Title Prevencija i liječenje tromboembolijskih bolesti u trudnoći Title (english) Prevention and treatment of thromboembolic disease in pregnancy Author Ema Hercog Mentor Željko Vučičević (mentor)Committee member Vlatko Pejša (predsjednik povjerenstva)Committee member Jasenka Markeljević (član povjerenstva)Committee member Željko Vučičević (član povjerenstva)Granter University of Zagreb Defense date and country 2016-07-15, Croatia Scientific / art field, BIOMEDICINE AND HEALTHCARE Abstract Venska tromboembolija (VTE) je medicinski pojam koji obuhvaća duboku vensku
trombozu (DVT) i plućnu emboliju (PE). Poznati čimbenici rizika za VTE su trudnoća i
puerperij. Uzrok tome su fiziološke promjene u trudnoći koje rezultiraju
hiperkoagulabilnošću, venskom stazom donjih udova i ozljedom endotela. Liječenje i
prevencija VTE u trudnoći zahtijevaju prilagođen pristup. ----- U antepartalnom i postpartalnom periodu, pacijentice u kojih postoji visok stupanj
sumnje na PE, liječe se antikoagulantnom terapijom prije potvrde dijagnoze. Ukoliko je
sumnja umjerena ili niska, potreban je individualan pristup. Pacijenti u kojih postoji sumnja
samo na DVT ne primaju antikoagulantnu terapiju prije dijagnostičke evaluacije.
Varfarin se u trudnoći ne primjenjuje u terapiji VTE jer prolazi placentu i dokazano je
teratogen. Neki drugi antikoagulansi također se ne preporučuju u trudnoći: fondaparinuks iz
skupine pentasaharida po strukturi sličan niskomolekularnom heparinu, prelazi placentarnu barijeru i stoga je potencijalno opasan, a o peroralnim direktnim inhibitorima trombina i inhibitorima faktora Xa nema za sada dovoljno podataka o sigurnosti u trudnoći.
Zajedničke smjernice većina studija upućuju na primjenu niskomolekularnog heparina
(Low Molecular Weight Heparin - LMWH) koji se primijenjuje isključivo subkutano.
Za razliku od LMWH-a, nefrakcionirani heparin (Unfractionated Heparin - UFH),
može se primjenjivati intravenski i subkutano. Osim u iznimnim slučajevima, prednost u
liječenju trudnica treba dati LMW heparinu zbog jednostavnije primjene, bolje učinkovitosti i manje nuspojava. ----- UFH je pak prikladniji u stanjima šoka ili kad postoji visoki rizik krvarenja, bubrežno zatajenje ili ako pretpostavljamo da bi mogla zatrebati brza reverzija antikoagulantnog učinka (npr. raniji porod ili hitna operacija).
Terapiju LMWH treba obustaviti bar 24 sata prije poroda, a terapiju UFH 4 do 6 sati
prije poroda. Antikoagulantnu terapiju treba nastaviti bar šest tjedana postpartalno. Ukupno, terapija u pacijenata s prolaznim faktorom rizika treba trajati 3 do 6 mjeseci. Žene s trajnim rizikom (npr. protetičke mehaničke srčane valvule) zahtijevaju prilagođen pristup.
Pacijentice koje su prije prve trudnoće već preboljele neki tromboembolijski incident
ili imaju dokazanu trombofiliju, moraju dobivati profilaktičke, a ponekad i terapijske doze
LMWH-a od početka do kraja trudnoće.
Abstract (english) Venous thromboembolism (VTE) is a medical entity that refers to deep vein
thrombosis (DVT) and pulmonary embolism (PE). Two well known risk factors for VTE are
pregnancy and puerperium. This is due to physiological changes in pregnancy which result in
hypercoagulability, venous stasis of lower extremities and endothelial injury. Treatment and
prevention of VTE in pregnant patients require a modified approach. ----- In antepartal and postpartal period, patients who are highly suspected of having PE are
treated with anticoagulant therapy before confirming diagnosis. If suspicion is low or
moderate, an individual approach is needed. Patients suspected of having DVT alone are not
given therapy before diagnostic evaluation.
Warfarin is not used in therapy of VTE in pregnant women because it crosses the
placenta and is proven to be teratogenic. Most studies advise against synthetic heparin
pentsaccharides like fondaparinux, oral direct thrombin inhibitors and factor Xa inhibitors, for
the lack of safety data in pregnancy.
It is generally recommended and consistent with latest guidelines to administer
subcutaneous low molecular weight heparin (SC LMWH). It is preferred over other two
options: intravenous unfractionated heparin (IV UFH) and subcutaneous unfractionated
heparin (SC UFH). This is due to easier use, apparent higher efficacy and better safety profile
of SC LMWH. IV UFH is still an acceptable alternative and even more appropriate in shock,
renal failure, high risk of bleeding or when rapid reversal of anticoagulation is required ( eg,
an urgent surgery or unexpected delivery). ----- SC LMWH is to be discontinued at least 24 hours prior to delivery, and IV UFH
should cease to be administered only 4-6 hours before delivery. Anticoagulant therapy should
be continued at least six weeks postpartum. In total, anticoagulant therapy for patients with
transient risk factors (e.g. pregnancy) is recommended to last three to six months. Women
with persistent risk (e.g. mechanical heart valves) require modified approach.
Patients who have a history of VTE before the first pregnancy, proven thrombophilia
or otherwise meet the criteria for pharmacologic thromboprophylaxis are treated during the
whole pregnancy with prophylactic doses of the same drugs used in treatment of VTE, and
sometimes even with therapeutic doses.
Keywords
venska tromboembolija
duboka venska tromboza
plućna embolija
liječenje
prevencija
antikoagulantna terapija
nefrakcionirani heparin
niskomolekularni heparin
Keywords (english)
venous thromboembolism
deep vein thrombosis
pulmonary embolism
treatment
prevention
anticoagulant therapy
low molecular weight heparin
unfractionated heparin
Language croatian URN:NBN urn:nbn:hr:105:969113 Study programme Title: Medicine Type of resource Text File origin Born digital Access conditions Open access Terms of use Repository Dr Med - University of Zagreb School of Medicine Digital Repository Created on 2017-06-21 08:54:46
