Profilaxis del tromboembolismo venoso en embarazo y puerperio: actualización en tiempos de infección por COVID-19
Revista Hematología
pdf

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 https://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.

pdf

Citas

Referencias:
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.
33. Data on COVID-19 during Pregnancy https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/special-populations/pregnancy-data-on-covid-19.html
34. Ellington S, Strid P, Tong VT et al. Characteristics of Women of Reproductive Age with Laboratory-Confirmed SARS-CoV-2 Infection by Pregnancy Status — United States, January 22–June 7, 2020. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html.
35. Lippi G and Favaloro E. D-dimer is associated with severity of Coronavirus Disease 2019: A pooled analysis. Thromb Haemost 2020; 120:876–878.
36. Thachil J, Longstaff C, Favaloro E et al. The need for accurate D-dimer reporting in COVID-19: Communication form the ISTH SSC on Fibrinolysis. doi:10.1111/JTH.14956.
37. Al-Samkari H, Karp Leaf RS, Dzik WH, et al. COVID and coagulation: Bleeding and thrombotic manifestations of SARS-CoV2 infection. Blood. 2020;136 (4): 489–500. https://doi.org/10.1182/blood.2020006520
38. Chan N, Weitz J. COVID-19 coagulopathy, thrombosis, and bleeding Blood. 2020;136(4):381-382.
39. Levi M, Thachil J, Iba T et al. Coagulation abnormalities and thrombosis in patients with COVID-19. Lancet 2020;7:e438-440.
40. J Throm Haemost 2020; Hantoushzadeh S, Shamshirsaz AA, Aleyasin A, et al. Maternal death due to COVID-19. Am J Obstet Gynecol 2020; 223:109. e1-16
41. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020; 18:844-847.
42. Hu W, Wang Y,Li J et al. The Predictive Value of D-Dimer Test for Venous Thromboembolism During Puerperium: A Prospective Cohort Study. Clin Appl Thromb Hemost 2020;26: 1-6.
43. Tang J, Lin Y, Mai H et al. Meta-analysis of reference values of haemostatic markers during pregnancy and childbirth. Taiwanese J Obstet Gynecol. 2019; 58:29-35.
44. Ahmed I, Azhar A, Eltaweel N et al. First Covid-19 maternal mortality in the UK associated with thrombotic complications. doi:10.1111/bjh.16849.
45. Martinelli I, Ferrazzi E, Ciavarella A et al. pulmonary embolism in a young pregnant woman with COVID-19. Thromb Res 2020; 191:36-37.
46. Mohammadi S, Abouzaripour M, Shariati N et al. Ovarian vein thrombosis after coronavirus disease (COVID-19) infection in a pregnant woman: case report. J Throm Thrombolysis. https://doi.org/10.1007/s11239-020-02177-6.
47. COVID-19 recomendaciones para la atención de embarazadas y recién nacidos en contexto de pandemia recomendaciones 20 de julio de 2020. http://www.msal.gob.ar/images/stories/bes/graficos/0000001839cnt-covid-19-recomendaciones-atencion-embarazadas-recien-nacidos.pdf
48. https://www.argentina.gob.ar/salud/coronavirusCOVID-19/alta.
49. Grand B. and Voto L. The Textbook of Perinatal Medicine. Second Edition. Publisher Taylor & Francis. Edited by Asim Kurjak and Frank Chevernak. Maternal issues in thrombosis and thrombophilia. 191; 2044-2050. 2006.
50. Grand B. Introducción y Prevención del tromboembolismo venoso en embarazo. Capítulo 4, pág. 79-96. . Libro Tromboembolismo venoso en embarazo y técnicas de reproducción asistida. Grupo CAHT. Edición 2018. ISBN: 978-987-21580-4-0.
51. Grand B. Parte VIII-Puerperio Capítulo 42: Puerperio patológico. Tromboembolismo pulmonar. Obstetricia: Fundamentos y enfoque práctico. Editor Dr. Juan Carlos Nassif. Editorial Panamericana.2012. Buenos Aires. Argentina.
52. Grand B. Tromboembolismo venoso en el embarazo.tulo 18, pág.223-246. Libro Manejo práctico del tromboembolismo venoso. Grupo CAHT. Edición 2019. ISBN: 978-078-21580-5-7.
53. Hunt BJ, Parmar K, Horspool K, Shepard N, Nelson Piercy C, Goodacre S. DiPEP research group. The DiPEP (diagnosis of PE in pregnancy) biomarker study: an observational cohort study augmented with additional cases to determine the diagnostic utility of biomarkers for suspected venous thromboembolism during pregnancy and puerperium. Br J Haematol. 2018; 180(5):694-704.
54. Pomp ER, Lenselink AM, Rosendaal FR, et al. Pregnancy, the postpartum period and prothrombotic defects: risk of venous thrombosis in the MEGA study. J Thromb Haemost. 2008; 6:632-637.
55. Bates S M, Middeldorp S, Rodger M, James A, Greer I. Guidance for the treatment and prevention of obstetric-associated venous thromboembolism. J Thromb Thrombolysis. 2016; 41:92-128.
56. ACOG Practice Bulletin. Inherited Thrombophilia in Pregnancy. Number 197. Obstetrics & Gynecology 2018;132: e18-e34.
57. Croles FN, Nasserinejad K, Duvekot J et al. Pregnancy, thrombophilia, and the risk of a first venous thrombosis: systematic review and Bayesian meta-analysis. BMJ 2017;359: j4452 doi:10.1136/bmj. j4452.
58. Gerhardt A, Scharf RE, Grre I et al. Hereditary risk factors of thrombophilia and probability of venous thromboembolism during pregnancy and the puerperium. Blood 2016; 128:2343-2349.
59. Bates SM, Greer IA, Middeldorp S, et al. Venous thromboembolism, thrombophilia, antithrombotic therapy and pregnancy. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (9th Edition) Chest 2012; 141: e691S-e736S.
60. Bates S, Rajasekhar A, Middeldorp S. et al. American Society of Hematology 2018 Guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood Adv. 2018; 2 (22): 3317–3359.
DOI 10.1182/bloodadvances.2018024802.
61. RCOG Royal College of Obstetricians & Gynecologists. Reducing the risks of venous thromboembolism during Pregnancy and the Puerperium. Green-top Guideline No 37a, April 2015.
62. Colmorn LB, Ladelund S, Rasmussen S et al. Risk of a venous thromboembolic episode due to caesarean section and BMI: A study in northern Denmark covering 2000–2010. Journal of Obstetrics and Gynaecology. 2014; 34:4, 313-316.
63. Allman-Farinelli MA. Obesity and venous thrombosis: a review. Semin Thromb Hemost. 2011; 37(8): 903–907.
64. Ageno W, Becattini C, Brighton T, Selby R, Kamphuisen PW. Cardiovascular risk factors and venous thromboembolism: a meta-analysis. Circulation 2008;117(1):93–102
65. Di Minno G, Mannucci PM, Tufano A, et al; First Ambulatory Screening On Thromboembolism (fast) Study Group. The first ambulatory screening on thromboembolism: a multicentre, cross-sectional, observational study on risk factors for venous thromboembolism. J Thromb Haemost 2005;3(7):1459–1466[Multicenter Study]
66. Samama MM. An epidemiologic study of risk factors for deep vein thrombosis in medical outpatients: the Sirius study. Archives of Internal Medicine. [Research Support, Non-U.S. Govt]. 2000 Dec 11–25;160(22):3415–20.
67. Galambosi PJ, Gissler M, Kaaja RJ et al. Incidence and risk factors of venous thromboembolism during postpartum period: a population-based cohort-study. Acta Obstet Gynecol Scand. 2017 Jul; 96(7):852-861
68. Sultan AA, West J, Grainge MJ, et al. Development and validation of risk prediction model for venous thromboembolism in postpartum women: multinational cohort study. BMJ. 2016 Dec 5; 355:i6253
69. James AH, Jamison MG, Brancazio LR, et al. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol. 2006;194: 1311-1315.
70. Jacobsen AF, Skjeldestad FE, Sandset PM. Incidence and risk patterns of venous thromboembolism in pregnancy and puerperium—a register-based case control study. Am J Obstet Gynecol. 2008; 198:233 e231-237.
71. Simpson EL, Lawrenson RA, Nightingale AL, Farmer RD. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. BJOG 2001;108:56–60.
72. Liu S, Rouleau J, Joseph KS, Sauve R, Liston RM, Young D, et al.; Maternal Health Study Group of the Canadian Perinatal Surveillance System. Epidemiology of pregnancy-associated venous thromboembolism: a population-based study in Canada. J Obstet Gynaecol Can 2009; 31:611–20.
73. Blondon M, Casini A, Hoppe KK et al. Risks of venous thromboembolism after cesarean sections: A meta-analysis. CHEST (2016), doi: 10.1016/j.chest.2016.05.021.
74. ACOG Practice Bulletin. Thromboembolism in Pregnancy. Number 196. Obstetrics & Gynecology 2018;132: e1-e17.
75. McLintock C, Brigthon T, Chunilal S et al. Recommendations for the prevention of pregnancy associated venous thromboembolism. ANZJOG 2011; 52:3-13.
76. MCLintock C, Brighton T, Chunilal S y col. Recommendations for the diagnosis and treatment of deep vein thrombosis and pulmonar embolism in pregnancy and the postpartum period. ANZJOG 2012; 52:14-22.
77. Palmerola KL, D´Alton ME, Friedman AM. A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines. BJOG 2015; 2157-2162.
78. Consenso SOGIBA 2017: Tromboprofilaxis durante el parto y puerperio. Latino O; Grand B, Gowdak A, Udry S. De Larrañaga G, Avila N. Vol 96; Nº1:1001.
79. Bleker S , Buchmüller A, Chauleur C et al. Low-molecular-weight heparin to prevent recurrent venous thromboembolism in pregnancy: Rationale and design of the Highlow study, a randomised trial of two doses. Thromb Res 2016;144: 62–68
80. Cox S. Mc Lintock C. Effectiveness and safety of thromboprophylaxis with
enoxaparin for prevention of pregnancy-associated venous thromboembolism. J Throm
Haemost 2019; 7:1160-1170.
81. Kearon C, Ageno W, Cannegieter SC et al. Categorization of patients as having provoked or unprovoked venous thromboembolism: guidance from the SSC of ISTH. J Throm Haemost 2016; 14:1480-3.
82. Kamel H, Navi BB, Sriram N et al. Risk of thrombotic event after the 6-week postpartum period. N Eng J Med 2014; 370:1307-1315.
83. Wichmann D, Sperhake J P, Lütgehetmann M.Autopsy Findings and Venous Thromboembolism in Patients With COVID-19. A Prospective Cohort Study. Ann Int Med.2020; 173:268-277 https://doi.org/10.7326/M20-2003
84. Lax S, Skok K, Zechner P et al. Pulmonary Arterial Thrombosis in COVID-19 With Fatal Outcome: Results From a Prospective, Single-Center, Clinicopathologic Case Series. Ann Int Med https://doi.org/10.7326/M20-2566.
85.Vazquez F, Korin J, Baldessari E. Recomendaciones para el uso de tromboprofilaxis en pacientes hospitalizados por covid-19 en la Argentina. MEDICINA (Buenos Aires) 2020; Vol. 80 (Supl. III): 65-66.
86. Pandemia por Coronavirus SARS-CoV2. Recomendaciones de la Sociedad Argentina de Hematología.
http://revistahematologia.com.ar/uploads/vol24_nro_extraordinario_covid2.pdf
87. Spyropoulos A, Levy J, Ageno W et al. Scientific and Standardization Committee Communication: Clinical Guidance on the Diagnosis, Prevention and Treatment of Venous Thromboembolism in Hospitalized Patients with COVID-19
doi:10.1111/JTH.14929.
88. Bikdeli, B, Mahesh M, Madhavan V et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up. JACC 2020. https://doi.org/10.1016/j.jacc.2020.04.031.
89. Samama MM, Cohen AT, Darmon J et al. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. N Engl J Med 1999;341: 793-800.
90. Zayed Y, Kheiri B,Barbarawi M. Extended duration of thromboprophylaxis for medically ill patients: a systematic review and meta-analysis of randomized controlled trials. Internal Medicine Journal 50 (2020) 192–199.
91. Neumann I , Izcovich A, Zhang Y. DOACs vs LMWHs in hospitalized medical patients: a systematic review and meta-analysis that informed 2018 ASH guidelines. Blood Adv. 2020; 4(7): 1512–1517.
92. López M, Gonce A, Meler E, et al. Coronavirus disease 2019 in pregnancy: a clinical management protocol and considerations for practice.Fetal Diagn Therapy. 2020; 47:519-528.
93. Knol H, Schultinge L, Veeger J et al. The risk of postpartum hemorrhage in women using high dose of low-molecular-weight heparins during pregnancy. Thromb Res 2012; 130: 334–338.

Todo el material publicado en la revista Hematología (versión electrónica y versión impresa), será cedido a la Sociedad Argentina de Hematología. De conformidad con la ley de derecho de autor (ley 11723) se les enviara a los autores de cada trabajo aceptado formulario de cesión de derechos de autor que deberá ser firmado por todos los autores antes de la publicación. Los autores deberán retener una copia del original pues la revista, no acepta responsabilidad por daños o pérdidas del material enviado. Los autores deberán remitir una versión electrónica al correo: revista@sah.org.ar

Descargas

Los datos de descargas todavía no están disponibles.