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Bleeding and thrombotic risk in pregnant women with Fontan physiology

Heart (British Cardiac Society), 2021-09, Vol.107 (17), p.1390-1397 [Peer Reviewed Journal]

Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ. ;2021 Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ. ;ISSN: 1355-6037 ;EISSN: 1468-201X ;DOI: 10.1136/heartjnl-2020-317397 ;PMID: 33234672

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Title:
Bleeding and thrombotic risk in pregnant women with Fontan physiology
Author: Girnius, Andrea ; Zentner, Dominica ; Valente, Anne Marie ; Pieper, Petronella G ; Economy, Katherine E ; Ladouceur, Magalie ; Roos-Hesselink, Jolien W ; Warshak, Carri ; Partington, Sara L ; Gao, Zhiqian ; Ollberding, Nicholas ; Faust, Michelle ; Girnius, Saulius ; Kaemmerer, Harald ; Nagdyman, Nicole ; Cohen, Scott ; Canobbio, Mary ; Akagi, Teiji ; Grewal, Jasmine ; Bradley, Elisa ; Buber, Yonathan ; Palumbo, Joseph ; Walker, Niki ; Aboulhosn, Jamil ; Oechslin, Erwin ; Baumgartner, Helmut ; Kurdi, Wesam ; Book, Wendy M ; Mulder, Barbara J M ; Veldtman, Gruschen R
Subjects: Adult ; Anticoagulants ; Birth weight ; Blood clots ; Cardiac arrhythmia ; Cardiovascular disease ; Chemoprevention - methods ; Chemoprevention - statistics & numerical data ; Congenital diseases ; Cyanosis ; Disease prevention ; Drug dosages ; Drug Monitoring - methods ; Ejection fraction ; Female ; Fibrinolytic Agents - administration & dosage ; Fibrinolytic Agents - adverse effects ; Fibrinolytic Agents - classification ; Fontan Procedure - adverse effects ; Gestational age ; Heart ; Hematology ; Hemorrhage - chemically induced ; Hemorrhage - epidemiology ; Hemorrhage - prevention & control ; Hemorrhage - therapy ; Humans ; Hypertension ; International Cooperation ; Obstetrics ; Physiology ; Pregnancy ; Pregnancy Complications, Cardiovascular - blood ; Pregnancy Complications, Cardiovascular - epidemiology ; Pregnancy Complications, Cardiovascular - etiology ; Pregnancy Complications, Cardiovascular - therapy ; Pregnancy Complications, Hematologic - epidemiology ; Pregnancy Complications, Hematologic - etiology ; Pregnancy Complications, Hematologic - physiopathology ; Pregnancy Complications, Hematologic - therapy ; Pulmonary arteries ; Risk Adjustment - methods ; Risk factors ; Thromboembolism ; Thrombophilia - drug therapy ; Thrombophilia - etiology ; Thrombosis ; Thrombosis - epidemiology ; Thrombosis - etiology ; Thrombosis - therapy ; Variables ; Womens health
Is Part Of: Heart (British Cardiac Society), 2021-09, Vol.107 (17), p.1390-1397
Description: Background/objectivesPregnancy may potentiate the inherent hypercoagulability of the Fontan circulation, thereby amplifying adverse events. This study sought to evaluate thrombosis and bleeding risk in pregnant women with a Fontan.MethodsWe performed a retrospective observational cohort study across 13 international centres and recorded data on thrombotic and bleeding events, antithrombotic therapies and pre-pregnancy thrombotic risk factors.ResultsWe analysed 84 women with Fontan physiology undergoing 108 pregnancies, average gestation 33±5 weeks. The most common antithrombotic therapy in pregnancy was aspirin (ASA, 47 pregnancies (43.5%)). Heparin (unfractionated (UFH) or low molecular weight (LMWH)) was prescribed in 32 pregnancies (30%) and vitamin K antagonist (VKA) in 10 pregnancies (9%). Three pregnancies were complicated by thrombotic events (2.8%). Thirty-eight pregnancies (35%) were complicated by bleeding, of which 5 (13%) were severe. Most bleeds were obstetric, occurring antepartum (45%) and postpartum (42%). The use of therapeutic heparin (OR 15.6, 95% CI 1.88 to 129, p=0.006), VKA (OR 11.7, 95% CI 1.06 to 130, p=0.032) or any combination of anticoagulation medication (OR 13.0, 95% CI 1.13 to 150, p=0.032) were significantly associated with bleeding events, while ASA (OR 5.41, 95% CI 0.73 to 40.4, p=0.067) and prophylactic heparin were not (OR 4.68, 95% CI 0.488 to 44.9, p=0.096).ConclusionsCurrent antithrombotic strategies appear effective at attenuating thrombotic risk in pregnant women with a Fontan. However, this comes with high (>30%) bleeding risk, of which 13% are life threatening. Achieving haemostatic balance is challenging in pregnant women with a Fontan, necessitating individualised risk-adjusted counselling and therapeutic approaches that are monitored during the course of pregnancy.
Publisher: England: BMJ Publishing Group LTD
Language: English
Identifier: ISSN: 1355-6037
EISSN: 1468-201X
DOI: 10.1136/heartjnl-2020-317397
PMID: 33234672
Source: MEDLINE
ProQuest Central

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Bleeding and thrombotic risk in pregnant women with Fontan physiology

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