THE INFORMATION IN THE OBPHARMACOPOEIA^TM IS INTENDED SOLELY FOR USE BY THE MEDICAL PROFESSION. IT IS NOT INTENDED FOR LAY PERSONS.

FOCUS INFORMATION TECHNOLOGY, INC. DOES NOT ASSUME ANY RESPONSIBILITY FOR ANY ASPECT OF HEALTHCARE ADMINISTERED WITH THE AID OF THIS CONTENT. THE PRESCRIBING PHYSICIAN MUST BE FAMILIAR WITH THE FULL PRODUCT LABELING AS PROVIDED BY THE MANUFACTURER AND RELEVANT MEDICAL LITERATURE PRIOR TO USING THE OBPHARMACOPOEIA^TM .

Background

The incidence of VTE is reported to be from 0.6 to 1.3 episodes per 1,000 deliveries.
Risks of pharmacological (heparin-induced thrombocytopenia, bleeding, and osteoporotic fracture) or mechanical prophylaxis must be weighed against this risk of VTE [2].

The American College of Chest Physicians (ACCP) recommends that acutely ill medical patients admitted to hospital who are confined to bed and have one or more additional risk factors have thromboprophylaxis with LMWH, LDUH, or fondaparinux [6]. LMHW is the preferred agent during pregnancy [2]. ACCP recommends mechanical methods of thromboprophylaxis be used primarily in\ patients at high risk for bleeding, or as an adjunct to anticoagulant-based thromboprophylaxis [6].


Monitoring
While the risk for HIT has been considered to be low with the use of LMWH [7], there is some evidence that periodic monitoring of patient’s platelet count while on LMWH may be warranted [8]. “Renal function should be considered when making decisions about theuse and/or the dose of LMWH Evaluation of renal function is indicated with the use of LMWH “[6].
 

See also

• DVT Risk Assessment and Prevention Orders

The Pregnancy and Thrombosis Working Group recommends no pharmacological  thromboprophylaxis antepartum or postpartum for patients with the following thrombophilias who have NO history of venous thromboembolism (VTE) unless there are other reasons for providing VTE prophylaxis such as cesarean delivery.

• Factor V Leiden heterozygote
• Prothrombin G20210A heterozygote
• Antiphospholipid antibodies
• Protein C deficiency
• Protein S deficiency
• Hyperhomocysteinemia

• Thrombophilias with or without H/O VTE [1-3]:
  • Factor V Leiden homozygote
  • Prothrombin G20210A homozygote
  • Antithrombin III deficiency
  • Compound heterozygote of Factor V Leiden and Prothrombin G20210A
• Antiphospholipid antibodies with H/O VTE [2,3]
• Active arterial and or venous embolism [1]
• Multiple (two or more) episodes of VTE and/or women receiving long-term anticoagulants (e.g., single episode of VTE—either idiopathic or associated with thrombophilia) [1-3]

• History of rheumatic heart disease with current atrial fibrillation [2]
• Patients with Mechanical Heart Valves [2]
  
  • "Adjusted-dose, twice-daily LMWH throughout pregnancy in doses adjusted either to keep a 4-hour postinjection anti-Xa heparin level at approximately 1.0 to 1.2 U/mL (preferable) or according to weight OR
    
  • Aggressive adjusted-dose UFH throughout pregnancy: i.e., administered SC every 12 hours in doses adjusted to keep the mid-interval aPTT at least twice control or to attain an anti-Xa heparin level of 0.35 to 0.70 U/mL  OR
    
  • UFH or LMWH (as above) until the thirteenth week, change to warfarin until the middle of the third trimester, and then restart UFH or LMWH .
  • In women with prosthetic heart valves at high risk low-dose aspirin, 75 to 162 mg/day ."

• Removal of an epidural catheter should be done when the anticoagulant effect of the thromboprophylaxis is at a minimum (usually just before the next scheduled subcutaneous injection). Anticoagulant thromboprophylaxis should be delayed for at least 2 h after spinal needle or epidural catheter removal.”[6]
• Patients who undergo cesarean delivery with thrombophilias without a history of VTE or WITH a history of adverse pregnancy outcome (APO) should receive prophylactic UFH or LMWH for 6 weeks postpartum [1].
• Patients on prophylactic LMWH or UFH for VTE  should continue on the same dose for 6 weeks  postpartum.
• Patients on adjusted dose of UFH or LMWH can be restarted on heparin and warfarin 5 mg concurrently. Adjust the warfarin dosage according to pharmacy protocols [5]. Do not discontinue heparin until  INR has been therapeutic for at least 2 days [1]. Therapeutic anticoagulation is usually achieved in 5 to 7 days, but may take longer.
• Obtain hematology consultation for patients on long term anticoagulation .