Keywords
Pregnancy
Anticoagulant
Mechanical prosthetic valves
Antiphospholipid syndrome
Thrombosis
Anticoagulant
Mechanical prosthetic valves
Antiphospholipid syndrome
Thrombosis
How to Cite
Durán-Morales, M. A., Ariza-Parra, E. J., & Colonia-Toro, A. (2020). Management of anticoagulant therapy during pregnancy. Médicas UIS, 33(2), 65–73. https://doi.org/10.18273/revmed.v33n2-2020007
Abstract
Pregnancy is associated with a 5 to 10-fold increased risk of venous thromboembolic disease, making it a complex setting for anticoagulation, given the need for fetal safety and limited representation in available efficacy studies. During pregnancy there are three main clinical situations: venous thromboembolic disease without a precipitating risk factor, antiphospholipid syndrome and prosthetic mechanical valve carriers; all with a high risk of maternal-fetal complications, so it is vital to know the anticoagulants available for each pathology, their scientific evidence, adverse events and pharmacological characteristics in order to perform the best therapeutic approach and reduce associated complications. The objective is to describe the advances of anticoagulants in clinical scenarios of greater impact before conception, during pregnancy and postpartum and to serve as a tool in order to carry out the best therapeutic approach and reduce associated complications. MÉD.UIS.2020;33(2):65-73
References
James A. Practice Bulletin No. 123: thromboembolism in pregnancy. Obstet Gynecol. 2011;118(3):718-29.
OMS, UNICEF, UNFPA, Grupo del Banco Mundial y División de Población de las Naciones Unidas, Trends in maternal mortality: 1990-2015, december 2015.
Ghaji N, Boulet SL, Tepper N, et al. Trends in venous thromboembolism among pregnancy-related hospitalizations, United States, 1994-2009. Am J Obstet Gynecol. 013;209(5):433. e1-8.
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-33.
Grillo-Ardila CF, Amaya-Guío J, Molano-Franco D, Correa LP. Guía de práctica clínica para la prevención de eventos tromboembólicos venosos durante la gestación, el parto o el puerperio. Rev Colomb Obstet Ginecol. 2017;68(4):286-304.
Ministerio de salud y protección social. Análisis de situación de salud. Colombia. Diciembre. 2015.
Monroy AM, Martínez A, Montes de Oca D, Bolatti HE, Escobar MF. Guía clínica de la federación latino americana de sociedades de ginecología y obstetricia: enfermedad tromboembólica venosa y embarazo. FLASOG, GC;2014:1
Equipo Maternidad Segura Instituto Nacional de Salud Colombia. Vigilancia en salud pública de la maternidad segura. Sivigila. INS 2015.
Committee on Practice Bulletins—Obstetrics, American College of Obstetricians and Gynecologists. Practice bulletin no. 132: antiphospholipid syndrome. Obstet ynecol. 2012;120(6):1514-21.
D’Souza R, Ostro J, Shah PS, Silversides CK, Malinowski A, Murphy KE, et al. Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis. Eur Heart J. 2017; 38(19):1509-16.
Center for Drug Evaluation and Research. Evaluating the Risks of Drug Exposure in Human Pregnancies. U.S Department of Health and Human Services. Food and Drug Administration; 2005. http://www.fda.gov/downloads/Drugs/ GuidanceComplianceRegulatoryInformation/Guidances/UCM071645.pdf
Garcia D, Baglin T, Weitz J, Samama M. Parenteral Anticoagulants. Chest. 2012;141(2): e24S-e43S.
Romualdi E, Dentali F, Rancan E. Anticoagulant therapy for venous thromboembolism during pregnancy: a systemic review and a meta-analysis of the literature. J hromb Haemost. 2013; 11(2): 270-81.
Knol H, Schultinge L Erwich J, Meijer K. Fondaparinux as an alternative anticoagulant therapy during pregnancy. J Thromb Haemost. 2010;8(8):1876-9.
Greer JP, Arber DA, Glader B, List AF, Means RT, Rodgers GM. Wintrobe’s clinical hematology. 13th ed. Wolters Kluwer; 2018.
Steinberg Z, Dominguez-Islas C, Otto C, Stout K, Krieger E. Maternal and Fetal Outcomes of Anticoagulation in Pregnant Women with Mechanical Heart Valves. J Am Coll Cardiol. 2017;69(22):2681-91.
Basu S, Aggarwal P, Kakani N, Kumar A. Low-dose maternal warfarin intake resulting in fetal warfarin syndrome: In search for a safe anticoagulant regimen during pregnancy. Birth Defects Res a Clin Mol Teratol. 2016; 106(2):142-7.
Beyer-Westendorf J, Michalski F, Tittl L, Middeldorp S, Cohen H, Abdul Kadir R, et al. Pregnancy outcome in patients exposed to direct oral anticoagulants - and the challenge of event reporting. Thromb and Haemost. 2016; 116(4):651-8.
Bapat P, Kedar R, Lubetsky A, Matlow JN, Aleksa K, Berger H, et al. Transfer of dabigatran and dabigatran etexilate mesylate across the dually perfused human lacenta. Obstet Gynecol. 2014; 123(6): 1256–61.
Bapat P, Pinto LS, Lubetsky A, Aleksa K, Berger H, Koren G, et al. Examining the transplacental passage of apixaban using the dually perfused human placenta. Thromb and Haemost. 2016; 14(7): 1436–41.
Hoeltzenbein M, Beck E, Meixner K, Schaefer C, Kreutz R. Pregnancy outcome after exposure to the novel oral anticoagulant rivaroxaban in women at suspected risk for thromboembolic events: case series from the German Embryotox Pharmacovigilance Centre. Clin Res Cardiol. 2016; 105(2): 17-26.
Blondon M, Casini A, Hoppe KK, Boehlen F, Righini M, Smith N. Risks of Venous Thromboembolism After Cesarean Sections: A Meta-Analysis. Chest. 2016;150(3):572-96.
Alhassan S, Pelinescu A, Gandhi V, Naddour M, Singh A, Bihler E. Clinical Presentation and Risk Factors of Venous hromboembolic Disease. Crit Care Nurs Q. 017;40(3):201-9.
Parunov LA, Soshitova NP, Ovanesov MV, Panteleev M, Serebriyskiy I. Epidemiology of venous thromboembolism (VTE) associated with pregnancy. Birth Defects Res C Embryo Today. 2015;105(3):167-84.
Gray G, Nelson-Piercy C. Thromboembolic disorders in obstetrics. Best Pract Res Clin Obstet Gynaecol. 2012;26(1):53-64.
Barco S, Nijkeuter M, Middeldorp S. Pregnancy and venous thromboembolism. Semin Thromb Hemost. 2013;39(5):549-58.
Chan WS, Rey E, Kent NE, Rey E, Corbett T, David M, et al. Venous thromboembolism and antithrombotic therapy in pregnancy. J Obstet Gynaecol Can. 2014; 6(6):527–53.
Konkle BA. Diagnosis and management of thrombosis in pregnancy. Birth Defects Res C Embryo Today. 2015;105(3):185-9.
Fogerty AE, Connors JM. Treating venous thromboembolism in pregnancy. Hematol Oncol Clin North Am. 2011;25(2):379-91.
Fukuda W, Chiyoya M, Taniguchi S, Daitoku K, Fukuda I. Management of deep vein thrombosis and pulmonary embolism (venous thromboembolism) during pregnancy. Thorac Cardiovasc Surg. 2016;64(6):309-14.
Chan WS, Spencer FA, Ginsberg JS. Anatomic distribution of deep vein thrombosis in pregnancy. Can Med Assoc J. 2010;182(7):657- 60.
Limmer JS, Grotegut CA, Thames E, Dotters-Katz SK, Brancazio LR, James AH. Postpartum wound and bleeding complications in women who received peripartum anticoagulation. Thromb Res. 2013; 132(1): e19 – 23.
Butwick A, Hass C, Wong J, D Lyell , El-Sayed . Anticoagulant prescribing practices and anesthetic interventions among anticoagulated pregnant patients: a etrospective study. Int J Obstet Anesth. 2014;23(3):238-45.
Virkus RA, Løkkegaard EC, Lidegaard Ø, Langhoff-Roos J, Bjerregaard L, Skovlund CH, et al. Venous thromboembolism in pregnancy and the puerperal period: a study of 1210 events. Acta Obstet Gynecol Scand. 2013;92(10):1135-42.
Royal College of Obstetricians and Gynaecologists. Thromboembolic disease in pregnancy and the puerperium: acute management. Royal College of Obstetricians and Gynaecologists. 2015; 37(b).
Dobbenga-Rhodes Y. Shedding Light on Inherited Thrombophilias: The Impact on Pregnancy. J Perinat Neonatal Nurs. 2016;30(1):36- 44.
Ziakas PD, Poulou LS, Pavlou M, Zintzaras E. Thrombophilia and venous thromboembolism in pregnancy: a meta-analysis of genetic risk. Eur J Obstet Gynecol Reprod Biol. 2015; 191:106-11.
Arachchillage DRJ, Laffan M. Pathogenesis and management of antiphospholipid syndrome. Br J. Haematol. 2017;178(2):181- 195.
Antovic A, Sennström M, Bremme K, Svenungsson E. Obstetric antiphospholipid sindrome. Lupus Sci. Med. 2018;5(1):e000197.
Rezk M, Dawood R, Badr H. Maternal and fetal outcome in women with antiphospholipid syndrome: a three-year observational study. J Matern Fetal Neonatal Med. 2016;29(24):4015-9.
Rodrigues M, Afonso G, Kupty M, Bertassoni JC. Treatments and new perspectives of antiphospholipid syndrome in pregnancy. Medical Research. 2018;6(5).
Van Hagen IM, Roos-Hesselink JW, Ruys TP, Merz WM, Goland S, Gabriel H, et al. Pregnancy in women with a mechanical heart valve. ROPAC. 2015;132(2):132-42.
Xu Z, Fan J, Luo X, Zhang WB, Ma J, Lin YB, et al. Anticoagulation regimens during pregnancy in patients with mechanical heart valves: a systematic review and meta-analysis.Can J Cardiol. 2016;32(10): 1248.e1-1248.e9.
Goland S, Schwartzenberg S, Fan J, Kozak N, Khatri N, Elkayam U. Monitoring of anti-Xa in pregnant patients with mechanical prosthetic valves receiving low-molecular-weight heparin: peak or trough levels. J Cardiovasc Pharmacol Ther. 2014; 19(5):451.
Nishimura RA, Otto CM, Bonow RO, Carabello BA, ErwinIII JP, Fleisher LA, et al. Guideline for the management of patients with valvular heart disease: a report of the american college of cardiology/american heart association task force on practice guidelines. J Am Coll Cardiol. 2014; 63:e57.
OMS, UNICEF, UNFPA, Grupo del Banco Mundial y División de Población de las Naciones Unidas, Trends in maternal mortality: 1990-2015, december 2015.
Ghaji N, Boulet SL, Tepper N, et al. Trends in venous thromboembolism among pregnancy-related hospitalizations, United States, 1994-2009. Am J Obstet Gynecol. 013;209(5):433. e1-8.
Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323-33.
Grillo-Ardila CF, Amaya-Guío J, Molano-Franco D, Correa LP. Guía de práctica clínica para la prevención de eventos tromboembólicos venosos durante la gestación, el parto o el puerperio. Rev Colomb Obstet Ginecol. 2017;68(4):286-304.
Ministerio de salud y protección social. Análisis de situación de salud. Colombia. Diciembre. 2015.
Monroy AM, Martínez A, Montes de Oca D, Bolatti HE, Escobar MF. Guía clínica de la federación latino americana de sociedades de ginecología y obstetricia: enfermedad tromboembólica venosa y embarazo. FLASOG, GC;2014:1
Equipo Maternidad Segura Instituto Nacional de Salud Colombia. Vigilancia en salud pública de la maternidad segura. Sivigila. INS 2015.
Committee on Practice Bulletins—Obstetrics, American College of Obstetricians and Gynecologists. Practice bulletin no. 132: antiphospholipid syndrome. Obstet ynecol. 2012;120(6):1514-21.
D’Souza R, Ostro J, Shah PS, Silversides CK, Malinowski A, Murphy KE, et al. Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis. Eur Heart J. 2017; 38(19):1509-16.
Center for Drug Evaluation and Research. Evaluating the Risks of Drug Exposure in Human Pregnancies. U.S Department of Health and Human Services. Food and Drug Administration; 2005. http://www.fda.gov/downloads/Drugs/ GuidanceComplianceRegulatoryInformation/Guidances/UCM071645.pdf
Garcia D, Baglin T, Weitz J, Samama M. Parenteral Anticoagulants. Chest. 2012;141(2): e24S-e43S.
Romualdi E, Dentali F, Rancan E. Anticoagulant therapy for venous thromboembolism during pregnancy: a systemic review and a meta-analysis of the literature. J hromb Haemost. 2013; 11(2): 270-81.
Knol H, Schultinge L Erwich J, Meijer K. Fondaparinux as an alternative anticoagulant therapy during pregnancy. J Thromb Haemost. 2010;8(8):1876-9.
Greer JP, Arber DA, Glader B, List AF, Means RT, Rodgers GM. Wintrobe’s clinical hematology. 13th ed. Wolters Kluwer; 2018.
Steinberg Z, Dominguez-Islas C, Otto C, Stout K, Krieger E. Maternal and Fetal Outcomes of Anticoagulation in Pregnant Women with Mechanical Heart Valves. J Am Coll Cardiol. 2017;69(22):2681-91.
Basu S, Aggarwal P, Kakani N, Kumar A. Low-dose maternal warfarin intake resulting in fetal warfarin syndrome: In search for a safe anticoagulant regimen during pregnancy. Birth Defects Res a Clin Mol Teratol. 2016; 106(2):142-7.
Beyer-Westendorf J, Michalski F, Tittl L, Middeldorp S, Cohen H, Abdul Kadir R, et al. Pregnancy outcome in patients exposed to direct oral anticoagulants - and the challenge of event reporting. Thromb and Haemost. 2016; 116(4):651-8.
Bapat P, Kedar R, Lubetsky A, Matlow JN, Aleksa K, Berger H, et al. Transfer of dabigatran and dabigatran etexilate mesylate across the dually perfused human lacenta. Obstet Gynecol. 2014; 123(6): 1256–61.
Bapat P, Pinto LS, Lubetsky A, Aleksa K, Berger H, Koren G, et al. Examining the transplacental passage of apixaban using the dually perfused human placenta. Thromb and Haemost. 2016; 14(7): 1436–41.
Hoeltzenbein M, Beck E, Meixner K, Schaefer C, Kreutz R. Pregnancy outcome after exposure to the novel oral anticoagulant rivaroxaban in women at suspected risk for thromboembolic events: case series from the German Embryotox Pharmacovigilance Centre. Clin Res Cardiol. 2016; 105(2): 17-26.
Blondon M, Casini A, Hoppe KK, Boehlen F, Righini M, Smith N. Risks of Venous Thromboembolism After Cesarean Sections: A Meta-Analysis. Chest. 2016;150(3):572-96.
Alhassan S, Pelinescu A, Gandhi V, Naddour M, Singh A, Bihler E. Clinical Presentation and Risk Factors of Venous hromboembolic Disease. Crit Care Nurs Q. 017;40(3):201-9.
Parunov LA, Soshitova NP, Ovanesov MV, Panteleev M, Serebriyskiy I. Epidemiology of venous thromboembolism (VTE) associated with pregnancy. Birth Defects Res C Embryo Today. 2015;105(3):167-84.
Gray G, Nelson-Piercy C. Thromboembolic disorders in obstetrics. Best Pract Res Clin Obstet Gynaecol. 2012;26(1):53-64.
Barco S, Nijkeuter M, Middeldorp S. Pregnancy and venous thromboembolism. Semin Thromb Hemost. 2013;39(5):549-58.
Chan WS, Rey E, Kent NE, Rey E, Corbett T, David M, et al. Venous thromboembolism and antithrombotic therapy in pregnancy. J Obstet Gynaecol Can. 2014; 6(6):527–53.
Konkle BA. Diagnosis and management of thrombosis in pregnancy. Birth Defects Res C Embryo Today. 2015;105(3):185-9.
Fogerty AE, Connors JM. Treating venous thromboembolism in pregnancy. Hematol Oncol Clin North Am. 2011;25(2):379-91.
Fukuda W, Chiyoya M, Taniguchi S, Daitoku K, Fukuda I. Management of deep vein thrombosis and pulmonary embolism (venous thromboembolism) during pregnancy. Thorac Cardiovasc Surg. 2016;64(6):309-14.
Chan WS, Spencer FA, Ginsberg JS. Anatomic distribution of deep vein thrombosis in pregnancy. Can Med Assoc J. 2010;182(7):657- 60.
Limmer JS, Grotegut CA, Thames E, Dotters-Katz SK, Brancazio LR, James AH. Postpartum wound and bleeding complications in women who received peripartum anticoagulation. Thromb Res. 2013; 132(1): e19 – 23.
Butwick A, Hass C, Wong J, D Lyell , El-Sayed . Anticoagulant prescribing practices and anesthetic interventions among anticoagulated pregnant patients: a etrospective study. Int J Obstet Anesth. 2014;23(3):238-45.
Virkus RA, Løkkegaard EC, Lidegaard Ø, Langhoff-Roos J, Bjerregaard L, Skovlund CH, et al. Venous thromboembolism in pregnancy and the puerperal period: a study of 1210 events. Acta Obstet Gynecol Scand. 2013;92(10):1135-42.
Royal College of Obstetricians and Gynaecologists. Thromboembolic disease in pregnancy and the puerperium: acute management. Royal College of Obstetricians and Gynaecologists. 2015; 37(b).
Dobbenga-Rhodes Y. Shedding Light on Inherited Thrombophilias: The Impact on Pregnancy. J Perinat Neonatal Nurs. 2016;30(1):36- 44.
Ziakas PD, Poulou LS, Pavlou M, Zintzaras E. Thrombophilia and venous thromboembolism in pregnancy: a meta-analysis of genetic risk. Eur J Obstet Gynecol Reprod Biol. 2015; 191:106-11.
Arachchillage DRJ, Laffan M. Pathogenesis and management of antiphospholipid syndrome. Br J. Haematol. 2017;178(2):181- 195.
Antovic A, Sennström M, Bremme K, Svenungsson E. Obstetric antiphospholipid sindrome. Lupus Sci. Med. 2018;5(1):e000197.
Rezk M, Dawood R, Badr H. Maternal and fetal outcome in women with antiphospholipid syndrome: a three-year observational study. J Matern Fetal Neonatal Med. 2016;29(24):4015-9.
Rodrigues M, Afonso G, Kupty M, Bertassoni JC. Treatments and new perspectives of antiphospholipid syndrome in pregnancy. Medical Research. 2018;6(5).
Van Hagen IM, Roos-Hesselink JW, Ruys TP, Merz WM, Goland S, Gabriel H, et al. Pregnancy in women with a mechanical heart valve. ROPAC. 2015;132(2):132-42.
Xu Z, Fan J, Luo X, Zhang WB, Ma J, Lin YB, et al. Anticoagulation regimens during pregnancy in patients with mechanical heart valves: a systematic review and meta-analysis.Can J Cardiol. 2016;32(10): 1248.e1-1248.e9.
Goland S, Schwartzenberg S, Fan J, Kozak N, Khatri N, Elkayam U. Monitoring of anti-Xa in pregnant patients with mechanical prosthetic valves receiving low-molecular-weight heparin: peak or trough levels. J Cardiovasc Pharmacol Ther. 2014; 19(5):451.
Nishimura RA, Otto CM, Bonow RO, Carabello BA, ErwinIII JP, Fleisher LA, et al. Guideline for the management of patients with valvular heart disease: a report of the american college of cardiology/american heart association task force on practice guidelines. J Am Coll Cardiol. 2014; 63:e57.
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