We are grateful to Dr Jacqueline CONARD

(Htel-Dieu, Paris, France)

for expert assistance in reviewing this document

Thrombosis and Pregnancy 1

 :

Thrombosis and Pregnancy 2

 :

Thrombosis and Pregnancy 3



:
0.7-1.3/1,000
1/10,000

10 -

Thrombosis and Pregnancy 4

 :

(11%
27% )

Thrombosis and Pregnancy 5



100,000

Greer IA. Lancet 1999;353:1258-65

200

164

150
138 140 /
/
100 95
82
61
50 45 43
36 30
28 29 30 24

0
1955-57 61-63 67-69 73-75 79-81 85-87 91-93
58-60 64-66 70-72 76-78 82-84 88-90 94-96

Thrombosis and Pregnancy 6



(> 35 )

> 80 kg
72%

1

Thrombosis and Pregnancy 7


:

Thrombosis and Pregnancy 8


-
Thrombosis and Pregnancy 9
 Clexane

(
,
Clexane - -
- );

E, 24 ;
;
100% ( 29%
);
, .

Thrombosis and Pregnancy 10

 Clexane

- (50% ),

Clexane
;
- , -
Clexane 8000
,
;
, ,
; 20 mg 40 mg
Clexane - - Clexane
- .

Thrombosis and Pregnancy 11

 Clexane
:

Thrombosis and Pregnancy 12


Enoxaparin

Thrombosis and Pregnancy 13

 Enoxaparin

Thrombosis and Pregnancy 14

 Enoxaparin
-

- :
UFH: 2.7% (9/332 patients)
Enoxaparin: 0% (0/333 patients) p=0.0018

- IgG :
UFH: 7.8% (16/205)
Enoxaparin: 2.2% (4/182) p=0.02

Warkentin et al. N Engl J Med 1995;332:1330-5

Thrombosis and Pregnancy 15

 Enoxaparin

Authors Pregnancies Treatment Bone Density Spinal Fracture

(n) (n)

1
Backos et al. 150 UFH: 5,000 U q12h No significant 0
enoxaparin 20 mg q24h changes
3-9 months
2
Nelson-Piercy et al. 28 enoxaparin 40mg Decrease in 9 0
q24h women vs control
3-9 months value

1Br J Obstet 1999;106:102-7

2Am J Gynecol Obstet 1997;176:1062-8

Thrombosis and Pregnancy 16

 Enoxaparin (1)

47 (42 ), 1992-1998
39
22

Enoxaparin:
40 mg q24 h 45
40 mg q12 h 2 (
)
Ellison et al. Br J Obstet Gynaecol, 2000;107:1116-21

Thrombosis and Pregnancy 17


Enoxaparin (2)
: 0
:
, enoxaparin: 0
: -: 3 (1
, 2 )
/: 0
Ellison et al. Br J Obstet Gynaecol, 2000;107:1116-21

Thrombosis and Pregnancy 18

 Enoxaparin
/
:
10 12

- (1 mg/kg q12h 1.5 mg/kg q24h):

24 h
-
2

Thrombosis and Pregnancy 19

 Enoxaparin

- !

Thrombosis and Pregnancy 20

 Enoxaparin

Lepercq et al. Br J Gynaecol Obstet 2001;108:1134-40

Thrombosis and Pregnancy 21

 (1)

: enoxaparin
,

:
,
55 , 624 604
1988 1997
(CIAC)

Thrombosis and Pregnancy 22

 (2)

604

180 (29.8%)

92 (15.2%)

Thrombosis and Pregnancy 23

 (3)

enoxaparin


enoxaparin

Preconception / T1*, n 5 42 48 (7.7%)
T2, n 20 137 157 (25.2%)
T3, n 24 395 419 (67.1%)
Total, n 49 (7.8%) 574 (92.0%) 624 (100.0%)
*Data missing for one pregnancy
st nd rd
T1, T2, T3 : 1 , 2 and 3 trimesters of pregnancy
Thrombosis and Pregnancy 24
 (4)

624 (622 2 )
: 69 (11.1%)
(<37 ): 173 (27.8%)
: 175 (28.1%)
701 : 693 and 8

enoxaparin
Thrombosis and Pregnancy 25
 (5)

Enoxaparin Enoxaparin

72 (11.5%) 6 11 1
32 (5.1%) 2 9 0
- 10 (1.6%) 1 0 0
10 (1.6%) 1 2 0
(<100 G/L)
8 (1.3%) - - -
= 624; 386 (61.9%)

Thrombosis and Pregnancy 26

 (6)

Enoxaparin
8 - 0
14 10 0
3 - 0
(<100G/L)
42 17 0

= 701

Thrombosis and Pregnancy 27

 (7)

- :
180 (29.8%)
92 (15.2%)

: 12 , 5
-: 6 , 3
: 8 / 624 (1.3%)

Thrombosis and Pregnancy 28


:
The American College
of Chest Physicians Guidelines - 2001

Thrombosis and Pregnancy 29

 The ACCP Guidelines - 2001

UFH 5,000 s/cq 12h -

s/cq 12h - mid-interval anti-Xa: 0.1-0.3U/mL

s/cq 12h - mid-interval APTT: 1.5-25x

- mid-interval anti-Xa: 0.3-0.7U/mL

LMWH 40 mg s/cq 24h - peak anti-Xa: 0.2-0.6 U/mL

(enoxaparin) 1 mg/kg s/cq 12h - not required

- VKA* - INR: 2 3 4 6
UFH or LMWH

*VKA vitamin K

Thrombosis and Pregnancy 30



,1,2

,3 ENOXAPARIN
4
1Geertset al. Chest 2001 (suppl):132S-175S
2Hyerset al. Chest 2001 (suppl):176S-193S
3Sanson et al. Thromb Haemost 1999;81:668-72
4Ginsberg et al. Chest 2001 (suppl):122S-131S

Thrombosis and Pregnancy 31