Thrombophilia+Evaluation+and+Treatment+in+Pregnancy

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** Prenatal Guideline ** Consultation available 24 hours per day from OB on-call at 925-370-5608 or via page/amion, via inbasket to OB dept member or by calling Perinatologist at 510-444-0790 during the day and 510-204-1572 after hours. Consultation appointments or transfer of care to more experienced prenatal clinician available at major clinics sites—see consultation guidelines for more information.

Thrombophilia Evaluation and Treatment in Pregnancy
Acquired thrombophilias are generally more associated with fetal loss and Inherited thrombophilias are more often associated with increased risk of thrombosis formation.

Testing indicated for 3 or more first trimester losses/SABs, an otherwise unexplained second or third trimester fetal loss, maternal Lupus, severe preterm preeclampsia (controversial if indicated)
 * __Acquired Thrombophilias :__**
 * Lupus Anticoagulant**
 * Anti-cardiolipin antibody**
 * Beta-2 Glycoprotein**

Prevalence 1 -15 % Prevalence 3% Highly thrombotic, but rare Prevalence 0.2 – 0.3 % Different cut offs when pregnant as normally low in pregnancy: Second trimester screen is positive if < 30 % Third trimester screen is positive if < 24% Outside of pregnancy < 50% Need to WAIT at least 2 weeks after an event and must be off anticoagulants to measure.
 * __ Inherited Thrombophilias: __**
 * Factor V Leiden **
 * Prothrombin Gene Mutation **
 * Antithrombin III Deficiency **
 * Protein C Deficiency **
 * Protein S Deficiency **

Though there is an association between inherited Thrombophilias and venous thromboembolism, it is unclear if there is an association between inherited Thrombopilias and uteroplacental thrombosis that can lead to poor pregnancy outcomes (for instance: fetal loss, preeclampsia, IUGR, and placental abruption). Benefits in treating these patients has not been confirmed. NO association has been found between first trimester loss or IUGR and inherited thrombophilias. There is insufficient evidence to conclude that inherited thrombophilias are associated with increased occurrence of preeclampsia. There might be an association between placental abruption and inherited thrombophilias (inconclusive). Who should be tested for inherited thrombophilias? Screenings are controversial and useful only when results will affect management decisions. Consider screening if: Personal hx of venous thromboembolism was associated with a nonrecurrent risk factor. A first degree relative with a history of high-risk thrombophilia.

IF PATIENT IS POSITIVE FOR ONE OF THE ACQUIRED or INHERITED THROMBOPHILIAS AND HAS HAD A THROMBOTIC EVENT START THEM ON AT LEAST A PROPHLAXIS LMWH IN THE FIRST TRIMESTER AND CALL ONE OF THE OB/GYN STAFF OR THE PERINATOLOGIST. “The decision to treat with thromboprophylaxis, anticoagulant therapy, or no pharmacologic treatment (antepartum surveillance) is influenced by the venous thromboembolism history, severity of the inherited thrombophilia, and additional factors”.

__** Treatment **__ Primary Treatment in Pregnancy is with Lovenox. Lovenox is typically switched to heparin bid in after 36 weeks gestation.

Dosing is either PROPHYLACTIC 40 mg daily or INTERMEDIATE PROPHYLAXIS at 1mg/kg/day (assumes need more than prophylaxis due to pregnancy metabolism) or THERAPEUTIC 1mg/kg bid and then adjusted based on Factor Xa levels depending on indication and risk. Consult with OB or Perinatology for dose.

Dosing is continued for 6 weeks postpartum. If longer term anticoagulation indicated, switch to Coumadin (fine with breast feeding).