This study assessed the thrombotic risk during oral contraceptive use and pregnancy in 798 female relatives with heterozygous, double heterozygous, or homozygous factor V Leiden or prothrombin mutation from 4 family cohorts. The overall absolute venous thromboembolism (VTE) risk in women with no, single, or combined defects was 0.13, 0.35, and 0.94 per 100 person-years, respectively, while during oral contraceptive use the risks were 0.19, 0.49, and 0.86 per 100 person-years. The risks were highest during pregnancy and postpartum, at 0.73, 1.97, and 7.65 per
Reversal of warfarin associated coagulopathy prothrombin complex concentratesTÀI LIỆU NGÀNH MAY
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Reversal of warfarin associated coagulopathy prothrombin complex concentratesTÀI LIỆU NGÀNH MAY
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The role of #apixaban and #rivaroxaban in the primary prevention of #venous_thromboembolism in ambulatory patients with #cancer (#AVERT & #CASSINI Trials)
#ALPIC2019 #metsovo #greece
Blood transfusion is a complex activity in healthcare, constitutes an important part of various treatment protocols. Thus the indications for ordering blood must be fully justified to avoid over or misusage of this resource. In a 5 year retrospective study, details of patient’s diagnosis and indications for transfusion are correlated with whole blood and components transfused from the blood bank data base in SAQR Hospital, in Ras Al Khaimah UAE. It was found that 7,045 blood units which were transfused, maximum blood was supplied to surgical wards; most common indications for transfusion were injuries during road traffic accidents, orthopedic surgeries and cardiovascular surgeries. Nearly half (52%) of all blood was given to female recipients. UAE nationals received the maximum units of blood; most prevalent blood group among blood transfusion recipients was O +ve. Major usage of blood products transfused were packed RBC’s. The study concludes that regular assessment of blood component usage followed by academic sessions for clinicians is recommended for effective and efficient use of available blood to patients in a life-threatening situation.
Intracranial venous sinus thrombosis: Medical and surgical management conside...bijnnjournal
Cerebral venous thrombosis is a serious neurological condition characterized by thrombus formation in the venous
sinuses or cerebral veins. Although rare, it is a potentially fatal condition that requires prompt diagnosis and
treatment. This review aims to present the most current trends in our understanding of CVT risk factors, diagnosis,
medical management, role of endovascular management, risk of intracranial hemorrhage, and emerging therapies.
Most cases of CVT are diagnosed by clinical features and neuroimaging suggestive of sinus occlusion. While
anticoagulation with heparin is the mainstay of medical management, direct-oral anticoagulants are emerging as
a potential alternative, and severe cases have been managed successfully with thrombectomy and/or intrasinus urokinase thrombolysis. Despite recent advances in anticoagulation therapy and diagnostics, larger randomized studies are required to adequately assess these emerging therapies and better inform the management of patients suffering from CVT.
The role of #apixaban and #rivaroxaban in the primary prevention of #venous_thromboembolism in ambulatory patients with #cancer (#AVERT & #CASSINI Trials)
#ALPIC2019 #metsovo #greece
Blood transfusion is a complex activity in healthcare, constitutes an important part of various treatment protocols. Thus the indications for ordering blood must be fully justified to avoid over or misusage of this resource. In a 5 year retrospective study, details of patient’s diagnosis and indications for transfusion are correlated with whole blood and components transfused from the blood bank data base in SAQR Hospital, in Ras Al Khaimah UAE. It was found that 7,045 blood units which were transfused, maximum blood was supplied to surgical wards; most common indications for transfusion were injuries during road traffic accidents, orthopedic surgeries and cardiovascular surgeries. Nearly half (52%) of all blood was given to female recipients. UAE nationals received the maximum units of blood; most prevalent blood group among blood transfusion recipients was O +ve. Major usage of blood products transfused were packed RBC’s. The study concludes that regular assessment of blood component usage followed by academic sessions for clinicians is recommended for effective and efficient use of available blood to patients in a life-threatening situation.
Intracranial venous sinus thrombosis: Medical and surgical management conside...bijnnjournal
Cerebral venous thrombosis is a serious neurological condition characterized by thrombus formation in the venous
sinuses or cerebral veins. Although rare, it is a potentially fatal condition that requires prompt diagnosis and
treatment. This review aims to present the most current trends in our understanding of CVT risk factors, diagnosis,
medical management, role of endovascular management, risk of intracranial hemorrhage, and emerging therapies.
Most cases of CVT are diagnosed by clinical features and neuroimaging suggestive of sinus occlusion. While
anticoagulation with heparin is the mainstay of medical management, direct-oral anticoagulants are emerging as
a potential alternative, and severe cases have been managed successfully with thrombectomy and/or intrasinus urokinase thrombolysis. Despite recent advances in anticoagulation therapy and diagnostics, larger randomized studies are required to adequately assess these emerging therapies and better inform the management of patients suffering from CVT.
High Prevalence Of Thrombophilic Traits In Children With Family History Of Th...cassidydanielle
Authors: Meghan J. Calhoon, MS, Cassie N. Ross, Elizabeth Pounder, PA-C, Danielle Cassidy, PharmD, Marilyn J. Manco-Johnson, MD, Neil A. Goldenberg, MD, PhD
Deep Venous Thromboembolism in Gynecological Malignanciessemualkaira
Deep venous thrombosis is a severe complication often following
gynecological malignancy. It presents a main reason of post-operative complication, morbidity and mortality in these patients. It is
crucial to know risk factors and to diagnose possible early manifestations of the disease in time [1]. DVT is the second leading
cause of death in patients with gynecologic cancer and the risk of
DVT in women underwent gynecologic surgery ranged from 17%
to 40%, while the rate of pulmonary embolism (PE) was about 1%
to 26% [2].
Deep Venous Thromboembolism in Gynecological Malignanciessemualkaira
Deep venous thrombosis is a severe complication often following
gynecological malignancy. It presents a main reason of post-operative complication, morbidity and mortality in these patients. It is
crucial to know risk factors and to diagnose possible early manifestations of the disease in time [1]. DVT is the second leading
cause of death in patients with gynecologic cancer and the risk of
DVT in women underwent gynecologic surgery ranged from 17%
to 40%, while the rate of pulmonary embolism (PE) was about 1%
to 26% [2].
Deep Venous Thromboembolism in Gynecological Malignanciessemualkaira
Deep venous thrombosis is a severe complication often following
gynecological malignancy. It presents a main reason of post-operative complication, morbidity and mortality in these patients. It is
crucial to know risk factors and to diagnose possible early manifestations of the disease in time [1]. DVT is the second leading
cause of death in patients with gynecologic cancer and the risk of
DVT in women underwent gynecologic surgery ranged from 17%
to 40%, while the rate of pulmonary embolism (PE) was about 1%
to 26% [2].
Deep vein thrombosis prophylaxis in a tertiary care center: An observational ...Apollo Hospitals
Deep vein thrombosis (DVT) is a major health problem with substantial mortality and morbidity in medically ill patients. Prevention of DVT by risk factor stratification and subsequent antithrombotic prophylaxis in moderate- to severe-risk category patients is the most rational means of reducing morbidity and mortality.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
1. From bloodjournal.hematologylibrary.org by guest on April 30, 2012. For personal use only.
2011 118: 2055-2061
Prepublished online June 9, 2011;
doi:10.1182/blood-2011-03-345678
Thrombotic risk during oral contraceptive use and pregnancy in women
with factor V Leiden or prothrombin mutation: a rational approach to
contraception
Elizabeth F. W. van Vlijmen, Nic J. G. M. Veeger, Saskia Middeldorp, Karly Hamulyák, Martin H.
Prins, Harry R. Büller and Karina Meijer
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Copyright 2011 by The American Society of Hematology; all rights reserved.
3. From bloodjournal.hematologylibrary.org by guest on April 30, 2012. For personal use only.
2056 van VLIJMEN et al BLOOD, 25 AUGUST 2011 ⅐ VOLUME 118, NUMBER 8
and prothrombin-20210A, as associated with an unacceptable health analysis. Relatives were contacted through the probands and were all seen
risk.4 These recommendations are mainly based on case-control studies in person at our clinics.
reporting increased relative risks of VTE during COC use in women Information on VTE, exposure to exogenous risk factors for VTE, and
anticoagulant treatment was collected by physicians and research nurses
with hereditary thrombophilic defects.5-11
through medical interviews using a validated questionnaire,24 and by
However, to qualify all hereditary thrombophilic defects as
reviewing medical records.
similarly strong risk factors might be questioned. The absolute risk All relatives were tested for the presence of factor V Leiden, prothrombin-
of VTE in factor V Leiden carriers is estimated being 0.15 per G20210A, high factor VIII levels, hyperhomocysteinemia (original index
100 person-years,12 whereas in antithrombin-, protein C–, or defects), and for a deficiency of antithrombin, protein C, and protein S.
protein S–deficient persons these estimates range from 0.7 to Because of the retrospective nature of the study, collection of medical
1.7 per 100 person-years, indicating a considerably higher history took place at the end of the observation period. As thrombophilia
degree of risk.12,13 testing was performed after collection of these data, the taking of medical
We previously demonstrated that women with severe hereditary histories of relatives was not influenced by the results of thrombophilia
testing. For the same reason, any decisions on diagnostic outcome and
thrombophilic defects, that is, a deficiency of antithrombin, protein
treatments during the observation periods were made without knowledge on
C, or protein S, are at very high risk during actual COC use,
presence of thrombophilia.
particularly when concomitant thrombophilic defects are present Female relatives with a deficiency of antithrombin, protein C, or protein
(4.6 per 100 pill-years), and the use of COCs should be strongly S were excluded, as these deficiencies are strong risk factors for VTE.12-15
discouraged in these women.14,15 As hyperhomocysteinemia is no longer considered an independent thrombo-
As the absolute risk in women with mild thrombophilic defects philic risk factor,23,25 this defect was not taken into account, but these
is substantially lower than in women with severe thrombophilic women were not excluded from our cohort.
defects, withholding COCs in women with mild hereditary throm- For the purpose of our study, information on contraceptive use and
bophilic defects might be less favorable. When discouraging pregnancies (including pregnancy losses) was reconfirmed by a written
COC use, an increased risk of unintended pregnancy must be questionnaire sent by mail. In addition, also general practitioners were
contacted for further information. All relatives gave informed consent in
taken into account as alternative nonhormonal contraception is
accordance with the Declaration of Helsinki and the studies were approved
less reliable.16,17 by the institutional review boards of the 3 participating Dutch hospitals.
Pregnancy and especially the postpartum period is a strong risk
factor for VTE, with an absolute risk of VTE in the general
population that is higher than noted for COCs, that is, 0.2 per Diagnosis of VTE
100 pregnancy-years18 versus 0.06 per 100 pill-years.19 To balance VTE was considered established when diagnosed by compression ultra-
the risk and benefits of COCs, reliable estimates of the VTE risk sound or venography (deep vein thrombosis), by ventilation/perfusion
associated with both COC use and pregnancy are needed. lung-scan, spiral computed tomography scan or pulmonary angiography
To evaluate whether mild thrombophilic defects indeed have (pulmonary embolism), or when the patient had received full-dose heparin
lower risk of VTE during COC use, which would be the basis for and vitamin K antagonists for at least 3 months without objective testing at
counseling, the risk of first VTE during COC use and pregnancy a time when these techniques were not available. VTE was classified as
“provoked” when occurring up to 3 months after exposure to exogenous
postpartum was assessed in a large retrospective family cohort of
risk factors, which included surgery, trauma, immobilization for at least
women with heterozygous, double heterozygous, or homozygous 7 days, COC use, pregnancy-postpartum up to 3 months, and malignancy.
factor V Leiden or prothrombin-G20210A mutation. Women were In the absence of these risk factors, VTE was defined as “unprovoked.”
divided into those with no, single, or combined mild thrombo- Superficial phlebitis was not considered a thrombotic event.
philic defects, as we recently demonstrated that aggregation of
defects is often noted in thrombophilic families, and that especially
Laboratory studies
the presence of multiple defects may significantly increase the
absolute risk of VTE.13-15 To put results into perspective, obtained Factor V Leiden and prothrombin-G20210A were demonstrated by PCRs.26,27
absolute risks are compared with those during use of alternative Factor VIII:C was measured by 1-stage clotting assay and considered
contraception. increased at levels above 150 IU/dL.28 Protein S– and protein C–Ag levels
were measured by ELISA (DAKO); protein C activity and antithrombin
levels (Chromogenix) were measured by chromogenic substrate assays.
Normal ranges were determined in healthy volunteers without a (family)
history of VTE, who were neither pregnant nor used COCs within 3 months
Methods before blood sampling. Deficiency of antithrombin, protein S, and protein C
was defined by levels below the lower limit of their normal ranges. In
Subjects
probands and symptomatic relatives, blood samples were collected at least
In the present retrospective family cohort study, all female relatives were 3 months after VTE had occurred. If they were still treated with vitamin K
included from 4 family cohorts, which were described in detail else- antagonists, samples were taken after temporary change of this therapy to
where.20-23 These were first-degree relatives of consecutive patients (pro- low-molecular-weight heparin for at least 2 weeks.
bands) with VTE or premature atherosclerosis (Ͻ 50 years) and factor V
Leiden, prothrombin-G20210A, high factor VIII levels (Ͼ 150 IU/dL), or
Statistical analysis
hyperhomocysteinemia, respectively (Figure 1). Probands and their first-
degree relatives were enrolled between 1995 and 1998 (factor V Leiden We estimated the overall absolute risk of first VTE in female relatives with
study) and 1998 and 2004 (prothrombin-G20210A, hyperhomocysteine- no defects, a single defect, or a combination of factor V Leiden and
mia, and factor VIII studies) in 3 university hospitals in The Netherlands prothrombin-G20210A. Homozygosity for factor V Leiden or prothrombin-
(University Medical Center Groningen, University Medical Center Amster- G20210A was classified as a combined defect, as their prevalence is too low
dam, and University Hospital Maastricht). Probands were excluded to avoid to calculate reliable estimates separately. Furthermore, the absolute risk during
bias, as they have experienced VTE by definition. Relatives of probands actual COC use and during the pregnancy/postpartum period was estimated.
with premature atherosclerosis were not included in the present study. The absolute risk was expressed as the incidence rate per 100 person-
First-degree relatives aged 15 years or older were identified by pedigree years. Corresponding 95% confidence intervals (CI) were calculated by
4. From bloodjournal.hematologylibrary.org by guest on April 30, 2012. For personal use only.
BLOOD, 25 AUGUST 2011 ⅐ VOLUME 118, NUMBER 8 ORAL CONTRACEPTIVES, PREGNANCY, & MILD THROMBOPHILIA 2057
Family cohorts of affected probands with VTE
Affected probands Factor V Leiden Prothrombin High factor VIII Hyperhomocysteinaemia
271 109 156 103
All relatives ≥ 15 years 4315
Deceased 921
Non-responders 1371
Relatives enrolled 2023
Male relatives 1034
Female relatives with antithrombin, 54
protein C, or protein S deficiency
Female relatives eligible 935
Female relatives with incomplete
thrombophilic tests 137
Female relatives evaluable for analysis 798
Figure 1. Recruitment of the study population from families with factor V Leiden, prothrombin G20120A mutation, high factor VIII levels, and hyperhomocysteine-
mia, respectively.
using the binomial probability model (conditional small-sample ap-
proach).29 Person-years were counted from age 15 until age 50 years, first
VTE, or end of study. A minimum age of 15 years was chosen because VTE
Results
is rare at younger age, and a maximum age of 50 years as end of fertile Clinical characteristics
lifetime. The duration of exposure to COCs (pill-years) included actual use
including a 3-month exposure window after COC use was discontinued. For The study consisted of 639 unrelated families including 271 pro-
pregnancy, including pregnancy losses, exposure was defined as the bands with factor V Leiden, 109 with prothrombin-G20210A,
gestation time plus 3-month postpartum.
156 with high factor VIII levels, and 103 with hyperhomocysteine-
We used a time-varying exposure Cox proportional-hazard model to
estimate adjusted hazard ratios (HRs) of actual COC use and the pregnancy- mia (Figure 1). Of their 4315 relatives aged 15 years or older,
postpartum period next to the presence of single or combined hereditary 2292 relatives could not be enrolled; 1371 were nonresponders (no
mild thrombophilic defects. With this model, we specifically took into consent, geographic distance); and 921 had deceased. Of the
account that both COC use and the pregnancy-postpartum period are 2023 relatives enrolled, 989 were female. Of these women, 54 were
temporary risk periods during fertile lifetime. Effect modification (interac- not eligible as they had a deficiency of antithrombin, protein C,
tions) of mild thrombophilic defects on both COC use and the pregnancy- or protein S, leaving 935 eligible female relatives. A total of
postpartum period were also considered. In addition, the influence of an
137 eligible women were excluded for incomplete thrombophilic
increased factor VIII level (Ͼ 150 IU/mL) as an acquired independent risk
factor for VTE was estimated. tests. The remaining 798 women were available for analysis
Furthermore, the absolute risk of VTE during COC use in women with or (Figure 1).
without mild hereditary thrombophilia was put into the perspective of contracep- Table 1 lists the characteristics of the 798 female relatives. Of
tive failure of COC and alternative contraceptives. Alternative contraceptives those, 301 had one or more defects. Among these women, 14 were
include condom, the copper-intrauterine devices (IUD; 380 mm2), and the homozygous for factor V Leiden, of whom 3 were also heterozy-
levonorgestrel IUD (LNG-IUD). The LNG-IUD is presented as having no
gous for prothrombin-G20210A mutation, and 4 women were
increased risk of VTE, as recently reported in a large study.19
Continuous variables were expressed as mean values and SD or median
homozygous for the prothrombin-G20210A mutation.
values and range, and categorical data as counts and percentages. A 2-sided A total of 205 (68%) of the 301 women with single or combined
P value Ͻ .05 indicated statistical significance. Analyses were performed defects, and 366 (74%) of the 497 women without a defect reported
using SAS Version 9.1 software. COC use during their lifetime. The majority of women (76%) had
5. From bloodjournal.hematologylibrary.org by guest on April 30, 2012. For personal use only.
2058 van VLIJMEN et al BLOOD, 25 AUGUST 2011 ⅐ VOLUME 118, NUMBER 8
Table 1. Characteristics of 798 female first-degree relatives with either factor V Leiden, prothrombin G20210A, or a combination of these
defects, including homozygosity
All female relatives
No defects Single defects Combined defects*
Female relatives, n 497 251 50
Follow-up, y† 32 (0.1-35) 28 (0.1-35) 24 (2-35)
Factor V Leiden (%) NA 160 (64) 46 (92)
Prothrombin G20210A (%) NA 91 (36) 39 (81)
Ever COC users, n (%) 366 (74) 171 (68) 34 (68)
Age at start of COC, y 19 (15-47) 20 (15-49) 19 (15-49)
Duration of COC use, y 8 (0.1-30) 6 (0.1-27) 6 (0.5-16)
Ever pregnant, n (%) 364 (73) 175 (70) 36 (72)
Age at first pregnancy 24 (15-41) 24 (15-36) 23 (17-38)
Number of pregnancies, n 2 (1-10) 3 (1-10) 2 (1-7)
Total pregnancy time, y 2 (0.3-9) 3 (0.3-9) 2 (0.8-6)
Age at time of VTE, y 31 (18-46) 34 (17-48) 26 (17-39)
VTE, n† 17 22 11
Unprovoked, n 1 4 1
Provoked, n
COC use 4 1 2
Pregnancy/postpartum 5 9 7
COC use ϩ postpartum 2 1 0
COC use ϩ other risk factor 0 4 0
Major trauma, surgery, immobilization 5 3 1
High factor VIII level was present in 8 (22%), 99 (39%), and 197 (40%) women with combined defects, single defects, and no defects, respectively (in 14 women factor VIII
levels were not available). Data are given as median (min Ϫ max) unless otherwise indicated.
COC indicates combined oral contraceptive; NA, data not applicable; and VTE, venous thromboembolism.
*Including 14 homozygote carriers of factor V Leiden, of whom 3 were also heterozygous for prothrombin G20210A, and 4 homozygote carriers of the prothrombin
G20210A mutation, respectively.
†Restricted to those aged 15-50 years.
only one period of COC use. Seventy-two percent of women had pregnancy-postpartum period (21), and 3 VTEs occurred after
1 or more pregnancies, with a median number of 3 (range 1-10) starting COC use during the 12 weeks postpartum (Table 1).
pregnancies. Sixty-nine percent of the women who had used COCs,
Absolute risk of first VTE
and 75% of women who never used COCs had 1 or more
pregnancies (Table 1). Table 2 lists the absolute risk of VTE associated with COC use and
A total of 50 first episodes of VTE were reported, of which the pregnancy-postpartum period. The crude overall absolute risk
44 (88%) were provoked by exogenous risk factors. The majority, of first VTE in our cohort was 0.25 per 100 person-years (95% CI,
that is, 35 provoked episodes of VTE, occurred during COC use 0.18-0.32), based on 50 VTEs in 798 women with 20 317 person-
(11), of which 4 in the presence of another risk factor, or during the years. In women with no, a single, or combined defects, these were
Table 2. Absolute risk of VTE in all 798 female relatives
All female relatives
Defects None Single Combined*
All women
Total no. 497 251 50
No. with event 17 22 11
Observation period, y 12 908 6234 1175
Incidence rate per 100 person-years (95% CI) 0.13 (0.08-0.21) 0.35 (0.22-0.53) 0.94 (0.47-1.67)
Actual pill use
Total no. 366 171 34
No. with event 6 6 2
Observation period, pill-years 3211 1218 232
Incidence rate per 100 pill-years (95% CI) 0.19 (0.07-0.41) 0.49 (0.18-1.07) 0.86 (0.10-3.11)
Actual pregnancy
Total no. 364 175 36
No. with event 7 10 7
Observation period, pregnancy-years 955 507 92
Incidence rate per 100 pregnancy-years (95% CI) 0.73 (0.30-1.51) 1.97 (0.94-3.63) 7.65 (3.08-15.76)
Absolute risk of VTE in all 798 female relatives with no defects, a single defect (factor V Leiden or prothrombin G20210A), or a combination of these defects (including
homozygosity) and during actual use of COCs and during actual pregnancy.
VTE indicates venous thromboembolism; and CI, confidence interval.
*Including 14 homozygote carriers of factor V Leiden, of whom 3 were also heterozygous for prothrombin G20210A, and 4 homozygote carriers of the prothrombin
G20210A mutation, respectively.
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BLOOD, 25 AUGUST 2011 ⅐ VOLUME 118, NUMBER 8 ORAL CONTRACEPTIVES, PREGNANCY, & MILD THROMBOPHILIA 2059
Table 3. Comparison of thrombosis outcome in women with factor V Leiden or prothrombin G20210A, or a combination of these defects
(including homozygosity)
Defects No defects
Copper IUD Copper IUD
COC LNG-IUD (380 mm2) Condom* COC LNG-IUD (380 mm2) Condom*
Incidence of first VTE per 100 pregnancy-years 0.55† 0.25‡ 0.25‡ 0.25‡ 0.19 0.09 0.09 0.09
Cases of VTE per 100 000 pregnancy-years 550 250 250 250 190 90 90 90
Contraceptive failure rate, per 100 women-years§ 0.2 0.7 1.4 12 0.2 0.7 1.4 12
Unintended pregnancies per 100 000 pregnancy-years 200 700 1400 12 000 200 700 1400 12 000
Incidence of VTE per 100 pregnancy-years¶ 2.8 2.8 2.8 2.8 0.7 0.7 0.7 0.7
Additional cases of VTE 6 20 40 336 2 5 10 84
Total number of VTE 556 270 290 586 192 95 100 174
According to the method described by Koster et al.39
LNG-IUD indicates levonorgestrel intrauterine device; HR, hazard ratio; and VTE, venous thromboembolism.
*US data.
†(6 ϩ 2) events during (1218 ϩ 232) pill-years (see Table 2).
‡Based on an adjusted HR of 2.2 for COC use when compared to no COC use.
§Pearl Index for correct use (method failure).
¶(10 ϩ 7) events during (507 ϩ 92) pregnancy-years (see Table 2).
0.13 (95% CI, 0.08-0.21), 0.35 (95% CI, 0.22-0.53), and 0.94 risks of VTE associated with contraception failure were
(95% CI, 0.47-1.67) per 100 person-years, respectively. estimated.
Restricting the observation time to actual COC use, the crude In this analysis, both the direct risk of VTE because of the
incidence of VTE was 0.30 (95% CI, 0.16-0.50) per 100 pill-years, contraceptive method (only present in COC users) and the addi-
based on 14 VTEs during 4661 pill-years. In women with no, a tional risk of VTE because of contraceptive failure resulting in
single, or combined defects, the incidences were 0.19 (95% CI, unintended pregnancies are taken into account. In Table 3, the
0.07-0.41), 0.49 (95% CI, 0.18-1.07), and 0.86 (95% CI, 0.10-3.11) absolute risk of VTE of 0.55 per 100 pill-years in COC users with
per 100 pill-years, respectively (Table 2). thrombophilic defect(s) is derived from combining both the
When considering only the pregnancy-postpartum periods, the number of VTEs and observation years in women with single and
crude incidence of first VTE was 1.55 (95% CI, 0.99-2.30) per combined defects as presented in Table 2. The absolute risk of VTE
100 pregnancy-years, based on 24 VTEs during 1553 pregnancy- of in users of alternative contraceptives is 2.2-fold lower, 0.25 per
years. In women with no, a single, or combined defects, the 100 years in users of alternative contraceptive methods, that is,
incidences rose from 0.73 (95% CI, 0.30-1.51) and 1.97 (95% CI, based on the adjusted HR of 2.2 for COC use. The absolute risk of
0.94-3.63) to 7.65 (95% CI, 3.08-15.76) per 100 pregnancy-years, VTE of 2.8 per 100 pregnancy years is derived from combining
respectively. both the number of VTEs and observation years noted in pregnant
Relative risk of first VTE women with single and combined defects, see Table 2. A similar
approach is used in the calculations in women without thrombo-
The increased risk of VTE in women with single and combined philic defects.
defects in comparison to women without defects was confirmed in In women with a thrombophilic defect, the total number of
our time-dependent multivariable Cox regression analysis (also VTEs is 556 in COC users, 270 in LNG-IUD users, 290 in
including pregnancy and COC use). The HRs were 2.7 (95% CI, copper-IUD users, and 586 in condom users. In women without
1.4-5.1) for a single defect and 8.5 (95% CI, 3.8-19.2) for thrombophilic defects, the total number of VTEs is 192, 174, 95,
combined defects. The substantially higher risk of VTE during the and 100, respectively. In these estimations, the possibility that
pregnancy-partum period was confirmed by a HR of 16.4 (95% CI, unintended pregnancies are interrupted is not taken into consider-
8.2-32.8). For actual COC use, the HR was 2.1 (95% CI, 1.1-4.1). ation; in that situation, it is expected that the risk of VTE is lower
When adjusted for factor VIII, HRs were 2.7 (95% CI,1.4-5.0) than presented here.
and 10.1 (95% CI, 4.4-23.0) for single and combined defects,
2.2 (95% CI, 1.1-4.0) for COC use and 16.0 (95% CI, 8.0-32.2) for
pregnancy.
A high factor VIII level was present in 197 (40%), 99 (39%), Discussion
and 8 (22%) of women with no, single, and combined defects,
respectively. Independent of the presence of factor V Leiden or In a cohort of women with a positive family history of VTE, the
prothrombin-G20210A mutation, the presence of high factor VIII presence of single or combined factor V Leiden and prothrombin-
level was associated with an increased risk of VTE (adjusted HR G20210A mutation, including homozygotes, resulted in a modest
2.3; 95% CI, 1.3-4.2). increase in absolute risk of VTE. COC use and the pregnancy-
Absolute risk of VTE in COC users versus users of alternative postpartum period were confirmed as risk factors for VTE.
contraception Although the absolute risk of VTE significantly increased during
COC use (up to 0.86 [95% CI, 0.10-3.11] per 100 pill-years) in
The absolute VTE incidence in COC users and in users of women with combined defects, the absolute risk during the
alternative contraceptive methods, that is, LNG-IUD users, pregnancy-postpartum period was by far the most important (up
copper-IUD users, and users of male condom, for a hypothetical to 7.65 [95% CI, 3.08-15.76] per 100 pregnancy years). The
group of 100 000 women over 1 year is presented in Table 3. In substantially higher risk of VTE during the pregnancy-postpartum
addition to the absolute risk related to COC use, the hypothetical period was confirmed by an adjusted HR of 16.0 (95% CI,
7. From bloodjournal.hematologylibrary.org by guest on April 30, 2012. For personal use only.
2060 van VLIJMEN et al BLOOD, 25 AUGUST 2011 ⅐ VOLUME 118, NUMBER 8
8.0-32.2), compared with an adjusted HR of 2.2 (95% CI, 1.1-4.0) not clinically relevant in daily practice as these contraceptives are
for COC use. not dependent on compliance. However, the specific side effects of
Our results further show that, in line with recent publications, LNG-IUD and copper-IUD related to changes in bleeding pattern,
the a priori absolute risk of VTE during the pregnancy-postpartum that often lead to discontinuation of use, and women’s preferences
period noted in women without any thrombophilic defect is higher need be taken into account.
than noted in COC users, that is, 0.73 versus 0.19 per 100 person- Our study has its limitations. With the retrospective design, not
years. However, as these risks were observed in thrombophilic all events were established by objective techniques because these
families, the absolute risk during the pregnancy-postpartum period were not yet available at the time. Consequently, the reported
and during COC use in our study was approximately 3.5 to 5 times absolute risk of VTE may have been overestimated. On the other
higher than reported in the general community, incidences of hand, because of the retrospective design, treating physicians were
0.2 per 100 pregnancy-years18 and 0.06 per 100 pill-years.19 unaware of the presence of any thrombophilic defects. Further-
As our cohort also included women from one of the original more, there was a potential for recall bias on COC exposure.
family studies with familial high factor VIII level, which is an Therefore, extensive efforts were made to minimize the recall bias
acquired risk factor for VTE, the effect of high factor VIII level was on COC exposure by verification of patient information through
also estimated.21 Independent of the presence or absence of factor medical files and treating physicians. Not all relatives were tested
V Leiden or prothrombin-G20210A, the presence of high factor for all thrombophilic defects. Furthermore, the overall risk of VTE
VIII level was associated with an increased risk of VTE (adjusted might be overestimated because of the family cohort design by
HR 2.3; 95% CI, 1.3-4.2). selecting symptomatic affected probands. The risk of VTE associ-
Several studies have reported COC use5-11,30-33 and pregnancy- ated with these mild hereditary thrombophilic defects will probably
postpartum33-36 as contributing factors to the risk of VTE in women be even lower when unselected women are tested for those defects
with factor V Leiden and/or prothrombin-G20210A. However, as part of counselling before COC use.
adequate interpretation of risks is hampered as most studies only Strong points of our study are its size and the testing for all
reported relative risks and these estimates differ considerably. In known thrombophilic defects. Furthermore, we estimated the
carriers of factor V Leiden or prothrombin-20210A, odds ratios for absolute and relative risk of VTE and took both COC use and
COC use ranged from 1.3 to 30, while for the pregnancy- pregnancy into account. Moreover, these risks were put into
postpartum period these ranged from 2 to 53. In addition, it is often perspective in a modeling exercise, in which both the risks of
unclear whether the presence of other thrombophilic defects was contraceptive-related VTE and the risk of pregnancy-related VTE
excluded. Furthermore, although COCs prevent from pregnancy, (resulting from contraceptive failure) are considered.
the clinical consequences of both hormonal risks of VTE are In conclusion, factor V Leiden and prothrombin-G20210 are
seldom considered simultaneously within 1 study. mild risk factors for VTE in fertile women. Although in the women
The major finding in the present study is the high pregnancy- with a factor Leiden and prothrombin-G20210 mutation, the
related risk of VTE, relative to the observed risk during COC use. absolute risk of VTE increased during COC use, this risk was
Therefore, if it is decided against COC use, adequate alternative importantly lower than the absolute risk observed during the
contraception is needed to keep the risk of unintended pregnancy in pregnancy-postpartum period. These data provide evidence that the
these women as low as possible. The actual choice in alternative policy to contraindicate COC use in these women needs reconsid-
contraception is very limited; only copper-intrauterine devices eration. The results of the study do not allow to “promote” a COC
(IUDs) and condoms. All hormonal contraceptives are consid- use in asymptomatic family-carriers of FVL or PT G20210A, but
ered to increase the risk of VTE, including progestagen-only indicate that when COC use is discontinued the need for adequate
contraceptives (desogestrel-only pill: Cerazette; etonogestrel alternative contraception has high priority.
implant: Implanon; medroxyprogesterone-acetate injections: Rather than strictly contraindicating COC use, we advocate that
Depoprovera; and LNG-IUD: Mirena), though this is merely on detailed counseling on all contraceptive options, including COCs,
theoretical grounds by extrapolation of data from combined should be performed, addressing the associated risks of both VTE
hormonal contraceptives. However, a recent large cohort study and unintended pregnancy, to enable these women to make an
reported the LNG-IUD to not increase the risk of VTE, based on informed choice.
Ͼ 100 000 women-years of use.19
To put our results into a risk-benefit perspective, we estimated
absolute VTE risk of COC use and alternative contraceptive Acknowledgments
methods, that is, LNG-IUD, copper-IUD, and condoms for a This manuscript is dedicated to Jan van der Meer, Professor of
hypothetical group of 100 000 women over 1 year of use, together Hemostasis and Thrombosis at the University Medical Center
with VTE risk associated with contraception failure (Table 3). Groningen in The Netherlands, who died at the age of only 58 in
Although COC use results in COC-related VTEs, because of its 2009. He was the inspiration for this study.
excellent contraceptive efficacy,37 the number of unintended preg- This study was supported by grants from The Netherlands
nancies and subsequent number of pregnancy-related VTEs (6) is Organization for Health Research and Development (ZonMw no.
very low. The pregnancy-related VTE risk associated with the 28-2783) and the Dutch Heart Foundation (no. 99.187).
LNG-IUD and Cu-IUD (380 mm2 Cu-IUD) is estimated to be
higher because of their slightly lesser contraceptive efficacy.16,38
Condom use has the lowest contraceptive efficacy, with an up to Authorship
60-fold increased risk of unintended pregnancy,17 which makes this
option the least favorable alternative. Summarizing these extrapola- Contribution: J.v.d.M., E.F.W.v.V., and N.J.G.M.V. developed the
tions, the LNG-IUD and copper-IUD both carry a lower overall risk study concept and design; E.F.W.v.V., S.M., K.H., and H.R.B.
of VTE and are therefore good alternatives to COCs. The reported acquired data; E.F.W.v.V., N.J.G.M.V., and K.M. analyzed and
higher rate of unintended pregnancies versus COC use is expected interpreted data; E.F.W.v.V. drafted the manuscript; N.J.G.M.V.,
8. From bloodjournal.hematologylibrary.org by guest on April 30, 2012. For personal use only.
BLOOD, 25 AUGUST 2011 ⅐ VOLUME 118, NUMBER 8 ORAL CONTRACEPTIVES, PREGNANCY, & MILD THROMBOPHILIA 2061
S.M., K.H., M.H.P., H.R.B., and K.M. performed critical revision Conflict-of-interest disclosure: The authors declare no compet-
of the manuscript for important intellectual content; N.J.G.M.V. ing financial interests.
provided statistical analysis; J.v.d.M. and K.M. supervised the Correspondence: Elizabeth F. W. van Vlijmen, University
study; and all authors had full access to the database, and have read Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen,
and approved the final version of the manuscript. The Netherlands; e-mail: e.f.w.van.vlijmen@int.umcg.nl.
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