Monitoring the effects and managing the side effects of anticoagulation during pregnancy

Delayed-type heparin allergy: diagnostic procedures and treatment alternatives-a case series including 15 patients

Delayed-type hypersensitivity reactions (DTHRs) after subcutaneous application of unfractionated heparins or low-molecular-weight heparins are not uncommon. Standard allergological testing usually includes intracutaneous skin tests and patch testing of different heparins, heparinoids, and thrombin inhibitors followed by subcutaneous and/or intravenous challenge with skin test-negative drugs. We present data from a single-center case series of 15 patients with DTHR after low-molecular-weight heparin administration. Intracutaneous testing that can be considered as gold standard identified the suspicious elicitor in 11 (73.4%) of 15 of the patients. Patch testing was positive in 5 (33.4%) of 15 of the patients and was only positive in patients who were also reacting in the intradermal testing. Intravenous challenge with heparin sodium was performed in 10 of 15 patients and was well tolerated in all cases, despite prior positive intracutaneous tests with the same substance. Intracutaneous documentation of DTHR was not an adequate predictor of intravenous challenge.

Efficacy of three different antithrombotic regimens on pregnancy outcome in pregnant women affected by recurrent pregnancy loss

INTRODUCTION

Recurrent pregnancy loss (RPL) is a common health problem affecting 1-5% of women at reproductive age.

AIM OF THE STUDY

Evaluation of three different antithrombotic treatments in women with antecedent of RPL, comparing the results in negative and positive to thrombophilic screening pregnant women.

MATERIALS AND METHODS

We recruited 361 women with an antecedent of two or more pregnancy losses. From this group, 167 women became pregnant and considered for the study. The evaluated pregnant women were divided as negative/positive to thrombofilic screening: (a) 80 (48%) with negative thrombophilic screening, (b) 87 (52%) positive to thrombophilic screening. Pregnant women included in the study and considered negative or positive for thrombophilic screening, were randomized into three different therapy groups: (a) group 1: Acetil salicylic acid (ASA) 100 mg daily until third month of pregnancy, (b) group 2: low molecular-weight heparin (LMWH) - enoxaparine 40 mg daily until third month of pregnancy, (c) group 3: ASA 100 mg plus LMWH 40 mg daily until third month of pregnancy.

RESULTS

In 80 negative to thrombophilic screening pregnant women, the comparison of efficacy of the three treatments, shows that all three treatment regimens were significantly effective comparing live births against fetal losses. In 87 positive to thrombophilic screening pregnant women, the comparison of efficacy for the three regimens, shows that the therapy with LMWH or LMWH plus ASA are significantly protective against fetal losses with respect to ASA, which showed a high number of fetal losses (11 live births, 18 fetal losses).

COMMENT

We suggest that thromboprophylaxis is indicated in women with RPL independently from positiveness to thrombophilic markers.

Management of thromboembolism in pregnancy

The incidence of venous thromboembolism is increased during pregnancy and the postpartum period. This risk is high for women with documented hereditary or acquired risk factors who have experienced a prior thrombotic event. These individuals require a minimum of prophylactic dose anticoagulation with unfractionated or low molecular weight heparin during pregnancy, with anticoagulation continuing for 4 to 6 weeks postpartum. Women receiving therapeutic dose anticoagulation with warfarin before pregnancy for a hereditary or acquired condition should be transitioned to therapeutic doses of unfractionated heparin or low molecular weight heparin before or within 6 weeks of becoming pregnant, and can then resume warfarin postpartum. Women experiencing a thromboembolic event during pregnancy should receive therapeutic treatment with unfractionated heparin or low molecular weight heparin during pregnancy, with anticoagulation continuing for 4 to 6 weeks postpartum, and for a total of at least 6 months.