When HIT is diagnosed, heparin therapy is stopped and alternative anticoagulation initiated. Platelet transfusions are avoided (Greinacher, 2015). LMWH may not be entirely safe because it has some cross reactivity with UFH. The Ameri can College of Chest Physicians recommends danaparoid (Orgaran)-a sulfated glycosaminoglycan heparinoid (Bates, 2012; Linkins, 2012). In a review of nearly 50 pregnant women with either HIT or a skin rash, Lindhof-Last and associates tive. However, they reported two fatal maternal hemorrhages and three fetal deaths. Magnani (2010) reviewed case reports of 83 pregnant women treated with danaparoid. Although it was generally efective, two patients died related to bleeding, three patients sufered nonfatal major bleeds, and three women developed thromboembolic events unresponsive to danaparoid.
The drug has been removed from the u.S. market.
bin inhibitor (Kelton, 2013; Linkins, 2012). Successful use in pregnancy has been reported (Elsaigh, 2015; Knol, 2010).
Tanimura and coworkers (2012) successfully used argatroban, and later fondaparinux, to manage HIT in a pregnant woman with hereditary antithrombin deficiency.
Bone loss may develop with long-term heparin administration-usually 6 months or longer-and is more prevalent in cigarette smokers. UFH can cause osteopenia, and this is less likely with LMWHs (Deruelle, 2007). Women treated with any heparin should be encouraged to take an oral daily 1500-mg calcium supplement (Cunningham, 2005; Lockwood, 2012). In one study, Rodger and colleagues (2007) found that long-term use of dalteparin for a mean of212 days was not associated with a signiicant decline in bone mineral density.
he treatment of deep-vein thrombosis with heparin does not preclude pregnancy termination by careful curettage. After the products are removed without trauma to the reproductive tract, full-dose heparin can be restarted in several hours.
The efects of heparin on blood loss at delivery depend on several variables: (1) dose, route, and timing of administration; (2) number and depth of incisions and lacerations; (3) intensity of postpartum myometrial contractions; and (4) presence of other coagulation defects. Blood loss should not be greatly increased with vaginal delivery if the episiotomy is modest in depth, there are no lacerations, and the uterus promptly contracts. Unfortunately, such ideal circumstances do not always prevail. For example, Mueller and Lebherz (1969) described 10 women with antepartum thrombophlebitis treated with heparin. hree women who continued to receive heparin during labor and delivery bled remarkably and developed large hematomas. Thus, heparin therapy generally is stopped during labor and delivery. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (20a17) recommend restarting UFH or LMWH no sooner than 4 to 6 hours after vaginal delivery or 6 to 12 hours after cesarean delivery. We wait at least 24 hours to restart therapy after cesarean delivery or after vaginal delivery with significant lacerations.
Slow intravenous administration of protamine sulfate generally reverses the efect of heparin promptly and efectively. It should not be given in excess of the amount needed to neutralize the heparin, because it also has an anticoagulant efect.