Поясню свою позицию. Обратимся к уже упоминавшимся последним из опубликованных рекомендациям АССР. Думаю, их авторитетность сомнений не вызывает. Раздел по антитромботической терапии у беременных. Use of Antithrombotic Agents During Pregnancy. The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
http://www.chestjournal.org/cgi/content/full/126/3_suppl/627S
Based on safety data, a heparin-related compound (LMWH or UFH) is the anticoagulant of choice during pregnancy for situations in which its efficacy is established. There are two potential fetal complications of maternal anticoagulant therapy: teratogenicity and bleeding. Neither UFH nor LMWH cross the placenta; therefore, these agents do not have the potential to cause fetal bleeding or teratogenicity, although bleeding at the uteroplacental junction is possible. Several studies strongly suggest that UFH/LMWH therapy is safe for the fetus.
Итак, гепарины – препарат выбора.
In order to avoid an unwanted anticoagulant effect during delivery (especially with neuroaxial anesthesia) in women receiving adjusted-dose SC UFH therapy, it is suggested that heparin be discontinued 24 h prior to elective induction of labor or cesarean section. If spontaneous labor occurs in women receiving adjusted-dose SC UFH, careful monitoring of the aPTT is required. If it is markedly prolonged near delivery, protamine sulfate may be required to reduce the risk of bleeding. Although bleeding complications appear to be very uncommon with LMWH, we suggest the same approach to women receiving "therapeutic doses" of LMWH as in those receiving adjusted-dose UFH, namely discontinuing LMWH 24 h prior to elective induction of labor or cesarean section.
В большинстве случаев введение прекращается за 24 часа до родов (или Кесарева).
Safety of Aspirin During Pregnancy
Potential complications of aspirin during pregnancy include birth defects and bleeding in the neonate and in the mother. Both a metaanalysis and a large randomized trial that enrolled > 9,000 patients reported that low-dose (60 to 150 mg/d) aspirin therapy administered during the second and third trimesters of pregnancy in women at risk for pregnancy-induced hypertension or IUGR was safe for the mother and fetus. Thus, based on current evidence, low-dose aspirin (< 150 mg/d) during the second and third trimesters appears to be safe. The safety of higher doses of aspirin and/or aspirin ingestion during the first trimester remains uncertain.
Низкие дозы аспирина признаются относительно безопасными даже в третьем триместре, однако назначаются только женщинам с искусственными клапанами сердца. Это соответствует различным подходам к артериальным и венозным тромбозам, о чем мы уже говорили.
Резюме рекомендаций и их градация «достоверности»:
Recommendations.
In women with acute VTE, we recommend either adjusted-dose LMWH throughout pregnancy or IV UFH (bolus followed by a continuous infusion to maintain the aPTT in the therapeutic range) for at least 5 days, followed by adjusted-dose UFH or LMWH for the remainder of the pregnancy. Anticoagulants should be administered for at least 6 weeks postpartum (Grade 1C+).
In women receiving adjusted-dose LMWH or UFH therapy, we recommend discontinuing the heparin 24 h prior to elective induction of labor (Grade 1C).
In women with prosthetic heart valves at high risk, we suggest the addition of low-dose aspirin, 75 to 162 mg/d (Grade 2C).
Раздел рекомендаций Antithrombotic Therapy for Venous Thromboembolic Disease. Пункт, посвященный компрессии при тромбозе гл. вен верхних конечностей.
http://www.chestjournal.org/cgi/content/full/126/3_suppl/401S
8.5 Elastic bandages for the long-term treatment of upper extremity DVT
8.5.1. In patients with upper-extremity DVT who have persistent edema and pain, we suggest elastic bandages for symptomatic relief (Grade 2C).
Отмечено, что выводы основаны на описательных исследованиях (без группы контроля и т.п.), откуда и степень 2С.
Считаю, что проще предотвратить отеки и формирование ХВН, хр. лимфедемы, чем бороться с последствиями. Так что слабая выраженность отеков не повод отказаться от компрессии.
Система гемостаза весьма мобильна, 12 дней - не гарантия того что не может случиться рецидив, нарастание тромба, ухудшения регион. гемодинамики и тромбоэмболические осложнения. Поэтому назначение гепаринов - главное и обязательное мероприятие.
О никотинке ни слова, думаю с ней обсуждать особо нечего.
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