Anticoagulants

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Thromboembolism in pregnancy: recurrence risks, prevention and management. Who is the culprit ?? The increased risk of thrombosis in pregnancy is hypercoagulability. Other risk factors include a history of thrombosis, inherited and acquired thrombophilia, certain medical conditions, and complications of pregnancy and childbirth.The hypercoagulability of pregnancy is present as early as the first trimester and so is the increased risk of thrombosis.

Anticoagulants when??  Ans:-Candidates for anticoagulation are women with a 1) current thrombosis,2)  a history of thrombosis, 3) thrombophilia and 4) a history of poor pregnancy outcome, or 5) risk factors for postpartum thrombosis. For  fetal reasons, the preferred agents for anticoagulation in pregnancy are heparins.

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. These risks may be further increased in the presence of an acquired or inherited thrombophilia. Thrombophilias have been associated with both maternal and fetal complications. The use of anticoagulants during pregnancy may reduce the risk of maternal thromboses as well as the risk of adverse pregnancy outcomes. The choice of an anticoagulant requires consideration of maternal risks, potential for teratogenicity, the underlying condition necessitating the treatment, and cost. This review examines the options for anticoagulation, the clinical situations that may warrant such treatment, and factors to be considered at delivery and during the postpartum period.

LEARNING OBJECTIVES:

After completion of this article, the reader should be able to describe the roles of acquired and inherited thrombophilia in furthering the hypercoagulable state of pregnancy, identify the potential consequences of using anticoagulants during pregnancy, and summarize the treatment options when anticoagulation is required during pregnancy.

PMID:

16359570

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Know your best friend my dear friends of  Fair Sex!!!!!

Low Molecular weight Heparin, Heparin & Oral anticoagulants  in Abortion, Pregnancy, infertility.

I. Oral Agents.

a)     Oral Anticoagulant: Vitamin K Antagonist: (Acenocoumarol).

In trade it is marketed as Acitorm (1/2/3/4 mg/-Abbott). Daily single dose as prophylaxis for VTE.

b) Coumarin Derivative: Warfarin

: Anticoagulant- Trade name Warf (Cipla) or Sofarin (Samarth) Daily single dose as prophylaxis for VTE.

Monitoring while on oral anticoagulants:-Warfarin sodium decreases all Vit K dependent coagulation factors like Factor II, VII, IX, X, Therefore women and men on long term Warfarin Ry  should be monitored by P.T.  Which is expressed as INR (International Normalized ratio)?.

Parenteral   Anticoagulants.

Both LMWH and UFH do not cross placenta. Therefore both are not teratogenic.

A)  LMWH:-

The various fractions of LMWH have different actions. There are 5 types of parental anticoagulants.e.g.- 1) LMWH( requires minimal monitoring, & less bleeding complications-so favored by ART specialists).2)  UFH, 3) Parnaparin 4) Reviparin

A).LMWH

A).LMWH:- a).Dalteparin, expressed as 5000 i.u. ---60 mg, Trade names are Inj. Fragmin, Inj. Beparine,( 5ml. vial-2500/- per vial 1ml per day,  Inj. Hibor(Elder).Rs. 420/-.Inj. Caprin multi-dose vial 5ml= 294/- therefore per day cost is 60/-Inj. Daltepin,  Daltehep.

                  b) Enoxaparin:- inj, Dose:- 5,000 i.u. (20-40 mg/day).

 Lonopin(Bharat Serum),Inj. Exhep( Emcure) 220/-, inj. LMWH(Nicholas)-0.4ml subcut, LMWX(Abbott);  CElAXANE(Sanofi).

DOSE:-a) PROPHYLACTIC   against VTE and RPL:-

b)    Therapeutic dose

Monitoring:-

Action against overdosing:

Advantages of LMWH over UFH?

a)               Less complications b) Bleeding complications are few in contrast to UFH. Does not alter P.Time and aPTT significantly. One can resort to Anti-Xa Assay 4 hours after last dose of LMWH in cases with renal failure and morbid obesity.

B),. 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.,

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

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

i)           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.

ii)      

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:-

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

Action against overdosing:-

A)LMWH    :-Dalteparin- Fragmin(Pfizer); Daltepin; Daltehep  Enoxaparin. Enoxarin, LMWX (Abbott); CElAXANE(Sanofi).

B)   UFH. C)    Parnaparin

D)  Reviparin

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

Parenteral   Anticoagulants.

Anticoagulant	A)LMWH	Dalteparin	Fragmin(Pfizer); Daltepin; Daltehep	Fragmin 5,000 u=PFS Rs. 525/-
-do-	-do-	Enoxaparin.	Enoxarin, LMWX(Abbott);CElAXANE(Sanofi).
Heparin	B)Antithrombotic & Anticoagulant also		Hep(Gland); 5ml=25,000U=294/- Inj. Rin(Samarth)=25,000 u/ 5ml. = Rs 85/-
Parnaparin			Fluxum(USV)
Reviparin			Clivarine (Abbott)

C) Thrombolytic:- 

Thrombolytic & Fibrinolytics	Alteplase	Tr. of MI & PE, Stroke.
D) Endogenous PLASMINOGEN activator & Thrombolytic	INJ. Streptokinase	Tr of Acute MI &  PE
E) Proteolytic Enzyme & Thrombolytic	Inj. Urokinase	Peripheral arterial Thrombosis	Cath Lab, clearing catheters.	Tr of VTE

·             LMWH. A) Dalteparin:- (5000 i.u.)-Fragmin,

·             B) Enoxaparin:-Inj. Lonopin 600 mg. ,PFS, Bharat serum (Rs.557/-)

·             Unfractionated Heparin.

Anticoagulant	A)LMWH	Dalteparin	Fragmin(Pfizer); Daltepin; Daltehep	Fragmin 5,000 u=PFS Rs. 525/-
-do-	-do-	Enoxaparin.	Enoxarin, LMWX(Abbott);CElAXANE(Sanofi).
Heparin	B)Antithrombotic & Anticoagulant also		Hep(Gland); 5ml=25,000U=294/- Inj. Rin(Samarth)=25,000 u/ 5ml. = Rs 85/-
Parnaparin			Fluxum(USV)
Reviparin			Clivarine (Abbott)

C) Thrombolytic:- 

Thrombolytic & Fibrinolytics	Alteplase	Tr. of MI & PE, Stroke.
) Endogenous PLASMINOGEN activator & Thrombolytic	INJ. Streptokinase	Tr of Acute MI &  PE

II. Parenteral   Anticoagulants.

Anticoagulant	A)LMWH	Dalteparin	Fragmin(Pfizer); Daltepin; Daltehep	Fragmin 5,000 u=PFS Rs. 525/-
-do-	-do-	Enoxaparin.	Enoxarin, LMWX(Abbott);CElAXANE(Sanofi).
Heparin	B)Antithrombotic & Anticoagulant also		Hep(Gland); 5ml=25,000U=294/- Inj. Rin(Samarth)=25,000 u/ 5ml. = Rs 85/-
Parnaparin			Fluxum(USV)
Reviparin			Clivarine (Abbott)

C) Thrombolytic:- 

Thrombolytic & Fibrinolytics	Alteplase	Tr. of MI & PE, Stroke.
D) Endogenous PLASMINOGEN activator & Thrombolytic	INJ. Streptokinase	Tr of Acute MI &  PE
E) Proteolytic Enzyme & Thrombolytic	Inj. Urokinase	Peripheral arterial Thrombosis	Cath Lab, clearing catheters.	Tr of VTE

Features of  &  Indications of LMWH:-

A)  Curative(Pharmacologic):-DVT/PE

B)   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.

A