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Re: anticoagulationFrom: Peter Wein (p.wein@obsgyn-mercy.unimelb.EDU.AU)Tue Mar 31 23:23:54 1998
At 12:03 AM 01/04/98 -0600, you wrote: >I have a 22 year-old currently 10 weeks pregnant, first pregnancy. About 2 weeks >ago she developed a deep vein thrombosis in the left calf and thigh. She's been >on Coumadin (warfarin) since then (with heparin the first three days), and is >now basically asymptomatic. > >So now the question is, how long should she stay on the Coumadin? 3 months? 6 >months? The duration of the pregnancy? > >--------------------------------------------------------------------------- > >--------------------------------------------------------------------------- > >--------------------------------------------------------------------------- >Bob Woolley >St. Paul, Minnesota > >"THE PRESIDENT HAS KEPT ALL OF THE PROMISES HE INTENDED TO KEEP." > -Clinton aide George Stephanopolous speaking on "Larry King Live" > She shouldn't be on warfarin at all - especially in the first trimester! It is teratogenic, although he exact risk is uncertain, and there is a risk of fetal bleeding ( e.g. inracranial) at any time in pregnancy because it crosses the placenta. Outside of pregnancy one would usually continue anticoagulation for a "spontaneous" DVT for 6 months - in pregnancy, the pregnancy itself ( including the puerperium) is the risk factor, so anticoagulation should be for the entire pregnancy. This has to be either with unfractionated or (probably preferably) low-molecular weight heparin. The latter is more convenient - only once daily dosing needed with no testing needed,and may have lower risk of HITS and osteoporosis. After delivery, warfarin can be used, and anticoagulation should be continued for 6 weeks after delivery. After this time, the patient should be investigated for thrombophilia - protein C, protein S, lupus anticoagulant, anti cardiolipin antibodies, activated factor V resistance, factor V Leyden mutation, plasminogen activator deficiency. Most of these test can't be done on an anticoagulated patient and in any case many of them are altered by pregnancy.
-- Peter Wein Senior Lecturer Department of Obstetrics and Gynaecology University of Melbourne, Mercy Hospital for Women Clarendon Street, East Melbourne 3002 Australia Tel: +61 3 9270 2556 Fax: +61 3 9417 5406 Mobile: 0414 691690
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