Kalish, Yosef

ObjectivesTo examine the outcomes of planned induction of labour versus spontaneous onset of labour among women using prophylactic‐dose low‐molecular weight heparin (LMWH) therapy.DesignRetrospective cohort study.SettingUniversity hospital.PopulationWomen receiving antepartum prophylactic LMWH therapy undergoing a trial of vaginal delivery.MethodsCharts from 2018–2019 were reviewed.Main outcome measuresDuration of anticoagulation interruption and eligibility to receive neuraxial anaesthesia.ResultsData from 199 women were analysed; 78 (39.2%) were admitted following spontaneous onset of labour and 121 (60.8%) underwent planned induction of labour. Compared to women who underwent planned induction of labour, women who presented with spontaneous onset of labour had a shorter median admission‐to‐delivery interval (4.7 versus 29.3 hours, P < 0.001). Similarly, intervals from the last LMWH injection to delivery (25.8 versus 48.2 hours, P < 0.001) and to the first postpartum LMWH injection (41.2 versus 63.7 hours, P < 0.001) were shorter. Among those with spontaneous onset of labour, 69 (88.5%) were eligible to receive neuraxial anaesthesia. Rates of postpartum haemorrhage and blood transfusion were similar between the groups. No thrombotic events were encountered in those with spontaneous onset of labour, but four (3.3%) women who delivered following induction of labour developed a postpartum thrombotic event.ConclusionPlanned induction of labour was associated with a higher risk of postpartum thrombotic events than was spontaneous onset of labour (4 of 121 [3.3%] versus 0 of 78 [0%]), presumably due to prolonged duration of anticoagulation interruption, although the difference was not statistically significant. Allowing spontaneous onset of labour was associated with comparable rates of bleeding complications, and only a low proportion (9 of 78, 11.5%) were not eligible to receive neuraxial anaesthesia.Tweetable abstractPlanned induction among women using prophylactic LMWH therapy might increase the risk of thromboembolic complications.

AbstractObjectiveWe aimed to determine hemostatic changes and characterize the procoagulant potential among patients with reactive thrombocytosis (RT).MethodsSixty patients with RT (median platelet count 718 × 109/L) and 20 healthy persons were tested for complete blood count, C‐reactive protein, von Willebrand factor (VWF), factor VIII and fibrinogen, and thrombin generation. Platelet studies, including light transmission aggregometry and Cone and Plate(let) Analyzer, were also conducted. Reticulated platelets and platelet P‐selectin expression were measured using flow cytometry.ResultsCompared to patients with mild thrombocytosis (platelet count 500‐700 × 109/L; n = 27), those with moderate‐to‐severe thrombocytosis (platelet count >700 × 109/L; n = 33) had significantly higher fibrinogen, factor VIII, and VWF antigen and activity levels; higher endogenous thrombin potential, peak thrombin generation and velocity index levels, and shorter time‐to‐peak thrombin level. VWF antigen and activity, fibrinogen, and factor VIII were positively associated with platelet count, whereas VWF activity/antigen ratio was inversely correlated. In a multivariate analysis of RT and control participants, only platelet count predicted endogenous thrombin potential with a positive‐linear correlation. No patients developed acquired von Willebrand syndrome.ConclusionsAs determined by thrombin generation, RT was associated with in vitro prothrombotic tendency, which correlated with platelet count. This may explain the increased thromboembolic risk previously reported in patients with RT.

AbstractBackgroundThromboembolic events following splenectomy are not uncommon. However, the role of thromboprophylaxis and risk factors for thrombosis, as well as the clinical course and outcomes, are not well characterized.MethodsA retrospective review of individuals who underwent splenectomy between January 2006 and December 2015 in two university hospitals.ResultsOverall, 297 patients underwent splenectomy [open splenectomy (n = 199), laparoscopic splenectomy (n = 98)]. Mechanical (thigh‐length pneumatic compression stockings) and pharmacologic thromboprophylaxis (40 mg enoxaparin daily, starting 12 h after surgery until discharge) was provided for all patients. One hundred and sixteen patients (39%) also received an extended thromboprophylaxis course of enoxaparin for 2–4 weeks after discharge. Twenty‐three patients (7.7%) experienced thrombotic complications following splenectomy, including 16 cases (5.4%) of portal‐splenic mesenteric venous thrombosis (PSMVT), 5 (1.7%) pulmonary embolism and 2 (0.7%) deep vein thrombosis. Longer operative time (mean operative time of 405 vs. 273 min, P = 0.03) was independently associated with PSMVT. Post‐splenectomy thrombocytosis was not associated with thrombosis (P = 0.41). The overall thrombosis rate was significantly lower in patients who received an extended thromboprophylaxis course following splenectomy (3.4 vs. 10.5%, P = 0.02). Complete resolution of thrombosis was observed in most cases (n = 20, 87.0%), with no recurrent thrombosis during a mean follow‐up of 38 ± 25 months.ConclusionsThromboembolic complications, mainly PSMVT, are common following splenectomy. Longer operative time was associated with thrombosis. Significantly lower rates of thrombosis were found in patients who received an extended thromboprophylaxis course.

Background and ObjectivesWe investigated the risk factors, incidence, and role of thromboprophylaxis in the development of thrombosis following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).MethodsWe reviewed data of patients with CRS/HIPEC in three hospitals.ResultsOverall, 192 patients underwent CRS/HIPEC during 2007‐2016. Mechanical (thigh‐length pneumatic compression stockings) and pharmacologic thromboprophylaxis (40 mg enoxaparin daily, starting 12 h before surgery until discharge) was provided for all patients; and 116 (60.4%) also received an extended course of enoxaparin for 2‐4 weeks after discharge. Twenty‐six patients experienced thrombotic complications (13.5%) including portal‐splenic‐mesenteric venous thrombosis (n = 11, 5.7%), pulmonary embolism (n = 10, 5.2%), and deep vein thrombosis (n = 5, 2.6%); most (n = 21, 80.8%) occurred after hospital discharge. Univariate analysis identified Peritoneal Cancer Index, intraoperative transfusion requirement, operative blood loss, operative time, lengths of hospital, and intensive care unit stay, and lack of administration of anticoagulation at discharge as significantly associated with thrombosis. With multivariate analysis, only the lack of anticoagulation therapy at discharge remained significantly associated with thrombosis (P = 0.0001).ConclusionsThromboembolic complications are common following CRS/HIPEC. As significantly lower rates of thrombosis were found in patients who received an extended course of anticoagulation, we support its use for at least 2 weeks after discharge.