Ian A Greer

..Low-molecular-weight heparins are now replacing unfractionated heparin for the treatment of DVT and PTE in pregnancy...

..However, many unanswered questions remain, including who to treat, how to treat them, and when to treat in the case of patients with thrombophilia and a history of previous pregnancy complications...

..Venous thromboembolism (VTE) is a leading cause of maternal mortality in western countries. Many of these deaths could be prevented by optimal prophylaxis and management...

..Such therapy is not restricted only to prevention and treatment of VTE but is now being assessed in additional clinical situations such as the prevention of pregnancy complications...

..Because acute VTE is relatively uncommon, greater use of proposed guidelines [24,84,85] may be of value in improving management, but the involvement of clinicians with expertise in the management of these cases is also important...

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..Such agents should be used in women with significant risk factors for VTE both antenatally and post-partum...

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..01%-0.20%) of pregnancies. Overall, live births were reported in 94.7% of pregnancies, including 85.4% in those receiving LMWH for recurrent pregnancy loss. LMWH is both safe and effective to prevent or treat VTE in pregnancy...

..Thus LMWH is now the agent of choice in pharmacological thromboprophylaxis in pregnancy..

..However, whether established or putative novel cardiovascular risk factors including vascular and metabolic function are disrupted in women who delivered small for gestational age (SGA) offspring is unknown...

..Obesity in pregnancy is increasing and is a risk factor for metabolic pathology such as preeclampsia. In the nonpregnant, obesity is associated with dyslipidemia, vascular dysfunction, and low-grade chronic inflammation...

..They also have significantly impaired skin microvascular function as assessed by laser Doppler imaging, consistent with generalized vascular dysfunction, a finding with potential diagnostic implications...

..In conclusion, preeclampsia is associated with short- and long-term changes in inflammatory status...

..Pre-eclampsia (PE) and intrauterine growth restriction (IUGR) may both arise secondary to inadequate trophoblast invasion. Maternal vascular disease is evident only in PE. Little mechanistic evidence exists to explain this dichotomy...

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..We studied placental PPARdelta, PPARgamma, and retinoid X receptor alpha (RXRalpha) expression in healthy pregnancy and in preeclampsia (PET) and intrauterine growth restriction (IUGR)...

..However, further studies are required to establish with greater confidence the associations of these, and other, thrombophilias with venous thromboembolism among hormone users...

..Heparan sulphates play key roles in conception and early pregnancy events. The role of heparin, a structural analogue, and its application to assisted conception, is largely unknown...

..This review aims to describe the recent developments in pharmacological thromboprophylaxis and acute treatment of arterial and venous thromboembolism in pregnancy...

..Such knowledge combined with the appropriate use of thromboprophylaxis and treatment in women who have objectively confirmed VTE continue to improve maternal and perinatal outcomes...

..The correlation between maternal 22:6n3 and 24:1n9 suggests that mobilisation of these fatty acids may be coordinated. The inverse relationship between 16:1n7 and maternal central obesity warrants further investigation...

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..These data support the view that trophoblast D6 scavenges maternal chemokines at the fetomaternal interface and that, in some circumstances, this can help to ensure fetal survival...

..CONCLUSIONS: Metformin may improve vascular function and decrease myocardial ischemia in nondiabetic women with chest pain and angiographically normal coronary arteries. Larger controlled trials of longer duration are warranted...

..These women may be an appropriate cohort for CVD risk screening and for possible intervention...

..The aim of this review was to examine the current evidence on the cost-effectiveness of screening for thrombophilia...

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..The safety profile of each agent was such that it would be reasonable to give isosorbide mononitrate, but not prostaglandin E2, on an outpatient basis...

..9% vs 9.4%) rising to greater than threefold higher in multivariate analysis. These findings suggest that obesity-related pregnancy complications are likely to increase with implications for both mother and child...

..Our aim was to study vascular function and metabolic and inflammatory risk factors during the antenatal and postpartum periods in women with type 1 diabetes compared with healthy control subjects...

..Clearly, these data provide further rationale to examine the potential benefits of preconceptual weight loss and antenatal exercise...

..These data support a beneficial effect of metformin in improving ovarian function in women with oligomenorrhea and polycystic ovaries...

..Use of a low-resistance vehicle combined with larger chamber sizes and lower currents can prevent such artefacts, thereby increasing the robustness of this methodology for clinical assessment of endothelial function...

..There has also been an observed association between maternal factor V Leiden and fetal or neonatal stroke. These areas require further study and at present there is no evidence-based approach to investigation, prevention or management...

..There is also a lack of controlled trials of antithrombotic intervention to prevent pregnancy complications. Thus, at present, universal screening for thrombophilia in pregnancy cannot be justified clinically...

..Pre-eclampsia is associated with increased placental debris circulating in maternal plasma...

..CONCLUSIONS: Enoxaparin is a safe and effective treatment for venous thromboembolism during pregnancy and confers a major advantage over unfractionated heparin through its simplified regimen of administration...

..Such an interaction raises the possibility of haemorrhagic complications developing perioperatively when these agents are used concomitantly. Further studies are required to examine the clinical importance of this interaction...

..002) and after the onset of labour (P: < 0.002) when compared with non-pregnant samples. The increased expression of NOS isoforms in late pregnancy supports the hypothesis that NO is involved in the process of cervical ripening...

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..To assess whether waist circumference at the first antenatal visit predicts risk of developing hypertension later in pregnancy...

..Higher APC:SRs were observed in blood group O subjects and smokers. An inverse relationship of the APC:SR with age, diastolic blood pressure and total serum cholesterol was observed...

..Large randomized controlled trials of such low dose preparations, powered for cardiovascular end points, are now needed...

..To perform a case note review of pregnancies complicated by thyroid dysfunction to determine management and therapeutic intervention in relation to pregnancy outcome...

..Pregnancies complicated by pre-eclampsia may identify women at risk of vascular disease in later life and may provide the opportunity for lifestyle and risk factor modification to alter maternal vascular disease risk...

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..Our findings are potentially pertinent to understanding the future cardiovascular health of the offspring...

..Future studies should determine whether adiponectin concentrations help improve prediction of PE...

..However, potential associations between the low-grade inflammatory response as represented by C-reactive protein (CRP) concentrations and low birth weight have been sparsely examined...

..We aimed to determine the effect of pravastatin on incident VTE in older people; we also studied the impact of clinical and plasma risk variables...

..Thrombophilia may play a minor role in the aetiology of SVT associated with pregnancy, although a larger study is required to confirm this...

..This confirms reduction in venous stasis in the deep venous system in the immediate postpartum woman by the use of GCS, supporting their use in improving venous function in this context...

..9, 52.4 and 3.8 respectively). LRR findings correlated with moderate, but not mild, PTS. There was no correlation between development of PTS and body mass index...

..These data lend further support to the hypothesis that labour is an inflammatory process...

..Women who experience adverse pregnancy outcomes are also at increased risk of premature cardiovascular disease, and potential therapeutic strategies to minimize their risk profile are discussed...

..7 (CI95 0.4-1.1). We conclude that the presence of leucine at this site is not associated with a protection against pre-eclampsia to the magnitude of that reported in other thrombotic disease...

..We examined metabolic parameters in cohorts of women with and without subcutaneous estrogen therapy with concomitant supra-normal concentrations of estradiol (SE)...

..The changes which characterize normal and complicated pregnancies are outlined and the evidence for the impact of heritable and acquired disorders of the protein C/protein S system on pre-eclampsia and fetal loss are discussed...

..She was delivered by elective caesarean section at 35 weeks under general anaesthesia. The anaesthetic management is discussed and a review of the literature presented...

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..We neither confirmed the protective effect of FVL on pregnancy-related blood loss reported in previous smaller studies, nor did we find the increased risk of some vascular complications reported in retrospective studies...

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..This additional cost would result in prevention of less than one and three vascular events,respectively. Our findings, therefore, suggest that screening of pregnant women for the FVL mutation is not cost-effective...

..In high-risk women with prosthetic heart valves, we suggest the addition of low-dose aspirin, 75 to 162 mg/d (Grade 2C)...

..Rather markedly elevated ICAM-1 concentrations and specific but subtle features of the metabolic syndrome (glucose, blood pressure) are likely to be involved...

..Physiologic changes of pregnancy include insulin resistance, thrombophilia, immunosuppression, and hypervolemia. These changes may herald the development of disease in later life...

..The lack of the intervention effect may be related to the complexity of the guideline recommendations and the nature of the implementation strategy...

..Given the availability of effective VTE prophylaxis, many of these events and deaths could have been prevented. These results have important implications for the allocation of healthcare resources...

..This review details the management options for prevention of arterial occlusions in these at-risk patients and outlines potential management strategies for arterial occlusions occurring during pregnancy...