anticoagulant use in pregnancy

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Warfarin, heparin use and management in pregnancyWarfarin syndrome

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ANTICOAGULANTS DURING PREGNANCY & PUERPERIUM : 

ANTICOAGULANTS DURING PREGNANCY & PUERPERIUM BY ROSEMARY PALMER RN, RM, BSc Hons (Sport science & administration), ADM

USAGE : 

USAGE Anticoagulants are used to i) Prevent thrombus formation ii) Stop extension of an existing thrombus IN THE VENOUS SIDE OF CIRCULATION Do not dissolve the clot.

MAIN ANTICOAGULANTS USED : 

MAIN ANTICOAGULANTS USED 1) HEPARIN: A rapid short acting anticoagulant used as initial treatment to stabilize patient with DVT / pulmonary embolism & DIC Used if patients need anticoagulation &pregnancy <12 weeks gestation and > 36 weeks gestation. As prophylactic treatment for cardiac patients in labour For neonates with CVP lines, DIC & DVT

ACTION : 

ACTION Can only be administered either IV or s/c Heparin interfers with pro-coagulation factors Xa 7 thrombin stopping fibrinogen converting to fibrin. Does not cross the placenta. Onset of action immediate given IV & 20-60 minutes duration if given s/c ½ life 1-2 hrs. Metabolised in the liver & excreted in urine

CONTRA INDICATIONS : 

CONTRA INDICATIONS Haemphilia & other bleeding disorders Peptic Ulcer SEVERE HYPERTENSION Recent CVA Hypersensitivity Severe liver disease Patients taking asprin NSAIDS

DRUG INTERACTIONS : 

DRUG INTERACTIONS Asprin NSAIDS Infusion GTN

CAUTION : 

CAUTION Liver failure ( not severe) Renal failure Pregnancy – can cause maternal haemorrhage Cavitating TB Active bleeding e.g. abortion, Ca Cx bleeding.

BEFORE INITIATION : 

BEFORE INITIATION Full FBC PTT U&E LFT RISK ASSESSMENT- obesity, AMA, Grande Multip, for surgery, history of being ‘a bleeder’ Cardiac patient –esp mitral valve prosthesis If a possible risk of DVT sometimes asprin is prescribed initially –always check history.

SIDE EFFECTS : 

SIDE EFFECTS Hypersensitivity reactions- should do test dose Haemorrhage esp if not correctly monitored/taking herbal medications Thrombocytopaenia Osteoporosis if long term usage.

DOSAGES : 

DOSAGES FOR DVT: IV LOADING DOSE 5000- 10 000 units initially followed by infusion of 1000-2000u/hr or s/c 15 000 u BD ORAL ANTICOAGULANTS ARE STARTED WITH HEPARIN THEN HEPARIN IS WITHDRAWN WHEN BLOOD RESULTS SATISFACTORY (3 days)

MONITORING : 

MONITORING PTT 6 hrs after loading dose then PTT daily - aim for 1.5 -2.5 times the laboratory control value. This should be reached within 24 hours Heparin is discontinued once oral anticoagulants are effective. Heparin is not contra indicated for breastfeeding.

FOR OVERDOSE : 

FOR OVERDOSE Protamine sulphate. 1 mg IV neutralises 80-100 u heparin if given immediately heparin is overdosed. Max 50 mg otherwise it becomes anti coagulant itself.

WARFARIN : 

WARFARIN 2) Warfarin. Antagonises the effects of VIT K and is long acting. Take 48-72 hours for full anticoagulant effect to take place.

CONTRAINDICATIONS : 

CONTRAINDICATIONS Pregnancy <12 weeks >36 weeks: Warfarin crosses the placenta Teratogenic and >36 weeks because need warfarin out of the system before labour –haemorrhage. Heparin is substituted. SEVERE HYPERTENSION Peptic ulcer or other bleeding sites. Epidural/spinal anaesthetic -caution

DRUG INTERACTIONS : 

DRUG INTERACTIONS Alcohol > Asprin /NSAIDS > Rifampicin- decreases effect < Bactrim, erythromycin, flagyl, naladixic acid > Broad spectrum antibiotics > Warfarin enhances action of Antidiabetics Carbamazepine, phenobarb < MAJOR CHANGES IN DIET esp salads & spinach kale, parsley, cranberry juice

INDICATIONS : 

INDICATIONS Prophylactic use for patients with mitral valve prosthesis/ rheumatic value disease, continuing treatment for DVT or pulmonary embolism

DOSAGE : 

DOSAGE Depends on INR –taken daily 10mg daily but very patient dependent. Presented as 1mg –brown 2mg- blue 5mg –pink tablets. May need to alter dosages when INR result indicates

SIDE EFFECTS : 

SIDE EFFECTS Bleeding eg Malaena Allergy Bruising easily Nausea Vomiting Joint pain Chest pain Numbness or tingling in any part of body Can cause placental/ foetal haemorrhage.

MONITORING & HEALTH EDUCATION : 

MONITORING & HEALTH EDUCATION INR. Initially 12, 24, 48, 72 hrs after starting. Range 2.0 -2.5 then weekly bloods and as prolonged use can go to monthly. Take tablets same time each day. If a dose is missed DO NOT double up the next day. Wear a medic alert Report abnormal bleeding –malaena, urine, bruising, nose bleeds, mennorhagia, bleeding gums. Report rashes, vomiting, diarrhoea No alcohol, do not change diet drastically. Keep appointments and blood tests

HEALTH EDUCATION cont : 

HEALTH EDUCATION cont DO NOT take asprin or any asprin containing drugs –read labels. Do not take brufen Herbal medications- take advice first. If you want to become pregnant or think you are pregnant GO TO THE MO/Clinic a.s.a.p –warfarin is teratogenic.

AFFECT ON FOETUS : 

AFFECT ON FOETUS Deformities of skeleton scoliosis - early use Nose deformities Eye abnormalities Mental retardation –late trimester use Haemorrhage- crosses placenta Stillbirth 16% exposed have malformations 3% haemorrhage 8% stillbirths

OVERDOSE : 

OVERDOSE Vitamin K 5mg IV

Puerperium : 

Puerperium Can be used with breastfeeding. Must be restarted in puerperium withing 12 hours delivery together with heparin ( should have been on heparin already) Give 4-6 weeks post delivery for cardiacs. If DVT or PE in pregnancy must be continued 3 months

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