heparin-preeclampsia

Information about heparin-preeclampsia

Published on December 18, 2009

Author: hamoda1992

Source: authorstream.com

Content

Heparin use in management of preeclampsia : Heparin use in management of preeclampsia Dr. Mohammed Abdalla Egypt, Domiat General Hospital thrombophilia : thrombophilia I will not exert much effort to explain the cause and effect relationship between thrombophilia and some adverse pregnancy outcomes. thrombophilia : thrombophilia Recurrent pregnancy loss, IUGR, IUFD, abruptio placenta , and early onset sever pre eclampsia are common associantes to thrombophilia . thrombophilia : thrombophilia The thrombotic nature of placental vasculopathy associated with these conditions are a mirror image of thrombophilia . Thrombophilia is either inherited or acquired : : Thrombophilia is either inherited or acquired : F V Leiden mutation (A506G) mutation. hyperhomocysteinemia (C677T) mutation. mutation in prothrombin (G 20210 A) . protein S deficiency. Protein C deficiency. Antithrombin III deficiency. Are acquired types. APAS is the inherited type. thrombophilia : thrombophilia (FV) Leiden mutation is found in about 5% of the population . 20–30% of venous thromboembolism events are due to FVL gene mutation . FVL gene mutation have a seven fold increased risk for thrombosis for heterozygotes , eighty fold increase for homozygotes. mutation in methylenetetrahydrofolate reductase can be found in 5–15% of the population. How to pick up such cases? : How to pick up such cases? Investigating a case of suspected thrombophilia is truly a dilemma , how much test you have to do , the list is quite large of what you look for: lupus anticoagulant, anticardiolipin , protein C and protein S deficiency, antithrombin III, the factor V Leiden, the factor II mutations, a prothrombin mutation, and prothrombin activator inhibitor mutation. How many patient can cope with this coast? not all of the tests are standardized. How to pick up such cases? : It is also important to note that, if you find incidentally antiphospholipid antibody, there are a lot of other associated causes, some of which are simple viral infections, and so on. it is important to keep in mind that infectious disease is quite capable of producing the antibody without thrombosis. How to pick up such cases? How to pick up such cases? : antiphospholipid antibody committee meeting in Sapporo, Japan, in the end of 1998, clinical criteria published in Arthritis and Rheumatism in 1999. How to pick up such cases? How to pick up such cases? : CLINICAL CRITERIA How to pick up such cases? Previous venous or arterial thrombosis. one or more unexplained fetal deaths after ten weeks of pregnancy. three or more unexplained consecutive spontaneous abortions less than 10 weeks. one or more preeclampsia or placental insufficiencies occurring before 34 weeks . OR OR OR Prophylaxis therapy : Prophylaxis therapy Prophylaxis therapy : Prophylaxis therapy prophylactic heparin and low dose aspirin for the prevention of these adverse effects associated with thrombophilia during subsequent pregnancies were already documented Prophylaxis therapy : The gold standard therapy to prevent miscarriages and obstetrical complications is represented by the association of low-dose aspirin and heparin (unfractionated or low molecular weight heparin). The Pregnancy Loss Study Group. Am J Obstet Gynecol 2000 Prophylaxis therapy Prophylaxis therapy : The combination of aspirin and heparin or low molecular weight (LMW) heparin is effective in recurrent fetal loss in APS and could be considered for women with inherited thrombophilias and history of severe preeclampsia, IUGR, abruptio placentae or fetal loss, although no controlled studies on the subject are currently available) Antiplatelet drugs for prevention of pre-eclampsia and its consequences: Systematic review. BMJ 2001 Prophylaxis therapy Slide 16: but what about the therapeutic role of this regimen during a current pregnancy associated with sever preeclampsia ? CASE REPORT : CASE REPORT Slide 18: I managed two cases of primigravidae with sever preeclampsia using unfractionated heparin (5000u/12h) and low dose aspirin in one case and in the other one I used LMWH (clexan 40 mg / day ) and low dose aspirin . Nifedipine was given for both. MgSo4 was given at admission. The blood pressure in both cases was above 180/110 , proteinuria +++ , gestational age 32 -33 wk , marked oligohydramnios was evident in both cases . Slide 19: Both cases showed good prognosis regarding reduction in blood pressure . the LMWH case needed no more Nifedipine after one week . proteinuria was improved in both cases falling to ( + , ++ ) and the liquor amount was increased ,the amniotic fluid index was much better in LMWH case . At 35 weeks both cases were delivered by s.c after giving both ladies 24 mg. dexamethasone divided on 3 doses before planned delivery. Similar trials : Similar trials Slide 22: By searching the net for similar treatment modalities I found two search results . one of them is a randomized prospective control study on 29 patients of sever preeclampsia to determine whether treatment with antithrombin (AT) concentrates plus heparin is better than heparin alone provide clinical efficacy without the full systemic antihypertensive drug or not. One group was given AT1500u/d + 5000u UFH/day by infusion ,the other group was given heparin alone. Slide 23: Antithrombin plus heparin is better than heparin alone for treating severe preeclampsia. Kobayashi and colleagues Shinshu University of Health Sciences published their study in Seminars in Thrombosis and Hemostasis . 2004 FEB 26 -(NewsRx com - NewsRx .net) Slide 24: the other trial was a case report published by Saisto and colleagues about use of Heparin to reverses preeclampsia in a factor V Leiden mutation carrier. Published in Hum Reprod 2004 MAY. Oxford University Press Slide 26: Saisto and colleagues said Previously, only prophylactic LMWH, in subsequent pregnancy, have been administered in patients with thrombophilia and a history of severe PE. We describe a case of sever very early onset PE, where the clinical characteristics of PE improved after beginning LMWH therapy . Slide 27: Sapporo clinical criteria are alarming signs that you may be facing a case of either inherited or acquired thrombophilia . CONCLUSION Slide 28: Investigating a case of suspected thrombophilia has met a long list of sophisticated investigations not available everywhere, not all of the tests are standardized and is considered out of hand of most patients . CONCLUSION Slide 29: FH or UFH in fixed dose ( 5000u/12h UFH –or 40 mg/day enoxaparin ) plus low dose aspirin proved by evidence beneficial in prophylaxis . CONCLUSION Slide 30: heparin and low dose aspirin in a fixed dose beside MgSo4, and hypotensive drugs seems to be beneficial in management of early onset sever preeclampsia . CONCLUSION Slide 31: Waiting for evidence proved by prospective RCT. May need many additional years on the expense of dreams and hopes of many women. CONCLUSION Slide 33: American Heart Association/American College of Cardiology Clinical Practice Guidelines for Management of Acute Myocardial Infarction. April 2001 CONTRAINDICATIONS TO THROMBOLYSIS Severe uncontrolled hypertension (Systolic BP greater than 200, diastolic greater than 120 mmHg) Relative Contraindications: Hypertension: systolic BP greater than 180 mmHg and/or diastolic BP greater than 110 mmHg Slide 34: Thank you

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