High rates of venous thromboembolism among deliveries complicated by cancer.

BACKGROUND: Venous thromboembolism (VTE) risk is increased independently by both cancer and pregnancy. OBJECTIVES: To estimate VTE risk in the postpartum period among patients delivering with a cancer diagnosis, stratified by cancer type and delivery route. METHODS: We performed a retrospective cohort study utilizing the large, all-payer Nationwide Readmissions Database from October 2015 through December 2020. We identified delivery hospitalizations, cancer diagnoses, and VTE using patient demographics and diagnosis codes. The primary outcome was VTE incidence at 42 and 330 days from delivery admission date, comparing patients with and without cancer diagnoses. A secondary analysis included VTE risk stratified by cancer diagnosis and delivery route. Outcomes were compared using inverse probability-weighted survival curves. RESULTS: The study population included 9 793 503 delivery hospitalizations (weighted estimate, 18 207 346), with a weighted estimate of 10 428 (0.06%) pregnant patients with cancer. Individuals with cancer were older, with higher rates of comorbid conditions, than those without cancer. VTE incidence in individuals with cancer at 42 and 330 days was 1.11% and 2.19%, respectively, vs 0.11% and 0.14%, respectively, in those without cancer. At 330 days, this finding was significant in both unadjusted (relative risk, 15.52; 95% CI, 11.54-19.51) and adjusted (relative risk, 9.68; 95% CI, 7.18-12.18) models. Stratification by cancer type and delivery route demonstrated elevated VTE risk across cancer types, with cesarean delivery conferring a greater risk. CONCLUSION: Cancer in pregnancy confers excess thromboembolic risk extending beyond the immediate postpartum period. Further study is needed to identify optimal VTE prophylactic strategies for this population.

American Society of Hematology 2023 guidelines for management of venous thromboembolism: thrombophilia testing.

Hereditary and acquired thrombophilia are risk factors for venous thromboembolism (VTE). Whether testing helps guide management decisions is controversial. These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about thrombophilia testing. ASH formed a multidisciplinary guideline panel covering clinical and methodological expertise and minimizing bias from conflicts of interest. The McMaster University GRADE Centre provided logistical support, performed systematic reviews, and created evidence profiles and evidence-to-decision tables. The Grading of Recommendations Assessment, Development, and Evaluation approach (GRADE) was used. Recommendations were subject to public comment. The panel agreed on 23 recommendations regarding thrombophilia testing and associated management. Nearly all recommendations are based on very low certainty in the evidence due to modeling assumptions. The panel issued a strong recommendation against testing the general population before starting combined oral contraceptives (COCs) and conditional recommendations for thrombophilia testing in the following scenarios: (a) patients with VTE associated with nonsurgical major transient or hormonal risk factors; (b) patients with cerebral or splanchnic venous thrombosis, in settings where anticoagulation would otherwise be discontinued; (c) individuals with a family history of antithrombin, protein C, or protein S deficiency when considering thromboprophylaxis for minor provoking risk factors and for guidance to avoid COCs/hormone replacement therapy; (d) pregnant women with a family history of high-risk thrombophilia types; and (e) patients with cancer at low or intermediate risk of thrombosis and with a family history of VTE. For all other questions, the panel provided conditional recommendations against testing for thrombophilia.

Iron Deficiency Anemia in Pregnancy.

Anemia is defined as a low red blood cell count, a low hematocrit, or a low hemoglobin concentration. In pregnancy, a hemoglobin concentration of less than 11.0 g/dL in the first trimester and less than 10.5 or 11.0 g/dL in the second or third trimester (depending on the guideline used) is considered anemia. Anemia is the most common hematologic abnormality in pregnancy. Maternal anemia is associated with adverse fetal, neonatal and childhood outcomes, but causality is not established. Maternal anemia increases the likelihood of transfusion at delivery. Besides hemodilution, iron deficiency is the most common cause of anemia in pregnancy. The American College of Obstetricians and Gynecologists recommends screening for anemia with a complete blood count in the first trimester and again at 24 0/7 to 28 6/7 weeks of gestation. Mild anemia, with a hemoglobin of 10.0 g/dL or higher and a mildly low or normal mean corpuscular volume (MCV) is likely iron deficiency anemia. A trial of oral iron can be both diagnostic and therapeutic. Mild anemia with a very low MCV, macrocytic anemia, moderate anemia (hemoglobin 7.0-9.9 g/dL) or severe anemia (hemoglobin 4.0-6.9 g/dL) requires further investigation. Once a diagnosis of iron deficiency anemia is confirmed, first-line treatment is oral iron. New evidence suggests that intermittent dosing is as effective as daily or twice-daily dosing with fewer side effects. For patients with iron deficiency anemia who cannot tolerate, cannot absorb, or do not respond to oral iron, intravenous iron is preferred. With contemporary formulations, allergic reactions are rare.

Illustrated State-of-the-Art Capsules of the ISTH 2020 Congress.

This year's Congress of the International Society of Thrombosis and Haemostasis (ISTH) was hosted virtually from Philadelphia July 17-21, 2021. The conference, now held annually, highlighted cutting-edge advances in basic, population and clinical sciences of relevance to the Society. Despite being held virtually, the 2021 congress was of the same scope and quality as an annual meeting held in person. An added feature of the program is that talks streamed at the designated times will then be available on-line for asynchronous viewing. The program included 77 State of the Art (SOA) talks, thematically grouped in 28 sessions, given by internationally recognized leaders in the field. The SOA speakers were invited to prepare brief illustrated reviews of their talks that were peer reviewed and are included in this article. The topics, across the main scientific themes of the congress, include Arterial Thromboembolism, Coagulation and Natural Anticoagulants, COVID-19 and Coagulation, Diagnostics and Omics, Fibrinogen, Fibrinolysis and Proteolysis, Hemophilia and Rare Bleeding Disorders, Hemostasis in Cancer, Inflammation and Immunity, Pediatrics, Platelet Disorders, von Willebrand Disease and Thrombotic Angiopathies, Platelets and Megakaryocytes, Vascular Biology, Venous Thromboembolism and Women's Health. These illustrated capsules highlight the major scientific advances with potential to impact clinical practice. Readers are invited to take advantage of the excellent educational resource provided by these illustrated capsules. They are also encouraged to use the image in social media to draw attention to the high quality and impact of the science presented at the congress.

National trends in tranexamic acid use in the peripartum period, 2015-2019.

BACKGROUND: The purpose of this study was to measure trends in the use of tranexamic acid (TXA) during delivery in the United States and to evaluate demographic data and morbidity outcomes among these patients. METHODS: This retrospective cohort study includes data from 19 hospitals in the Universal Health Services network. We compared rates of TXA use between January 2015 and June 2019 across geographic sectors. We also evaluated associations of demographic variables and perinatal outcomes of women who received TXA. RESULTS: 209 cases of TXA use were found from analysis of 101,564 deliveries. TXA use increased over time and rates were higher in the West than in Central and East; the slope of increase over years did not differ between regions. Women who received TXA were more likely to have a history of postpartum hemorrhage (59 (28.2%) vs. 2290 (2.2%), P < 0.0001) but were not more likely to have a chronic disease, including diabetes mellitus, hypertension and heart disease. Women who received TXA were more likely to have estimated blood loss greater than or equal to 1000 mL (adjusted odds ratio (aOR) 15.3; 95% CI 11.1-21.1; P < 0.0001). Likelihood of venous thromboembolism was not significantly increased in TXA recipients (aOR 2.0; 95% CI 0.3-14.6; P = 0.49). CONCLUSION: Increasing national trends of TXA use in the peripartum period was observed, with variable increases by geographic region. Likelihood of venous thromboembolism was not significantly increased among women who received TXA. Increasing TXA use throughout the country suggests that updated hemorrhage guidelines from national obstetrical organizations can shape clinical practice.

Case-based discussion on the implications of exogenous estrogens in hemostasis and thrombosis: the obstetrician's view.

This is the obstetrician's view on 3 different clinical scenarios involving bleeding and thrombotic disorders. In the first scenario, an 18 year old with a history of heavy menstrual bleeding since menarche presents with abdominal pain and ultrasound findings suggestive of a hemorrhagic ovarian cyst. The association with an underlying bleeding disorder is recognized. The goals of management, which are controlling hemorrhage and preserving fertility, are stated. Ovarian suppression, the most effective method to prevent recurrent hemorrhagic ovarian cysts, is outlined. Long-term management of heavy menstrual bleeding with hormonal contraception is described. In the second scenario, the same patient returns 5 years later for a preconception visit. The potential risks to an unborn baby with von Willebrand disease (VWD) are addressed. The natural rise in von Willebrand factor (VWF) during pregnancy is discussed, but the fact that women with VWD do not achieve the same VWF levels as women without VWD is emphasized and the implications are presented. In anticipation of pregnancy, the need for nonhormonal management of heavy menstrual bleeding and hemorrhagic ovarian cysts is mentioned. In the third and final scenario, the patient's cousin with factor V Leiden seeks consultation regarding the risks of thrombosis with in vitro fertilization. The steps of assisted reproductive technology are described. The strategies to prevent venous thromboembolism by preventing ovarian hyperstimulation and reducing the likelihood of multiple gestation are detailed.

Management of Menopausal Symptoms for Women Who Are at High Risk of Thrombosis.

For women at elevated risk of thrombosis, clinicians are challenged to relieve menopausal symptoms without increasing the risk of thrombosis. Oral menopausal hormone therapy increases the risk of venous thromboembolism by 2-fold to 3-fold. Observational studies suggest less thrombotic risk with transdermal therapies and with progesterone over synthetic progestogens (progestins), but the data are limited. Beneficial nonpharmacologic therapies include cognitive behavioral therapy and clinical hypnosis, whereas beneficial nonhormonal pharmacologic therapies include selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. For treatment of the genitourinary syndrome of menopause, vaginal lubricants and moisturizers, low-dose vaginal estrogen, and intravaginal dehydroepiandrosterone are options.

Origin, Incidence, and Management of Nongynecologic Pelvic Masses Seen on Cross-sectional Imaging.

OBJECTIVE: To characterize the origin of nongynecologic pelvic masses. STUDY DESIGN: Using a radiology database, women who underwent transvaginal ultrasound, CT scan, or MRI for the indication of pelvic mass or pelvic fullness were identified. Demographic information, radiologic data, and outcomes were reviewed. RESULTS: A total of 450 women underwent imaging for the above indications been 2002 and 2012. Of those women, 347 had at least 1 pelvic mass; 3 women had both gynecologic and nongynecologic masses, and 13 women had 2 gynecologic masses. Forty women (12%) had nongynecologic pathology. Of the nongynecologic masses 13 were gastrointestinal in origin, 9 were urologic, and 9 were neuromuscular. Other etiologies included metastatic cancers, iatrogenic masses, and hematologic masses. Seventy-four women had malignant pathology (21%): 17/40 (43%) of nongynecologic pelvic masses and 57/320 (18%) of gynecologic masses (p < 0.05). CONCLUSION: Compared to pelvic masses of gynecologic origin, nongynecologic pelvic masses are more likely to be malignant.

Medical and obstetric complications among pregnant women with cystic fibrosis.

OBJECTIVE: The objective of this study was to estimate the nationwide prevalence of cystic fibrosis (CF) in pregnancy and determine what medical complications exist at delivery among pregnant women with CF. STUDY DESIGN: The Nationwide Inpatient Sample (NIS) was queried for all delivery-related discharges. Women with CF were identified by International Classification of Diseases, 9th revision, Clinical Modifications codes and compared with women without CF. The prevalence of selected severe medical complications was compared between the 2 groups (NIS years 2008-2010) using multivariable logistic regression and the linear change in prevalence of CF at delivery determined (NIS years 2000-2010). RESULTS: From 2000 to 2010, there was a significant linear increase in the prevalence of CF at delivery from 3.0 to 9.8 per 100,000 deliveries, in 2000 and 2010, respectively (R(2) = 0.92, P < .0001). From 2008-2010, there were 1119 deliveries to women with CF and 12,627,627 to women without CF. Women with CF were more likely to be white (P < .0001) and have diabetes (odds ratio [OR], 14.0; 95% confidence interval [CI], 11.8-16.7) or asthma (OR, 5.1; 95% CI, 4.3-6.1). Multivariable logistic regression demonstrated that women with CF were more likely to die (adjusted OR [aOR], 76.0; 95% CI, 31.6-183), require mechanical ventilation (aOR, 18.3; 95% CI, 10.8-31.2), or have pneumonia (aOR, 56.5; 95% CI, 43.2-74.1), acute renal failure (aOR, 17.3; 95% CI, 9.1-32.6), preterm labor (aOR, 2.2; 95% CI, 1.9-2.6), or an adverse composite CF outcome (aOR, 28.1; 95% CI, 21.8-36.3). CONCLUSION: Pregnant women with CF are more likely to die, require mechanical ventilation, and have infectious complications compared with women without CF, although the absolute risks are low and these events are relatively rare.

Temporal trends in maternal medical conditions and stillbirth.

OBJECTIVE: The objective of this study was to estimate the prevalence and temporal trends of medical conditions among women with stillbirth and to determine the effect of medical comorbidities on the trend of stillbirth. STUDY DESIGN: The Nationwide Inpatient Sample (NIS) for the years 2008-2010 was first queried for all delivery-related discharges. A multivariable logistic regression model was constructed with adjusted odds ratios (ORs) and 95% confidence intervals (CIs) calculated for medical conditions among women with stillbirth. The NIS was then queried for the years 2000-2010, and the effect of maternal medical conditions on the stillbirth rate was estimated. RESULTS: From 2008 to 2010, there were 51,080 deliveries to women with stillbirth, giving a rate of 4.08 per 1000 live births. Women with stillbirth were more likely to be African American (OR, 2.12; 95% CI, 2.07-2.17), with an age less than 25 years (OR, 1.19; 95% CI, 1.16-1.22) or older than 35 years (OR, 1.40; 95% CI, 1.37-1.44) compared with women without stillbirth. Medical conditions such as cardiac, rheumatological, and renal disorders; hypertension; diabetes; thrombophilia; and drug, alcohol and tobacco use, were independent predictors of fetal demise in multivariable logistic regression modeling. From 2000 to 2010, despite an increase in the total number of births to women with comorbidities, there was a significant decrease in the stillbirth rate, which was more pronounced among women with comorbidities compared with women without comorbidities (P=.021). CONCLUSION: From 2000 to 2010, there was a significantly greater decrease in the stillbirth rate among women with maternal medical conditions than there was among women without comorbidities. These findings occurred despite an overall increase in the number of pregnancies to women with medical comorbidities over the time period. Because the NIS does not include information on gestational age, birthweight, or whether subjects had antepartum testing, we are not able to determine the effect of these variables on the observed outcomes.

Use of a thrombopoietin mimetic for chronic immune thrombocytopenic purpura in pregnancy.

BACKGROUND: Romiplostim, a thrombopoietin mimetic, is a novel therapeutic option for patients with chronic immune thrombocytopenic purpura. We report on the effects of romiplostim use throughout pregnancy. CASE: A 28-year-old primigravid woman with chronic immune thrombocytopenic purpura initiated a planned pregnancy on romiplostim. The second and third trimesters were marked by a cyclic pattern of thrombocytopenia requiring supplemental corticosteroids or intravenous immunoglobulin and resultant thrombocytosis. Increased romiplostim doses and daily corticosteroids stabilized the platelet count before induction of labor at 33 weeks of gestation. The newborn manifested intraventricular hemorrhage at birth, although no developmental delay was present on follow-up at 10 months of age. CONCLUSION: The decreased efficacy of romiplostim monotherapy is attributed to increased target-mediated drug disposition and the physiologic changes of pregnancy. Safety concerns still exist for the developmental effects of romiplostim on the fetus.

How I treat thrombocytopenia in pregnancy.

A mild thrombocytopenia is relatively frequent during pregnancy and has generally no consequences for either the mother or the fetus. Although representing no threat in the majority of patients, thrombocytopenia may result from a range of pathologic conditions requiring closer monitoring and possible therapy. Two clinical scenarios are particularly relevant for their prevalence and the issues relating to their management. The first is the presence of isolated thrombocytopenia and the differential diagnosis between primary immune thrombocytopenia and gestational thrombocytopenia. The second is thrombocytopenia associated with preeclampsia and its look-alikes and their distinction from thrombotic thrombocytopenic purpura and the hemolytic uremic syndrome. In this review, we describe a systematic approach to the diagnosis and treatment of these disease entities using a case presentation format. Our discussion includes the antenatal and perinatal management of both the mother and fetus.

Cancer in pregnancy: cross-sectional oncologic imaging utilization at a tertiary care center with an algorithmic approach to imaging.

PURPOSE: To review utilization of imaging in pregnant patients with malignancies and define an imaging algorithm in this patient population. METHODS: Pregnant patients with concurrent diagnoses of malignancy from January 2002 to January 2011 were identified using an institutional electronic medical record system. Patients with history of malignancy concurrent with pregnancy who had documented cross-sectional imaging studies were included. Clinical charts were reviewed, and patient demographics, diagnoses, indication for imaging, imaging findings, and oncologic stage were recorded. Descriptive statistics were performed. RESULTS: Thirty-eight women were identified with malignancy concurrent with pregnancy. Twenty-seven patients had cross-sectional imaging studies during their pregnancy. There were 20 new diagnoses of malignancy and 7 with recurrent tumor. The most common new malignancies were lymphoma (5/27, 19%) and breast cancer (4/27, 15%). Two thirds (18/27, 66%) of the patients underwent at least one imaging study associated with ionizing radiation. CT imaging was utilized in 13 (48%) of 27 patients and MRI was used in 14 (52%) of 27 patients. Fifteen (75%) of the 20 patients with new diagnoses underwent oncologic staging with imaging that meets the standard of care based on National Comprehensive Cancer Network guidelines. An imaging algorithm was created as a guideline for the most common malignancies in pregnancy. CONCLUSIONS: Cross-sectional oncologic imaging in the pregnant patient involves a variety of imaging modalities including those with ionizing radiation. This imaging largely follows standard of care for the nonpregnant patient and is tailored to specific patient complaints. A generalized algorithm is offered here for imaging pregnant oncology patients.

Management of gynecologic surgery in the patient with factor XI deficiency: a review of the literature.

UNLABELLED: Factor XI deficiency is a rare bleeding disorder that is more commonly found in Ashkenazi Jews. Bleeding manifestations of this disorder are varied and poorly correlate with factor XI levels. Spontaneous bleeding is uncommon, whereas delayed postoperative bleeding is often the presentation of factor XI deficiency. To date, there are no standard recommendations for prophylactic treatment in women undergoing gynecologic surgery. Here, we review published cases of gynecological surgery in women with factor XI deficiency and discuss the risks and benefits of various therapeutic options. TARGET AUDIENCE: Obstetricians And Gynecologists. LEARNING OBJECTIVES: After participating in this activity, physicians should be better able to identify the pathophysiology of factor XI deficiency. Compare previous outcomes of prophylactic treatment in patients with factor XI deficiency undergoing gynecological surgery. Implement possible prophylactic therapies for patients with factor XI deficiency undergoing gynecological surgery.

Prevention of venous thromboembolism in pregnancy: a review of guidelines, 2000-2011.

INTRODUCTION: Pregnant women are four to five times more likely than nonpregnant women to develop venous thromboembolism (VTE). The aim of this review is to provide an overview of guidelines in the literature on VTE risk assessment, screening for thrombophilias, and thromboprophylaxis dissemination among pregnant women. METHODS: We performed a review of the published literature to identify evidence-based guidelines published between the years 2000 and 2011. We searched for guidelines from U.S. and international organizations that identified clinically based practice recommendations to healthcare providers on how VTE risk should be assessed, thrombophilias screened, and thromboprophylaxis disseminated among pregnant women. RESULTS: We found nine guidelines that met our requirements for assessing VTE risk and found seven guidelines addressing thrombophilia screening. Seven of the nine agreed that all women should undergo a risk factor assessment for VTE either in early pregnancy or in the preconception period. Seven of the nine agreed that pregnant women with more than one additional VTE risk factor be considered for thromboprophylaxis, and five of the seven groups addressing thrombophilia screening agreed that selected at-risk populations should be considered for thrombophilia screening. CONCLUSIONS: There is some agreement between U.S. and international guidelines that women should be assessed for VTE risk during preconception and again in pregnancy. Although there is agreement that the general population of women should not be screened for thrombophilias, no agreement exists as to the clinical subgroups for which screening should be done.

Lack of genomic imprinting of DNA primase, polypeptide 2 (PRIM2) in human term placenta and white blood cells.

PRIM2, encoding a subunit of primase involved in DNA replication and transcription, is expressed in the placenta and is crucial for mammalian development and growth. Its role in placental function is not well understood. Recently, PRIM2 was reported as imprinted in human white blood cells (WBC). We report here our failure to confirm imprinting of the PRIM2 locus in human placenta or WBC. The discordance between our results and those of others are likely due to an incorrectly annotated PRIM2 pseudogene found in the human genome database.

American Thoracic Society documents: an official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline--Evaluation of Suspected Pulmonary Embolism in Pregnancy.

BACKGROUND: Pulmonary embolism (PE) is a leading cause of maternal mortality in the developed world. Along with appropriate prophylaxis and therapy, prevention of death from PE in pregnancy requires a high index of clinical suspicion followed by a timely and accurate diagnostic approach. METHODS: To provide guidance on this important health issue, a multidisciplinary panel of major medical stakeholders was convened to develop evidence-based guidelines for evaluation of suspected pulmonary embolism in pregnancy using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system. In formulation of the recommended diagnostic algorithm, the important outcomes were defined to be diagnostic accuracy and diagnostic yield; the panel placed a high value on minimizing cumulative radiation dose when determining the recommended sequence of tests. RESULTS: Overall, the quality of the underlying evidence for all recommendations was rated as very low or low with some of the evidence considered for recommendations extrapolated from studies of the general population. Despite the low quality evidence, strong recommendations were made for three specific scenarios: performance of chest radiography (CXR) as the first radiation-associated procedure; use of lung scintigraphy as the preferred test in the setting of a normal CXR; and performance of computed-tomographic pulmonary angiography (CTPA) rather than digital subtraction angiography (DSA) in a pregnant woman with a nondiagnostic ventilation-perfusion (V/Q) result. DISCUSSION: The recommendations presented in this guideline are based upon the currently available evidence; availability of new clinical research data and development and dissemination of new technologies will necessitate a revision and update.

An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy.

BACKGROUND: Pulmonary embolism (PE) is a leading cause of maternal mortality in the developed world. Along with appropriate prophylaxis and therapy, prevention of death from PE in pregnancy requires a high index of clinical suspicion followed by a timely and accurate diagnostic approach. METHODS: To provide guidance on this important health issue, a multidisciplinary panel of major medical stakeholders was convened to develop evidence-based guidelines for evaluation of suspected pulmonary embolism in pregnancy using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system. In formulation of the recommended diagnostic algorithm, the important outcomes were defined to be diagnostic accuracy and diagnostic yield; the panel placed a high value on minimizing cumulative radiation dose when determining the recommended sequence of tests. RESULTS: Overall, the quality of the underlying evidence for all recommendations was rated as very low or low, with some of the evidence considered for recommendations extrapolated from studies of the general population. Despite the low-quality evidence, strong recommendations were made for three specific scenarios: performance of chest radiography (CXR) as the first radiation-associated procedure; use of lung scintigraphy as the preferred test in the setting of a normal CXR; and performance of computed-tomographic pulmonary angiography (CTPA) rather than digital subtraction angiography (DSA) in a pregnant woman with a nondiagnostic ventilation-perfusion (V/Q) result. DISCUSSION: The recommendations presented in this guideline are based upon the currently available evidence; availability of new clinical research data and development and dissemination of new technologies will necessitate a revision and update.

Thrombotic storm revisited: preliminary diagnostic criteria suggested by the thrombotic storm study group.

Physicians periodically encounter patients with an extraordinarily accelerated course of hypercoagulability who develop thromboses in multiple organ systems over days to weeks. Such patients may harbor underlying hypercoagulable clinical conditions, but their clinical course sets them apart from most patients with similar risk factors. Underlying triggers of "thrombotic storm" include pregnancy, inflammation, trauma, surgery, and infection. Aggressive anticoagulant therapy may control thrombotic storm, yet thrombotic storm may resume with even brief interruptions of anticoagulant therapy. The authors of this communication formed the Thrombotic Storm Study Group in order to identify clinical characteristics of such patients, thus constructing preliminary criteria to better define, identify, and study the course of patients deemed to have thrombotic storm. The characteristics culled from these 10 patients are: younger age (oldest was 38 years old at time of presentation); at least 2 arterial or venous (or both) thromboembolic events, typically in unusual sites with or without microangiopathy; unexplained recurrence; and frequently proceeded by a trigger. The following characteristics were not used in defining thrombotic storm: underlying malignancies; use of acute myocardial infarction as a defining arterial event in the setting of established coronary artery disease; use of cocaine; thrombotic complications expected with various intravascular devices; known paroxysmal nocturnal hemoglobinuria or myeloproliferative disorders; severe trauma; and premorbid conditions.

Von Willebrand disease in women: awareness and diagnosis.

Based on its pattern of inheritance, von Willebrand disease (VWD) is expected to affect an equal number of men and women. Clinically, however, more women are diagnosed with VWD than men because the bleeding symptoms associated with VWD are more readily apparent during menstruation and childbirth. Menorrhagia is one of the most common symptoms of VWD, and the prevalence of VWD is increased in women who present with menorrhagia. Other obstetric/gynaecological symptoms of VWD include haemorrhagic ovarian cysts, endometriosis, and postpartum haemorrhage. Awareness of VWD as a possible cause of menorrhagia is low among clinicians, including obstetricians and gynaecologists. Simple screening techniques can identify women who may have an underlying bleeding disorder. Several medical and surgical treatment options are available for menorrhagia, and the appropriate choice of therapy can be tailored to the individual needs of the patient. Adequate prophylaxis during surgery and childbirth may help to prevent bleeding complications in women with VWD.