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Dvt in pregnancy
1. PHARMACOLOGIC
MANAGEMENT OF DEEP
VEIN TROMBOSIS IN
PREGNANCY AND
NURSING IMPLICATIONS
Dora Aguilar
Isabel Barradas
Linda Guevara
Luz Luque
2. Deep Vein Thrombosis in Pregnancy
• In pregnancy
• Hypercoagulable state.
• Leading cause of maternal death in the United States
3. Epidemiology
• Incidence of DVT
• Estimated at 1 in 500 – 2000 deliveries.
• 75% - 80% of cases of pregnancy associated venous tromboembolism.
• Most frequent on the left side lower extremity (85%).
4. Risk factors
• Physiological pregnancy process
• Virchow’s triad of hypercoagulation.
• Hypercoagulable state
• Vascular damage
• Venous stasis
• Inherited
• Acquired
• Antiphospholipid antibody syndrome
• Pregnancy age more than 35
• Parity more than 3
• Obesity
• Inmobilization
• Smoking
• Medical problems
• Hypertension, nephrotic syndrome, sever infection
• Cesarean dellivery
5. Pathophysiology
• Hypercoagulable state.
• Increased serum levels of procoagulants
• II, VII, VIII, X, XII
• Fibrinogen
• Decreased during pregnancy
• Protein S
• Protein C
• Decreased fibrinolytic state
• Increase Serum plasminogen activator inhibitor-1 (PAI-1)
• Placental activator inhibitor-2 (PAI-2)
6. Signs and Symptoms
• Most frequent on the left side lower extremity.
• Leg pain and swelling are unilateral.
• Hofman’s sign
• No specific for DVT diagnosis
9. Treatment
• Therapeutic anticoagulation
All women with acute venous thromboembolism
• Women with high risk of thrombosis
Mechanical heart valve
History of thrombosis
Thrombophilia
10. Treatment
• Drugs used during pregnancy or postpartum
• Unfractionated heparine
• Low molecular weight heparin (LMWH)
• Warfarin
11. Treatment
• Heparin Compounds
• Unfractionated heparin (UFH)
• Low molecular weight heparin (LMWH)
• They both bind to anti-thrombine II increasing its interaction with the clotting factor X
producing anticoagulant effect.
• LMWH can be monitor with anti-factor Xa Levels every 1-3 months keeping them at
0.5 – 1.2 U/ml.
• UFH increase interaction between anti-thrombine II and thrombine (factor II), prolonging the
aPTT that is used to monitor unfractionated heparine.
12. Treatment
• UFH and LMWH are harmless during the gestation
• Does not cross the placenta
• Does not cause teratogenic or toxic fetal effect.
• Have shorter half-lives
• Lower peak plasma concentration
• High rate of clearance in pregnancy women
• Augmented glomerular filtration
13. Treatment
Adverse effects UFH and LMWH
• Osteoporosis
• Heparin-induced thrombocytopenia
• Calcium and Vitamin D reduce risk of osteoporosis.
Advantages of LMWH
•Fewer adverse effects than UFH
•Fewer bleeding episodes
•Lower risk of heparin-induced thrombocytopenia
•Less bone mineral density loss
•More predictable therapeutic response
•Disadvantages of LMWH
•More expensive
•Longer half-life compared with UFH
14. Treatment
• LMWH must be stopped 24 hours previous regional anesthesia or
induction of labor.
• LMWH can be change for UFH at 36 weeks of pregnancy and
instruct to the patient to stop UFH when spontaneous labor starts.
• Anticoagulation will be reassumed after 6 hours of vaginal delivery
or 6 to 12 hours after cesarean.
• UFH therapeutic dosage is 80 U/kg bolus intravenous
• 18 U/kg/hour adjusted to aPTT of 60-80 SC
• 216 U/kg /12 hr
• UFH prophylactic dose is 5,000 U (1st trimester)
7,500 U (2nd trimester)
10,000 U (3rd trimester) SC twice daily.
16. Treatment
• Warfarin
• Inhibits the generation of Vit K-dependent procoagulants factors
• II, VII, IX, X, protein C and S.
• Associated with warfarin embriopathy when is used during the 1st semester
• Nasal bone, hypoplasia, condrodysplasia puntata, congenital heart defects,
agenesis of corpus callosum.
• After 12 weeks of gestation, it is related with fetal bleeding and pregnancy loss.
• Incidence of congenital abnormalities is 6-10% and fetal demise is 30%.
• Mother with mechanical heart valves after 12 week of gestation.
• More used during postpartum
• Dosage is 5 -10 mg daily. It must be overlap with heparin for 5 to 7 days until
get INR.
17. Treatment
• Allergic patient
• Danaparoid
• Probably does not cross the placent
• Has long half-life without a reversible agent
• It is not available in the United States since 2002
• It is accessible in Canada and Europe
• Fondaparinux
• First option in patients with heparin-induced trobocitopenia
• Binds to antithrombin III to facilitate its binding to factor X to inactivate it and stopping
the clotting cascade.
• Released intact and can keep inhibiting more factor X.
• Its half-life is 17 hrs.
• Cathegory B (studies in-vitro human show that does not cross placenta significantly
• Profilaxis dosage is 2.5 mg SC daily
• Therapeutic dosage is 5-10 mg SC daily
18. Nursing Implications
• The “gold standard” in DVT is LMWH by SC injections.
• Reduce risk of a pulmonary embolism
• Reduce risk of developing another clot in the legs.
•LMWH:
•Has potential advantages over UFH during pregnancy.
•Cause less heparin induced thrombocytopenia.
•Has the potential for once-daily administration.
•Lower risk of heparin-induced osteoporosis.
•Coumarin:
•Can cross the placenta:
•Bleeding in the fetus and teratogenicity.
•Embryopathy (nasal hypoplasia and/or stippled epiphyses).
Trauma of delivery can lead to bleeding in the neonate.
19. Nursing Implications
• Potential fetal complications of maternal anticoagulant therapy:
• Teratogenicity
• Bleeding
• UFH and LMWH do not cross the placenta.
• Inhibit complications.
• Bleeding at the uteroplacental junction is possible.
20. Nursing Implications
• Enoxaparin (LovenoxR)
• Assess the patient for signs of bleeding and hemorrhage
• Bleeding gums
• Nose bleeding
• Unusual bruising
• Tarry stools
• Hematuria
• Fall in hematocrit
• Fall in the blood pressure levels
• Monitor for signs of hypersensitivity reactions
• Chills
• Fever
• Urticaria
• Platelets count, elevation of AST and ALT levels
• Special monitoring of aPTT is not necessary
21. Nursing Implications
• Fondaparinux (ArixtraR)
• Alternative medication used in acute DVT in pregnancy.
• Advise the patient to report unusual
• Bleeding
• Itchiness
• Rash
• Fever
• Platelet count must be monitored on regular intervals
• It may cause asymptomatic elevation of AST and ALT
• Fully reversible while having no association with increased bilirubin levels
22. Nursing Implications
• Measures recommended:
• Staying active as tolerated
• Wearing prescribed compression stocking to help circulation in the legs.
• Warm compresses to the affected area
• Elevation of the affected extremity
• To reduce the risk of acute DVT when travelling:
• Drink plenty of water
• Do not drink alcohol (it can lead to dehydration)
• Perform simple leg exercises (flexing ankles up and down)
• Take short walks when in-flight.
23. Nursing Implications
• American College of Chest Physicians (Bates et al. ACCP, 2012)
recommends:
• LMWH for the prevention and treatment of VTE in pregnant women instead of
unfractionated heparin (Grade 1B).
• For pregnant women with acute VTE, the anticoagulants will 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).
24. Nursing Implications
• Women with criteria for antiphospholipid antibody syndrome (APLA) with three
or more pregnancy losses give:
• Antepartum administration of prophylactic or intermediate-dose unfractionated heparin
of prophylactic LMWH combined with low-dose aspirin (75-100mg/dl) over no treatment
(Grade 1B).
• For women with inherited thrombophilia and history of pregnancy complications:
• Eliminating antithrombotic prophylaxis (Grade 2C).
• For women with two or more miscarriages but without APLA or thrombophilia:
• Antithrombotic prophylaxis (Grade 1B).
