In recent years, more and more pregnant women have daily anticoagulant injections during pregnancy and during delivery after the advice of their gynecologist or hematologist.
Why is this happening;
In the last 15-20 years, the use of antithrombotic treatment in pregnancy and childbirth has been widely spread, both injectable, which involves low molecular weight heparins, and oral, which involves the use of aspirin.
“The reasons for this are many and given that thrombotic complications are the most common cause of death in pregnant women even in modern times, some of them make the use of antithrombotic drugs necessary, while for several of them their use not only it does not offer anything, but it can also potentially be harmful to the course of the pregnancy.
The role of the hematologist, in this case, is to use his knowledge to give the right direction to the pregnant woman and her gynecologist, in order for the pregnancy to proceed without or with the smallest possible complications”, points out Mr. Ilias Evmorfiadis, Deputy Chief Haematologist at Metropolitan Hospital.
What is thrombophilia and for what other reason, apart from it, do hematologists intervene in pregnancy?
Thrombophilia in pregnancy is the cause for which hematologists who deal with disorders of the hemostasis mechanism are most often asked to answer, and it concerns inherited and acquired factors that lead to an increase in thrombotic risk.
In the last 25-30 years there has been a plethora of studies, which correlated the presence of obstetric complications with various factors that came under the term “thrombophilia”. However, the clinical significance of all of these has not been confirmed in subsequent, better-designed studies and analyzes by expert bodies. For this reason, there is still confusion as to what constitutes ‘thrombophilia’.
Haematologists are asked to explain to women who visit them worried about the significance of thrombophilia results both in pregnancy and in the rest of their lives, what they mean, whether they should take precautions and what kind of measures these will be in each case ( in or out of pregnancy).
However, the interpretation of thrombophilia results and their significance for each pregnant woman is not the only reason why gynecologists refer pregnant women or women preparing for pregnancy for an overall thrombotic risk assessment.
“Pregnancy itself is a factor in hypercoagulability, because nature, over thousands of years, has regulated this mechanism, through natural selection, so that it is, in this way, more efficient. However, as in the course of the human species, living conditions and the way in which couples do their family planning have changed a lot, to the normal increased coagulation of pregnancy, in addition to thrombophilia, other factors are added that may increase the thrombotic risk and which have more to do with the modern lifestyle, such as the more advanced age at which women become pregnant today, the use of hormone therapy, assisted reproductive methods, obesity, smoking, vascular damage and other comorbidities” , explains the expert.
By taking a good personal and family history as well as the objective examination, the specialist hematologist can “weigh” whether or not the woman he sees should receive anticoagulation in pregnancy, its type and dose, primarily for the safety of the woman herself, but also to reduce the risk of complications concerning the fetus.
Thrombotic risk assessment by a hematologist should be done in every pregnant woman who is considering taking anticoagulants?
What should be done routinely is thrombotic risk assessment in all women planning to become pregnant, both before and during pregnancy. In the vast majority of cases, this assessment is made by the attending gynecologists, but in some cases when the attending physicians are on the verge of giving antithrombotic prophylaxis or not, or need help choosing the optimal type and dose that should be to administer, they refer the women for evaluation to the specialist hematologist.
After the initial advice from the hematologist, is another follow-up needed?
Given the rapidly changing state of the pregnant woman’s body, it is possible that during pregnancy she will need a re-check at intervals, usually every trimester, but this is not absolute, i.e. women with a very low risk profile may not need a re-check and women at a higher risk more frequent checks may be needed.
Can the hematologist help reduce the risk of complications involving the fetus?
Yes maybe. Women with a history of multiple miscarriages, intrauterine death, intrauterine growth retardation, preeclampsia and some rarer syndromes are often referred for evaluation in order to investigate hematological factors that could have influenced the occurrence of these complications and to provide the most appropriate preventive treatment to avoid them in a subsequent pregnancy.
Can the hematologist also help in cases of infertility to increase the chances of success of an assisted reproduction attempt?
“In assisted reproduction things get more complicated. The mechanism of hemostasis certainly plays an important role in the development of the fetus, as some of the substances used by the body to create clots are also stimulating factors for the creation of new vessels as well as for cell proliferation, which very likely explains a part of the normal hypercoagulability of pregnancy”, points out the doctor.
Therefore, since infertility is usually multifactorial, blood coagulation is one of many parameters that should be as well regulated as possible in an assisted reproduction attempt. For this reason, one must be careful how one interferes with its mechanism, in case one wants to increase the chances of success of an IVF.
Each candidate for antithrombotic treatment in cases of infertility/assisted reproduction is different from each other and the logic of applying the same protocol to all should be avoided, as even if there is evidence from some studies that support such an approach, these concern the average of the women who took part in these studies and not each one individually.
The aim of an experienced hematologist in the field of assisted reproduction is to improve the micro-management of elements such as vitamins and hematological factors, to carry out the relevant immunological control but above all to help in the selection of the appropriate antithrombotic regimen, where and if this is needed, in a personalized level, so as to approach the maximum of the chances of success of the assisted reproduction method.
Are there other situations in which the hematological assessment can contribute to pregnancy?
Hematological monitoring during pregnancy is necessary for all women with a pre-existing hematological problem (e.g. hemoglobinopathies, hemophilia, anemia, thrombocytopenia, hematological malignancies, etc.), as pregnancy can affect the course of their disease, but also the diseases of the course of pregnancy.
“In these cases, frequent monitoring may be necessary. In addition to the above, hematological evaluation in pregnancy helps to investigate and treat conditions that were not known before and/or appeared during pregnancy, without necessarily being specific to pregnancy (e.g. autoimmune thrombocytopenic purpura, anemias from lack of hematological factors, hemolysis, etc.), concludes Mr. Evmorfiadis.
Written by:
K. Ilias Efmorfiadis, Deputy Director Hematologist at Metropolitan Hospital
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