Medical Dialogues
  • Dermatology
Login Register
This site is intended for healthcare professionals only
Login Register
  • MD Brand Connect
  • Vaccine Hub
  • MDTV
    • Breaking News
    • Medical News Today
    • Health News Today
    • Latest
    • Journal Club
    • Medico Legal Update
    • Latest Webinars
    • MD Shorts
    • Health Dialogues
  • Fact Check
  • Health Dialogues
Medical Dialogues
  • Medical News & Guidelines
      • Anesthesiology
      • Cardiology and CTVS
      • Critical Care
      • Dentistry
      • Dermatology
      • Diabetes and Endocrinology
      • ENT
      • Gastroenterology
      • Medicine
      • Nephrology
      • Neurology
      • Obstretics-Gynaecology
      • Oncology
      • Ophthalmology
      • Orthopaedics
      • Pediatrics-Neonatology
      • Psychiatry
      • Pulmonology
      • Radiology
      • Surgery
      • Urology
      • Laboratory Medicine
      • Diet
      • Nursing
      • Paramedical
      • Physiotherapy
  • Health news
      • Doctor News
      • Government Policies
      • Hospital & Diagnostics
      • International Health News
      • Medical Organization News
      • Medico Legal News
      • NBE News
      • NMC News
  • Fact Check
      • Bone Health Fact Check
      • Brain Health Fact Check
      • Cancer Related Fact Check
      • Child Care Fact Check
      • Dental and oral health fact check
      • Diabetes and metabolic health fact check
      • Diet and Nutrition Fact Check
      • Eye and ENT Care Fact Check
      • Fitness fact check
      • Gut health fact check
      • Heart health fact check
      • Kidney health fact check
      • Medical education fact check
      • Men's health fact check
      • Respiratory fact check
      • Skin and hair care fact check
      • Vaccine and Immunization fact check
      • Women's health fact check
  • AYUSH
    • Ayurveda
    • Homeopathy
    • Siddha
    • Unani
    • Yoga
  • State News
      • Andaman and Nicobar Islands
      • Andhra Pradesh
      • Arunachal Pradesh
      • Assam
      • Bihar
      • Chandigarh
      • Chattisgarh
      • Dadra and Nagar Haveli
      • Daman and Diu
      • Delhi
      • Goa
      • Gujarat
      • Haryana
      • Himachal Pradesh
      • Jammu & Kashmir
      • Jharkhand
      • Karnataka
      • Kerala
      • Ladakh
      • Lakshadweep
      • Madhya Pradesh
      • Maharashtra
      • Manipur
      • Meghalaya
      • Mizoram
      • Nagaland
      • Odisha
      • Puducherry
      • Punjab
      • Rajasthan
      • Sikkim
      • Tamil Nadu
      • Telangana
      • Tripura
      • Uttar Pradesh
      • Uttrakhand
      • West Bengal
  • Medical Education
      • Ayush Education News
      • Dentistry Education News
      • Medical Admission News
      • Medical Colleges News
      • Medical Courses News
      • Medical Universities News
      • Nursing education News
      • Paramedical Education News
      • Study Abroad
  • Industry
      • Health Investment News
      • Health Startup News
      • Medical Devices News
      • Pharma News
      • Pharmacy Education News
      • Industry Perspective
  • MDTV
      • Health Dialogues MDTV
      • Health News today MDTV
      • Latest Videos MDTV
      • Latest Webinars MDTV
      • MD shorts MDTV
      • Medical News Today MDTV
      • Medico Legal Update MDTV
      • Top Videos MDTV
      • Health Perspectives MDTV
      • Journal Club MDTV
      • Medical Dialogues Show
This site is intended for healthcare professionals only
LoginRegister
Medical Dialogues
LoginRegister
  • Home
  • Medical news & Guidelines
    • Anesthesiology
    • Cardiology and CTVS
    • Critical Care
    • Dentistry
    • Dermatology
    • Diabetes and Endocrinology
    • ENT
    • Gastroenterology
    • Medicine
    • Nephrology
    • Neurology
    • Obstretics-Gynaecology
    • Oncology
    • Ophthalmology
    • Orthopaedics
    • Pediatrics-Neonatology
    • Psychiatry
    • Pulmonology
    • Radiology
    • Surgery
    • Urology
    • Laboratory Medicine
    • Diet
    • Nursing
    • Paramedical
    • Physiotherapy
  • Health news
    • Doctor News
    • Government Policies
    • Hospital & Diagnostics
    • International Health News
    • Medical Organization News
    • Medico Legal News
    • NBE News
    • NMC News
  • Fact Check
    • Bone Health Fact Check
    • Brain Health Fact Check
    • Cancer Related Fact Check
    • Child Care Fact Check
    • Dental and oral health fact check
    • Diabetes and metabolic health fact check
    • Diet and Nutrition Fact Check
    • Eye and ENT Care Fact Check
    • Fitness fact check
    • Gut health fact check
    • Heart health fact check
    • Kidney health fact check
    • Medical education fact check
    • Men's health fact check
    • Respiratory fact check
    • Skin and hair care fact check
    • Vaccine and Immunization fact check
    • Women's health fact check
  • AYUSH
    • Ayurveda
      • Ayurveda Giuidelines
      • Ayurveda News
    • Homeopathy
      • Homeopathy Guidelines
      • Homeopathy News
    • Siddha
      • Siddha Guidelines
      • Siddha News
    • Unani
      • Unani Guidelines
      • Unani News
    • Yoga
      • Yoga Guidelines
      • Yoga News
  • State News
    • Andaman and Nicobar Islands
    • Andhra Pradesh
    • Arunachal Pradesh
    • Assam
    • Bihar
    • Chandigarh
    • Chattisgarh
    • Dadra and Nagar Haveli
    • Daman and Diu
    • Delhi
    • Goa
    • Gujarat
    • Haryana
    • Himachal Pradesh
    • Jammu & Kashmir
    • Jharkhand
    • Karnataka
    • Kerala
    • Ladakh
    • Lakshadweep
    • Madhya Pradesh
    • Maharashtra
    • Manipur
    • Meghalaya
    • Mizoram
    • Nagaland
    • Odisha
    • Puducherry
    • Punjab
    • Rajasthan
    • Sikkim
    • Tamil Nadu
    • Telangana
    • Tripura
    • Uttar Pradesh
    • Uttrakhand
    • West Bengal
  • Medical Education
    • Ayush Education News
    • Dentistry Education News
    • Medical Admission News
    • Medical Colleges News
    • Medical Courses News
    • Medical Universities News
    • Nursing education News
    • Paramedical Education News
    • Study Abroad
  • Industry
    • Health Investment News
    • Health Startup News
    • Medical Devices News
    • Pharma News
      • CDSCO (Central Drugs Standard Control Organisation) News
    • Pharmacy Education News
    • Industry Perspective
  • Home
  • Obstetrics and Gynaecology
  • Obstetrics and Gynaecology Guidelines
  • Management of...

Management of individuals with bleeding or thrombotic disorders undergoing abortion: Part 2

Written By : Dr Nirali Kapoor |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2021-09-25T09:00:05+05:30  |  Updated On 25 Sept 2021 4:19 PM IST
Management of individuals with bleeding or thrombotic disorders undergoing abortion: Part 2
  • facebook
  • twitter
  • linkedin
  • whatsapp
  • Telegram
  • Email

Individuals with thrombotic disorders: Approximately one half of the thromboembolic events that occur in the peri-partum period occur during pregnancy, the other half occurring in the post-partum period. There is no data on the whether D&E or labor induction abortion is safer for individuals with thrombotic disorders. However, given the immobility often associated with labor induction abortion, individuals at higher risk for VTE may be offered D&E as a preferred option.

Some individuals are at high risk for thrombosis during their pregnancies, and clinical recommendations from expert groups have recommended antenatal anticoagulation for several specific groups, although the certainty of evidence is low.

The American Society of Hematology guidelines (2018) recommend antenatal anticoagulation at prophylactic doses for women at high risk for VTE:

1. Women with a personal history of unprovoked or hormonally provoked VTE

2. Women with antithrombin deficiency and a family history of VTE

3. Women with homozygosity for factor V Leiden or combined factor V Leiden/prothrombin gene mutation regardless of family history

The use of VTE prophylaxis in pregnant women with a history of VTE reduces the risk of recurrent VTE by approximately 75%, which is similar to the risk reduction seen with VTE prophylaxis following high-risk orthopedic procedures. It can be assumed that the risk reduction when prophylaxis is in the period surrounding abortion would be similar.

Since there are no teratogenic effects to limit the choice of anticoagulants in an abortion patient, any of the standard anticoagulants would be appropriate. LMWH is recommended at standard prophylactic doses or intermediate doses in the postpartum setting. Warfarin is recommended at doses to produce an INR of 2- 3. In the rare case that a pregnancy continues in a patient taking warfarin, the patient should be counseled regarding the risks of warfarin embryopathy. By extension, prophylactic doses of the direct oral anticoagulants would also be a possible option. If there is concern or question about the appropriate agent to start, a hematologist should be consulted.

Individuals who meet the criteria for antenatal anticoagulation should be instituted on anticoagulation if the abortion procedure is not going to take place in the immediate future. There is not enough evidence to recommend that a procedure be delayed specifically to start anticoagulation. Authors would recommend LMWH given in standard prophylactic doses (the equivalent of 40 mg daily of enoxaparin) prior to the procedure, stopping it 24 hours in advance of the abortion.

There is no evidence on how long the period of increased risk of VTE persists after abortion. The postpartum guidelines recommend 6 weeks of postpartum prophylaxis in women with prior VTE and with some inherited thrombophilias. There is no evidence regarding the optimal duration of anticoagulation. Using the fall in risk after a full-term pregnancy as a guideline, a duration of 4-6 weeks after an abortion would be reasonable.

All individuals should undergo an individualized risk assessment for VTE when they present for abortion. If they have multiple risk factors and are determined to be high risk for VTE and are not currently on VTE prophylaxis, they can be offered anticoagulation prior to the abortion if there is a delay until the procedure, or can forego pre-procedure anticoagulation. High risk individuals can be offered 4-6 weeks of anticoagulation post procedure.

Additional considerations

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and ketorolac, are generally recommended as safe and effective options for post-operative pain. NSAIDs are alternatives to opioid medication without any significant associations with increased post-operative bleeding, development of hematomas, or increased complications.

NSAIDs inhibit platelet cyclooxygenase and block the formation thromboxane A2 which is involved in platelet aggregation. The effects of non-aspirin NSAIDs are reversible and function of the platelets are restored once the drugs are cleared from circulation. Platelet function returns to normal within 12 hours after ibuprofen administration.

In individuals on anticoagulation or with coagulopathies, use of NSAIDs should be carefully assessed and tailored on an individual basis. Most NSAIDs can enhance the activity of oral anticoagulants, such as warfarin, apixaban, rivaroxaban, or clopidogrel, and potentially result in increased bleeding risk. Use of NSAIDs for post-abortion pain management is generally recommended; however, NSAID use should be tailored to the risks and benefits for the specific individual with a bleeding disorder or on anticoagulation, with specific attention paid to the possible interaction of NSAIDs with anticoagulants.

What treatment to prefer:

Individuals with bleeding disorders or on anticoagulation diagnosed with early pregnancy loss, including incomplete abortion, should be offered surgical management given the lower and more predictable blood loss with this management option as compared to expectant or medical management.

Clinical recommendations

The following recommendations are based primarily on consensus and expert opinion:

  • For first-trimester abortion, surgical management is generally preferred over medical management for individuals with bleeding disorders or who are on anticoagulation. For secondtrimester abortion, surgical management may be recommended to limit bleeding though this has not been studied in these populations. Providers should individualize the mode of abortion with the approach of shared decision making, interdisciplinary collaboration, and accounting for the availability of procedural abortion and resources if complications
  • In an individual who presents for second-trimester procedural abortion with a suspected bleeding disorder, prompt referral to a hematologist should be initiated
  • Decision on the ideal setting for individuals undergoing procedural abortion with bleeding disorders or who are on anticoagulation should be individualized. Given the low bleeding risk of first-trimester procedures, it is possible to manage individuals without additional risk factors for bleeding in a hospital outpatient clinic or free-standing clinic setting. In general, second trimester abortions in these individuals should be preferably done in a hospital-based setting given increased access to resources should complications or hemorrhage occur.
  • Although data concerning bleeding risk is limited, for a first trimester procedural abortion in an individual on anticoagulation who has no additional risk factors for bleeding and is to undergo a procedure that is anticipated to be uncomplicated, anticoagulation can generally continue uninterrupted.
  • All individuals should undergo an individualized risk assessment for VTE when they present for abortion. If they have multiple risk factors and are determined to be high risk for VTE and are not currently on VTE prophylaxis, they can be offered anticoagulation prior to the abortion if there is a delay until the procedure, or can forego preprocedure anticoagulation. High risk individuals can be offered 4-6 weeks of anticoagulation post procedure.
  • The decision to interrupt anticoagulation in an individual currently on anticoagulation desiring a second-trimester procedural abortion must be done after an individualized risk assessment including absolute risk of VTE if anticoagulation is to be interrupted and bleeding risks with anticoagulation if it is continued.
  • Use of NSAIDs for post-abortion pain management is generally recommended; however, NSAID use should be tailored to the risks and benefits for the specific individual with a bleeding disorder or on anticoagulation, with specific attention paid to the possible interaction of NSAIDs with anticoagulants.
  • Surgical management of incomplete abortion in individuals with bleeding disorders or on anticoagulation is generally recommended over medical management

Source: J.K. Lee, A.B. Zimrin and C. Sufrin; Contraception 104 (2021) 119–127

https://doi.org/10.1016/j.contraception.2021.03.016


abortionthrombotic disordersthromboprophylaxis
Source : Contraception
Dr Nirali Kapoor
Dr Nirali Kapoor

    MBBS, MD Obstetrics and Gynecology

    Dr Nirali Kapoor has completed her MBBS from GMC Jamnagar and MD Obstetrics and Gynecology from AIIMS Rishikesh. She underwent training in trauma/emergency medicine non academic residency in AIIMS Delhi for an year after her MBBS. Post her MD, she has joined in a Multispeciality hospital in Amritsar. She is actively involved in cases concerning fetal medicine, infertility and minimal invasive procedures as well as research activities involved around the fields of interest.

    Dr. Kamal Kant Kohli
    Dr. Kamal Kant Kohli

    Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751

    Show Full Article
    Next Story

    Editorial

    Real-World Case study: Darbepoetin Alfa for Chemotherapy-Induced Anemia in Metastatic Breast Cancer - Dr Aditya Murali

    Real-World Case study: Darbepoetin Alfa for Chemotherapy-Induced Anemia in Metastatic Breast Cancer...

    Aspirin in Primary Prevention- When to Consider?

    Aspirin in Primary Prevention- When to Consider?

    Featured image representing medico legal

    What's the Role of Expert Opinion in Medical Negligence?

    7- Point Discharge Protocol for AECOPD: Time to Inculcate in Practice

    7- Point Discharge Protocol for AECOPD: Time to Inculcate in Practice

    Aspirin Use in Women Aged 40-50 with Diabetes and Hypertension: Identifying the Ideal Candidates

    Aspirin Use in Women Aged 40-50 with Diabetes and Hypertension: Identifying the Ideal Candidates

    View All

    Journal Club Today

    Real-World Case study: Darbepoetin Alfa for Chemotherapy-Induced Anemia in Metastatic Breast Cancer - Dr Aditya Murali

    Real-World Case study: Darbepoetin Alfa for Chemotherapy-Induced Anemia in Metastatic Breast Cancer...

    View All

    Health News Today

    Health Bulletin 09/ May/ 2025

    Health Bulletin 09/ May/ 2025

    View All
    © 2022 All Rights Reserved.
    Powered By: Hocalwire
    X
    We use cookies for analytics, advertising and to improve our site. You agree to our use of cookies by continuing to use our site. To know more, see our Cookie Policy and Cookie Settings.Ok