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8 results

  • 9 - CHALLENGING TRADITION: THE STORY OF EMBOLISM

  • James Owen Drife, University of Leeds, Gwyneth Lewis, University College London, James P Neilson, University of Liverpool, Marian Knight, National Perinatal Epidemiology Unit, Oxford, Griselda Cooper, University of Birmingham, Roch Cantwell, Southern General Hospital, Glasgow
  • Book:
    Why Mothers Died and How their Lives are Saved
    Published online:
    05 April 2023
    Print publication:
    30 March 2023, pp 110-123

  • Summary

    Lying in after giving birth has a long tradition but carries a risk of thrombosis. Blood clots form in leg veins and may embolise to the lungs, causing death. Early CEMD Reports did not recognise the benefits of early ambulation but divided thromboembolism deaths into three groups – during pregnancy, after vaginal delivery and after caesarean section. The Reports identified risk factors including age, obesity and caesarean section, and found that warning symptoms were being ignored. Shorter hospital stay reduced the number of deaths after vaginal birth. Caesarean section rates rose and an Enquiry into Perioperative Deaths (modelled on the CEMD) revealed the risk factors for post-operative thromboembolism. An 1995 an RCOG report advised on preventive measures including anticoagulants, previously avoided lest they cause bleeding. A sharp fall in deaths after caesarean section followed in 1997-9. By then thromboembolism was the leading Direct cause of maternal death and the benefits of guidelines had become clear. In 2004 the RCOG published a guideline on thromboprophylaxis in pregnancy and in 2006-8 thomboembolism fell to third place among causes of Direct death.

  • Thromboprophylaxis strategies for children with single-ventricle circulations (superior or total cavo-pulmonary connections) after stent implantation

  • Yinn K. Ooi, R. Allen Ligon, Michael Kelleman, Robert N. Vincent, Holly D. Bauser-Heaton, Dennis W. Kim, Christopher J. Petit
  • Journal:
    Cardiology in the Young / Volume 29 / Issue 7 / July 2019
    Published online by Cambridge University Press:
    18 June 2019, pp. 877-884
  • Objective:

    To define optimal thromboprophylaxis strategy after stent implantation in superior or total cavopulmonary connections.

    Background:

    Stent thrombosis is a rare complication of intravascular stenting, with a perceived higher risk in single-ventricle patients.

    Methods:

    All patients who underwent stent implantation within superior or total cavopulmonary connections (caval vein, innominate vein, Fontan, or branch pulmonary arteries) were included. Cohort was divided into aspirin therapy alone versus advanced anticoagulation, including warfarin, enoxaparin, heparin, or clopidogrel. Primary endpoint was in-stent or downstream thrombus, and secondary endpoints included bleeding complications.

    Results:

    A total of 58 patients with single-ventricle circulation underwent 72 stent implantations. Of them 14 stents (19%) were implanted post-superior cavopulmonary connection and 58 (81%) post-total cavopulmonary connection. Indications for stenting included vessel/conduit stenosis (67%), external compression (18%), and thrombotic occlusion (15%). Advanced anticoagulation was prescribed for 32 (44%) patients and aspirin for 40 (56%) patients. Median follow up was 1.1 (25th–75th percentile, 0.5–2.6) years. Echocardiograms were available in 71 patients (99%), and advanced imaging in 44 patients (61%). Thrombosis was present in two patients on advanced anticoagulation (6.3%) and none noted in patients on aspirin (p = 0.187). Both patients with in-stent thrombus underwent initial stenting due to occlusive left pulmonary artery thrombus acutely post-superior cavopulmonary connection. There were seven (22%) significant bleeding complications for advanced anticoagulation and none for aspirin (p < 0.001).

    Conclusions:

    Antithrombotic strategy does not appear to affect rates of in-stent thrombus in single-ventricle circulations. Aspirin alone may be sufficient for most patients undergoing stent implantation, while pre-existing thrombus may warrant advanced anticoagulation.

  • 17 - Acute puerperal uterine inversion

  • from Section 4 - PostpartumEmergencies
  • Edited by Edwin Chandraharan, Sabaratnam Arulkumaran
  • Book:
    Obstetric and Intrapartum Emergencies
    Published online:
    05 November 2012
    Print publication:
    11 October 2012, pp 120-125

  • Summary

    This chapter describes the types, key implications and management strategies of massive obstetric haemorrhage. Antepartum haemorrhage due to placental abruption and intrapartum haemorrhage due to uterine rupture are associated with increased perinatal mortality. Visible blood loss greater than 2 litres, ongoing bleeding are some key pointers of massive obstetric haemorrhage. Immediate management involves active resuscitation to ensure a patient airway, breathing and maintaining circulation with intravenous fluids, blood and blood products as well as correction of coagulopathy. In women who are not acutely compromised or bleeding severely, interventional radiology can be considered. If the bleeding is predominantly from the lower segment, a total abdominal hysterectomy is warranted. Women with massive obstetric haemorrhage often need multi-organ support. Hence, transfer to an intensive care unit or high dependency unit should be considered for monitoring. Thromboprophylaxis should be considered once the coagulation parameters return to normal.

  • Chapter 17 - Pre-eclampsia

  • from Section 6 - Microangiopathies
  • Edited by Sue Pavord, Beverley Hunt
  • Book:
    The Obstetric Hematology Manual
    Published online:
    06 December 2010
    Print publication:
    15 April 2010, pp 203-217

  • Summary

    This chapter addresses the practical obstetric and anesthetic management of women on prophylactic heparin and therapeutic anticoagulation in the peri-partum period, and the dilemmas for obstetricians, anesthetists, and hematologists. It considers issues surrounding use of thrombolytic agents in pregnancy, and unusual but complex situations such as cardiopulmonary bypass in pregnancy. Increasing use of prophylactic anticoagulants in pregnancy, both for venous thromboprophylaxis and to modify fetal risk, as in antiphospholipid syndrome, means that more women are now reaching the peri-partum period on anticoagulants, usually a low molecular weight heparin. The safety in pregnancy of other antiplatelet agents such as clopidogrel or ticlopidine at usual therapeutic doses has not been established and they are rarely used. Most of the women requiring prophylactic doses of anticoagulant will be given one of the low molecular weight heparins (LMWH).

  • Chapter 15 - Inherited coagulopathies

  • from Section 5 - Hemorrhagic disorders
  • Edited by Sue Pavord, Beverley Hunt
  • Book:
    The Obstetric Hematology Manual
    Published online:
    06 December 2010
    Print publication:
    15 April 2010, pp 186-193

  • Summary

    Venous thromboembolism (VTE) is the leading direct cause of maternal mortality in the UK, but many cases are potentially preventable. Risk factors for VTE should be identified pre-pregnancy, or at least early in pregnancy, and reassessed throughout pregnancy and the puerperium, as level of risk may change. Pregnancy itself is a risk factor for VTE, and additional risk factors include previous VTE, thrombophilia, and obesity. Thromboprophylaxis should be introduced depending on the level of risk. Guidelines are given for both ante-natal and post-natal management and in particular for the highest risk period immediately postpartum. Thromboprophylaxis involves both nonpharmacological and pharmacological measures, and the various modalities and drugs that can be used are discussed in this chapter. Non-pharmacological measures include appropriate hydration, early mobilization after surgery or delivery, graduated compression stockings (TEDS), and pneumatic compression boots. Aspirin, heparin, and warfarin are the main pharmacological agents to be used in thromboprophylaxis.

  • 7 - Venous thromboembolism in obstetrics and gynaecology

  • Edited by Ann Harper
  • Book:
    Haemorrhage and Thrombosis for the MRCOG and Beyond
    Published online:
    05 October 2014
    Print publication:
    01 June 2005, pp 90-110

  • Summary

    Venous thromboembolism (VTE) remains the major cause of mortality in association with pregnancy and childbirth and a source of morbidity. Many therapeutic agents may be used in the management of VTE. The choice of the agent and dosage is determined by the setting, balance of risks and benefit, and individual patient factors such as allergy or co-morbidity. Certain therapeutic agents include heparin, warfarin, dextran 70, aspirin and hirudin. The identification of risk factors for VTE provides an opportunity for prevention. The symptoms and signs of deep veins of lower limbs (DVT) include leg pain, swelling, tenderness, oedema, pyrexia, lower abdominal pain and elevated white cell count. Traditionally, unfractionated heparin (UFH) has been used in the initial management of VTE as such treatment reduces the risk of further thromboembolism compared with no treatment. Thromboprophylaxis is effective in reducing the incidence of VTE.