Venous Thromboembolism in COVID-19: Are Women Different?

Abstract

The epidemiological data suggests predominant male prevalence, morbidity and mortality with SARS COVID-2. Similarly, venous thromboembolic (VTE) events have a male sex predilection with variant mechanisms involving angiotensin-converting enzyme 2 (ACE-2) expression and pathways in women. COVID-19 could directly affect or it could be an indirect action of the disease via critical ailment hypoxemia, or hemostatic abnormalities might be the underlying mechanisms of VTE in a COVID-19 patient with baseline risk factor profile. VTE diagnosis in a COVID scenario has issues of a prone positioned patient, exposure of health workers and minimal therapeutic benefits in a critically ill patient with acute respiratory distress syndrome (ARDS). Anticoagulation with low-molecular weight heparin (LMWH) can be chosen over unfractionated heparin (UFH) with less monitoring requirements and thereby low exposure to healthcare workers. Variant guidelines for thromboprophylaxis (in hospital/extended postdischarge) have come up, stating anticoagulant administration, according to baseline risk profile and hemostatic biomarkers. Catheter-directed interventions should be reserved only for life-threatening situations. In women, hormonal milieu (for e.g., 17 β-estradiol) might influence occurrence of favorable ACE 2 polymorphisms with less VTE events. The management strategies in a female patient with VTE would be more or less similar to males. Combined oral contraceptives (COC) and estrogen replacement therapies (ERT) may be curtailed in COVID-19 positive patients, given their thrombogenic potential. Pregnancy and postpartum state in COVID-19 positive patient need VTE prophylaxis all the more in the presence of risk profile favoring VTE. Also, VTE prophylaxis when indicated should be continued in women in a normal menstrual cycle. Bleeding risks specific to women (menorrhagia secondary to dysfunctional uterine bleeding [DUB], fibroids, adnexal malignancies and masses, hypothyroidism, etc.) need to be weighed while taking a decision for indicated anticoagulation regimen.

Heparin for patients with coronavirus disease 2019 and hypercoagulation complications: A cohort study

“…COC use is associated with a two-to six-fold increase in the risk of VTE. The risk of VTE in COVID-19 can also be exacerbated in pregnancy (the risk increases by four to five times) and in postmenopausal women [ 8 , [17] , [18] , [19] ].…”

The Relationship Between the Effectiveness of Heparin Administration and Hypercoagulation Complications in Hospitalized Patients With Confirmed COVID-19

“…Consequently, Ddimer can be used as one of the parameters for measuring thrombus formation. An increase in the D-dimer value indicates the presence of a brinolysis process in these patients, so that a negative value on the Ddimer examination can rule out the suspicion of a diagnosis of venous or arterial thrombosis; in contrast, an increase in the D-dimer value indicates a sign of thrombus formation [10,11].…”

Evento trombótico em paciente gestante durante infecção por Sars-CoV-2: Relato de caso / Thrombotic event in a pregnant patient during Sars-CoV-2 infection: Case report

“…Essa condição é revertida após cerca de 8 semanas do parto (1,5) . Logo, quando a gravidez ocorre em mulheres que apresentam fatores de risco individuais, como história pessoal de TEV, índice de massa corpórea (IMC) ≥ 30, trombofilias hereditárias, história de câncer ativo e mobilidade reduzida, tem-se um risco aumentado de desenvolvimento de TEV, que é relacionado a cerca de 10% dos casos de mortalidade materna (1,6) . Nos pacientes contaminados com o Sars-CoV-2, a resposta pró-inflamatória, quando ultrapassa um limiar benéfico que estabelece combate efetivo ao patógeno, pode ocasionar a formação de trombina e lesão do endotélio vascular, elevando o risco de TEV (1,7,8) .…”

“…Nas grávidas com infecção confirmada de COVID-19 e evidência definitiva de TEV em exame de imagem padrão, a heparina é a droga de escolha para a anticoagulação terapêutica. A heparina não fracionada (HNF) permite reversão mais rápida da anticoagulação caso o parto ou qualquer procedimento invasivo seja necessário dentro de 12 a 24 horas, enquanto a heparina de baixo peso molecular (HBPM) possibilita uma terapia anticoagulante mais previsível, sendo aconselhável caso o parto não seja esperado nas próximas 24 horas e durante o pós-parto (4,6) . Entretanto, a indicação de iniciar a anticoagulação profilática ou terapêutica deve ser individualizada, já que os fatores de Brazilian Journal of Development, Curitiba, v.7, n.8, p. 76586-76594 aug. 2021 risco para TEV e a gravidade do quadro de infecção pelo Sars-CoV-2 devem ser avaliados (4,6,8) .…”