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The 2012 ACCP Guideline Regarding the Pregnant Patient: a Case-Based Discussion

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The 2012 ACCP Guideline Regarding the Pregnant Patient: a Case-Based Discussion Canadian Society of Internal Medicine Annual Meeting Quebec City, October 2012 The 2012 ACCP guideline regarding the pregnant patient: A case-based discussion Dr. Michèle Mahone CHUM Montréal, Québec. Canadian Society of Internal Medicine Annual Meeting Quebec City, October 2012 The following presentation represents the views of the speaker at the time of the presentation. This information is meant for educational purposes, and should not replace other sources of information or your medical judgment. A selection of slides from this talk will be available on the CSIM website in PDF format. M.Mahone October 17th 2012 Canadian Society of Internal Medicine Annual Meeting Quebec City, October 2012 Conflict Disclosures The speaker has not received fees/honoraria. Some of the drugs, devices, or treatment modalities mentioned in this presentation are: aspirin LMWH Rivaroxaban Dabigatran Objectives • After the conference, the participant will be able to: – Follow an analysis and resolution of complex clinical cases on thrombophilia, antithrombotic and anticoagulation therapies in pregnant women by experts in the field. – Review the new recommendations of the 2012 CHEST consensus. Recognize the inherent difficulties linked to a paucity of evidence-based medicine in the literature. – Attend a discussion between various specialists who will attest to the diversity of practices in the field of obstetrical medicine. Themes that will be discussed: • New antithrombotic drugs in pregnancy • Asymptomatic thrombophilia • Secondary prophylaxis for obstetrical complications during pregnancy METHODS • Structured clinical questions • Update of English literature search from January 2005 to January 2010. • If a benefit is uncertain and a probability of important harm exists, they generally recommended against. • Patient preference: Recommendations in this article, therefore, reflect our belief that although average women considering antithrombotic therapy will also want to avoid medicalizing their pregnancy, they will put an extremely high value on avoiding fetal risk. Case 1 • 32 year-old G1Po, 6 weeks pregnant • Left deep vein thrombosis 4 weeks ago • She was put on rivaroxaban • What to do ? • Risk for fetus and mother ? • What does the ACCP 9th edition guideline say ? Drug counseling • What is the general risk of malformation? • The timing of the exposition and dosage • Other medications or drug usage • Comorbidities • Data on medication and pregnancy – Do not use FDA classification – Pubmed search – Drugs in Pregnancy and Lactation. Briggs et al., 2008. – Motherisk (Toronto) www.motherisk.org – Centre IMAGE Hôpital St-Justine (Montreal) Developmental progression and susceptibility to teratogens New antithrombotic • No human data available • Animal data (rabbits and rats) – Increases miscarriage – Low birth weight – Increase in malformations – Placental abnormalities Boehringer Ingelheim . Summary of product characteristics: dabigatran etexilate. Date of text revision: March 2009 Bayer Schering Pharma AG . Summary of product characteristics: rivaroxaban. Date of text revision: May 2009 Rivaroxaban • Anti-Xa inhibitor • Half life of 5-9 hours • Crosses placenta • Found in breast milk ACCP 9th Edition: Fetal complication of antithrombotic therapy during pregnancy and breast-feeding • 3.0.4. For pregnant women, we recommend avoiding the use of oral direct thrombin (e.g. dabigatran) and anti-Xa (e.g. rivaroxaban, apixaban) inhibitors (Grade 1C). • 4.0.4. For breast-feeding women, we recommend alternative anticoagulants rather than oral direct thrombin (e.g. dabigatran) and factor Xa inhibitors (e.g. rivaroxaban, apixaban) (Grade 1C). ACCP 9th Edition: Maternal and fetal complications of anticoagulant therapy • 2.2.1. For pregnant patients, we recommend LMWH for the prevention and treatment of VTE, instead of UFH (Grade 1B). • 3.0.1. For women receiving anticoagulation for the treatment of VTE who become pregnant, we recommend LMWH over vitamin K antagonists during the first trimester (Grade 1A), in the second and third trimesters (Grade 1B), and during late pregnancy when delivery is imminent (Grade 1A). Case 1 • Discuss the risk: probably low given the timing and dosage • Stop Rivaroxaban immediately and switch to LMWH at therapeutic dosage • Remainder of pregnancy – Induction at 38 weeks – Switch to UFH at 36 weeks PANEL ACCP 9th Edition: Treatment of proven acute VTE during pregnancy • 7.1.1. For pregnant women with acute VTE, we recommend therapy with adjusted-dose subcutaneous LMWH over adjusted-dose UFH (Grade 1B). • 7.1.2. For pregnant women with acute VTE, we recommend LMWH over vitamin K antagonist treatment antenatally (Grade 1A). • 7.1.3. For pregnant women with acute VTE, we suggest that anticoagulants should be continued for at least 6 weeks postpartum (for a minimum total duration of therapy of 3 months) in comparison with shorter durations of treatment (Grade 2C). • 7.1.4. For pregnant women receiving adjusted- dose LMWH therapy and where delivery is planned, we recommend discontinuation of LMWH at least 24 h prior to induction of labor or cesarean section (or expected time of neuraxial anesthesia) rather than continuing LMWH up until the time of delivery (Grade 1B). Treatment of proven acute VTE during pregnancy • Weight adjusted of LMWH • Routine anti-Xa level difficult to justify • Bid or daily regimen • Anticoagulation throughout the pregnancy • Decrease the dose to 75% if – high risk of bleeding – Risk of osteoporosis • Delivery plan Summary: • Better the devil you know than the devil you don’t • New oral direct thrombin and anti-Xa inhibitors are probably not safe in pregnancy and breastfeeding. • Minimum duration of treatment is 3 months PANEL Case 2 • 28 year-old G1P0, 6 weeks • Family history of thromboembolic disease • Antithrombin deficiency, type 1 • No personal history of thrombosis • What is her risk of thrombosis ? • Prophylaxis or not ? • What does the ACCP 9th guideline tell us ? What is the risk of thromboembolic disease in asymptomatic thrombophilia ? Estimated absolute risk in antepartum and Thrombophilia postpartum (95%CI) WITH FAMILY HISTORY Deficit in antithrombin 3.0 (0.08-15.8) Deficit in protein C 1.7 (0.4-8.9) Deficit en protein S 6.6 (2.2-14.70) Factor V Leiden heterozygote 3.1 (2.1-4.6) Prothrombin heterozygote 2.6 (0.9-5.6) Leiden homozygote 14.0 (6.3-25.8) Adapted from Bates et al, ACCP9th 2012 Antithrombin deficiency Rhéaume et al., 2012. Systematic review. Risk Ratio for Thrombosis in Retrospective Cohorts Studies of Antithrombin Deficiency Study RR (95% CI) Weight, % Folkeringa 2007 23.28 (1.38, 393.24) 39.61 Friederich 1996 6.03 (0.39, 94.07) 26.70 Van Boven 1999 16.07 (0.90, 287.70) 33.69 16.25 (2.93, 90.00) 100.00 Overall (I-squared = 0.0%, p = 0.755) .00254 1 393 Estimated absolute risk 1.6 % (0.29-9) Antithrombin deficiency Rhéaume et al., 2012. Systematic review. Odds ratio for thrombosis in case-control studies of Antithrombin deficiency Study OR (95% CI) Weight, % 11.55 (0.61, 218.16) Mitic 2009 24.96 8.46 (0.90, 79.51) 35.53 Meglic 2003 1.96 (0.12, 31.58) 39.51 Martinelli 2002 6.66 (1.59, 27.95) 100.00 Overall (I-squared = 0.0%, p = 0.630) .00458 1 218 Estimated absolute risk 0.67 % (0.16-2.80) ACCP 9th: Prevention of VTE in pregnant women with thrombophilia and no prior VTE THROMBOPROPHYLAXIS NO < 1% POSTPARTUM 4% ANTEPARTUM + POSTPARTUM >10% All thrombophilia Leiden Homo or Leiden Homo or Protrombin Homo Except Leiden Homo or Protrombin Protrombin Homo Homo FAMILY HX NO FAMILY HX NO FAMILY HX All others thrombophilia WITH FAMILY HX WHAT DO I DO ? • Risk of bleeding is low • Should cost be taken into the decision? • Risk factors other than family history • I worry about the large CI and the limited study data • I give antepartum prophylaxis to AT women – Prophylaxis versus intermediate dose PANEL Case 3 • 29 years-old G2P1, 6 weeks pregnant • G1 severe preeclampsia at 30 weeks – IUGR • Thrombophilia screening ? • Secondary prophylaxis ? Association of thrombophilia and obstetrical complications Thrombophilia Recurrent Late loss Preeclampsia Abruptio IUGR loss T1 FVL heteroz. + ? - - - - Prothrombin - - - - - AT deficiency NA - - - NA Protein C NA - - - NA Protein S NA ? - - NA APLA + + ? + +? +? Adapted from: Rodger MA. Thromb Hemost; 2011. Do Prado et al., Obstect Gynecol; 2010 Bates et al 2012. ACCP 9th Edition: Thrombophilia and pregnancy complications • 10.2.1. For women with recurrent early pregnancy loss (three or more miscarriages before 10 weeks of gestation), we recommend screening for APLAs (Grade 1B). • 10.2.2. For women with a history of pregnancy complications, we suggest not screening for inherited thrombophilia (Grade 2C). ACCP 9th Edition: Thrombophilia and pregnancy complications • No recommendation for or against screening for APLA if: – Late pregnancy loss – Preeclampsia – IUGR Prevention of recurrent preeclampsia in women without thrombophilia • 11.1.1. For women considered at risk for pre- eclampsia, we recommend low-dose aspirin throughout pregnancy, starting from the second trimester, over no treatment (Grade 1B) . Bates et al ACCP9th 2012 Prevention of recurrent preeclampsia in women without thrombophilia • No recommendation on LMWH • Awaits more data Secondary prophylaxis of obstetrical complications Studies # Thrombophilia Interventions Outcomes NNT Mello et al. 80 NO Dalteparin 5000 mg Preeclamspia 5 2005 VS NO 7.3 vs. 28.2 % Rey el al. 2009 116 NO Dalteparin 5000 mg Severe PE, IUGR, 5 VS NO abruptio, fetal death 5.5 vs. 23.6 NOH-PE 2011 224 NO Enoxaparin 40 mg PE,Abruptio, IUGR, 7 vs NO fetal death 8.9 vs. 25 % FRUIT-RCT 139 YES Dalteparin 5000 mg PE < 34 weeks 2012 + ASA 80mg VS ASA 0% vs. 8.7% 12 80mg PE 18.6 vs. 21.7% NS 32 Martelli et al. 128 YES Nadroparin 3800 IU PE, eclampsia, 2012 (70 VS 72%) VS medical HELLP,IUGR, abruptio surveillance 21% vs. 18% NS Case 3 • Screening for antiphospholid syndrome • ASA 81 mg HS • Prophylactic dose of LMWH – Dalteparin 5000 mg – Enoxaparin 40 mg – Tinzaparin 75 U/kg PANEL CONCLUSION • Anticoagulation with women in childbearing age should be associated with adequate contraception.
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