Use of Antithrombotic Agents During Pregnancy

This study used a descriptive phenomenological approach to explore the lived experience of women diagnosed with VTE in pregnancy and the perinatal period. The study setting was a London, university affiliated hospital. The sample consisted of nine women with deep vein thrombosis or pulmonary embolism in pregnancy or up to six weeks post-partum, diagnosed in the last two years. Semi-structured interviews were undertaken using an interview guide. Interviews were transcribed and analysed using phenomenological descriptive analysis. Clustered invariant constituents that represented the lived experience of subjects emerged.

The study revealed that the experience of pregnancy-related venous thrombosis is an overwhelmingly negative one with the journey through diagnosis and treatment being fraught with challenges, uncertainty and anxiety. Four main themes that contributed to the women's lived experience were identified: 1. Challenges in establishing a diagnosis; 2. Dealing with diagnosis; 3. Coping with treatment; and 4. Fears for the future.

This is the first study to explore the experience of pregnancy-related venous thrombosis and offers valuable insight into the phenomenon. There is opportunity for clinicians to enhance the experience of pregnancy-related venous thromboembolism (PRVTE) by improving communication and information given to patients, clarifying diagnostic and treatment pathways and improving awareness of the condition.

Antiphospholipid syndrome (APS) is characterized by arterial and venous thrombosis and pregnancy complications that include recurrent early pregnancy loss and late adverse pregnancy outcomes such as foetal death, severe preeclampsia, placental insufficiency, and foetal growth restriction. The pathogenic mechanisms that lead to injury in vivo are not clearly understood, and evidence-based management of ongoing pregnancies in women with APS and late pregnancy complications is difficult to provide due to the lack of randomized clinical trials for this particular group of women. In this chapter, we outline some of the proposed mechanisms by which antiphospholipid antibodies can cause and may perpetuate late complications of pregnancy. The identification of new mechanisms holds promise for new, more effective, and safer treatments. In addition, we focus on available therapeutic options for pregnant women with APS and late adverse pregnancy outcomes.

The antiphospholipid syndrome (APS) is an autoimmune disease characterized by the occurrence of venous and/or arterial thrombosis and pregnancy morbidity in the presence of pathogenic autoantibodies known as antiphospholipid antibodies (aPL). APS may be associated with other diseases, mainly systemic lupus erythematosus (SLE). The presence or absence of SLE might modify the clinical or serological expression of APS. Apart from the classical manifestations, APS patients with associated SLE more frequently display a clinical profile with arthralgias, arthritis, autoimmune hemolytic anemia, livedo reticularis, epilepsy, glomerular thrombosis, and myocardial infarction.

The management of patients with SLE and APS/aPL should include an accurate stratification of vascular risk factors. Low dose aspirin and hydroxychloroquine should be considered as primary prophylaxis. In high risk situations, such as surgery, prolonged immobilization, and puerperium, the prophylaxis should be potentiated with low molecular weight heparin. The challenge of treating patients with a previous vascular event (secondary prophylaxis) is the choice of treatment (anti-platelet agents, anticoagulation with vitamin K antagonists or combined therapy) and its duration, based on individual risk stratification and the site of vascular presentation. The role of novel anticoagulants in APS patients is still to be clearly defined. Novel approaches are needed since the prognosis of SLE patients with APS/aPL is still worse than that of SLE patients with negative aPL. The goal for the future is to improve the outcome of these patients by means of early recognition and optimal preventative treatment.

L’embolie pulmonaire (EP) est l’une des principales étiologies de la mortalité maternelle en France et dans les autres pays développés. Sa prévention est bien codifiée, mais sa prise en charge demeure complexe tant au plan diagnostique que thérapeutique. Le but de cette revue est d’actualiser les connaissances sur la prise en charge diagnostique et thérapeutique de l’EP durant la grossesse.

Revue générale.

Recherche dans les banques de données Medline^® des articles publiés en anglais et français entre 1965 et 2012 combinant les mots clés : EP, grossesse, héparine, thrombolyse et filtre cave employés séparement ou en combinaison. Les éditoriaux, articles originaux, revues générales et cas cliniques ont été sélectionnés.

L’EP est l’une des principales causes de décès maternel en France. Les signes cliniques et les examens biologiques étant peu spécifiques durant la grossesse, le diagnostic repose sur l’imagerie, en utilisant en priorité l’échographie Doppler, examen complémentaire n’exposant pas la parturiente et le fœtus aux radiations. Le traitement repose sur l’anticoagulation curative, en faisant appel en première intention aux héparines de bas poids moléculaire. Un filtre cave temporaire peut être proposé comme traitement complémentaire, notamment en fin de grossesse ou en cas de contre-indication à l’héparinothérapie. En cas d’EP avec choc cardiogénique, le recours à la thrombolyse intraveineuse est possible.

L’approche diagnostique fait appel à l’échographie Doppler en priorité, sans hésiter à recourir à l’angioscanner ou à la scintigraphie de ventilation–perfusion. Le traitement est basé sur les héparines de bas poids moléculaire en première intention (prescription hors AMM). D’autres thérapeutiques, comme la thrombolyse ou le filtre cave, sont à envisager selon les circonstances.

Pulmonary embolism remains a leading cause of maternal death in France and in other developed countries. Prevention is well codified, but management remains complex both for diagnosis and therapeutics. The objective of this review was to update the knowledge on diagnosis and treatment of pulmonary embolism during pregnancy.

Review.

Medline^® database looking for articles published in English or French between 1965 and 2012, using pulmonary embolism, pregnancy, heparin, thrombolysis and vena cava filter as keywords. Editorials, original articles, reviews and cases reports were selected.

Pulmonary embolism is one of the leading causes of maternal death in France. Clinical signs and biologic tests are not specific during pregnancy. Doppler ultrasound is helpful for diagnosis and avoids maternal and fetal radiation. Treatment is based on full anticoagulation. Low molecular weight heparin is the treatment of choice. A temporary vena cava filter may be proposed, especially at the end of pregnancy, or when heparin is contraindicated. In case of pulmonary embolism with cardiogenic shock, thrombolysis is an alternative treatment.

Diagnostic approach is first based on the use of ultrasound- Doppler, and frequently on-to computed tomographic pulmonary angiography or ventilation–perfusion lung scanning. The treatment is based on low molecular weight heparin. Others therapeutics, such as thrombolysis or temporary vena cava filter, may be useful in certain circumstances.