ASH Clinical News December 2016 | Page 90

TRAINING and EDUCATION Patient Education • progestin-only pills, which studies show do not increase the risk for blood clots • age >60 years The National Blood Clot Alliance (NBCA) is dedicated to advancing the prevention, early diagnosis, and successful treatment of lifethreatening blood clots, such as DVT, PE, and clot-provoked stroke. NBCA works on behalf of those who may be susceptible to blood clots, including those with clotting disorders, atrial fibrillation, cancer, traumatic injury, risks related to surgery, lengthy immobility, child birth, and birth control. Women should talk with their doctors about blood clotting risks both before and while taking an estrogenbased birth control method. Women should also be familiar with their family history of blood clots. The most common inherited disorder leading to blood clots is factor V Leiden, which is typically suspected in individuals who develop blood clots at a young age, who are white with European ancestry, have a family history of clots, or have blood clots in unusual sites. For more information on NBCA, visit stoptheclot.org. Pregnancy and Child Birth For more patient resources on blood clots, visit stoptheclot.org/ learn_more/about-clots.htm. For more information specifically on a woman’s risk for blood clots, visit womenandbloodclots.org. • tubal ligation or vasectomy for their partner Though pregnancy does not directly cause blood clots, it does introduce a four-fold increased risk of developing a blood clot. That risk increases to about 20-fold in the weeks immediately following childbirth, and is at its highest – 100-fold – in the first week after the baby is born. Risk factors for blood clots related to pregnancy and childbirth include hospitalization, surgery, trauma, obesity, smoking, and immobility. In general, there are three groups of women who are advised to take blood-thinning medication (anticoagulation) during pregnancy: • women who have had a blood clot in the past and are already on blood-thinning medication • women who have had a blood clot in the past, but are not currently on blood-thinning medication • women who develop a blood clot during pregnancy After labor and delivery, women who have not had a blood clot but who have major risk factors also may need anticoagulation for a short period of time. Major risk factors include: Though oral anticoagulants (such as warfarin, dabigatran, rivaroxaban, and api xaban) are the most commonly prescribed blood thinners, they are not considered safe for the fetus. Women who take blood thinners should contact their doctors immediately upon finding out they are pregnant. The doctor may recommend switching from oral anticoagulants to blood thinning medications that are injected under the skin (subcutaneous administration), such as standard or unfractionated heparin and low-molecular-weight heparin (LMWH). These medications do not cross the placenta or enter the bloodstream of the fetus. Childbirth While Taking Blood Thinners Women are at a higher risk for a blood clot in the six weeks following the baby’s birth, but it may be necessary to suspend anticoagulation therapy to minimize postpartum bleeding complications. After delivery, women with clotting disorders should resume anticoagulation therapy (no sooner than 4-6 hours after vaginal delivery or 6-12 hours after Cesarean delivery) and continue taking anticoagulants – either injections or an oral anticoagulant – for at least six weeks postdelivery as the risk for bleeding is reduced. The duration of anticoagulation after this point should be determined by the individual woman’s risk. Women can breastfeed while receiving LMWH injections or warfarin, but the safety of newer oral anticoagulants (including dabigatran, apixaban, and rivaroxaban) during breastfeeding has not yet been established. Women should discuss their potential risk factors with their doctors, and make sure that they take steps to address any risks, including: • taking any prescribed medications as directed • avoiding sitting still for prolonged periods of time • making lifestyle changes, like losing weight and quitting smoking • prolonged immobilization, such as bed rest • exercising regularly • cancer ASH Clinical News Anticoagulation Therapy During Pregnancy • an inherited blood clotting disorder • smoking 88 • heart failure Treatment of Menopausal Symptoms As women approach menopause, they begin to experience menopausal symptoms that are sometimes treated with a hormone therapy, which contains estrogen and can increase the risk of blood clots up to three-fold. Again, the absolute risk of blood clots associated with hormone therapy is 1 in 300 per year. For women looking to avoid the risk of blood clots related to hormone therapy, the physical effects of menopause – such as mood changes, hot flashes, sleeplessness, and vaginal dryness – can be managed with non-estrogen-containing medications for symptomatic relief. When entering menopause, women with a history of blood clots should only use hormone therapies containing estrogen or progestin if they also are taking anticoagulation. Women should talk with their doctor about starting hormone therapy and the risks involved. ● December 2016 Cut out and give to a patient The National Blood Clot Alliance Resources