- Email: [email protected]
P-055: Severe ITP on a term pregnancy: case report
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Abstracts / Thrombosis Research 151, Suppl. 1 (2017) S103–S140
Abstract P-053 – Figure 1
2 trimester and 3 trimester. The Siemens analyser BCS XP and Siemens methods were used. Interim results: We only managed due to the strict inclusion criteria to include only 25 women into our study, 4 drops off, so that we got less data for the 2 and 3. trimester. With this small data it is not useful to calculate reference ranges. Discussion/Conclusion: Only the results of our 21 Patients can help to have an idea, where the reference range for healthy women could be. Especially the vWF/F VIII-complex increases by factor 2.6. Also F V and VII increase, F XIII decreases during pregnancy. (see Boxplots) We need more patients to participate in this study. Reference ranges also depend on the population attending the centre and of the methods used there. Therefore this data has to be used with caution when it would be used in other centres or for other methods. Disclosure: The authors declare that they receive research grant from Biotest AG.
P-054 Analysis of thrombotic risk factors in caesarean sections in Vall d’Hebron population and comparison between Royal College’s recommendations and Chest’s ones E. Bonacina, M. Casellas Caro, M.H. Tur Torres, B. Serrano Sanchez, E. Carreras Moratonas Hospital Universitario Vall d’Hebron, Barcelona, Spain Objectives: To analyze the principal thrombotic risk factors and identify the thrombotic profile of women that underwent a caesarean section in our hospital, and compare the Royal College’s recommendations of thrombotic prophylaxis and the Chest’s ones. Based on the OR published by Jacobsen in 2008 we made an estimation of the absolute thrombotic risk in our population and its distribution. Materials and methods: Observational study that analyzes the presence and type of thrombotic risk factors in the population of women that underwent a caesarean section in Vall d’Hebron Hospital in the last semester
of 2015. We compared the amount of patients who should have received antithrombotic prophylaxis postpartum according to Royal College’s recommendations versus Chest’s ones. Results: There have been 147 caesarean sections between June 2015 and December 2015, of which 53 were elective caesarean sections and 94 emergency caesarean sections. The main thrombotic risk factors were hospitalization lasting more than 3 days (21%), preterm birth (15%), age more than 35 years (14%), BMI more than 30 (10%) and preeclampsia (7%). According to Royal College’s recommendations 135 patients should have received antithrombotic prophylaxis, and 33 according to Chest’s ones. There were 42 patients with no thrombotic risk factors, 38 with one, 19 with 2, and 48 with 3 or more. They were related to high risk pregnancies, such as preeclampsia with long hospitalization and preterm birth. Conclusions: Our hospital counts with a high risk population, and this reflects in risk factors, which are related to long hospitalization and pregnancy complications. Only elective caesarean sections with no thrombotic risk factors shouldn’t receive antithrombotic prophylaxis according to Royal College recommendations, and this leads to a high tax of patients that should receive a pharmacologic treatment in our center.
P-055 Severe ITP on a term pregnancy: case report B. Díaz Rabasa 1 , L. Gotor 1 , M.P. Rabasa Baraibar 2 , A. Pallarés 1 , M. Benito Vielba 1 , J.M. Campillos Maza 1 1 Department of Ginecología y Obstetricia, Hospital Universitario Miguel Servet, Zaragoza, Spain; 2 Department of Hematología y hemoterapia, Hospital San Pedro, Logroño, Spain Introduction: Inmune thrombocytopenic purpura (ITP) is the 2nd most common cause of thrombocytopenia in pregnancy (1/1000). Main outcome: To report a severe case of ITP on a term pregnancy that complicates perinatal period. Case report: A 28-year-old primigravid woman was diagnosticated of thrombocytopenia (45×103 /μl platelets, previously normal) at 36th week
Abstracts / Thrombosis Research 151, Suppl. 1 (2017) S103–S140
of gestation on routin 3rd trimester blood test. She was therefore referred to a fetomaternal outpatient clinic, and platelet count at 37 week was 20×106 /μl platelets with no haemorragic nor hypertensive symptoms. She was admitted to the hospital at 38+3 –39+0 and iv inmunoglobulins and corticosteroids were iniciated during 5 days. Platelets raised up to 80×106 /μl and patient was discharged with 60mg/day oral prednisone. Two days later she went back to the hospital due to active labour. Platelet count at admision was 35×106 /μl. A platelet pool was administered prior to delivery. She had an eutocic vaginal delivery (2570-g male). She suffered a postpartum haemorrage which required a 2nd platelet pool. During early puerperium, iv inmunoglobulins were administered during 5 days as well as iv methylprednisolone. Blood test showed Hb as low as 8.4g/dl, Ht 26.7% and 20×106 /μl platelets on 2nd day, administering a 3rd platelet pool.
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[3] S.M. Bates, et al. Venous thromboembolism, thrombophilia, antithrombotic therapy, and pregnancy. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th edition). Chest 2012. [4] A. Santamaría, et al. Recomendaciones sobre enfermedad tromboembólica venosa gestacional. Proyecto TEAM (trombosis en el ámbito de la mujer). [5] K. Bramham, et al. How I treat heterozygous hereditary antithrombin deficiency in pregnancy. Thromb Haemost 2013; 110: 550–559
P-057 AnticoagObs: an application for antenatal and postpartum risk assessment and prophylaxis of venous thromboembolism A.C. Lou Mercade 1 , R. Saviron Cornudella 2 , R. Cornudella Lacasa 3 Department of Obstetrics and Gynecology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain; 2 Department of Obstetrics and Gynecology, Hospital General de Villalba, Madrid, Spain; 3 Department of Hematology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
1
Figure 1
Discussion: ITP might be a severe condition which leads to a lifethreathening situation. Multidisciplinary team is required. Vaginal delivery requires a safety platelet count >50×106 /μl platelets and locoregional anesthesia >80,000. Indication of cesarean delivery depends on obstetric criteria. Fetal thrombocytopenia cannot be predicted by maternal platelet count nor symptoms.
Objective: Venous thromboembolism (VTE) is a leading cause of maternal mortality in developed countries. An individualized risk assessment of preexisting and new-onset/transient risk factors during pregnancy and after delivery, and an appropriate thromboprophylaxis, may prevent this potentially preventable cause of mortality and morbidity in fertile women. However, proper evaluation of the VTE risk factors involved is complex, and there is a growing global concern over the underuse of thromboprophylaxis. The aim of this app is to simplify access to current recommendations and facilitate decision-making on which women may benefit from pharmacological thromboprophylaxis.
P-056 High thrombotic risk in a pregnant woman with an antithrombin deficiency: management and outcome A. Esteban Figuerola, A. Martínez Roca, M. Solà Fernández, A. Culebras, M. Reyes Department of Hematology, Institut Català d’Oncologia (ICO), Hospital Joan XXIII, Tarragona, Spain Introduction: Antithrombin (AT) is protease inhibitor that inactivates thrombin and factor Xa [1]. The inherited deficiency is a disorder that elevates the risk of thromboembolism in the venous circulation. We present a case of a 24-year-old pregnant woman with a history of an AT deficit. Case: Our patient had an AT deficiency (basal levels 39%), diagnosed after a massive thromboembolism in relationship with oral contraceptives. She received oral anticoagulation until pregnancy, then a change to low molecular weight heparin (LMWH), Tinzaprina 10.000UI was made. Regular controls of anti Xa for dose adjustment of LMWH were performed. At the time of delivery LMWH was suspended 24hrs before labor and adjusted weight dose (50 UI/kg) of AT were administrated 1hr before epidural anesthesia, a control was made after the infusion to prevent the necessity of a new dose if levels were below 80%. Only one dose was required. Not thrombotic not hemorrhagic events were presents. LMWH was restarted 12hr after at full dose. Discussion: LMWH are safe as prophylaxis during pregnancy due that they do not cross de placental barrier. It is recommended shifting to LMWH during the first 4–6 weeks of pregnancy, and maintain it for 6 weeks after delivery in patients with very high thrombotic risk [3]. There is no consensus over the recommended dose, most guidelines recommend a therapeutic dose before and after delivery [2,3,4,5]. It is also recommended to administrate peripartum concentrates of AT with regular monitoring due to heparin resistance in some cases. Our patient had a favorable outcome, being necessary a strict management of high risk patients. References: [1] M. Patnaik, et al. Inherited antithrombin deficiency: a review. Haemophilia 2008; 14, 1229–1239. [2] J. H. Levy, et al. ntithrombin: anti-inflammatory properties and clinical applications. Thromb Haemost 2016; 115: 712–728
Figure 1
Method: We developed a software tool to evaluate the individual risk of gestational VTE based on clinical evidence, where available, consensus statements and expert opinions. The app AnticoagObs is freely accessible for Android devices and from any electronic device (http://www. anticoagulationinpregnancy.com/). The program uses a decision tree to generate a personalized report for the preconception stage, pregnancy, and the postpartum period, according to the American College of Chest Physicians, 9th edition guideline, and the recently published Green-top Guideline No. 37a from the Royal College of Obstetricians and Gynaecologists (RCOG), 3rd edition. Results: The App evaluates the risk of gestational VTE associated with previous thrombosis episodes, heritable or acquired thrombophilia, positive family history of VTE and presence of additional risk factors, resulting in an individualized report based on the main guideline published. Conclusions: The use of this novel app, AnticoagObs, may increase adherence to the guidelines, decrease variability in clinical practice and improve implementation of thromboprophylaxis in pregnant and postpartum women.
Abstracts / Thrombosis Research 151, Suppl. 1 (2017) S103–S140
Abstract P-053 – Figure 1
2 trimester and 3 trimester. The Siemens analyser BCS XP and Siemens methods were used. Interim results: We only managed due to the strict inclusion criteria to include only 25 women into our study, 4 drops off, so that we got less data for the 2 and 3. trimester. With this small data it is not useful to calculate reference ranges. Discussion/Conclusion: Only the results of our 21 Patients can help to have an idea, where the reference range for healthy women could be. Especially the vWF/F VIII-complex increases by factor 2.6. Also F V and VII increase, F XIII decreases during pregnancy. (see Boxplots) We need more patients to participate in this study. Reference ranges also depend on the population attending the centre and of the methods used there. Therefore this data has to be used with caution when it would be used in other centres or for other methods. Disclosure: The authors declare that they receive research grant from Biotest AG.
P-054 Analysis of thrombotic risk factors in caesarean sections in Vall d’Hebron population and comparison between Royal College’s recommendations and Chest’s ones E. Bonacina, M. Casellas Caro, M.H. Tur Torres, B. Serrano Sanchez, E. Carreras Moratonas Hospital Universitario Vall d’Hebron, Barcelona, Spain Objectives: To analyze the principal thrombotic risk factors and identify the thrombotic profile of women that underwent a caesarean section in our hospital, and compare the Royal College’s recommendations of thrombotic prophylaxis and the Chest’s ones. Based on the OR published by Jacobsen in 2008 we made an estimation of the absolute thrombotic risk in our population and its distribution. Materials and methods: Observational study that analyzes the presence and type of thrombotic risk factors in the population of women that underwent a caesarean section in Vall d’Hebron Hospital in the last semester
of 2015. We compared the amount of patients who should have received antithrombotic prophylaxis postpartum according to Royal College’s recommendations versus Chest’s ones. Results: There have been 147 caesarean sections between June 2015 and December 2015, of which 53 were elective caesarean sections and 94 emergency caesarean sections. The main thrombotic risk factors were hospitalization lasting more than 3 days (21%), preterm birth (15%), age more than 35 years (14%), BMI more than 30 (10%) and preeclampsia (7%). According to Royal College’s recommendations 135 patients should have received antithrombotic prophylaxis, and 33 according to Chest’s ones. There were 42 patients with no thrombotic risk factors, 38 with one, 19 with 2, and 48 with 3 or more. They were related to high risk pregnancies, such as preeclampsia with long hospitalization and preterm birth. Conclusions: Our hospital counts with a high risk population, and this reflects in risk factors, which are related to long hospitalization and pregnancy complications. Only elective caesarean sections with no thrombotic risk factors shouldn’t receive antithrombotic prophylaxis according to Royal College recommendations, and this leads to a high tax of patients that should receive a pharmacologic treatment in our center.
P-055 Severe ITP on a term pregnancy: case report B. Díaz Rabasa 1 , L. Gotor 1 , M.P. Rabasa Baraibar 2 , A. Pallarés 1 , M. Benito Vielba 1 , J.M. Campillos Maza 1 1 Department of Ginecología y Obstetricia, Hospital Universitario Miguel Servet, Zaragoza, Spain; 2 Department of Hematología y hemoterapia, Hospital San Pedro, Logroño, Spain Introduction: Inmune thrombocytopenic purpura (ITP) is the 2nd most common cause of thrombocytopenia in pregnancy (1/1000). Main outcome: To report a severe case of ITP on a term pregnancy that complicates perinatal period. Case report: A 28-year-old primigravid woman was diagnosticated of thrombocytopenia (45×103 /μl platelets, previously normal) at 36th week
Abstracts / Thrombosis Research 151, Suppl. 1 (2017) S103–S140
of gestation on routin 3rd trimester blood test. She was therefore referred to a fetomaternal outpatient clinic, and platelet count at 37 week was 20×106 /μl platelets with no haemorragic nor hypertensive symptoms. She was admitted to the hospital at 38+3 –39+0 and iv inmunoglobulins and corticosteroids were iniciated during 5 days. Platelets raised up to 80×106 /μl and patient was discharged with 60mg/day oral prednisone. Two days later she went back to the hospital due to active labour. Platelet count at admision was 35×106 /μl. A platelet pool was administered prior to delivery. She had an eutocic vaginal delivery (2570-g male). She suffered a postpartum haemorrage which required a 2nd platelet pool. During early puerperium, iv inmunoglobulins were administered during 5 days as well as iv methylprednisolone. Blood test showed Hb as low as 8.4g/dl, Ht 26.7% and 20×106 /μl platelets on 2nd day, administering a 3rd platelet pool.
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[3] S.M. Bates, et al. Venous thromboembolism, thrombophilia, antithrombotic therapy, and pregnancy. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th edition). Chest 2012. [4] A. Santamaría, et al. Recomendaciones sobre enfermedad tromboembólica venosa gestacional. Proyecto TEAM (trombosis en el ámbito de la mujer). [5] K. Bramham, et al. How I treat heterozygous hereditary antithrombin deficiency in pregnancy. Thromb Haemost 2013; 110: 550–559
P-057 AnticoagObs: an application for antenatal and postpartum risk assessment and prophylaxis of venous thromboembolism A.C. Lou Mercade 1 , R. Saviron Cornudella 2 , R. Cornudella Lacasa 3 Department of Obstetrics and Gynecology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain; 2 Department of Obstetrics and Gynecology, Hospital General de Villalba, Madrid, Spain; 3 Department of Hematology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
1
Figure 1
Discussion: ITP might be a severe condition which leads to a lifethreathening situation. Multidisciplinary team is required. Vaginal delivery requires a safety platelet count >50×106 /μl platelets and locoregional anesthesia >80,000. Indication of cesarean delivery depends on obstetric criteria. Fetal thrombocytopenia cannot be predicted by maternal platelet count nor symptoms.
Objective: Venous thromboembolism (VTE) is a leading cause of maternal mortality in developed countries. An individualized risk assessment of preexisting and new-onset/transient risk factors during pregnancy and after delivery, and an appropriate thromboprophylaxis, may prevent this potentially preventable cause of mortality and morbidity in fertile women. However, proper evaluation of the VTE risk factors involved is complex, and there is a growing global concern over the underuse of thromboprophylaxis. The aim of this app is to simplify access to current recommendations and facilitate decision-making on which women may benefit from pharmacological thromboprophylaxis.
P-056 High thrombotic risk in a pregnant woman with an antithrombin deficiency: management and outcome A. Esteban Figuerola, A. Martínez Roca, M. Solà Fernández, A. Culebras, M. Reyes Department of Hematology, Institut Català d’Oncologia (ICO), Hospital Joan XXIII, Tarragona, Spain Introduction: Antithrombin (AT) is protease inhibitor that inactivates thrombin and factor Xa [1]. The inherited deficiency is a disorder that elevates the risk of thromboembolism in the venous circulation. We present a case of a 24-year-old pregnant woman with a history of an AT deficit. Case: Our patient had an AT deficiency (basal levels 39%), diagnosed after a massive thromboembolism in relationship with oral contraceptives. She received oral anticoagulation until pregnancy, then a change to low molecular weight heparin (LMWH), Tinzaprina 10.000UI was made. Regular controls of anti Xa for dose adjustment of LMWH were performed. At the time of delivery LMWH was suspended 24hrs before labor and adjusted weight dose (50 UI/kg) of AT were administrated 1hr before epidural anesthesia, a control was made after the infusion to prevent the necessity of a new dose if levels were below 80%. Only one dose was required. Not thrombotic not hemorrhagic events were presents. LMWH was restarted 12hr after at full dose. Discussion: LMWH are safe as prophylaxis during pregnancy due that they do not cross de placental barrier. It is recommended shifting to LMWH during the first 4–6 weeks of pregnancy, and maintain it for 6 weeks after delivery in patients with very high thrombotic risk [3]. There is no consensus over the recommended dose, most guidelines recommend a therapeutic dose before and after delivery [2,3,4,5]. It is also recommended to administrate peripartum concentrates of AT with regular monitoring due to heparin resistance in some cases. Our patient had a favorable outcome, being necessary a strict management of high risk patients. References: [1] M. Patnaik, et al. Inherited antithrombin deficiency: a review. Haemophilia 2008; 14, 1229–1239. [2] J. H. Levy, et al. ntithrombin: anti-inflammatory properties and clinical applications. Thromb Haemost 2016; 115: 712–728
Figure 1
Method: We developed a software tool to evaluate the individual risk of gestational VTE based on clinical evidence, where available, consensus statements and expert opinions. The app AnticoagObs is freely accessible for Android devices and from any electronic device (http://www. anticoagulationinpregnancy.com/). The program uses a decision tree to generate a personalized report for the preconception stage, pregnancy, and the postpartum period, according to the American College of Chest Physicians, 9th edition guideline, and the recently published Green-top Guideline No. 37a from the Royal College of Obstetricians and Gynaecologists (RCOG), 3rd edition. Results: The App evaluates the risk of gestational VTE associated with previous thrombosis episodes, heritable or acquired thrombophilia, positive family history of VTE and presence of additional risk factors, resulting in an individualized report based on the main guideline published. Conclusions: The use of this novel app, AnticoagObs, may increase adherence to the guidelines, decrease variability in clinical practice and improve implementation of thromboprophylaxis in pregnant and postpartum women.