This article is more than 5 years old. Information may no longer be current.
Thrombosis guidelines address pregnant women, children
The revised guidelines contain recommendations on the prevention, treatment and long-term management of thrombotic disorders.
Click Here to Manage Email Alerts
The American College of Chest Physicians has issued revised, evidence-based guidelines on the prevention and management of thromboembolic complications, particularly in children and pregnant women.
The guidelines include over 700 recommendations for the prevention, treatment and long-term management of thrombotic disorders in children, pregnant women and patients undergoing surgery. Guidelines on the management of peri- and postoperative patients as well as the routine use of preventive therapies are also included.
The guidelines were published in Chest.
Prevention, treatment and management in children
Since the last guidelines were issued in 2004, the panel has made more expansive recommendations for childhood stroke and congenital heart disease.
The guidelines suggest that children with arterial ischemic stroke receive initial antithrombotic therapy until underlying causes can be determined. Maintenance therapy to prevent long-term recurrence is recommended as well. Ventricular assist devices and prosthetic heart valves for thrombosis related to congenital heart disease are also discussed.
Pregnant women
The guidelines recommend that pregnant women taking vitamin K antagonists such as warfarin should discontinue use of the drugs six weeks prior to fetal gestation due to the increased risk for fetal defects and miscarriages.
Due to concerns about the efficacy of alternative anticoagulants, pregnant women with certain mechanical heart valves may continue on vitamin K antagonists.
Other women taking vitamin K antagonists are encouraged to substitute low–molecular-weight heparin or unfractionated heparin by one of two methods:
- Continue vitamin K antagonists but perform frequent pregnancy tests to determine when pregnancy is achieved, then begin therapy with low–molecular-weight heparin or unfractionated heparin.
- Substitute vitamin K antagonists with low–molecular-weight heparin or unfractionated heparin prior to conception.
The second option eliminates the possibility of fetal exposure to vitamin K antagonists, but adds challenges due to the high cost of heparin therapy, frequent injections required and the association between long-term use of the drug and osteoporosis.
Surgery patients
Most patients on long-term antithrombotic therapy undergoing surgery must terminate therapy prior to and during surgery to minimize surgery-related bleeding. According to the guidelines, the risk for a thromboembolic event during interruption should be balanced against the risk for bleeding when antithrombotic therapy is discontinued just prior to surgery.
The guidelines also suggest that thromboprophylaxis are used regularly in patients having major general, gynecologic or orthopedic surgeries. Bariatric and coronary artery bypass surgery are also included in the guidelines.
Universal guidelines
Patients who are hospitalized should receive thromboprophylaxis, except those with a low risk of venous thromboembolism like patients having laparoscopic surgery, knee arthroscopy or those who take long airplane flights, according to the American College of Chest Physicians. Such patients should receive thromboprophylaxis on an individualized basis.
Because more effective preventive methods are available, the guidelines recommend against the use of aspirin to prevent VTE in any patient population. – by Stacey L. Adams
The publication of the 8th Consensus Guidelines has been eagerly anticipated by many coagulationists, as it is now four years since the last guidelines were published. Each of these chapters represents a Herculean task of compiling and grading all the literature in the relevant areas. Although the evidence from existing literature cannot answer all questions in the diagnosis and treatment of arterial and venous thrombosis, the contributors are to be congratulated once again for their efforts to rationalize these everyday clinical decisions.
– Nigel Key, MD
HemOnc Today Editorial Board member
For more information:
- Hirsh J, Guyatt G, Albers GW, et al. Antithrombotic and thrombolytic therapy: American College of Physicians Evidence-based Clinical Practice Guidelines (8th Edition). Chest. 2008;133:110-112.