anticoagulants in pregnancy

ROLE OF ANTICOAGULANTS IN

PREGNANCY

LAKSHMI SUJANI CHPOST GRADUATE, ASRAMS

ANTICOAGULANTS

THROMBIN INHIBITORS

VIT K ANTAGONISTS

FACTOR Xa INHIBITORS

DIRECT

INDIRECT

RIVAROXABAN

APIXABAN

FONDAPARINAUX

COUMARINANTICOAGULANTS WARFARIN

INDIRECT HEPARIN CONGENERS

DANAPAROID

LMWH(enoxaparin,dalteparin,tinzaparin)

UNFRACTIONATED HEPARIN (UFH)

DIRECT

PARENTERAL

ORAL

HIRUDIN

BIVALRUDIN

AGRATOBAN

XIMELAGATRAN

DABIGATRAN

INDICATIONS

Prophylaxis and treatment of DEEP VEIN THROMBOSIS and PULMONARY EMBOLISM.Proven deep vein involvement in SUPERFICIAL VEIN THROMBOPHLEBITIS. THROMBOPHILIAS Pregnancy with ARTIFICIAL VALVES. Pregnancy with ATRIAL FIBRILLATION. POST CEREBRAL VEIN THROMBOSIS. Single VTE with pateint on long term anticoagulants.

THROMBOPHILIAS¹

INHERITED THROMBOPHILIAs

ACQUIRED THROMBOPHILIAS

• Antiphospholipid syndrome• Heparin induced

thrombocytopaenia• Associated cancer

Factor V leiden mutation

Prothrombin gene mutation

Hyperhomocystinemia Factor S deficiency Factor C deficiency Anti thrombin

deficiency¹CUNNIGHAM,LEVENO,BLOOM,SPONG,WILLIAMS OBSTETRICS,24TH EDITION

UNFRACTIONATED HEPARIN[UFH]

PROPHYLACTIC DOSE THERAPEUTIC DOSE

• Monitoring by daily aPTT.a) IV BOLUS – 10,000 U b) IV INFUSION ⁱ for seven

days or till pain subsides in DVT

[ target aPTT- 2 to 2.5] c) SC heparin – 10,000U or more [ target aPTT- 1.5 to 2] 6hrs post SC….

• Needs no monitoring.• MINIDOSE- 5000IU SC 12hrs.• PROPHYLACTIC DOSE

TRIMESTER UNITS SC every 12hrs

First 5000 - 7500

Second 7500 – 10,000

Third 10,000.

FERNANDO ARIAS,PRACTICAL GUIDE TO HIGH RISK PREGNANCY, 4TH EDITION.

…. Therapeutic dose.

• SC heparin till delivery• Stopped 24 hrs before

induction/ elective section.• Unexpected labour/section

interval less than 12hrs needs reversal with PROTAMINE SULPHATE.

• Start heparin 12 to 24 hrs later + 5mg warfarin.

ⁱCALCULATION OF IV INFUSION DOSE = CSS X K X V Css is steady state concentration , 0.2 to 0.3 micro/ml-therapeutic level K is elimination constant(0.832micro/hr) V is volume of distribution

FERNANDO ARIAS,PRACTICAL GUIDE TO HIGH RISK PREGNANCY, 4TH EDITION.

UNFRACTIONATED HEPARIN[UFH]

LOW MOLECULAR WEIGHT HEPARIN

Prophylactic dose

• No need of monitoring.

Therapeutic dose

• Monitored by anti Xa levels.

DRUG DOSE SC ONCE DAILY

ENOXAPARIN 40mg

DALTEPARIN 5000U

TINZAPARIN 4500U

DRUG SC EVERY 12HRS

ENOXAPARIN 1mg/kg

DALTEPARIN 100U/kg

TINZAPARIN 100U/kg.

FERNANDO ARIAS,PRACTICAL GUIDE TO HIGH RISK PREGNANCY, 4TH EDITION.

• Target anti Xa levels 0.6 to 1 U/ml.• Switched to UFH – 36 weeks• Can start LMWH with WARFARIN on postpartum day 1.

GUIDELINES• ACOG 2013—advises that adjusted dose LMWH or

UFH can be discontinued 24 to 36 hrs before induction of labour or caesarean delivery.

• Withhold neuraxial blockade for

• ACOG 2012– recommends interval to restart LMWH/UFH

PROPHYLACTIC DOSE 12 hrs

THERAPEUTIC DOSE 24 hrs

--ASRAPM (Horlocker,2010)

POST NVD 4 to 6hrs

POST LCSC 6 to 12hrs

• PROPHYLACTIC LMWH/UFH + WARFARIN 5 to 10mg (4 to 5 days) (6weeks)• Target INR -- 2 to 3.• Early UFH or LMWH to avoid paradoxical

thrombosis .• Weekly PT INR monitoring.

POSTPARTUM ANTICOAGULATION

UFH vs LWMH

side effects

Haemorrhage Thrombocytopaeniaosteoporosis

• Known large oesophageal varices.

• + Significant thrombocytopaenia(less than 50,000/cc)

• Within 72 hrs of major surgery with risk of bleeding.

• Previously documented hypersensitivity to drug or exciepients.

• Acute clinically significant bleed.

CONTRAINDICATIONS

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