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DvT in pregnancy.pptx
- 1. DVT IN PREGNANCY • TREATMENT • THROMBOPROPHYLAXIS
- 2. MANAGEMENT • Treatment with anticoagulant - Low Molecular weight Heparin - Unfractionated heparin pregnancy : heparin therapy postpartum : anticoagulation simultaneously with warfarin • Limitation of activity
- 3. UNFRACTIONATED HEPARIN • Regimen UFH, 10,000 units or more SC every 12 hours • Monitoring aPTT Target therapeutic range (1.5–2.5) 6 hours after heparin • Antagonist : PROTAMINE SULPHATE
- 4. LOW MOLECULAR WEIGHT HEPARIN • Regimen Enoxaparin, 1 mg/kg every 12 hours Dalteparin, 200 units/kg once daily Tinzaparin, 175 units/kg once daily Dalteparin, 100 units/kg every 12 hours Monitoring anti-Xa level therapeutic range : 0.6–1.0 units/mL for twice daily regimen
- 5. VITAMIN K ANTAGONIST • Used for Postpartum venous thrombosisd in pregnancy reason: readily cross the placenta & cause fetal death and malformations from hemorrhages • Used for Postpartum venous thrombosis Adv : do not accumulate in breast milk == safe during breastfeeding. Rx : intravenous heparin and oral warfarin initiated simultaneously. • dose of warfarin is usually 5-10 mg for first 2 days • Subsequent doses titrated to achieve an (INR) Of 2- 3.
- 6. NEWER ANTICOAGULANTS New oral anticoagulants: dabigatran (Pradaxal) : Inhibits thrombin. Rivaroxaban (Xarelto) and apixaban (Eliquis) : inhibit factor Xa. Disadvantage : • human reproductive risks are essentially unknown • Dabigatran crosses the human placenta • Unknown whether excreted in breast milk -- potential for infant harm. So not used in postpartum women
- 7. ANTICOAGULATION DURING DELIVERY • heparin therapy is stopped during labor and delivery. • In the last month of pregnancy or if delivery appears imminent: converted from LMWH to shorter half-life UFH Purpose : neuraxial blockade ---- epidural or spinal hematoma neuraxial blockade should be withheld for 10 to 12 hours after last Prophylactic dose of LMWH or 24 hrs after last therapeutic dose In case of planned delivery : • On twice-daily Sc UFH or LMWH – discontinue their heparin 24 hours before labor induction or cesarean delivery • On Once-daily LMWH ---Take 50 % of normal dose on the morning of the day before delivery. • On adjusted-dose sc LMWH or UFH --- discontinued 24 to 36 hours before an induction of labor or scheduled cesarean delivery.
- 8. Post partum Anticoagulation • UFH or LMWH is Restarted 4 to 6 hours after vaginal delivery 6 to 12 hours after Caesarean section • If warfarin therapy is chosen, the patient should receive both warfarin and heparin for at least five days • The heparin should not be stopped until INR has been within therapeutic range (INR: 2 to 3) for two consecutive days • Duration of therapy — Anticoagulant therapy for at least six weeks postpartum
- 9. COMPLICATIONS OF ANTICOAGULATION 1.Hemorrhage : • more likely if there is recent surgery /Lacerations. . • heparin dose is excessive 2. Thrombocytopenia Two types—1. nonimmune . benign, reversible thrombocytopenia develops within the first few days of therapy resolves in approximately 5 days without therapy cessation. 2. Immune reaction – Severe form of heparin-induced thrombocytopenia (HIT) involves IgG antibodies directed against complexes of platelet factor 4 and heparin diagnosis : platelet count > 50 percent or thrombosis beginning 5 to 10 days after start of heparin + appearance of Platelet activating HIT antibody Rx : heparin therapy is stopped alternative anticoagulation initiated Platelet transfusions are avoided
- 10. 3. Heparin induced osteoporosis: Due to Long-term heparin administration—usually 6 months or longer More with UFH > LMWH Prophylaxis : Calcium supplement 1500g once daily
- 11. THROMBOPROPHYLAXIS • Pharmacologic -- anticoagulation • Mechanical -- graduated compression stockings . Mobilisation
- 12. THROMBOPROPHYLAXIS • Regimen Prophylactic LMWH: Enoxaparin, 40 mg SC once daily Dalteparin, 5,000 units SC once daily Tinzaparin, 4,500 units SC once daily Minidose prophylactic UFH : UFH, 5,000 units SC every 12 hours Prophylactic UFH : UFH, 5,000–10,000 units SC every 12 hours First trimester : UFH, 5,000–7,500 units SC every 12 hours in Second trimester : UFH 7,500–10,000 units SC every 12 hours in the Third trimester : UFH, 10,000 units SC every 12 hours unless the aPTT is elevated
- 13. • Post partum : Prophylactic LMWH/UFH for 4–6 weeks OR vitamin K antagonists for 4–6 weeks (target INR of 2.0–3.0) with initial UFH or LMWH therapy overlap until the INR is 2.0 or more for 2 day
- 14. Indication: The 2008 American College of Chest Physicians (ACCP) guidelines • Single prior episode of VTE plus a higher risk thrombophilia • Multiple prior episodes of VTE • Antithrombin deficiency The benefits Vs risks should be carefully weighed: • Single prior episode of VTE that was related to pregnancy or estrogen use (eg, contraceptives) • Single prior episode of idiopathic VTE • Single prior episode of VTE in a patient with thrombophilia that is not considered higher risk Higher risk thrombophilias :antithrombin deficiency, persistent antiphospholipid antibodies, compound heterozygosity for the prothrombin and factor V Leiden mutations,
- 15. Postpartum thromboprophylaxis : • women who have had one or more episodes of VTE • Women who have any type of thrombophilia, even those that are not considered higher risk Thromboprophylaxis is NOT recommended for women whose only risk factors for VTE are the pregnancy and CS THROMBOPROPHYLAXIS AFTER CS • one additional risk factor for VTE : thromboprophylaxis, graduated compression stockings, or a pneumatic compression device while in the hospital following delivery • multiple additional risk factors for VTE : Thromboprophylaxis plus graduated compression stockings and/or pneumatic compression devices while in the hospital following delivery