anticoagulants in pregnancy
TRANSCRIPT
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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