Prevention and Tr of DVT & pulmonary embolism in Obstetric practice

Basics of  Deep vein thrombosis & Pulm embolism What are the risk factors for Deep vein thrombosis?? 1) Antiphospholipid antibody syndrome 2) Operative procedure and 3) CS delivery 4) Parity > 4: 5) Pregnancy induced hypertension 6)Age  > 35 years 7) Obesity 8) Gross varicose veins 9) Previous limb # or limb defects or  even Paraplegia 9) Medical disorders: nephritic syndrome, 10) sickle cell disease 11) Myeloproliferative disorders

12) Hypovolemia – so in obese women one can  continue  the drip for 36 hrs or more 13) , massive blood loss 14)

Hyperemesis, 15) dehydration 16) Nonpreg or even pregàif Long distance travel 17) Prolonged immobilization. 18) >35 yrs 2) Smoking 3) Migraine with aura / focal neurologic symptoms 4) Those who have coronary artery diseases 5) Those who have P/H/O CVA  or CCF 6) Hyper Homocysteinaemia 7) Hypertriglyceridameia 8) Decreased Vit B12 function 9) Deficiency of Protein C, S, Antithrombin III. 10) SLE.

Prolonged labor 19) septic abortion,  peritonitis or severe infection, e.g. pyelonephritis 20 ) Ovarian hyperstimulation syndrome21) Operations for ca Cx /Ca ovary à  Malignancy especially pelvic and abdominal

Decrease in naturally occurring anticoagulants like antithrombin III, protein S,

When do you start administration of LMWH?

Inj. LMWH 0.6 ml sc daily   for 3 to 5 days depending on  degree and day of ambulation. Other factors 1)   , duration of surgery,2)  Past history, 3) smokers ) Antiphospholipid antibody syndrome 2) Operative procedure and 3) CS delivery 4) Parity > 4: 5) Pregnancy induced hypertension 6)Age  > 35 years 7) Obesity 8) Gross varicose veins 9) Previous limb # or limb defects or  even Paraplegia 9) Medical disorders: nephritic syndrome, 10) sickle cell disease 11)

12) Hypovolemia – so in obese women one can  continue  the drip for 36 hrs or more 13) , massive blood loss 14)

Hyperemesis, 15) dehydration 16) Nonpreg or even pregàif Long distance travel 17) Prolonged immobilization. 18)

Prolonged labor 19) septic abortion,  peritonitis or severe infection, e.g. pyelonephritis 20 ) Ovarian hyperstimulation syndrome21) Operations for ca Cx /Ca ovary à  Malignancy especially pelvic and abdominal etc can start inj Clexane 80mg sc , OD, 12hrs after the spinal. Give for 5-7days. No monitoring is required for prophylactic dose. -Enoxaparin 60 mg s/c OD* 5 days. Start 12 hrs post surgery.
-Prophylaxis (other steps):_Early ambulation
-Stockings for prophylaxis
-Monitoring not needed.

Only 6 doses of Lonopin 40.1st after 24 hours ,later every day .for 5 days

Unfractionated  Heparin

Beparin Injection, 25000 I.U in   5 ml Mfg: Samarth Life Sciences Pvt  Ltd

CAPRIN 25000 IU 5ML INJ),. Unfractionated Heparin. Inj Hep (Gland.  ),b)  Inj Rin (Samarth.)

Brand Names:- UFH  is superior to LMWH in regard to aPL Syndrome. Each vial consists 25,000 i.u. per 5 ml. vial.,

Inj Hep (Gland.  ),b)  Inj Rin (Samarth.) Beparin Injection, 25000 I.U in   5 ml Mfg: Samarth Life Sciences Pvt Ltd

CAPRIN 25000 IU 5ML INJ),.

DOSE:-Prophylactic  Dose:- 5,000 i.u. BD,

In cases with +ve serum markers for aPL, but negative for H/O VTE and negative for H/O Rec. abortion: - Aspirin & UFH 5000 i.u. BD or opt for aspirin & LMWH 40 mg/ day.

Target :--Therapeutic dose in PE or VTE:- The dose adjusted according to aPTT keeping it 1.5-2 times the normal. Usually 7,500- 10,000 i.u. subcut BD. As initial dose

Monitoring:- UFH can cause immune mediated thrombocytopenia, May add Calcium and Vit D to augment bone metabolism. Thrombocytopenia-.So it is mandatory to perform to aPTT & Platelate count after 2weks of initiation of UFH (5,000) preparations. If more than 6 months estimate BMD.

Dose:-

a) in prophylactic dose for prevention of further VTE and APL syndrome:-

While patient on therapeutic dose ; aPTT(Activated Partial Thromboplastin Time). aPTT should be kept 1.5 to 2 times than normal., Platelate count .

Action against overdosing:-

D). Thrombolytic & Fibrinolytics  Alteplase: used in MI patients.

E). Inj. Urokinase Proteolytic  Enzyme & Thrombolytic

F).) Endogenous PLASMINOGEN activator & Thrombolytic Inj. Urokinase Proteolytic  Enzyme & Thrombolytic Inj. Urokinase

Disease which can lead to spont thrombosis:_-Age  >35 yrs 2) Smoking 3) Migraine with aura / focal neurologic symptoms 4) Those who have coronary artery diseases 5) Those who have P/H/O CVA  or CCF 6) Hyper Homocysteinaemia 7) Hypertriglyceridameia 8) Decreased Vit B12 function 9) Deficiency of Protein C, S, Antithrombin III. 10) SLE.

Coagulation Disorders and Thromboembolism in Pregnancy

Venous thromboembolism (VTE) comprises of deep vein thrombosis (DVT) or pulmonary thromboembolism (PE) or both.

Venous thromboembolism results in significant morbidity and mortality during pregnancy and puerperium: Venous thromboembolism is globally recognized  a leading cause of maternal mortality. However in   West

Incidence 1 in 1500 deliveries (West) 1 in 1000 (India). This may postpartum or post operative. Postpartum DVT  is 3 times  more than antepartum (3-16 times)

More after cesarean section than normal delivery :-The incidence is approximately in 1 in 1500 deliveries seen in the west and according to an Indian study, antenatal DVT is 0.1%. The risk is lower for Asian and Hispanic women, higher for white and highest for black women. Postpartum DVT has been reported to occur 3 to 5 times more often than antepartum DVT and 3 to 16 times more frequent after cesarean section compared to vaginal delivery.

MMR & DVT:_Venous thromboembolism is leading cause of maternal mortality in western world and accounts for 17% of all maternal deaths.

Mortality is primarily due to massive pulmonary embolism which commonly occurs from a thrombus embolising  from deep veins of lower extremities. Pulmonary embolism can occur in up to 24% of untreated patients of deep vein thrombosis. Thrombosis of ileo-femoral veins is more common than thrombosis of calf vein in pregnancy and has a higher risk of pulmonary embolism. Early diagnosis and treatment in patients with acute venous thromboembolism decreases the mortality rate to <1%. Risk factors associated with increased risk for venous thromboembolism have been identified. Primary prophylaxis decreases the rate of thromboembolic events in high risk patients.

PATHOPHYSIOLOGY

Hemostasis is a physiological process of four major steps occurring in set order.

Step 1: Vasoconstriction

Coagulation Disorders and Thromboembolism in Pregnancy

Venous thromboembolism (VTE) comprises of deep vein thrombosis (DVT) or pulmonary thromboembolism (PE) or both.

Venous thromboembolism results in significant morbidity and mortality during pregnancy and puerperium: Venous thromboembolism is globally recognized  a leading cause of maternal mortality. However in   West Incidence 1 in 1500 deliveries (West) 1 in 1000 (India). This may postpartum or post operative. Postpartum DVT  is 3 times  more than antepartum (3-16 times)

More after cesarean section than normal delivery :-The incidence is approximately in 1 in 1500 deliveries seen in the west and according to an Indian study, antenatal DVT is 0.1%. The risk is lower for Asian and Hispanic women, higher for white and highest for black women. Postpartum DVT has been reported to occur 3 to 5 times more often than antepartum DVT and 3 to 16 times more frequent after cesarean section compared to vaginal delivery.

MMR & DVT:_Venous thromboembolism is leading cause of maternal mortality in western world and accounts for 17% of all maternal deaths.

Mortality is primarily due to massive pulmonary embolism which commonly occurs from a thrombus embolising  from deep veins of lower extremities. Pulmonary embolism can occur in up to 24% of untreated patients of deep vein thrombosis. Thrombosis of ileo-femoral veins is more common than thrombosis of calf vein in pregnancy and has a higher risk of pulmonary embolism. Early diagnosis and treatment in patients with acute venous thromboembolism decreases the mortality rate to <1%. Risk factors associated with increased risk for venous thromboembolism have been identified. Primary prophylaxis decreases the rate of thromboembolic events in high risk patients.

PATHOPHYSIOLOGY

Hemostasis is a physiological process of four major steps occurring in set order.

Step 1: Vasoconstriction

Step 2: Activation and aggregation of platelets

Step 3: Formation of fibrin clot

Step 4: Dissolution of clot by plasmid

Hypercoagulability, venous stasis and vascular damage are components of Virchow's triad, all of which occur in pregnancy.

Various physiological changes occur in pregnancy which predispose to a procoagulant state:

Increase in factors VII, VIII, and IX, X and XII and fibrinogen.

Increase in plasminogen activator inhibitors such as tissue plasminogen activator inhibitor and decrease in the levels of tissue plasminogen activator

What are the risk factors for Deep vein thrombosis?? 1) Antiphospholipid antibody syndrome 2) Operative procedure and 3) CS delivery 4) Parity > 4: 5) Pregnancy induced hypertension 6)Age  > 35 years 7) Obesity 8) Gross varicose veins 9) Previous limb # or limb defects or  even Paraplegia 9) Medical disorders: nephritic syndrome, 10) sickle cell disease 11) Myeloproliferative disorders

12) Hypovolemia – so in obese women one can  continue  the drip for 36 hrs or more 13) , massive blood loss 14)

Hyperemesis, 15) dehydration 16) Nonpreg or even pregàif Long distance travel 17) Prolonged immobilization. 18)

Prolonged labor 19) septic abortion,  peritonitis or severe infection, e.g. pyelonephritis 20 ) Ovarian hyperstimulation syndrome21) Operations for ca Cx /Ca ovary à  Malignancy especially pelvic and abdominal

Decrease in naturally occurring anticoagulants like antithrombin III, protein S,

When do you start administration of LMWH?

Inj. LMWH 0.6 ml sc daily for 3 to 5 days depending on day & degree and day of ambulation. Other factors 1 kind, duration of surgery, Past history, smokers etc can start inj Clexane 80mg sc , OD, 12hrs after the spinal. Give for 5-7days. No monitoring is required for prophylactic dose. -Enoxaparin 60 mg s/c OD* 5 days. Start 12 hrs post surgery.
-Early ambulation
-Stockings for prophylaxis
-Monitoring not needed.

 Only 6 doses of Lonopin 40.1st after 24 hours and 2nd after 48hours.for 5 days

Beparin Injection, 25000 I.U i 5 ml Mfg: Samarth Life Sciences Pvt Ltd

CAPRIN 25000 IU 5ML INJ),. Unfractionated Heparin.

Brand Names:-This (UFH) is superior to LMWH in regard to aPL Syndrome. Each vial consists 25,000 i.u. per 5 ml. vial.,

Inj Hep (Gland.  ),b)  Inj Rin (Samarth.)

DOSE:-Prophylactic Dose:- 5,000 i.u. BD,

In cases with +ve serum markers for aPL, but negative for H/O VTE and negative for H/O Rec. abortion: - Aspirin & UFH 5000 i.u. BD or opt for aspirin & LMWH 40 mg/ day.

Therapeutic dose in PE or VTE:- The dose adjusted according to aPTT keeping it 1.5-2 times the normal. Usually 7,500- 10,000 i.u. subcut BD. As initial dose

Monitoring:- UFH can cause immune mediated thrombocytopenia, May add Calcium and Vit D to augment bone metabolism. Thrombocytopenia-.So it is mandatory to perform Platelate count after 2weks of initiation of UFH (5,000) preparations. If more than 6 months estimate BMD.

Dose:-

a) in prophylactic dose for prevention of further VTE and APL syndrome:-

While patient on therapeutic dose ; aPTT(Activated Partial Thromboplastin Time). aPTT should be kept 1.5 to 2 times than normal.

Action against overdosing:-

D). Thrombolytic & Fibrinolytics Alteplase: used in MI patients.

E). Inj. Urokinase Proteolytic  Enzyme & Thrombolytic

F).) Endogenous PLASMINOGEN activator & Thrombolytic Inj. Urokinase Proteolytic Enzyme & Thrombolytic Inj. Urokinase

Disease which can lead to spont thrombosis:::Age >35 yrs 2) Smoking 3) Migraine with aura / focal neurologic symptoms 4) Those who have coronary artery diseases 5) Those who have P/H/O CVA  or CCF 6) Hyper Homocysteinaemia 7) Hypertriglyceridameia 8) Decreased Vit B12 function 9) Deficiency of Protein C, S, Antithrombin III. 10) SLE.

Coagulation Disorders and Thromboembolism in Pregnancy

Venous thromboembolism (VTE) comprises of deep vein thrombosis (DVT) or pulmonary thromboembolism (PE) or both.

Venous thromboembolism results in significant morbidity and mortality during pregnancy and puerperium: Venous thromboembolism is globally recognized  a leading cause of maternal mortality. However in   West

Incidence 1 in 1500 deliveries (West) 1 in 1000 (India). This may postpartum or post operative. Postpartum DVT  is 3 times  more than antepartum (3-16 times)

More after cesarean section than normal delivery :-The incidence is approximately in 1 in 1500 deliveries seen in the west and according to an Indian study, antenatal DVT is 0.1%. The risk is lower for Asian and Hispanic women, higher for white and highest for black women. Postpartum DVT has been reported to occur 3 to 5 times more often than antepartum DVT and 3 to 16 times more frequent after cesarean section compared to vaginal delivery.

MMR & DVT:_Venous thromboembolism is leading cause of maternal mortality in western world and accounts for 17% of all maternal deaths.

Mortality is primarily due to massive pulmonary embolism which commonly occurs from a thrombus embolising from deep veins of lower extremities. Pulmonary embolism can occur in up to 24% of untreated patients of deep vein thrombosis. Thrombosis of ileo-femoral veins is more common than thrombosis of calf vein in pregnancy and has a higher risk of pulmonary embolism. Early diagnosis and treatment in patients with acute venous thromboembolism decreases the mortality rate to <1%. Risk factors associated with increased risk for venous thromboembolism have been identified. Primary prophylaxis decreases the rate of thromboembolic events in high risk patients.

PATHOPHYSIOLOGY

Hemostasis is a physiological process of four major steps occurring in set order.

Step 1: Vasoconstriction

Step 2: Activation and aggregation of platelets

Step 3: Formation of fibrin clot

Step 4: Dissolution of clot by plasmid

Hypercoagulability, venous stasis and vascular damage are components of Virchow's triad, all of which occur in pregnancy.

Various physiological changes occur in pregnancy which predispose to a procoagulant state:

Increase in factors VII, VIII, and IX, X and XII and fibrinogen.

Increase in plasminogen activator inhibitors such as tissue plasminogen activator inhibitor and decrease in the levels of tissue plasminogen activator

What are the risk factors for Deep vein thrombosis?? 1) Antiphospholipid antibody syndrome 2) Operative procedure and 3) CS delivery 4) Parity > 4: 5) Pregnancy induced hypertension 6)Age  > 35 years 7) Obesity 8) Gross varicose veins 9) Previous limb # or limb defects or  even Paraplegia 9) Medical disorders: nephritic syndrome, 10) sickle cell disease 11) Myeloproliferative disorders

12) Hypovolemia – so in obese women one can  continue  the drip for 36 hrs or more 13) , massive blood loss 14)

Hyperemesis, 15) dehydration 16) Nonpreg or even pregàif Long distance travel 17) Prolonged immobilization. 18)

Prolonged labor 19) septic abortion,  peritonitis or severe infection, e.g. pyelonephritis 20 ) Ovarian hyperstimulation syndrome21) Operations for ca Cx /Ca ovary à  Malignancy especially pelvic and abdominal

Decrease in naturally occurring anticoagulants like antithrombin III, protein S,

Of the three anticoagulants available in the market usually warfarin (Brand name Actinorm) is prescribed for long term prevention of  rec thrombosis in susceptible men & women. But thus drug should be stopped as soon preg test is positive and she should be switched over to Inj Heparin or LMWH & ecosprin as soon as foetal cardiac activity is demonstrated. Warfarin is teratogenioc.  However after 12 weeks of preg and may be switched over to warfarin if heparin is unaffordable

Few words about Unfractionated Heparin:--Beparin Injection, 25000 I.U i 5 ml Mfg: Samarth Life Sciences Pvt Ltd

CAPRIN 25000 IU 5ML INJ),. Unfractionated Heparin.

Brand Names:-This (UFH) is superior to LMWH in regard to aPL Syndrome. Each vial consists 25,000 i.u. per 5 ml. vial.,

Inj Hep (Gland. ),b) Inj Rin (Samarth.)

DOSE:-Prophylactic Dose:- 5,000 i.u. BD,

In cases with +ve serum markers for aPL, but negative for H/O VTE and negative for H/O Rec. abortion: - Aspirin & UFH 5000 i.u. BD or opt for aspirin & LMWH 40 mg/ day

Therapeutic dose in PE or VTE:- The dose adjusted according to aPTT keeping it 1.5-2 times the normal. Usually 7,500- 10,000 i.u. subcut BD. As initial dose

Monitoring:- UFH can cause immune mediated thrombocytopenia, May add Calcium and Vit D to augment bone metabolism. Thrombocytopenia-.So it is mandatory to perform Platelate count after 2weks of initiation of UFH (5,000) preparations. If more than 6 months estimate BMD.

Dose:-

a) in prophylactic dose for prevention of further VTE and APL syndrome:-

While patient on therapeutic dose ; aPTT(Activated Partial Thromboplastin Time). aPTT should be kept 1.5 to 2 times than normal.

Action against overdosing:-

D). Thrombolytic & Fibrinolyis Alteplase: used in MI patients.

E). Inj. Urokinase Proteolysis Enzyme & Thrombolytic

F).) Endogenous PLASMINOGEN activator & Thrombolytic Inj. Urokinase Proteolysis Enzyme & Thrombolytic Inj. Urokinase

Composition

Heparin 25000 IU

Therapeutic Class

Anticoagulants and Antiplatelets25000 IU i 5 ml

Rs 101.02/Piece Get Latest Price

Brand Beparin

Composition Heparin(5000 I.U)+ Packaging Size 25000 I.U i 5 ml

Packing Type Vial

Indications:-Use in preventing blood clots in patients who have certain illnesses or who will be having certain types of A) surgeries. It is also used along with aspirin to prevent certain problems caused by 1) heart attacks or 2) unstable angina. It is also used to reduce the recurrence of blood clots in 3) cancer patients..

0. Inj Beparin 5000 units,: Inj Hibor(Elder) :: Inj Caprin (SAMRATH) Multidose vial:

Drug A) Low molecular weight heparin are of basically two kinds : e,g, Drug A) Enoxaparin : 1) Lonopin(Bharat serum) 40 mg PFS, 2) Exhep (Emcure) 40/60 mg 3) Inj Exhep( Gland) 40/60 mg PFS.4) Inj LMWH( Nicholas) 0.4 ml subcut,5) Inj Cutenox ( 40 mg in 0.4 ml) LMWH n, LMWX (Abbott); CElAXANE(Sanofi). 

Drug B) Dalteparin :A) - Fragmin(Pfizer); ;B) Daltehep - Duraiion of Therapy. LMWH or heparin should be contd at least up to 34 weeks as a minimum..

Edit or delete this

Curative(Pharmacologic):-DVT/PE

As prophylaxis

I) Post operative thrombosis, e.g. hip replacement, ii) Venous thrombo embolic events during pregnancy. Dose is 200 units/kg daily –either as single dose or in BD schedule.

Dose & Duration of Therapy.
LMWH or heparin should be contd at least up to 34 weeks as a minimum.
Side effects:of Heparin but not of LMWH:-
Heparin induced thrombocytopenia which may be of immediate onset or late onset . Heparin induced osteopenia if prolonged use: -Such osteopenia prevalence is 2% but in case of LMWH use osteoporosis risk is less – 0.2%.&rarely Heparin induced idiosyncratic reaction

·         ..Continue till 37 weeks

·          24 hrs before planned delivery

·          24 hrs before delivery in proved APLAS.

o     · 

·          In RPL... f started after the cardiac activity is seen
Then continue till 34 weeks
First TM loss ..Many continue till 14 weeks ..And uterine Doppler at 12 weeks alongwith NT NB scan is must ..
Dual marker ...
If all well..I stop ..Or max continue till 18weeks ..I stop only if Ut.A Doppler at 18 weeks is fine

·          

·          If started before the cardiac activity is found
Stop when cardiac activity is seen… 8 · 13h

·          Till 36 weeks

·         37wks

H

Srimanta Pal Enoxaparin is available as an injectable medicine that helps prevent blood clots in the legs and other parts of the body. If these blood clots are not prevented, they can travel to the lungs and cause serious complications and even death. 
After a patient has surgery, such as hip or knee replacement or in some cases abdominal surgery, enoxaparin is often used for several days to up to a month to prevent blood clots. This medicine is also used to prevent blood clots in patients confined to bed and also for patients experiencing chest pain and heart attacks. 
Enoxaparin belongs to a class of drugs known as “low molecular weight heparin” (LMWH), which is different than heparin, another drug that helps to prevent blood clots.
2. What is the difference between LMWH and heparin?
LMWH and heparin are both used to prevent blood from clotting inside the body, but are used in different situations. 
Heparin, sometimes called “standard heparin,” is available as a liquid solution injected directly into the blood (intravenous or “IV”) and only given to hospitalized patients, for instance, to prevent blood clots during surgery. Because patients vary widely in their response to heparin sodium, laboratory monitoring of anticoagulant activity is needed to adjust the dose of heparin and monitor its effect in the hospital. In addition, heparin has potential to cause a possibly deadly condition known as Heparin Induced Thrombocytopenia (HIT), where the body stops producing blood platelets. Thus, in the hospital, doctors can notice HIT right away and take action to reverse the condition. Doctors or other healthcare professionals must inject a patient with heparin. Patients cannot use heparin themselves. 
LMWH, such as enoxaparin, is made from heparin. It is also available as a liquid injectable solution used to prevent blood clots, but it is used differently than heparin. LMWH produces a more predictable anticoagulant response so frequent monitoring is not needed to adjust the dose. LMWH is also designed to last much longer in the body, so it does not need to be injected intravenously. Instead, LMWH is injected under the skin. Additionally, LWMH has a lower incidence of HIT. Because LMWH has more predictable efficacy and a lower incidence of adverse effects such as HIT, patients can inject LMWH themselves at home (although it is also often used in the hospital).

 Low molecular weight heparin are of basically two kinds : e,g, Drug A) Enoxaparin : 1) Lonopin(Bharat serum) 40 mg PFS, 2) Exhep (Emcure) 40/60 mg 3) Inj Exhep( Gland) 40/60 mg PFS.4) Inj LMWH( Nicholas) 0.4 ml subcut,5) Inj Cutenox ( 40 mg in 0.4 ml) LMWH n, LMWX (Abbott); CElAXANE(Sanofi). 

Drug B) Dalteparin :A) - Fragmin(Pfizer); ;B) Daltehep - Duraiion of Therapy. LMWH or heparin should be contd at least up to 34 weeks as a minimum..

 · 

LMWH or heparin should be contd at least up to 34 weeks as a minimum.
Side effects:of Heparin but not of LMWH:-
Heparin induced thrombocytopenia which may be of immediate onset or late onset . Heparin induced osteopenia if prolonged use: -Such osteopenia prevalence is 2% but in case of LMWH use osteoporosis risk is less – 0.2%.&rarely Heparin induced idiosyncratic reaction

Edit or delete this Enoxaparin is available as an injectable medicine that helps prevent blood clots in the legs and other parts of the body. If these blood clots are not prevented, they can travel to the lungs and cause serious complications and even death. 
After a patient has surgery, such as hip or knee replacement or in some cases abdominal surgery, enoxaparin is often used for several days to up to a month to prevent blood clots. This medicine is also used to prevent blood clots in patients confined to bed and also for patients experiencing chest pain and heart attacks. 
Enoxaparin belongs to a class of drugs known as “low molecular weight heparin” (LMWH), which is different than heparin, another drug that helps to prevent blood clots.
2. What is the difference between LMWH and heparin?
LMWH and heparin are both used to prevent blood from clotting inside the body, but are used in different situations. 
Heparin, sometimes called “standard heparin,” is available as a liquid solution injected directly into the blood (intravenous or “IV”) and only given to hospitalized patients, for instance, to prevent blood clots during surgery. Because patients vary widely in their response to heparin sodium, laboratory monitoring of anticoagulant activity is needed to adjust the dose of heparin and monitor its effect in the hospital. In addition, heparin has potential to cause a possibly deadly condition known as Heparin Induced Thrombocytopenia (HIT), where the body stops producing blood platelets. Thus, in the hospital, doctors can notice HIT right away and take action to reverse the condition. Doctors or other healthcare professionals must inject a patient with heparin. Patients cannot use heparin themselves. 
LMWH, such as enoxaparin, is made from heparin. It is also available as a liquid injectable solution used to prevent blood clots, but it is used differently than heparin. LMWH produces a more predictable anticoagulant response so frequent monitoring is not needed to adjust the dose. LMWH is also designed to last much longer in the body, so it does not need to be injected intravenously. Instead, LMWH is injected under the skin. Additionally, LWMH has a lower incidence of HIT. Because LMWH has more predictable efficacy and a lower incidence of adverse effects such as HIT, patients can inject LMWH themselves at home (although it is also often used in the hospital).

Enoxaparin sodium is an anticoagulant medication (blood thinner).It is used to treat and prevent deep vein thrombosis(DVT) and pulmonary embolism (PE) including during pregnancy and following certain types of surgery. It is also used in those with acute coronary syndrome (ACS) and heart attacks. It is given by injection just under the skin or into a vein.  Other uses include inside kidney dialysis machines.

Common side effects include bleeding, fever, and swelling of the legs. Bleeding may be serious especially in those who are undergoing a spinal tap. Use during pregnancy appears to be safe for the baby. Enoxaparin is in the low molecular weight heparin family of medications.

Enoxaparin was first made in 1981 and approved for medical use in 1993. It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system. Enoxaparin is sold under several brand names and is available as a generic medication.  Enoxaparin is made from heparin.  In 2016 it was the 295th most prescribed medication in the United States with more than a million Treatment of unstable angina (UA) and non-Q-wave myocardial infarction (NQMI), administered concurrently with aspirin

DVT prophylaxis in knee replacement surgery

DVT prophylaxis in hip replacement surgery

DVT prophylaxis in abdominal surgery

Treatment of DVT with or without pulmonary embolism

Treatment of DVT inpatient, with ST-segment elevation myocardial infarction (STEMI)

Enoxaparin has predictable absorption, bioavailability, and distribution therefore monitoring is not typically done. However, there are instances where monitoring may be beneficial for special populations, for example individuals with kidney insufficiency or those that are obese. In this case, anti-Xa units can be measured and dosing adjusted accordingly. Reversal agent  .Protamine sulfate is less effective at reversing enoxaparin compared to heparin, with a maximum neutralization of approximately 60% of the anti-factor Xa effect.

Enoxaparin is a FDA pregnancy category B drug which means enoxaparin is not expected to cause harm to an unborn baby when used during pregnancy. This statement is based on reproductive studies involving pregnant rats and rabbits. No birth defects or toxic effects to an unborn fetus due to enoxaparin were observed during these animals studies. However a human's response to enoxaparin might be different than that of a small animal, therefore enoxaparin should be used during pregnancy only if there is a definite need.

Enoxaparin does not cross the placenta therefore it is unlikely an unborn baby would be exposed to it.^[8]

Some fetal deaths have been reported by women who used enoxaparin during pregnancy, but it is unclear if enoxaparin caused these deaths.^[8]

Pregnant woman on enoxaparin should be monitored on a regular basis for bleeding and/or "excessive anticoagulation" especially when the delivery date is approaching. The risk of hemorrhage is higher during delivery if the person is still using enoxaparin and this could endanger the life of the baby and/or the mother.

The multiple-dose vials of the brand name enoxaparin (Lovenox) contain 15 mg benzyl alcohol per 1 mL as a preservative. Premature infants who have been given large amounts of benzyl alcohol (99–405 mg/kg/day) have experienced "gasping syndrome".Although enoxaparin is used to prevent blood clots it is necessary to remember that pregnancy alone can raise a woman's risk of clotting.

Side effects

Uncommon (<1%)

In people with unstable angina or non-Q-wave myocardial infarction:

Atrial fibrillation, heart failure, lung edema, pneumonia: ≥ 0.5%v

Common (>1%)

Thrombocytopenia, i.e. can be associated with heparin-induced thrombocytopenia (0.5-5.0% of persons treated for at least five days)^[10]

Elevations in serum aminotransferases: 5.9%-6.1%^[8]

In people undergoing abdominal or colorectal surgery:

Bleeding, anemia, ecchymosis: ≥ 2%^[8]

In persons undergoing hip or knee replacement:

Fever, nausea, anemia, edema, peripheral edema: ≥ 2%^[8]

In persons with severely restricted mobility during acute illness:

Dyspnea, thrombocytopenia, confusion, diarrhea, nausea: ≥ 2%^[8]

In people being treated for deep vein thrombosis:

Injection site hemorrhage, injection site pain, hematuria: ≥ 2%^[8]

Frequency under investigation

Local reactions: local irritation, pain, hematoma, ecchymosis, erythema^[8]

Bleeding^[8]

Hyperkalemia^[8]

Transaminitis^[8]

Hemorrhage^[8]

Boxed warning[edit]

The FDA issued a revision to the boxed warning for enoxaparin in October 2013.^[11] The revision recommends exercising caution regarding when spinal catheters are placed and removed in persons taking enoxaparin for spinal puncture or neuroaxial anesthesia.^[12] It may be necessary to delay anticoagulant dosing in these persons in order to decrease the risk for spinal or epidural hematomas, which can manifest as permanent or long-term paralysis.^[12] Persons at risk for hematomas may present with indwelling epidural catheters, concurrent use of medications that worsen bleeding states such as non-steroidal anti-inflammatory drugs (NSAIDs), or a past medical history of epidural or spinal punctures, spinal injury, or spinal deformations.^[11] The FDA recommends that at-risk persons be monitored for bleeding and neurological changes.^[11][13]

Pharmacology[edit]

Mechanism of action[edit]

Enoxaparin binds to and potentiates antithrombin (a circulating anticoagulant) to form a complex that irreversibly inactivates clotting factor Xa.^[14] It has less activity against factor IIa (thrombin) compared to unfractionated heparin (UFH) due to its low molecular weight.^[15]

Pharmacokinetics[edit]

Absorption: Bioavailability (subcutaneous injection) ~ 100%^[11]

Distribution: Volume of distribution (anti-Factor Xa activity) = 4.3 liters^[11]

Metabolism: Enoxaparin is metabolized in the liver into low molecular weight species by either or both desulfation and depolymerization.^[11]

Elimination: A single dose of a subcutaneous injection of enoxaparin has an elimination half-life of 4.5 hours.^[11] Approximately 10%-40% of the active and inactive fragments from a single dose are excreted by the kidneys.^[11] Dose adjustments based on kidney function are necessary in persons with reduced kidney function.^[11]

Drug class[edit]

Enoxaparin belongs to the class of drugs known as low molecular weight heparins. Other drugs in this class include dalteparin, fondaparinux and tinzaparin.^[16] Clexane belongs to a group of drugs called anticoagulants. Clexane stops unwanted blood clots from forming and can stop any blood clots that have already formed from growing bigger. Clexane does NOT break down blood clots that have already formed. Clexane acts as a roadblock, interfering with how the process of blood clotting occurs. Who needs Clexane? Infants and children are given clexane for only two reasons. 1. They have had a blood clot and are taking clexane to make sure the blood clot doesn’t grow or break off and travel to another part of the body (e.g. the lungs). 2. They haven’t had a blood clot yet, but for some reason their doctor thinks they have a bigger risk than other people for getting a blood clot. How do I give clexane? Clexane cannot be taken by mouth, or given through an intravenous drip. It must be given by injection under the skin, twice a day. We can make these injection a little bit easier for infants and children by using an Insuflon catheter. Insuflons are small devices that are placed into the layer of fat between the skin and muscles. They can stay in place for 7 days. A child can then have their clexane injected into the insuflon, where the body will absorb it. Before inserting an insuflon, we can place some local anaesthetic cream over the site where it will be placed. This is usually the stomach or the outer side of the thigh. Once the skin has been made numb, the cream is removed. A small needle guides the insuflon into place, and is then removed, leaving a very small plastic tube sitting under the skin. Monitoring Clexane Therapy The amount of clexane needed by a child is based on how much they weigh. A blood test is taken a few days after starting clexane to work out how a child’s body is responding to the medication. This test is called an anti-Factor Ten-A (anti-Xa) test. Once a child’s anti-Xa level is in the right range, we usually don’t need to do blood tests more often than once every two to four weeks. Clexane’s Side Effects Bleeding is the most common side effect of clexane therapy. You can make the risk of bleeding much smaller by injecting the correct dose of clexane and having blood tests when instructed. Contact the Haematology Department if any of the following happen: Any head injury caused by a fall or knock to the head, even if there was no loss of consciousness or headache. Prolonged bleeding: - from minor cuts. - from the gums after brushing of teeth. - from the nose. - during periods. Severe headache or back pain Bruises or tender swollen areas without clear cause. Blood in the urine, poo, vomit or coughed up from the lungs. Very uncommon side-effects of clexane include hair loss and ‘thinning’ of the bones (both resolve when clexane is stopped). There is a very rare condition that can happen in patients taking clexane that causes part of the blood that helps with clotting (the platelets) to stop working properly. Your doctors will keep an eye out for all these problems, but they are very uncommon. Sport and Activity Clexane makes the risk of bleeding bigger, so contact sports should be avoided (e.g. football, rugby, martial arts). When riding a bicycle, rollerblading or participating in any activity where falling is possible, a helmet should be worn. A child’s usual physical activities should be discussed with the Haematology Department, and if there are any changes to these activities, the Haematology team should be notified. Seeing Other Doctors/ Dentists/ Health Specialists Tell any other doctors or health professionals (eg. physiotherapists, chiropractors, dentists etc) that you are taking clexane. They may need to think about how clexane affects what they plan do to you. If you wish to contact the Haematology Team, contact options are listed below: Non-Urgent Contact Haematology Team Answering Machine Telephone 9345 5827 (Messages are checked daily Monday to Friday – for urgent concerns see below) Urgent Contact M

Although the EMA Guideline requires clinical studies to demonstrate comparable effectiveness to a similar LMWH, FDA notes that its approach (i.e., the five criteria) is more sensitive to differences between two enoxaparin products than the clinical studies recommended in the EMA guideline. hat is Enoxaparin for:

This medication prevents blood clots in patients who are on bed rest or who are having orthopedic surgery of the hip replacement, knee replacement, or large intestinal surgery. It is also used alone or in combination with warfarin to prevent and treat blood clots in the leg. It is a low molecular weight heparin. It stops the formation of substances that cause clots. It is also used in unstable angina and heart attacks.

How does Enoxaparin work:

Enoxaparin changes the bodys clotting system. It thins the blood to stop clots from forming.

How should Enoxaparin be used:

Adult-SC- Abdominal Surgery- the recommended dose is 40 mg once a day. Hip or Knee Replacement Surgery- the recommended dose is 30 mg every 12 hours. It comes as a solution for injection, to be administered by a healthcare provider under the skin.

Common side effects of Enoxaparin :

Bleeding problems. Irritation where the shot is given.

What do I do if I miss a dose

Take a missed dose as soon as you think about it. If it is close to the time for your next dose, skip the missed dose and go back to your normal time. Do not take 2 doses at the same time or extra doses. Do not change the dose or stop this drug. Talk with the doctor.

What precautions should I take when taking Enoxaparin :

If you have an allergy to enoxaparin or any other part of this drug. If you are allergic to pork products, talk with the doctor. Tell your doctor if you are allergic to any drugs. Make sure to tell about the allergy and what signs you had. This includes telling about rash; hives; itching; shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or any other signs. If you have any of these health problems: Bleeding problems or low platelet count during past use. If you know that you will not take the drug as you have been told. If you are pregnant and have had a heart valve replaced.

When do I need to seek medical help

If you think there was an overdose, call your local poison control center or ER right away. Signs of a very bad reaction to the drug. These include wheezing; chest tightness; fever; itching; bad cough; blue or gray skin color; seizures; or swelling of face, lips, tongue, or throat. A fast heartbeat. Very bad dizziness or passing out. A fall or crash when you hit your head. Talk with your doctor even if you feel fine. Swelling, warmth, or pain in the leg or arm. Change in thinking clearly and with logic. Very upset stomach or throwing up. Very bad headache. Weakness, numbness, or tingling. Any bruising or bleeding. Any rash. Side effect or health problem is not better or you are feeling worse.

Can I take Enoxaparin with other medicines:

Sometimes drugs are not safe when you take them with certain other drugs and food. - Taking them together can cause bad side effects. - Be sure to talk to your doctor about all the drugs you take.

Are there any food restrictions

Avoid Alcohol

How do I store Enoxaparin :

Injection: Store at 25°C. Store it in airtight container and keep away from children. as low molecular weight heparins. Other drugs in this class include B) dalteparin, B) fondaparinux and C) Clexane belongs to a group of drugs called anticoagulants. Clexane stops unwanted blood clots from forming and can stop any blood clots that have already formed from growing bigger. Clexane does NOT break down blood clots that have already formed. Clexane acts as a roadblock, interfering with how the process of blood clotting occurs. Who needs Clexane? Infants and children are given clexane for only two reasons. 1. They have had a blood clot and are taking clexane to make sure the blood clot doesn’t grow or break off and travel to another part of the body (e.g. the lungs). 2. They haven’t had a blood clot yet, but for some reason their doctor thinks they have a bigger risk than other people for getting a blood clot. How do I give clexane? Clexane cannot be taken by mouth, or given through an intravenous drip. It must be given by injection under the skin, twice a day. We can make these injection a little bit easier for infants and children by using an Insuflon catheter. Insuflons are small devices that are placed into the layer of fat between the skin and muscles. They can stay in place for 7 days. A child can then have their clexane injected into the insuflon, where the body will absorb it. Before inserting an insuflon, we can place some local anaesthetic cream over the site where it will be placed. This is usually the stomach or the outer side of the thigh. Once the skin has been made numb, the cream is removed. A small needle guides the insuflon into place, and is then removed, leaving a very small plastic tube sitting under the skin. Monitoring Clexane Therapy The amount of clexane needed by a child is based on how much they weigh. A blood test is taken a few days after starting clexane to work out how a child’s body is responding to the medication. This test is called an anti-Factor Ten-A (anti-Xa) test. Once a child’s anti-Xa level is in the right range, we usually don’t need to do blood tests more often than once every two to four weeks. Clexane’s Side Effects Bleeding is the most common side effect of clexane therapy. You can make the risk of bleeding much smaller by injecting the correct dose of clexane and having blood tests when instructed. Contact the Haematology Department if any of the following happen: Any head injury caused by a fall or knock to the head, even if there was no loss of consciousness or headache. Prolonged bleeding: - from minor cuts. - from the gums after brushing of teeth. - from the nose. - during periods. Severe headache or back pain Bruises or tender swollen areas without clear cause. Blood in the urine, poo, vomit or coughed up from the lungs. Very uncommon side-effects of clexane include hair loss and ‘thinning’ of the bones (both resolve when clexane is stopped). There is a very rare condition that can happen in patients taking clexane that causes part of the blood that helps with clotting (the platelets) to stop working properly. Your doctors will keep an eye out for all these problems, but they are very uncommon. Sport and Activity Clexane makes the risk of bleeding bigger, so contact sports should be avoided (e.g. football, rugby, martial arts). When riding a bicycle, rollerblading or participating in any activity where falling is possible, a helmet should be worn. A child’s usual physical activities should be discussed with the Haematology Department, and if there are any changes to these activities, the Haematology team should be notified. Seeing Other Doctors/ Dentists/ Health Specialists Tell any other doctors or health professionals (eg. physiotherapists, chiropractors, dentists etc) that you are taking clexane. They may need to think about how clexane affects what they plan do to you. If you wish to contact the Haematology Team,

Pregnancy Category

Category B : Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women OR Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester.