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Dempfle CE, Koscielny J, Lindhoff-Last E, Linnemann B, Bux-Gewehr I, Kappert G, Scholz U, Kropff S, Eberle S, Bramlage P, Heinken A. Fondaparinux Pre-, Peri-, and/or Postpartum for the Prophylaxis/Treatment of Venous Thromboembolism (FondaPPP). Clin Appl Thromb Hemost 2021; 27:10760296211014575. [PMID: 33942675 PMCID: PMC8114740 DOI: 10.1177/10760296211014575] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We analyzed data for women who received fondaparinux for ≥7 days during pregnancy. The study retrospectively included women who received fondaparinux pre-, peri- and/or postpartum for ≥7 days for prophylaxis/venous thromboembolism (VTE) treatment at German specialist centers (2004-2010). Data on pregnancy, VTE risk factors, anticoagulant treatment, pregnancy outcome and adverse events were extracted from medical records. 120 women (mean age 31.5 years) were included. Among 84 women with prior pregnancies, 41.0% had ≥1 abortion. Anticoagulation was indicated for prophylaxis in 92.5% cases, including 82.5% women with an elevated VTE risk (82.8% thrombophilia, 34.2% VTE history). All women received low-molecular-weight heparin (LMWH) as first-line therapy; 3 also unfractionated heparin. Treatment changed to fondaparinux, due to heparin allergy (41.7%) or heparin-induced thrombocytopenia (10.0%). Fondaparinux was generally well tolerated. Adverse events included bleeding events (n = 5), abortion (n = 2), premature births (n = 2), stillbirth (n = 1), arrested labors (n = 2), injection site erythema (n = 4) and unspecified drug hypersensitivity (n = 6). No VTE events or increased liver enzymes occurred during treatment. In this retrospective study, fondaparinux was effective and well tolerated. Trial registration: ClinicalTrials.gov NCT01004939.
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Affiliation(s)
| | - Jürgen Koscielny
- Institut für Transfusionsmedizin, 14903Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | | | | | - Ute Scholz
- Zentrum für Gerinnungsstörungen, Leipzig, Germany
| | | | | | - Peter Bramlage
- 566322Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
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Zhao L, Bi S, Fu J, Qi L, Li L, Fu Y. Retrospective Analysis of Fondaparinux and Low-Molecular-Weight Heparin in the Treatment of Women With Recurrent Spontaneous Abortion. Front Endocrinol (Lausanne) 2021; 12:717630. [PMID: 34721290 PMCID: PMC8553245 DOI: 10.3389/fendo.2021.717630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/17/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To compare the clinical efficacy of fondaparinux and LMWH and provide clinical evidence for the effectiveness of fondaparinux in the treatment of recurrent spontaneous abortion caused by PTS. METHODS A retrospective analysis was conducted for 120 patients diagnosed with a recurrent spontaneous abortion caused by PTS in Qingdao Jinhua Women's Hospital from March 2019 to April 2020. The patients were divided into two groups: 68 cases in the control group, treated with LMWH, 52 cases in the observational group, treated with fondaparinux. The pregnancy outcomes and adverse reactions between the two groups of recurrent miscarriage patients were compared. RESULTS No significant difference was detected in the general data between the two groups of patients before treatment (P>0.05). In the observational group, the R value was increased, and the α and MA values were decreased after three months of treatment compared to those before treatment (P<0.05). In the control group, the R value was increased, and the MA value was decreased after three months of treatment compared to those before treatment (P<0.05). After treatment, no significant difference was observed in the pregnancy outcome between the two groups (P>0.05). The total adverse reaction rate of the fondaparinux group was lower than that of the LMWH group (P<0.05). CONCLUSIONS In this study, no significant difference was detected in the pregnancy outcome between fondaparinux and LMWH in the treatment of recurrent spontaneous abortion caused by PTS, but fondaparinux had a low occurrence rate of adverse reactions and high safety.
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Affiliation(s)
- Long Zhao
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Long Zhao,
| | - Shuqin Bi
- Department of Obstetrics, Qingdao Jinhua Gynecology Hospital, Qingdao, China
| | - Jinhua Fu
- Department of Obstetrics, Qingdao Jinhua Gynecology Hospital, Qingdao, China
| | - Lijuan Qi
- Department of Obstetrics, Qingdao Jinhua Gynecology Hospital, Qingdao, China
| | - Lin Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yinghui Fu
- Department of Obstetrics, Qingdao Jinhua Gynecology Hospital, Qingdao, China
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Abstract
Low-molecular-weight heparin is the anticoagulant of choice in pregnancy. Enoxaparin has been increasingly used over the past 20 years in pregnant women at risk of thrombosis and pregnancy complications. The main indications are prophylaxis of venous thromboembolism and prevention of pregnancy loss in thrombophilic women. Other indications include treatment of venous thromboembolism, prophylaxis of arterial thrombosis in pregnant women with mechanical heart valves and prevention of late gestational complication such as pre-eclampsia and intrauterine growth restriction. Enoxaparin does not cross the placenta and is safe for the fetus. Maternal side effects are uncommon and include mild localized allergic reactions in 2% and increased bleeding in 2%, which is dose dependent. Heparin-induced thrombocytopenia is very rare and bone resorption is not clinically relevant. The mechanisms of action of enoxaparin in pregnancy are multiple and include anti-factor Xa (anti-Xa) activity in maternal circulation, tissue factor pathway inhibitor release from endothelial cells and trophoblasts at the placental level as well as anti-inflammatory effects.
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Affiliation(s)
- Benjamin Brenner
- Caster Chair in Leukemia Research, Bruce Rappaport Faculty of Medicine, Technion, Department of Hematology, Rambam Medical Centre, PO Box 9602, Haifa 31096, Israel, Tel.: +97 248 543 520; Fax: +97 248 542 343
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Bates SM, Middeldorp S, Rodger M, James AH, Greer I. Guidance for the treatment and prevention of obstetric-associated venous thromboembolism. J Thromb Thrombolysis 2016; 41:92-128. [PMID: 26780741 PMCID: PMC4715853 DOI: 10.1007/s11239-015-1309-0] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Venous thromboembolism (VTE), which may manifest as pulmonary embolism (PE) or deep vein thrombosis (DVT), is a serious and potentially fatal condition. Treatment and prevention of obstetric-related VTE is complicated by the need to consider fetal, as well as maternal, wellbeing when making management decisions. Although absolute VTE rates in this population are low, obstetric-associated VTE is an important cause of maternal morbidity and mortality. This manuscript, initiated by the Anticoagulation Forum, provides practical clinical guidance on the prevention and treatment of obstetric-associated VTE based on existing guidelines and consensus expert opinion based on available literature where guidelines are lacking.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute (TaARI), 1280 Main Street West, HSC 3W11, Hamilton, ON, L8S 4K1, Canada.
| | - Saskia Middeldorp
- Department of Vascular Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc Rodger
- Departments of Medicine, Epidemiology and Community Medicine, and Obstetrics and Gynecology, University of Ottawa, Ottawa, ON, Canada
| | - Andra H James
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - Ian Greer
- Faculty of Medical and Human Sciences, The University of Manchester, Manchester, UK
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5
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Fondaparinux in pregnancy: Could it be a safe option? A review of the literature. Thromb Res 2015; 135:1049-51. [DOI: 10.1016/j.thromres.2015.04.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 04/01/2015] [Accepted: 04/06/2015] [Indexed: 11/20/2022]
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6
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Elsaigh E, Thachil J, Nash MJ, Tower C, Hay CRM, Bullough S, Byrd L. The use of fondaparinux in pregnancy. Br J Haematol 2014; 168:762-4. [PMID: 25270038 DOI: 10.1111/bjh.13147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Esra Elsaigh
- Manchester Medical School, University of Manchester, Manchester, UK
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Liu Z, Ji S, Sheng J, Wang F. Pharmacological effects and clinical applications of ultra low molecular weight heparins. Drug Discov Ther 2014; 8:1-10. [DOI: 10.5582/ddt.8.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Bates SM. Preventing thrombophilia-related complications of pregnancy: an update. Expert Rev Hematol 2013; 6:287-300. [PMID: 23782083 DOI: 10.1586/ehm.13.18] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Approximately half of all pregnancy-related venous thromboembolic events are associated with thrombophilia. Although the most compelling data for a link between thrombophilia and other adverse pregnancy outcomes derive from women with antiphospholipid antibodies, some studies also suggest an association between these pregnancy complications and hereditary thrombophilias. Management of thrombophilia often involves anticoagulant therapy; however, use of these agents during pregnancy is challenging. There is a paucity of high-quality studies and consequently, recommendations are based largely on extrapolation from data in nonpregnant women, in addition to observational studies and a few small randomized studies. This article will review the impact of the thrombophilias on pregnancy and its outcome, evidence for therapies aimed at the prevention of thrombophilia-related pregnancy complications, and the most recent recommendations contained in the 9th Edition of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute (TaARI), Hamilton, ON, Canada.
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Tang AW, Greer I. A systematic review on the use of new anticoagulants in pregnancy. Obstet Med 2013; 6:64-71. [PMID: 27757159 DOI: 10.1177/1753495x12472642] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2012] [Indexed: 12/17/2022] Open
Abstract
New anticoagulants such as direct factor Xa inhibitors and direct thrombin inhibitors have been recently developed, but their experience in pregnancy is limited. This review therefore aims to systematically search for studies on the use of these newer anticoagulants in pregnancy and the puerperal period. Searches were performed on electronic databases MEDLINE (from 1966), EMBASE (from 1974) and the Cochrane Library, until October 2011 using terms of 'pregnancy', 'puerperium', 'breastfeeding' and names of specific anticoagulants. The search yielded 561 citations and 11 studies (10 on fondaparinux, 1 on ximelagatran) were included. Newer anticoagulants (fondaparinux, hirudin and argatroban) on the limited evidence appear not to have adverse pregnancy outcomes, but there is currently no experience of new oral anticoagulants (rivaroxaban, apixaban, betrixaban or dabigatran) use in pregnancy. There is a need for reporting on new oral anticoagulation use in pregnancy to provide more information about the safety and risks to the fetus in utero.
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Affiliation(s)
- Ai-Wei Tang
- Fetal Medicine Unit, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool L8 7SS, UK
| | - Ian Greer
- Faculty of Health & Life Sciences, University of Liverpool, Foundation Building, Liverpool L69 7ZX, UK
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Castellano JM, Narayan RL, Vaishnava P, Fuster V. Anticoagulation during pregnancy in patients with a prosthetic heart valve. Nat Rev Cardiol 2012; 9:415-24. [DOI: 10.1038/nrcardio.2012.69] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Pregnancy is associated with an increased risk of venous thromboembolism (VTE) and this condition remains an important cause of maternal morbidity and mortality. The use of anticoagulant therapy for treatment and prophylaxis of VTE during pregnancy is challenging because of the potential for fetal, as well as maternal, complications. Although evidence-based recommendations for the use of anticoagulants have been published, given the paucity of available data, guidelines are based largely upon observational studies and from data in nonpregnant patients. This article reviews the available literature and provides guidance for the management and prevention of VTE during pregnancy.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University & Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
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12
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Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e691S-e736S. [PMID: 22315276 PMCID: PMC3278054 DOI: 10.1378/chest.11-2300] [Citation(s) in RCA: 834] [Impact Index Per Article: 69.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The use of anticoagulant therapy during pregnancy is challenging because of the potential for both fetal and maternal complications. This guideline focuses on the management of VTE and thrombophilia as well as the use of antithrombotic agents during pregnancy. METHODS The methods of this guideline follow the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS We recommend low-molecular-weight heparin for the prevention and treatment of VTE in pregnant women instead of unfractionated heparin (Grade 1B). For pregnant women with acute VTE, we suggest that anticoagulants be continued for at least 6 weeks postpartum (for a minimum duration of therapy of 3 months) compared with shorter durations of treatment (Grade 2C). For women who fulfill the laboratory criteria for antiphospholipid antibody (APLA) syndrome and meet the clinical APLA criteria based on a history of three or more pregnancy losses, we recommend antepartum administration of prophylactic or intermediate-dose unfractionated heparin or prophylactic low-molecular-weight heparin combined with low-dose aspirin (75-100 mg/d) over no treatment (Grade 1B). For women with inherited thrombophilia and a history of pregnancy complications, we suggest not to use antithrombotic prophylaxis (Grade 2C). For women with two or more miscarriages but without APLA or thrombophilia, we recommend against antithrombotic prophylaxis (Grade 1B). CONCLUSIONS Most recommendations in this guideline are based on observational studies and extrapolation from other populations. There is an urgent need for appropriately designed studies in this population.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.
| | - Ian A Greer
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, England
| | - Saskia Middeldorp
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Anne-Marie Prabulos
- Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, CT
| | - Per Olav Vandvik
- Medical Department, Innlandet Hospital Trust and Norwegian Knowledge Centre for the Health Services, Gjøvik, Norway
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13
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Fondaparinux - data on efficacy and safety in special situations. Thromb Res 2011; 129:407-17. [PMID: 22133273 DOI: 10.1016/j.thromres.2011.10.037] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 10/27/2011] [Accepted: 10/28/2011] [Indexed: 12/20/2022]
Abstract
New anticoagulants promise to have better efficacy, more safety and/or a better manageability than traditional anticoagulants. However, knowledge is limited regarding special situations such as renal insufficiency, obesity, pregnancy, long-term therapy, heparin-induced thrombocytopenia, treatment in patients with mechanical heart valves, use for children, and in patients with a high risk of thromboembolic complications. These situations have rarely or even never been the objective of randomised controlled trials. The purpose of the present article is to summarize and discuss available data on efficacy and safety in these special situations for one of the first new anticoagulants, the indirect factor-Xa inhibitor fondaparinux. Furthermore, we discuss safety in licensed indications and management of bleeding complications and comment on measuring of drug concentration in plasma.
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14
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Chauleur C, Gris JC, Seffert P, Mismetti P. [News on antithrombotic therapy and pregnancy]. Therapie 2011; 66:437-43. [PMID: 22031688 DOI: 10.2515/therapie/2011061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 05/17/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVES State of the art of antithrombotics and their use recommendations during pregnancy. METHODS A review RESULTS Aspirin and heparins remain the safest molecules during pregnancy, and oral anticoagulants are still used for mechanical valves. Heparinoids are the methods of choice in case of heparin-induced thrombopenia but other molecules could find their place: fondaparinux at first and possibly the direct thrombin inhibitors. Thrombolysis may be used in case of life-threatening incident. At present, the new oral forms can not be used during pregnancy CONCLUSIONS During pregnancy, all antithrombotics, except the oral forms, can be used, but the low molecular weight heparins replacing the unfractionated ones in the treatment and prevention of venous thromboembolism remain the treatment of choice.
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Affiliation(s)
- Céline Chauleur
- Département d'Obstétrique et Gynécologie, CHU Saint-Étienne Hôpital Nord, Saint-Priest-en-Jarez, France.
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Emerging Anticoagulants and Heparin-Induced Thrombocytopenia: Indirect and Direct Factor Xa Inhibitors and Oral Thrombin Inhibitors. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/9781420045093.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Knol HM, Schultinge L, Erwich JJHM, Meijer K. Fondaparinux as an alternative anticoagulant therapy during pregnancy. J Thromb Haemost 2010; 8:1876-9. [PMID: 20492464 DOI: 10.1111/j.1538-7836.2010.03926.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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17
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Abstract
Low molecular weight heparins (LMWHs) appear to be as safe and effective as unfractionated heparin (UFH) for venous thromboembolic disease (VTED) treatment or prophylaxis during pregnancy. Experience with other parenteral anticoagulant drugs is very limited, and no alternative oral anticoagulants are available to date. In addition to cost, challenges of long-term LMWH use during pregnancy that have not been addressed by controlled clinical trials include a) ideal dosing as pregnancy advances, b) the need for LMWH monitoring by anti-Xa activity levels, and c) ideal therapeutic management as the delivery date nears. Because therapeutic-intensity anticoagulation during pregnancy is challenging, many practitioners favor a more "aggressive" approach toward VTED prophylaxis in women perceived to be at very high risk of thrombosis during pregnancy. Best evidence to date suggests that most women with thrombophilias or with a previous "situational" VTED event probably do not require VTED prophylaxis antepartum, but postpartum anticoagulation prophylaxis is recommended for a few weeks. For those with a history of previous idiopathic VTED or VTED associated with "hormonal challenge" (such as with contraceptive use or previous pregnancy), prophylaxis beginning antepartum may be considered and discussed with the patient. Selected cases of "severe" thrombophilia are probably best managed by initiation of pharmacologic VTED prophylaxis antepartum. However, it must be emphasized that data from prospective controlled clinical trials are lacking.
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Affiliation(s)
- Marcelo P Villa-Forte Gomes
- Section of Vascular Medicine, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-5, Cleveland, OH 44195, USA.
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Winger EE, Reed JL. A retrospective analysis of fondaparinux versus enoxaparin treatment in women with infertility or pregnancy loss. Am J Reprod Immunol 2009; 62:253-60. [PMID: 19703143 DOI: 10.1111/j.1600-0897.2009.00733.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PROBLEM We compared the pregnancy success rates and safety parameters of fondaparinux versus enoxaparin, combined with immunotherapy, in patients with a history of miscarriage and/or infertility and coagulant defects. METHOD OF STUDY A total of 127 pregnancies in 110 patients with a history of miscarriage and/or infertility were retrospectively evaluated. Of these, 29 pregnancies used fondaparinux 2.5 mg daily and 98 pregnancies used enoxaparin 30 mg twice daily. RESULTS The pregnancy success rate was 59% (17/29; 95% CI, 41-75%) for patients receiving fondaparinux and 58% (57/98; 95% CI, 48-68%) for patients receiving enoxaparin. No difference was detected in birth weight (2.7 +/- 0.8 and 2.9 +/- 0.6 kg, respectively) or gestational age at delivery (37.3 +/- 2.2 and 37.7 +/- 2.1 weeks, respectively). No birth defects, severe bleeding-related complications, or serious allergic reactions were observed. CONCLUSION In patients with a history of miscarriage, infertility, and coagulant defects receiving immunotherapy, fondaparinux resulted in successful pregnancy outcomes comparable with enoxaparin therapy. Although no difference in outcome was observed in our analysis, a much larger study is required to achieve statistical power.
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Affiliation(s)
- Edward E Winger
- Alan E. Beer Center for Reproductive Immunology & Genetics, San Francisco, CA 94111, USA.
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Tagaloa LAL, Carvalho B. Epidural labor analgesia in a patient receiving fondaparinux. Int J Obstet Anesth 2009; 18:94-5. [DOI: 10.1016/j.ijoa.2008.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Accepted: 07/22/2008] [Indexed: 11/27/2022]
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Abstract
Abstract The risk of venous thromboembolism (VTE) varies throughout a woman’s life and is associated primarily with underlying hormonal exposure. Alteration in hemostatic mechanisms, including resistance to activated protein C, may explain this altered risk. Initially, development of VTE with the use of contraception in young adulthood may reveal inherited thrombophilia. Pregnancy, and particularly the post-partum period, likely confer the greatest risk of VTE, but the absolute risk is small. Guidelines for prevention of VTE during pregnancy are based on personal or family history of VTE, and known inherited thrombophilia. Use of hormone replacement therapy later in life is associated with increased risk of VTE, and may be safest if given as an estrogen-only preparation to young postmenopausal women for less than 5 years. Universal screening for thrombophilia prior to pregnancy or initiating hormonal therapy is not recommended; however, selected testing in high-risk groups may be warranted. The lack of firm recommendations for the prevention of VTE in women highlights the need for future investigation aimed at identifying high-risk groups and evaluating the efficacy of prophylactic measures.
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Affiliation(s)
- Suman Rathbun
- Non-invasive Vascular Laboratories, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Abstract
Normal pregnancy is accompanied by an increase in clotting factors. The resulting hypercoagulable state has likely evolved to protect women from hemorrhage at the time of miscarriage and childbirth. During pregnancy, women are 4 times more likely to suffer from venous thromboembolism (VTE) compared with when they are not pregnant. Relative to pregnancy, the risk postpartum is even higher. The incidence of VTE is approximately 2 per 1,000 births, and VTE accounts for 1 death per 100,000 births, or approximately 10% of all maternal deaths. The most important risk factors during pregnancy are thrombophilia and a history of thrombosis. A history of thrombosis increases the risk for VTE to 2% to 12%. Thrombophilia increases not only the risk for maternal thrombosis but also the risk of poor pregnancy outcome. Despite the increased risk for thrombosis during pregnancy and the postpartum period, most women do not require anticoagulation. Those who do require anticoagulation include women with current VTE, women on lifelong anticoagulation, and many women with thrombophilia or a history of thrombosis. Recommended options for anticoagulation in pregnancy are limited to heparins, which do not cross the placenta. Low-molecular-weight heparin (LMWH) is preferred over unfractionated heparin because LMWH has a longer half-life and is presumed to have fewer side effects. The longer half-life is a disadvantage around the time of delivery, when unfractionated heparin, with its shorter half-life, is easier to manage. For women who develop or are at high risk for heparin-induced thrombocytopenia or severe cutaneous reactions, fondaparinux is probably the agent of choice. Women who do not require lifelong anticoagulation, but require anticoagulation during pregnancy, will still require anticoagulation for the first 6 weeks postpartum.
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Affiliation(s)
- Andra H James
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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