The evaluation and management of postnatal thromboses

Abstract

In the pediatric population, neonates have the highest risk for thromboembolism (TE), most likely due to the frequent use of intravascular catheters. This increased risk is attributed to multiple risk factors. Randomized clinical trials dealing with management of postnatal thromboses do not exist, thus, opinions differ regarding optimal diagnostic and therapeutic interventions. This review begins with an actual case study illustrating the complexity and severity of these types of cases, and then evaluates the neonatal hemostatic system with discussion of the common sites of postnatal thrombosis, perinatal and prothrombotic risk factors, and potential treatment options. A proposed step-wise evaluation of neonates with symptomatic postnatal thromboses will be suggested, as well as future research and registry directions. Owing to the complexity of ischemic perinatal stroke, this topic will not be reviewed. Case study A full-term male infant born through spontaneous vaginal delivery was admitted to the neonatal intensive care unit (NICU) shortly after birth due to a history of low APGAR scores and respiratory distress requiring mechanical ventilation. The pregnancy was complicated by gestational diabetes treated with glyburide and chorioamnionitis was evident during labor. The patient was started on ampicillin and gentamicin and appropriate fluid resuscitation was initiated. The patient improved over the next few days and was able to be weaned off of ventilator support. The patient had an umbilical arterial catheter (UAC) placed after birth that was removed on day 3 of life.On day 4 of life the patient's legs appeared pale. Physical examination demonstrated cool lower extremities and markedly decreased pulses in the feet. Over the previous 24 h, urine output declined significantly.Ultrasound (US) examination of the heart, major vessels and abdomen demonstrated a large thrombus in the descending aorta with very minimal flow to the renal and iliac arteries. A literature search did not reveal any level I management guidelines for thrombosis in neonatal patients, and consideration is now given to surgical thrombectomy, anticoagulation therapy or fibrinolytic therapy. Incidence of neonatal thromboembolic diseaseAlthough neonates have the highest risk of thromboembolism (TE) in the pediatric population, the incidence of postnatal TE varies due to the types of thromboses that were reported and how aggressively centers screened for thromboses. 1 Data from the three international registries are displayed in Table 1. All three registries observed that thromboses occurred in both term and preterm infants and affected male and female infants equally, other than renal vein thrombosis (RVT) that affected more male neonates. [2][3][4] These registries also demonstrated that approximately 90% of venous thromboses in neonates were associated with central venous catheters (CVLs). [2][3][4] The recurrence rate of TE following symptomatic neonatal events ranges from 3.3 to 7%. 5 The international registries are the first step toward...

Neonatal Cerebral Sinovenous Thrombosis From Symptom to Outcome

“…31,33 There are substantial differences in reported neonatal SVT neurodevelopmental outcome data. 1,4,5,28,34 In our cohort, outcome in survivors was normal in 45%, neurological deficits were seen in 47%, and persistent epilepsy in 16%. These results are comparable with those of deVeber et al 5 In the only other study focusing solely on neonatal SVT, more adverse sequelae occurred.…”

Difficult Diagnosis: Acute Myocarditis or Myocardial Ischemia in an Infant with Thrombophilia? Clinical Case

“…Мощным триггером является катетеризация сосудов. В настоящее время отсутствуют рекомендации по прове-дению скрининга тромбофилии у новорожденных детей, не имеющих симптомов обширного тромбоза [15,16], что затрудняет раннее выявление больных и профилактику развития тяжелых проявлений болезни.…”

Preterm Infant with a Catastrophic Hemorrhagic-Thromboembolic Incident

“…While more common thrombophilias, including FVL and PGM, are associated with a lower thrombosis risk than the less common ones (antithrombin III, protein C, protein S deficiency), the risk is 5–10 times higher in FVL heterozygotes than in normal individuals and 50–100 times higher in homozygotes than in normal individuals [9]. …”

“…Neonatal thrombophilia presents in different ways and involves different organ systems, especially the brain, resulting in neonatal stroke, central venous thrombosis and porencephaly, alongside such manifestations as purpura fulminans and renal vein thrombosis [9]. …”

“…Although all thrombophilias have been associated with neonatal thrombosis, only homozygous or compound heterozygous protein C and/or protein S deficiencies are reported as adequate to induce neonatal thrombosis [9]. …”