Blood Donors, Blood Collection Dr. Soheila Zareifar Department of Hematology/Oncology January 2016.
Obstetrics Department Hematology Department for thromboprophylaxis in pregnancy and puerperium Dra....
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Scenarios for thromboprophylaxis in pregnancy and puerperium Dra. Rosa Cornudella Hematology Department Dra. Ana Cristina Lou Obstetrics Department LMWH AVAILABLE AT HOSPITAL CLINICO UNIVERSITARIO “LOZANO BLESA” Weight (Kg) <50 50 - 90 91- 130 Intermediate dose (50 - 90 Kg) Therapeutic dose 20 mg / 24 h 40 mg / 24 h 40 mg / 12 h 1 mg/kg / 12 h or 1,5mg / 24 h 60 mg / 24 h or 40 mg / 12 h 2500 U / 24 h 3500 U / 24h - - - - - - - - 115 U/kg / 24h 5000 U / 24h Enoxaparin (Lovenox ® ) Bemiparin (Hibor ® ) LMWH entire pregnancy + 6 weeks postpartum (VTE due to transient RF: only LMWH post-partum) - PERIPARTUM MANAGMENT LMWH with bleeding or dynamic • Suspend LMWH LMWH at therpaeutic dose • LRA after >24 hours since last dose LMWH at prophylactic dose Unfractionated Heparin (UNH) • LRA after >12 hours since last dose Suspend UFH 4-6 hours before or Protamine sulphate • Start up LMWH again after birth • >12-24 hours post-aprtum and at least 6 hours after removing catheter, if there is no bleeding or risk of ASA at low dose • Consider suspending 24 hours before birth REFERENCES ABBREVIATIONS Hospital Clínico Universitario Lozano Blesa ZARAGOZA CONTRAINDICATIONS FOR LMWH • Active antenatal and post-partum bleeding. Woman considered having high risk of bleeding (for example, placenta praevia) Woman with coagulation impairment (von Willebrand disease, haemophilia or acquired coagulopathy) Thrombocytopenia (<75,000) Renal disease (FG< 30 mL/min/1.73m2) or severe liver disease (prolonged TP or oesophageal varices) Uncontrolled hypertension (SBP > 200 mmHg or DBP > 120 mmHg) • • • • • Junio 2012 Risk factors of thrombosis High risk thrombophilia with FH of VTE High risk thrombophilia without FH Moderate thrombophilia/Low risk Previous episode of VTE APA: Antiphospholipid antibodies ASA: Acetylsalicylic Acid CVA: Cerebrovascular accident FH: Family History LRA: Local regional anaesthesia PH: Personal History RM: Recurrent Miscarriage AT: Antithrombin VKA: Vitamin K antagonists IUGR: Intrauterine growth retardation GA: Gestational age VTE: Venous Thromboembolism VTE: Venous Thromboembolism Royal College of Obstetricians and Gynaecologist. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. Green-top Guideline Nº 37, 2009. Khamashta MA. Systemic lupus erytematous and pregnancy. Best Pract Res Clin Rheumatol. 2006Aug;20(4):685-94. Bates S et al. Thrombophilia, Antithrombotic Therapy, and Pregnancy. 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141;e691S-e736S. – – – FII: Factor II of the prothrombin G20210A GF: Glomerular filtration RF: Risk factors FVL: Factor V Leiden LMWH: Low molecular weight heparins UFH: Unfractionated heparin BMI: Body mass index APS: Antiphospholipid Syndrome DBP: Diastolic blood pressure OAT: Oral anticoagulant therapy SBP: Systolic blood pressure PTE: Pulmonary thromboembolism LMWH entire pregnancy + 6 weeks post-partum. - Antenatal surveillance - LMWH if additional RF. - LMWH 6 weeks post-partum - Antenatal surveillance - LMWH 7 days post-natal Risk assessment at the beginning of gestation, faced with intercurrent and post-partum problems. LMWH if > 2 additional RF. - - Author's note: bemiparin every 12 hours is not included in the SmPC
Transcript of Obstetrics Department Hematology Department for thromboprophylaxis in pregnancy and puerperium Dra....
Scenarios for thromboprophylaxis
in pregnancyand puerperium
Dra. Rosa CornudellaHematology Department
Dra. Ana Cristina LouObstetrics DepartmentLMWH AVAILABLE AT HOSPITAL CLINICO
UNIVERSITARIO “LOZANO BLESA”Weight (Kg)
<50
50 - 90
91- 130
Intermediate dose(50 - 90 Kg)
Therapeutic dose
20 mg / 24 h
40 mg / 24 h
40 mg / 12 h
1 mg/kg / 12 h or 1,5mg / 24 h
60 mg / 24 h or 40 mg / 12 h
2500 U / 24 h
3500 U / 24h
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115 U/kg / 24h
5000 U / 24h
Enoxaparin (Lovenox®) Bemiparin (Hibor®)
LMWH entire pregnancy+ 6 weeks postpartum (VTE due to transient RF: only LMWH post-partum)
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PERIPARTUM MANAGMENTLMWH with bleeding or dynamic • Suspend LMWH
LMWH at therpaeutic dose • LRA after >24 hours since last dose
LMWH at prophylactic doseUnfractionated Heparin (UNH)
• LRA after >12 hours since last doseSuspend UFH 4-6 hours before orProtamine sulphate
•
Start up LMWH again after birth • >12-24 hours post-aprtum and at least6 hours after removing catheter, if there is no bleeding or risk of
ASA at low dose • Consider suspending 24 hours before birth
REFERENCES
ABBREVIATIONS
Hospital ClínicoUniversitarioLozano BlesaZARAGOZA
CONTRAINDICATIONS FOR LMWH• Active antenatal and post-partum bleeding.
Woman considered having high risk of bleeding (for example, placenta praevia)Woman with coagulation impairment (von Willebrand disease, haemophilia or acquired coagulopathy)Thrombocytopenia (<75,000)Renal disease (FG< 30 mL/min/1.73m2) or severe liver disease (prolonged TP or oesophageal varices)Uncontrolled hypertension (SBP > 200 mmHg or DBP > 120 mmHg)
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Junio 2012
Risk factors of thrombosis
High risk thrombophilia with FH of VTE
High risk thrombophilia
without FH
Moderate thrombophilia/Low risk
Previousepisodeof VTE
APA: Antiphospholipid antibodiesASA: Acetylsalicylic AcidCVA: Cerebrovascular accidentFH: Family History LRA: Local regional anaesthesia PH: Personal History RM: Recurrent MiscarriageAT: AntithrombinVKA: Vitamin K antagonistsIUGR: Intrauterine growth retardationGA: Gestational ageVTE: Venous ThromboembolismVTE: Venous Thromboembolism
Royal College of Obstetricians and Gynaecologist. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. Green-top Guideline Nº 37, 2009.Khamashta MA. Systemic lupus erytematous and pregnancy. Best Pract Res Clin Rheumatol. 2006Aug;20(4):685-94. Bates S et al. Thrombophilia, Antithrombotic Therapy, and Pregnancy. 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141;e691S-e736S.
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FII: Factor II of the prothrombin G20210AGF: Glomerular filtration RF: Risk factors FVL: Factor V Leiden LMWH: Low molecular weight heparinsUFH: Unfractionated heparin BMI: Body mass index APS: Antiphospholipid Syndrome DBP: Diastolic blood pressure OAT: Oral anticoagulant therapy SBP: Systolic blood pressurePTE: Pulmonary thromboembolism
LMWH entire pregnancy+ 6 weeks post-partum.
- Antenatal surveillance- LMWH if additional RF.- LMWH 6 weeks post-partum
- Antenatal surveillance- LMWH 7 days post-natal
Risk assessment at the beginning of gestation, faced with intercurrent and post-partum problems.LMWH if > 2 additional RF.
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Author's note: bemiparin every 12 hours is not included in the SmPC
ASSESSMENT OF INDIVIDUAL RISK••••
INDICATIONS TO REQUEST STUDY OF THROMBOPHILIA*
MANAGEMENT OF ACUTE EPISODE OF VTE IN PREGNANCY••
GESTATIONAL VASCULAR COMPLICATIONSþTHROMBOPHILIA WITHOUT PREVIOUS EPISODE
• AT deficiency
IDIO
PATH
IC
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• •
THRO
MBO
PHILI
A • •
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WITH PREVIOUS EPISODE OF VTE
HIGH
RISK
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INTE
RMED
IATE
RISK
IN
TERM
EDIA
TE /
LOW
RISK
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MANAGEMENT OF THROMBOPROPHYLAXIS IN PREGNANCY
ANTENATAL RISK SITUATIONS•
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THROMBOPHILIA WITHOUT PREVIOUS EPISODE OF VTE
HIGH
RISK
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With AFof VTE
WithoutFH of VTE
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*Plasma thrombophilia is recommended 2-3 months postpartum, instead of during pregnancy.
THROMOBPROPHYLAXIS IN PUERPERIUM HIGH RISK
• Any that requires prenatal LMWH
VTE disease due to transient RF not present during pregnancy
Other diseases (medical comorbidity, lupus, drepanocytosis, cancer,…)
BMI > 40
Obstetric hysterectomy
– LMWH 6 weeks postnatal
- Graduated compression stokings
Start again VKA
Prophylactic LMWH at least 7 days postpartum
• High risk thromobophilia
• Patients with VKA prior to pregnancyn
INTERMEDIATE RISK
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– Consider prophylactic LMWH 7 days if >2 RF
LOW RISK• – Foster mobilisation and
avoid dehydration
** Prophylactic/intermediate dose LMWH
MANAGEMENT OF EXPECTANT MOTHER WITH ANTIPHOSPHOLIPID SYNDROME
APS without clinical symptoms
Recurrent foetal loss or late foetal loss
There is no clinical evidence. Individual evaluationTherapeutic abstinence orEmpirical treatment (ASA/LMWH/ASA+LMWH)
ASA* entire pregnancy, starting in 2nd trimester Prophylactic LMWH if additional RF
Strict ECO-Doppler surveillance
Individual management according to thrombophilia, PH or FH of VTE disease and RF
ASA* antenatal + LMWHLMWH postpartum 4-6 weeks
IGR
Inherited
Acquired(Obstetric APS)
History of preeclampsia or high risk of PE
Abstinence/strict control or ASA*
ASA* preconceptionASA* + Prophilactic LMWH antenatal
If VKA: suspend < week 6ASA* + prophylactic LMWH or LMWH terapéutica
Prophylactic LMWH 4-6 weeks postpartumIf previousVKA, start again.Long-term ASA* ? (controversy)
OBSTETRIC APS
APS with THROMBOSIS
Recurrent miscarriage (< EG 10)
Late foetal losses, IGR, pre-eclampsia
Previous arterial thrombosis ASA* + Prophilactic LMWH
Puerperium of APS
Individual management, according to clinical or immunological status. Active participaton of patient in therapeutic strategy decision in own individual case. Multidisciplinary control by experts in APS
*ASA at low dose
NOTE: Patients selected with persistence of RF, consider prolonging thromboprophylaxis until 6 weeks post-partum
Type of thrombophiliaPersonal or family history of VTE diseaseHistory of gestational vascular complicationsAntenatal and postnatal risk factors
RecurrentPatient with OATAT deficiency and APS
Other thrombophilias or FH of VTE Not provoked or idiopathicRelated to oestrogens
Transient risk factor not present in pregnancy
AT deficiency – LMWH** entire pregnancy- Graduated compression stockings- Haematology Control
- Antenatal surveillance- Evaluate prophylactic LMWH if additional RF.- Haematology Control
- Consider prophylactic LMWH if admission + 2 RF (until resolution of symptoms)
- Antenatal clinical surveillance- Evaluate prophylactic LMWH if additional RF
– Prophylactic LMWH during admission and maintain it for 1st trim.
- Prophylactic LMWH for at least 7 days
- Evaluation by experts if prenatal LMWH is needed
Intercurrent surgical procedure
Other diseases (lupus, drepanocitosis, medical comorbidity, cancer,…)
Immobilisation due to hospitalisation (>3 d) + other RF
- Age >35 years– BMI > 30– Multiparity ≥ 3- Concurrent systemic infection- Multiple pregnancy- Pre-eclampsia- Thrombophilia- Symptomatic macroscopic veins- Nicotine addiction
FII homozygotes
FVL heterozygotesFII heterozygotesProtein S or Protein C deficiency
Severe Ovarian Hyperstimulation syndrome
- Suspend AVK drugs– Therapeutic LMWH for entire pregnancy- Haematology Control
– LMWH** entire pregnancy- Graduated compression stockings- Haematology Control
- Evaluate prophylactic LMWH if additional RF.- Haematology Control
Treatment must be begun faced with clinical suspicion.Full anticoagulation with adjusted doses of LMWH for at least 3 months after the episode occurs, maintaining the treatment throughout the entire pregnancy and up to 6 weeks after birth.
VTE that appears before the age of 50, idiopathic or recurrent.VTE of atypical locationRecurrent superficial thrombophlebitis in absence of neoplasia.Gestational vascular complications (RM, late foetal loss, pre-eclampsia, IGR.1st degree family history of arterial or VTE disease < 50 year
Previous venous thrombosis
Asintomatic thrombophilia (moderate/low risk)
Evaluaton of risk factors:– Age >35 years– BMI > 30– Caesearean section– Surgical procedure in puerperium– Immobility > 4 days before caesarean section– Immobility postpartum (paraplexia, traumatological lesion in lower limbs,…)– Multiparity ≥ 3– Concurrent systemic infection– Pre-eclampsia–Macroscopic veins–Blood loss > 1 L or blood transfusion
Puerperium without complications
FVL homozygotesCombined defects
