Anti Coagulation In Pregnancy


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Anti Coagulation In Pregnancy

  1. 1. Anticoagulation in Pregnancy and Neuraxial block<br />MehtabAlamHaidry<br />
  2. 2. Case Scenario<br />32 years old patient with a history of mitral valve replacement is scheduled for elective C/S. <br />She has one uneventful vaginal delivery 2 years back. <br />She is booked for LSCS due to breech presentation. <br />She is currently receiving unfractionated heparin on twice daily dose and has discontinued warfarin 6 days back. <br />How will you manage this patient?<br />
  3. 3. Anticoagulants commonly used in pregnancy and recommendation for neuraxial block.<br />Management of the pregnant patient receiving warfarin.<br />Management of pregnant patient receiving unfractionated heparin.<br />Diagnosis and treatment of spinal hematoma.<br />
  4. 4. Management of a pregnant woman with prosthetic heart valve and Anticoagulation<br />
  5. 5. Anti-Coagulants in pregnancy<br />
  6. 6. Anti coagulation in Pregnancy<br />Warfarin.<br />Unfractionated Heparin.<br />LMWH<br />
  7. 7. Hypercoaguable state of pregnancy<br />vWF, fibrinogen, and factors VII, VIII, and X.<br />Protein S, the activity of t PA.<br />Hypervolemia - the integrity of the vessel wall.<br />Obstet Gynecol Clin N Am 33 (2006) 481–491<br />The risk of venous thrombosis in pregnant women has been estimated to be up to 5-10 times greater than in nonpregnant women of the same age.<br />JAMA 1986;256:744–9.<br />ObstetGynecol 1999;94:595–9.<br />
  8. 8. Thrombosis of prosthetic heart valves during pregnancy<br />The risk of thomboembolism - Bjork-Shiley tilting disc prosthesis vs. St. Jude valve.<br />Obstet Gynecol Clin N Am 33 (2006) 481–491.<br />Valve thrombosis - resultant mortality rates are as high as 10% to 40%.<br />Br Heart J 1993;71:196–201.<br />Thrombolysisvs surgery(high risk of fetal loss).<br />Obstet Gynecol Clin N Am 33 (2006) 481–491.<br />
  9. 9. Warfarin<br />First trimester - coumadin embryopathy.<br />Facial abnormalities, optic atrophy, digital abnormalities, epithelial changes, and mental impairment.<br />JAMA 1985;243:1549–51.<br />Risk is highest, 6-12wks of gestation.<br />Effect of warfarin on calcium deposition and bone formation during embryologic ossification.<br />Am J Med 1980; 68:122–140.<br />Anesthesiology Clin 26 (2008) 1–22<br />Incidence - 5% to 30%.<br />Am J Cardiol 1989;63:1462–5.<br />Bleeding in the fetus.<br />ThrombHaemost 1989; 61:197–203<br />
  10. 10. Dose related Effect<br />43 women. 58 pregnancies.<br />Warfarin throughout pregnancy for having a prosthetic valve .<br />The target INR - 2.8.<br />2 groups<br />&gt; 5mg.<br />&lt; 5mg.<br />
  11. 11. Cont…<br />27 fetal complications.<br />22 abortions, <br />2 warfarinembryopathies,<br /> 1 stillbirth, <br />1 VSD. and <br />1 growth restriction.<br />22 in &gt;5mg.<br />Warfarinembryopathies in &gt;5mg.<br />J Am CollCardiol 1999;33:1637–41<br />
  12. 12. Unfrationated heparin<br />Does not cross placenta.<br />17,500 to 20,000 IU - Q12H.<br />Target aPTT – 1.5-2.5X control.<br />Increased dosing required.<br />
  13. 13. WarfarinvsUnfractionated Heparin<br />Systematic review.<br />976 women with 1234 pregnancies 1966 to 1997.<br />Three groups,<br />Use of VKAs throughout pregnancy.<br />Replacement of VKAs with UFH from 6 to 12wks.<br />UFH use throughout pregnancy.<br />
  14. 14. Results<br />Coumadin embryopathy – 6.4%.<br />Substitution of UFH for warfarin during 6 - 12wk of gestation eliminated its occurrence.<br />Fetal wastage (spontaneous loss, stillbirths, and neonatal deaths) – similar.<br />
  15. 15. Cont…<br />Valve thrombosis with Warfarin - 3.9%.<br />Valve thrombosis with heparin – 9.2%.<br />Maternal risk of death - 4.2% when heparin is substituted for warfarin in the first trimester.<br />1.8% when warfarin is used throughout pregnancy.<br />Chan et al. Arch Intern Med 2000;160:191–6.<br />
  16. 16. LMWH<br />Less HIT.<br />Lower risk of heparin induced osteoporosis.<br />Longer plasma half life.<br />
  17. 17. LMWH<br />Comparison of enoxaparin with warfarin and unfractionated heparin in pregnant women who have prosthetic heart valves.(110)<br />The safety committee terminated the study after only 12 patients were enrolled due to two deaths from prosthetic valve thrombosis in the enoxaparin group.<br />Subtherapeutic levels of factor Xa.<br />Am J ObstetGynecol 2004;191:1024–9.<br />
  18. 18.
  19. 19.
  20. 20. Cont…<br />Warning from LMWH manufacturer.<br />FDA Warning<br />
  21. 21. Aspirin<br />Low dose (60 to 150 mg/d) aspirin therapy administered during the second and third trimesters of pregnancy is safe.<br />JAMA 1991; 266:260–264. (metaanalysis)<br />Lancet 1994; 343:619–629. (RCT)<br />
  22. 22. Summary<br />
  23. 23.
  24. 24. Use of antithrombotic agents during pregnancy: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy<br />
  25. 25. Cont…<br />Adjusted-dose, twice-daily LMWH throughout pregnancy in doses adjusted either to keep a 4-hour postinjection anti-Xa heparin level at approximately 1.0 to 1.2 U/mL (preferable) or according to weight (Grade 1C), or <br />Aggressive adjusted-dose UFH throughout pregnancy: i.e., administered SC every 12 hours in doses adjusted to keep the mid-interval aPTT at least twice control (Grade 1C), or <br />Bates S.M. et al. Chest 2004;126:627S-44S.<br />
  26. 26. Cont…<br />UFH or LMWH (as above) until the thirteenth week, change to warfarin until the middle of the third trimester, and then restart UFH or LMWH (Grade 1C). <br />Long-term anticoagulants should be resumed postpartum with all regimens.<br /> In women with prosthetic heart valves at high risk, add low-dose aspirin, 75 to 162 mg/day (Grade 2C). <br /><ul><li>Bates S.M. et al. Chest 2004;126:627S-44S.</li></li></ul><li>European Society of Cardiology and American Collegeof Cardiology/American Heart Association<br />Use of warfarin – 35 wks gestation.<br />If the patient does not wish to use warfarin in the first trimester.<br />Adjusted-dose heparin - aPTT 2 to 3 times control.<br />UFH should replace warfarin - 36th week of pregnancy.<br />Heparin and Warfarin - 4 to 6 hours after delivery. <br />Circulation 1998;98:1949–84.<br />
  27. 27. European Society of Cardiology 2007<br />Low-dose aspirin (75 to 162 mg/day) might be added to women deemed to be at high thromboembolic risk. <br />Close collaboration among the patient, cardiologist, and obstetrician is required, and a thorough discussion of the risks and benefits of various anticoagulation strategies must be held. <br />In a pregnant woman with a mechanical prosthesis, the choice of anticoagulant therapy during the first trimester should take into account the greater thromboembolic risk with heparin and the risk of embryopathy with vitamin K antagonists. The use of vitamin K antagonists during the first trimester is the safest regimen for the mother, and the risk of embryopathy is thought to be very low if the warfarin dose is ≤5 mg/day.<br />Delivery should, if possible, be planned and its modality discussed in close collaboration with the obstetricians and anesthetists.<br />Eur Heart J 2007; 28:230.<br />
  28. 28. Conclusion and Recommendation<br />
  29. 29. Regional Anesthesia<br /> Based on 2nd Consensus Conference on Neuraxial Anesthesia and Anticoagulation, 2002).<br />Regional Anesthesia and Pain Medicine 2003: 28:172-197<br />
  30. 30. UFH<br />Heparin &gt; 4 days, aPTT and platelet count prior to neuraxial block and catheter removal. <br />Catheter removal - 2-4 hours after the last heparin dose and the patient&apos;s coagulation status is evaluated; <br />Re-heparinization - one hour after catheter removal.<br />
  31. 31. LMWH<br />Traumatic needle or catheter placement may signify an increased risk of spinal hematoma – delay dose 24H.<br />Needle placement 10-12H or 24H.<br />First dose - 24 hours postoperatively.<br />Catheter removal – 10-12 H.<br />Next dose – 2H.<br />
  32. 32. Warfarin<br />D/C :- 4-5 days prior to the planned procedure.<br />PT/INR.<br />Catheters removal - when the INR is &lt;1.5.<br />
  33. 33. Special Considerations<br />Neurologic testing of sensory and motor function should be performed routinely during epidural analgesia.<br />The type of analgesic solution should be tailored to minimize the degree of sensory and motor blockade. <br />These checks should be continued after catheter removal for at least 24 hours.<br />
  34. 34. Spinal Epidural Hematoma<br />
  35. 35. Spinal Epidural Hematoma<br />Accumulation of blood.<br />Epidural veins are valveless and are located in the low-pressure epidural space. <br />Increase in intraabdominal or intrathoracic pressure (as in the Valsalva maneuver), is transmitted to these veins.<br />Neurosurgery 1997;41:483–487<br />The epidural venous plexus - most prominent in the thoracic spine.<br />
  36. 36. Spinal Haematoma<br />Incidence<br /> &lt; 1% of spinal space-occupying lesions.<br />Spine 1998;23:1810–1813. <br />&lt; 1 in 150,000 epidural.<br />&lt; 1 in 220,000 spinal anesthesias.<br />AnasthesiolIntensivmedNotfallmedSchmerzther 1993;28:179–181. <br />1:200,000 in labor epidural.<br />1:3,600 for knee arthroplasty.<br />Evidence-Based Practice of Anesthesiology: Expert Consult By Lee A. Fleisher p346.<br />
  37. 37. Risk factors<br />Old age.<br />Female gender.<br />Anticoagulated or thrombocytopenic patient. <br />The length and intensity of anticoagulation.<br />Thrombolytic therapy represents the greatest risk factor for bleeding complications.<br />Liver or renal disease.<br />Evidence-Based Practice of Anesthesiology: Expert Consult By Lee A. Fleisher p346.<br />
  38. 38. Diagnosis<br />Pain.<br />Localized ache + nerve root pain.<br />Back pain  percussion over the spine, coughing, sneezing, or straining. <br />Sensory disturbance and dyskinesia.<br />Weakness.<br />Urinary or Fecal incontinence.<br />J Neurosurg 1995;83:1–7. <br />
  39. 39. Differential Diagnosis<br />Prolonged or exaggerated neuraxial block.<br />Epidural abscess.<br />Acute disc herniation. <br />Neoplasms.<br />Spinal cord disease.<br />
  40. 40. Emergency MRI<br />
  41. 41. Management<br />D/C anti coagulants or anti platelets.<br />CBC, PT and aPTT.<br />Steroids to prevent secondary injury.<br />Nonoperative treatment with good outcome <br />Hematomas localized at the caudaequina level<br />With mild neurologic deficit.<br />Emergency removal of Hematoma (Laminectomy).<br />The golden operative period - within 8 hours after the appearance of symptoms, and the period can be extended to 48 hours for those with incomplete paralysis.<br />Neurosurgery 1996;39:494–502. <br />Remove blood clot, stop bleeding, and place drainage-tube.<br />YU Hang-ping, Chinese Medical Journal 2007; 120(15):1303-1308.<br />
  42. 42. Practical Approach for suspected SEH<br />
  43. 43. Management of a pregnant woman with prosthetic heart valve and Anticoagulation<br />
  44. 44. History<br />Reason for MVR.<br />Duration.<br />Other comorbids (A Fib.)<br />Any complications during previous delivery.<br />Current medications.<br />Functional status.<br />
  45. 45. Examination<br />Vitals.<br />BMI<br />Airway and Back.<br />Chest and cardiac auscultation.<br />
  46. 46. Investigations<br />CBC<br />PT, aPTT.<br />ECG<br />Review Echo and CXR<br />
  47. 47. Pre Operative<br />Routine.<br />Blood products. <br />D/C Warfarin at 36 wks.<br />Heparin/LMWH.<br />D/C Heparin 6H &gt; surgery.<br />GA vs. regional (Spinal).<br />BE Prophylaxis at Delivery.<br />
  48. 48. Intra Op<br />Risk of Bleeding.<br />Large bore IVs.<br />
  49. 49. Post op<br />Resume anticoagulation.<br />Analgesia.<br />F/up for hematoma if regional was employed.<br />