Venous thromboembolism risk score during hospitalization in pregnancy: results of 10694 prospective evaluations in a clinical trial

Abstract Objectives Hospitalization during pregnancy and childbirth increases the risk of Venous Thromboembolism Risk (VTE). This study applied a VTE risk score to all hospitalized pregnant women to ascertain its effectiveness in preventing maternal death from VTE until 3 months after discharge. Methods In this interventional study, patients were classified as low- or high-risk according to the VTE risk score (Clinics Hospital risk score). High-risk patients (score ≥ 3) were scheduled for pharmacological Thromboprophylaxis (TPX). Interaction analysis of the main risk factors was performed using Odds Ratio (OR) and Poisson regression with robust variance. Results The data of 10694 cases (7212 patients) were analyzed; 1626 (15.2%, 1000 patients) and 9068 (84.8%, 6212 patients) cases were classified as high-risk (score ≥ 3) and low-risk (score < 3), respectively. The main risk factors (Odds Ratio, 95% Confidence Interval) for VTE were age ≥ 35 and < 40 years (1.6, 1.4-1.8), parity ≥ 3 (3.5, 3.0-4.0), age ≥ 40 years (4.8, 4.1-5.6), multiple pregnancies (2.1, 1.7-2.5), BMI ≥ 40 kg/m2 (5.1, 4.3-6.0), severe infection (4.1, 3.3-5.1), and cancer (12.3, 8.8-17.2). There were 10 cases of VTE: 7/1636 (0.4%) and 3/9068 (0.03%) in the high- and low-risk groups, respectively. No patient died of VTE. The intervention reduced the VTE risk by 87%; the number needed to treat was 3. Conclusions This VTE risk score was effective in preventing maternal deaths from VTE, with a low indication for TPX. Maternal age, multiparity, obesity, severe infections, multiple pregnancies, and cancer were the main risk factors for VTE.

Serum vascular endothelial growth factor as a marker for tubal pregnancy

SUMMARY OBJECTIVE: The objective of this study was to evaluate whether a single measurement of vascular endothelial growth factor could distinguish between intrauterine pregnancy and ectopic pregnancy and to correlate the levels of vascular endothelial growth factor with serum levels of progesterone andβ-human chorionic gonadotropin in each subgroup. METHODS: Ninety patients with a positive human chorionic gonadotropin test and either abdominal pain or vaginal bleeding were selected; pregnancies were singletons, spontaneously conceived, 42-56 days of gestational age. All patients had a transvaginal ultrasound examination and were divided into three subgroups: abnormal intrauterine pregnancy, tubal pregnancy, and normal intrauterine pregnancy. Tubal pregnancies were surgically treated and histologically confirmed. Blood samples were collected for the determination of β-human chorionic gonadotropin, progesterone, and vascular endothelial growth factor and their concentrations were compared in each subgroup. Receiver operating characteristic curve was calculated by comparing the subgroup of tubal pregnancy to the other groups. A Fisher discriminant function analysis was performed. The level of significance was 5%. RESULTS: One-way analysis of variance revealed a significant correlation between the different subgroups and β-human chorionic gonadotropin, progesterone, and vascular endothelial growth factor serum levels (p<0.001). Vascular endothelial growth factor concentration was significantly higher for patients with tubal pregnancy than for other subgroups (p<0.05). β-Human chorionic gonadotropin and progesterone levels were higher in the subgroup with normal intrauterine pregnancies compared with the subgroups with tubal and abnormal intrauterine pregnancies (p<0.05). Serum vascular endothelial growth factor level >188.7 ng/mL predicted tubal pregnancy with 96.7% sensitivity, 95.0% specificity, 90.6% positive predictive value, and 98.3% negative predictive value. CONCLUSIONS: Serum vascular endothelial growth factor could be a marker in discriminating intrauterine pregnancy from tubal pregnancy; its levels are increased in women with ectopic pregnancy compared with women with normal and abnormal intrauterine pregnancies.

Risk assessment of venous thromboembolism and thromboprophylaxis in pregnant women hospitalized with cancer: Preliminary results from a risk score

OBJECTIVES: Hospitalized patients with cancer are at high risk of developing venous thromboembolism, and the risk increases with pregnancy. The aim of this study was to apply a thromboprophylaxis protocol with a venous thromboembolism risk score for hospitalized pregnant women with cancer and to evaluate the effects on maternal morbidity and mortality. METHODS: A longitudinal and prospective study was conducted from December 2014 to July 2016. The venous thromboembolism risk score was modified from the guidelines of the Royal College of Obstetricians and Gynaecologists. Patients were classified as low (score <3) or high risk (score ≥3). The high-risk group received thromboprophylaxis with low-molecular-weight heparin, unless the patient had a contraindication for anticoagulation. One patient could have undergone more than one evaluation. RESULTS: Fifty-two ratings were descriptively analyzed: 34 (65.4%) were classified as high risk, and 28/34 (82.3%) received low-molecular-weight heparin, 1 received unfractionated heparin, and 5 did not receive intervention. Most patients (23/52; 44.2%) had breast cancer. The main risk factors for venous thromboembolism in the high-risk group were chemotherapy (within 6 months; 22/34; 64.7%). No patient exhibited venous thromboembolism, adverse effects of anticoagulation or death up to three months after hospitalization. CONCLUSIONS: Most pregnant women with cancer had a high risk for venous thromboembolism at the time of hospitalization. Breast cancer was the most prevalent cancer, and recent chemotherapy was the main risk factor for anticoagulation. The application of a thromboprophylaxis protocol and determination of a venous thromboembolism risk score for these patients was useful for the prevention of maternal morbidity and mortality due to venous thromboembolism.

Reduced placental volume and flow in severe growth restricted fetuses

OBJECTIVES: To evaluate placental volume and vascular indices in pregnancies with severe fetal growth restriction and determine their correlations to normal reference ranges and Doppler velocimetry results of uterine and umbilical arteries. METHODS: Twenty-seven fetuses with estimated weights below the 3rd percentile for gestational age were evaluated. Placental volume and vascular indices, including vascularization, flow, and vascularization flow indices, were measured by three-dimensional ultrasound using a rotational technique and compared to a previously described nomogram. The observed-to-expected placental volume ratio for gestational age and observed-to-expected placental volume ratio for fetal weight were calculated. Placental parameters correlated with the Doppler velocimetry results of uterine and umbilical arteries. RESULTS: The mean uterine artery pulsatility index was negatively correlated with the observed-to-expected placental volume ratio for gestational age, vascularization index and vascularization flow index. The observed-to-expected placental volume ratio for gestational age and observed-to-expected placental volume ratio for fetal weight and vascularization index were significantly lower in the group with a bilateral protodiastolic notch. No placental parameter correlated with the umbilical artery pulsatility index. CONCLUSIONS: Pregnancies complicated by severe fetal growth restriction are associated with reduced placental volume and vascularization. These findings are related to changes in uterine artery Doppler velocimetry. Future studies on managing severe fetal growth restriction should focus on combined results of placental three-dimensional ultrasound and Doppler studies of uterine arteries.

Estudo do desempenho da dopplervelocimetria e dos métodos de avaliação das atividades biofísicas fetais na predição das condições pós-natais adversas / Doppler velocimetry and fetal well-being assess, exams performance's study for adverse neonatal outcomes

Este estudo retrospectivo e transversal teve como objetivo verificar o desempenho dos exames antenatais, para a predição de resultados pós-natais adversos. Selecionaram-se 1387 pacientes com alto risco gestacional, no Setor de Avaliação da Vitalidade Fetal, da Clínica Obstétrica do Hospital das Clínicas da FMUSP. O desempenho de todos os exames foi testado, para a predição dos resultados pós-natais adversos, por meio do cálculo da sensibilidade, especificidade, VPP e VPN / The aim of this retrospective study was to assess the role prenatal exams to predict neonatal adverse outcomes. The sample was divided accoding to maternal and gestational complications, as placental insufficiency sthiology. Furthermore, the predictive values of the exams were analyzed in relation to postnatal adverse outcomes. The sample was constituted by 1,387 high-risk pregnancies assisted in the Obstetrics Department - Fetal Well-being Assessment Section of the Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo - Brazil. The performance of all prenatal enrolled exams were evaluated in order to predict the adverse outcomes, using sensitivity, specificity, PPV and NPV estimations...

Alterações na gasometria de fetos aloimunizados após procedimento de transfusão intra-uterina / Fetal blood gas changes in red-cell transfusion in alloimmunization

OBJETIVO: este estudo, realizado em gestaçöes com aloimunizaçäo pelo fator Rh, tem como objetivo descrever as alteraçöes gasométricas e do equilíbrio ácido-básico fetal antes e após transfusöes intra-uterinas (TIU). MÉTODO: no período de junho de 2001 a outubro de 2001, antes e após a TIU em fetos de gestantes aloimunizadas, foram avaliados prospectivamente a gasometria e o equilíbrio ácido-básico no sangue da veia umbilical. As medidas foram realizadas em 8 amostras de sangue de 5 fetos. O sangue fetal foi obtido por cordocentese da veia umbilical antes e após TIU. Os resultados obtidos foram comparados com a expansäo volêmica na TIU, a idade gestacional no procedimento, o peso fetal estimado pela ultra-sonografia e as variaçöes da hemoglobina fetal (g/dL). RESULTADOS: em todos os casos foi observada queda nos valores do pH, com reduçäo média de 0,09 (DP=0,02). A hemoglobina fetal apresentou aumento médio de 8,4 g/dL (DP=2,9 g/dL). Foi constatada também variaçäo negativa da pO2 (média = -1,28 mmHg) na concentraçäo de HCO3_ (média = _2,25 mEq/l). Houve aumento da pCO2 (média = 3,2 mmHg) e reduçäo nos valores do excesso de bases (média = -3,75). CONCLUSÄO: a análise das gasometrias permite concluir que o procedimento de TIU acompanha-se de queda nos valores do pH de sangue de veia umbilical, demonstrando haver acidemia fetal relativa após o procedimento

Tratamento de gestantes com sindrome antifosfolipide de risco moderado com enoxaparina e aspirina / Treatment of antiphospholipid syndrome of moderate risk during pregnancy with aspirin and enoxaparin

A sindrome antifosfolipide faz parte de um grupo de trombofilias relacionadas a complicacoes durante a gestacao como trombose e perdas fetais. A gravidade do quadro clinico e variavel e determinada por...

Dopplervelocimetria dos compartimentos arterial e venoso da circulaçäo fetal e umbilical em gestaçäo de alto-risco: análise dos resultados perinatais / Dopplervelocimetry of the arterial and venous compartments of the fetal and umbilical circulation in high-risk pregnancy: perinatal results

Objetivos: estudar o perfil hemodinâmico fetal em gestantes de alto risco e avaliar a relaçäo das suas alteraçöes com os resultados perinatais. Métodos: realizou-se estudo prospectivo transversal em 108 gestantes atendidas no ambulatório de pré-natal da Clínica Obstétrica do HCFMUSP. Tais gestantes foram encaminhadas ao Setor de Avaliaçäo de Vitalidade Fetal, onde foram submetidas à dopplervelocimetria das artérias umbilicais, cerebral média, aorta, ducto venoso e veia cava inferior. Os critérios de inclusäo foram gestantes que apresentavam qualquer doença ou intercorrência na gravidez encaminhadas para avaliaçäo da vitalidade fetal, nas quais a resoluçäo da gestaçäo ocorreu nas próximas 24 horas após os exames. Foram excluídas as pacientes com gestaçäo gemelar ou com malformaçäo fetal. Resultados: as repercussöes hemodinâmicas na circulaçäo fetal foram demonstradas pela observaçäo de alteraçöes na dopplervelocimetria das artérias umbilicais, aorta, artéria cerebral média, ducto venoso e veia cava inferior. Valores alterados do índice de pulsatilidade (IP) da artéria umbilical foram observados em 25,9 por cento dos casos, da aorta em 24,0 por cento e da artéria cerebral média em 34,2 por cento. O IPV do ducto venoso estava alterado em 18,2 por cento dos casos e o da veia cava inferior em 46,6 por cento. Os segmentos da circulaçäo fetal que melhor se correlacionaram com os resultados perinatais foram a artéria umbilical e o ducto venoso. O IP alterado da artéria umbilical correlacionou-se significativamente com índices de Apgar de 1º minuto inferior a 7 em 42,8 por cento e com necessidade de UTI neonatal em 50,0 por cento dos casos. O IPV (indice de pulsatilidade para veias) do ducto venoso alterado apresentou associaçäo significativa com o índice de Apgar de 1º minuto inferior a 7 (52,6 por cento), Apgar de 5º minuto inferior a 7 (15,7 por cento), acidemia no nascimento (60,0 por cento), necessidade de UTI neonatal (52,6 por cento) e óbito neonatal (21,1 por cento). Os valores de prediçäo da alteraçäo do IPV do ducto venoso para o diagnóstico de acidemia foram: sensibilidade de 39,1; especificidade de 90,4; valor preditivo positivo de 60,0 e valor preditivo negativo de 80,2. Conclusäo: a dopplervelocimetria permite avaliar a hemodinâmica fetal nas mais variadas situaçöes e o estudo do ducto venoso constitui exame importante na avaliaçäo das alteraçöes hemodinâmicas decorrentes da hipoxia fetal

Obito fetal em gestacoes com diastole zero ou reversa na dopplervelocimetria das arterias umbilicais: analise do perfil hemodinamico fetal / Fetal death in pregnancies with absent or reversed end-distolic flow velocity in the umbilical arteries: analisys of fetal hemodinamic profile

Objetivo: descrever o perfil hemodinamico fetal e as caracteristicas de gestacoes com diagnosticos de diastole zero (DZ) ou reversa (DR) na dopplervelocimetria das arterias umbilicais que apresentaram diagnosticos de obito fetal. Metodos: foram estudados retrospectivamente 29 casos de gestantes que evoluiram com...

Dopplerfluxometria da arteria cerebral media em gestacoes com oligoidramnio / Doppler velocimetry of middle cerebral artery in pregnant women who had oligohydramnios

Os autores estudam 118 gestacoes com oligoidramnio, utilizando a dopplerfluxometria para diagnostico de centralizacao da circulacao fetal. Verificaram incidencia maior de alteracoes nos exames de carditocografia e perfil biofisico fetal nos casos centralizados. Os resultados neonatais foram semelhantes em ambos os grupos (centralizados e nao centralizados) exceto quando a cardiotocografia e ou perfil biofisico estivessem alterados, quando pode-se constatar maior morbidade neonatal