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| ID | Type | Description | Link |
|---|---|---|---|
| 2012-001505-24 | EudraCT Number | ||
| NL40326.018.12 | Other Identifier | CCMO | |
| NTR3894 | Registry Identifier | Netherlands Trial Register |
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| Name | Class |
|---|---|
| Netherlands Organisation for Scientific Research | OTHER_GOV |
| Aspen Pharma | UNKNOWN |
| CHU of Saint Etienne: French Ministry of Health Grant (sponsor of the French part of the study) | UNKNOWN |
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This is a randomized-controlled open-label trial comparing two different doses of low-molecular-weight heparin (LMWH) in pregnant patients with a history of previous venous thromboembolism (VTE). Both doses are recommended doses in the 2012 guidelines of the American College of Chest Physicians (ACCP), but it is not known which dose is more efficacious in preventing recurrent venous thromboembolism in pregnancy.
Patients enter the study and will be randomized as soon as a home test confirms pregnancy. LMWH will be administered until 6 weeks postpartum. Follow-up will continue until 3 months postpartum. Patients will be recruited by their treating physician, either an obstetrician or internist.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Low dose LMWH | Active Comparator | Fixed low dose low-molecular-weight heparin:
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| Intermediate dose LMWH | Active Comparator | Intermediate dose low-molecular-weight heparin. Dosing is weight-adjusted according to the protocol.
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Low dose nadroparin | Drug | Fixed low dose nadroparin:
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| Measure | Description | Time Frame |
|---|---|---|
| Symptomatic confirmed deep venous thrombosis | All events of symptomatic deep venous thrombosis in subjects will be recorded from the the date of randomization up to 6 weeks postpartum. Definition of symptomatic deep venous thrombosis (DVT): Suspected (recurrent) DVT with one of the following findings: If there were no previous DVT investigations:
If there was a previous DVT investigation:
| From date of randomization up to 6 weeks postpartum |
| Symptomatic confirmed pulmonary embolism | All events of symptomatic pulmonary embolism in subjects will be recorded from the the date of randomization up to 6 weeks postpartum. Definition of symptomatic pulmonary embolism (PE): Suspected PE with one of the following findings:
| From date of randomization up to 6 weeks postpartum |
| Measure | Description | Time Frame |
|---|---|---|
| Symptomatic confirmed deep venous thrombosis | All events of symptomatic deep venous thrombosis in subjects will be recorded from the the date of randomization up to 3 months postpartum. Definition of symptomatic deep venous thrombosis (DVT): Suspected (recurrent) DVT with one of the following findings: If there were no previous DVT investigations:
If there was a previous DVT investigation:
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| Measure | Description | Time Frame |
|---|---|---|
| Major bleeding | Major bleeding is defined as overt bleeding and:
| During pregnancy until 3 months postpartum |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Saskia Middeldorp, MD PhD | Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA) | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Weill Cornell Medicine | NewYork-Presbyterian | New York | New York | United States | |||
| KU Leuven |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 10217099 | Background | Greer IA. Thrombosis in pregnancy: maternal and fetal issues. Lancet. 1999 Apr 10;353(9160):1258-65. doi: 10.1016/S0140-6736(98)10265-9. | |
| 12130523 | Background | Pabinger I, Grafenhofer H, Kyrle PA, Quehenberger P, Mannhalter C, Lechner K, Kaider A. Temporary increase in the risk for recurrence during pregnancy in women with a history of venous thromboembolism. Blood. 2002 Aug 1;100(3):1060-2. doi: 10.1182/blood-2002-01-0149. |
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| Rotunda Hospital: Definitive Interventions and Feasibility Awards (DIFA) 2017 (sponsor of the Irish part of the study)) | UNKNOWN |
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| Intermediate dose nadroparin | Drug | Intermediate weight-adjusted dose nadroparin:
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| Low dose enoxaparin | Drug | Fixed low dose enoxaparin:
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| Intermediate dose enoxaparin | Drug | Intermediate weight-adjusted dose enoxaparin:
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| Low dose dalteparin | Drug | Fixed low dose dalteparin:
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| Intermediate dose dalteparin | Drug | Intermediate weight-adjusted dose dalteparin:
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| Fixed low dose tinzaparin | Drug | Fixed low dose tinzaparin:
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| Intermediate dose tinzaparin | Drug | Intermediate weight-adjusted dose tinzaparin:
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| From date of randomization up to 3 months postpartum |
| Symptomatic confirmed pulmonary embolism | All events of symptomatic pulmonary embolism in subjects will be recorded from the the date of randomization up to 3 months postpartum. Definition of symptomatic pulmonary embolism (PE): Suspected PE with one of the following findings:
| From date of randomization up to 3 months postpartum |
| Composite of major bleeding and clinically relevant non-major bleeding | See 'Major bleeding' for the definition. Clinically relevant non-major bleeding is defined as overt bleeding not meeting the criteria for major bleeding but associated with medical intervention, unscheduled contact (visit or telephone call) with a physician, (temporary) cessation of study treatment, or associated with discomfort such as pain, or impairment of activities of daily life.
| During pregnancy until 3 months postpartum |
| Early postpartum hemorrhage | Postpartum haemorrhage is defined as blood loss of more than 500 mL within 24 hours of delivery (WHO-criteria). Severe postpartum haemorrhage is defined as blood loss of more than 1000 mL within 24 hours of delivery. | Within 24 hours of delivery |
| Blood transfusion < 6 weeks after delivery | Within 6 weeks of delivery |
| Blood transfusion < 24 hours postpartum | Within 24 hours of delivery |
| Late postpartum hemorrhage | Postpartum haemorrhage is defined as blood loss of more than 500 mL within 24 hours of delivery (WHO-criteria). Severe postpartum haemorrhage is defined as blood loss of more than 1000 mL within 24 hours of delivery. | From 24 hours postpartum to 6 weeks postpartum |
| Mortality | During pregnancy until 3 months postpartum |
| Minor bleeding | Minor bleeding is defined as all other overt bleeding episodes not meeting the criteria for major or clinically relevant bleeding or postpartum haemorrhage. | During pregnancy until 3 months postpartum |
| Skin complications | e.g. itching, swelling, pain | During pregnancy until 3 months postpartum |
| Easy bruising | During pregnancy until 3 months postpartum |
| Necessity to switch to other LMWH | During pregnancy until 6 weeks postpartum |
| Heparin-induced thrombocytopenia | Heparin-induced thrombocytopenia is defined according to the criteria of the ACCP guidelines. | During pregnancy until 3 months postpartum |
| Congenital anomalies or birth defects | During pregnancy until 3 months postpartum |
| Leuven |
| Belgium |
| The Ottawa Hospital | Ottawa | Canada |
| Aalborg University Hospital | Aalborg | Denmark |
| Aarhus University Hospital | Aarhus | Denmark |
| CHU de Besancon | Besançon | France |
| CHU de Bordeaux | Bordeaux | France |
| CHU de Brest | Brest | France |
| CHU de Caen | Caen | France |
| CHU de Clermont - Ferrand | Clermont-Ferrand | France |
| APHP Louis Mourier | Colombes | France |
| CHU de Grenoble | Grenoble | France |
| CHU de Limoges | Limoges | France |
| Hopiteaux de Marseille | Marseille | France |
| Marseille St Joseph | Marseille | France |
| CHU de Nancy | Nancy | France |
| CHU de Nice | Nice | France |
| CHU de Nîmes | Nîmes | France |
| APHP Antoine Béclère | Paris | France |
| APHP Port Royal | Paris | France |
| CHU de Poitiers | Paris | France |
| Centra Hospitalier de Roanne | Roanne | France |
| La Réunion - Saint-Denis | Saint-Denis | France |
| Hopital Nord, CHU de Saint Etienne | Saint-Etienne | France |
| La Réunion deSt Pierre | Saint-Pierre | France |
| Polyclinique de Sète | Sète | France |
| CHIC de Toulon | Toulon | France |
| CHU de Tours | Tours | France |
| Corke University Hospital | Cork | Ireland |
| Coombe Women's Hospital | Dublin | Ireland |
| Rotunda Hospital | Dublin | Ireland |
| The National Maternity Hospital | Dublin | Ireland |
| Letterkenny University Hospital | Letterkenny | Ireland |
| University Hospital Limerick | Limerick | Ireland |
| Academic Medical Center | Amsterdam | North Holland | 1105 AZ | Netherlands |
| Jeroen Bosch Ziekenhuis | 's-Hertogenbosch | Netherlands |
| Flevoziekenhuis | Almere Stad | Netherlands |
| OLVG oost | Amsterdam | Netherlands |
| SLAZ | Amsterdam | Netherlands |
| VU medical center | Amsterdam | Netherlands |
| Gelre Ziekenhuizen | Apeldoorn | Netherlands |
| Rijnstate hospital | Arnhem | Netherlands |
| Wilhelmina Ziekenhuis | Assen | Netherlands |
| Rode Kruis Ziekenhuis | Beverwijk | Netherlands |
| Amphia ziekenhuis | Breda | Netherlands |
| Reinier de Graaf Groep | Delft | Netherlands |
| Deventer Ziekenhuis | Deventer | Netherlands |
| Slingeland | Doetinchem | Netherlands |
| Albert Schweitzer | Dordrecht | Netherlands |
| Gelderse Vallei | Ede | Netherlands |
| Admiraal de Ruijter Ziekenhuis | Goes | Netherlands |
| Groene Hart Ziekenhuis | Gouda | Netherlands |
| Martini Ziekenhuis | Groningen | Netherlands |
| UMCG | Groningen | Netherlands |
| Spaarne Gasthuis | Haarlem | Netherlands |
| St Jansdal | Harderwijk | Netherlands |
| Atrium MC | Heerlen | Netherlands |
| MC Leeuwarden | Leeuwarden | Netherlands |
| LUMC | Leiden | Netherlands |
| MUMC | Maastricht | Netherlands |
| Canisius-Wilhelmina Ziekenhuis | Nijmegen | Netherlands |
| St. Radboud UMC | Nijmegen | Netherlands |
| Erasmus MC | Rotterdam | Netherlands |
| Bronovo ziekenhuis | The Hague | Netherlands |
| HAGA ziekenhuis | The Hague | Netherlands |
| TweeSteden | Tilburg | Netherlands |
| Diakonessen Utrecht | Utrecht | Netherlands |
| UMCU | Utrecht | Netherlands |
| Máxima MC | Veldhoven | Netherlands |
| Oslo University Hospital | Oslo | Norway |
| Federal State Institution "Research Center for Obstetrics, Gynecology and Perinatology" | Moscow | Russia |
| Vall d'Hebron Hospital | Barcelona | Spain |
| 18690344 | Background | White RH, Chan WS, Zhou H, Ginsberg JS. Recurrent venous thromboembolism after pregnancy-associated versus unprovoked thromboembolism. Thromb Haemost. 2008 Aug;100(2):246-52. |
| 22315276 | Background | Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. 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 Feb;141(2 Suppl):e691S-e736S. doi: 10.1378/chest.11-2300. |
| 15811953 | Background | Greer IA, Nelson-Piercy C. Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood. 2005 Jul 15;106(2):401-7. doi: 10.1182/blood-2005-02-0626. Epub 2005 Apr 5. |
| 20464719 | Background | Tooher R, Gates S, Dowswell T, Davis LJ. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. Cochrane Database Syst Rev. 2010 May 12;(5):CD001689. doi: 10.1002/14651858.CD001689.pub2. |
| 10365733 | Background | Sanson BJ, Lensing AW, Prins MH, Ginsberg JS, Barkagan ZS, Lavenne-Pardonge E, Brenner B, Dulitzky M, Nielsen JD, Boda Z, Turi S, Mac Gillavry MR, Hamulyak K, Theunissen IM, Hunt BJ, Buller HR. Safety of low-molecular-weight heparin in pregnancy: a systematic review. Thromb Haemost. 1999 May;81(5):668-72. |
| 11762651 | Background | Lepercq J, Conard J, Borel-Derlon A, Darmon JY, Boudignat O, Francoual C, Priollet P, Cohen C, Yvelin N, Schved JF, Tournaire M, Borg JY. Venous thromboembolism during pregnancy: a retrospective study of enoxaparin safety in 624 pregnancies. BJOG. 2001 Nov;108(11):1134-40. doi: 10.1111/j.1471-0528.2003.00272.x. |
| 15869590 | Background | Pabinger I, Grafenhofer H, Kaider A, Kyrle PA, Quehenberger P, Mannhalter C, Lechner K. Risk of pregnancy-associated recurrent venous thromboembolism in women with a history of venous thrombosis. J Thromb Haemost. 2005 May;3(5):949-54. doi: 10.1111/j.1538-7836.2005.01307.x. |
| 21232006 | Background | Roeters van Lennep JE, Meijer E, Klumper FJ, Middeldorp JM, Bloemenkamp KW, Middeldorp S. Prophylaxis with low-dose low-molecular-weight heparin during pregnancy and postpartum: is it effective? J Thromb Haemost. 2011 Mar;9(3):473-80. doi: 10.1111/j.1538-7836.2011.04186.x. |
| 21314819 | Background | Lindqvist PG, Bremme K, Hellgren M; Working Group on Hemostatic Disorders (Hem-ARG), Swedish Society of Obstetrics and Gynecology. Efficacy of obstetric thromboprophylaxis and long-term risk of recurrence of venous thromboembolism. Acta Obstet Gynecol Scand. 2011 Jun;90(6):648-53. doi: 10.1111/j.1600-0412.2011.01098.x. Epub 2011 Apr 15. |
| 22102641 | Background | Roshani S, Cohn DM, Stehouwer AC, Wolf H, van der Post JA, Buller HR, Kamphuisen PW, Middeldorp S. Incidence of postpartum haemorrhage in women receiving therapeutic doses of low-molecular-weight heparin: results of a retrospective cohort study. BMJ Open. 2011 Nov 14;1(2):e000257. doi: 10.1136/bmjopen-2011-000257. Print 2011. |
| 20335572 | Background | Kaandorp SP, Goddijn M, van der Post JA, Hutten BA, Verhoeve HR, Hamulyak K, Mol BW, Folkeringa N, Nahuis M, Papatsonis DN, Buller HR, van der Veen F, Middeldorp S. Aspirin plus heparin or aspirin alone in women with recurrent miscarriage. N Engl J Med. 2010 Apr 29;362(17):1586-96. doi: 10.1056/NEJMoa1000641. Epub 2010 Mar 24. |
| 36695396 | Derived | Bistervels IM, Wiegers HMG, Ainle FN, Bleker SM, Chauleur C, Donnelly J, Jacobsen AF, Rodger MA, DeSancho MT, Verhamme P, Hansen AT, Shmakov RG, Ganzevoort W, Buchmuller A, Middeldorp S; Highlow Investigators. Onset of labor and use of analgesia in women using thromboprophylaxis with 2 doses of low-molecular-weight heparin: insights from the Highlow study. J Thromb Haemost. 2023 Jan;21(1):57-67. doi: 10.1016/j.jtha.2022.11.004. Epub 2022 Dec 22. |
| 36354038 | Derived | Bistervels IM, Buchmuller A, Wiegers HMG, Ni Ainle F, Tardy B, Donnelly J, Verhamme P, Jacobsen AF, Hansen AT, Rodger MA, DeSancho MT, Shmakov RG, van Es N, Prins MH, Chauleur C, Middeldorp S; Highlow Block writing committee; Highlow Investigators. Intermediate-dose versus low-dose low-molecular-weight heparin in pregnant and post-partum women with a history of venous thromboembolism (Highlow study): an open-label, multicentre, randomised, controlled trial. Lancet. 2022 Nov 19;400(10365):1777-1787. doi: 10.1016/S0140-6736(22)02128-6. Epub 2022 Oct 28. |
| 33779986 | Derived | Middleton P, Shepherd E, Gomersall JC. Venous thromboembolism prophylaxis for women at risk during pregnancy and the early postnatal period. Cochrane Database Syst Rev. 2021 Mar 29;3(3):CD001689. doi: 10.1002/14651858.CD001689.pub4. |
| 25903529 | Derived | Middeldorp S. New studies of low-molecular-weight heparin in pregnancy. Thromb Res. 2015 Feb;135 Suppl 1:S26-9. doi: 10.1016/S0049-3848(15)50436-2. Epub 2015 Feb 9. |
| 24768093 | Derived | Bleker SM, Coppens M, Middeldorp S. Sex, thrombosis and inherited thrombophilia. Blood Rev. 2014 May;28(3):123-33. doi: 10.1016/j.blre.2014.03.005. Epub 2014 Apr 1. |
| ID | Term |
|---|---|
| D020246 | Venous Thrombosis |
| D011655 | Pulmonary Embolism |
| ID | Term |
|---|---|
| D013927 | Thrombosis |
| D016769 | Embolism and Thrombosis |
| D014652 | Vascular Diseases |
| D002318 | Cardiovascular Diseases |
| D008171 | Lung Diseases |
| D012140 | Respiratory Tract Diseases |
| D004617 | Embolism |
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| ID | Term |
|---|---|
| D017762 | Nadroparin |
| D017984 | Enoxaparin |
| D017985 | Dalteparin |
| D000078222 | Tinzaparin |
| ID | Term |
|---|---|
| D006495 | Heparin, Low-Molecular-Weight |
| D006493 | Heparin |
| D006025 | Glycosaminoglycans |
| D011134 | Polysaccharides |
| D002241 | Carbohydrates |
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