All women should undergo a documented assessment of risk factors for venous thromboembolism (VTE)in early pregnancy or before pregnancy. This assessment.

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Presentation transcript:

All women should undergo a documented assessment of risk factors for venous thromboembolism (VTE)in early pregnancy or before pregnancy. This assessment should be repeated if the woman is admitted to hospital for any reason or develops other intercurrent problems.

unprovoked VTE estrogen-provoked (estrogen-containing contraception or pregnancy) VTE thrombophilia (heritable or acquired) or family history-associated VTE temporary risk factor (e.g. major trauma or surgery).

Women should be counselled about the risks of warfarin to the fetus and advised to stop warfarin and change to LMWH as soon as pregnancy is confirmed, ideally within two weeks of the missed period and before the sixth week of pregnancy. Women not on warfarin should be advised to start LMWH as soon as they have a positive pregnancy test.

should be offered antenatal thromboprophylaxis with LMWH: Women with previous unprovoked estrogen or pregnancy-related VTE a previous VTE and a history of VTE in a first- degree relative (or a documented thrombophilia) other risk factors.

Women with a previous single provoked (excluding estrogen-related) VTE and no other risk factors require close surveillance; antenatal LMWH is not routinely recommended.

thromboprophylaxis in women with previous VTE and/or thrombophilia

Women with recurrent VTE associated with either antithrombin deficiency or the antiphospholipid syndrome (who will often be on long-term oral anticoagulation) higher-dose LMWH (either high prophylactic (12-hourly) or weight-adjusted (75% of treatment dose) antenatally and for 6 weeks postpartum or until converted back to warfarin after delivery.

Women in whom the original VTE was unprovoked idiopathic related to estrogen who have other risk factors a family history of VTE in a first-degree relative a documented thrombophilia These women require thromboprophylaxis with LMWH antenatally and for 6 weeks postpartum.

Women in whom the original VTE was provoked by a transient major risk factor that is no longer present and who have no other risk factors. In these women, thromboprophylaxis with LMWH can be withheld antenatally, provided that no additional risk factors are present (in which case they should be offered LMWH). They require close surveillance for the development of other risk factors. They should be offered thromboprophylaxis with LMWH for 6 weeks postpartum.

thromboprophylaxis in women with previous venous thromboembolism (VTE) and/or thrombophilia

thrombophilia in women with antithrombin deficiency or more than one thrombophilic defect (including homozygous factor V Leiden, homozygous prothrombin G20210A and compound heterozygotes) or those with additional risk factors where advice of a local expert should be sought and antenatal prophylaxis considered.

thrombophilia Women with asymptomatic inherited thrombophilia without other risk factors may be managed with close surveillance antenatally but should be considered for LMWH for at least 7 days postpartum.

Antiphospholipid syndrome Women with previous thromboses and antiphospholipid syndrome should be offered both antenatal and 6 weeks of postpartum thromboprophylaxis..

Women with persistent antiphospholipid antibodies with no previous VTE and no other risk factors or fetal indications for LMWH may be managed with close surveillance antenatally but should be considered for LMWH for 7 days postpartum 6 weeks

Timing of initiation of thromboprophylaxis: Antenatal thromboprophylaxis should begin as early in pregnancy as practical

Antenatal assessment

Any woman with three or more current or persisting risk factors should be considered for prophylactic LMWH antenatally and will usually require prophylactic LMWH for 6 weeks postnatally; a postnatal risk reassessment should be made. < 3 risk factors: Mobilisation and avoidance of dehydration

Any woman with two or more current or persisting risk factors should be considered for prophylactic LMWH for at least 7 days postpartum.

Women receiving either therapeutic or prophylactic anticoagulation should be converted from LMWH to the shorter half-life UFH in the last month of pregnancy or sooner if delivery appears imminent.

Women receiving antenatal LMWH should be advised that if they have any vaginal bleeding or once labour begins, they should not inject any further LMWH.

American College of Chest Physicians women scheduled for a planned delivery who are receiving twice-daily adjusted- dose subcutaneous UFH or LMWH discontinue their heparin 24 hours before labor induction or cesarean delivery. Patients receiving once-daily LMWH should take only 50 percent of their normal dose on the morning of the day before delivery

American College of Obstetricians and Gynecologists advises that adjusted-dose subcutaneous LMWH or UFH can be discontinued 24 to 36 hours before an induction of labor or scheduled cesarean delivery.

RCOG For delivery by elective caesarean section in women receiving antenatal LMWH, the woman should receive a thromboprophylactic dose of LMWH on the day before delivery. On the day of delivery, any morning dose should be omitted and the operation should be performed that morning.

Reversal of heparin with protamine sulfate is rarely required and is not indicated with a prophylactic dose of heparin. For women in whom anticoagulation therapy has temporarily been discontinued, pneumatic compression devices are recommended (ACOG, 2011)

حداقل فاصله زمانی ( به ساعت ) LMWHUFH فاصله بین تزریق آخرین دوز دارو و انجام بیحسی اسپاینال یا اپیدورال 124 فاصله بین خروج کاتتر اپیدورال و تزریق اولین دوز دارو پس از سزارین 26 فاصله بین تزریق آخرین دوز دارو ( قبل از سزارین ) و خروج کاتتر اپیدورال 126 فاصله بین زایمان طبیعی و تزریق اولین دوز دارو پس از زایمان فاصله بین سزارین و تزریق اولین دوز دارو پس از سزارین 12- 6

1. توصیه می شود برای زنان بارداری که داروی LMWH (دوز Adjusted ) دریافت می کنند حداقل 24 ساعت قبل از زمان پیش بینی شده برای ختم بارداری ( سزارین با آنستزی اپیدورال یا اسپاینال، القای زایمان، شروع دردهای زودرس زایمان و...) دارو قطع شود. بدیهی است القای زایمان و همچنین انجام سزارین باید در شرایط کلینیکی مناسب انجام شود.

There is an increased risk of wound haematoma following caesarean section with both unfractionated heparin and LMWH of around 2%.

In the exceptional situation of a pregnant woman who has had a VTE within the past 2 to 4 weeks, peripartum use of intravenous UH during the latent stage of labour may be necessary.

Postnatal assessment and management

Thromboprophylaxis should be continued for 6 weeks in women at high risk of postpartum VTE and for 1 week in women with intermediate risk.

The first thromboprophylactic dose of LMWH should be given as soon as possible after delivery provided that there is no postpartum haemorrhage or there has been regional analgesia.

Restarting UFH or LMWH no sooner than 4 to 6 hours after vaginal delivery or 6 to 12 hours after cesarean delivery. It is our practice, however, to wait at least 24 hours if there are significant lacerations or following a major surgical procedure.

All women with class-3 obesity (BMI greater than 40 kg/m2) should be considered for prophylactic LMWH for 7 days after delivery.

In women who have additional persistent (lasting more than 7 days postpartum) risk factors, such as prolonged admission or wound infection, thromboprophylaxis should be extended for up to 6 weeks or until the additional risk factors are no longer present.

All women with a previous history of confirmed VTE should be offered thromboprophylaxis with LMWH or warfarin for 6 weeks postpartum, regardless of the mode of delivery.

thrombophilia All women with known heritable or acquired thrombophilia should be considered for LMWH for at least 7 days following delivery, even if they were not receiving antenatal thromboprophylaxis. This could be extended to 6 weeks if there is a family history or other risk factors present

Caesarean section All women who have had an emergency caesarean section should be considered for thromboprophylaxis with LMWH for 7 days after delivery.

Caesarean section All women who have had an elective caesarean section who have one or more additional risk factors (such as age over 35 years, BMI greater than 30) should be considered for thromboprophylaxis with LMWH for 7 days after delivery.

LMWHs are the agents of choice for antenatal thromboprophylaxis. They are at least as effective as and safer than unfractionated heparin.

Suggested thromboprophylactic doses for antenatal and postnatal LMWH

for example, if no LMWH has been given for 24 hours but the woman has not yet delivered and there is concern about delaying further doses of LMWH, a prophylactic dose of 5000 iu subcutaneously of unfractionated heparin could be used and repeated every 12 hours until LMWH can be resumed after delivery.

Agents for postpartum thromboprophylaxis LMWH is appropriate for postpartum thromboprophylaxis although, if women are receiving long term anticoagulation with warfarin, this can be started when the risk of haemorrhage is low, usually 5–7 days after delivery.

Both warfarin and LMWH are safe when breastfeeding.

Contraindications to LMWH

The required interval between a prophylactic dose of unfractionated heparin and regional analgesia or anaesthesia is less (4 hours) than with LMWH (12 hours).

Unfractionated heparin has a shorter half-life than LMWH and there is more complete reversal of its activity by protamine sulphate.

Occasionally unfractionated heparin may be used around the time of delivery in women at very high risk of thrombosis (when there may be reluctance to use LMWH in case regional anaesthetic techniques are required) or in women at increased risk of haemorrhage.

In some women (particularly those on high- dose prophylactic or treatment doses of LMWH) there may be an indication for induction of labour to help plan thromboprophylaxis around delivery. for example, if the woman takes the morning dose but omits the evening dose on the day before induction of labour

Which women with prior VTE require thrombophilia testing? Women with a previous non-estrogen-related VTE provoked by a minor risk factor should undergo testing for thrombophilia, as this will influence management and decisions regarding thromboprophylaxis antenatally.

women with active antenatal or postpartum bleeding women considered at increased risk of major haemorrhage (such as placenta previa) women with a bleeding diathesis, such as von Willebrand’s disease, haemophilia or acquired coagulopathy women with thrombocytopenia (platelet count less than 75000)

acute stroke in the last 4 weeks (ischaemic or haemorrhagic) severe renal disease (glomerular filtration rate less than 30 ml/minute/1.73 m2) severe liver disease (prothrombin time above normal range or known varices) uncontrolled hypertension (blood pressure greater than 200 mmHg systolic or greater than 120 mmHg Diastolic)

Postnatal assessment and management

Prophylactic-dose انوکساپارین هر 24 ساعت 40 میلیگرم زیر جلدی ( در مورد زنان خیلی لاغر یا خیلی چاق، با توجه به وزن قابل تغییر است ) دالتپارین هر 24 ساعت 5000 واحد زیر جلدی یا تینزاپارین هر 24 ساعت 4500 واحد زیر جلدی نادروپارین هر 24 ساعت 2850 واحد زیر جلدی LMWH

Intermediate-dose انوکساپارین هر 12 ساعت 40 میلیگرم زیر جلدی دالتپارین هر 12 ساعت 5000 واحد زیر جلدی دالتپارین 200 واحد به ازای هر کیلوگرم وزن یا تینزاپارین 175 واحد به ازای هر کیلوگرم وزن یک بار در روز Adjusted-dose انوکساپارین 1 میلیگرم به ازای هر کیلوگرم وزن یا دالتپارین 100 واحد به ازای هر کیلوگرم وزن هر 12 ساعت LMWH

Prophylactic-dose هپارین UFH هر 12 ساعت 5000 واحد زیر جلدی : Adjusted-dose هپارین UFH هر 12 ساعت زیر جلدی مقدار دارو : به اندازه ای که نتیجه Midinterval aPTT (6 ساعت پس از تزریق ) در محدوده درمانی حفظ شود Unfractionated Heparin(UFH)

بستری در بیمارستان : تجویز LMWH( دوز Prophylactic) یا UFH ( دوز Prophylactic ) و اقدامات حمایتی ( انجام تمرینات ساده روی تخت و...) و کمک به مادر برای از تخت پایین آمدن و راه رفتن هر چه سریعتر پس از ترخیص : ادامه تجویز LMWH( دوز Prophylactic ) یا UFH ( دوز Prophylactic ) تا یک هفته پس از زایمان آموزش به مادر در مورد علائم DVT و مراجعه به موقع، توصیه به تحرک و مصرف کافی مایعات سزارین اورژانس یا غیر اورژانس به همراه یک یا بیشتر عامل خطر

بستری در بیمارستان : تجویز LMWH( دوز Prophylactic) یا UFH ( دوز Prophylactic ) و اقدامات حمایتی ( انجام تمرینات ساده روی تخت و...) و کمک به مادر برای از تخت پایین آمدن و راه رفتن هر چه سریعتر پس از ترخیص : آموزش به مادر در مورد علائم DVT و مراجعه به موقع، توصیه به تحرک و مصرف کافی مایعات. سزارین اورژانس بدون هیچ عامل خطر

نکته 1 : در صورتی که برای دریافت داروی ضد انعقاد منع مصرف وجود دارد : پیشگیری مکانیکی ( جوراب الاستیک یا pneumatic compression Intermittent) ، اقدامات حمایتی و در صورت نیاز مشاوره با متخصص هماتولوژی یا داخلی توصیه می شود. نکته 2 : در صورتی که عامل خطر دائمی یا شدیدی وجود دارد یا مادر بیشتر از یک هفته در بیمارستان بستری میباشد پیشگیری دارویی و مکانیکی تا قبل از ترخیص باید ادامه یابد. نکته 3 : در مقطع پس از زایمان، در مورد مادران خیلی چاق با معیار BMI> 40 ( حتی اگر فقط همین یک عامل خطر وجود دارد ) پیشگیری دارویی تا یک هفته پس از زایمان ( طبیعی و یا سزارین ) توصیه می شود. پیشگیری از ترومبوآمبولی وریدی پس از سزارین

سابقه ترومبوآمبولی وریدی ( VTE) قبل از حاملگی ابتلا به ترومبوفیلی مشکلات طبی مانند : بیماری قلبی یا ریوی، لوپوس، سرطانها، التهابها ( بیماری التهابی روده، پلی آرتروپاتی التهابی ) ، سندرم نفروتیک ( پروتیین اوری بیشتر از 3 گرم در روز ) ، بیماری سایکل سل، اعتیاد تزریقی سن بیشتر از 35 سال چاقی (BMI بیشتر از 30 ) قبل یا اوایل بارداری / وزن بیشتر از 80 کیلوگرم استعمال دخانیات وجود وریدهای واریسی واضح فلج / استفاده از صندلی چرخدار

* ترومبوفیلیهای پرخطر : کمبود آنتی ترومبین، فاکتور 5 لیدن هموزیگوت، ژن پروترومبین G20210A هموزیگوت، فاکتور 5 لیدن هتروزیگوت به همراه ژن پروترومبین G20210A هتروزیگوت که خود سابقه VTE نداشته اند ( سابقه خانوادگی VTE داشته یا نداشته اند ) اقدام هنگام بارداری : تجویز LMWH ( دوز Prophylactic یا Intermediate ) یا UFH ( دوز Prophylactic ) اقدام پس از زایمان تا 6 هفته : تجویز LMWH( دوز Prophylactic یا Intermediate ) یا UFH ( دوز Prophylactic ) یا آنتا گونیست ویتامین K با حفظ INR در حد 2 تا 3 پیشگیری از ترومبوآمبولی وریدی در زنان باردار مبتلا به ترومبوفیلی ( وضعیت بالینی )

فاکتور FVL هتروزیگوت ، پروترومبین G20210A هتروزیگوت، کمبود پروتیین C یا S که خود سابقه VTE نداشته اند ولی سابقه خانوادگی VTE یا یک عامل خطر دیگر دارند اقدام هنگام بارداری : هشدار و مراقبت (Clinical Vigilance ) شامل : آموزش به مادر در مورد علائم DVT و مراجعه به موقع بررسی دقیق علائم DVT و VTE توسط پزشک در هربار مراجعه، در صورت نیاز شروع داروی ضد انعقاد اقدام پس از زایمان تا 6 هفته : تجویز LMWH ( دوز Prophylactic یا Intermediate ) یا UFH ( دوز Prophylactic ) یا آنتاگونیست ویتامین K با حفظ INR در حد 2 تا 3 ( فقط در مواردی که کمبود پروتیین S یا C وجود ندارد ) ترومبوفیلی ارثی از نوع کم خطر :( وضعیت بالینی )

اقدام هنگام بارداری : واقدام پس از زایمان تا 6 هفته : هشدار و مراقبت (Clinical Vigilance ) شامل : آموزش به مادر در مورد علائم DVT و مراجعه به موقع، بررسی دقیق علائم DVT و VTE توسط پزشک در هربار مراجعه، در صورت نیاز شروع داروی ضد انعقاد ترومبوفیلی ارثی از نوع کم خطر که خود سابقه VTE نداشته و تاریخچه خانوادگی VTE و هیچیک از عوامل خطر دیگر را نیز ندارند

سندرم آنتی فسفولیپید آنتی بادی یعنی وجود حداقل یک معیار آزمایشگاهی وحداقل یک معیار بالینی اقدام هنگام بارداری : تجویز LMWH ( دوز Prophylactic یا Intermediate ) یا UFH ( دوز Prophylactic ) همراه با آسپرین (Low dose ) تا 36 هفته اقدام پس از زایمان تا 6 هفته : تجویز LMWH ( دوز Prophylactic یا Intermediate ) یا UFH ( دوز Prophylactic ) یا آنتاگونیست ویتامین K با حفظ INR در حد 2 تا 3 ( فقط در مواردی که کمبود پروتیین S یا C وجود ندارد ) ترومبوفیلی اکتسابی :

فقط وجود معیار آزمایشگاهی آنتی فسفولیپید آنتی بادی بدون وجود معیار بالینی اقدام هنگام بارداری : هشدار و مراقبت (Clinical Vigilance ) شامل : آموزش به مادر در مورد علائم DVT و مراجعه به موقع، بررسی دقیق علائم DVT و VTE توسط پزشک در هربار مراجعه اقدام پس از زایمان تا 6 هفته : شروع داروی ضد انعقادتجویز LMWH ( دوز Prophylactic یا Intermediate ) یا UFH ( دوز Prophylactic ) تا یک هفته پس از زایمان نکته : در صورتی که در طی بارداری داروی ضد انعقاد دریافت شده، تا 6 هفته پس از زایمان ادامه یابد. ( ترومبوفیلی اکتسابی ):

از هفته 36 بارداری یا هر زمان که زایمان قریب الوقوع باشد تبدیل LMWH به UFH توصیه می شود.

The thromboprophylactic dose of LMWH should be given 4 hours post- operatively or 4 hours after removal of the epidural catheter.

بستری در بیمارستان : اقدامات حمایتی ( انجام تمرینات ساده روی تخت و...) و کمک به مادر برای از تخت پایین آمدن و راه رفتن هر چه سریعتر پس از ترخیص : آموزش به مادر در مورد علائم DVT و مراجعه به موقع، توصیه به تحرک و مصرف کافی مایعات سزارین غیر اورژانس بدون هیچ عامل خطر

Graduated elastic compression stockings those who are hospitalised and have a contraindication to LMWH those who are hospitalised post-caesarean section (combined with LMWH) and considered to be at particularly high risk of VTE (such as previous VTE, more than three3 risk factors) outpatients with prior VTE (usually combined with LMWH) women travelling long distance for more than 4 hours

In women with antithrombin deficiency who are asymptomatic, an intermediate dose of heparin may be required.