TY - JOUR
T1 - Bleeding and thrombotic risk in pregnant women with Fontan physiology
AU - Girnius, Andrea
AU - Zentner, Dominica
AU - Valente, Anne Marie
AU - Pieper, Petronella G.
AU - Economy, Katherine E.
AU - Ladouceur, Magalie
AU - Roos-Hesselink, Jolien W.
AU - Warshak, Carri
AU - Partington, Sara L.
AU - Gao, Zhiqian
AU - Ollberding, Nicholas
AU - Faust, Michelle
AU - Girnius, Saulius
AU - Kaemmerer, Harald
AU - Nagdyman, Nicole
AU - Cohen, Scott
AU - Canobbio, Mary
AU - Akagi, Teiji
AU - Grewal, Jasmine
AU - Bradley, Elisa
AU - Buber, Yonathan
AU - Palumbo, Joseph
AU - Walker, Niki
AU - Aboulhosn, Jamil
AU - Oechslin, Erwin
AU - Baumgartner, Helmut
AU - Kurdi, Wesam
AU - Book, Wendy M.
AU - Mulder, Barbara J. M.
AU - Veldtman, Gruschen R.
N1 - Funding Information: Acknowledgements Sheila Drakeley (Boston Children’s Hospital), and the International Society of Adult Congenital Heart Disease (ISACHD, www.isachd.org) and the AARCC under whose auspices this study was supported. EO currently holds the Bitove Family Professorship of Adult Congenital Heart Disease. Dr Elisa Bradley holds a grant with the following grant number:K08HL148701 Contributors AG and GRV are primarily responsible for the conceptualisation, planning, data analysis and writing. ZG and NO are responsible for the primary statistical analysis and contributed to the manuscript. MF is responsible for project management and coordination, including data collection. DZ, AMV, PGP, KEE, ML, JWR-H, CW, SLP, SG, HK, NN, SC, MC, TA, JG, EB, YB, JPV, NW, JA, EO, HB, WK, WMB and BJMM contributed to conceptualisation, data collection and editing of the manuscript. The corresponding author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive license (or non-exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to permit this article (if accepted) to be published in HEART editions and any other BMJPGL products to exploit all subsidiary rights. Publisher Copyright: © 2021 BMJ Publishing Group. All rights reserved.
PY - 2021/9/1
Y1 - 2021/9/1
N2 - Background/objectives: Pregnancy 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. Methods: We 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. Results: We 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). Conclusions: Current 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.
AB - Background/objectives: Pregnancy 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. Methods: We 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. Results: We 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). Conclusions: Current 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.
KW - Fontan physiology
KW - pregnancy
UR - http://www.scopus.com/inward/record.url?scp=85096746008&partnerID=8YFLogxK
U2 - https://doi.org/10.1136/heartjnl-2020-317397
DO - https://doi.org/10.1136/heartjnl-2020-317397
M3 - Article
C2 - 33234672
SN - 1355-6037
VL - 107
SP - 1390
EP - 1397
JO - Heart
JF - Heart
IS - 17
ER -