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7 - Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy
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- By William F. Baker, Jr., M.D., F.A.C.P.,, Associate Clinical Professor of Medicine Center for Health Sciences, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA, USA Thrombosis, Hemostasis, and Special Hematology Clinic, Kern Medical Center, Bakersfield, Eugene P. Frenkel, M.D., F.A.C.P.,, Professor of Medicine and Radiology Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas, USA, Rodger L. Bick, M.D., Ph.D., F.A.C.P., Clinical Professor of Medicine and Pathology, University of Texas Southwestern Medical Medical Center, Director: Dallas Thrombosis Hemostasis and Vascular Medicine Clinical Center, Dallas, Texas, USA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
- Print publication:
- 20 April 2006, pp 222-249
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Summary
Venous thromboembolism (VTE) represents a major cause of morbidity and mortality during pregnancy, complicating from 0.5 to 3.0 of every 1000 pregnancies. Pulmonary embolism (PE) has been the leading cause of maternal mortality in the United States and Great Britain for at least 20 years and complicates approximately 1 in 1,000 pregnancies. This represents a VTE risk of 3–4 times greater than age-matched non-pregnant controls. Diagnosing venous thromboembolism is challenging because clinical findings are often misleading. When evaluated with objective testing, as many as 75% of patients suspected of having venous thromboembolism are found to have an alternative diagnosis. This poses an even greater problem in the pregnant patient who experiences vasodilatation and intravascular volume expansion (20–25% increase) with associated lower extremity edema. The accuracy of many diagnostic tests used in the non-pregnant patient are either not useful at all or are potentially misleading. Diagnosis of VTE is critical since 24% of pregnant women with untreated deep vein thrombosis (DVT) develop PE, with a death rate of 15% to 30%. Proper diagnosis and treatment reduces the mortality rate of PE to 1%–3%. In addition, postphlebitic syndrome in the affected leg occurs nearly 80% of the time following DVT in pregnancy, compared to 30–40% in the non-pregnant patient. Although it is well recognized that the incidence of PE is greatly reduced with treatment for deep vein thrombosis (DVT), treatment is also problematic since anticoagulation regimens used in the non-pregnant patient may be highly teratogenic or in other ways hazardous to mother and/or fetus.
2 - Recurrent miscarriage syndrome and infertility caused by blood coagulation protein/platelet defects
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- By Rodger L. Bick, M.D., Ph.D., F.A.C.P., Clinical Professor of Medicine and Pathology, University of Texas Southwestern Medical Center; Director: Dallas Thrombosis Hemostasis and Vascular Medicine Clinical Center, Dallas, Texas, USA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
- Print publication:
- 20 April 2006, pp 55-74
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Summary
Introduction
Recurrent miscarriage syndrome (RMS) is a common obstetrical problem, affecting over 500,000 women in the USA per year; infertility although less well defined in the population is also a common clinical problem.
Recurrent miscarriage, based upon literature available and our experience is generally due to well defined defects as follows: about 7% are secondary to chromosomal abnormalities, about 10% are due to anatomical abnormalities, about 15% appear due to hormonal abnormalities (progesterone, estrogens, diabetes or thyroid disease), about 6% cannot be explained and the remainder, about 55 to 62%, are due to blood coagulation protein/platelet defects. The approximate prevalence of causes of RMS/infertility are summarized in Figure 2.1. This is in contrast to first time miscarriage, which in about 90% of cases, is due to a chromosomal defect and may effect up to 25 percent of first time pregnancies.
Blood coagulation protein/platelet defects
Recurrent miscarriage syndrome (RMS) due to blood protein or platelet defects may come about through two mechanisms, those disorders associated with a hemorrhagic tendency or those defects associated with a thrombotic tendency. Hemorrhagic (bleeding) defects associated with RMS are very rare, while thrombotic or hypercoagulable/thrombophilic defects are extremely common. The hemorrhagic defects associated with fetal wastage syndrome presumably lead to inadequate fibrin formation, thus precluding adequate implantation of the fertilized ovum into the uterus.
5 - Hereditary and acquired thrombophilia in pregnancy
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- By Rodger L. Bick, M.D., Ph.D., F.A.C.P., Professor of Medicine and Pathology, University of Texas Southwestern Medical Center; Director: Dallas Thrombosis Clinical Center, Dallas, Texas; Director: Pacific Thrombosis Clinical Center, Southern California, USA, William F. Baker, Jr., M.D., F.A.C.P., Associate Clinical Professor of Medicine, Center for Health Sciences, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA, USA, Thrombosis, Hemostasis, and Special Hematology Clinic, Kern Medical Center, Bakersfield; California Clinical Thrombosis Center, Bakersfield, California, USA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
- Print publication:
- 20 April 2006, pp 122-199
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Summary
Introduction
Thrombophilia in pregnancy represents a challenging problem for obstetricians, reproductive medicine specialists and hematologists. Normal pregnancy is known to be associated with an enhanced risk of deep vein thrombosis (DVT) and pulmonary embolus (PE). When combined with a thrombophilic disorder, this risk is significantly enhanced, usually considered to about 5–8-fold elevated in normal pregnant women, and addition of a thrombophilia, or other clinically significant risk factor, requires particular attention to avoid unnecessary fetal loss and maternal morbidity and mortality. Thrombophilia in obstetrics and pregnancy is known to be associated with not only enhanced risks of DVT and PE, but also recurrent miscarriage syndrome, infertility, stillborn births, eclampsia intrauterine growth retardation, pre-eclampsia, frank eclampsia, HELLP syndrome and abruption, with the additional usual thrombohemorrhagic complications, such as disseminated intravascular coagulation. Indeed many women with undiagnosed thrombophilia will experience their first clinical manifestation when pregnant – usually miscarriage or DVT with or without PE. In addition, many pregnancy patients who have had a prior DVT/PE harbor an undiagnosed thrombophilic disorder, thus emphasizing the importance of adequate investigation when a suggestive personal or family history warrants. This chapter summarizes (1) antithrombotic approaches to pregnant women with thrombophilia and other risk factors, and (2) the particular thrombophilias of concern to the obstetrician, reproductive medicine specialist and hematologist. In addition, treatment discussions and recommendations will be discussed in general and then, when necessary, for any particular disorder. It must be appreciated the clinical course of thrombophilic patients, particularly during pregnancy, is highly dynamic.
1 - Disseminated intravascular coagulation in obstetrics, pregnancy, and gynecology: Criteria for diagnosis and management
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- By Rodger L. Bick, M.D., Ph.D., F.A.C.P., Clinical Professor of Medicine and Pathology, University of Texas Southwestern Medical Center, Director: Dallas Thrombosis Hemostasis and Vascular Medicine Clinical Center, Dallas, Texas, USA, Deborah Hoppensteadt, Ph.D., D.I.C., Associate Professor of Pathology, Loyola University Medical Center, Maywood, Illinois, USA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
- Print publication:
- 20 April 2006, pp 1-54
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Summary
Syndromes of disseminated intravascular coagulation in obstetrics, pregnancy and gynecology Objective criteria for diagnosis and management
Introduction
Disseminated intravascular coagulation is a confusing syndrome, regarding diagnostic and therapeutic modalities. Confusion and controversy stem from (1) the fact that many unrelated clinical scenario may induce DIC (2) a lack of uniformity in clinical manifestations (3) confusion regarding appropriate laboratory diagnosis and (4) unclear guidelines for management with respect to specific therapeutic modalities potentially available. Recommendations for and evaluation of management becomes even more difficult because: (1) the morbidity and survival is often dependent on the specific cause of DIC and (2) few of the generally used specific modes of therapy, heparin, antithrombin concentrate, protein C concentrate, and others, have been subjected to objective prospective randomized trials, except antithrombin concentrates.
This chapter provides specific and objective guidelines and criteria for (1) the clinical diagnosis, (2) laboratory diagnosis, and (3) to provide objective systems to assess efficacy of any given specific therapeutic modality, independent of influences of the underlying (inducing) disease causing the DIC in obstetrical, pregnancy or gynecological patients. This approach allows for objective decisions regarding diagnosis and management in particular obstetric and gynecological settings and in individual patients. A general review of the etiology, pathophysiology, clinical and laboratory diagnosis, and management modalities suggested for DIC in obstetrics and gynecology is provided.
Disseminated intravascular coagulation (DIC) is an intermediary mechanism of disease usually seen in association with well-defined clinical disorders.