Thromboembolic events in patients with severe inherited fibrinogen deficiency.

Inherited afibrinogenemia and hypofibrinogenemia are rare bleeding disorders characterized by markedly reduced levels of fibrinogen in blood. Thrombotic complications in these disorders have been rarely described. We performed a multicenter retrospective study and reviewed the occurrence of thrombotic complications among patients with inherited fibrinogen deficiency. Cases were identified during a review of medical records of all patients with inherited fibrinogen deficiency followed at three different university hospitals in Israel. Nine patients were included in this study: five were afibrinogenemic and four hypofibrinogenemic. There were seven thrombotic events, mostly venous, that occurred in four out of nine patients (44 %). All thrombotic events occurred in afibrinogenemic patients. Mean age at the time of thrombosis was 45 (range 28-61) years. Thrombophilic evaluation performed was negative in all cases. At the time of thrombosis in five out of seven (71.4 %) events, fibrinogen replacement therapy was concurrently given. Therapeutic approach was different among patients ranging from supportive therapy alone, antiplatelet agents and anticoagulant therapy with the concurrent administration of fibrinogen replacement therapy. This study discloses a high rate of thrombosis in patients with afibrinogenemia. Events were both venous and arterial and may be recurrent. Management is highly problematic due to the precarious balance between bleeding and thrombotic risk in these patients. Fibrinogen replacement therapy should be cautiously used in these patients as most thrombotic events followed the administration of fibrinogen replacement therapy. Larger cohorts are warranted to better characterize the best management strategy in these paradoxical events.

Diagnosis of pregnancy-associated uterine venous plexus thrombosis on the basis of transvaginal sonography.

OBJECTIVE: To describe the sonographic signs of uterine venous plexus thrombosis. METHODS: Four pregnant patients had a diagnosis of uterine venous plexus thrombosis in the first half of gestation. The diagnosis was based on transvaginal sonography only in 3 cases, and the fourth had magnetic resonance imaging corroboration. RESULTS: All 4 patients had similar sonographic features of uterine venous plexus thrombosis on transvaginal sonographic examination. The thrombi within the dilated veins were shown as elongated echogenic structures along the lumen that appeared round on transverse views of the affected veins. They showed swinging movements provoked by gentle transducer pressure. Power and color Doppler sonography enhanced the uterine venous plexus thrombosis diagnosis by showing blood flow around the thrombi. There were no signs of thromboembolic disease. Sonographic findings in deep leg veins and iliac veins were normal in all cases. Complete thrombophilia studies did not reveal any abnormalities. The uterine venous plexus thrombosis could not be detected on transabdominal sonography and was shown better by transvaginal sonography compared with magnetic resonance imaging. During 3 months of anticoagulation therapy, the thrombi gradually disappeared in all cases. CONCLUSIONS: Focusing on the pelvic veins while performing a transvaginal sonographic study during pregnancy may reveal important findings, which may have clinical implications. The therapeutic treatment of uterine venous plexus thrombosis is controversial and still empirical.