Background
Women with a previous venous thromboembolism (VTE) are at risk of recurrence during pregnancy.
Objectives
We aimed to assess the incidence rate of recurrent VTE during pregnancy, according ...to the period of pregnancy, and the clinical parameters associated with recurrence, in a prospective cohort of women of childbearing age after a first VTE.
Patients/Methods
A total of 189 women aged 15–49 years with a first documented VTE were followed until a subsequent pregnancy of at least 20 weeks’ gestation between 2000 and 2020. VTE recurrences during pregnancy were recorded, as were potential clinical risk factors for recurrence.
Results
Recurrent VTE occurred in six women during antepartum: five during the first trimester (incidence rate 106.4 per 1000 women‐years) (95% confidence interval CI 46.3–226.0); none during the second trimester; and one during the third trimester (incidence rate 27.0 per 1000 women‐years 95% CI 4.8–138.2). During postpartum, recurrences occurred in 11 women (incidence rate 212.8 per 1000 women‐years 95% CI 119.9–349.1). These 17 recurrent VTEs presented as pulmonary embolism ± deep vein thrombosis (DVT) in five patients and isolated DVT in 12. Failure of thromboprophylaxis occurred in two cases (33.3%) antepartum and in 10 cases (90.9%) postpartum. In multivariable analysis, only obesity (defined on prepregnancy body mass index) was associated with recurrent VTE (odds ratio 3.34 95% CI 1.11–10.05, p = .03).
Conclusions
This study confirms a high risk of recurrent VTE postpartum, despite thromboprophylaxis, in women with a previous VTE. Only obesity was associated with VTE recurrence during pregnancy, suggesting that low‐dose anticoagulation might not be appropriate in obese pregnant women.
The diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) is a major challenge as it is a curable cause of pulmonary hypertension (PH). Ventilation/Perfusion (V/Q) lung scintigraphy is ...the imaging modality of choice for the screening of CTEPH. However, there is no consensus on the criteria to use for interpretation. The aim of this study was to assess the accuracy of various interpretation criteria of planar V/Q scintigraphy for the screening of CTEPH in patients with PH.
The eligible study population consisted of consecutive patients with newly diagnosed PH in the Brest University Hospital, France. Final diagnosis (CTEPH or non-CTEPH) was established in a referential center on the management of PH, based on the ESC/ERS guidelines and a minimum follow-up of 3 years. A retrospective central review of planar V/Q scintigraphy was performed by three nuclear physicians blinded to clinical findings and to final diagnosis. The number, extent (sub-segmental or segmental) and type (matched or mismatched) of perfusion defects were reported. Sensitivity and specificity were evaluated for various criteria based on the number of mismatched perfusion defects and the number of perfusion defects (regardless of ventilation). Receiver operating characteristic (ROC) curves were generated and areas under the curve (AUC) were calculated for both.
A total of 226 patients with newly diagnosed PH were analyzed. Fifty six (24.8%) were diagnosed with CTEPH while 170 patients (75.2%) were diagnosed with non-CTEPH. The optimal threshold was 2.5 segmental mismatched perfusion defects, providing a sensitivity of 100 % (95% CI 93.6-100%) and a specificity of 94.7% (95%CI 90.3-97.2%). Lower diagnostic cut-offs of mismatched perfusion defects provided similar sensitivity but lower specificity. Ninety five percent of patients with CTEPH had more than 4 segmental mismatched defects. An interpretation only based on perfusion provided similar sensitivity but a specificity of 81.8% (95%CI 75.3-86.9%).
Our study confirmed the high diagnostic performance of planar V/Q scintigraphy for the screening of CTEPH in patients with PH. The optimal diagnostic cut-off for interpretation was 2.5 segmental mismatched perfusion defects. An interpretation only based on perfusion defects provided similar sensitivity but lower specificity.
The optimal duration of anticoagulation after a first episode of unprovoked deep-vein thrombosis is uncertain. We aimed to assess the benefits and risks of an additional 18 months of treatment with ...warfarin
placebo, after an initial 6 months of anticoagulation for a first unprovoked proximal deep-vein thrombosis. We conducted a multicenter, randomized, double-blind, controlled trial comparing an additional 18 months of warfarin with placebo in patients with a unprovoked proximal deep-vein thrombosis initially treated for 6 months (treatment period: 18 months; follow up after treatment period: 24 months). The primary outcome was the composite of recurrent venous thromboembolism or major bleeding at 18 months. Secondary outcomes were the composite at 42 months, as well as each component of the composite, and death unrelated to pulmonary embolism or major bleeding, at 18 and 42 months. All outcomes were centrally adjudicated. A total of 104 patients, enrolled between July 2007 and October 2013 were analyzed on an intention-to-treat basis; no patient was lost to follow-up. During the 18-month treatment period, the primary outcome occurred in none of the 50 patients in the warfarin group and in 16 out of 54 patients (cumulative risk, 29.6%) in the placebo group (hazard ratio, 0.03; 95% confidence interval: 0.01 to 0.09;
<0.001). During the entire 42-month study period, the composite outcome occurred in 14 patients (cumulative risk, 36.8%) in the warfarin group and 17 patients (cumulative risk, 31.5%) in the placebo group (hazard ratio, 0.72; 95% confidence interval: 0.35-1.46). In conclusion, after a first unprovoked proximal deep-vein thrombosis initially treated for 6 months, an additional 18 months of warfarin therapy reduced the composite of recurrent venous thrombosis and major bleeding compared to placebo. However, this benefit was not maintained after stopping anticoagulation.
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VTE‐BLEED is a validated score for identification of patients at increased risk of major bleeding during extended anticoagulation for venous thromboembolism (VTE). It is unknown whether VTE‐BLEED ...high‐risk patients also have an increased risk for recurrent VTE, which would limit the potential usefulness of the score.
This was a post hoc analysis of the randomized, double‐blind, placebo‐controlled PADIS‐PE trial that randomized patients with a first unprovoked pulmonary embolism (PE) initially treated during 6 months to receive an additional 18‐month of warfarin vs. placebo. The primary outcome of this analysis was recurrent VTE during 2‐year follow‐up after anticoagulant discontinuation, that is, after the initial 6‐month treatment in the placebo arm and after 24 months of anticoagulation in the active treatment arm. This rate, adjusted for study treatment allocation, was compared between patients in the high‐ vs. low‐risk VTE‐BLEED group.
In complete case analysis (n = 308; 82.4% of total population), 89 (28.9%) patients were classified as high risk; 44 VTE events occurred after anticoagulant discontinuation during 668 patient‐years. The cumulative incidence of recurrent VTE was 16.4% (95% confidence interval CI, 10.0%‐26.1%; 14 events) and 14.6% (95% CI, 10.4%‐20.3%; 30 events) in the high‐risk and low‐risk VTE‐BLEED groups, respectively, for an adjusted hazard ratio of 1.16 (95% CI, 0.62‐2.19).
In this study, patients with unprovoked PE classified at high risk of major bleeding by VTE‐BLEED did not have a higher incidence of recurrent VTE after cessation of anticoagulant therapy, supporting the potential yield of the score for making management decisions on the optimal duration of anticoagulant therapy.
To provide recommendations to facilitate the management of severe thermal burns during the acute phase in adults and children.
A committee of 20 experts was asked to produce recommendations in six ...fields of burn management, namely, (1) assessment, admission to specialised burns centres, and telemedicine; (2) haemodynamic management; (3) airway management and smoke inhalation; (4) anaesthesia and analgesia; (5) burn wound treatments; and (6) other treatments. At the start of the recommendation-formulation process, a formal conflict-of-interest policy was developed and enforced throughout the process. The entire process was conducted independently of any industry funding. The experts drew up a list of questions that were formulated according to the PICO model (Population, Intervention, Comparison, and Outcomes). Two bibliography experts per field analysed the literature published from January 2000 onwards using predefined keywords according to PRISMA recommendations. The quality of data from the selected literature was assessed using GRADE® methodology. Due to the current paucity of sufficiently powered studies regarding hard outcomes (i.e. mortality), the recommendations are based on expert opinion.
The SFAR guidelines panel generated 24 statements regarding the management of acute burn injuries in adults and children. After two scoring rounds and one amendment, strong agreement was reached for all recommendations.
Substantial agreement was reached among a large cohort of experts regarding numerous strong recommendations to optimise the management of acute burn injuries in adults and children.
To evaluate patient and surgical characteristics of laparoscopic hysterectomy (LH), including both total laparoscopic hysterectomy (TLH) and laparoscopic supracervical hysterectomy (LSH), compared ...with total abdominal hysterectomy (TAH).
Retrospective, comparative study (Canadian Task Force classification II-2).
Health maintenance organization/residency-training program.
One hundred eight patients who underwent TLH, 251 patients who underwent LSH, and 255 patients who underwent TAH. There was no randomized controlled system to assign patients to the three types of hysterectomy. Patients with ancillary procedures were excluded from all three groups. The study period included February 2000 through September 2002.
Hysterectomy.
Analysis of covariance revealed that laparoscopic procedures require significantly more time to complete than TAH. Adjusted differences were 46.4 minutes longer for TLH (p <.0001) and 38.3 minutes longer for LSH (p <.0001). The adjusted estimated blood loss was 91.0 mL less with TLH (p <.0001) and 72.6 mL less with LSH (p < .0001) than with TAH. The hospital lengths of stay were significantly shorter for LH compared with TAH. The adjusted differences were 41.7 hours less with TLH (p <.0001) and 45.1 hours less with LSH (p <.0001). Rates of major complications were 5.6% with TLH, 0.8% with LSH, and 8.2% with TAH. Rates of minor complications were 17.6% with TLH, 16.7% with LSH, and 14.1% with TAH. Rates of any complication were 21.3% with TLH, 17.1% with LSH, and 20.8% with TAH. (Note: some patients in each group had both a minor and a major complication, so that minor and major complications do not exactly add up to "any complication.") The readmission rates for TLH, LSH, and TAH were 5.6%, 1.2%, and 2.0%, respectively. Same-day discharge for TLH and LSH occurred in 16.7% and 25.1% of patients, respectively. The variables indicating minor complications, any complications, wound infections, urinary tract infections, readmissions, and same-day discharges (in the laparoscopic groups) were not differentiated by surgery type. Major complications were differentiated by procedure class; namely, total hysterectomy (TLH and TAH) had significantly more major complications than LSH (adjusted p = .001). Wound abscesses (16 patients) occurred only in the TAH group (adjusted p <.0001). Pelvic cellulitis (17 patients) occurred in all surgical groups, but was more likely to occur in the LH groups (adjusted p = .01).
Laparoscopic hysterectomy, both total and supracervical, can be successfully integrated into a large health maintenance organization/residency-training program. Laparoscopic hysterectomy took significantly longer to perform than TAH in this new program. Estimated blood loss was significantly less with LH than with TAH. Hospital length of stay was significantly less with LH than TAH. Major complications with TLH, minor complications with LH, overall complications, wound infections, urinary tract infections, and readmissions appear comparable with these parameters in TAH within the limits of our study size and design. Pelvic cellulitis was significantly more common with LH, and wound abscess was significantly more common with TAH. Major complications were significantly less common with LSH compared with combined TLH and TAH. Same-day discharge after LH seems to be an attractive option worth developing further. Our patients have enthusiastically accepted these new minimally invasive techniques for performing hysterectomy. We anticipate continued expansion of our LH program.
A 36-year-old woman had a history of worsening menorrhagia, refractory to medical therapy. She underwent a total laparoscopic hysterectomy. Postoperatively, she experienced significant dyspareunia, ...dysuria, and pelvic pain. Ten months after her initial procedure, laparoscopy revealed several parasitized fragments of uterine and cervical origin in the pelvis. As laparoscopic morcellation is performed with increased frequency, the need to understand its sequelae has also increased. A concern of morcellating tissue within the abdomen is the fate of fragments inadvertently left behind.
Asthmatic mothers have been reported to deliver infants of lower mean birth weight than nonasthmatic mothers. This study examined the relationship between intrauterine growth and serial gestational ...spirometry in 352 pregnant asthmatic women who were prospectively treated and observed during pregnancy. A small (r = 0.11) but significant (p<0.04) direct correlation was demonstrated between infant birth weight and individual mean percent predicted FEV1 during pregnancy. In addition, lower maternal mean FEV1 during pregnancy was associated with increased incidences of birth weight in the lower quartile of the infant population (p = 0.002) and ponderal indices <2.2 (suggestive of asymmetric intrauterine growth retardation) (p<0.05), but not with increased incidences of preterm (<38 weeks) or low birth weight (<2,500 g) infants. Although lower mean birth weight occurred in infants of smoking compared with nonsmoking asthmatic mothers (p<0.02), the relationships of lower FEV1 to birth weight in the lower quartile of the population (odds ratio 3.0, p = 0.002) and ponderal indices <2.2 (odds ratio 2.8, p<0.05) were shown by multivariate analysis to be above and beyond the influence of smoking and also independent of the effects of age, parity, acute asthmatic episodes, and asthma medications. These data support the hypothesis that lower maternal gestational FEV1 during pregnancy is related to intrauterine growth retardation and suggest that the goals of gestational asthma therapy should include optimization of pulmonary function in addition to achievement of symptomatic control.
Background: Although no asthma or allergy medications can be considered proven safe for use during pregnancy, these medications are often used to prevent the potential direct and indirect ...consequences of uncontrolled asthma or allergy.
Objective: The safety of asthma medications, antihistamines, and decongestants was assessed in a prospectively monitored cohort of 824 pregnant women with and 678 pregnant women without asthma.
Methods: Medications used since conception were recorded on each subject's initial visit (< 28 weeks' gestation). Thereafter, diary cards for medications were completed by the patient through the time of delivery. Perinatal outcomes were compared in exposed versus unexposed individuals. A multivariate analysis accounted for the potential effects of age, parity, smoking, race, weight gain during pregnancy, maternal pulmonary function, acute asthmatic episodes, and multiple medication exposure.
Results: No significant relationships were identified between major congenital malformations and first trimester or any exposure to β-agonists, theophylline, cromolyn, corticosteroids, antihistamines, or decongestants. In the multivariate analyses, oral corticosteroids were independently associated with preeclampsia (odds ratio = 2.0,
p = 0.027), but no other independent associations were observed between asthma or allergy medications and adverse perinatal outcomes.
Conclusion: Use of most common asthma and allergy medications during pregnancy was not associated with increased perinatal risks. Maternal use of oral corticosteroids was independently associated with the occurrence of preeclampsia in this study, although the mechanism of this association is not clear. However, because prior observations suggest that severe asthma may be associated with maternal and/or fetal mortality, risk-benefit considerations still favor the use of oral corticosteroids when indicated for the treatment of asthma during pregnancy. (J Allergy Clin Immunol 1997;100:301-6.)
Background:
Previous studies reported an association between maternal psychological factors and adverse pregnancy outcomes. The objective of this study was to evaluate the relationships between ...maternal personality characteristics, as determined by the Minnesota Multiphasic Personality Inventory (MMPI), and infant birth outcomes and development. Method:The inventory was administered during pregnancy to 638 pregnant women enrolled in a staff model health maintenance organization. MMPI validity as well as clinical and research scales were evaluated in relationship to infant birth outcomes (low birthweight, preterm birth) and 15‐month‐old infant development as assessed by the Bayley Scales of Infant Development. Results:Mothers of low birthweight infants scored significantly lower on the hypochondriasis scale, a relationship which was no longer significant after controlling for ethnicity. No other relationships were observed between infant birth outcomes and maternal MMPI scale scores. A higher infant Mental Developmental Index (MDI) was related to higher maternal masculinity‐femininity and ego‐strength scale scores and lower lie and hypochondriasis scale scores. Only the relationship between infant MDI and maternal masculinity‐femininity scale score remained significant after controlling for ethnicity and socioeconomic index (β= 0.104, p =0.036). Conclusions:Maternal personality characteristics, as determined by the MMPI, did not appear to be significantly related to the occurrence of preterm birth or low birthweight in this healthy, general population. Maternal personality characteristics reflected in the MMPI masculinity‐femininity scale appeared to be related to infant mental development, above and beyond the effects of socioeconomic status and ethnicity.
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