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In the name of GOD. Which agents should be used for thromboprophylaxis ?. Dr. Fatemeh Cheraghi Gynecologist - Oncologist Assisstant professor in Ahvaz Joundishapour University. Systematic reviews have concluded that LMWH is a safe alternative to unfractionated heparin as an
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Which agents should be used for thromboprophylaxis? Dr. FatemehCheraghi Gynecologist- Oncologist Assisstant professor in Ahvaz Joundishapour University
Systematic reviews have concluded that LMWH is a safe alternative to unfractionated heparin as an anticoagulant during pregnancy, and, from a safety perspective, LMWH is preferred ( Evidence level 1++supportedby level 2)
Advantages of LMWH : • They have greater bioavailability than UFH when given by subcutaneous injection. • The duration of the anticoagulant effect is greater, permitting administration only once or twice daily. • The anticoagulant response (anti-Xa activity) to LMW heparin is highly correlated with body weight, permitting administration of a fixed dose. • Laboratory monitoring is not necessary • They are much less likely to induce immune-mediated thrombocytopenia than unfractionatedheparin : 0 versus 2.7 percent in one study. • They do not increase osteoclast number and activity as much as unfractionatedheparin , and may therefore produce less bone loss • LMW heparin can be safely administered in the outpatient setting.
Prolonged unfractionated heparin use during pregnancy may result in osteoporosis and fractures but this risk is very low with LMWH In the systematic review of LMWH use in pregnancy by Greer and Nelson-Piercy, the incidence of osteoporotic fractures was 0.04% (95% CI 0.01–0.2), and of allergic skin reactions was 1.8% .Significant bleeding, usually related primarily to obstetric causes, occurred in 1.98%
Low molecular weight heparin*(ACCP guidelines) . dalteparin5000 units once daily, dalteparin 5000 units every 12 hours, tinzaparin4500 units once daily, enoxaparin40 mg once daily, or enoxaparin 40 mg every 12 hours
in antithrombin deficiency, higher doses of LMWH (weight-adjusted: either 75% or 100% of treatmentdose) may be necessary, as judged by anti-Xa levels and monitoring should be by a haemostasis expert.
Which women should not be given thromboprophylaxis with LMWH? • active antenatal or postpartum bleeding • ● women considered at increased risk of major haemorrhage (such as placenta previa) • ● women with a bleeding diathesis, such as von Willebrand’s disease, haemophilia or acquired coagulopathy • ● women with thrombocytopenia (platelet count less than 75000) • ● acute stroke in the last 4 weeks (ischaemic or haemorrhagic) • ● severe renal disease (glomerular filtration rate less than 30 ml/minute/1.73 m2) • ● severe liver disease (prothrombin time above normal range or known varices) • ● uncontrolled hypertension (blood pressure greater than 200 mmHg systolic or greater than 120 mmHg diastolic).
There is evidence that this incidence is dose-dependent, with a higher incidence in women taking greater than 5 mg/day
The experience in the use of this agent in a total of 51 pregnancies was reviewedin 2002. The women had either heparin-induced thrombocytopenia (32 cases) or skin allergy to heparin(19 cases) and the median duration of danaparoid exposure was 10 weeks. four maternal bleeding events No anti-Xa was detected in the cord blood and breast milk There were no adverse fetal outcomes attributed to danaparoid
No placental passage of fondaparinux was found in a human cotyledon model, Although no adverse effectswere observed in the newborns, it is premature to conclude that it is safe and its role in pregnancy at this time should be reserved for women intolerant of heparin compounds
graduated compression stockings of appropriate strength is recommended in pregnancy and the puerperium for: • those who are hospitalised and have a contraindication to LMWH • ● those who are hospitalised post-caesarean section (combined with LMWH) and considered to be at particularly high risk of VTE (such as previous VTE, more than three3 risk factors) • ● outpatients with prior VTE (usually combined with LMWH) • ● women travelling long distance for more than 4 hours.
Which agents are appropriate for post partum thromboprophylaxis?
Conversion from LMWH back to warfarin should be delayed for at least 5–7 days after delivery to minimise the risk of haemorrhage during the period of overlap of LMWH and warfarin treatment.
