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Thrombosis Guidelines Emphasize Difficult Choices for Pregnant Women
Date:6/24/2008

of fetal gestation. However, some pregnant women with certain types of mechanical heart valves may be continued on VKA therapy because of concerns about the effectiveness of alternative anticoagulants in preventing stroke and valve thrombosis. For other women taking VKAs who become pregnant, the guidelines recommend substituting low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). The guidelines recommend two options for doing this: (1) continuing VKA but performing frequent pregnancy tests to determine when pregnancy has been achieved, followed by the substitution of LMWH or UFH as therapy; or (2) substituting VKAs with LMWH or UFH prior to conception. Although the second option eliminates the potential for fetal exposure to VKA, it provides additional challenges. LMWH and UFH are more expensive than VKAs and must be administered through a once- or twice-daily injection as opposed to a once daily oral dose of VKAs. In addition, long-term use of LMWH or UFH can be associated with osteoporosis.

"If women substitute heparin prior to pregnancy and have difficulties conceiving, they may find themselves taking the medication for a much longer timeframe than expected," said guideline coauthor Shannon Bates, MD, McMaster University and Henderson Research Centre, Hamilton, Ontario, Canada. "This is not only inconvenient but also increases treatment costs and may be associated with long-term risks for the mother."

Children

Recommendations related to childhood stroke, one of the top ten causes of death in children, and congenital heart disease have been substantially expanded since the previous guideline. Arterial ischemic stroke (AIS), usually caused by embolism or thrombosis, is difficult to diagnose in children because underlying health conditions are markedly different than those in adult stroke and up to 15% of children with AIS have no apparent risk factors. The guidelines recommend that children with AIS receive initial antithrombo
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SOURCE American College of Chest Physicians
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