thromboprophylaxis
TRANSCRIPT
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الله بسمالرحمن الرحيم
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12th Annual Congress “RAS EL BAR ” 5- 2009
12th Annual Congress “RAS EL BAR ” 5- 2009
Thromboprophylaxis During Pregnancy, Birth and Puerperium
Dr. Mahdy El-MazzahyDamietta General Hospital
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problem solving
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Case 1 A 29-year-old gravida 3, para 1 At 7 weeks' gestational age History of L.DVT while taking COC
pills History of 2 miscarriages at 7&9
weeks Tall 162cm weight 71 kg : BMI < 27
kg/m2)
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Which of the following should be done?
A. Factor V Leiden mutation, Protein C and
protein S deficiency
B. Antithrombin deficiency
C. Lupus anticoagulant /anticardiolipin
D. All of the above
E. None of the above
E
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What is the evidence?
Women with previous VTE
should receive thromboprophylaxis with LMWH
antenatally and for 6 weeks post partum if :
Recurrent VTE
Unprovoked
Estrogen/pregnancy related
With history of VTE in a first degree relative
With other risk factors
RCOG Guideline April 2009Grade C
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• Which women with prior VTE require a
thrombophilia screen?
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Women with previous provoked and non estrogen related VTE.
Grade C
Women with a previous single provoked VTE (and no other risk factors) require close surveillance antenatally and prophylaxis with LMWH for 6 weeks post partum.
Grade C
Green-top Guideline April 2009
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Antenatal Assessment & Management (To be assessed at booking and repeated if admitted)
1. Single previous VTE +
*Thrombophilia, or FH
*Unprovoked/estrogen related
2. Previous recurrent VTE (>1)
HIGH RISK
REQUIRES ANTENATAL
prophylaxis with LMWH
•Single previous provoked VTE without FH or thrombophilia •Thrombophilia + no VTE
Intermediate Risk require close surveillance antenatally andprophylaxis with LMWH for 6 W post partum
Green-top Guideline April 2009
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Antenatal Assessment & Management (To be assessed at booking and repeated if admitted)
1.Age > 35 yrs2.Obesity (BMI>30kg/m2) 3.Parity > 34 Smoker5.MEDICAL CO-MORBIDITIESe.g. heart or lung disease; SLE; cancer; inflammatory conditions; Proteinuria >3g/24 hrs; Sickle Cell Disease.6.Gross varicose veins 7.Current systemic infection 8.Immobility, e.g. paraplegia, SPD, long-haul travel 9.Pre-eclampsia10.Dehydration/hyperemesis/OHSS 11.Multiple pregnancy or ART12.Surgical procedure e.g. ERPC
3 or more risk factors2 or more if admitted
<3 risk factors
Intermediate RiskConsider antenatal prophylaxis with LMWH
Low RiskMobilisation &avoidance of dehydration.
Green-top Guideline April 2009
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Timing of initiation of thromboprophylaxis
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Timing of initiation of thromboprophylaxis
first trimester is associated with the greatest risk of VTE, many antenatal VTE events (including fatal events) occur in the first trimester
So women should be advised to start LMWH as soon as they have a positive pregnancy test.
Green-top Guideline April 2009
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Which agents should be used for thromboprophylaxis?
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Which agents should be used for thromboprophylaxis?
LMWHs are the agents of choice for antenatal thromboprophylaxis. They are as effective and safer than unfractionated heparin.
Grade A
Green-top Guideline April 2009
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•FDA warns docs to stop using Baxter's heparin•Hundreds of allergic reactions to the blood thinner have been reported
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weightEnoxaparin (100 U/mg)
Tinzaparin20,000U/ml
Body weight < 50 kg
Normal weight : 50–90 kg
Body weight 91-130 kg
Body weight 131-170 kg
>170 kg
Higher prophylactic dose(50-90kg)
Treatment dose
20 mg/d
40 mg/d
60 mg/d*
80mg/d*
0.5mg/kg/d*
40 mg/12h
1mg/kg/12h
(antenatal)
1.5 mg post
3500 U/d
4500 U/d
7000 U/d*
9000 u/d*
75u/kg/d*
4500U/12h
175U/kg/12h
(antenatal
&postnatal)
RCOG Guideline April 2009
Thromboprophylaxis During Pregnancy
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ThromboprophylaThromboprophylaxis after deliveryxis after delivery
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Postnatal Assessment & Management
(to be assessed on Delivery Suite)
•Any previous VTE•Asymptomatic Thrombophilia
High RiskAt least 6 weekspostnatal prophylactic LMWH
Caesarean Section in Labour BMI > 40 kg/m2 Prolonged Hospital Admission
Intermediate RiskAt least 7days postnatal prophylactic LMWH
Green-top Guideline April 2009
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Postnatal Assessment & Management (to be assessed on Delivery Suite)
1.Age > 35 yrs 2.Obesity (BMI>30kg/m2) 3.Parity 3 4.Smoker5. Elective Caesarean Section 6.MEDICAL CO-MORBIDITIES e.g. heart or lung disease; SLE; cancer; inflammatory conditions; Proteinuria >3g/24 hrs; Sickle Cell Disease; IVDU 7.Gross varicose veins8. Current systemic infection9. Immobility, e.g. paraplegia, SPD, long-haul travel10 Pre-eclampsia 11.mid-cavity or rotational forceps 12.Prolonged labour (>24 hrs)13.PPH > 1litre or Blood Transfusion
2 or more risk factors
<2 risk factors
Intermediate RiskAt least 7 days postnatal prophylactic LMWH
Low RiskEARLY Mobilisation and avoidance of dehydration.
NB If persisting or > 3 risk factors consider extending prophylaxis with LMWH
Green-top Guideline April 2009
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Thromboprophylaxis after delivery
The first thromboprophylactic dose of LMWH should be given as soon as possible after delivery provided there is no post partum haemorrhage .
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7 D Thromboprophylaxis with CS
1-Eemergency CS2-Elective CS + one or more additional risk
Green-top Guideline April 2009
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When should thromboprophylaxis be interrupted for delivery?
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Delivery by elective caesarean section in women receiving
antenatal LMWH On the day prior to delivery ,the
woman should receive a thromboprophylactic dose of LMWH
On the day of delivery, any morning dose should be omitted.
The thromboprophylactic dose of LMWH heparin should be given by four hours post-operatively or four hours after removal of the epidural catheter.
Green-top Guideline April 2009
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Regional techniques should not be used until:- 12 hours after the previous
prophylactic dose of LMWH and 24 hours after the last therapeutic
dose.. cannula should not be removed
within 10-12 hours of the most recent injection.
LMWH should not be given for four hours after the epidural catheter has been removed
Green-top Guideline April 2009
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