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Thrombosis Research
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Article history: Introduction: Low molecular weight heparin (LMWH) prophylaxis has been recommended for morbidly obese
Received 10 December 2013 pregnant women (N 40 kg/m2). There is very little data on the anticoagulant effects of LMWH in this group. We
Received in revised form 5 April 2014 investigated two different dosing regimens; fixed dose and weight-adjusted dose on the anticoagulant effects
Accepted 7 April 2014 of the LMWH tinzaparin used for thromboprophylaxis in obese pregnant women.
Available online 13 April 2014
Materials and Methods: Twenty morbidly obese pregnant women were started on a fixed dose of tinzaparin
(4,500 iu/day) at 32 weeks gestation and then changed to a weight-adjusted dose (75iu/kg/day) for the
Keywords:
Obesity
remainder of their pregnancy. Four-hour post LMWH, venous bloods were taken after each initial dose and
Thrombin Generation repeated every two weeks until delivery. Twenty normal weight women who did not receive LMWH at the
LMWH same gestation were used as controls.
Pregnancy Results: Prior to LMWH prophylaxis, tissue factor pathway inhibitor (TFPI) levels in the obese group at 32 weeks
Thromboprophylaxis were significantly lower (p b 0.001) and endogenous thrombin potential (ETP) and peak thrombin levels in
obese group were significantly higher, compared with controls (p b 0.0001; p b 0.001).
There was no significant difference between ETP levels before and after fixed LMWH. However, ETP levels were
significantly lower post weight-adjusted dose compared with post fixed dose. There was a significant effect
of LMWH on TFPI levels, (p b 0.0001). ETP correlated positively with total body weight prior to LMWH (r =
0.631) (p b 0.05) and at fixed dose (r = 0.578) (p b 0.05).
Conclusion: Morbidly obese pregnant women have increased thrombin generation and reduced natural anti-
coagulant in third trimester. This prothrombotic state was more effectively attenuated by weight-adjusted
than fixed LMWH doses.
© 2014 Published by Elsevier Ltd.
http://dx.doi.org/10.1016/j.thromres.2014.04.006
0049-3848/© 2014 Published by Elsevier Ltd.
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S.K. Ismail et al. / Thrombosis Research 134 (2014) 234–239 235
Materials and methods for LMWH and had no personal or family history of VTE or known
thrombophilia. Ethical approval was obtained from the Cork Teaching
Patients and study design Hospital Ethics Committee. Venous blood was taken from each
woman at 30 weeks gestation.
This is a cohort study in which 1) coagulation parameters of obese At 32 weeks gestation, the morbidly obese women were started on a
pregnant women were compared to normal weight pregnant women fixed dose of tinzaparin (4,500 iu/day). These patients were crossed
and 2) the effects of two LMWH prohlylactic doses were compared over after two doses to a weight-adjusted dose (75iu/kg/day) after
within the obese pregnant women. Forty women having given full in- 48 hour wash-out period and four-hour post dose blood samples were
formed written consent were recruited for this study at Cork University taken. In the morbidly obese group, LMWH dose was based on their
Maternity Hospital. Twenty morbidly obese pregnant women with BMI current pregnancy weight and they continued on this weight-adjusted
≥40 kg/m2 (Obese Group) and twenty normal weight (defined by BMI dose throughout the remainder of their pregnancy (Fig. 1). The normal
b 25 kg/m2) pregnant women (Normal Weight Group) were recruited weight pregnant women were not on any LMWH. Anti-Xa monitoring
at 30 weeks gestation. Participants were matched for age and parity. (Hyphen BioMed, France) performed in the haematology laboratory,
All women had a baseline bio profile done to check for renal and liver Cork University Hospital was used to check peak levels at 4 hours post
dysfunction prior to inclusion in the study. All women recruited were LMWH administration. Target prophylactic anti-Xa range was defined
Caucasian, non-smokers, had singleton pregnancies, had normal creati- as 0.1-0.5u/ml for 4,500iu per day. For patients with anti-Xa levels out-
nine clearance, normal liver function tests, no other contraindications side the target range, dose adjustments were discussed with Consultant
Fig. 1. Flowchart of Venous Blood Sampling Time Points and LMWH administration.
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236 S.K. Ismail et al. / Thrombosis Research 134 (2014) 234–239
At each time point, venous blood (4.5mls) was taken from the ante-
cubital fossa with minimum venous stasis using 3.13% sodium citrate as All patients maintained normal renal and liver function throughout
anticoagulant. Samples were centrifuged at 4˚C for 20 minutes at 2000 g. this study.
The resulting platelet poor plasma was carefully removed, aliquoted There were no patients in the obese group who had anti-Xa levels
into cryotubes, snap frozen and stored in cardboard cryoboxes at significantly outside the target range (0.1-0.5 iu/ml) that the hae-
− 80 ̊C until assay. All samples were processed and stored within matologist or obstetrician felt warranted, dose adjustment. None of
1 hour of phlebotomy. the women in either group of this study developed VTE, abnormal
bleeding or poor obstetric outcome. Two patients in the obese group
Laboratory methods reported bruising while on weight-adjusted LMWH, which resolved
with rotating injection sites. All patients in this study delivered healthy
In the obese group, anti-Xa, Tissue Factor Pathway Inhibitor (TFPI), live newborns. Twelve (60%) of the patients in the obese group had
Thrombin Antithrombin complex (TAT) and endogenous thrombin po- caesarean delivery compared with five (25%) in the normal weight group.
tential (ETP) were measured using calibrated automated thrombogram
(CAT) in each sample. In the control group, ETP, TFPI and TAT were Coagulation parameters at 30 weeks gestation in the morbidly obese and
measured. All assays were performed in large batches to minimise normal weight pregnant women
intra-assay variation. Anti-Xa activity was measured using chromogenic
substrate assay with tinzaparin used as standard (Hyphen BioMed, TFPI and TAT levels were measured in the obese group (prior to
France)[9]. Plasma levels of TAT (Enzygnost® TAT Micro, Siemens, LMWH administration) and were compared with those in a group
Marburg, Germany) and TFPI (Quantikine®, R&D Systems, Minneapolis, of control women of normal weight. TFPI levels in the obese group
USA) were measured with commercially available enzyme linked were significantly lower than the control group at 30 weeks gesta-
immunosorbent assays (ELISA). tion (p b 0.0005) (Table 2). TAT levels in the obese group were
Endogenous thrombin potential (Thrombinoscope™, Synapse BV, higher than control group at 30 weeks but this did not reach statisti-
Maastricht, Netherlands), was measured as previously described [10]. cal significance (p N 0.05). ETP (Table 2) and Peak thrombin levels in
Briefly, 80 μls of plasma was incubated with 20μls of platelet poor the obese group were significantly higher compared with control group
plasma reagent containing 5pM of Tissue factor. Thrombin generation at 30 weeks (p b 0.0005; p b 0.01 respectively). Similarly lag time
was initiated by addition of fluorogenic thrombin substrate (Fluca® and time to peak was significantly shorter in the obese group obese
Thrombinoscope™, Maastricht, Netherlands) and quantified by throm- group compared with that in a group of control women of normal weight
bin calibration standard. Fluorescence was measured at 20 second (p b 0.0005).
intervals for 60 minutes or until thrombin generation was completed.
Peak thrombin production and area under the thrombin generation Effects of LMWH on coagulation markers in the morbidly obese pregnant
curve (ETP) was determined and reported for each sample. women in third trimester
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S.K. Ismail et al. / Thrombosis Research 134 (2014) 234–239 237
Table 3
Coagulation Parameters in Morbidly Obese Pregnant Women on LMWH at 32 Weeks
Gestation In the Obese group levels were measured at 32 weeks prior to LMWH
administration (Pre LMWH Dose) and four hours post LMWH (4500iu tinzaparin)
(Fixed LMWH Dose) (n = 20). After a 48-hour washout period, the Obese group was
changed to a weight-adjusted dose at 32 weeks and levels were determined four hours
post LMWH (75iu/kg tinzaparin) (n = 20). Values represent mean (±SD). * = p b 0.01
compared with pre-dose levels. ** = p b 0.001 compared with pre-dose levels.
† = P b0.001 fixed dose v weight-adjusted dose.
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238 S.K. Ismail et al. / Thrombosis Research 134 (2014) 234–239
The second aim of our study was to investigate the anticoagulant Conflict of interest statement
effects of two different dosing regimens; fixed dose versus weight-
adjusted dose of LMWH tinzaparin used for thromboprophylaxis in JRH has received honoraria for guest lectures from Leo Pharma. JRH,
morbidly obese pregnant women. There was significant increase in SO’S and LN have received unrestricted research grants from Leo
TFPI and decrease in TAT levels following LMWH prophylaxis at both Pharma.
fixed dose and weight-adjusted dose. However, the weight-adjusted
dose provided greater inhibition of thrombin production and a more
Acknowledgement
significant increase in TFPI levels. Our findings are comparable to
data from non-pregnant obese subjects where increased levels of
The authors would like to thank Dr Ali Kashan for his expertise in
TFPI (3-fold above basal) post tinzaparin at 75iu/kg were demon-
statistical analysis and Ms Noelle Gill for her invaluable assistance in
strated in obese subjects [20]. This higher TFPI release with increased
patient recruitment.
LMWH exposure may suggest that TFPI release post LMWH may be
invoked in a dose dependant fashion. In the morbidly obese pregnant
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