[Thromboembolism complications--most frequent cause of death after cesarean section].
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Cause of Death↗
Biomedical subjects
L Heilmann
Publications and source records attributed to L Heilmann.
[Effect of thrombophilic factors on thromboembolism and other pregnancy complications].
Pulmonary embolism and/or deep vein thrombosis are a major cause of maternal mortality. In a number of adverse pregnancy outcome including preeclampsia, recurrent spontaneous abortion, restricted fetal growth and fetal death a role for thrombophilia (acquired and hereditable) has been postulated. Monitoring of acquired factors such as antiphospholipid-antibodies and hereditable factors (factor V Leiden, prothrombin mutation) may help predict the occurrence of pregnancy complications. Low molecular weight heparins (LMWH), since their introduction well established during pregnancy, and the rate of adverse fetal outcomes are related to co-morbidity maternal conditions rather than to the treatment itself. The use of LMWH is recommended for all moderate risk and high-risk pregnant patients.
Blood Coagulation Factors↗
Lack of anti-factor Xa activity in umbilical cord vein samples after subcutaneous administration of heparin or low molecular mass heparin in pregnant women.
Prophylaxis of thromboembolism with low molecular mass (LMM) heparin may offer several advantages over conventional heparin during pregnancy. Heparin-related side effects as osteoporosis, local allergy, thrombocytopenia and increase in liver enzymes may occur less frequently with LMM heparin. However, LMM heparins of different origins have to be considered as individual pharmaceutical compounds. This is of special clinical importance regarding a possible placental passage. We performed a randomized controlled study comparing the anti-factor Xa activities in plasma samples of 60 pregnant women undergoing delivery at term and in the umbilical cord vein of the newborn after subcutaneous administration of 5,000 IU unfractionated (UF) heparin or 1,500 activated partial thromboplastin time units LMM heparin or placebo. Injections were performed about 2 h prior to the delivery. Maternal and fetal blood samples were taken at the same time to assay heparin activity by the heptest coagulation assay and the S2222 chromogenic substrate method. LMM heparin was detected in all maternal plasma samples whereas UF heparin was measurable only in about one third of them. UF heparin as well as LMM heparin were not detectable in samples taken from the umbilical cord vein. The data demonstrate that neither UF nor the LMM heparin used in this study cross the placenta in relevant inhibitory activity towards factor Xa. This finding is in accordance with the previous experiences regarding the safe administration of other LMM heparins for prophylaxis of thromboembolism during pregnancy.
Adult↗
[Perioperative prevention of thrombosis in cesarean section: results of a randomized prospective comparative study with 6% hydroxyethyl starch and 0.62 low dose heparin].
In 207 consecutive randomized women undergoing cesarean section, of whom 104 received 3 X 5000 IE unfractionated heparin and 103 3 X 500 ml hydroxyethylstarch 6% 0.62, the frequency of deep vein thrombosis was evaluated with a non-invasive diagnostic technique-impedance plethysmography. 5.9% of the patients in the hydroxyethylstarch group and 7.8% in the heparin-group developed deep vein thrombosis. Activation of blood coagulation at cesarean section results in an increasing of factor VIIIR:Ag, Fibrinogen and Reptilase clotting time. Hydroxyethylstarch 6% 0.62 produces minor abnormalities of coagulation test results. After 1500 ml infusions HES the following effects were noted: 1. Factor VIIIR:Ag fell by about 20%, a greater decrease than could be explained simply by hemodilution. 2. Reptilase clotting times shortened without a different increase in fibrin activation products (resulting in an increased lysability of the thrombus). 3. Plasma fibrinogen decreased by approximately 7% due to hemodilution caused by plasma volume expansion. For patients with a low risk of deep vein thrombosis (Cesarean section) HES has an excellent safety record in doses not exceeding 1500 ml/24 h.
Blood Coagulation Tests↗
[Changes in plasma coagulation and fibrinolysis following cesarean section and relationship to deep venous thrombosis. Results of a randomized prospective comparative study with 6% hydroxyethyl starch 0.62 and low-dose heparin as thrombosis prophylaxis].
Routine postoperative monitoring of plasma coagulation and fibrinolysis system values after cesarean delivery in 191 women who did not develop thrombosis and 16 who did revealed a preoperative defect in the fibrinolysis (PAI, TAT) and inhibitor (AT III) systems. Significant postoperative correlations in the drop in antithrombin levels could not be explained solely by hemodilution. Moreover, a disturbance of the equilibrium of the alpha-2 increase and plasminogen was observed, favouring alpha-2 antiplasmin. Hydroxyethyl starch is capable of simultaneously influencing hypercoagulability and postoperative status. The only difference noted between the two groups of drugs was in the course of the PAI concentration (P less than 0.02). It would therefore appear logical in clinical practice to extend preoperative tests to include determination of the plasminogen activator inhibitor and the thrombin-antithrombin complex.
Adult↗
[Deep venous thrombosis in pregnancy: risk factors and possibilities for prevention].
Twenty-two cases of acute venous thrombosis in pregnancy (0.64%) were studied. Concomitant pulmonary embolism was documented in 0.23%. Prophylactic heparinization was performed in 32 gravidae. In the acute thrombosis group therapy was instituted in the 26th week, and in the prophylaxis group in the 20th week of pregnancy. Recurrent thromboses after cesarean section occurred in 4.5% of the patients with acute venous thrombosis and in 5.6% of those in the prophylaxis group. Reduced red blood cell deformability, low antithrombin III and high leukocyte count were identified as risk factors. Heparinization did not prevent increased red blood cell aggregation and plasma viscosity at birth. Rheologic factors played only a secondary role in the prophylaxis group. Prophylactic heparinization in pregnancy is currently the only means of reducing the thrombosis recurrence rate in patients with a history of thromboembolism.
Adolescent↗
[Clinical results after hemodilution with hydroxyethyl starch in pregnancy].
Plasma volume contraction in pregnancy is diagnosed by an increase of hematocrit above 38%. Hydroxyethylstarch was administered to 30 patients with hemoconcentration alone, to 36 patients with fetal growth weight retardation and to two patients with pre-eclampsia. In the present study the tolerance and effectiveness of middle molecular hydroxyethylstarch as volume replacement was studied. The data presented a significant decrease in the incidence of small for date babies (from 52% to 34%). In addition to these findings, hematocrit, erythrocyte aggregation and plasma viscosity were decreased and cardiac output was increased. By twenty three women we registered a newborn weight below the 10th percentile according to Hohenauer. The impaired rheological properties of blood in this group were associated with a decrease of cardiac output. We conclude that hydroxyethylstarch is a safe (no maternal-fetal transfer and only a small incidence of starch storage (1.4% of patients) in the placenta) and effective colloid substance for plasma volume expansion in pregnancy.
Adult↗
[Effect of low molecular dextran on maternal microrheologic parameters, fetal heart rate and transcutaneous fetal oxygen partial pressure in labor].
The results from animal experimental research have shown that the infusion of dextran 40 increased the uterine blood flow mainly by decreasing the vascular resistance and by this improving the oxygen supply to the fetus. Dextran 40 given in a dosage of 50 ml/min within 10 minutes to 11 pregnant women during parturition showed that the fetal blood PO2 increased if the PO2 before infusion was low and decreased if the PO2 before infusion was high. Therefore the question enhanced if the reduced maternal oxygen capacity results in a reduction of fetal PO2 (tcPo2) too. After informed consent 10 healthy pregnant women at term with a normal pregnancy got an infusion of 500 ml dextran 40 during 30 minutes. The following maternal parameters were measured: heart rate, mean arterial blood pressure, intrauterine pressure and transcutaneous carbon dioxide tension (tcPCO2). Maternal microrheological parameters before and after infusion of dextran 40 were estimated as following: plasma viscosity, erythrocyte aggregation, serum osmolality, colloid osmotic pressure, hemoglobin and haematocrit. The mothers were laying in the side position and their ventilation was controlled by tcPco2 (Dräger, Lübeck). The following fetal parameters were registered: basal fetal heart rate, transcutaneous fetal oxygen partial pressure (tcPo2) and the umbilical cord blood gases. After rupture of the fetal membranes and at a cervix dilatation of about 5-7 cm a tcPo2 electrode (Dräger, Lübeck) was fixed at the fetal scalp with an acrylate glue (Histoacryl) and by this fetal tcPo2 and its "flow" registered.(ABSTRACT TRUNCATED AT 250 WORDS)
Blood Pressure↗
[Chorioamniotic infections following diagnostic amniocentesis in the 2d trimester].
Between 1978 and 1984 we performed 3 122 amniocentesis for prenatal diagnosis in second trimester. Based on a four week follow-up in more than 96% of all amniocentesis the percentage of fetal loss was 0.74% (n = 23). In 13 cases abortion was accompanied by chorioamnionitis. These cases were examined for various technical details and it could be concluded, that the incidence of febrile abortion is related to the early gestational age for amniocentesis. On the other hand, multiple insertions or the localisation of placenta both show no relation to the short-time febrile complications. To investigate the maternal-fetal transfer of mezlocillin, a single dose of 5 g mezlocillin was administered intravenously in 25 patients. In amniotic fluid mezlocillin levels exceeded 2 micrograms/ml nearly 120 minutes after administration. These pharmacokinetic data suggest, that a prophylactic regimen with antibiotics in the course of amniocentesis seems not to be beneficial for the prevention of chorio-amniotic infections.
Abortion, Septic↗
[Hemodynamic changes during tocolysis with hexoprenaline and fenoterol].
The authors examined two groups of 50 patients each who had been given an average dose of 0.24 microgram/min Hexoprenaline or respectively 1.8 micrograms/min Fenoterol as beta-mimetics for premature labor. The patients who received Fenoterol were also given Verapamil as additional medication in a ratio of 1 : 40. In addition to blood pressure, heart rate, urine elimination and serum or urine osmolarity, the hemodynamic parameters stroke volume, cardiac output and total peripheral resistance were investigated. Stroke volume was measured by means of impedance cardiography. Giving equipotent doses, Hexoprenaline/Fenoterol dose ratio of 1 : 8, there was a slower and smaller increase in heart rate over 24 hours with Hexoprenaline, with identical suppression of uterine contractility (external tocography). This was also reflected in the cardiac output, while there were no differences in the stroke volumes. Inhibition of diuresis was lower with Hexoprenaline. This might be due to the fact that since there is no organ specificity for beta-1 or respectively beta-2 receptors and the patterns of distribution differ, Hexoprenaline has a somewhat less pronounced action on beta-1 receptors than Fenoterol, though the same beta-2 action.
Drug Therapy, Combination↗
[Doppler ultrasound results of hemodilution treatment].
In a double-blind study, 12 patients with an Hb > 13 g/dl in the second trimester, a pretherapeutic hematocrit > 38%, and a fetal aortal resistance index > 0.75 underwent hemodilution. The patients were given either 500 ml hydroxyethyl starch (HAES) or 500 ml NaCl 0.9%. In addition, all patients received 500 ml NaCl 0.9% by infusion. HAES therapy caused a lowering of the fetal aortal and uterine artery resistance indices. This was not the case with NaCl. The causes for this lie in the specific anti-aggregation and viscosity-reducing effect of hydroxyethyl starch with an identical lowering of hematocrit.
Blood Flow Velocity↗
[Clinical experiences with passive immunotherapy in habitual abortion].
In a pilot study, 25 patients with histories of repeated abortion were treated by passive immunotherapy with high-dosage immunoglobulin administration (Sandoglobulin). Plasma viscosity, RBC aggregation, hematocrit, PAI, D-dimer and Factor VIIIR:AG were studied in order to detect risks. By September 1, 1992, 16 women had given birth; abortion had recurred in 2 women and 7 were pregnant between the 10th and 37th GW. Five pregnancies terminated in premature/small-for-date births and one neonate had a congenital malformation syndrome. Under immunoglobulin therapy no hyperviscosity or excessive fibronolysis defects with a tendency to thrombosis or restriction of intervillous perfusion were observed. Besides safety for mother and fetus, intravenous immunoglobulin administration has the added advantage that it can be used in cases of primary and secondary abortion and for women with deficient immune response.
Abortion, Habitual↗
[Acquired resistance to activated protein C in pregnancy].
A recently identified mechanism for familial thrombophilia--the poor anticoagulant response to activated protein C (APC-resistance)--is said to be one of the leading risk factors for thrombosis. This has been demonstrated by a large number of studies. But there is still a need for data concerning the prevalence of APC-resistance in pregnancy. Therefore we performed the study with 50 pregnant women and 10 non-pregnant controls to evaluate this question with the blood samples drawn at trimester 1., 2., 3. and at term. A progressive shortening of the APC-ratio (APCR) and normalised APCR (nAPCR) was noted in our population. In comparison to the first (APCR 2.32 +/- 0.39; nAPCR 0.99 +/- 0.17) significant differences were noticed at 2. (APCR 2.12 +/- 0.34; nAPCR 0.92 +/- 0.14) (p = 0.001) and 3. trimester (APCR 1.98 +/- 0.26; nAPCR 0.87 +/- 0.13) and at term (APCR 1.98 +/- 0.26; nAPCR 0.92 +/- 0.19) (p = 0.001). In addition to the APC-resistance we determined protein C and factor VIII:C. Whereas factor VIII:C showed an increasing trend which achieved statistical significance (1. trimester: 109%; 2.: 115%; 3.: 128%) (p = 0.005) protein C remained unchanged. Physiological changes during pregnancy lead to an acquired APC-resistance. Our study suggests that e.g. an increase in factor VIII contributes to this phenomenon.
Factor VIII↗
[Intravenous immunoglobulins (IVIG) in treatment of an antiphospholipid syndrome in pregnancy].
A patient with a history of early onset preeclampsia and repeated fetal death, high titer IgG anticardiolopin antibodies and prolonged aPTT was treated during her third pregnancy with intravenous immunoglobulins (IVIG) from the seventh month of pregnancy onwards. Every month--after a loading dose of 30 g immunoglobulins--a daily infusion of 3 g immunoglobulin was for three days was given during six consecutive cycles. The patients pregnancy ended preterm with a life birth, delivered by cesarean section, because of a severe preeclampsia. The 1600 g weighing boy was in good health. Each treatment with IVIG resulted in a reduction of anticardiolipin-antibodies. During the seventh months observation period, a gradual increase in PAI activity/factor VIIIR:Ag was found. A partial transient reduction of antiphospholipid-antibody levels was observed immediately following each treatment course resulting in an accelerated fetal outcome.
Adult↗