warfarin and Pre-Eclampsia

For haemostatic and circulatory reasons pregnancy is associated with an about 6-fold relative increase of thrombotic risk which is further raised by additional risk factors, such as history of thrombosis or acquired and hereditary thrombophilia, respectively. Recently, the thrombophilias have been revealed as risk factors for severe preeclampsia, abruptio placentae, fetal growth retardation, abortion and still birth as well. Thus, there are several situations in which the question for the need of antithrombotic medication is raised in a pregnant woman, either for therapy of acute thromboembolism or for prophylaxis of thrombosis and obstetrical complications, respectively. While acute thromboembolism has to be treated in every case, indication for prophylaxis has to be weighed in the light of the individual risk profile of the pregnant woman and the potential side effects and inconvenience of the medication. The first part of this article deals with the pregnancy related problems of coumarins, heparins and aspirin and demonstrates that the low molecular weight heparins are the anticoagulants of choice for most indications in pregnancy. The second part of this overview shows in which specific situations and how the antithrombotic medications mentioned above are used in pregnancy.

Topics: Abnormalities, Drug-Induced; Abortion, Spontaneous; Abruptio Placentae; Administration, Oral; Adult; Anticoagulants; Aspirin; Blood Coagulation Tests; Coumarins; Female; Fetal Death; Fetal Growth Retardation; Fibrinolytic Agents; Heart Valve Prosthesis; Heparin; Heparin, Low-Molecular-Weight; Humans; Infant, Newborn; Platelet Aggregation Inhibitors; Pre-Eclampsia; Pregnancy; Pregnancy Complications, Cardiovascular; Puerperal Disorders; Pulmonary Embolism; Risk Factors; Thrombocytopenia; Thrombophilia; Thrombosis; Warfarin

Thromboembolic complications are leading causes of both maternal and fetal morbidity and mortality. To reduce the incidence of venous thromboembolism (VTE) in pregnancy and improve outcomes, a wider understanding of the risk factors involved and better identification of women at risk of thrombosis are required. Optimal management of thromboembolic disease, both to prevent VTE and to avoid recurrence of pregnancy complications such as miscarriage, centers on the use of low-molecular-weight heparin (LMWH). LMWHs, such as enoxaparin and dalteparin, have clinical and practical advantages compared with unfractionated heparin in terms of improved safety (significantly lower incidence of osteoporosis, thrombocytopenia, and possibly allergic skin reactions) and the potential for outpatient treatment of acute VTE. However, many unanswered questions remain, including who to treat, how to treat them, and when to treat in the case of patients with thrombophilia and a history of previous pregnancy complications.

Topics: Abnormalities, Drug-Induced; Adult; Contraindications; Female; Fibrinolytic Agents; Genetic Testing; Heparin; Heparin, Low-Molecular-Weight; Humans; Infant, Newborn; Maternal Age; Osteoporosis; Practice Guidelines as Topic; Pre-Eclampsia; Pregnancy; Pregnancy Complications, Hematologic; Pregnancy Outcome; Pulmonary Embolism; Recurrence; Risk Factors; Thrombocytopenia; Thrombolytic Therapy; Thrombophilia; Thrombophlebitis; Warfarin

Carotid dissection has rarely been described in pregnancy. We report a 24-year-old woman who developed an acute stroke 14 days postpartum after a complicated pregnancy. Her left internal carotid artery was found to be occluded, presumably secondary to a carotid dissection. Her neurologic symptoms resolved and she was treated with short-term warfarin therapy and blood pressure control.

Topics: Anticoagulants; Antihypertensive Agents; Blood Coagulation Disorders; Brain; Carotid Artery, Internal; Carotid Artery, Internal, Dissection; Female; Humans; Hypertension; Magnetic Resonance Angiography; Magnetic Resonance Imaging; Pre-Eclampsia; Pregnancy; Stroke; Warfarin; Young Adult

Topics: Adult; Anticoagulants; Antihypertensive Agents; Atenolol; Cerebral Veins; Female; Heparin; Humans; Magnetic Resonance Imaging; Phlebography; Postpartum Period; Pre-Eclampsia; Pregnancy; Sinus Thrombosis, Intracranial; Warfarin

A patient with previously undiagnosed antiphospholipid syndrome (APS) developed atypical severe preeclampsia at 31 weeks' gestation. Other complications of pregnancy included intrauterine growth retardation, thrombocytopenia and fetal distress necessitating urgent delivery of a live infant. There was a prior history of unexplained jugular venous thrombosis. Prophylaxis against thrombosis was commenced immediately postoperatively and no postpartum complications occurred. Recent evidence supports the use of antepartum prophylaxis with low dose heparin in patients with APS. The role of low dose aspirin, either alone or in combination with heparin, is yet to be determined. Human immunoglobulin may be useful in selected cases. Early diagnosis is a key factor in their management.

Topics: Adult; Antibodies, Anticardiolipin; Antiphospholipid Syndrome; Cesarean Section; Female; Fetal Distress; Fetal Growth Retardation; HELLP Syndrome; Heparin; Humans; Infant, Newborn; Jugular Veins; Lupus Coagulation Inhibitor; Male; Pre-Eclampsia; Pregnancy; Pregnancy Complications; Pregnancy Trimester, Third; Respiratory Distress Syndrome, Newborn; Thrombocytopenia; Thrombosis; Warfarin

Heparin cofactor II (HC II) is a recently characterized protein that is capable of neutralizing thrombin but not activated factor X. Recent evidence suggests that it may be a physiologically important regulator of thrombin activity. We evaluated and modified a method for clinical laboratory determination of this protein and then utilized the method to analyze HC II activity in various clinical samples. Low levels were associated with liver disease, consumptive coagulopathy, and preeclampsia; normal levels were seen with uncomplicated pregnancy, oral anticoagulant therapy, hereditary antithrombin III (AT III) deficiency, and in 31 patients evaluated for a thrombotic tendency. Except in hereditary AT III deficiency, decreased HC II activity was associated with decreased AT III activity. The potential clinical role of this assay is discussed.

Topics: Antithrombin III; Antithrombin III Deficiency; Antithrombins; Dermatan Sulfate; Disseminated Intravascular Coagulation; Female; Glycoproteins; Heparin Cofactor II; Humans; Liver Diseases; Methods; Pre-Eclampsia; Pregnancy; Thrombosis; Warfarin

The case is described of a patient whose third pregnancy ended successfully, after 2 perinatal deaths caused by severe pre-eclampsia in the second trimester of her previous pregnancies. Anticoagulant therapy with warfarin was given in the third pregnancy.

Topics: Adult; Female; Fetal Death; Humans; Pre-Eclampsia; Pregnancy; Recurrence; Warfarin

A patient is described who had two pregnancies complicated by severe pre-eclampsia in the second trimester which resulted in intrauterine death. During the third pregnancy anticoagulant therapy with warfarin was instituted at 14 weeks gestation and a healthy female infant was delivered at 38 weeks gestation.

Topics: Adult; Female; Humans; Pre-Eclampsia; Pregnancy; Pregnancy Trimester, Second; Warfarin

Topics: Blood Coagulation Disorders; Female; Fetus; Hemorrhage; Heparin; Humans; Infant, Newborn; Maternal-Fetal Exchange; Pre-Eclampsia; Pregnancy; Warfarin

Topics: Adult; Cesarean Section; Female; Heart Valve Prosthesis; Heparin; Humans; Infant, Newborn; Male; Mitral Valve; Pre-Eclampsia; Pregnancy; Pregnancy Complications, Cardiovascular; Vitamin K Deficiency Bleeding; Warfarin