Report of the ISTH registry on pregnancy and COVID-19-associated coagulopathy (COV-PREG-COAG).

Background: Concerns about COVID-19-associated coagulopathy (CAC) in pregnant individuals were raised in early pandemic. Methods: An ISTH-sponsored COVID-19 coagulopathy in pregnancy (COV-PREG-COAG) international registry was developed to describe incidence of coagulopathy, VTE, and anticoagulation in this group. Results: All pregnant patients with COVID-19 from participating centers were entered, providing 430 pregnancies for the first pandemic wave. Isolated abnormal coagulation parameters were seen in 20%; more often with moderate/severe disease than asymptomatic/mild disease (49% vs 15%; p < 0.0001). No one met the ISTH criteria for disseminated intravascular coagulopathy (DIC), though 5/21 (24%) met the pregnancy DIC score. There was no difference in antepartum hemorrhage (APH) with asymptomatic/mild disease versus moderate/severe disease (3.4% vs 7.7%; p = 0.135). More individuals with moderate/severe disease experienced postpartum hemorrhage (PPH) (22.4% vs 9.3%; p = 0.006). There were no arterial thrombotic events. Only one COVID-associated venous thromboembolism (VTE) was reported. Conclusions: Low rates of coagulopathy, bleeding, and thrombosis were observed among pregnant people in the first pandemic wave.

Pregnancy, childbirth and neonatal outcomes of women with rare inherited coagulation disorders.

Background: We aimed to describe the characteristics and the pregnancy outcomes of women with rare inherited coagulation factor disorders managed at a tertiary obstetric-haematology unit in the United Kingdom. Methods: A retrospective service evaluation was conducted using routinely collected medical records. Descriptive analyses were applied to investigate pregnancy, childbirth and neonatal management and outcomes. Results: Overall, 20 patients with rare inherited coagulation disorders were included who birthed 30 live infants from 29 pregnancies. Regarding maternal bleeding outcomes, 3% experienced antepartum haemorrhage, 38% of pregnancies experienced primary post-partum haemorrhage, and none experienced secondary post-partum haemorrhage. Five (17%) neonates had cranial ultrasound scans for imaging to investigate for a neonatal haemorrhage, which were all normal. Conclusions: Although women with rare inherited coagulation disorders may be more susceptible to complications in pregnancy, within this cohort there was no evidence that the condition led to increased morbidity or mortality when best practices were observed.

A case of Fanconi anaemia in pregnancy.

Fanconi anaemia is a rare autosomal recessive chromosomal instability syndrome characterised by progressive bone marrow failure, skeletal defects, reduced fertility and increased susceptibility to malignancy. Successful pregnancy in both transplanted and non-transplanted patients have been recorded. In this paper, we present a woman diagnosed with Fanconi anaemia and who had a spontaneous conception at the age of 25 years with an uneventful delivery at 38 weeks of pregnancy.

Pregnancy outcomes in women receiving eculizumab for the management of paroxysmal nocturnal haemoglobinuria.

Aims: To report pregnancy outcomes and complications in women receiving eculizumab for the management of paroxysmal nocturnal haemoglobinuria. Methods: A service evaluation of routinely collected medical records across 49 pregnancies in 21 women. Results: Eculizumab was used in 37 pregnancies, 31 of which (83.8%) ended in live birth. Eight infants (25.8%) were born prematurely. Over half (54%) of women required increases in their dose of eculizumab to control their haemolysis. There were no reported cases of maternal thrombosis. Major ante/postpartum bleeding necessitating urgent intervention was reported in 10.8% of pregnancies. There were two cases of intrauterine death and three miscarriages. There were no maternal or neonatal deaths. Three newborns required prolonged hospital stays. Conclusions: Eculizumab appears to benefit pregnant women with paroxysmal nocturnal haemoglobinuria and pregnancy outcomes following its use are largely good.

Severe antithrombin deficiency in pregnancy: Achieving adequate anticoagulation.

Antithrombin deficiency is identified as one of the most potent risk factors for venous thromboembolism during pregnancy. Therapeutic low molecular weight heparin is recommended, but it can be difficult to attain sufficient anticoagulation since low molecular weight heparin requires antithrombin to exert its anticoagulant effect. We carried out a multicentre case-series assessing the dose of low molecular weight heparin required to achieve therapeutic anti-activated factor X levels in pregnant women with antithrombin deficiency. We assessed 27 pregnancies in 18 women with severe antithrombin deficiency, which we defined as an antithrombin level of <0.55 IU/ml (with or without prior venous thromboembolism) or an antithrombin level < 0.8 IU/ml and a personal history of venous thromboembolism. Our data illustrate the need for high doses of low molecular weight heparin to achieve therapeutic anti-activated factor X levels (average 20,220 IU/day). All pregnancies ended in live birth (excluding one elective termination), although intrauterine growth restriction occurred in five (18%).

Is infant arterial stiffness associated with maternal blood pressure in pregnancy? Findings from a UK birth cohort (Baby VIP study).

BACKGROUND: In adults, arterial stiffness measured by pulse wave velocity (PWV) is regarded as a predictor of cardiovascular disease. Infant vascular development depends on factors related to pregnancy, including maternal blood pressure (BP). This study assessed the association between maternal BP in pregnancy and infant brachio-femoral PWV at age 2-6 weeks. METHODS: The Baby Vascular health and Iron in Pregnancy (Baby VIP) study is a birth cohort which measured PWV and heart rate (HR) in 284 babies in Leeds, UK, at 2-6 weeks after birth. Maternal BP measurements at 12 and 36 weeks gestation was collected from antenatal clinical records. Multivariable linear regression models assessed associations between maternal systolic and diastolic BPs, and BP change from booking to 36 weeks, with infant PWV adjusting for covariables at both mother and baby level. RESULTS: There was no evidence of an association between infant PWV and maternal systolic BP at booking (adjusted regression coefficient -0.01 m/s per 10mmHg, 95% CI -0.11, 0.14, p = 0.84) or at 36 weeks (adjusted regression coefficient 0.00 m/s per 10mmHg, 95% CI -0.12, 0.11, p = 0.95). Change between 12 and 36 weeks gestation of more than 30 mmHg in systolic BP or 15 mmHg in diastolic BP was also not associated with infant PWV. There was an inverse relationship between infant HR and infant PWV (regression coefficient -0.14 m/s per 10 bpm, 95% CI -0.22, -0.05, p<0.01). CONCLUSIONS: This study has shown no evidence of association between infant PWV at 2-6 weeks of age and maternal BP in early or late pregnancy. Infant HR was inversely associated with infant PWV. Further studies are required to determine the predictors of infant PWV as well as the importance and long term implications of PWV measurements in infants.

Near-peer education the Leeds way; Gynaecology, Obstetrics and Sexual Health: a case study.

This article was migrated. The article was marked as recommended. Near-peer education the Leeds way; Gynaecology, Obstetrics and Sexual Health: a case study. Two doctors in training and a consultant obstetrician present a case study of near-peer education in Gynaecology, Obstetrics and Sexual Health for 4 th year undergraduate students in Leeds. They offer their own perspectives as near-peer educators, and consider the benefits to medical students, institutions and themselves as near-peer educators.

Hermansky-Pudlak syndrome in pregnancy: A case report.

Hermansky-Pudlak syndrome is a rare autosomal recessive disorder estimated to affect 1 in 500,000 to 1,000,000 individuals worldwide. Clinically, it presents as oculocutaneous albinism combined with bleeding diathesis. This is due to the absence of dense bodies in platelets causing a delayed secondary response resulting in prolonged bleeding time despite normal platelet count and coagulation factors. This has consequences for major bleeding, the risk of which is high at delivery. In the longer term, the condition is also associated with the development of pulmonary fibrosis, inflammatory bowel disorders caused by granulomatous colitis and renal failure. We present a case of a patient with Hermansky-Pudlak syndrome diagnosed and managed through her second pregnancy by the Obstetric Haematology team in a Tertiary Unit. During her previous pregnancy at a District Hospital, they had not been aware of the diagnosis; she then had a forceps delivery and her haemoglobin dropped to 69 g/L. During this pregnancy, she was managed in a multidisciplinary setting involving obstetrics, haematology, anaesthesia and neonatology. She was induced at 39 weeks and had human leukocyte antigen-matched platelets prepared for her delivery. Her platelet count was normal throughout the pregnancy. She had a normal vaginal delivery under platelet cover and also received tranexamic acid at the time of cord clamping. Her blood loss was moderate and her haemoglobin dropped from 115 to 97 g/L. She recovered well. We discuss the diagnosis, pathology and management of this very rare condition in pregnancy and thereafter.

Infant Arterial Stiffness and Maternal Iron Status in Pregnancy: A UK Birth Cohort (Baby VIP Study).

BACKGROUND: In animal studies, iron deficiency during pregnancy has been linked to increased offspring cardiovascular risk. No previous population studies have measured arterial stiffness early in life to examine its association with maternal iron status. OBJECTIVE: This study aimed to examine the association between maternal iron status in early pregnancy with infant brachio-femoral pulse wave velocity (PWV). METHODS: The Baby VIP (Baby's Vascular Health and Iron in Pregnancy) study is a UK-based birth cohort which recruited 362 women after delivery from the Leeds Teaching Hospitals postnatal wards. Ferritin and transferrin receptor levels were measured in maternal serum samples previously obtained in the first trimester. Infant brachio-femoral PWV was measured during a home visit at 2-6 weeks. RESULTS: Iron depletion (ferritin <15 µg/l) was detected in 79 (23%) women in early pregnancy. Infant PWV (mean = 6.7 m/s, SD = 1.3, n = 284) was neither associated with maternal ferritin (adjusted change per 10 µg/l = 0.02, 95% CI: -0.01, 0.1), nor with iron depletion (adjusted change = -0.2, 95% CI: -0.6, 0.2). No evidence of association was observed between maternal serum transferrin receptor level and its ratio to ferritin with infant PWV. Maternal anaemia (<11 g/dl) at ≤20 weeks' gestation was associated with a 1.0-m/s increase in infant PWV (adjusted 95% CI: 0.1, 1.9). CONCLUSION: This is the largest study to date which has assessed peripheral PWV as a measure of arterial stiffness in infants. There was no evidence of an association between markers of maternal iron status early in pregnancy and infant PWV.

Pre-eclampsia, severe pre-eclampsia and hemolysis, elevated liver enzymes and low platelets syndrome: what is new?

Pre-eclampsia and eclampsia have been known to us for centuries. Significant improvements have been made in our knowledge of the disease, however, delivery remains the only effective form of treatment. There is widespread variation of practice in the management of hypertensive disease in pregnancy, which may lead to substandard care. The use of aspirin in preventing pre-eclampsia, the lack of correlation between urinary protein and adverse outcome, and the ineffectiveness of corticosteroids in the management of hemolysis and elevated liver enzymes and low platelets syndrome are a few of the developments that will alter the way this condition is managed. This article aims to provide a general overview of pre-eclampsia, eclampsia and hemolysis, hemolysis and elevated liver enzymes and low platelets syndrome supported by the latest evidence, which will help the care provider adopt a focused approach and use the latest knowledge to understand and manage this old condition.