Anti coagulants..in pregnancy

1. ROLE OF
ANTICOAGULANTS IN
PREGNANCY
LAKSHMI SUJANI CH
POST GRADUATE, ASRAMS

3. A
N
T
I
C
O
A
G
U
L
A
N
T
S
THROMBIN
INHIBITORS
VIT K
ANTAGONISTS
FACTOR Xa
INHIBITORS
DIRECT
INDIRECT
RIVAROXABAN
APIXABAN
FONDAPARINAUX
COUMARIN
ANTICOAGULANTS
WARFARIN
INDIRECT HEPARIN
CONGENERS
DANAPAROID
LMWH(enoxaparin,
dalteparin,tinzapari
n)
UNFRACTIONATED
HEPARIN (UFH)
DIRECT
PARENTERAL
ORAL
HIRUDIN
BIVALRUDIN
AGRATOBAN
XIMELAGATRAN
DABIGATRAN

4. INDICATIONS
Prophylaxis and treatment of DEEP VEIN
THROMBOSIS and PULMONARY EMBOLISM.
Proven deep vein involvement in SUPERFICIAL VEIN
THROMBOPHLEBITIS.
THROMBOPHILIAS
Pregnancy with ARTIFICIAL VALVES.
Pregnancy with ATRIAL FIBRILLATION.
POST CEREBRAL VEIN THROMBOSIS.
Single VTE with pateint on long term
anticoagulants.

5. INHERITED THROMBOPHILIAs
ACQUIRED THROMBOPHILIAS
• Antiphospholipid syndrome
• Heparin induced
thrombocytopaenia
• Associated cancer
Factor V leiden
mutation
Prothrombin gene
mutation
Hyperhomocystinemia
Factor S deficiency
Factor C deficiency
Anti thrombin
deficiency
¹CUNNIGHAM,LEVENO,BLOOM,SPONG,WILLIAMS OBSTETRICS,24TH EDITION

6. UNFRACTIONATED
HEPARIN[UFH]
PROPHYLACTIC DOSE THERAPEUTIC DOSE
• Monitoring by daily aPTT.
a) IV BOLUS – 10,000 U
b) IV INFUSION ⁱ for seven
days or till pain subsides in
DVT
[ target aPTT- 2 to 2.5]
c) SC heparin – 10,000U or
more
[ target aPTT- 1.5 to 2]
6hrs post SC….
• Needs no monitoring.
• MINIDOSE- 5000IU SC 12hrs.
• PROPHYLACTIC DOSE
TRIMESTER UNITS SC every 12hrs
First 5000 - 7500
Second 7500 – 10,000
Third 10,000.
FERNANDO ARIAS,PRACTICAL GUIDE TO HIGH RISK PREGNANCY, 4TH EDITION.

7. …. Therapeutic dose.
• SC heparin till delivery
• Stopped 24 hrs before
induction/ elective section.
• Unexpected labour/section
interval less than 12hrs
needs reversal with
PROTAMINE SULPHATE.
• Start heparin 12 to 24 hrs
later + 5mg warfarin.
ⁱCALCULATION OF IV INFUSION DOSE
= CSS X K X V
Css is steady state concentration ,
0.2 to 0.3 micro/ml-therapeutic level
K is elimination constant(0.832micro/hr)
V is volume of distribution
FERNANDO ARIAS,PRACTICAL GUIDE TO HIGH RISK PREGNANCY, 4TH EDITION.
UNFRACTIONATED
HEPARIN[UFH]

8. Prophylactic dose
• No need of monitoring.
Therapeutic dose
• Monitored by anti Xa
levels.
DRUG DOSE SC ONCE DAILY
ENOXAPARIN 40mg
DALTEPARIN 5000U
TINZAPARIN 4500U
DRUG SC EVERY 12HRS
ENOXAPARIN 1mg/kg
DALTEPARIN 100U/kg
TINZAPARIN 100U/kg.
FERNANDO ARIAS,PRACTICAL GUIDE TO HIGH RISK PREGNANCY, 4TH EDITION.
• Target anti Xa levels 0.6 to 1 U/ml.
• Switched to UFH – 36 weeks
• Can start LMWH with WARFARIN
on postpartum day 1.

9. GUIDELINES
• ACOG 2013—advises that adjusted dose LMWH
or UFH can be discontinued 24 to 36 hrs before
induction of labour or caesarean delivery.
• Withhold neuraxial blockade for
• ACOG 2012– recommends interval to restart
LMWH/UFH
PROPHYLACTIC DOSE 12 hrs
THERAPEUTIC DOSE 24 hrs
--ASRAPM (Horlocker,2010)
POST NVD 4 to 6hrs
POST LCSC 6 to 12hrs

10. • PROPHYLACTIC LMWH/UFH + WARFARIN 5 to 10mg
(4 to 5 days) (6weeks)
• Target INR -- 2 to 3.
• Early UFH or LMWH to avoid paradoxical
thrombosis .
• Weekly PT INR monitoring.
POSTPARTUM
ANTICOAGULATION

11. UFH vs LWMH

12. side effects
Haemorrhage
Thrombocytopaenia
osteoporosis

13. • Known large oesophageal varices.
• + Significant thrombocytopaenia(less than
50,000/cc)
• Within 72 hrs of major surgery with risk of
bleeding.
• Previously documented hypersensitivity to drug
or exciepients.
• Acute clinically significant bleed.
CONTRAINDICATIONS

14. thankyou