Women should be advised to withhold any further doses of LMWH as soon as there are signs of labour or if they have any vaginal bleeding. Regional anaesthesia should not be used for Table 12.8 Indications for postpartum thromboprophylaxis
Indication Usual duration of
LMWH (weeks)
Received antenatal prophylaxis 6
Previous VTE 6
Class III obesity 1
Emergency caesarian section 1
Elective caesarian section with one or more additional risk factors
1
Presence of some thrombophilias without personal history of VTE
1
ANTENATAL OBSTETRICS Thromboembolic disease and pregnancy 109
31. Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrom-botic therapy, and pregnancy VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:e691S-e736S.
32. RCOG. The Acute Management of Thrombosis and Embolism During Pregnancy and the Puerperium. Green-top Guigeline No. 37b, 2007. London, RCOG.
33. Greer IA, Nelson-Piercy C. Low-molecular-weight hep-arins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood 2005;106:401–7.
34. Baglin T, Gray E, Greaves M et al. Clinical guidelines for testing for heritable thrombophilia. British Journal of Haematology 2010;149:209–20.
35. Galli M, Luciani D, Bertolini G, Barbui T. Lupus antico-agulants are stronger risk factors for thrombosis than anticardiolipin antibodies in the antiphospholipid syndrome: a systematic review of the literature. Blood 2003;101:1827–32.
36. Pengo V, Biasiolo A, Pegoraro C, Cucchini U, Noventa F and Iliceto S. Antibody profiles for the diagno-sis of antiphospholipid syndrome. Thromb Haemost 2005;93:1147–52.
37. D’Ippolito S, Di Simone N, Di Nicuolo F, Castellani R, Caruso A. Antiphospholipid antibodies: effects on trophoblast and endothelial cells. Am J Reprod Immunol 2007;58:150–8.
38. Empson M, Lassere M, Craig, Scott J. Prevention of recurrent miscarriage for women with antiphospholipid antibody or lupus anticoagulant. The Cochrane Library, 2005.
39. Keeling D, Mackie I, Moore GW, Greer IA, Greaves M and BCSH. Guidelines on the investigation and manage-ment of antiphospholipid syndrome. British Journal of Haematology 2012;157:47–58.
40. Pomp ER, Lenselink AM, Rosendaal FR, Doggen CJ.
Pregnancy, the postpartum period and prothrombotic defects: risk of venous thrombosis in the MEGA study. J Thromb Haemost 2008;6:632–7.
41. James AH, Tapson VF, Goldhaber SZ. Thrombosis during pregnancy and the postpartum period. American Journal of Obstetrics and gynaecology 2005;193:216–19.
42. De Stefano V, Martinelli I, Rossie E et al. The risk of recurrent venous thromboembolism in pregnancy and puerperium without antithrombotic prophylaxis. British Journal of Haematology 2006;135:386–91.
43. RCOG. Reducing the Risk of Thrombosis and Embolism During Pregnancy and the Puerperium. Green-top Guideline No. 37a, 2009. London, RCOG.
44. Robertson L, Wu O, Langhorne P et al. Thrombosis: risk and economic assessment of thrombophilia screening (TREATS) study. Thrombophilia in pregnancy: a system-atic review. Br J Haematol 2005;132:171–96.
16. Webert KE, Mittal R, Sigouin C, Heddle NM and Kelton JG. A retrospective 11-year analysis of obstetric patients with idiopathic thrombocytopenic purpura. Blood 2003;102:4306–11.
17. Christiaens GC, Niewenhuis HK, Bussel JB. Comparison of platelet counts in first and second newborns of moth-ers with immune thrombocytopenic purpura. Obstetrics and Gynaecology 1997;90:546–52.
18. RCOG. The Use of Anti-D Immunoglobulin for Rhesus D Prophylaxis. Green-top Guideline No. 22, 2011.
19. Qureshi H, Massey E, Kirwan D et al. BCSH guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn. Transfusion Medicine 2014;24:8–20.
20. MacKenzie IZ, Bowell P, Gregory H, Pratt G, Guest C, Entwistle CC. Routine antenatal Rhesus D immuno-globulin prophylaxis: the results of a prospective 10 year study. Br J Obstet Gynaecol 1999;106:492–7.
21. Alcock GS, Liley H. Immunoglobulin infusion for iso-immune haemolytic jaundice in neonates. Cochrane Database of Systematic Reviews 2002; CD003313.
22. Pacheco LD, Berkowitz RL, Moise KJ Jr et al. Fetal and neonatal alloimmune thrombocytopenia: a management algorithm based on risk stratification. Obstet Gynecol 2011;118:1157.
23. Berkowitz RL, Kolb EA, McFarland JG. et al. Parallel ran-domized trials of risk-based therapy for fetal alloimmune thrombocytopenia. Obstet Gynecol 2006;107:91.
24. Lee CA, Chi C, Pavord SR. et al. The obstetric and gynae-cological management of women with inherited bleeding disorders – review with guidelines produced by a task-force of UK Haemophilia Centre Doctors Organization.
Haemophilia 2006;12:301–336.
25. Pasi KJ, Collins PW, Keeling DM. et al. Management of von Willebrand disease: a guideline from the UK Haemophilia Centre Doctors’ Organization. Haemophilia 2004;10:218–31.
26. Bustamante-Aragones A, Rodriguez de Alba M, Gonzalez-Gonzalez C et al. Foetal sex determination in maternal blood from seventh week of gestation and its role in diagnosing haemophilia in the foetuses of female carriers. Haemophilia 2008; 14:593–8.
27. Chalmers E, Williams M, Brennand J, Liesner R, Collins P, Richards M. Guideline on the management of haemophilia in the fetus and neonate. British Journal of Haematology 2011;154:208–15.
28. Chi C, Lee CA, Shiltagh N, Khan A, Pollard D, Kadir RA. Pregnancy in carriers of haemophilia. Haemophilia 2008;14:56–64.
29. Chan WS, Lee A, Spencer FA. et al. Predicting deep venous thrombosis in pregnancy: out in ‘LEFt’ field?. Ann Intern Med 2009;151: 85–92.
30. Righini M, Jobic C, Boehlen F. et al. and the EDVIGE study group. Predicting deep venous thrombosis in preg-nancy: external validation of the LEFt clinical prediction rule. Haematologica 2013;98:545–8.
110 Haematological conditions
ANTENATAL OBSTETRICS
48. Sultan AA, West J, Tata LJ, Fleming KM, Nelson-Piercy C, Grainge MJ. Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England. BMJ 2013;347:f6099.
49. Becattini C, Agnelli G, Schenone A et al. for the WARFASA Investigators. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med 2012;366:1959–67.
45. Jacobsen AF, Skjeldestad FE, Sandset PM. Incidence and risk patterns of venous thromboembolism in pregnancy and puerperium – a register-based case-control study.
Am J Obstet Gynecol 2008;198:233.
46. Knight M on behalf of UKOSS. Antenatal pulmonary embolism: risk factors, management and outcomes.
BJOG 2008;115:453–61.
47. Sultan AA, Tata LJ, West J et al. Risk factors for first venous thromboembolism around pregnancy: a population-based cohort study from the United Kingdom. Blood 2013;121:19.
INTRODUCTION
Urinary tract infection (UTI) is a common cause of maternal morbidity and a potential cause of perinatal morbidity and mortality via preterm delivery. Renal disease is an important predisposing factor for pre-eclampsia and fetal growth restric-tion (FGR). The combinarestric-tion of hypertension and proteinu-ria at booking (provided that this is in the first or early second trimester) suggests pre-existing renal disease and should prompt further investigation. A serum creatinine is manda-tory in such cases to exclude pre-existing chronic kidney dis-ease (CKD).
The number of women with renal transplants considering pregnancy is increasing and success rates are high, but case selection is required. Acute kidney injury in pregnancy is most commonly due to obstetric conditions, particularly haemor-rhage and pre-eclampsia.
Chapter 13 Renal disease
Catherine Nelson-Piercy
MRCOG standards
Relevant standardsTo understand and demonstrate appropriate knowledge, skills and attitudes in relation to pregnant women with kidney disease.
Theoretical skills
Understand the epidemiology, aetiology, patho-physiology, clinical characteristics, prognostic features and management of women with kidney disease.
Practical skills
Be able to manage independently:
• urinary tract infection,
• pyelonephritis.
Be able to manage under direct supervision pregnant women with:
• chronic kidney disease,
• a renal transplant,
• acute kidney injury.