Preoperative workup
J. Richard Smith, Giuseppe Del Priore, Robert L. Coleman, John M. Monaghan in An Atlas of Gynecologic Oncology, 2018
Inherited risk factors for VTE typically do not result in VTE until an additional precipitating event induces formation (Middeldorp et al. 1998). Factor V Leiden mutation and prothrombin gene mutation G20210A are the most common mutations uncovered with VTE occurrence. Factor V Leiden is carried by 5% of Caucasians and in up to 20% of patients with VTE (Dahlback et al. 1993). Prothrombin G20210A mutations are less common, almost exclusively found in Caucasians, and found in 6% of patients with VTE (Poort et al. 1996). Antithrombin III, protein C, and protein S are additional inherited deficiencies that also result in an increased risk of VTE. Although rare, patients with a strong family history of clots who are negative for Factor V Leiden or prothrombin mutation should consider additional testing (Rosendaal 2005). Antiphospholipid syndrome is an acquired thrombophilia associated with arterial and venous thrombosis. Testing for antiphospholipid syndrome includes serum analysis for lupus anticoagulant and anticardiolipin antibodies (de Groot and Derksen, 2005).
Practice Paper 4: Answers
Anthony B. Starr, Hiruni Jayasena, David Capewell, Saran Shantikumar in Get ahead! Medicine, 2016
Antiphospholipid syndrome is characterized by recurrent arterial and venous thromboses (pulmonary embolism, deep vein thrombosis, stroke and peripheral thrombosis), recurrent miscarriage and thrombocytopenia. The diagnosis is confirmed by the presence of specific autoantibodies (anticardiolipin and lupus anticoagulase). Note that the presence of the anticardiolipin antibody will lead to a false-positive VDRL (Venereal Disease Reference Laboratory – syphilis) test. The management of antiphospholipid syndrome involves avoidance of thrombotic risk factors, including smoking and the contraceptive pill, and treating hypertension, hyperlipidaemia and diabetes. Patients who have no history of thrombosis should take low-dose aspirin. After the first thrombotic episode, lifelong warfarin is taken, aiming for an INR of 2.5. If a patient is planning on getting pregnant, warfarin should be stopped (as it is teratogenic) and subcutaneous heparin used instead.
The Immunobiology of Recurrent Miscarriage
Howard J.A. Carp in Recurrent Pregnancy Loss, 2020
Approximately 20% of women with recurrent pregnancy loss (RPL) have increased serum levels of autoantibodies, with antiphospholipid antibodies (aPL) predominating [1]. The etiology of the antiphospholipid syndrome is the subject of another chapter and will not be discussed here. Suffice to say, an aPL-related etiology should be suspected in women with ≥3 consecutive pre-embryonic or embryonic pregnancy losses or ≥1 unexplained fetal deaths above 10 weeks of gestation [3]. In women where an aPL-associated etiology is suspected, other autoantibodies may coexist. Such as antithyroid autoantibodies (ATA) (against thyroglobulin [TG] or thyroid peroxidase [TPO]) may be independent markers of “at-risk” pregnancy even with euthyroid status. It is possible that the high rate of miscarriage in the presence of ATA is related to very mild thyroid “underfunction,” with the thyroid gland being less able to adapt to the increased requirements of pregnancy; thus, these women might benefit from thyroid replacement therapy [4]. Furthermore, ATA may represent a generalized activation of the immune system. ATA have been found to coexist with activated T cells in the uterus and with non-organ-specific autoantibodies as well as with increased and hyperactive cytotoxic natural killer (NK) cells in RPL. Hence, treatment with intravenous immune globulin (IVIg), may neutralize the antibodies and also provide the required modulation of immune functioning [5].
Thrombotic complications in adult patients with severe single coagulation factor or platelet defects – an overview
Published in Expert Review of Hematology, 2019
Hanne Skaadel, Øystein Bruserud
Catastrophic antiphospholipid syndrome. Antiphospholipid syndrome is characterized by venous or arterial thromboses, and/or recurrent pregnancy morbidity, associated with persistent antiphospholipid antibodies [50]. On the other hand, the catastrophic form of the syndrome is characterized by microvascular thrombotic events, venous thrombosis is also common whereas arterial thrombosis is less common [50]. Between 20% and 50% of patients with antiphospholipid syndrome have thrombocytopenia <100 x 109/L [59] and there seems to be a subset of patients that is characterized by high IgG anticardiolipid antibodies or lupus anticoagulant, neuropsychiatric manifestations, arterial or venous thrombosis, thrombocytopenia, and autoimmune hemolysis [60]. The mechanisms behind the thrombocytopenia can be immune mediated, microangiopathy, decreased production, or increased pooling [59]. The treatment of antiphospholipid syndrome is based on supportive care, anticoagulation, immunomodulation or immunosuppression [61].
Acute portal vein thrombosis in noncirrhotic patients – different prognoses based on presence of inflammatory markers: a long-term multicenter retrospective analysis
Published in Scandinavian Journal of Gastroenterology, 2019
Radan Keil, Jana Koželuhová, Jiří Dolina, Aleš Hep, Radek Kroupa, Vladimír Kojecký, Tomáš Krejčí, Jan Havlín, Ivana Hadačová, Jitka Segethová, Petra Koptová, Zdena Zádorová, Jan Matouš, Barbora Frýbová, Petr Chmátal, Martin Wasserbauer, Jan Šťovíček, Melvin Bae, Tolga Guven, Mahmood Zaeem, Štěpán Hlava
The most commonly detected prothrombotic hematologic factor was a higher level of coagulation factor VIII. Values over 150% were considered pathological [3]. Elevation was found in 49 patients (62.8%). Significantly reduced antithrombin III was found in 27 patients (34.6%), and reduced levels of protein C and S were found in 39 (50.0%) and 36 patients (46.2%), respectively. A significantly elevated blood pellet count was found in 17 (21.8%) patients, four of them had essential thrombocytosis with JAK2 mutation positivity. Positivity for JAK2 was completely present in 10 patients (12.8%). Three patients (3.8%) had diagnosed primary myelofibrosis, 4 (5.1%) patients had essential thrombocytosis, and 3 (3.8%) patients had polycythemia vera. Polycythemia vera was diagnosed 4 years after thrombosis in one patient. Twelve patients (15.4%) had APC resistance or a factor V Leiden mutation. Three (9.4%) females (27, 35, and 54 years old) used hormonal contraception or hormonal substitution therapy. The youngest one was JAK2+ and had elevated factor VIII while the other two had no other risk factors. Antiphospholipid syndrome was excluded in all investigated patients. One patient was positive for anti-beta 2GPI antibodies.
Evaluation of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in pregnant women with systemic lupus erythematosus
Published in Journal of Obstetrics and Gynaecology, 2022
Huseyin Ekici, Metehan Imamoglu, Firat Okmen, Gizem Gencosman, Gunes Ak, Mete Ergenoglu
Foetal growth restriction was defined as birth weight <5th percentile of the normal growth curve. For the diagnosis of preeclampsia, hypertension is defined as a systolic blood pressure of ≥140 mmHg or diastolic blood pressure of ≥90 mmHg on two occasions that are at least four hours apart. The diagnostic criteria for preeclampsia include hypertension with proteinuria occurring at more than 20 weeks of gestation, while preeclampsia in the absence of proteinuria is diagnosed with a new onset of thrombocytopenia (<100,000 mm3), renal insufficiency (creatinine >1.1 mg/dl or more than double the baseline level), elevated liver function tests (ALT/AST >twice the upper limit), pulmonary oedema, cerebral or visual disturbance (ACOG 2020). Foetal loss was defined as foetal death after 22 weeks of gestation and premature birth (preterm) as live birth before 37 weeks of gestation. Diagnosis of antiphospholipid syndrome was established according to the updated Sapporo classification (Miyakis et al. 2006).
Related Knowledge Centers
- Antibody
- Autoimmunity
- Coagulation
- Vein
- Thrombus
- Artery
- Thrombosis
- Complications of Pregnancy
- Genetics
- Blood Test