Palabras clave
SARS-CoV-2, COVID-19, embarazo, tromboprofilaxis, hospitalización, tromboembolismo venoso
Cómo citar
Grand, B., González Alcántara, M. M., Damico, V., Ilzarbe, A. B., Orti, J., & Voto, L. S. (2021). Profilaxis del tromboembolismo venoso en embarazo y puerperio: actualización en tiempos de infección por COVID-19. Revista Hematología, 24(3), 51–70. Recuperado a partir de http://revistahematologia.com.ar/index.php/Revista/article/view/306
Resumen
La enfermedad por coronavirus 2019 (COVID-19), considerada desde marzo por la OMS una pandemia, es una infección altamente contagiosa causada por un nuevo coronavirus responsable del síndrome respiratorio agudo relacionado al coronavirus 2 (SARS-CoV-2). Apareció en Wuhan, Hubei, provincia de China, en noviembre de 2019. Puede predisponer a los pacientes a enfermedad trombótica debido a la excesiva inflamación (tormenta de citoquinas), activación plaquetaria, disfunción endotelial y estasis. El incremento del riesgo de muerte se asocia con un marcado incremento de los valores de dímero-D.
Actualmente es considerada como una coagulopatía asociada a COVID-19 (CAC). En particular, en embarazo, la infección por COVID-19 es un desafío excepcional para el sistema de salud. El primer caso en Argentina apareció en marzo 2020. En el embarazo se presentan los tres elementos de la clásica tríada de Virchow. El régimen óptimo de tromboprofilaxis en embarazadas con COVID-19 no está establecido. Nosotros trabajamos en base a lo reportado en publicaciones, en conjunto con nuestra experiencia y adaptado a los requerimientos hospitalarios. En embarazadas COVID-19 positivas que se hospitalizan se recomienda la administración de heparina de bajo peso molecular 40 mg/día enoxaparina o heparina no fraccionada en caso de cercanía de parto.
La prolongación de la tromboprofilaxis en pacientes externados, ya sea que continúen su embarazo o luego del parto, requiere de una estratificación en base a sus factores de riesgo y evolución del cuadro
infeccioso. En este trabajo revisamos la experiencia de otros países y describimos nuestras recomendaciones.
Citas
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1. Kreuziger LB, Lee A, Garcia D et als. COVID-19 and VTE/Anticoagulation: Frequently asked questions. American Society of Hematology, ASH. Version 1.0; last updated March 27, 2020.
2. Sehn L. Balancing risk and benefit during coronavirus. Blood, 2020:135:1817.
3. Gauss T, Pasquier P, Joannes-Boyau Preliminary pragmatic lessons from the SARS-CoV-2 pandemic in France. Anaesth Crit Care Pain Med 39 (2020) 329–33.
4. Porfidia A, Pola R. Venous thromboembolism and heparin use in COVID-19 patients: juggling between pragmatic choices, suggestions of medical societies. J Throm Thrombolysis 2020 https: doi.org/10.1007/s11239-020-02125-4.
5. Ferner R. Chloroquine and hydroxychloroquine in covid-19: Use of these drugs is premature and potentially harmful. BMJ 2020;369:m1432.
6. Ciavarella A, Peyvandi F, Martinelli I et al. Where do we stand with antithrombotic prophylaxis in patients with COVID-19? Thromb Res 2020.
7. Iba T, Levy JH, Connors J et al. The unique characteristics of COVID-19 coagulopathy. Critical Care 2020; 24:360 https://doi.org/10.1186/s13054-020-03077-0.
8. Levi M. Pathogenesis and diagnosis of disseminated intravascular coagulation. Int J Lab Hematol. 2018;40(Suppl 1):15-20. O Levi M. COVID-19 Coagulopathy versus Disseminated Intravascular Coagulation. Blood Advanced Talks.2020.
9. Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood. 2020 Jun 4; 135(23): 2033–2040.
10. Tang N et als. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Throm Haemost 2020; 18:844-847.
11. Lillicrap D. Disseminated intravascular coagulation in patients with 2019-nCoV pneumonia. J Thromb Haemost. 2020; 00:1-2
12. Di Renzo GC, Giardina I. COVID-19 in pregnancy: consider thromboembolic disorders and thromboprophylaxis. Am J Obstet Gynecol 2020; 223(1): 135.
13. Coagulation changes and thromboembolic risk in COVID-19 obstetric patients. Benhamou D, Keita H, Ducloy-Bouthors AS. CARO working group. Anaesth Crit Care Pain Med 2020;39: 351–353.
14. D’Souza R, Malhamé I, Teshler L et al. A critical review of the pathophysiology of thrombotic complications and clinical practice recommendations for thromboprophylaxis in pregnant patients with COVID-19. Acta Obstet Gynecol Scand. 2020; 00:1–11.
15. Klok FA, Kruip M, van der Meer N, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020; 191:145-147.
16. Middeldorp S, Coppens M, van Haaps TF, et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost. 2020. https://doi.org/10.1111/jth.14888.
17. Hunt B, Retter A, McLIntock C. Practical guidance for the prevention of thrombosis and management of coagulopathy and disseminated intravascular coagulation of patients infected with COVID-19: Thrombosis-UK; 2020. Available from: https://throm bosisuk.org/downloads/T&H%20and%20COVID.pdf
18. Akima S, McLintock C, Hunt BJ. RE: ISTH interim guidance to recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020. https://doi.org/10.1111/jth.14853.
19. Thachil J, Tang N, Gando S, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020; 18:1023-1026.
20. RCOG. Coronavirus (COVID-19) Infection in Pregnancy – Version 9 [4 June 2020] London, UK: RCOG; 2020. Available from: https:// www.rcog.org.uk/globalassets/documents/guidelines/2020-06- 04-coronavirus-covid-19-infection-in-pregnancy.pdf
21. Marim F, Karadogan D, Eyuboglu T et al. Lessons Learned so Far from the Pandemic: A Review on Pregnants and Neonates with COVID-19. Eurasian J Med 2020; 52(2): 202-10.
22. Kasraeian M, Zare M, Vafaei M et al. (2020): COVID-19 pneumonia and pregnancy; a systematic review and meta-analysis, The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2020.1763952
23.Trocado V, Silvestre-Machado J, Azevedo L et al. (2020): Pregnancy and COVID-19: a systematic review of maternal, obstetric and neonatal outcomes, The Journal of Maternal-Fetal & Neonatal Medicine, DOI: 10.1080/14767058.2020.1781809
24. Hantoushzadeh S, Shamshirsaz AA, Aleyasin A et al. Maternal death due to COVID-19. Am J Obstet Gynecol 2020; 223:109. e1-16.
25. Grand B, González Alcántara M, Orti J, Lapidus A, Voto L. Obstetric patients in the intensive care unit (ICU): hematologic aspects. J Throm Haemost 2014; 12(Suppl. 1):102. WH07.
26. Zipursky J. and Barrett J. COVID-19 in pregnancy: Maintaining clarity with expanding evidence. Obstetric Med. 2020; 13(2) 53–54.
27. Smith DD, Pippen JL, Adesomo AA, et al. Exclusion of pregnant women from clinical trials during the Coronavirus Disease 2019 pandemic: a review of international registries. Am J Perinatol May 2020; doi:10.1055/s-0040-1712103.
28. Sutton D, Fuchs K, D’ Alton, M. Universal Screening for SARS-CoV-2 in Women Admitted for Delivery. DOI: 10.1056/NEJMc2009316.
29. Breslin N, Baptiste C, Gyamfi-Bannerman C, et al. Coronavirus disease 2019 among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals. Am J Obstet Gynecol MFM 2020; 2:100118.
30. Clinical features and obstetric and neonatal outcomes of pregnant patients with COVID-19 in Wuhan, China: a retrospective, single-centre, descriptive study. Yu N, Li W, Kang Q, Xiong Z et al. Lancet Infect Dis 2020; 20: 559–64.
31. Favre G, Pomar L, Musso D. 2019-nCoV epidemic: what about pregnancies? Lancet. 2020; 395:40.
32. Knight M, Bunch K, Vousden N, et al. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: national population-based cohort study. BMJ 2020;369:m2107. doi:10.1136/bmj.m2107.
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