individualized approach to identify acutely ill medical patients at increased risk of venous thromboembolism (VTE) and a low risk of bleeding to optimize the benefit and risk of extended thromboprophylaxis (ET) is needed. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE risk score has undergone extensive external validation in medically ill patients for in-hospital use and a modified model was used in the MARINER trial of ET also incorporating an elevated D-dimer. The MAGELLAN study demonstrated efficacy with rivaroxaban but had excess bleeding. This retrospective analysis investigated whether the modified IMPROVE VTE model with an elevated D-dimer could identify a high VTE risk subgroup of patients for ET from a subpopulation of the MAGELLAN study, which was previously identified as having a lower risk of bleeding. We incorporated the modified IMPROVE VTE score using a cutoff score of 4 or more or 2 and 3 with an elevated D-dimer (>2 times the upper limit of normal) to the MAGELLAN subpopulation. In total, 56% of the patients met the high-risk criteria. In the placebo group, the total VTE event rate at Day 35 was 7.94% in the high-risk group and 2.83% for patients in the lower-risk group. A reduction in VTE was observed with rivaroxaban in the high-risk group (relative risk [RR]: 0.68, 95% confidence interval [CI]: 0.51–0.91, p = 0.008) and in the lower-risk group (RR: 0.69, 95% CI: 0.40 -1.20, p = 0.187). The modified IMPROVE VTE score with an elevated D-dimer identified a nearly threefold higher VTE risk subpopulation of patients where a significant benefit exists for ET using rivaroxaban.

scholarly journals Case Report: Unprovoked venous thromboembolism in a young adult

F1000Research ◽  
2019 ◽  
Vol 8 ◽  
pp. 182
Author(s):  
Jeyhan Dhabhar ◽  
Varshil Mehta ◽  
Nimit Desai ◽  
Sameer Dawoodi ◽  
Sojib Bin Zaman
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Trauma Surgery ◽  
Sudden Onset ◽  
Vein Thrombosis ◽  
Doppler Study ◽  
Pulmonary Angiogram ◽  
Co Morbidity ◽  
History Of ◽  
Prolonged Immobilization

A 24-year-old male was presented to us with sudden onset of chest pain and dyspnea for the past one hour. There was no history of calf pain, trauma, surgery, prolonged immobilization, long-haul air travel, bleeding diathesis or any other co-morbidity. The patient denied any addiction history. The Electrocardiogram showed tachycardia with S1Q3T3 pattern. The left arterio-venous Doppler study was suggestive of a thrombus in popliteal vein and sapheno-popliteal junction. The CT-Pulmonary Angiogram scan was suggestive of a massive pulmonary thromboembolism. The patient was thrombolysed with Intravenous Alteplase immediately and was put on tab Rivaroxaban for maintenance. He was later discharged after being stable. Unprovoked venous thromboembolism (VTE) is very rare and has the potential to lead to pulmonary embolism which could be disastrous, especially in young adults. We present such a case where unprovoked VTE was diagnosed and treated. This case suggests that high clinical suspicion is the key for the diagnosis of acute pulmonary embolism, especially in the absence of history suggestive of deep vein thrombosis.

Risk stratification and heparin prophylaxis to prevent venous thromboembolism in pregnant women

2007 ◽  
Vol 98 (12) ◽  
pp. 1237-1245 ◽  
Author(s):  
Joachim Dudenhausen ◽  
Andree Faridi ◽  
Thorsten Fischer ◽  
Samson Fung ◽  
Ulrich Geisen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Venous Thromboembolism ◽  
Pregnant Women ◽  
Management Strategies ◽  
Prospective Trial ◽  
High Risk Group ◽  
Group I ◽  
Increased Risk ◽  
History Of ◽  
Heparin Prophylaxis

SummaryWomen with a history of venous thromboembolism (VTE), thrombophilia or both may be at increased risk of thrombosis during pregnancy, but the optimal management strategy is not well defined in clinical guidelines because of limited trial data. A strategy of risk assessment and heparin prophylaxis was evaluated in pregnant women at increased risk of VTE. In a prospective trial (Efficacy of Thromboprophylaxis as an Intervention during Gravidity [EThIG]), 810 pregnant women were assigned to one of three management strategies according to pre-defined risk factors related to history of VTE and thrombophilic profile. Low-risk women (group I), received 50–100 IU dalteparin/ kg body weight/ day for 14 days postpartum, or earlier when additional risk factors occurred. Women at high (group II) or very high risk (group III) received dalteparin from enrolment until six weeks postpartum (50–100 IU and 100–200 IU/ kg/ day, respectively). Objectively confirmed, symptomatic VTE occurred in 5/810 women (0.6%; 95% confidence interval [CI], 0.2 to 1.5%) (group I, 0 of 225; II, 3/469; III, 2/116). The rate of serious bleeding was 3.0% (95 % CI, 1.9 to 4.4%); 1.1% (95 % CI, 0.5 to 2.2%) was possibly dalteparin-related. There was no evidence of heparin- induced thrombocytopenia, one case of osteoporosis, and rates of miscarriage and stillbirth were similar to previous, retrospective studies. Risk-stratified heparin prophylaxis was associated with a low incidence of symptomatic VTE and few clinically important adverse events. Antepartum heparin prophylaxis is, therefore, warranted in pregnant women with idiopathic thrombosis or symptomatic thrombophilia.

scholarly journals Pregnancy vs. Paycheck: A qualitative study of patient’s experience with employment during pregnancy at high risk for preterm birth

2020 ◽  
Author(s):  
Sarahn M. Wheeler ◽  
Kelley E. C. Massengale ◽  
Konyin Adewumi ◽  
Thelma A. Fitzgerald ◽  
Carrie B. Dombeck ◽  
...  
Keyword(s):  
Preterm Birth ◽  
High Risk ◽  
Prenatal Care ◽  
Pregnant Women ◽  
Structured Interview ◽  
Close Monitoring ◽  
Risk Pregnancy ◽  
Increased Risk ◽  
History Of ◽  
In Pregnancy

Abstract Background: Pregnant women with a history of preterm birth are at risk for recurrence, often requiring frequent prenatal visits for close monitoring and/or preventive therapies. Employment demands can limit uptake and adherence to recommended monitoring and preterm birth prevention therapies. Method: We conducted a qualitative descriptive study using in-depth interviews (IDIs) of pregnant women with a history of preterm birth. IDIs were conducted by trained qualitative interviewers following a semi-structured interview guide focused on uncovering barriers and facilitators to initiation of prenatal care, including relevant employment experiences, and soliciting potential interventions to improve prompt prenatal care initiation. The IDIs were analyzed via applied thematic analysis. Results: We described the interview findings that address women’s employment experiences. The current analysis includes 27 women who are majority self-described as non-Hispanic Black (74%) and publically insured (70%). Participants were employed in a range of professions; food services, childcare and retail were the most common occupations. Participants described multiple ways that being pregnant impacted their earning potential, ranging from voluntary work-hour reduction, involuntary duty hour reductions by employers, truncated promotions, and termination of employment. Participants also shared varying experiences with workplace accommodations to their work environment and job duties based on their pregnancy. Some of these accommodations were initiated by a collaborative employee/employer discussion, others were initiated by the employer’s perception of safe working conditions in pregnancy, and some accommodations were based on medical recommendations. Participants described supportive and unsupportive employer reactions to requests for accommodations. Conclusions: Our findings provide novel insights into women’s experiences balancing a pregnancy at increased risk for preterm birth with employment obligations. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful. Many of the findings suggest profound misunderstandings likely exist at the patient, employer and clinical provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy.

scholarly journals Risk Factor Profiles in Patients with Different Clinical Manifestations of Venous Thromboembolism: A Focus on the Factor V Leiden Mutation

1996 ◽  
Vol 76 (04) ◽  
pp. 510-513 ◽  
Author(s):  
Bert Manten ◽  
Rudi G J Westendorp ◽  
Ted Koster ◽  
Pieter H Reitsma ◽  
Frits R Rosendaal
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Clinical Manifestations ◽  
Factor V Leiden ◽  
Factor V ◽  
Factor V Leiden Mutation ◽  
Vein Thrombosis ◽  
Increased Risk ◽  
Deep Vein

Summary Background. Patients with venous thromboembolic disease may present with different clinical manifestations. Factor V Leiden mutation leading to resistance to activated protein C is associated with a sevenfold increased risk for presenting with deep-vein thrombosis. It is not yet established whether carriers of the mutation have a similarly increased risk for manifesting with pulmonary embolism. Methods. From an Anticoagulation Clinic monitoring coumarin therapy, a consecutive series of patients with a first thromboembolic event (objectively proven by current radiological methods) were enrolled. All patients were interviewed and blood was drawn for geno-typing. From the hospital charts and the personal interview, information was obtained on acquired risk factors and the signs and symptoms on hospital admission. Results. 45 patients presented with symptoms of pulmonary embolism only, 211 had only symptoms of deep-vein thrombosis whereas 23 had clinical features of both. In about half of the patients acquired risk factors for venous thromboembolism were present which did not differ between the three groups of patients. Recent surgery had been performed more often in patients presenting with pulmonary embolism than in other patients (33.3% vs. 18.5%, p <0,05). Factor V Leiden was present in 9% of the patients presenting with pulmonary embolism (relative risk: 3.3 95% Cl: 1.0-10.6) and 17% of the patients presenting with deep-vein thrombosis (relative risk: 6.9 95% Cl: 3.6-12.8). The prevalence of factor V Leiden was intermediate in patients with both clinical characteristics. Conclusion. These data suggest that patients with venous thromboembolism have different clinical presentation depending on the risk factor profile. Factor V Leiden may preferentially lead to manifest deep-vein thrombosis. Differences in structure of venous thrombi could underlie differences in embolic tendency.

scholarly journals Case Report: Unprovoked venous thromboembolism in a young adult male

F1000Research ◽  
2019 ◽  
Vol 8 ◽  
pp. 182
Author(s):  
Jeyhan Dhabhar ◽  
Varshil Mehta ◽  
Nimit Desai ◽  
Sameer Dawoodi ◽  
Sojib Bin Zaman
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Trauma Surgery ◽  
Sudden Onset ◽  
Vein Thrombosis ◽  
Doppler Study ◽  
Pulmonary Angiogram ◽  
Co Morbidity ◽  
History Of ◽  
Prolonged Immobilization

A 24-year-old male was presented to us with sudden onset of chest pain and dyspnea for the past one hour. There was no history of calf pain, trauma, surgery, prolonged immobilization, long-haul air travel, bleeding diathesis or any other co-morbidity. The patient denied any addiction history. The heart rate was 114 beats/min, and blood pressure was 106/90 mmHg. Electrocardiogram showed tachycardia with S 1Q 3T 3 pattern. The left arterio-venous Doppler study was suggestive of a thrombus in popliteal vein and sapheno-popliteal junction. The CT-Pulmonary Angiogram scan was suggestive of a massive pulmonary thromboembolism. The patient was thrombolysed with Intravenous Alteplase immediately and was put on tab Rivaroxaban for maintenance. He was later discharged after being stable. Unprovoked venous thromboembolism (VTE) is very rare and has the potential to lead to pulmonary embolism which could be disastrous, especially in young adults. We present such a case where unprovoked VTE was diagnosed and treated. This case suggests that high clinical suspicion is the key for the diagnosis of acute pulmonary embolism, especially in the absence of history suggestive of deep vein thrombosis.

scholarly journals Obstetric Thromboprophylaxis: The Swedish Guidelines

2011 ◽  
Vol 2011 ◽  
pp. 1-6 ◽  
Author(s):  
Pelle G. Lindqvist ◽  
Margareta Hellgren
Keyword(s):  
Risk Factors ◽  
Cost Effectiveness ◽  
High Risk ◽  
Risk Score ◽  
Risk Estimation ◽  
Lifestyle Advice ◽  
Estimation Model ◽  
Increased Risk ◽  
History Of ◽  
The Cost

Obstetric thromboprophylaxis is difficult. Since 10 years Swedish obstetricians have used a combined risk estimation model and recommendations concerning to whom, at what dose, when, and for how long thromboprophylaxis is to be administrated based on a weighted risk score. In this paper we describe the background and validation of the Swedish guidelines for obstetric thromboprophylaxis in women with moderate-high risk of VTE, that is, at similar or higher risk as the antepartum risk among women with history of thrombosis. The risk score is based on major risk factors (i.e., 5-fold increased risk of thromboembolism). We present data on the efficacy of the model, the cost-effectiveness, and the lifestyle advice that is given. We believe that the Swedish guidelines for obstetric thromboprophylaxis aid clinicians in providing women at increased risk of VTE with effective and appropriate thromboprophylaxis, thus avoiding both over- and under-treatment.

scholarly journals Pregnancy vs. paycheck: a qualitative study of patient’s experience with employment during pregnancy at high risk for preterm birth

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Sarahn M. Wheeler ◽  
Kelley E. C. Massengale ◽  
Konyin Adewumi ◽  
Thelma A. Fitzgerald ◽  
Carrie B. Dombeck ◽  
...  
Keyword(s):  
Preterm Birth ◽  
High Risk ◽  
Prenatal Care ◽  
Pregnant Women ◽  
Structured Interview ◽  
Close Monitoring ◽  
Risk Pregnancy ◽  
Increased Risk ◽  
History Of ◽  
In Pregnancy

Abstract Background Pregnant women with a history of preterm birth are at risk for recurrence, often requiring frequent prenatal visits for close monitoring and/or preventive therapies. Employment demands can limit uptake and adherence to recommended monitoring and preterm birth prevention therapies. Method We conducted a qualitative descriptive study using in-depth interviews (IDIs) of pregnant women with a history of preterm birth. IDIs were conducted by trained qualitative interviewers following a semi-structured interview guide focused on uncovering barriers and facilitators to initiation of prenatal care, including relevant employment experiences, and soliciting potential interventions to improve prompt prenatal care initiation. The IDIs were analyzed via applied thematic analysis. Results We described the interview findings that address women’s employment experiences. The current analysis includes 27 women who are majority self-described as non-Hispanic Black (74%) and publically insured (70%). Participants were employed in a range of professions; food services, childcare and retail were the most common occupations. Participants described multiple ways that being pregnant impacted their earning potential, ranging from voluntary work-hour reduction, involuntary duty hour reductions by employers, truncated promotions, and termination of employment. Participants also shared varying experiences with workplace accommodations to their work environment and job duties based on their pregnancy. Some of these accommodations were initiated by a collaborative employee/employer discussion, others were initiated by the employer’s perception of safe working conditions in pregnancy, and some accommodations were based on medical recommendations. Participants described supportive and unsupportive employer reactions to requests for accommodations. Conclusions Our findings provide novel insights into women’s experiences balancing a pregnancy at increased risk for preterm birth with employment obligations. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful. Many of the findings suggest profound misunderstandings likely exist at the patient, employer and clinical provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy.

Abstract 6205: Variants of CYP4V2, SERPINC1 and GP6 Are Associated with Pulmonary Embolism

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Lance A Bare ◽  
Irene D Bezemer ◽  
Carmen H Tong ◽  
Andre R Arellano ◽  
Charles M Rowland ◽  
...  
Keyword(s):  
Risk Factors ◽  
Pulmonary Embolism ◽  
Venous Thrombosis ◽  
Risk Allele ◽  
Population Attributable Risk ◽  
Nucleotide Polymorphisms ◽  
Logistic Regression Models ◽  
Vein Thrombosis ◽  
Increased Risk ◽  
History Of

Background: Pulmonary Embolism is a potentially fatal manifestation of venous thrombosis that may share genetic risk factors with deep vein thrombosis (DVT). Recently, 3 single nucleotide polymorphisms (SNPs) were reported to be associated with DVT in three studies: rs13146272 in CYP4V2 , rs2227589 in SERPINC1 , rs1613662 in GP6 . We investigated whether these 3 SNPs were also associated with pulmonary embolism. Methods: We genotyped 5840 subjects from the Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA study). Cases were 1,206 patients who had a pulmonary embolism without a symptomatic DVT: isolated pulmonary embolism (PE iso ). Controls were 4,634 subjects who had no history of DVT or pulmonary embolism. We tested the association between genotypes and PE iso using logistic regression models that adjusted for age and sex. Results: For all three SNPs, the same allele that had been previously found to be associated with increased risk of DVT was also associated with increased risk of PE iso . For homozygous carriers of the risk allele, compared with noncarriers, the ORs were 1.34 (95% CI, 1.08–1.67) for rs13146272 in CYP4V2 , 1.85 (95% CI, 1.08–3.16) for rs2227589 in SERPINC1 , and 1.20 (95% CI, 1.04–1.39) for rs1613662 in GP6. The frequencies of risk allele homozygotes in the controls of the MEGA study were 41% for rs13146272, 1% for rs2227589, and 67% for rs1613662. Conclusions: Three SNPs previously reported to be associated with DVT were found to be associated with PE iso . Because of the high frequencies of two of these polymorphisms in Caucasians, these SNPs are likely make an appreciable contribution to the population attributable risk for PE iso .

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