Venous thromboembolism during pregnancy

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Venous thromboembolism during pregnancy

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Venous thromboembolism during pregnancy

  1. 1. ` VENOUS THROMBOEMBOLISM DURING PREGNANCY 1A-MOWAFY 2013 VTE = Venous thromboembolism Includes; Deep venous thrombosis DVT, Pulmonary embolism PE INCIDENCE :  2-3 in 1000 pregnancies  DVT 80% PE 20%  2/3 of DVT are antepartum  Caesarean section increases the risk 3-5 fold than vaginal delivery PATHOGENESIS Virchow’s triade = 1. Circulatory stasis 2. Vascular damage 3. Increased blood co-agulation AETIOLOGY Risk factors: 1. Pregnancy itself is a risk factor 2. Previous VTE in patient on hormonal contraception 3. Previous VTE during pregnancy ( risk is 12 % ) 4. Rheumatic heart disease and patients with heart prosthesis 5. Thrombophilias (congenital and acquired?!) 6. Age ˃ 35 years old 7. Obesity ; BMI ˃ 30 8. Multiparity ; parity ˃ 4 9. Recurrent miscarriage 10. Bed rest and physical immobility 11. Hyperemesis gravidarum 12. Shock and dehydration 13. Infections Venous thromboembolism during pregnancy Venous thromboembolism during pregnancy
  2. 2. ` VENOUS THROMBOEMBOLISM DURING PREGNANCY 2A-MOWAFY 2013 14. Pregnancy-induced hypertension 15. Excessive blood loss 16. Prolonged labour 17. Instrumental delivery 18. Cesarean section 19. Pelvic surgery in peri-partum period 20. Sickle cell anemia 21. Gross varicose veins 22. Fetal demise with remaining viable fetus 23. Intra-uterine gross restriction IUGR Q: What is thrombophilia? It is abnormalities in the blood co-agulation that is increases the risk of thrombosis; (congenital, Acquired?)
  3. 3. ` VENOUS THROMBOEMBOLISM DURING PREGNANCY 3A-MOWAFY 2013 RISKY GROUPS AND THEIR MANAGEMENT: Very high risk Criteria  Previous VTE with thrombophilia  Long term warfarin therapy Antepartum  High prophylactic dose or therapeutic dose of LMWH Postpartum  LMWH for 5 days + Warfarin High risk Criteria  Previous recurrent VTE  VTE once with thrombophilia  VTE once with positive family history  Diagnosed important thrombophilia  Valvular mechanical prosthesis Antepartum  prophylactic dose LMWH Postpartum  LMWH for 5 days + Warfarin for 6 weeks Moderate risk Criteria  Single provoked VTE without thrombophilia  Thrombophilia + Anti-thrombin III deficiency  Mitral stenosis Antepartum  Antenatal aspirin Postpartum  LMWH for 5 days + Warfarin for 6 weeks Low risk Criteria Two or more of the following :  Obesity  Age ˃ 35  Parity ˃ 4  Gross varicose veins  Recurrent hypertensive disorders Antepartum  Antenatal aspirin Postpartum  Warfarin for 6 weeks
  4. 4. ` VENOUS THROMBOEMBOLISM DURING PREGNANCY 4A-MOWAFY 2013 ANTI-COAGULANT DRUGS: Heparin Types I. Unfractionated heparin → UFH “Cal-heparin” II. Low molecular weight heparin → LMWH “Clexan” Onset Within 10 minutes Half-life 6 hours Doses I. Unfractionated heparin  Normal body weight → 5000 IU/day  Body weight ˂ 50 kg → 2500 IU/day  Body weight ˃ 90 kg → 5000 IU/12 h  High prophylactic dose→ 100 IU/kg/12h II. Low molecular weight heparin  Normal body weight → 40 mg/day  Body weight ˂ 50 kg → 20 mg /day  Body weight ˃ 90 kg → 40 mg / 12h  High prophylactic dose→ I mg/kg/12h Monitoring 1. Activated partial thromboplastin aPPT twice weekly 2. Plattlets concentration monthly 3. Bone mineral density every 3 months Advantages 1. No effect on the fetus ( does not cross placental blood barrier ) 2. Not secreted on milk ( no effect on lactation ) N.B : advantages of LMWH over UFH o Fewer side effect o Prolonged half-life o Greater inhibitory effect on factor X o Prophylactic dose once daily o No need for continuous laboratory monitoring Drawbacks  Increase bleeding tendency  Osteoporosis ( improved by adding calcium , hence name “ Cal-heparin “  Fat necrosis at site of injection  Alopecia Anti-dot Protamine sulphate 1mg/100IU
  5. 5. ` VENOUS THROMBOEMBOLISM DURING PREGNANCY 5A-MOWAFY 2013 Oral anti-coagulant drugs Types I. Coumarine → Warfarin sodium “Marevan” II. Indandione → phenoidione “Dindevan” Onset Full effect after 5 days Half-life  Warfarin → 44 hours  Phenoidione → 5 hours Doses 2 to 5 mg/day Monitoring 1. INR = “ international randomized ratio “→ should be 2 to 3 2. PT = “ prothrombine time “→ 30–50 % of normal control Advantages Oral route , potent and long acting Drawbacks  Maternal : 1. Skin: allergy, fever, rash, urticarial and dermatitis 2. Blood: agranulocytosis 3. Liver: liver disturbances; jaundice 4. Renal: renal disturbances; hematuria 5. Over dose → bleeding tendency  Fetal : 1. Warfarin embryopathy; nasal hypoplasia, depression of nasal bone, mental retardation, optic atrophy, skeletal defect ‘ bone splitting’ 2. Can cross placental-blood barrier; bleeding tendency and increases the risks of intracranial hemorrhage and accidental hemorrhage  Drug interactions : 1. drugs increases the effect : salicylates, quinine, steroids 2. drugs decreases the effect : hepatic enzyme inducers Anti-dot  Vitamin K IM. , SC.  For rapid effect : 1. Fresh blood , fresh frozen plasma 2. Vitamin K to the mother and baby PROTOCOLS FOR ANTI-COAGULATION DURING PREGNANCY Frist trimester → only heparin for fear of warfarin embryopathy Second trimester → warfarin starting from 13 weeks Continue till:  33 weeks if risk of preterm laobour exist  36 weeks if no risk of preterm labour However, oral anti-coagulants are not absolutely safe as delayed warfarin embryopathy is recorded Late in pregnancy: at 33 – 36 weeks → shift to heparin again Postpartum: Vitamin K to the mother and baby and readjust the dose

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