Management der akuten heparininduzierten Thrombozytopenie Typ II während der Schwangerschaft und peripartal

Zusammenfassung

In der Schwangerschaft und im Wochenbett wird nur bei akuten Thromboembolien bzw. bei Patientinnen mit deutlich erhöhtem Thromboembolierisiko Heparin appliziert. Da die Therapie inzwischen weit gehend mit niedermolekularen Heparinen erfolgt, bei denen die HIT-II-Inzidenz deutlich geringer ist als bei den unfraktionierten Heparinen, stellt die heparininduzierte Thrombozytopenie Typ II ein seltenes Ereignis bei diesem Kollektiv dar. Die HIT II ist eine vital bedrohliche Heparinnebenwirkung, die bereits bei Verdacht zum sofortigen Abbruch der Heparintherapie führen muss. Die Erfahrungen mit alternativen Antikoagulanzien in der Gravidität und Puerperium sind begrenzt. Der Einsatz von Vitamin-K-Antagonisten (Kumarinderivaten) ist in der Akutphase der HIT Typ II kontraindiziert. Auch ist ihre Gabe v. a. in der Phase der Organogenese wegen der Gefahr von Fetopathien und in der 2. Hälfte des dritten Trimenons wegen des erhöhten maternalen und kindlichen intra- und peripartalen Blutungsrisikos nicht unproblematisch und nur unter strengen Kautelen vertretbar. Danaparoid-Natrium und rekombinantes Hirudin stellen Alternativen dar, wobei wegen der besseren Datenlage und der intravenösen und insbesondere auch der subkutanen Applikationsform dem Danaparoid der Vorzug bei der Therapie der HIT II in der Gravidität zu geben ist. Im Wochenbett stellen Warfarin oder Phenprocoumon die Therapie der Wahl dar. Stillen ist hierunter möglich. Berichtet wird über eine Patientin mit akuter Sinusvenenthrombose in der Frühschwangerschaft und der Entwicklung einer HIT Typ II unter der darauf erfolgenden Heparintherapie. Das Management der Langzeit- und peripartalen Antikoagulation mit Danaparoid-Natrium wird dargestellt.

Abstract

In pregnancy and in puerperium heparin is prescribed only for acute thromboembolism and/or for female patients with a clearly increased risk of venous thromboembolism. Since treatment changed from unfractionated heparin to low-molecular- weight heparin, the incidence of heparin-induced thrombocytopenia type II (HIT type II) is therefore a rare event in this collective. HIT type II is a life threatening side effect of heparin which must immediately lead to the stop of heparin administration. Experiences with alternative anticoagulation in pregnancy and puerperium are limited. Oral anticoagulation with coumarin (vitamin K antagonists) is contraindicated for the initial therapy of HIT II. The treatment with these substances is dangerous, especially in the phase of organogenesis, because it can cause malformation and because of the elevated maternal and the child intra- and peripartal bleeding risk in the 2nd half of the third trimenon. Danaparoid Sodium and recombinant Hirudin represent treatment options, whereby because of the better data and the intravenous and especially the subcutaneous application form the application of Danaparoid in the therapy of HIT typ II in pregnancy would appear to be more favourable. In the puerperium Warfarin or Phenprocoumon represent the therapy of choice. Breast-feeding is possible with this option. We report on a female patient with an acute thrombosis of the cerebral sinus vein during early pregnancy who developed a HIT type II under heparin treatment. The long-term anticoagulation with Danaparoid Sodium and the peripartale management are presented.

Schlüsselwörter

Schwangerschaft - Sinusvenenthrombose - heparininduzierte Thrombozytopenie - Danaparoid-Langzeitantikoagulation

Key words

Pregnancy - sinus vein thrombosis - heparin-induced thrombocytopenia - Danaparoid - long-term anticoagulation

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