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P35 Factor XIII deficiency and postpartum haemorrhage — two case reports
3rd Women’s Health Issues in Thrombosis and Haemostasis in amplitude of 2 mm; Clot Formation Time (CFT), the time between an increase in amplitude from 2 to 20 mm; Alfa angle, the tangent to the clotting curve through the 2 mm point; Maximum Clot Firmness (MCF), the maximum amplitude. Results: The 19 pregnant women enrolled in the study showed a hypercoagulable ROTEM® profile as compared to the control group. In particular, in all three assays considered (INTEM, EXTEM, and FIBTEM), CFT, a-angle, and MCF were statistically significant higher in cases than in controls (p ranging from <0.02 to <0.0001). Moreover, MCF was statistically significant higher in each of the three subgroups of cases than in controls (p < 0.02). Conclusions: Rotation thromboelastometry was able to identify a hypercoagulable state in pregnant women as compared to healthy female controls. This was true both for pathologic and healthy pregnancies. Future clinical studies are needed to assess the predictive role of ROTEM® profile in the evaluation of the risk of thrombosis in pregnancy. P34 A single centre experience using aspirin and low molecular weight heparin to improve pregnancy outcome in pregnant women with known thrombophilia and recurrent miscarriage C.N. Bagot, R.K. Patel, R. Arya. King’s College Hospital, London, UK Women with thrombophilia and a history of recurrent miscarriage have less than a 25% chance of experiencing a future live birth. We report a cohort of 45 pregnancies in 31 women with thrombophilia and previous recurrent miscarriage, treated with aspirin and low molecular weight heparin to improve pregnancy outcomes. The thrombophilias affecting these women included the antiphospholipid syndrome, factor V Leiden heterozygosity, PTG20210A heterozygosity, Protein S deficiency and antithrombin deficiency. Both aspirin and low molecular weight heparin (enoxaparin) were administered in all but three pregnancies, with the majority of women receiving a dose of 40 mg enoxaparin daily. Treatment was commenced in the first trimester in 37 pregnancies and the remainder in the second trimester. Five women had not reached their delivery date by the end of the study but had all progressed as far as the third trimester. Of the remaining 40 pregnancies, 29 resulted in live births (72.5%). 28 of these were delivered at term. In women with antiphospholipid syndrome, live births were achieved in 60% of pregnancies and in the remaining women with all other thrombophilia types, the rate of successful pregnancy outcome was 73.7%. Post partum haemorrhage occurred following four deliveries (8.9%), an incidence similar to that reported nationally in the UK (5 12%). There were no documented cases of heparin induced thrombocytopenia or osteoporosis. Our experience provides further evidence that pregnancy outcome in women with thrombophilia and previous recurrent miscarriage is dramatically improved when treated with aspirin and low molecular weight heparin, leading to a live birth rate of approximately 75%. Furthermore, the side effects of these treatments appear to be negligible. P35 Factor XIII deficiency and postpartum haemorrhage two case reports K.C. Quack Loetscher1 , B. Brand-Staufer2 , R. Zimmermann1 . 1 Clinic of Obstetrics, University Hospital Zurich, Switzerland, 2 Clinic of Haematology, University Hospital Zurich, Switzerland Objective: To discuss the possible role of factor XIII (FXIII) deficiency in postpartum haemorrhage
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Methods: We analysed medical history and measured FXIII (%) in two women with haemorrhagic complications after caesarean section. Results: Case 1: A 32 year old III gravida with a primarily twin pregnancy had a fetozid at 23 weeks of gestation of one twin due to trisomy 21. At 36 weeks she delivered a singleton by caesarean section. At day three and four after caesarean section massive hematomas in the abdominal scar had to be evacuated. FXIII was 38% after the second operation. Bleeding stopped immediately after substitution of FXIII (Fibrogammin). Three months later FXIII level (functional and antigen) was reduced to 50%. Therefore, heterozygosity of FXIIII deficiency was suspected. The caesarean section in her prior pregnancy was uneventful. Case 2: A 42 years old II gravida with placenta praevia and increta had a caesarean section with 34 weeks. Unsuccessful conservative treatment of postpartum haemorrhage led to total abdominal hysterectomy. One day later diffuse intraabdominal bleeding requested relapartomy. At this moment FXIII level was 13% and substitution of FXIII stopped the bleeding. FXIII rose to 63% and was normal three months later. In her prior pregnancy the woman had had an increased bleeding tendency after caesarean section, but the pregnancy was complicated by a placenta accrete. Conclusions: Factor XIII is the only coagulation factor not rising during normal pregnancy, but sometimes is decreased due to dilution of expanding plasma volume. Incidence of heterozygote FXIII deficiency is not known, but could be predisposing for bleeding complications after caesarean section. Early postpartum control of FXIII in bleeding women and consequently substitution of FXIII could improve outcome. P36 D-dimers as a screening test for venous thromboembolism in pregnancy: Is it of any use? M. Damodaram1 , M. Kaladindi1 , J. Luckit2 , W. Yoong1 . 1 Department of Obstetrics and Gynaecology, 2 Department of Haematology, North Middlesex University Hospital, London N18 1QX, UK Introduction: In non-pregnant women, D-dimers are used successfully to aid diagnosis of suspected pulmonary embolus (PE), as they have high sensitivity, moderate specificity and high negative predictive value. However, D dimer are physiologically raised in pregnancy and thus overlap the values normally associated with PE. The aim of this retrospective study therefore was to investigate the use of D-dimer levels as a screening test for suspected PE in pregnancy and to determine if a negative D-dimer level could exclude the diagnosis in pregnant women. Method: Thirty seven women suspected of PE had both ventilation perfusion (VQ) scans and D-dimer levels performed. Thirteen were reported as having a low probability of PE following VQ scan, while 24 were thought to have a moderate or high probability of PE. Women who had a low probability of PE following VQ scanning were found to have D-dimer levels ranging from 0.25 2.2 mg/l, while women who had a high probability of PE following scanning had D-dimer levels ranging from 0.31 1.74 mg/l. Results: The sensitivity and specificity of D-dimer as a test for suspected PE in pregnancy was calculated to be 0.73 and 0.15 respectively, while the negative likelihood ratio was 1.8. Discussion: Current guidelines advocate the use of a negative D-dimer result to exclude the diagnosis of PE in pregnancy. However, this study suggests that D-dimer testing in pregnancy has a high negative likelihood ratio and should not be used. Larger prospective observational studies are required to collaborate the findings from this study.
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Methods: We analysed medical history and measured FXIII (%) in two women with haemorrhagic complications after caesarean section. Results: Case 1: A 32 year old III gravida with a primarily twin pregnancy had a fetozid at 23 weeks of gestation of one twin due to trisomy 21. At 36 weeks she delivered a singleton by caesarean section. At day three and four after caesarean section massive hematomas in the abdominal scar had to be evacuated. FXIII was 38% after the second operation. Bleeding stopped immediately after substitution of FXIII (Fibrogammin). Three months later FXIII level (functional and antigen) was reduced to 50%. Therefore, heterozygosity of FXIIII deficiency was suspected. The caesarean section in her prior pregnancy was uneventful. Case 2: A 42 years old II gravida with placenta praevia and increta had a caesarean section with 34 weeks. Unsuccessful conservative treatment of postpartum haemorrhage led to total abdominal hysterectomy. One day later diffuse intraabdominal bleeding requested relapartomy. At this moment FXIII level was 13% and substitution of FXIII stopped the bleeding. FXIII rose to 63% and was normal three months later. In her prior pregnancy the woman had had an increased bleeding tendency after caesarean section, but the pregnancy was complicated by a placenta accrete. Conclusions: Factor XIII is the only coagulation factor not rising during normal pregnancy, but sometimes is decreased due to dilution of expanding plasma volume. Incidence of heterozygote FXIII deficiency is not known, but could be predisposing for bleeding complications after caesarean section. Early postpartum control of FXIII in bleeding women and consequently substitution of FXIII could improve outcome. P36 D-dimers as a screening test for venous thromboembolism in pregnancy: Is it of any use? M. Damodaram1 , M. Kaladindi1 , J. Luckit2 , W. Yoong1 . 1 Department of Obstetrics and Gynaecology, 2 Department of Haematology, North Middlesex University Hospital, London N18 1QX, UK Introduction: In non-pregnant women, D-dimers are used successfully to aid diagnosis of suspected pulmonary embolus (PE), as they have high sensitivity, moderate specificity and high negative predictive value. However, D dimer are physiologically raised in pregnancy and thus overlap the values normally associated with PE. The aim of this retrospective study therefore was to investigate the use of D-dimer levels as a screening test for suspected PE in pregnancy and to determine if a negative D-dimer level could exclude the diagnosis in pregnant women. Method: Thirty seven women suspected of PE had both ventilation perfusion (VQ) scans and D-dimer levels performed. Thirteen were reported as having a low probability of PE following VQ scan, while 24 were thought to have a moderate or high probability of PE. Women who had a low probability of PE following VQ scanning were found to have D-dimer levels ranging from 0.25 2.2 mg/l, while women who had a high probability of PE following scanning had D-dimer levels ranging from 0.31 1.74 mg/l. Results: The sensitivity and specificity of D-dimer as a test for suspected PE in pregnancy was calculated to be 0.73 and 0.15 respectively, while the negative likelihood ratio was 1.8. Discussion: Current guidelines advocate the use of a negative D-dimer result to exclude the diagnosis of PE in pregnancy. However, this study suggests that D-dimer testing in pregnancy has a high negative likelihood ratio and should not be used. Larger prospective observational studies are required to collaborate the findings from this study.