Assessment of pregnancy outcome with low molecular weight heparin therapy: a retrospective, single centre observational study
DOI:
https://doi.org/10.18203/2320-1770.ijrcog20181333Keywords:
Low molecular weight heparin therapy, Pregnancy, ThromboembolismAbstract
Background: The objective of this study was to determine the outcomes of Low Molecular Weight Heparin Therapy (LMWH) given for various indications during pregnancy.
Methods: In this context, a detailed retrospective analysis of all the patients who received LMWH for various indications over a period of two years from October 2015 to November 2017 at a single center, Sri Aurobindo Medical College and PG institute in Indore was performed.
Results: Total 100 patients were studied, included over the period of 2 years for various indications for which Enoxaparin (1 mg/kg body weight OD/BD subcutaneously) was used. The indications were valvular heart disease with valve replacement and atrial fibrillation (54.0%), chronic deep vein thrombosis (DVT) (13.0%), thrombophilias (9.0%), recurrent pregnancy loses (21.0%) and prophylaxis for deep vein thrombosis (3.0%) in overall patients. Abortion was seen in 8.0 % patients; fetal growth restriction in 13% patients; and oligohydramnios, preeclampsia, gestational hypertension, placenta previa, abruptio placentae, postpartum hemorrhage patients and Stillbirth occurred in 4.0 % patients. No thromboembolic event was noted in any of the patients. None of the patients had any documented thrombocytopenia or clinical fracture.
Conclusions: Low Molecular Weight Heparin Therapy (LMWH) used amongst pregnant women with various indications for anticoagulation therapy was associated with successful pregnancy outcome in the vast majority of cases. Further multicenter prospective studies and international registries of pregnant women on LMWH are necessary to broaden our knowledge in optimizing the care of women who require anticoagulation during pregnancy.
References
Lockwood CJ. Heritable coagulopathies in pregnancy. Obstet Gynecol Surv. 1999;54:754-65.
Walker MC, Garner PR Keely EJ, Rock GA, Reis MD. Changes in activated protein C resistance during normal pregnancy. Am J Obstet Gynecol. 1997;177(1):162-9.
Thurnau GR, Welsh J, Esmon CT. Functional and immunologic protein S levels are decreased during pregnancy. Blood. 1986;68(4):881-5.
Brenner B. Inherited thrombophilia and pregnancy loss. Best Pract Res Clin Haematol. 2003;16(2):311-20.
Chighizola CB, Gerosa M, Trespidi L, Di Giacomo A, Rossi F, Acaia B, et al. Update on the current recommendations and outcomes in pregnant women with antiphospolipid syndrome. Expert Rev Clin Immunol. 2014;10(11):1505-17.
Ćetković A, Kastratović B, Novaković I. Prospective study of perinatal outcome in pregnancies with primary antiphospholipid syndrome. Vojnosanit Pregl. 2014;71(8):742-5.
Kwak-Kim J, Agcaoili MS, Aleta L, Liao A, Ota K, Dambaeva S, et al. Management of women with recurrent pregnancy losses and antiphospolipid antibody syndrome. Am J Reprod Immunol. 2013;69(6):596-607.
Alfi rević Z, Roberts D, Nartlew V. How strong is the association between maternal thrombophilia and adverse pregnancy outcome? A systematic review. Eur J Obstet Gynecol Reprod Biol. 2002;101(1):6-14.
Clark P, Walker ID, Langhorne P, Crichton L, Thomson A, Greaves M, et al. Scottish Pregnancy Intervention Study (SPIN) collaborators. SPIN (Scottish Pregnancy Intervention) study: A multicenter, randomized controlled trial of low molecular-weight heparin and low-dose aspirin in women with recurrent miscarriage. Blood. 2010;115(21):4162-7.
Kaandorp SP, Goddijn M, van der Post JA, Hutten BA, Verhoeve HR, Hamulyák K, et al., Aspirin plus heparin or aspirin alone in women with recurrent miscarriage. N Engl J Med. 2010;362(17):1586-96.
Laskin CA, Spitzer KA, Clark CA, Crowther MR, Ginsberg JS, Hawker GA, et al., Low molecular weight heparin and aspirin for recurrent pregnancy loss: Results from the randomized, controlled HepASA trial. J Rheumatol. 2009;36(2):279-87.
Visser J, Ulander VM, Helmerhorst FM, Lampinen K, Morin-Papunen L, Bloemenkamp KW, et al. Thromboprophylaxis for recurrent miscarriage in women with or without thrombophilia. HABENOX: A randomised multicentre trial. Thromb Haemost. 2011;105(2):295-301.
Santoro R, Iannaccaro P, Prejano S, Muleo G. Efficacy and safety of the long-termadministration of low-molecular-weight heparins in pregnancy. Blood Coagul Fibrinolysis. 2009;20(4):240-3.
Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA et al., Pregnancy-related mortality surveillance-United States, 1991-1999. MMWR Surveill Summ. 2003;52:1-8.
Lewis G, Drife JO, Clutton-Brock T., Why Mothers Die: 2000–2002. The Sixth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press, 2004.
Health Canada. Special Report on Maternal Mortality and Severe Morbidity in Canada—Enhanced Surveillance: The Path to Prevention. Ottawa: Minister of Public Works and Government Services Canada, 2004. www.phac-aspc.gc.ca/rhs-ssg/srmm-rsmm/page1-eng. php.
Stein PD, Hull RD, Kayali F, Olson RE, Alshab AK, Meyers FA et al. Venous thromboembolism in pregnancy: 21-year trends. Am J Med. 2004;117:121-5.
Greer IA. Thrombosis in pregnancy: maternal and fetal issues. Lancet. 1999;353:1258-65
Barbour LA, Oja JL, Schultz LK. A prospective trial that demonstrates that dalteparin requirements increase in pregnancy to maintain therapeutic levels of anticoagulation. Am J Obstet Gynecol. 2004;191:1024-9.
Smith MP, Norris LA, Steer PJ, Savidge GF, Bonnar J. Tinzaparin sodium for thrombosis treatment and prevention during pregnancy. Am J Obstet Gynecol. 2004;190:495-501.
Brenner B, Hoffman R, Blumenfeld Z, et al. Gestational outcome in thrombophilic women with recurrent pregnancy loss treated by enoxaparin. Thromb Haemost. 2000;83(5):693-7.
Gris JC, Neveu S, Tailland ML, Courtieu C, Mares P, Schved JF. Use of a low-molecular weight heparin (enoxaparin) or of a phenformin-like substance (moroxydine chloride) in primary early recurrent aborters with an impaired fibrinolytic capacity. Thromb Haemost. 1995;73:362-7.
Sanson BJ, Lensing AW, Prins MH, Ginsberg JS, Barkagan ZS, Lavenne-Pardonge E, et al. Safety of low-molecular weight heparin in pregnancy: a systematic review. Thromb Haemost. 1999;81:668-72
Melissari E, Parker CJ, Wilson NV, Monte G, Kanthou C, Pemberton KD, et al., Use of low molecular weight heparin in pregnancy. Thromb Haemost. 1992;68:652-6.
Hassell K. The management of patients with heparin-induced thrombocytopenia who require anticoagulant therapy. Chest. 2005;127(2):1S-8S.
Machado LS. Cesarean section in morbidly obese parturients: practical implications and complications. N Am J Med Sci. 2012;4(1):13-8.
Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of venous thromboembolism. Edinburgh: A National Clinical Guideline; 2010.
Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. London: Green-Top Guidelines; 2009.
Figueiró-Filho EA, Oliveira VM, Breda I, Coelho LR, Ferreira CM. Usefulness of a scoring system on perinatal outcomes in pregnant women with thrombophilia in the effectiveness of an enoxaparin-based intervention. Rev Bras Gynecol Obstet. 2012;34(10):459-65.
Greer IA, Nelson-Piercy C. Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood. 2005;106:401-7.
