Thromboprophylaxis During Pregnancy, Labour And


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Thromboprophylaxis During Pregnancy

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Thromboprophylaxis During Pregnancy, Labour And

  2. 2. Sources<br /> 1.Royal College Of Obstetrician & Gynaecologist guidelines<br /> 2.Medical disorders in Obstetrics & Gynaecology Edited by Michael de Swiet<br />
  3. 3. Pre conceptual antenatal risk assessment<br />Pre pregnancy counselling -women at high risk of VTE, including those with previous confirmed VTE, should be offered with a prospective management plan.<br />Pre pregnancy & early pregnancy -an individual assessment of thrombotic risk should be undertaken.<br />Assessment should be repeated if the woman is admitted to hospital or develops other intercurrent problems.<br />
  4. 4. Risk factors<br />2 types-Pre-existing/ New onset or transient<br />
  5. 5. Pre-existing<br />Previous DVT<br />Thrombophilia<br />Congenital<br />antithrombin deficiency<br />protein C deficiency<br />protein S deficiency<br />Factor V Leiden<br />prothrombin gene variant<br />Acquired<br />Antiphospolipid<br />
  6. 6. Pre-existing<br />Age over 35 years<br />Obesity (BMI &gt; 30 kg/m2) either pre-pregnancy or in early pregnancy<br />Parity &gt; 4<br />Gross varicose veins<br />Paraplegia<br />Sickle cell disease<br />Inflammatory disorders e.g. inflammatory bowel disease<br />Some medical disorders, e.g. nephrotic syndrome, certain cardiac diseases<br />Myeloproliferative disorders, e.g. essential thrombocythaemia, polycythaemiavera<br />
  7. 7. New onset or transient<br />Surgical procedure in pregnancy or puerperium, e.g. evacuation of retained products of conception, postpartum sterilisation<br />Midcavity instrumental delivery <br />Immobility after delivery <br />Pre-eclampsia<br />Hyperemesis<br />Dehydration<br />Excessive blood loss<br />Ovarian hyperstimulation syndrome<br />Severe infection, e.g. Pyelonephritis<br />Immobility (&gt; 4 days bed rest)<br />Long-haul travel<br />Prolonged labour <br />
  8. 8. Investigation of women with previous VTE<br />Recognition:<br />good history and received prolonged (6–12 weeks) therapeutic anticoagulation.<br />Investigation:<br />for congenital/acquired<br />ideally pre pregnancy<br />
  9. 9. 5 groups of women<br />a previous VTE and no thrombophilia<br />a previous VTE who have inherited thrombophilia<br />inherited thrombophilia without previous VTE<br />acquired thrombophilia (antiphospholipid syndrome)<br />Women without previous VTE or thrombophilia<br />
  10. 10. a previous VTE and no thrombophilia<br />antenatal thromboprophylaxis-controversial<br />Indicated if <br />more than one previous episode of VTE<br />a family history of VTE in a first degree relative<br />Consider if<br />Unprovoked DVT<br />Oestrogen related<br />Associated risks ex: high BMI<br />an unusual site (such as the axillary vein)<br />reasonable not to use antenatal thromboprophylaxis <br />If DVT was associated with temporary risk factor<br />Post natal-low molecular weight heparin (LMWH) for six weeks after<br />
  11. 11. Women with a previous VTE who have inherited thrombophilia<br />Thromboprophylaxis with LMWH antenatally and for at least six weeks postpartum.<br />higher doses of LMWH may be needed<br />women with symptomatic thrombophilia<br />specific thrombophilias,particularly AT deficiency<br />Seek expert haematological advice <br />
  12. 12. Antenatal prophylactic and therapeutic doses of low-molecular-weight heparin<br />
  13. 13. Women with inherited thrombophilia without previous VTE<br />Antenatal prophylaxis is not always necessary.<br />Consider if<br />Antithrombin deficiency<br />combined defects<br />homozygosity for defects<br />Other risk factors<br />Postnatal-LMWH or warfarin for six weeks<br />
  14. 14. Women with acquired thrombophilia (antiphospholipid syndrome)<br />Antiphospholipid syndrome (APS)<br />Definition:<br /> presence of lupus anticoagulant or anticardiolipin antibodies of medium–high titre <br />on two occasions eight weeks apart<br />found in association with a history of<br />thrombosis (arterial or venous) or <br />adverse pregnancy outcome<br />three or more unexplained miscarriages before ten weeks of gestation <br /> a fetal death after ten weeks of gestation <br />a premature {less than 35 weeks} birth due to<br /> severe pre-eclampsia or <br />intrauterine growth restriction)<br />
  15. 15. APS<br />
  16. 16. Women without previous VTE or thrombophilia<br />women with three or more <br />current or persisting risk factors should be considered for <br />prophylactic LMWH antenatally<br />at least three to five days postpartum.<br />two current or persisting risk factors <br />should be considered for prophylactic LMWH for three to five days after vaginal delivery.<br />Clinical judgement is required with regard to the weighting of the above risk factors.<br /> an extremely obese woman admitted to the antenatal ward may be sufficient to justify antenatal thromboprophylaxis<br />
  17. 17. Women without previous VTE or thrombophilia<br />important independent risk factors for postpartum VTE even after vaginal delivery<br />Age over 35 years and<br />BMI greater than 30/body weight greater than 90 kg<br />The combination of either of these risk factors with any other risk factor for VTE (such as pre-eclampsia or immobility) or the presence of two other persisting risk factors should lead the clinician to consider the use of LMWH for three to five days postpartum.<br />
  18. 18. Thrombophilia<br />Activated protein C inhibits Factors V & VIII<br />Levels of functional and immunological protein C doesn’t change in pregnancy<br />Protein S is a cofactor for protein C<br />Free protein S drop by 20% at the end of third trimester<br />Thrombosis in Antithrombin deficiency should be treated with heparin & Antithrombin concentrate.<br />
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