Bleeding and thrombotic risk in pregnant women with Fontan physiology

• Type of Material: Article
• Authors: Andrea Girnius, University of Cincinnati; Dominica Zentner, University of Melbourne; Anne Marie Valente, Harvard Medical School; Petronella G Pieper, University Medical Center Groningen; Katherine E Economy, Brigham and Women’s Hospital, Boston; Magalie Ladouceur, Hopital Europeen Georges Pompidou, Paris; Jolien W Roos-Hesselink, Erasmus MC; Carri Warshak, University of Cincinnati; Sara L Partington, University of Pennsylvania; Zhiqian Gao, Cincinnati Children’s Hospital; Nicholas Ollberding, Cincinnati Children’s Hospital; Michelle Faust, Cincinnati Children’s Hospital; Saulius Girnius, Trihealth Cancer Institute, Cincinnati; Harald Kaemmerer, Deutsch Herzzentrum Munich; Nicole Nagdyman, Deutsch Herzzentrum Munich; Scott Cohen, Medical College of Wisconsin, Milwaukee; Mary Canobbio, University of California Los Angeles; Teiji Akagi, Okayama University; Jasmine Grewal, University of British Columbia; Elisa Bradley, Ohio State University; Yonathan Buber, University of Washington; Joseph Palumbo, Cincinnati Children’s Hospital; Niki Walker, Golden Jubilee Hospital; Jamil Aboulhosn, David Geffen School of Medicine at UCLA; Erwin Oechslin, University of Toronto; Helmut Baumgartner, University Hospital Muenster; Wesam Kurdi, King Faisal Specialist Hospital and Research Center; Wendy M Book, Emory University; Barbara J M Mulder, Academic Medical Center, Amsterdam; Gruschen R Veldtman, King Faisal Specialist Hospital, Riyadh
• Language: English
• Date: 2021-09-01
• Publisher: BMJ PUBLISHING GROUP
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2024 BMJ Publishing Group Ltd & British Cardiovascular Society
• License: Creative Commons Attribution-NonCommercial 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1136/heartjnl-2020-317397
• Title of Journal or Parent Work: HEART
• Volume: 107
• Issue: 17
• Start Page: 1390
• End Page: 1397
• Grant/Funding Information: The Heart Institute, Cincinnati Children’s Hospital Medical Center, 333 Burnett Avenue, Cincinnati.
• Keywords: COMPLICATIONS; Life Sciences & Biomedicine; SOCIETY; pregnancy; THROMBOEMBOLISM; Cardiovascular System & Cardiology; Fontan physiology; Cardiac & Cardiovascular Systems; COAGULATION; ANTICOAGULATION; RANDOMIZED-TRIAL; Science & Technology; ADULT PATIENTS; POSTPARTUM HEMORRHAGE; PRIMARY THROMBOPROPHYLAXIS; MULTICENTER
• Research Categories: Engineering, Biomedical; Biology, Biostatistics; Health Sciences, Dentistry; Psychology, Physiological

Abstract

Background/objectives Pregnancy may potentiate the inherent hypercoagulability of the Fontan circulation, thereby amplifying adverse events. This study sought to evaluate thrombosis and bleeding risk in pregnant women with a Fontan. Methods We performed a retrospective observational cohort study across 13 international centres and recorded data on thrombotic and bleeding events, antithrombotic therapies and pre-pregnancy thrombotic risk factors. Results We analysed 84 women with Fontan physiology undergoing 108 pregnancies, average gestation 33±5 weeks. The most common antithrombotic therapy in pregnancy was aspirin (ASA, 47 pregnancies (43.5%)). Heparin (unfractionated (UFH) or low molecular weight (LMWH)) was prescribed in 32 pregnancies (30%) and vitamin K antagonist (VKA) in 10 pregnancies (9%). Three pregnancies were complicated by thrombotic events (2.8%). Thirty-eight pregnancies (35%) were complicated by bleeding, of which 5 (13%) were severe. Most bleeds were obstetric, occurring antepartum (45%) and postpartum (42%). The use of therapeutic heparin (OR 15.6, 95% CI 1.88 to 129, p=0.006), VKA (OR 11.7, 95% CI 1.06 to 130, p=0.032) or any combination of anticoagulation medication (OR 13.0, 95% CI 1.13 to 150, p=0.032) were significantly associated with bleeding events, while ASA (OR 5.41, 95% CI 0.73 to 40.4, p=0.067) and prophylactic heparin were not (OR 4.68, 95% CI 0.488 to 44.9, p=0.096). Conclusions Current antithrombotic strategies appear effective at attenuating thrombotic risk in pregnant women with a Fontan. However, this comes with high (>30%) bleeding risk, of which 13% are life threatening. Achieving haemostatic balance is challenging in pregnant women with a Fontan, necessitating individualised risk-adjusted counselling and therapeutic approaches that are monitored during the course of pregnancy.