Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH

Cohen, Hannah; Arachchillage, Deepa R. J.; Middeldorp, Saskia; Beyer‐Westendorf, Jan; Abdul‐Kadir, Rezan

doi:10.1111/jth.13366

Cited by 114 publications

(69 citation statements)

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“…Recently, MPV was also proven to be a critical inflammatory marker in infectious diseases, cardiovascular diseases and immune diseases [2][3][4]. However, numerous confounders could affect MPV levels [3,4].…”

Section: H C O H E N * † D R a R A C H C H I L L A G E * S mentioning

confidence: 99%

“…Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: reply We thank Desborough et al for their response to the recently published guidance from the SSC of the ISTH on the management of direct oral anticoagulants (DOACs) in women of childbearing potential [1,2]. We have carefully examined their view and seriously considered their proposal regarding the recommendation of this guidance as detailed below.…”

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confidence: 99%

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Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: reply

Cohen

Arachchillage

Beyer‐Westendorf

et al. 2017

Journal of Thrombosis and Haemostasis

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Section: H C O H E N * † D R a R A C H C H I L L A G E * S mentioning

confidence: 99%

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confidence: 99%

Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: reply

Cohen

Arachchillage

Beyer‐Westendorf

et al. 2017

Journal of Thrombosis and Haemostasis

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“…We thank Desborough et al for their response to the recently published guidance from the SSC of the ISTH on the management of direct oral anticoagulants (DOACs) in women of childbearing potential [1,2]. We have carefully examined their view and seriously considered their proposal regarding the recommendation of this guidance as detailed below.…”

Section: Disclosure Of Conflict Of Interestsmentioning

confidence: 99%

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Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: comment

Desborough

Pavord

Hunt

2017

Journal of Thrombosis and Haemostasis

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We welcome the recent guidelines from the SSC of the ISTH, which provide much-needed guidance on the management of direct oral anticoagulants (DOACs) in women of childbearing potential [1]. We agree with the guidance except for one area, and feel there would be benefit in reconsidering one of the recommendations: 'Should pregnancy be desired, we recommend that the DOAC is switched to an alternative anticoagulant preconceptually, with the main alternative anticoagulant options vitamin K antagonists (VKAs) (to be switched to low molecular weight heparin [LMWH] as soon as possible when pregnant and before 6 weeks of gestation), or LMWH, with cognizance that the latter may result in prolonged subcutaneous injections until pregnancy is achieved.'As the authors succinctly sum up in this guideline, there is uncertainty regarding the teratogenic risk of the DOACs. The Food and Drug Administration assigns dabigatran, edoxaban and rivaroxaban to pregnancy category C, reflecting the potential risks of teratogenicity demonstrated by animal data. Apixaban is assigned to pregnancy category B, as, to date, no teratogenicity has been demonstrated in animals. There is no clear evidence for an increased risk of teratogenicity in humans, although this cannot be ruled out.In contrast, VKAs have a well-established risk of teratogenicity, which is greatest between 6 weeks and 12 weeks of gestation. Skeletal anomalies may develop in the first trimester [2], and exposure in the second and third trimesters can cause fetal hemorrhage with central nervous system abnormalities or death. The rate of these anomalies is difficult to determine, with differing incidence rates being seen between cohorts [2-4]. Switching to LMWH before 6 weeks of gestation dramatically reduces the risk or embryopathy [4,5], although this relies on detecting pregnancy in a timely manner.We recommend reconsideration of the recommendation in this guideline that women who are taking a DOAC (with a theoretical risk of teratogenicity) should move to a VKA (with a known risk of teratogenicity) when they plan for a child. We feel that it would be safer to continue with the DOAC and switch to LMWH at the first sign of pregnancy, before 6 weeks of gestation. We feel that the option (as recommended in the guideline) of switching to LMWH preconceptually can result in potentially long periods on LMWH injections, making this an unpopular option.To date, the DOAC with the lowest risk of teratogenicity is apixaban, and this DOAC could be considered preferentially for women planning to have a child. We feel that this approach will reduce unnecessary exposure of women to a teratogenic agent at this critical time

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“…[169][170][171][172][173] New oral anticoagulation cannot be assumed in pregnancy because we lack information about its safety. 136,174 [ …”

Section: Warfarin and New Oral Anticoagulantsmentioning

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Pregnancy and heart disease: what Internists should know

Gerloni

Panuccio²

2017

Ital J Med

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Cardiac disease can rarely complicate pregnancy (e.g., only 1 to 4% of pregnancies in the United States), but it still remains a major cause of non-obstetric maternal morbidity and mortality. 1 During pregnancy, a woman can suffer from heart failure because of a pre-existing heart disease or a new onset cardiopathy pregnancy correlated. Approximately 2% of pregnancies involve cardiac disease, and in the current era, most maternal disease is due to congenital heart disease (CHD).2 Currently cardiac surgery improvement of the last 50 years has permitted an increased number of survivors. Instead, in the past, rheumatic heart disease was the leading cause of heart failure in pregnancy.3,4 Further, with increasing maternal age, other etiologies of heart disease should not be ignored and, particularly, ischemic and hypertensive heart disease should be considered in an over forty pregnant women. 5 Physiology of normal pregnancyImportant hemodynamic changes appear during pregnancy and are responsible for heart failure in pregnant women with pre-existing heart disease. These changes begin early in pregnancy, generally during the first eight weeks, reach their peak during the late second trimester, and then remain relatively constant until delivery. 6 The plasma volume and red cell mass are the first major cardiocirculatory modification, actually they expand in the 8 th week and peak around 30 th week, with a net plasma volume gain of 1000-1600 mL, corresponding to 30-50% above baseline.7 A greater increase in intravascular volume compared to red cell mass results in the dilutional anemia of pregnancy. This aspect generally results at 30-34 weeks when plasma volume peaks in relation to red cell mass and is associated with sodium and water retention. Actually 1000 mEq of sodium and 6 liters of water are retained and distributed among amniotic fluid, fetus and intra and extracellular spaces.8 Further cardiac output increases to satisfy increase fetal and maternal metabolic needs. It can be estimated 30-50% above baseline levels during the entire pregnancy, but half of this change occurs by 8 th week. This relevant change is a consequence of blood volume augmentation, afterload reduction and maternal heart rate rise.9 Systemic Pregnancy and heart disease: what Internists should know ABSTRACTPregnant women with heart disease are increasing due to medical and surgical progress and, nowadays, congenital heart disease is the most frequent heart disease affecting these women. Pregnancy represents a considerable effort for an altered heart with negative consequences for life quality, disease progression and mortality. Risk differs a lot among patients and depends not only on the type of heart disease. Clinician should stratify risk and offer patients a correct pre-counselling and accurate follow-up. At the same time Clinician should be able to diagnose rapidly heart failure as some cardiopathies, such as peripartum cardiomyopathy, are related to pregnancy and produce symptoms that can be confused with normal pregnancy progression...

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Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH

Cited by 114 publications

References 24 publications

Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: reply

Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: reply

Management of direct oral anticoagulants in women of childbearing potential: guidance from the SSC of the ISTH: comment

Pregnancy and heart disease: what Internists should know

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