Dose of anticoagulants

Prophylactic LMWH:

Low risk

A)   Enoxaparin 40 mg SC q 24 hr or Enoxaparin 30 mg SC q 12 hr

B)   Dalteparin 5,000 U SC q 24 hr C) Tinzaparin 4,500 U SC q 24 hr UFH

1)   UFH 5,000 U SC q 12 hr Alternative⁶

2)   UFH 5,000-7,500 U SC q 12 hr in first trimester

3)   UFH 7,500-10,000 U SC q 12 hr in second trimester

4)   UFH 10,000 U SC q 12 hr in third trimester (unless aPTT elevated)

Intermediate dose

LMWH

A)   Enoxaparin 40 mg SC q 12 hr B) Dalteparin 5,000 U SC q 12 hr UFH

1)   UFH SC q 12 hr; doses adjusted to target peak antifactor Xa levels (4 hr after injection) of 0.1 to 0.3 U/mL

Treatment (weight-adjusted) dose

LMWH

A)   Enoxaparin 1 mg/kg SC q 12 hr (or enoxaparin 1.5 mg/kg SC q 24 hr) B) Dalteparin 200 U/kg SC q 24 hr or 100 U/kg SC q 12 hr 1) Tinzaparin 175 U/kg SC q 24 hr UFH

UFH SC q 12 hr; doses adjusted to obtain midinterval (6 hr postinjection) therapeutic aPTT (often a ratio of 1.5-2.5)

Switching over fro LMWH to warfarin What about Postpartum anticoagulation (for 4-6 wk)?? Will be the dose same???

Warfarin with a target INR of 2.0-3.0 with initial UFH or LMWH overlap until INR >2.0 for 2d Prophylactic LMWH or UFH. Some experts recommend twice daily dosing of enoxaparin secondary to pharmacokinetic prop­erties of LMWH in pregnancy; however, comparison data are lacking. Additionally, women at the extremes of weight may require different dosing.  Women exposed to warfarin late in pregnancy develop central nervous system injuries, hemorrhage, or ophthalmologic abnormalities.  Warfarin , however may be used postpartum period and may be given to nursing mothers, as it does not enter breast milk. Antepar­tum use is indicated for women with mechanical heart valves, for which neither Lovenox nor heparin provide adequate anticoagulation.

Part B: Are U Planning CS who is UFH in pregancy period or say on UFH??? Cautions!!!!   When used in therapeutic doses, LMWH should be discontinued 24 hours before elective induction of labor or cesarean delivery. Epidural or spinal anesthesia should not be administered within 24 hours of the last therapeutic dose of LMWH. A common approach is to transition from LMWH to UFH at 36 to 38 weeks’ gestation. If the patient goes into spontaneous labor and is receiving SC UFH, she should be able to receive regional analgesia if the aPTT is normal. If significantly prolonged, protamine sulfate may be adminis­tered at 1 mg/100 U of UFH. If the patient is at very high risk for VTE, IV UFH can be started and then discontinued 4 to 6 hours before expected delivery. When receiving LMWH once daily for prophylaxis, regional anesthesia can be admin­istered 12 hours after the last dose. LMWH should be withheld for at least 2 to 4 hours after the removal of an epidural catheter.

Postpartum

Postpartum anticoagulation may be resumed within 12 hours of cesarean delivery and 4 to 6 hours after vaginal delivery. If at high risk of bleeding postpartum, IV UFH may be chosen initially because its effect dissipates more rapidly and may be reversed with protamine sulfate. Once adequate hemostasis is assured, warfarin can be started by initial overlap with UFH or LMWH until international normalized ratio (INR) is

for 2 consecutive days, with a target INR of 2.0 to 3.0. Anticoagulation should be administered for at least 6 weeks postpartum for DVT and 4 to 6 months for PE.

Birth control options for women with a history of VTE or those with high-risk thrombophilias:

Due to the thrombogenic potential of estrogen-containing contraceptives, progestin-only or nonhormonal contraceptive methods are recommended. Natu­ral family planning, condoms, progestin-only pills, Levonorgestrel-releasing IUD, copper IUD, or tubal ligation/ocdusion are methods that can be discussed with patients at high risk for VTE.