Thromboprophylaxie pendant la grossesse et le post-partum

doi:10.1016/j.lpm.2013.06.003

La Presse Médicale

Volume 42, Issue 9, Part 1, September 2013, Pages 1251-1258

https://doi.org/10.1016/j.lpm.2013.06.003 Get rights and content

Key points

The incidence of venous thromboembolism (VTE) during pregnancy is about one event per 1000 pregnancies and placenta-mediated pregnancy complications (PC) occurred in 15%.

Knowing the biological combined with clinical risk factors would help to prevent problems during the pregnancy.

Several antithrombotic therapies exist, including very recent ones but LMWH and aspirin are still molecules of choice.

The women should be assessed for VTE and PC risk in order to improve the outcome.

Points essentiels

Une grossesse sur mille se complique d’un épisode de maladie veineuse thromboembolique et 15 % d’une pathologie vasculaire placentaire.

La connaissance de ces facteurs de risque biologiques et cliniques est indispensable à la prévention de ces maladies.

Les thérapeutiques antithrombotiques sont nombreuses et certaines sont très récentes mais les HBPM et l’aspirine restent les molécules de choix pendant la grossesse.

L’utilisation d’une stratification du risque thromboembolique et de pathologie vasculaire placentaire est souhaitable pour l’amélioration de la prise en charge.

Section snippets

Facteurs de risque de MVTE

Les risques cliniques décrits sont très nombreux et sont résumés dans le tableau I, si certains sont indiscutables d’autres par manque d’homogénéité des définitions [9], [10], [12], [13], [14], [15]. Les plus importants sont les antécédents personnels de MTVE indépendamment d’un facteur héréditaire, surtout en absence de facteur déclenchant, avec un risque de récidive compris entre 10 et 20 % par an. L’OR chez la femme enceinte serait compris entre 10 et 25 (17–36) [14], [15]. Le risque est à

Facteurs de risque de PVP

La prévalence de la PE est comprise entre 3 à 8 % des grossesses [28], [29] et celle de l’HRP est entre 5 et 15 ‰. Concernant les MFIU, la prévalence est différente en fonction du terme considéré, on retrouve des valeurs comprises entre 3 % à 5‰ [29]. Pour les FSC, 9 à 13 % des patientes présenteront une perte fœtale [28], 5 % des patientes seront concernées par au moins deux FSC et 1 à 2 % auront trois FSC et plus [28], [30]. Le RCIU correspond à un poids de naissance inférieur à celui des

Moyens thérapeutiques

De nombreux moyens thérapeutiques existent et ont été utilisés chez la femme enceinte : les bas de contention recommandés chez les patientes à risque [39], l’acide folique dans le cadre de l’hyperhomocystéinémie bien qu’il ne diminue pas le risque de récurrence [40], l’aspirine, l’héparine non fractionnée (HNF), les héparines de bas poids moléculaire (HBPM), les héparinoïdes, les antivitamines K (AVK), les inhibiteurs sélectifs, antithrombine dépendant, du facteur Xa et enfin les inhibiteurs

Recommandations de prise en charge de ces patientes

La prise en charge de ces nombreuses patientes reste complexe principalement en raison du faible nombre d’études randomisées chez la femme enceinte. Plusieurs situations n’ont pas de réponse dans la littérature et, dans beaucoup de situations, les niveaux de preuve sont donc faibles. Chaque pays a développé ses recommandations. Il existe donc de nombreuses recommandations françaises et internationales, qui ont été publiées [8], [11], [16], [46], [47]. Les contradictions sont nombreuses, nous

Conclusions

Le dépistage en préconceptionnel et pour toutes les grossesses de ces patientes par un interrogatoire est l’élément déterminant de leur prise en charge. L’adoption d’une pratique consensuelle est susceptible d’améliorer la morbi-mortalité en limitant les excès et carences thérapeutiques. L’aide fournie par les outils de stratification du risque de MVTE et de PVP pourrait permettre de répondre à cette attente et ainsi améliorer leurs prises en charge.

Déclaration d’intérêts

les auteurs déclarent ne pas avoir de conflits d’intérêts en relation avec cet article.

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Cited by (4)

Induction or spontaneous labor for pregnant patients on anticoagulants?
2023, Journal of Gynecology Obstetrics and Human Reproduction
There are two approaches to peripartum management for pregnant patients undergoing anticoagulation treatments: spontaneous labor or scheduling an induction. A long interval without anticoagulation is a thrombosis risk factor, while a short interval leads to risks of delivery without epidural analgesia or post partum hemorrhage. Our objective was to evaluate the impact of planned induction versus spontaneous labor on obtaining neuraxial analgesia.
A retrospective single-center study was conducted from 2012 to 2020 including all patients on preventive or curative low molecular-weight heparin at the time of delivery, excluding planned cesarean sections. The rates of neuraxial analgesia were compared between two groups: spontaneous labor and induction, as well as the intervals without anticoagulants.
127 patients were included. In the spontaneous labor group, 78% (44/56) received neuraxial analgesia versus 88% (37/42) in the induction group (p = 0.29). For curative dose treatment, the rate of neuraxial analgesia was 45,5% in the spontaneous group versus 78,6% (p = 0.12). The median time without anticoagulation was 34 h [26–46] in the spontaneous labor group and 43 h [34–54] in the induction group (p = 0.01), without an increased incidence of thrombosis. The rate of postpartum hemorrhage did not differ between the two groups.
Planned induction tended to increase the rate of neuraxial analgesia, without reaching significance, and most women in spontaneous labor accessed analgesia. Peripartum management should be a shared decision with the patient considering the obstetrical and thrombosis risk context for each patient.
Is a therapeutic anticoagulation window needed for delivery when using prophylactic low molecular weight heparin during pregnancy? A retrospective monocentric study
2017, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
The risk of venous thromboembolism (VTE) in pregnancy is 5.7/10,000 [1]. VTE is the third cause of maternal mortality in France, occurring in 1.1/100,000 of the pregnancies [2]. In Europe, the rate of maternal death by thromboembolic cause is 0.5/100,000.
The aim of the study was to evaluate the usefulness of therapeutic window for delivery for patients under prophylactic anticoagulation by low molecular weight heparin (LMWH) by comparing those who had a planned delivery versus those who delivered spontaneously.
This retrospective monocentric study included pregnant patients with prophylactic anticoagulation (one injection per day of enoxaparin 4000 UI), who delivered after 24 weeks of gestation. We collected data on pregnancy characteristics and on the delivery. We divided patients in two groups: GROUP S were patients who delivered spontaneously and GROUP P were patients who had a planned delivery for a therapeutic anticoagulant window. Our primary endpoint was the neuraxial anaesthesia rate. We compared the two groups with the student test for quantitative data and the Chi-2 test or the exact test of Fisher for qualitative data.
Over a 3.5 years period, we included 100 pregnant patients with prophylactic anticoagulation. Indications of prophylactic LMWH were patients with a low risk of thrombosis, mostly personal history of cured deep venous thrombosis (36%) prior to pregnancy or non-thrombotic antiphospholid syndrome (37%). The overall rate of neuraxial anaesthesia during delivery was 86%. Twenty-six patients were included in GROUP S and 74 in GROUP P. In GROUP P, all patients had access to neuraxial anaesthesia versus 88.4% (23/26) in the GROUP S (p < 0.0001). For the three remaining patients, the contraindication was a short delay between the last injection of LMWH and the need for anaesthesia. The mean delay between the last injection of LMWH and neuraxial anaesthesia was 42.6 +/− 24.1 (13–123) h in the GROUP P and 22.7 +/− 9.9 (11–42) h in the GROUP S (p < 0.0001). One patient had deep venous thrombosis in the 6 weeks postpartum, in the GROUP P.
With a planned induced delivery between 38 and 39 weeks of gestation, 11.5% of patients who went into spontaneous labour before induction would not have a neuraxial anaesthesia when respecting the 12 h delay between the last injection of low molecular weight heparin and the need for anaesthesia.
Antithrombotic medication: Which modifications with the new oral anticoagulants?
2013, Presse Medicale
The influence of anticoagulant and antiagregant therapy during pregnancy on clinical characteristics and outcomes of periventricular hemorrhages in newborns
2018, Zhurnal Nevrologii i Psihiatrii imeni S.S. Korsakova

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Mise au pointThromboprophylaxie pendant la grossesse et le post-partumAntithrombotic therapy and pregnancy

Key points

Points essentiels

Section snippets

Facteurs de risque de MVTE

Facteurs de risque de PVP

Moyens thérapeutiques

Recommandations de prise en charge de ces patientes

Conclusions

Déclaration d’intérêts

Lancet

J Thromb Haemost

Eur J Obstet Gynecol Reprod Biol

Blood

J Thromb Haemost

J Thromb Haemost

BJOG

Am J Obstet Gynecol

Chest

Thromb Res

Baillieres Best Pract Res Clin Obstet Gynaecol

Obstet Gynecol Clin North Am

Lancet

Blood

Blood

Semin Perinatol

Am J Obstet Gynecol

J Gynecol Obstet Biol Reprod

Clin Chest Med

Blood

Therapie

Lancet

Int J Obstet Anesth

Int J Gynaecol Obstet

Blood Rev

Am J Obstet Gynecol

Mise au point
Thromboprophylaxie pendant la grossesse et le post-partumAntithrombotic therapy and pregnancy