William F. Baker

Diagnostic efficacy of the D-dimer assay in disseminated intravascular coagulation (DIC).

The D-Dimer (D-D) assay for measuring cross-linked fibrin degradation products is now available for the clinical laboratory. We combined this assay with other tests to assess patients with diagnosed or suspected DIC. Also, a small group of patients (20) with deep venous thrombosis (DVT) were studied. The D-D test, antithrombin-III assay, FDP titer, fibrinopeptide-A level, protamine sulfate test, fibrinogen, prothrombin time, and activated partial thromboplastin time were used. The D-D test was abnormal in 93.7%, the AT-III level was abnormal in 87.5%, the fibrinopeptide-A level was abnormal in 89.5%, and the FDP titer was elevated in 83.7% of patients with DIC. When assessing patients found not to have confirmed DIC the D-D assay was abnormal in 20%, the AT-III level was abnormal in 6%, and the fibrinopeptide-A level was elevated in 13%. We conclude the D-Dimer assay to be a useful molecular marker of hemostasis in diagnosing DIC and this test will often discriminate between those patients with or without DIC, especially when used with the AT-III and fibrinopeptide-A assays. Of the battery of tests used in this study, the most useful, in descending order of efficacy, appear to be the D-dimer assay (93.7% abnormal), the fibrinopeptide-A titer (89.5% abnormal), the AT-III level (87.5% abnormal), and the FDP titer (83.7% abnormal). Of the global tests, the diagnostic efficacy of the prothrombin time activated partial thromboplastin time, and protamine sulfate test were no greater than chance and appear to be of little use in aiding in a diagnosis of DIC. Also, the D-Dimer assay is similar in cost to the FDP titer and is cost effective for the routine clinical laboratory.

IRON DEFICIENCY IN PREGNANCY, OBSTETRICS, AND GYNECOLOGY

Iron deficiency remains a major health risk in the United States, despite the apparent availability of a high-quality diet. In the United States, at least 7.8 million adolescent girls and premenopausal women are iron-deficient. Worldwide, the challenge of identifying and treating iron deficiency is enormous. Physicians involved in the primary care and in the obstetric and gynecologic care of women of all ages must be aware of the nature of the problem and the correct approach to screening, diagnosis, and treatment. The potential benefit to newborns and infants and to their mothers is substantial. Furthermore, a thorough diagnostic evaluation has considerable potential for uncovering a potentially lethal disease, such as gastrointestinal malignancy, in a curable phase.

Thrombolytic therapy: Clinical applications

The therapeutic use of thrombolytic agents is the result of the increasing understanding of the pathophysiologic mechanisms underlying normal and deranged thrombosis and fibrinolysis. Plasminogen activators capable of increasing the production of plasmin exhibit considerable efficacy in the treatment of a variety of arterial and venous thrombotic disorders. The ideal thrombolytic agent has not been developed, but the desired clinical result of rapid opening of the thrombosed vessel without reocclusion, without activation of systemic fibrinogenolysis, and without a risk of hemorrhage are defined. Clinical studies clearly demonstrate that the addition of a variety of adjunctive agents to available thrombolytics enhances benefit without inordinate risk. The addition of intravascular angioplasty and stenting to thrombolysis increases the potential long-term benefit. Newer thrombolytic agents and new protocols for the use of existing therapies offer the promise of saving many who would otherwise succumb to coronary or cerebral arterial thrombosis or to venous thromboembolism.

Treatment options for patients who have antiphospholipid syndromes.

The antiphospholipid thrombosis syndrome, associated with anticardiolipin (aCL) or subgroup antibodies, can be divided into one of six subgroups (I-VI). There is little overlap (about 10% or less) between these subtypes, and patients usually conveniently fit into only one of these clinical types. Although there appears to be no correlation with the type, or titer, of aCL antibody and type of syndrome, the subclassification of thrombosis and aCL antibody patients into these groups is important from the therapy standpoint. This article also reviews the clinical presentations associated with each of these six subgroups.

Hematological Complications in Obstetrics, Pregnancy, and Gynecology

Preface Dedication 1. Disseminated intravascular coagulation in obstetrics, pregnancy and gynecology: criteria for diagnosis and management Rodger Bick and Deborah Hoppensteadt 2. Recurrent miscarriage syndrome and infertility due to blood coagulation protein and platelet defects Rodger Bick 3. Von Willebrand disease and other bleeding disorders in obstetrics Franklin Fuda and Ravindra Sarode 4. Hemolytic disease of the fetus and newborn due to ABO, Rh and other blood group alloantibodies Katharine Downes and Ravindra Sarode 5. Thrombophilia in pregnancy and obstetrics Rodger Bick and William Baker 6. Thromboprophylaxis and treatment of thrombosis in pregnancy Lowthar Heilmann and Rodger Bick 7. Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy William Baker and Rodger Bick 8. Hemorrhagic and thrombotic lesions of the placenta Raymond Redline 9. Iron deficiency, folate and vitamin b12 deficiency in pregnancy, obstetrics and gynecology William Baker and Ray Lee 10. Thrombosis prophylaxis and risk factors of thrombosis in gynecologic oncology Georg Fredrik von Templehoff 11. Low molecular weight heparins in pregnancy Deborah Hoppensteadt, Jawed Fareed, Harry Messmore, Omer Iqbal, William Wehrmacher and Rodger Bick 12. Postpartum hemorrhage - diagnosis, pharmacologic therapy, interventional radiologic therapy, and surgical therapy William Baker and Joseph Monsour 13. Hemoglobinopathies in pregnancy Adeboye Adewoye and Martin Steinberg 14. Genetic counseling and prenatal diagnosis Karen Heller and Robyn Horsager 15. Thrombocytopenia in pregnancy Ravinda Sarode and Eugene Frenkel 16. Neonatal immune thrombocytopenias Katharine Downes and Ravinda Sarode 17. The rational use of blood and its components in obstetrical and gynecological bleeding complications Katharine Downes and Ravinda Sarode 18. Heparin-induced thrombocytopenia in pregnancy Barbara Haley, Rodger Bick and Eugene Frenkel 19. Coagulation defects as a cause for menstrual disorders Albert Phillips.

Outcome Analysis for Treatment in 100 Patients with Deep Vein Thrombosis

The treatment of acute deep vein thrombosis has been the subject of much research aimed at delineat ing the safest and most effective approach to diagnosis and treatment. Studies regarding long-term treatment have been limited by the narrow scope of laboratory and clinical analyses of many patients. In this study of 100 patients with a history of deep vein thrombosis, treated on an outpatient basis by a diverse group of clinicians, follow-up data were retrieved in order to determine the outcomes of various approaches to acute and long-term care. Among individuals followed for > 1 year, in only two patients (2%) was death attributable to a thrombotic event related to the etiology of the first episode of deep vein thrombosis. Most deceased patients succumbed to unrelated causes (11%). Among the 77 survivors, most (52%) received long-term antiplatelet therapy. All individ uals with a plasma coagulation defect, whether inherited or acquired, received anticoagulation with either heparin or warfarin. Since the long-term clinical outcome of most patients with deep vein thrombosis is dependent upon the underlying factor predisposing to thrombosis, the most important treatment decision is to select the therapy most likely to provide benefit without causing hemorrhage. An tiplatelet therapy, heparin, or warfarin may be chosen as appropriate for the individual patient.

Thrombosis and Hemostasis in Cardiology: Review of Pathophysiology and Clinical Practice (Part I)

The adverse consequences of thrombosis are per haps nowhere more evident than in clinical cardiology. Throm bosis and hemostasis are primary issues in the management of patients with atrial fibrillation, prosthetic heart valves, severe left ventricular dysfunction, and coronary artery disease. Clini cal trials have defined a crucial role for anticoagulation with warfarin in patients with atrial fibrillation to reduce the inci dence of stroke. Anticoagulation with warfarin and aspirin in combination offers significant protection from systemic emboli in patients with mechanical prosthetic valves, without a sub stantial increased risk of hemorrhage. The risk of systemic emboli may also be reduced by anticoagulation in patients with severe left ventricular dysfunction. Disturbance of the normal balance of hemostasis is a major factor in the pathophysiology of coronary artery disease. Antiplatelet therapy, antithrombin agents, anticoagulants, and fibrinolytic agents have been used to prevent and treat acute coronary thrombosis and to prevent reocclusion following thrombolysis and interventional therapy. Guidelines are presented for antithrombotic therapy in the prac tice of clinical cardiology.

Thrombosis and Hemostasis in Cardiology: Review of Pathophysiology and Clinical Practice (Part II) Recommendations for Antithrombotic Therapy

The adverse consequences of thrombosis are per haps nowhere more evident than in clinical cardiology. Throm bosis and hemostasis are primary issues in the management of patients with atrial fibrillation, prosthetic heart valves, severe left ventricular dysfunction, and coronary artery disease. Clini cal trials have defined a crucial role for anticoagulation with warfarin in patients with atrial fibrillation to reduce the inci dence of stroke. Anticoagulation with warfarin and aspirin in combination offers significant protection from systemic emboli in patients with mechanical prosthetic valves, without a sub stantial increased risk of hemorrhage. The risk of systemic emboli may also be reduced by anticoagulation in patients with severe left ventricular dysfunction. Disturbance of the normal balance of hemostasis is a major factor in the pathophysiology of coronary artery disease. Antiplatelet therapy, antithrombin agents, anticoagulants, and fibrinolytic agents have been used to prevent and treat acute coronary thrombosis and to prevent reocclusion following thrombolysis and interventional therapy. Guidelines are presented for antithrombotic therapy in the prac tice of clinical cardiology. Key Words: Thrombosis— Cardiology—Coronary artery disease—Atrial fibrillation— Valvular heart disease.

Thorotrast-Induced Angiosarcoma Complicated by Disseminated Intravascular Coagulation and Microangiopathic Hemolytic Anemia: Case Report and Review

Thorium dioxide was first used for radiographic imaging studies as early as 1915. Carcinogenesis was clearly established by the 1940s, such that by 1956 worldwide usage had ceased. Malignancies were noted to appear from 15 to 45 years after injection. A case of thorotrast-induced hepatic angiosarcoma is presented, which was complicated by disseminated intravascular coagulation and microangiopathic hemolytic anemia. Since multiple medical conditions existed, it was unclear which was primarily responsible for these complications. This is the first reported association between thorotrast-induced malignancy and disseminated intravascular coagulation. The world literature is reviewed.