Therapeutische Umschau. Revue thérapeutique
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Review Comparative Study
[Anticoagulation and antiaggregation during pregnancy].
For haemostatic and circulatory reasons pregnancy is associated with an about 6-fold relative increase of thrombotic risk which is further raised by additional risk factors, such as history of thrombosis or acquired and hereditary thrombophilia, respectively. Recently, the thrombophilias have been revealed as risk factors for severe preeclampsia, abruptio placentae, fetal growth retardation, abortion and still birth as well. ⋯ The first part of this article deals with the pregnancy related problems of coumarins, heparins and aspirin and demonstrates that the low molecular weight heparins are the anticoagulants of choice for most indications in pregnancy. The second part of this overview shows in which specific situations and how the antithrombotic medications mentioned above are used in pregnancy.
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Comparative Study
[Anticoagulation and antiaggregation in patients with peripheral arterial occlusive diseases].
Peripheral vascular occlusive disease (PAOD) is frequently seen in patients suffering from coronary heart or cerebrovascular disease and is, considered as a prognostic predictor for the morbidity and mortality of this patient group. Thus, secondary antithrombotic and antiplatelet prophylaxis in these patients is not limited to achievement of long-term patency of the revascularized or recanalized arterial segment, but plays as well a pivotal role for the prevention of myocardial infarction and stroke. ⋯ On the other hand, those undergoing axillo-femoral, femoro-femoral crossover, aorto-profundal or femoro-popliteal infragenicular and femoro-distal venous bypass surgery should be treated with vitamin K antagonists. The role of Clopidogrel in secondary prevention after peripheral revascularization and recanalization still needs to be defined.
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The hemostatic system consisting of primary and secondary hemostasis as well as fibrinolysis is an evolving process throughout life with important qualitative and quantitative differences between children and adults. Moreover, the different age groups of childhood differ in many aspects of their hemostatic system. These differences reflect an adaptation to the young age rather than immaturity. ⋯ The management of children with defects of the hemostatic system is therefore characterized by controversies that are further fueled by a lack of data. There is, however, a beginning of international activities with clinical trials and attempts of developing evidence based guidelines, or guidelines clearly stating where evidence is lacking. This activity should be supported by the international community of pediatricians who promote progress in knowledge and management of pediatric hemostatic system disorders.
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Unfractionated heparin (UH) and low-molecular-weight heparins (LMWH) are antithrombotic drugs covering virtually all indications requiring immediately effective anticoagulation. For prevention and treatment of venous thromboembolism (VTE) UH have mainly been replaced by LMWH due to their practical usefulness (one or two subcutaneous daily doses without laboratory test for dose adjustment) and their more favourable risk-benefit profile. With respect to arterial occlusions this statement is also valid for unstable angina pectoris. ⋯ Higher UH activities required during extracorporeal circulation in heart surgery or during coronary angioplasty are usually guided by bedside ACT (activated clotting time). For LMWH tests of anti-Xa activities may only be necessary during weight adjusted treatment of pregnant women, children, or cases with reduced kidney function (glomerular filtration rate < 30 ml/min.) or increased bleeding risk. Expected anti-Xa activities are 0.5-1.1 IU/ml and 1.0-2.0 IU/ml 4 hours after subcutaneous LMWH for dosing intervals of 12 hours and 24 hours respectively.
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Induction of labor is one of the most important means for therapeutic intervention in modern obstetrics. The aim of labor induction is to achieve a better perinatal result for mother and baby as compared to expectative management. Different methods for induction include administration of oxytocin or prostaglandins, amniotomy, and mechanical means of cervical dilatation. ⋯ Until recently, prostaglandins E2 are used in the first line. Now, the prostaglandin E1-analogon misoprostol is also increasingly used. As a rule, induction of labor should be performed as an inpatient procedure in order to be able to provide the surveillance for maternal and fetal safety.