3 results
18 - Heparin-induced thrombocytopenia in pregnancy
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- By Barbara B. Haley, M.D., Professor of Medicine Sherry Wigley Crow Cancer Research Endowed Chair in Honour of Robert Lewis Kirby, M.D. University of Southwestern Medical School, Dallas, Texas, USA, Rodger L. Bick, M.D., Ph.D., Clinical Professor of Medicine and Pathology, University of Taxas, Southwestern Medical Center, Eugene P. Frenkel, M.D., Professor of Medicine and Radiology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas, SA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
- Print publication:
- 20 April 2006, pp 556-569
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Summary
Heparin is the most commonly used pharmacologic intervention to prevent or treat thrombosis in pregnancy. Both unfractionated heparin and low molecular weight heparins have been used successfully for therapeutic and prophylactic anticoagulation during gestation. Conversely, the use of coumadin in pregnancy is not advised as the drug crosses transplacentally and has been associated with a risk of fetal embryopathy and hemorrhage. The use of heparin, however, can have adverse clinical side effects for the pregnant female that include heparin-associated osteoporosis, eosinophilia, allergic reactions, ski rashes, and alopecia. However, the most significant and potentially devastating consequence is the development of heparin-induced thrombocytopenia. This is particularly true when the thrombocytopenia is paradoxically associated with either a venous or arterial thrombosis. Although heparin and low-molecular-weight (LMW) heparins are generally considered safe during pregnancy, a recent adverse reaction MedWatch report has been issued regarding the use of enoxaparin in pregnancy. This MedWatch report, issued January 9 2002 states the following: PRECAUTIONS:
Pregnancy
Teratogenic effects
There have been reports of congenital anomalies in infants born to women who received enoxaparin during pregnancy including cerebral anomalies, limb anomalies, hypospadias, peripheral vascular malformation, fibrotic dysplasia, and cardiac defect. A cause and effect relationship has not been established nor has the incidence been shown to be higher than in the general population.
Non-teratogenic effects
There have been post-marketing reports of fetal death when pregnant women received Lovenox Injection. Causality for these cases has not been determined. Pregnant women receiving anti-coagulants, including enoxaparin, are at increased risk for bleeding. Hemorrhage can occur at any site and may lead to death of mother and/or fetus. […]
7 - Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy
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- By William F. Baker, Jr., M.D., F.A.C.P.,, Associate Clinical Professor of Medicine Center for Health Sciences, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA, USA Thrombosis, Hemostasis, and Special Hematology Clinic, Kern Medical Center, Bakersfield, Eugene P. Frenkel, M.D., F.A.C.P.,, Professor of Medicine and Radiology Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas, USA, Rodger L. Bick, M.D., Ph.D., F.A.C.P., Clinical Professor of Medicine and Pathology, University of Texas Southwestern Medical Medical Center, Director: Dallas Thrombosis Hemostasis and Vascular Medicine Clinical Center, Dallas, Texas, USA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
- Print publication:
- 20 April 2006, pp 222-249
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Summary
Venous thromboembolism (VTE) represents a major cause of morbidity and mortality during pregnancy, complicating from 0.5 to 3.0 of every 1000 pregnancies. Pulmonary embolism (PE) has been the leading cause of maternal mortality in the United States and Great Britain for at least 20 years and complicates approximately 1 in 1,000 pregnancies. This represents a VTE risk of 3–4 times greater than age-matched non-pregnant controls. Diagnosing venous thromboembolism is challenging because clinical findings are often misleading. When evaluated with objective testing, as many as 75% of patients suspected of having venous thromboembolism are found to have an alternative diagnosis. This poses an even greater problem in the pregnant patient who experiences vasodilatation and intravascular volume expansion (20–25% increase) with associated lower extremity edema. The accuracy of many diagnostic tests used in the non-pregnant patient are either not useful at all or are potentially misleading. Diagnosis of VTE is critical since 24% of pregnant women with untreated deep vein thrombosis (DVT) develop PE, with a death rate of 15% to 30%. Proper diagnosis and treatment reduces the mortality rate of PE to 1%–3%. In addition, postphlebitic syndrome in the affected leg occurs nearly 80% of the time following DVT in pregnancy, compared to 30–40% in the non-pregnant patient. Although it is well recognized that the incidence of PE is greatly reduced with treatment for deep vein thrombosis (DVT), treatment is also problematic since anticoagulation regimens used in the non-pregnant patient may be highly teratogenic or in other ways hazardous to mother and/or fetus.
15 - Thrombocytopenia in pregnancy
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- By Ravindra Sarode, M.D., Professor of Pathology, University of Texas Southwestern Medical Center at Dallas, Texas, USA, Eugene P. Frenkel, M.D., Professor of Medicine and Radiology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas, USA
- Edited by Rodger L. Bick, University of Texas Southwestern Medical Center, Dallas, Eugene P. Frenkel, University of Texas Southwestern Medical Center, Dallas, William F. Baker, University of California, Los Angeles, Ravi Sarode, University of Texas Southwestern Medical Center, Dallas
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- Book:
- Hematological Complications in Obstetrics, Pregnancy, and Gynecology
- Published online:
- 01 February 2010
- Print publication:
- 20 April 2006, pp 490-505
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Summary
Thrombocytopenia is a common hematoloc1gical disorder that has classically been evaluated in an orderly clinical and laboratory approach. When thrombocytopenia is identified in the patient who is pregnant, important clinical differences and therapeutic implications exist when compared to the non-pregnant patient. These relate to the safety of the mother during pregnancy, viability of the fetus, the proper approach to parturition, and post-delivery care of the mother and the baby.
The recognition of thrombocytopenia is quite common in pregnancy, occurring in nearly 10% of patients. An unusual aspect of most of these events is that the majority are physiological. Thus the term “gestational thrombocytopenia” has been applied to this group of patients. This physiologic event must be differentiated from the less common, but clinically significant occurrence of a pathological mechanism for the thrombocytopenia. Such pathologic events are commonly associated with an evident clinical presentation and are potentially serious issues in the maintenance of the pregnancy and the health of the mother. In some circumstances, the thrombocytopenia is actually part of a more complex clinical disorder. The causes of thrombocytopenia in pregnancy are delineated in Table 15.1.
Gestational or physiological thrombocytopenia
Clearly, the most common cause of thrombocytopenia in pregnancy is a physiological event, since it is seen in 5 to 7% of all pregnancies, and actually accounts for more than 75% of all cases of thrombocytopenia during pregnancy.