Dvt.warda [compatibility mode]

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Dvt.warda [compatibility mode]

  1. 1. ‫ﷲ‬‫ﷲ‬‫ﷲ‬‫ﷲ‬‫ﷲ‬‫ﷲ‬‫ﷲ‬‫ﷲ‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬Osama Warda,MDOsama Warda,MD‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬‫ا‬
  2. 2. Deep Vein Thrombosis ( DVT )Deep Vein Thrombosis ( DVT )in Pregnancyin Pregnancy(((((((( AN OVERVIEW OF THE LITERATURE )AN OVERVIEW OF THE LITERATURE )ByByOSAMA M.WARDA, MDOSAMA M.WARDA, MDOSAMA M.WARDA, MDOSAMA M.WARDA, MDOSAMA M.WARDA, MDOSAMA M.WARDA, MDOSAMA M.WARDA, MDOSAMA M.WARDA, MDObstetrics and Gynecology Dept.Obstetrics and Gynecology Dept.Faculty of MedicineFaculty of Medicine--Mansoura UniversityMansoura University
  3. 3. EpidemiologyEpidemiologyDVT of the lower limbs during pregnancy occurs inDVT of the lower limbs during pregnancy occurs in00..1313 toto 00..6161 per thousand pregnancyper thousand pregnancy..Despite its relatively low incidence, DVT may leadDespite its relatively low incidence, DVT may leadto pulmonary embolism; the most common cause ofto pulmonary embolism; the most common cause ofmaternal death in developed countries.maternal death in developed countries.Osama Warda,MDOsama Warda,MDmaternal death in developed countries.maternal death in developed countries.DVT occurs with relatively equal frequency in allDVT occurs with relatively equal frequency in alltrimesterstrimesters.. However, in the past it was mostHowever, in the past it was mostcommon in the postcommon in the post--partum period due to medicalpartum period due to medicalpractices as instrumental deliveries, prescription ofpractices as instrumental deliveries, prescription ofprolonged bed rest after delivery, and use ofprolonged bed rest after delivery, and use ofestrogens to stop lactationestrogens to stop lactation..
  4. 4. Risk Factors for DVT inRisk Factors for DVT inPregnancyPregnancyPregnancyPregnancyPregnancyPregnancy itselfitselfitselfitself; DVT is; DVT is 55 times more in pregnant than nontimes more in pregnant than non--pregnant agepregnant age--matched female.matched female.VVirchowirchow’’s triad:s triad: (( hypercoagulabilityhypercoagulability, stasis, and endothelial, stasis, and endothelialOsama Warda,MDOsama Warda,MDVVirchowirchow’’s triad:s triad: (( hypercoagulabilityhypercoagulability, stasis, and endothelial, stasis, and endothelialinjury) operates during pregnancy and puerperium.injury) operates during pregnancy and puerperium.11-- HYPERHYPER--COAGULABILITYCOAGULABILITY: Increased levels of clotting factors: Increased levels of clotting factors(factor I,II,VII,IX, and X) .Decreased fibrinolysis and(factor I,II,VII,IX, and X) .Decreased fibrinolysis andreduced levels of natural anticoagulants (e.g. proteinreduced levels of natural anticoagulants (e.g. protein-- S)S)contribute to this state of hypercoagulability duringcontribute to this state of hypercoagulability duringpregnancy .pregnancy .
  5. 5. Risk factorsRisk factors (continued)(continued)VVirchowirchow’’s triad:s triad: (( hypercoagulabilityhypercoagulability,, stasisstasis, and endothelial, and endothelialinjury) operates during pregnancy and puerperium.injury) operates during pregnancy and puerperium.22-- STASISSTASIS: Venous stasis due to pressure of the: Venous stasis due to pressure of thegravid uterus on the IVC and decreased venousgravid uterus on the IVC and decreased venousOsama Warda,MDOsama Warda,MDgravid uterus on the IVC and decreased venousgravid uterus on the IVC and decreased venoustone are further predisposing factors present in alltone are further predisposing factors present in allpregnant women. At term, flow velocity of thepregnant women. At term, flow velocity of thefemoral vein slows to less thanfemoral vein slows to less than 11//33rdrd of the velocityof the velocityin the first trimester, and subsequently in the postin the first trimester, and subsequently in the post--partum period. Moreover, the vessel diameter ofpartum period. Moreover, the vessel diameter ofthe deep leg vein increases during pregnancy.the deep leg vein increases during pregnancy.
  6. 6. Risk factorsRisk factors (continued)(continued)VVirchowirchow’’s triad:s triad: (( hypercoagulabilityhypercoagulability, stasis, and, stasis, and endothelialendothelialinjuryinjury) operates during pregnancy and puerperium.) operates during pregnancy and puerperium.33-- ENDOTHELIAL VASCULAR INJURY:ENDOTHELIAL VASCULAR INJURY: Although pregnancyAlthough pregnancyOsama Warda,MDOsama Warda,MD33-- ENDOTHELIAL VASCULAR INJURY:ENDOTHELIAL VASCULAR INJURY: Although pregnancyAlthough pregnancyitself is not associated with endothelial injury, theitself is not associated with endothelial injury, thetrauma of operative delivery may result vasculartrauma of operative delivery may result vascularinjury, leading to postinjury, leading to post--partum DVT.partum DVT.
  7. 7. Risk factorsRisk factors ((continued)continued)OtherOther RiskRisk FactorsFactors include:include:Increased parity (Increased parity (>> 44).).Obesity .Obesity .Osama Warda,MDOsama Warda,MDObesity .Obesity .Operative or difficult instrumental delivery.Operative or difficult instrumental delivery.Prolonged immobility.Prolonged immobility.Previous thromboPrevious thrombo--embolism or DVT.embolism or DVT.Thrombophilias.Thrombophilias.
  8. 8. Pathogenesis:Pathogenesis:Multiple risk factors are often presentMultiple risk factors are often presentin women who develop DVT duringin women who develop DVT duringpregnancy and these risk factors arepregnancy and these risk factors areOsama Warda,MDOsama Warda,MDpregnancy and these risk factors arepregnancy and these risk factors arecumulative.cumulative.In addition, an occult thrombophiliaIn addition, an occult thrombophiliasuch assuch as FactorFactor--VV-- Leiden mutationLeiden mutationmay become unmasked during anmay become unmasked during anotherwise normal pregnancy.otherwise normal pregnancy.
  9. 9. PPathogenesis:athogenesis: (continued)(continued)WWhich side is more prone during pregnancy for DVT ?hich side is more prone during pregnancy for DVT ?During pregnancy venous thrombosis begins mostDuring pregnancy venous thrombosis begins mostfrequentlyfrequently either in the calf veins or in the ilioeither in the calf veins or in the ilio--femoral segmentfemoral segment of the deep venous system.of the deep venous system.Osama Warda,MDOsama Warda,MDThere is a striking propensity for theThere is a striking propensity for the leftleft legleg, with, with8080% of DVT in pregnancy occurring on this side.% of DVT in pregnancy occurring on this side.This may be due to the fact that the venousThis may be due to the fact that the venousdrainage of the left leg flows a more tortuousdrainage of the left leg flows a more tortuouscourse through the pelvis, with the left commoncourse through the pelvis, with the left commoniliac vein traversed by the right common iliac artery.iliac vein traversed by the right common iliac artery.
  10. 10. DDiagnosis :iagnosis : Clinical picture;Clinical picture;Clinical diagnosis of DVT and thromboembolism isClinical diagnosis of DVT and thromboembolism is notoriouslynotoriouslyunreliable because:unreliable because:The intensity of the classical symptoms of pain, tenderness,The intensity of the classical symptoms of pain, tenderness,and swelling of the affected limb depends on the extent of theand swelling of the affected limb depends on the extent of thevascular occlusion, existing collateral circulation, and thevascular occlusion, existing collateral circulation, and theassociated inflammatory response.associated inflammatory response.Osama Warda,MDOsama Warda,MDvascular occlusion, existing collateral circulation, and thevascular occlusion, existing collateral circulation, and theassociated inflammatory response.associated inflammatory response.The physiological changes of pregnancy further complicateThe physiological changes of pregnancy further complicateinterpretation of the patientinterpretation of the patient’’s history, physical findings, ands history, physical findings, andtest results.test results.DVT in pregnancy may present atypically with diffuseDVT in pregnancy may present atypically with diffuseabdominal pain.abdominal pain.Dyspnea, a common symptom of DVT, is experienced inDyspnea, a common symptom of DVT, is experienced in 7575%%of females during normal pregnancy.of females during normal pregnancy.
  11. 11. DDiagnosis :iagnosis : NonNon--invasive tests;invasive tests;In the lateIn the late 19901990--ies, nonies, non--invasive diagnostic studiesinvasive diagnostic studiessuch assuch as impedanceimpedance plethysmographyplethysmography,, realreal timetime BBmode U/Smode U/S, and, and duplex doppler scanningduplex doppler scanning havehavereplaced venography asreplaced venography as the initial screening testthe initial screening test ininOsama Warda,MDOsama Warda,MDreplaced venography asreplaced venography as the initial screening testthe initial screening test ininthe diagnosis of DVT.the diagnosis of DVT.These diagnostic tests have high sensitivity forThese diagnostic tests have high sensitivity fordetection of thrombosis in the iliodetection of thrombosis in the ilio--femoral veinsfemoral veins butbutnotnot in the distal deep veins of the lower limbs.in the distal deep veins of the lower limbs.
  12. 12. DDiagnosis :iagnosis : NonNon--invasive tests;invasive tests;ImpedanceImpedance PPlethysmography :lethysmography :Measures changes in electric resistanceMeasures changes in electric resistancemeasured bymeasured by 22 electrodes wrapped aroundelectrodes wrapped aroundthe calf in relation to changes in venousthe calf in relation to changes in venousthe calf in relation to changes in venousthe calf in relation to changes in venousvolume.volume.Serial normal studies areSerial normal studies are sufficient tosufficient towithhold therapywithhold therapy in both nonin both non--pregnant andpregnant andpregnant patientspregnant patients
  13. 13. DDiagnosis :iagnosis : NonNon--invasive tests;invasive tests;Doppler ultrasonography:Doppler ultrasonography:This technique has become the diagnostic test ofThis technique has become the diagnostic test ofchoice in cases of suspectedchoice in cases of suspected proximal veinproximal veinocclusion.occlusion.Osama Warda,MDOsama Warda,MDocclusion.occlusion.With expert sonographer, a correct diagnosis withWith expert sonographer, a correct diagnosis withhigh sensitivity and specificity (high sensitivity and specificity (9191% and% and 9999%%respectively) in evaluation of proximal veinrespectively) in evaluation of proximal veinthrombosis is obtained.thrombosis is obtained.Limitations includeLimitations include: less effectiveness in calf vein: less effectiveness in calf veinthrombosis, and less sensitivity for diagnosis ofthrombosis, and less sensitivity for diagnosis ofasymptomatic thrombosis.asymptomatic thrombosis.
  14. 14. DDiagnosis ;iagnosis ; VV e n o g r a p h y:e n o g r a p h y:What is the role?What is the role?Venography remains the diagnostic standardVenography remains the diagnostic standardfor DVT in both pregnant and nonfor DVT in both pregnant and non--pregnantpregnantpatients.patients.It has the advantage ofIt has the advantage of accuratelyaccuratelyOsama Warda,MDOsama Warda,MDIt has the advantage ofIt has the advantage of accuratelyaccuratelyevaluating theevaluating the entireentire lower limb from thelower limb from thecalf veins to the common iliac vessels.calf veins to the common iliac vessels.AlthoughAlthough invasiveinvasive, it is still more reliable, it is still more reliablethan the nonthan the non--invasive techniques ininvasive techniques indifferentiating betweendifferentiating between intraintra--luminalluminal defectsdefectsandand externalexternal venous compression.venous compression.
  15. 15. DDiagnosis ;iagnosis ; VV e n o g r a p h y:e n o g r a p h y:HHow safe is it?ow safe is it?Potential side effects include:Potential side effects include:1.1. Chemical phlebitis,Chemical phlebitis,2.2. Leg swelling, leg painLeg swelling, leg painOsama Warda,MDOsama Warda,MD3.3. Skin necrosis due to dye extraSkin necrosis due to dye extra--vasationvasationProcedure is invasive & associated withProcedure is invasive & associated withrisks of provoking thrombosis and contrastrisks of provoking thrombosis and contrastreaction.reaction.Procedure is relatively expensive & theProcedure is relatively expensive & theresults can be difficult to interpret.results can be difficult to interpret.
  16. 16. DDiagnosis ;iagnosis ; VV e n o g r a p h y:e n o g r a p h y:HHow safe is it? (contd.)ow safe is it? (contd.)Estimated fetal radiation exposure isEstimated fetal radiation exposure isnegligible; approximatelynegligible; approximately 00..314314 rad for arad for aunilateral procedure without abdominalunilateral procedure without abdominalshielding.shielding.Osama Warda,MDOsama Warda,MDshielding.shielding.Limited venography, using an abdominalLimited venography, using an abdominalshield, can reduce the estimated fetalshield, can reduce the estimated fetalexposure to less thanexposure to less than 00..0505 rad.rad.
  17. 17. DDiagnosis ;iagnosis ; VV e n o g r a p h y:e n o g r a p h y:CONCLUSIONCONCLUSIONCONCLUSIONCONCLUSIONThe role of venography in diagnosingThe role of venography in diagnosingDVT in pregnancy remains unresolved.DVT in pregnancy remains unresolved.Osama Warda,MDOsama Warda,MDVenography may be helpful when theVenography may be helpful when theresults of nonresults of non--invasive imaging studiesinvasive imaging studiesare equivocal OR serial scanning isare equivocal OR serial scanning isimpractical.impractical.
  18. 18. DDDDDDDD I A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SRecent Advances:Recent Advances:MAGNETICMAGNETIC RESONANCERESONANCE IMAGINGIMAGING::MRI has been established to be reliable methodMRI has been established to be reliable methodfor diagnosing pelvic and lower limb venousfor diagnosing pelvic and lower limb venousthrombosis.thrombosis.Osama Warda,MDOsama Warda,MDthrombosis.thrombosis.Despite its cost it has the following advantages:Despite its cost it has the following advantages:1.1. At least it is as accurate as venography forAt least it is as accurate as venography forproximal thrombosis in the lower limb and evenproximal thrombosis in the lower limb and evenmore sensitive for pelvic vein thrombosis.more sensitive for pelvic vein thrombosis.2.2. Advantages in pregnancy; nonAdvantages in pregnancy; non--invasive, noinvasive, noionizing radiation, and excellent resolution of theionizing radiation, and excellent resolution of theIVC and pelvic veins.IVC and pelvic veins.
  19. 19. DDDDDDDD I A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SRecent Advances:Recent Advances: (contd.,)(contd.,)B L O O D T E S T SB L O O D T E S T SSeveral tests are available that reflect the formation ofSeveral tests are available that reflect the formation ofintravascular fibrin. Results are invariablyintravascular fibrin. Results are invariably +ve when+ve whenthrombosis has occurred.thrombosis has occurred.Osama Warda,MDOsama Warda,MDThe most important tests are assays for fibrinopeptide A (FPA)The most important tests are assays for fibrinopeptide A (FPA)and fibrin degradation products (FDP); Dand fibrin degradation products (FDP); D--dimers are the mostdimers are the mostsensitive.sensitive.Elevations in DElevations in D--dimer levels are found even in uncomplicateddimer levels are found even in uncomplicatedpregnancy, in levels increasing during the course ofpregnancy, in levels increasing during the course ofpregnancy.pregnancy.However, a finding of normal level of these, essentially rulesHowever, a finding of normal level of these, essentially rulesout DVT.out DVT.
  20. 20. DDDDDDDD I A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SI A G N O S I SRecent Advances:Recent Advances: (contd.,)(contd.,)B L O O D T E S T SB L O O D T E S T SDIAGNOSTIC WORK UP FOR CONGENITALTHROMBOPHILIASDIAGNOSTIC WORK UP FOR CONGENITALTHROMBOPHILIASActivated protein-C resistance due to factor V Leidenmutation is the commonest thrombophilia. The defect israre in Africans, and Asians. So, diagnostic work-up forOsama Warda,MDOsama Warda,MDrare in Africans, and Asians. So, diagnostic work-up forthrombophilia is not indicated in all cases of DVT inpregnancy, but only in selected cases with clinical indicatorsof hypercoagulable state which include:1. Family history of thrombosis, Recurrent thrombosis, oridiopathic thrombosis2. Thrombosis at unusual sites (e.g., axillary, cerebral,mesenteric, portal, hepatic veins)3. Skin necrosis after starting warfarin therapy
  21. 21. M A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TThe Aims of TreatmentThe Aims of Treatment1.1. To prevent extension of the thrombusTo prevent extension of the thrombus2.2. To restore venous patencyTo restore venous patency ----------»»preventpreventpostpost--phlebitic syndrome (chronic pain,phlebitic syndrome (chronic pain,swelling, ulceration) due to venousswelling, ulceration) due to venousOsama Warda,MDOsama Warda,MDswelling, ulceration) due to venousswelling, ulceration) due to venousinsufficiencyinsufficiency3.3. The most important aim is to preventThe most important aim is to preventpulmonary embolism or its recurrencepulmonary embolism or its recurrence
  22. 22. M A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TIsIsIsIsIsIsIsIs bed rest absolutely necessary in all cases of acutebed rest absolutely necessary in all cases of acutebed rest absolutely necessary in all cases of acutebed rest absolutely necessary in all cases of acutebed rest absolutely necessary in all cases of acutebed rest absolutely necessary in all cases of acutebed rest absolutely necessary in all cases of acutebed rest absolutely necessary in all cases of acuteDVT?DVT?DVT?DVT?DVT?DVT?DVT?DVT?Bed rest with elevation of the affected limb isBed rest with elevation of the affected limb isinvaluable initially because it promotes venousinvaluable initially because it promotes venousreturn & decrease edema.return & decrease edema.As soon as symptoms permit, the patient should beAs soon as symptoms permit, the patient should beOsama Warda,MDOsama Warda,MDAs soon as symptoms permit, the patient should beAs soon as symptoms permit, the patient should beencouraged to ambulate, since bed rest itself mayencouraged to ambulate, since bed rest itself mayenhance venous stasis.enhance venous stasis.There is no evidence that bed rest will preventThere is no evidence that bed rest will preventembolus detachment .embolus detachment .Sitting with legs dependant is contraindicated.Sitting with legs dependant is contraindicated.
  23. 23. M A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TSSSSSSSShouldhouldhouldhouldhouldhouldhouldhould wwwwwwwweeeeeeee Advocate Elastic BandageAdvocate Elastic BandageAdvocate Elastic BandageAdvocate Elastic BandageAdvocate Elastic BandageAdvocate Elastic BandageAdvocate Elastic BandageAdvocate Elastic Bandage //////// Stocking?Stocking?Stocking?Stocking?Stocking?Stocking?Stocking?Stocking?When correctly designed, elastic stockings increaseWhen correctly designed, elastic stockings increasethe velocity of venous return.the velocity of venous return.Osama Warda,MDOsama Warda,MDThe pressure gradient should decrease from ankleThe pressure gradient should decrease from ankleto thigh without a constricting garter at the top.to thigh without a constricting garter at the top.Elastic bandages once in vogue, are best avoidedElastic bandages once in vogue, are best avoidedbecause they are easily wrapped incorrectly withbecause they are easily wrapped incorrectly withthe greatest pressure ending up at the top, thusthe greatest pressure ending up at the top, thusimpeding venous return.impeding venous return.
  24. 24. M A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TM A N A G E M E N TDoes DVT limited to theDoes DVT limited to theDoes DVT limited to theDoes DVT limited to theDoes DVT limited to theDoes DVT limited to theDoes DVT limited to theDoes DVT limited to the calfcalfcalfcalfcalfcalfcalfcalf require treatment?require treatment?require treatment?require treatment?require treatment?require treatment?require treatment?require treatment?The need for treatment of thrombosis below theThe need for treatment of thrombosis below thelevel of popliteal fossa remains disputable as risk oflevel of popliteal fossa remains disputable as risk ofpulmonary embolism in such cases is very low(pulmonary embolism in such cases is very low(11%).%).However, because aboutHowever, because about 2020% of lower DVT% of lower DVT’’ssOsama Warda,MDOsama Warda,MDHowever, because aboutHowever, because about 2020% of lower DVT% of lower DVT’’ssextend proximally and anticoagulants can preventextend proximally and anticoagulants can preventthis spread, many believe that treatment isthis spread, many believe that treatment isrequired.required.An alternative is frequent doppler flow studies toAn alternative is frequent doppler flow studies todetect extension and then treat.detect extension and then treat.
  25. 25. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant TherapyHow safe are the anticoagulants in pregnancyHow safe are the anticoagulants in pregnancyFDA categoryFDA categoryAgentAgentDDWarfarinWarfarinCCUnfractionated heparinUnfractionated heparinOsama Warda,MDOsama Warda,MDBBDalteparin sodium (LMWH)Dalteparin sodium (LMWH)BBEnoxaparin sodium (LMWH)Enoxaparin sodium (LMWH)CCStreptokinaseStreptokinaseBBUrokinaseUrokinase
  26. 26. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)W A R F A R I NW A R F A R I NIt is the most widely used coumarin derivative forIt is the most widely used coumarin derivative for oraloralanticoagulation. Its therapeutic efficacy lies in its ability toanticoagulation. Its therapeutic efficacy lies in its ability toinhibit the action of vitamin K, which is a cofactor for theinhibit the action of vitamin K, which is a cofactor for thesynthesis ofsynthesis of 44 essential clotting factors in the liver (essential clotting factors in the liver (factor VII,factor VII,IX, X, prothrombinIX, X, prothrombin).).Osama Warda,MDOsama Warda,MDIX, X, prothrombinIX, X, prothrombin).).DOSAGE: usual dose=DOSAGE: usual dose=1010--1515 mg daily until therapeuticmg daily until therapeuticprolongation of PT is achieved (INR=prolongation of PT is achieved (INR=22--33). Heparin is). Heparin iscontinued for thecontinued for the 11stst week of warfarin therapy as its action isweek of warfarin therapy as its action isnot immediate.not immediate.MONITOURING: PT daily forMONITOURING: PT daily for 77 days, thendays, then 22/week for/week for 22w,thenw,thenweekly for several months depending on the response.weekly for several months depending on the response.
  27. 27. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)W A R F A R I NW A R F A R I NAvoid large loading dose as it may cause overAvoid large loading dose as it may cause over--coagulationcoagulationdue to excessive protein C inhibition.due to excessive protein C inhibition.Warfarin use during pregnancy is limited as it crosses theWarfarin use during pregnancy is limited as it crosses theplacenta with the following fetal hazards:placenta with the following fetal hazards:Risk of embryopathy(Risk of embryopathy(55%) if taken between%) if taken between 66thth andand 1212ththOsama Warda,MDOsama Warda,MD1.1. Risk of embryopathy(Risk of embryopathy(55%) if taken between%) if taken between 66thth andand 1212ththweeks of gestation. (nasal, epiphysealweeks of gestation. (nasal, epiphyseal--limb hypoplasia).limb hypoplasia).2.2. If taken afterIf taken after 11stst trimester of pregnancy it may causetrimester of pregnancy it may causeneurological & ophthalmic anomalies. Also can cause fetal&neurological & ophthalmic anomalies. Also can cause fetal&neonatal hemorrhage, and placental abruptionneonatal hemorrhage, and placental abruptionIt can cause major maternal hemorrhage & its action is notIt can cause major maternal hemorrhage & its action is notas easily reversed as that of heparin.as easily reversed as that of heparin.
  28. 28. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)W A R F A R I NW A R F A R I NFor its risks, Warfarin:For its risks, Warfarin:Is absolutely contraIs absolutely contra--indicated during first trimester.indicated during first trimester.Its use inIts use in 22ndnd && 33rdrd trimesters is controversial.trimesters is controversial.If its use during pregnancy is specifically indicated;If its use during pregnancy is specifically indicated;Osama Warda,MDOsama Warda,MDIf its use during pregnancy is specifically indicated;If its use during pregnancy is specifically indicated;it should replace heparin after theit should replace heparin after the 1212thth week, andweek, andreplaced by heparin after thereplaced by heparin after the 3636thth week or at theweek or at theonset of labor.onset of labor.If labor started while using it, parenteral vitamin KIf labor started while using it, parenteral vitamin Kand fresh frozen plasma can reverse its effect.and fresh frozen plasma can reverse its effect.
  29. 29. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)WHAT IS THE MOST COMMONLY USED ANTICOAGULANTWHAT IS THE MOST COMMONLY USED ANTICOAGULANTWHAT IS THE MOST COMMONLY USED ANTICOAGULANTWHAT IS THE MOST COMMONLY USED ANTICOAGULANTWHAT IS THE MOST COMMONLY USED ANTICOAGULANTWHAT IS THE MOST COMMONLY USED ANTICOAGULANTWHAT IS THE MOST COMMONLY USED ANTICOAGULANTWHAT IS THE MOST COMMONLY USED ANTICOAGULANTDURING PREGNANCY?DURING PREGNANCY?DURING PREGNANCY?DURING PREGNANCY?DURING PREGNANCY?DURING PREGNANCY?DURING PREGNANCY?DURING PREGNANCY?Unfractionated heparin(UFH):Unfractionated heparin(UFH):Naturally occurring mucopolysaccharide.Naturally occurring mucopolysaccharide.In plasma, it combines with antiIn plasma, it combines with anti--thrombin III tothrombin III tobecome a potent inhibitor of thrombin& to increasebecome a potent inhibitor of thrombin& to increaseOsama Warda,MDOsama Warda,MDbecome a potent inhibitor of thrombin& to increasebecome a potent inhibitor of thrombin& to increasethe circulating levels of activated factor X inhibitor.the circulating levels of activated factor X inhibitor.ANTIDOTE :ANTIDOTE :If necessary heparin effects can beIf necessary heparin effects can bereversed rapidly withreversed rapidly with protamine sulfateprotamine sulfate in a dose ofin a dose of11mg/mg/100100 units of administered heparin. No moreunits of administered heparin. No morethanthan 5050mg should be given over anymg should be given over any 1010 min. periodmin. periodbecause itself can cause bleeding.because itself can cause bleeding.
  30. 30. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?Lack of adequate anticoagulation increase the riskLack of adequate anticoagulation increase the riskof recurrence of thrombosis byof recurrence of thrombosis by 1111--1515 folds.folds.Optimal anticoagulation is obtained with an APTT ofOptimal anticoagulation is obtained with an APTT of6060--8080 sec (sec (11..55--22..55 times control).times control).Osama Warda,MDOsama Warda,MDPrePre--treatment : CBC, Platelet count, PT, APTT,treatment : CBC, Platelet count, PT, APTT,Urine analysis.Urine analysis.Loading dose:Loading dose: 100100 u/kgu/kg with minimum ofwith minimum of 50005000 u.u.following it, the initial infusion rate should befollowing it, the initial infusion rate should be 1515--2525u/kg/hr.u/kg/hr.APTT should be obtained after the loading dose andAPTT should be obtained after the loading dose andappropriate adjustment should be made.appropriate adjustment should be made.
  31. 31. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?WHAT ARE THE THERAPEUTIC DOSES OF HEPARIN?MAINTENANCE DOSAGE: continuous IV infusion forMAINTENANCE DOSAGE: continuous IV infusion for 33--55days for active thromboembolism or symptoms resolved &days for active thromboembolism or symptoms resolved &there is no recurrence.there is no recurrence.It is followed by adjusted dose regimen of heparin forIt is followed by adjusted dose regimen of heparin for 44months followed by a prophylactic dose for the remainder ofmonths followed by a prophylactic dose for the remainder ofOsama Warda,MDOsama Warda,MDmonths followed by a prophylactic dose for the remainder ofmonths followed by a prophylactic dose for the remainder ofpregnancy andpregnancy and 66--1212 weeks postpartum.weeks postpartum.Adjusted dose regimen:Adjusted dose regimen: S.C.S.C. heparin /heparin /1212hrs. Dose adjusted tohrs. Dose adjusted toobtain APTT=obtain APTT=11..55--22..00 times control attimes control at 66hrs. Once a stablehrs. Once a stabledose reached, middose reached, mid--interval APTT done weekly at the antenatalinterval APTT done weekly at the antenatalvisits.visits.Heparin requirements should be anticipated to increase duringHeparin requirements should be anticipated to increase duringpregnancy until term.pregnancy until term.
  32. 32. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?If DVT occurredIf DVT occurred ≥≥ 33months before the EDD,months before the EDD,anticoagulation during labor is NOT indicated.anticoagulation during labor is NOT indicated.Patient instructed to discontinue therapy with onsetPatient instructed to discontinue therapy with onsetof labor. The morning dose should not be taken byof labor. The morning dose should not be taken byOsama Warda,MDOsama Warda,MDof labor. The morning dose should not be taken byof labor. The morning dose should not be taken bythose who are planned for cesarean delivery.those who are planned for cesarean delivery.Heparin is resumedHeparin is resumed 44--66 hours postpartum.hours postpartum.Regional anesthesia is not contraindicated if APTTRegional anesthesia is not contraindicated if APTTis normal and heparin not given in lastis normal and heparin not given in last 44--66hrs.hrs.
  33. 33. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?SHOULD ANTICOAGULANT BE GIVEN DURING LABOR?If heparin is required during labor, the dose shouldIf heparin is required during labor, the dose shouldbe adjusted to achieve an APTT ofbe adjusted to achieve an APTT of 11..55 times controltimes controlduring labor and delivery.during labor and delivery.Osama Warda,MDOsama Warda,MDConduction anesthesia is contraindicated in theseConduction anesthesia is contraindicated in thesepatients.patients.With this dose the incidence of PPHge.is notWith this dose the incidence of PPHge.is notincreased in a normal labor, but the incidence ofincreased in a normal labor, but the incidence ofepisiotomy hematoma is increased.episiotomy hematoma is increased.
  34. 34. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)WHAT ARE THE COMPLICATIONS OF HEPARIN THERAPY?WHAT ARE THE COMPLICATIONS OF HEPARIN THERAPY?WHAT ARE THE COMPLICATIONS OF HEPARIN THERAPY?WHAT ARE THE COMPLICATIONS OF HEPARIN THERAPY?WHAT ARE THE COMPLICATIONS OF HEPARIN THERAPY?WHAT ARE THE COMPLICATIONS OF HEPARIN THERAPY?WHAT ARE THE COMPLICATIONS OF HEPARIN THERAPY?WHAT ARE THE COMPLICATIONS OF HEPARIN THERAPY?Heparin does not cross placenta, soHeparin does not cross placenta, so no fetal hazardsno fetal hazards. All. Allcomplications are maternal;complications are maternal;1.1. BleedingBleeding: not significantly more in pregnant than non: not significantly more in pregnant than nonpregnant. SC heparin may cause persistent anticoagulationpregnant. SC heparin may cause persistent anticoagulationafter cessation of use, so it is recommended to convert toafter cessation of use, so it is recommended to convert toIV heparinIV heparin 2424 hrs before elective induction of labor.hrs before elective induction of labor.Osama Warda,MDOsama Warda,MDIV heparinIV heparin 2424 hrs before elective induction of labor.hrs before elective induction of labor.2.2. Osteoporosis;Osteoporosis; reversible, more in pregnant than nonreversible, more in pregnant than nonpregnant (prolonged therapy, pregnancy & lactationpregnant (prolonged therapy, pregnancy & lactationdemineralization.demineralization.3.3. ThrombocytopeniaThrombocytopenia;; 22 formsforms (a)(a) early benignearly benign, mild occurs, mild occurs11--66 days of treatmentdays of treatment (b)(b) delayed severedelayed severe,, immuneimmune--mediated, occursmediated, occurs 66--1010 days of treatment. Thedays of treatment. The 22ndnd form mayform maybe associated with paradoxical arterial and venousbe associated with paradoxical arterial and venousthrombosis. Requires immediate heparin withdrawal.thrombosis. Requires immediate heparin withdrawal.
  35. 35. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)WHAT IS HEPARIN RESISTANCE?WHAT IS HEPARIN RESISTANCE?WHAT IS HEPARIN RESISTANCE?WHAT IS HEPARIN RESISTANCE?WHAT IS HEPARIN RESISTANCE?WHAT IS HEPARIN RESISTANCE?WHAT IS HEPARIN RESISTANCE?WHAT IS HEPARIN RESISTANCE?Defined as the need for more thanDefined as the need for more than 2020,,000000 unitsunitsof heparin/day. Mainly occurs in patients withof heparin/day. Mainly occurs in patients withlarge venous thrombolarge venous thrombo--emboli.emboli.Mechanism of resistance:Mechanism of resistance:1.1. Inherited or acquired decrease in AT III levels.Inherited or acquired decrease in AT III levels.Osama Warda,MDOsama Warda,MD1.1. Inherited or acquired decrease in AT III levels.Inherited or acquired decrease in AT III levels.2.2. Increased plasma levels of factor VIII.Increased plasma levels of factor VIII.3.3. Increased plasma levels of heparin bindingIncreased plasma levels of heparin bindingproteins.proteins.Monitoring here is not with APTT, but with antiMonitoring here is not with APTT, but with anti--factor Xa assay.factor Xa assay.Low molecular weight heparin should be usedLow molecular weight heparin should be usedLow molecular weight heparin should be usedLow molecular weight heparin should be usedLow molecular weight heparin should be usedLow molecular weight heparin should be usedLow molecular weight heparin should be usedLow molecular weight heparin should be usedalternatively as they have less protein binding.alternatively as they have less protein binding.alternatively as they have less protein binding.alternatively as they have less protein binding.alternatively as they have less protein binding.alternatively as they have less protein binding.alternatively as they have less protein binding.alternatively as they have less protein binding.
  36. 36. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)WHAT ARE LOW MOLECULAR WEIGHT HEPARINWHAT ARE LOW MOLECULAR WEIGHT HEPARINWHAT ARE LOW MOLECULAR WEIGHT HEPARINWHAT ARE LOW MOLECULAR WEIGHT HEPARINWHAT ARE LOW MOLECULAR WEIGHT HEPARINWHAT ARE LOW MOLECULAR WEIGHT HEPARINWHAT ARE LOW MOLECULAR WEIGHT HEPARINWHAT ARE LOW MOLECULAR WEIGHT HEPARINS (LMWH)S (LMWH)S (LMWH)S (LMWH)S (LMWH)S (LMWH)S (LMWH)S (LMWH)????????Are fragments of conventional heparin produced byAre fragments of conventional heparin produced byenzymatic or chemical breakdown.enzymatic or chemical breakdown.Like heparin, they donLike heparin, they don’’t cross the placenta, aret cross the placenta, areOsama Warda,MDOsama Warda,MDLike heparin, they donLike heparin, they don’’t cross the placenta, aret cross the placenta, arenonnon--teratogenic, and not secreted in milk.teratogenic, and not secreted in milk.By virtue of their shorter & lighter structures,By virtue of their shorter & lighter structures,LMWHs produce predominantly antiLMWHs produce predominantly anti--thromboticthromboticeffect through their inhibition of factor Xa with littleeffect through their inhibition of factor Xa with littleanticoagulant activity.anticoagulant activity.
  37. 37. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)ARE DIFFERENT LMWHs SIMILAR IN ACTION?ARE DIFFERENT LMWHs SIMILAR IN ACTION?ARE DIFFERENT LMWHs SIMILAR IN ACTION?ARE DIFFERENT LMWHs SIMILAR IN ACTION?ARE DIFFERENT LMWHs SIMILAR IN ACTION?ARE DIFFERENT LMWHs SIMILAR IN ACTION?ARE DIFFERENT LMWHs SIMILAR IN ACTION?ARE DIFFERENT LMWHs SIMILAR IN ACTION?LMWs have a molecular weight betweenLMWs have a molecular weight between44,,000000 toto 66,,000000. Various formulations differ. Various formulations differin mean MW, glucosaminoglycan content,in mean MW, glucosaminoglycan content,and anticoagulant activity.and anticoagulant activity.Osama Warda,MDOsama Warda,MDand anticoagulant activity.and anticoagulant activity.Each LMWH has its own bioavailability,Each LMWH has its own bioavailability,plasma clearance, and release of tissueplasma clearance, and release of tissuefactor inhibitor. So properties of a particularfactor inhibitor. So properties of a particularLMWH are not applicable to another.LMWH are not applicable to another.
  38. 38. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?LMWHsLMWHsUFHUFHEffectEffect33,,000000--99,,0000001515,,000000--3030,,000000Mean MWt. [dalton]Mean MWt. [dalton]22--44::1111::11Anti Xa : Antithrombin ratioAnti Xa : Antithrombin ratioOsama Warda,MDOsama Warda,MD22--44::1111::11Anti Xa : Antithrombin ratioAnti Xa : Antithrombin ratioMinimalMinimalSignificantSignificantProtein bindingProtein bindingRareRareNot rareNot rareThrombocytopeniaThrombocytopenia±±9090%%±±3030%%BioavailabilityBioavailabilityscscSc or ivSc or ivRoute of administrationRoute of administration
  39. 39. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?WHAT ARE THE ADVANTAGES OF LMWHs OVER UFH?1.1. Less hemorrhagic complications.Less hemorrhagic complications.2.2. Lower risk of heparin induced thrombocytopenia.Lower risk of heparin induced thrombocytopenia.3.3. Less frequent dosages [increased bioavailability&Less frequent dosages [increased bioavailability&longer half life].longer half life].Osama Warda,MDOsama Warda,MDlonger half life].longer half life].4.4. No heparin induced osteoporosis.No heparin induced osteoporosis.5.5. Anti Xa, activity is correlated with body weight,Anti Xa, activity is correlated with body weight,this allows administration in fixed dose.this allows administration in fixed dose.6.6. No need for lab. Monitoring for coagulation testsNo need for lab. Monitoring for coagulation testslike PT and APTT.like PT and APTT.
  40. 40. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)CAN LMWHs BE USED FOR ACUTE TREATMENT OF D.V.T?CAN LMWHs BE USED FOR ACUTE TREATMENT OF D.V.T?CAN LMWHs BE USED FOR ACUTE TREATMENT OF D.V.T?CAN LMWHs BE USED FOR ACUTE TREATMENT OF D.V.T?CAN LMWHs BE USED FOR ACUTE TREATMENT OF D.V.T?CAN LMWHs BE USED FOR ACUTE TREATMENT OF D.V.T?CAN LMWHs BE USED FOR ACUTE TREATMENT OF D.V.T?CAN LMWHs BE USED FOR ACUTE TREATMENT OF D.V.T?Until recently, the use of LMWHs in pregnancy wasUntil recently, the use of LMWHs in pregnancy waslimited to chronic phase of the disease &forlimited to chronic phase of the disease &forprophylaxis.prophylaxis.Intravenous unfractionated heparin is graduallyIntravenous unfractionated heparin is graduallybeing replaced in modern practice by s.c. LMWs,being replaced in modern practice by s.c. LMWs,Osama Warda,MDOsama Warda,MDbeing replaced in modern practice by s.c. LMWs,being replaced in modern practice by s.c. LMWs,granting equal or even better efficacy;granting equal or even better efficacy; much easiermuch easierdosing, a wider therapeutic window, fewer bleedingdosing, a wider therapeutic window, fewer bleedingcomplications, and faster and more reliable resultscomplications, and faster and more reliable results..Full anticoagulation dose of LMWHs:ENOXAPARIN=ENOXAPARIN=11mg/kg SC bdmg/kg SC bdDALTEPARIN=DALTEPARIN=100100 iu/kg SC bdiu/kg SC bd
  41. 41. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTAnticoagulant TherapyAnticoagulant Therapy (cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)(cont’d.)DO ALL PATIENTS WITH DVT REQUIRE HOSPITALIZATION?DO ALL PATIENTS WITH DVT REQUIRE HOSPITALIZATION?DO ALL PATIENTS WITH DVT REQUIRE HOSPITALIZATION?DO ALL PATIENTS WITH DVT REQUIRE HOSPITALIZATION?DO ALL PATIENTS WITH DVT REQUIRE HOSPITALIZATION?DO ALL PATIENTS WITH DVT REQUIRE HOSPITALIZATION?DO ALL PATIENTS WITH DVT REQUIRE HOSPITALIZATION?DO ALL PATIENTS WITH DVT REQUIRE HOSPITALIZATION?Advent of LMWHs for treatment of DVTAdvent of LMWHs for treatment of DVTwith advantages of sc once or twicewith advantages of sc once or twicedaily dosage without monitoring hasdaily dosage without monitoring hasOsama Warda,MDOsama Warda,MDdaily dosage without monitoring hasdaily dosage without monitoring hasmade it possible to treat patients in anmade it possible to treat patients in anoutpatient setting.outpatient setting. But pregnant stateBut pregnant stateis a contraindication for suchis a contraindication for suchtreatment.treatment.
  42. 42. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTThrombolytic TherapyThrombolytic TherapyNo controlled trials on the safety and efficacyNo controlled trials on the safety and efficacyof thrombolytics in pregnant patients haveof thrombolytics in pregnant patients havebeen done.been done.Because of the risks of maternal hge. and fetalBecause of the risks of maternal hge. and fetalloss, thrombolytic therapy should beloss, thrombolytic therapy should beOsama Warda,MDOsama Warda,MDBecause of the risks of maternal hge. and fetalBecause of the risks of maternal hge. and fetalloss, thrombolytic therapy should beloss, thrombolytic therapy should bereserved to the following:reserved to the following:1.1. Massive PE with hemodynamic instability.Massive PE with hemodynamic instability.2.2. The affected limb viability is in jeopardy,The affected limb viability is in jeopardy,eg. Phlegmasia alba dolens & phlegmasiaeg. Phlegmasia alba dolens & phlegmasiacerulae dolenscerulae dolens..
  43. 43. MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENTThromboThrombo--prophylaxisprophylaxisRisk of recurrent DVT in pregnancy is aboutRisk of recurrent DVT in pregnancy is about 44--1515%.%.Prophylaxis: (sc heparinProphylaxis: (sc heparin 77..500500::1010..000000 U/bd)U/bd)1.1. H/O DVT + risk factor (eg, thrombophilia,H/O DVT + risk factor (eg, thrombophilia,Osama Warda,MDOsama Warda,MD1.1. H/O DVT + risk factor (eg, thrombophilia,H/O DVT + risk factor (eg, thrombophilia,APLAS): start inAPLAS): start in 11stst trimestertrimester-- toto-- 66 weeks postweeks post--partum.partum.2.2. Only H/O DVT:Only H/O DVT:a) clinical surveillance followed by warfarina) clinical surveillance followed by warfarinpostpartum xpostpartum x 44--66 weeks.weeks.b) UFH or LMWHs throughout pregnancy followedb) UFH or LMWHs throughout pregnancy followedby warfarin/LMWHs xby warfarin/LMWHs x 44--66 wks.wks.
  44. 44. REFFERENCESREFFERENCESBrandjes DP, Heijboer H, Buller HR, et al: Acenocoumarol and heparin comparedBrandjes DP, Heijboer H, Buller HR, et al: Acenocoumarol and heparin comparedwith acenocoumarol alone in the initial treatment of proximalwith acenocoumarol alone in the initial treatment of proximal--veinvein..[Medline][Medline]99--14851485):):2121((327327;;1919NovNov19921992thrombosis. N Engl J Medthrombosis. N Engl J MedFeied CF: Pulmonary embolism. In: Rosen P, Barkin RM, eds. EmergencyFeied CF: Pulmonary embolism. In: Rosen P, Barkin RM, eds. EmergencyMedicine Principles and Practice. VolMedicine Principles and Practice. Vol 33.. 44th ed. St. Louis, Mo: Mosby;th ed. St. Louis, Mo: Mosby; 19981998::ChapterChapter 111111..Feied CF: Peripheral venous disease. In: Rosen P, Barkin RM, eds. EmergencyFeied CF: Peripheral venous disease. In: Rosen P, Barkin RM, eds. EmergencyOsama Warda,MDOsama Warda,MDFeied CF: Peripheral venous disease. In: Rosen P, Barkin RM, eds. EmergencyFeied CF: Peripheral venous disease. In: Rosen P, Barkin RM, eds. EmergencyMedicine Principles and Practice. VolMedicine Principles and Practice. Vol 33.. 44th ed. St. Louis, Mo: Mosby;th ed. St. Louis, Mo: Mosby; 19981998::ChapterChapter 107107..Feied CF: Deep Vein Thrombosis and Pulmonary Embolism. In: Rosen P, BarkinFeied CF: Deep Vein Thrombosis and Pulmonary Embolism. In: Rosen P, BarkinRM eds. Emergency Medicine: Concepts and clinical practice .RM eds. Emergency Medicine: Concepts and clinical practice . 55th ed. St.th ed. St.Louis, MO: Mosby;Louis, MO: Mosby; 20012001: Chapter: Chapter 8383..Havig O: Deep vein thrombosis and pulmonary embolism. An autopsy study withHavig O: Deep vein thrombosis and pulmonary embolism. An autopsy study withmultiple regression analysis of possible risk factors. Acta Chir Scand Supplmultiple regression analysis of possible risk factors. Acta Chir Scand Suppl..[Medline][Medline]120120--11::478478;;19771977Konstantinides S, Geibel A, Olschewski M, et al: Association between thrombolyticKonstantinides S, Geibel A, Olschewski M, et al: Association between thrombolytictreatment and the prognosis of hemodynamically stable patients with majortreatment and the prognosis of hemodynamically stable patients with majorpulmonary embolism: results of a multicenter registry. Circulationpulmonary embolism: results of a multicenter registry. Circulation 19971997 AugAug..[Medline][Medline]88--882882):):33((9696;;55
  45. 45. Kucher N, Koo S, Quiroz R: Electronic alerts to prevent venousKucher N, Koo S, Quiroz R: Electronic alerts to prevent venousthromboembolism among hospitalized patients. N Engl J Medthromboembolism among hospitalized patients. N Engl J Med 20052005..[Medline][Medline]7777--969969):):1010((352352;;1010MarMarNakamura M, Nakanishi N, Yamada N: Effectiveness and safety of theNakamura M, Nakanishi N, Yamada N: Effectiveness and safety of thethrombolytic therapy for acute pulmonary thromboembolism: resultsthrombolytic therapy for acute pulmonary thromboembolism: resultsof a multicenter registry in the Japanese Society of Pulmonaryof a multicenter registry in the Japanese Society of Pulmonary..[Medline][Medline]99--8383):):11((9999Mar;Mar;20052005Embolism Research. Int J CardiolEmbolism Research. Int J CardiolOsama Warda,MDOsama Warda,MD..[Medline][Medline]99--8383):):11((9999Mar;Mar;20052005Embolism Research. Int J CardiolEmbolism Research. Int J CardiolTretbar LL: Venous Disorders of the Legs.Tretbar LL: Venous Disorders of the Legs. 11st ed. New York, NY:st ed. New York, NY:SpringerSpringer--Verlag;Verlag; 19981998:: 11--138138..Vossen CY, Conard J, Fontcuberta J: Risk of a first venous thromboticVossen CY, Conard J, Fontcuberta J: Risk of a first venous thromboticevent in carriers of a familial thrombophilic defect. The Europeanevent in carriers of a familial thrombophilic defect. The EuropeanProspective Cohort on Thrombophilia (EPCOT). J Thromb HaemostProspective Cohort on Thrombophilia (EPCOT). J Thromb Haemost..[Medline][Medline]6464--459459):):33((33Mar;Mar;20052005Weiss RA, Feied CF, Weiss MA, eds: Vein Diagnosis & Treatment: AWeiss RA, Feied CF, Weiss MA, eds: Vein Diagnosis & Treatment: AComprehensive Approach.Comprehensive Approach. 11st ed. New York, NY: McGrawst ed. New York, NY: McGraw--Hill;Hill; 20012001::11--304304..
  46. 46. ٓ‫ا‬ٓ‫ا‬ٓ‫ا‬ٓ‫ا‬ٓ‫ا‬ٓ‫ا‬ٓ‫ا‬ٓ‫ا‬Osama Warda,MDOsama Warda,MD

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