Thromboprophylaxis at Caesarean section
Authors:
Jan Bláha 1; Kateřina Bláhová 2; Ivana Kolníková 1; MUDr. Pavlína Nosková, Ph.D. 1
Authors‘ workplace:
Klinika anesteziologie, resuscitace a intenzivní medicíny 1. LF UK a VFN v Praze
1; Gynekologicko-porodnická klinika 1. LF UK a VFN v Praze
2
Published in:
Prakt Gyn 2012; 16(2-4): 81-88
Category:
Gynecology and Obstetrics: Review Article
Overview
Thromboembolism in developed countries belongs to the most frequent causes of maternal mortality and morbidity. A caesarean section is regarded as one of the important risk factors; therefore pharmacologic thromboprophylaxis with low-molecular-weight heparins (LMWH) is now a standard part of perioperative care for the woman in operative labor. On the basis of current evidence, however, the universal effectiveness of this prophylaxis in cesarean delivery is at least a matter of controversy. Prevention of TEN should not be generalized, but strictly on the basis of individualized risk stratification for each patient, while in patients with low risk of TEN an application of LMWH is no longer generally recommended. Therefore the aim of this article is to review the issue of thromboembolism in pregnant women with a specific focus on the caesarean section.
Key words:
thromboembolism – thromboprophylaxis – caesarean sectio – pregnancy – low molecular weight heparins – LMWH
Sources
1. Lyons G. Saving mothers‘ lives:confidential enquiry into maternal and child health 2003–5. Int J Obstet Anesth 2008; 17(2): 103–105.
2. James AH. Prevention and management of venous thromboembolism in pregnancy. Am J Med 2007; 120(10 Suppl 2): S26–S34.
3. Kujovich JL. Hormones and pregnancy:thromboembolic risks for women. Br J Haematol 2004; 126(4): 443–454.
4. Heit JA, Kobbervig CE, James AH et al. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005; 143(10): 697–706.
5. James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period:incidence, risk factors, and mortality. Am J Obstet Gynecol 2006; 194(5): 1311–1315.
6. James AH. Pregnancy-associated thrombosis. Hematology Am Soc Hematol Educ Program 2009: 277–285.
7. Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med 2008; 359(19): 2025–2033.
8. Tooher R, Gates S, Dowswell T, Davis LJ. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. Cochrane Database Syst Rev 2010(5): CD001689.
9. Gherman RB, Goodwin TM, Leung B et al. Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy. Obstet Gynecol 1999; 94(5 Pt 1): 730–734.
10. Zeitlin J, Mohangoo A, Cuttini M et al. The European Perinatal Health Report:comparing the health and care of pregnant women and newborn babies in Europe. J Epidemiol Community Health 2009; 63(9): 681–682.
11. Pomp ER, Lenselink AM, Rosendaal FR, Doggen CJ. Pregnancy, the postpartum period and prothrombotic defects:risk of venous thrombosis in the MEGA study. J Thromb Haemost 2008; 6(4): 632–637.
12. James AH. Pregnancy and thrombotic risk. Crit Care Med 2010; 38(2 Suppl): S57–S63.
13. Greer IA. Thrombosis in pregnancy:maternal and fetal issues. Lancet 1999; 353(9160): 1258–1265.
14. Mahieu B, Jacobs N, Mahieu S et al. Haemostatic changes and acquired activated protein C resistance in normal pregnancy. Blood coagulation & fibrinolysis :an international journal in haemostasis and thrombosis 2007; 18(7): 685–688.
15. Brenner B. Haemostatic changes in pregnancy. Thromb Res 2004; 114(5–6): 409–414.
16. Clark P, Brennand J, Conkie JA et al. Activated protein C sensitivity, protein C, protein S and coagulation in normal pregnancy. Thromb Haemost 1998; 79(6): 1166–1170.
17. Rosenkranz A, Hiden M, Leschnik B et al. Calibrated automated thrombin generation in normal uncomplicated pregnancy. Thromb Haemost 2008; 99(2): 331–337.
18. Bremme KA. Haemostatic changes in pregnancy. Best Pract Res Clin Haematol 2003; 16(2): 153–168.
19. Ku DH, Arkel YS, Paidas MP, Lockwood CJ. Circulating levels of inflammatory cytokines (IL-1 beta and TNF-alpha), resistance to activated protein C, thrombin and fibrin generation in uncomplicated pregnancies. Thromb Haemost 2003; 90(6): 1074–1079.
20. Kruithof EK, Tran-Thang C, Gudinchet A et al. Fibrinolysis in pregnancy:a study of plasminogen activator inhibitors. Blood 1987; 69(2): 460–466.
21. Macklon NS, Greer IA, Bowman AW. An ultrasound study of gestational and postural changes in the deep venous system of the leg in pregnancy. Br J Obstet Gynaecol 1997; 104(2): 191–197.
22. Macklon NS, Greer IA. The deep venous system in the puerperium:an ultrasound study. Br J Obstet Gynaecol 1997; 104(2): 198–200.
23. Marik PE. Venous thromboembolism in pregnancy. Clin Chest Med 2010; 31(4): 731–740.
24. Boer K, den Hollander IA, Meijers JC, Levi M. Tissue factor-dependent blood coagulation is enhanced following delivery irrespective of the mode of delivery. J Thromb Haemost 2007; 5(12): 2415–2420.
25. Miller MA, Chalhoub M, Bourjeily G. Peripartum pulmonary embolism. Clin Chest Med 2011; 32(1): 147–164, ix–x.
26. Roeters van Lennep JE, Meijer E, Klumper FJ et al. Prophylaxis with low-dose low-molecular-weight heparin during pregnancy and postpartum:is it effective? J Thromb Haemost 2011; 9(3): 473–480.
27. Jacobsen AF, Skjeldestad FE, Sandset PM. Ante- and postnatal risk factors of venous thrombosis:a hospital-based case-control study. J Thromb Haemost 2008; 6(6): 905–912.
28. Patel JP, Hunt BJ. Where do we go now with low molecular weight heparin use in obstetric care? J Thromb Haemost 2008; 6(9): 1461–1467.
29. RCOG. Thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the Risk (Green-top Guideline 37a) 2009. Dostupné z WWW: http://www.rcog.org.uk/womens-health/clinical-guidance/reducing-risk-of-thrombosis-greentop37a.
30. Liu S, Liston RM, Joseph KS et al. Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ: Canadian Medical Association journal 2007; 176(4): 455–460.
31. Jacobsen AF, Drolsum A, Klow NE, Dahl GF, Qvigstad E, Sandset PM. Deep vein thrombosis after elective cesarean section. Thrombosis research 2004; 113(5): 283–288.
32. Widimský J, Malý J, Eliáš P, Lang O, Franc P, Roztočil K. Doporučení diagnostiky, léčby a prevence plicní embolie. Vnitr Lek 2008; 54(Suppl 1): S25-S72.
33. Horlocker TT, Wedel DJ, Rowlingson JC et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy:American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35(1): 64–101.
34. Clark P, Twaddle S, Walker ID et al. Cost-effectiveness of screening for the factor V Leiden mutation in pregnant women. Lancet 2002; 359(9321): 1919–1920.
35. Wu O, Robertson L, Twaddle S et al. Screening for thrombophilia in high-risk situations:a meta-analysis and cost-effectiveness analysis. Br J Haematol 2005; 131(1): 80–90.
36. Bates SM, Greer IA, Hirsh J, Ginsberg JS. Use of antithrombotic agents during pregnancy:the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126(3 Suppl): 627S–644S.
37. Greer IA, Nelson-Piercy C. Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy:a systematic review of safety and efficacy. Blood 2005; 106(2): 401–407.
38. Patel JP, Patel RK, Davies JG, Arya R. Prophylaxis with low-dose low molecular weight heparin during pregnancy and the puerperium:is it effective? A rebuttal. J Thromb Haemost 2011; 9(6): 1269–1271; author reply 1272–1263.
39. Stock SJ, Walker MC, Edelshain BT et al. Fixed dosing regimes of enoxaparin for thromboprophylaxis do not reliably achieve target anti-Xa levels in women of normal weight during pregnancy. Eur J Obstet Gynecol Reprod Biol 2011; 158(1): 112–113.
40. Fox NS, Laughon SK, Bender SD et al. Anti-factor Xa plasma levels in pregnant women receiving low molecular weight heparin thromboprophylaxis. Obstet Gynecol 2008; 112(4): 884–889.
41. Yoneda M, Brosnan JF, Norris LA, Bonnar J. The effect of LMWH (tinzaparin) on coagulation and fibrinolytic activation in pregnant women at risk of thrombosis. Thromb Res 2006; 117(3): 283–290.
42. Shapiro NL, Kominiarek MA, Nutescu EA et al. Dosing and monitoring of low-molecular-weight heparin in high-risk pregnancy:single-center experience. Pharmacotherapy 2011; 31(7): 678–685.
43. Butwick AJ, Carvalho B. Neuraxial anesthesia in obstetric patients receiving anticoagulant and antithrombotic drugs. Int J Obstet Anesth 2010; 19(2): 193–201.
44. Norris LA, Bonnar J, Smith MP et al. Low molecular weight heparin (tinzaparin) therapy for moderate risk thromboprophylaxis during pregnancy. A pharmacokinetic study. Thromb Haemost 2004; 92(4): 791–796.
45. Sephton V, Farquharson RG, Topping J et al. A longitudinal study of maternal dose response to low molecular weight heparin in pregnancy. Obstet Gynecol 2003; 101(6): 1307–1311.
46. Greer I, Hunt BJ. Low molecular weight heparin in pregnancy:current issues. Br J Haematol 2005; 128(5): 593–601.
47. Lebaudy C, Hulot JS, Amoura Z et al. Changes in enoxaparin pharmacokinetics during pregnancy and implications for antithrombotic therapeutic strategy. Clinical pharmacology and therapeutics 2008; 84(3): 370–377.
48. Anderson GD. Pregnancy-induced changes in pharmacokinetics:a mechanistic-based approach. Clinical pharmacokinetics 2005; 44(10): 989–1008.
49. Bates SM, Greer IA, Pabinger I et al. Venous thromboembolism, thrombophilia, antithrombotic therapy, and pregnancy:American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133(6 Suppl): 844S–886S.
50. Kaiser P, Harenberg J, Walenga JM et al. Effects of a heparin-binding protein on blood coagulation and platelet function. Semin Thromb Hemost 2001; 27(5): 495–502.
51. Bláha J. LMWH vs. regionální anestezie v porodnictví. 18. národní kongres ČSARIM. Praha 2011 (přednáška).
52. Abad Rico JI, Lozano Sanchez FS, Rocha E. Clinical experience with bemiparin. Drugs 2010; 70(Suppl 2): 25–33.
53. Sanchez-Ferrer CF. Bemiparin: pharmacological profile. Drugs 2010, 70(Suppl 2): 19–23.
54. Fontcuberta Boj J. New frontiers with bemiparin: use in special populations. Drugs 2010, 70(Suppl 2):43–47.
55. Santamaría A, Vila J, Marco A et al. Clinical management using low-molecular-weight heparin (LMWH) in pregnant women with thrombophilia, thromboembolic disease (DVT) or thrombophilia-related maternoplacental syndrome: experience in one center. J Thromb Haemost 2007, 5(Suppl 2): P-W-587 (abstrakt ).
56. Alalaf S: Bemiparin versus low dose aspirin for management of recurrent early pregnancy losses due to antiphospholipd antibody syndrome. Arch Gynecol Obstet 2012; 285(3):641–647.
57. CLEXANE INJ SOL 2X0. 4ML/4KU. Dostupné z WWW: http://www.sukl.cz/modules/medication/detail.php?kod=0115406.
58. Gogarten W, Vandermeulen E, van Aken H et al. Regional anaesthesia and antithrombotic agents:recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 2010; 27(12): 999–1015.
59. Hull RD, Pineo GF, MacIsaac S. Low-molecular-weight heparin prophylaxis:preoperative versus postoperative initiation in patients undergoing elective hip surgery. Thromb Res 2001; 101(1): V155–162.
60. Strebel N, Prins M, Agnelli G, Buller HR. Preoperative or postoperative start of prophylaxis for venous thromboembolism with low-molecular-weight heparin in elective hip surgery? Arch Intern Med 2002, 162(13): 1451–1456.
61. Geerts WH, Bergqvist D, Pineo GF et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008, 133(6 Suppl): 381S–453S.
62. Huo MH, Spyropoulos AC: The eighth American college of chest physicians guidelines on venous thromboembolism prevention: implications for hospital prophylaxis strategies. J Thromb Thrombolysis 2011, 31(2): 196–208.
63. AWMF-Leitlinie Prophylaxe der venösen Thromboembolie (VTE). Dostupné z WWW:http://www.awmf.org/leitlinien/detail/ll/003–001.html
64. Sia WW, Powrie RO, Cooper AB et al. The incidence of deep vein thrombosis in women undergoing cesarean delivery. Thrombosis research 2009, 123(3): 550–555.
Labels
Paediatric gynaecology Gynaecology and obstetrics Reproduction medicineArticle was published in
Practical Gynecology
2012 Issue 2-4
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