How and why are abdominal injections performed during pregnancy?

Indications and contraindications for abdominal injections

Since childbirth is always accompanied by blood loss, even during pregnancy the body increases blood clotting. The amount of fibrinogen increases, and along with it the work of antithrombins is blocked. If the expectant mother has a pronounced tendency to form blood clots, then this poses a threat not only to her, but also to the life of the fetus.

Injections in the abdomen to thin the blood during pregnancy help stabilize the situation. They are used only as prescribed by the attending physician. Injections are given by the woman herself or by a medical professional.

Indications for prescribing the drug during pregnancy are the following patient diagnoses:

• thrombophilia;
• deep vein thrombosis and bleeding due to a decrease in platelet count;
• myocardial infarction;
• long-term bed rest for cardiovascular diseases, pathologies of the respiratory system, after surgery or complex trauma.

Pregnant women are prescribed injections when diagnosed with DIC syndrome. This disease carries a risk for the fetus: the child starves when the vessels of the uterus are damaged and, if the necessary measures are not taken in time, it subsequently ends in his death. A woman may also experience negative consequences, even fatal ones: severe blockage of blood vessels and hemorrhage in the brain.

In this regard, during pregnancy, all patients undergo a blood test during registration, which is called a coagulogram. It allows you to track fibrinogen parameters. Its norm: 2-4 g/l. If the indicators are too high, treatment is prescribed, and the analysis is repeated every 7 days. If fibrinogen is within normal limits, then a coagulogram must be taken once a trimester.

The first trimester of pregnancy is considered a contraindication to the use of heparin-based drugs. They do not have a positive effect on the blood flow of the embryo during this period, but in the course of studies conducted on pregnant animals, a negative effect of the substance on the formation of the fetus was discovered. No further trials were carried out on expectant mothers in the 1st trimester.

Since active formation of organs and all important systems takes place up to 12 weeks, and blood flow is carried out through the chorionic villi, injections are not prescribed. Subsequently, the placenta begins to function, through which the active substance does not penetrate and cannot harm the unborn child.

In addition to early pregnancy, there are a number of contraindications to the use of abdominal injections:

• risk of miscarriage;
• relapse of gastric ulcer;
• disturbances in the functioning of the pancreas;
• active form of tuberculosis;
• aneurysm;
• artificial heart valve;
• history of hemorrhagic or ischemic stroke;
• high risk of bleeding.

Individual intolerance to heparin by patients cannot be discounted. Injections are used with caution for high blood pressure, kidney or liver problems, type 2 diabetes and the postoperative period.

Use of heparins during pregnancy

Every woman who is in an interesting position probably dreams that her pregnancy will be easy and calm and that a healthy baby/children will be born on time. But, unfortunately, not everyone gets this wish. And then medicine can come to the rescue. What does she say about difficult pregnancies, in particular, with an eye to the risks of phlebological complications?

And she says that in some difficult situations anticoagulants - heparins - can help. Today, pregnant women are most often prescribed LMWH (low molecular weight heparins). Studies have shown that such drugs do not penetrate the placental barrier, and are therefore considered safe for the fetus. In addition to LMWH, in some cases, UFH (unfractionated heparins) and indirect coagulants: vitamin K antagonists - VKA (for example, warfarin) can also be used. They are used strictly according to indications, with an assessment of the risks of benefit/harm for the mother and child.

In general, let me remind you that heparins are prescribed to pregnant women for 2 purposes:

1. Minimize the risks of miscarriage and delayed development in women with APS (antiphospholipid syndrome).
2. Prevent and prevent VTEC (including in women with valvular heart defects and in the presence of prosthetic valves).

Much research has been conducted on the use of heparins during pregnancy. Results vary. In some cases they are completely disappointing. For example, studies conducted in a number of medical centers in Germany and Austria indicate that therapy with low molecular weight heparins in women with recurrent miscarriage does not reduce the risk of miscarriage (Ann Intern Med. 2015 May 5;162(9):601-9.) . These findings are based on observations of 449 patients with recurrent pregnancy loss of unknown etiology.

Other studies indicate a reduced risk of placenta-related complications when taking LMWH. The conclusion was made based on data from Medline, OVID and the Cochrane Register of Randomized Controlled Trials (Blood. 2014 Feb 6;123(6):822-8.). 848 pregnant women were submitted for observation. The result is that severe complications developed in almost 19% of pregnant women in the group who used LMWH, and in almost 43% of pregnant women in the group who did not use LMWH. That is, the approximate ratio is 1:2.3 (when taking low molecular weight heparins, complications occurred 2.3 times less often).

This means that heparins cope with the task of preventing thrombosis of the uteroplacental vessels (and, accordingly, prevent hypoxia, delayed fetal development and reduce the risk of miscarriage) in late pregnancy, but in early pregnancy, unfortunately, they are ineffective.

As for the connection between thrombophilia and placenta-related complications, the conclusion is that the presence or absence of thrombophilia is unlikely to affect the effectiveness of heparins in terms of minimizing the likelihood of complications.

So, heparins are very important in some situations related to the interesting situation of women! Only an experienced doctor should select and prescribe them, focusing primarily on the patient’s medical history.

List of the most effective drugs for injection and their pharmacological properties

Most often, doctors use Clexane and Fraxiparine for pregnant women. The basis of these drugs is low molecular weight heparin, which does not cause harm during gestation. Both medications are available in the form of a filled disposable syringe and a hollow needle. Everything is packed in a blister. Each syringe contains a single dose. There is no need to dilute the composition in the future.

Analogues of these drugs are Heparin, Fragmin, Heparin sodium and Tsibor. All injections are given subcutaneously in the stomach. Fragmin and Heparin can be used for intravenous bolus administration.

The basis of Clexane is enoxaparin sodium. It has high anticoagulant activity. In addition, the active substance has anti-inflammatory properties.

Pregnant women are most often prescribed Fraxiparine, since it has a higher degree of purification and has fewer side effects. The drug consists of nadroparin. Compared to heparin, which is not divided into fractions, this substance has less impact on platelet function and primary hemostasis.

Fragmin also consists of low molecular weight heparin. It has almost no effect on blood clotting time and platelet adhesion, while working as an anticoagulant.

The pharmacological properties of Heparin and Cibor are no different from their more common analogues.

Currently, treatment of pregnant women with drugs that affect the hemostasis system is widespread. It is difficult to find a patient who would not be prescribed dipyridamole during the 40th week of pregnancy. The practice of “correcting” some hemostasiogram parameters with anticoagulants is spreading. The duration of treatment and the combination of drugs used are determined differently, often completely arbitrarily; there are no laboratory methods for monitoring treatment that prove the effectiveness and safety of anticoagulant dosages. Last but not least is the cost of treatment. The physiological response of the body to pregnancy is hypercoagulation in the procoagulant part of the hemostasis system, probably with an adequate response of the anticoagulant part, which is difficult to assess due to the limited capabilities of modern clinical biology. It is important that the levels of hypercoagulability markers do not correlate with the level of clinical risk of thrombosis in pregnant women at high risk of developing venous thromboembolism (VTE) [7].

Rational anticoagulant therapy for pregnant women seems to us to be a treatment system for specific indications with appropriate laboratory monitoring to correct homeostasis indicators in a pregnant woman and prevent obstetric complications, thrombosis and bleeding. It is intended to use dosages of drugs whose pharmacological action is well known for the period necessary to realize the therapeutic effect.

Over the past 3 decades, there has been a consistent upward trend in maternal mortality from VTE. In addition, in most industrialized countries, the age of women giving birth is increasing, and the proportion of pregnant women suffering from severe extragenital pathology is growing. The successes of modern medicine lead to an increase in the life expectancy of patients and promote pregnancy in women with systemic connective tissue diseases, cancer, pathologies of the cardiovascular system, respiratory organs, endocrine pathology, diseases of the blood system, antiphospholipid syndrome, etc. Correct diagnosis and treatment can improve perinatal outcomes in such severe complications of pregnancy as recurrent miscarriage, intrauterine growth restriction syndrome, and gestosis. All of the above situations are associated with the intensification of intravascular thrombus formation both in the vascular bed of the pregnant woman and in the uteroplacental-fetal blood flow system, therefore the use of coagulologically active substances is pathogenetically justified. When prescribing anticoagulants, it should be remembered that the mechanisms of thrombus formation are different in the arterial and venous parts of the vascular bed, in macrovessels and the microcirculatory system (distal to the level of the precapillary sphincter).

The group of pregnant women for whom anticoagulant therapy is indicated include patients with:

1) deep vein thrombosis and pulmonary embolism during real pregnancy,

2) mechanical heart valves,

3) antiphospholipid syndrome (with a correct diagnosis),

4) with thrombophilia: antithrombin-III defect, a combination of hereditary thrombophilias, such as deficiency of proteins S and C, resistance to activated protein C due to the Leiden mutation FV, hyperprothrombinemia due to the prothrombin G20210A mutation, hyperhomocysteinemia, mutation in plasminogen activator inhibitor I like,

5) manifestation of arterial thrombosis,

6) non-developing pregnancy and a decrease in the number of platelets and/or fibrinogen in their preparation for emptying the uterine cavity,

7) fetoplacental insufficiency, confirmed by the results of fetometry, Doppler studies and/or hormonal studies and/or using cardiotocography.

The purpose of anticoagulant treatment is to prevent thromboembolic complications, bleeding, improve blood circulation in the mother-placenta-fetus system, and ensure an uncomplicated course and prolongation of pregnancy.

In our opinion, a necessary and sufficient technique for the prevention of thromboembolic disease (TED) is the use of a risk assessment scale and the prescription of anticoagulant prophylaxis, as is practiced in general surgical practice [9].

A score of 1 point is given if you are over 40 years old, have a body weight of more than 80 kg, have a history of abdominal surgery less than 6 months after, significant varicose veins of the lower extremities, or recent immobilization. 2 points are assessed for compliance with bed rest for more than 3 days, severe chronic obstructive pulmonary disease, inflammation of the intestinal tract, severe infection (pneumonia), condition after delivery (within 1 month), use of oral contraceptives or hormone replacement therapy. The presence of cancer, heart failure, myocardial infarction less than 3 months ago, and a history of an episode of pulmonary embolism are assessed as 3 points. If the score is 5 points or more, enoxaparin is prescribed prophylactically at a dose of 40 mg once subcutaneously until the patient is completely mobilized, the duration of treatment is up to 2 weeks.

Risk factors for VTE in pregnant women comprise two groups [14]. Group 1 includes factors related to the patient herself: age over 35 years, obesity (body mass index more than 29 kg/m2) in early pregnancy, thrombophilia, history of venous thromboembolism, severe varicose veins of the lower extremities, serious extragenital diseases , for example, nephrotic syndrome, the presence of infection or inflammation, immobilization, paraplegia, physical inactivity during long travel, dehydration, intravenous drug use, ovarian hyperstimulation syndrome. The 2nd group includes factors that make up complications of pregnancy: cesarean section, especially emergency in a woman in labor, operative vaginal delivery, massive obstetric hemorrhage, vomiting of pregnant women, gestosis.

More than 12 years ago, work [23] appeared on significantly greater perinatal losses in patients with such types of thrombophilia as deficiency of antithrombin-III, protein S, protein C, and the FV Leiden mutation.

M. de Swiet [29] draws attention to the age of pregnant women and the increase in the incidence of THA in pregnant women over 40 years of age (100 times compared to the group aged 20-25 years). Additional risk factors are excess body weight and a history of more than 3 pregnancies, surgical delivery (caesarean section), suppression of lactation by estrogen. Antenatal risk factors for TEB include in vitro fertilization, gestational diabetes, multiple pregnancies and maternal age over 35 years, and postnatal risk factors include gestosis, eclampsia, placenta previa, placental abruption and cesarean section [17] .

The method for confirming the diagnosis of deep vein thrombosis of the lower extremity in pregnant women is compression ultrasonography, and pulmonary embolism is ventilation-perfusion scanning of the lungs [13]. The low specificity of D-dimer does not allow the use of this laboratory indicator in pregnant women as a laboratory test for confirming TEB [11, 13, 22].

When determining a treatment regimen, the following conditions must be met: firstly, the safety of the drug for the fetus and mother; secondly, the effectiveness of the applied treatment and/or prevention regimen; thirdly, the dosage for the initial course of treatment and maintenance therapy during pregnancy, childbirth and the postpartum period [13].

Let's consider the most commonly used anticoagulant drugs used in obstetric practice.

Unfractionated heparin (UFH).

UFH is obtained from the intestinal mucosa of pigs or from the lungs of cattle. Drugs from different companies have their own pharmacodynamic characteristics, which, however, is offset by the fact that the dosage of the drug is selected depending on the reaction of the patient’s hemocoagulation system.

A. Continuous intravenous administration.

The success of UFH treatment depends on a sufficient initial dose, which should be at least 30,000-35,000 units/day [13]. This treatment regimen is used in acute cases with mandatory monitoring of the effectiveness and safety of treatment using a laboratory test - the activated partial thromboplastin time (aPTT) [29].

B. Subcutaneous intermittent administration

[13]:

a) mini-doses of UFH: 5000 units every 12 hours without laboratory control;

b) moderate doses of UFH: subcutaneously every 12 hours, monitoring changes in the antifactor Xa content to 0.1-0.3 U/ml 6 hours after injection;

c) adapted doses of UFH: subcutaneously every 12 hours, monitoring changes in APTT to values ​​1.5-2 times higher than normal, 6 hours after injection.

B. Inhalation

[1].

Indications for heparin inhalation:

1) prevention of obstetric complications: gestosis, fetoplacental insufficiency;

2) the presence of mild or moderate gestosis;

3) decompensation of diabetes mellitus;

4) treatment of fetoplacental insufficiency.

Inhalations are carried out using an ultrasonic inhaler, diluting heparin with distilled water 1:4, inhalations are carried out 2 times a day with an interval of 12 hours. For the prevention of gestosis, the daily dose is 300 IU/kg, course duration is 7 days, 2-3 courses are required, interval there are 2 days between courses, it is necessary to stop treatment 10 days before delivery; for other indications, the daily dose is 500 units/kg, course duration is 21 days, number of courses is 1-2, interval between courses is 2 weeks, treatment must be stopped 14 days before delivery.

Low molecular weight heparins (LMWH).

LMWH (Table 1)

are obtained by depolymerization of UFH with nitrous acid, or by induction of the benzyl ring and alkaline hydrolysis, or by depolymerization from amyl nitrate, or by peroxidation and, finally, cleavage by heparinase [26].
In general, rational therapy with heparins is presented in Table. 2.

Like UFH, LMWHs do not cross the placental barrier into milk, are safe for the fetus, and are considered the treatment of choice for the treatment of VTE in pregnant women [10, 13].

A prophylactic dose of the LMWH tinzaparin, according to K. Khasia et al. [18], should be 4500 IU/day if the patient’s body weight is less than 100 kg and 5000 IU/kg if she weighs more than 100 kg. The authors suggest that the final dose of LMWH should be based on antifactor Xa activity.

In 2001-2005 the main LMWH in Denmark used during pregnancy was tinzaparin - 95.2% of cases, and dalteparin sodium accounted for 4.8% [4]. According to A. Andersen et al. [4], indications for treatment of pregnant women with low molecular weight heparins in Denmark were an episode of thromboembolism with/or without thrombophilia - 37.3%, perinatal losses and congenital thrombophilia - 35%, recurrent miscarriage and congenital thrombophilia - 7.2%, other causes - 20 ,5%.

Taking into account the poor perinatal outcomes for mother and fetus in patients with antithrombin III deficiency, S. Schulman [27], in order to prevent thrombotic complications, recommends prescribing UFH in a dosage that can increase the aPTT to 1.3-1.5 reference values ​​after 5 days. 6 hours after injection with three subcutaneous injections or the use of LMWH with an antifactor Xa activity level of 0.1-0.2 U/ml.

Antivitamins K (warfarin).

The use of antivitamins K in pregnant women is limited by doctors' fear of the possible teratogenic effects of the drugs and the risk of bleeding in both the mother and the fetus. Disadvantages of drugs should also be considered a delayed onset of action and aftereffect of the drug, an unpredictable clinical effect depending on the dose, which requires laboratory monitoring, a narrow “therapeutic corridor”, multiple interactions with drugs and food products that change the effect of the drug [5]. Antivitamins K are used in pregnant women with artificial heart valves, with allergic reactions to heparin, and in the presence of a high titer of antiphospholipid antibodies [29]. Antivitamins K are not secreted into breast milk and can be used in nursing women [16].

When comparing anticoagulant therapy regimens in pregnant women with an artificial heart valve, the smallest number of thromboembolic and hemorrhagic complications were noted when using heparin in early pregnancy and during the period of organogenesis up to 12 weeks, then when pregnant women were transferred to taking indirect anticoagulants with a return to heparin therapy before childbirth [24 ].

Many drugs affect the effectiveness of antivitamins K; The effect is enhanced by drugs such as erythromycin, co-trimoxazole, fluconazole, isoniazid, metronidazole, amiodarone, clofibrate, propafenone, propranolol, sulfinperazone, phenylbutazone, piroxicam, ethyl alcohol, cimetidine, omeprazole. The effect of antivitamins K is weakened by griseofulvin, nafcillin, rifampin, cholestyramine, barbiturates, carbamazepine, chlordiazepoxide, and sucralfate [15].

Aspirin.

Aspirin acts by irreversibly inhibiting cyclooxygenase, which impairs thromboxane A2 synthesis and prostaglandin metabolism. At the same time, platelet aggregation induced by collagen, adenosine diphosphate, thrombin and thromboxane A2 is reduced [6].

Treatment with aspirin is usually given in conjunction with heparin therapy. The effectiveness of using 75 mg of aspirin with subcutaneous administration of 5000 units of heparin at an interval of 12 hours or in combination with the use of LMWH parnaparin at a dose of 0.3 ml subcutaneously in patients with the presence of antiphospholipid antibodies and recurrent miscarriage has been proven to improve perinatal parameters [25].

Japanese researchers, in 20 confirmed cases of VTE in pregnant women (up to 30 weeks), used UFH with aPTT monitoring to select an adequate dose, followed by switching to low doses of aspirin after the disappearance of the thrombus; However, not a single patient had a filter installed in the inferior vena cava. The need to continue anticoagulant treatment after the disappearance of thrombosis is absent in the Japanese population due to the lack of resistance to activated protein C [21].

A significant issue in clinical practice is the tactics of using anticoagulants during and after childbirth. Most researchers recommend discontinuation of heparin 24 hours before induction of labor during programmed labor, and in a group at very high risk of developing thromboembolic complications, intravenous administration of UFH is canceled 4-6 hours before induction of labor; with an excessive dosage of heparin, it is possible to use a solution of protamine sulfate; resumption of anticoagulant therapy is possible 12 hours after birth [13]. In high-risk groups (for example, the first episode of THA during pregnancy, a mechanical heart valve with thrombosis, multiple congenital thrombophilia with venous thrombosis), heparin therapy during labor is acceptable, for example, 7500 units subcutaneously 2 times a day [29]. If labor is prolonged for more than 18 hours and if labor does not occur within the next 3 hours, a prophylactic dose of LMWH may be used [16]. An original system has been developed [19], which provides anticoagulation during labor in high-risk patients receiving LMWH in a therapeutic dose, without the risk of hemorrhagic complications.

On the eve of a programmed birth or planned cesarean section, an infusion of an UFH solution of 15,000 units/24 hours - 625 units/hour begins with an infusion pump, and in the evening the subcutaneous injection of the drug is canceled.

4 hours before delivery (with the onset of the active phase of labor) or epidural analgesia during abdominal delivery, the infusion is stopped and resumed 2-4 hours after delivery.

Laboratory monitoring of anticoagulant treatment.

Use of APTT.

When monitoring the continuous intravenous administration of heparin, the aPTT should be increased by 1.5-2 times normal after 6 hours from the start of therapy.

Determination of antifactor Xa activity index.

The difficulty of using LMWHs in clinical practice is due to the fact that these drugs can have significant antithrombotic activity in vivo without demonstrating an anticoagulant effect in laboratory tests in vitro [26].

Monitoring of LMWH treatment is carried out monthly, while the level of antifactor Xa should be 0.5-1.2 U/ml (maximum value - 3-4 hours after injection) with a double dose of the drug and 1.0-2.0 U/ml ml if the drug is prescribed once a day [13, 16]. If the level of antifactor Xa activity is less than 0.4 U/ml, the patient will not have bleeding caused by taking heparin [29].

In the presence of artificial mechanical heart valves in pregnant women, with double subcutaneous administration of LMWH, peak concentrations of antifactor Xa should be 0.7-0.8 U/ml and echocardiography should be performed in parallel [2].

The prophylactic dose of tinzaparin should be 0.5-0.8 U/ml within 2 hours after injection, and with a small dose, the dose is adjusted according to the above-mentioned indicator [18].

There is an opinion [28] about the low predictive value of determining the activity of antifactor Xa in relation to the progression of thrombosis and the risk of bleeding.

Monitoring treatment with indirect anticoagulants-antivitamins K.

international normalized ratio
is currently used . INR is the ratio of the patient's prothrombin time to the control prothrombin time, raised to the power of the international sensitivity index of the thromboplastin used. These complexities are needed to standardize the laboratory reagent thromboplastin, which allows comparison of INR values ​​obtained anywhere in the world. To prevent thrombosis, the INR should be 2-3, with the exception of patients with mechanical heart valves and with antiphospholipid syndrome, in whom this indicator should be 3-4 [20].

Complications of anticoagulant therapy.

Complications of heparin treatment include bleeding, heparin-induced thrombocytopenia, and osteoporosis [13]. M. Damodaran et al. [10] reported greater blood loss during childbirth and a significantly higher number of congenital malformations in fetuses of pregnant women receiving LMWH, therefore, according to the authors, treatment with LMWH should be based on clear clinical indications.

In 166 observations of long-term use of LMWH, there were no cases of thromboembolic episodes or significant hematomas, as well as fractures due to osteoporosis with good perinatal indicators, although in 9.6% of observations there was increased blood loss after childbirth [4].

Until now, the question of preventive treatment with anticoagulants remains open. They are increasingly used to improve perinatal pregnancy outcomes in cases of vascular placental complications [8]. To address the issue of prophylactic use of anticoagulants in pregnant women, they are divided into high- and low-risk groups. In the absence of other risk factors, a repeated episode of thrombosis or thromboembolism in pregnant women has a probability of occurrence of 12%, therefore they are either limited to observation or prescribed aspirin in low (up to 100 mg/day) doses. High-risk patients have more than one episode of VTE during pregnancy, thrombophilia, and a family history of VTE. Such patients receive subcutaneous injections of UFH or LMWH from the moment pregnancy is confirmed [29]. The prophylactic use of LMWH and its effectiveness was assessed by M. Aldea et al. [3] in 14,624 pregnant women. Risk factors were obesity, the presence of varicose veins, uterine fibroids, arterial hypertension, cardiopathy, and a history of episodes of venous thrombosis. 22% of patients received prophylactic treatment with LMWH; anticoagulant treatment was discontinued 12 hours before and resumed 12 hours after delivery. The authors attribute the ineffectiveness of heparin prophylaxis (4 cases of venous thrombosis due to the use of drugs) to the use of a small dose of the drug (once a day) and draw attention to the use of LMWH according to indications - with existing risk factors, so as not to excessively increase the cost of treatment. The question of the dosage of heparin for its prophylactic use in patients with congenital antithrombin deficiency is raised in the publication of I. Dubedal et al. [12]: total doses of LMWH were 2500-17,500 U/day; at a daily dose of less than 7500 units/day, more than 50% of pregnant women developed thromboembolic complications, at a higher dose - in 15% (the difference is significant).

Contraindications to heparin therapy:

1) thrombocytopenia - platelet count less than 100 · 109/l;

2) arterial hypertension - systolic blood pressure above 160 mm Hg. Art.;

3) vascular or parenchymal bleeding;

4) acidosis - a decrease in the expected anticoagulant effect;

5) liver and kidney failure.

Thus, the prescription of anticoagulant drugs in pregnant women should be carried out according to clinical indications in groups of patients at high risk of developing VTE or to improve perinatal outcomes during current pregnancy. Monitoring of treatment with anticoagulants is not carried out in the case of inhaled heparin therapy, the use of mini-doses of UFH with subcutaneous administration up to 15,000 units/day, intravenous administration up to 20,000 units/day, and preventive treatment with LMWH with one dose per day. Control is carried out using a certain laboratory test at a certain time with subcutaneous administration of UFH - monitoring the change in aPTT to a level exceeding the norm by 1.5-2 times after 4-6 hours from the moment of injection of the drug; with subcutaneous administration of LMWH, the activity of antifactor Xa is monitored through 4-6 hours after injection to a level of 0.3-0.6 or 0.6-1.2 U/ml depending on the treatment regimen, treatment with warfarin is carried out under the control of INR to levels of 1.5-2.5 depending on groups of patients. A promising, reliable and convenient method of treating pregnant women is the use of warfarin, with the exception of periods from 5 to 15 weeks of pregnancy (the period of organogenesis) and the period before childbirth, taking into account the long half-life of the drug. Treatment with aspirin or chimes when there is a threat of developing VTE is not pathogenetically justified and should not be used. Anticoagulant therapy should be used as indicated and for a long time, sometimes throughout pregnancy. The problem of the future is the development of heparin therapy for amniotic fluid embolism.

Why is the drug injected into the abdominal area?

Injections directly into the abdomen allow long-term courses to be prescribed to patients during pregnancy. In severe cases, they can last until childbirth. This is important for women who suffer from high blood viscosity and are still carrying a child.

Since it is difficult for pregnant women to visit the treatment room every day, they can inject the medicine into the abdominal area on their own.

All drugs based on low molecular weight hyparin are destroyed in the digestive tract, so they are used in the form of injections. When administered into the subcutaneous layer of the abdomen, the therapeutic effect during pregnancy is achieved as quickly as possible and lasts for quite a long time.

Selection of dosage and algorithm for correct injection

The expected benefits for the unborn child outweigh the risks only if the dosage and method of administering the injection into the stomach are carefully followed. An adult is prescribed up to 5,000 units of medication per day. For pregnant women, this dosage is reduced by 2 times.

The amount of heparin also depends on the woman’s weight, so it is determined by the doctor individually. Most often during pregnancy it is from 0.2 to 0.4 ml of a drug based on a low molecular weight substance. It is strictly forbidden to prescribe medications and determine the dosage on your own, as this is fraught with the death of the fetus and health problems for the expectant mother.

To reduce risks to the fetus, calcium injections are often prescribed along with Clexane or Fraxiparine. It helps remove side effects from the administration of the substance.

To give yourself an injection in the stomach, you must strictly adhere to the rules of hygiene. Algorithm of actions:

1. Wash your hands thoroughly and wipe them with formic alcohol.
2. Moisten a disk or piece of cotton wool in the same solution and wipe the intended injection site.
3. Lie on a hard surface and press your hand over the fold of your stomach at a distance of 2 cm from your navel.
4. Remove the cap from the syringe, insert the needle 2/3 of the way at an angle of 45° and slowly press the plunger.
5. Moisten the injection site with alcohol. Make the next injection on the other side to avoid the appearance of bumps.

First days in the maternity hospital

Immediately after birth

Immediately after the baby is born, it is placed on the mother’s stomach.

, then they process and cross the umbilical cord and place the baby on the mother’s breast.
Then the skin of the newborn is cleaned, its length and weight, head and chest circumference are measured. The doctor examines the birth canal, if necessary, stitches up tears in the soft tissue of the birth canal, assesses the tone of the postpartum uterus, and helps the woman empty her bladder. But even after all these standard manipulations, the mother is not transferred to the postpartum ward; the postpartum woman remains in the maternity ward for another two to three hours
. Why? In the first two hours after birth, some complications are possible, primarily uterine bleeding or a rise in blood pressure. Therefore, during these two hours, the mother lies on a gurney or bed in the maternity ward, since there are always doctors and midwives there, and the operating department, in case of emergency, is also located nearby. At this time, the child is usually taken to the children's department, where he most often sleeps. And only after two hours, if everything is fine, the mother is transferred to the postpartum ward.

How does a woman feel at this time?

Chills are possible and abdominal pain may appear, especially in multiparous women.

What should a woman do at this time?

Rest and relax. Cover up to stay warm, especially if you have a chill. Place an ice heating pad on the uterus. If possible, ask the midwife to bring some hot tea.

1st day after birth

Shortly after the woman is transferred to the postpartum ward, the postpartum midwife

.
She will tell you about the structure of the department (where the shower, toilet, dining room is located), about the daily routine (times for visiting doctors, eating meals) and will help the young mother, if necessary, empty her bladder using a catheter. If a woman lies with the baby, the baby will be brought to her immediately after transfer to the postpartum ward. The midwife will help the mother properly attach the baby to the breast and begin breastfeeding. Then a pediatric nurse
: she will show how to swaddle the baby and explain how to care for him. You shouldn’t be afraid that after giving birth you won’t have enough strength to support your baby: most newborns sleep most of the day and wake up only to feed. In addition, in the maternity hospital, the baby’s nurses usually wash and change clothes, so the woman has enough time to rest. If the mother and child are not together in the maternity hospital, then the child will be brought to the feeding ward every three hours, and then taken back to the children's department. Over time, the woman herself will pick up and deliver the child.

How does a woman feel at this time?

On the first day after giving birth, women feel differently. Some experience incredible elation (this occurs due to the release of endorphins - pleasure hormones) into the blood; others, on the contrary, feel extreme fatigue. Some people want to call all their friends and inform them about the birth of a child; they are inspired, full of energy and ready to take care of the baby on their own. Other mothers want to be alone and recover; they don’t yet have the strength to be with their child all the time.

What should a woman do at this time?

In any case, immediately after childbirth, as after any heavy load, you need to regain strength: first eat, and then go to bed or just rest. By the way, the following situation is possible: the birth occurred in the evening or at night, and dinner time has already passed; therefore, in order not to starve, you need to take something light to snack (cookies, crispbread) with you to the maternity hospital in advance.

6 hours after birth, the mother can usually get out of bed.

In general, if the birth went without complications, then you should start getting up as early as possible, first with the help of a midwife, and then on your own.

This helps improve blood circulation, normalize the functioning of the urinary system and intestines, and accelerate healing processes. In addition, very soon the baby will require more attention.

Important point:

After childbirth, the tone of the bladder decreases, so the urge to urinate may be absent or it becomes painful and frequent. However, you should go to the toilet at least four times a day. Urination can be caused reflexively by opening a water tap; this helps many people. If there is no desired effect, the urine is removed with a catheter. Most often there is no stool on the first day after childbirth.

Next days

Every day the mother will be examined by an obstetrician-gynecologist

: he will evaluate the contraction of the uterus, the condition of the sutures and the amount of discharge, and see if colostrum is released. The midwife will regularly measure temperature, pulse, blood pressure and treat external sutures with disinfectant solutions several times a day. Also, every day the baby will be examined by a pediatrician, after which he will tell the mother about the child’s condition. After a normal birth, a woman is usually discharged on the 3rd–4th day (after a caesarean section - on the 5th–6th).

How does a woman feel at this time?

After childbirth, a woman may experience abdominal pain due to contractions of the uterus, as well as slight muscle pain in different parts of the body. A “rash” may appear on the face and on the whites of the eyes - pinpoint hemorrhages that appear due to the fact that small capillaries burst during straining. Blood pressure may be low, so dizziness is possible (to avoid this, you should get up smoothly, without sudden movements). There may be pain in the perineum, even if there were no tears or incisions (pain appears because the perineum was subjected to strong stretching during childbirth). If there are stitches in the perineum, you will not be able to sit for at least the first two weeks. Sometimes after childbirth, varicose veins appear in the anus (hemorrhoids), which means discomfort in this place.

What should a woman do at this time?

Mom needs to continue to rest and gain strength. You should also follow the rules of personal hygiene: change postpartum pads often, take air baths for sutures (if any), take a shower every day, and wash your face every time you have a bowel movement. Well, the most important thing is to establish breastfeeding and learn how to care for your baby in practice.

Time flies very quickly in the maternity hospital. Try to spend it usefully - restore your strength and acquire useful skills: all this will be very useful to you at home!

REMINDER

What you need to do in the maternity hospital

1. Have a good rest: sleep all your free time and eat well.
2. Get complete information about your child's condition: therefore, ask your pediatrician all your questions.
3. Establish contact with the child: therefore, spend as much time as possible with the baby, ideally, be with him constantly. Take the baby in your arms, unwrap the diapers, and carefully examine the baby without clothes.
4. Learn how to care for your baby: this means ask your nurse to show you how to wash your baby, change his clothes, swaddle him, change his diaper, clean his ears and nose, and cut his nails.
5. Establish breastfeeding: to do this, feed the baby on demand. Ask your midwife to show you how to hold your baby at the breast and how to give and take the breast.

Possible side effects and overdose

A lump or swelling may form at the injection site. Sometimes an allergic reaction develops. It manifests itself as a skin rash and is accompanied by severe itching. If the body reacted to Fraxiparine in this way during pregnancy, then most likely Clexane will not work either.

Another possible side effect of abdominal injections is bleeding and bruising. If a patient experiences metabolic disorders during pregnancy, there is a high risk of developing calcification.

The main symptom of an overdose of any drug that interferes with rapid platelet sedimentation is bleeding. In this regard, it is necessary for pregnant women to regularly undergo blood tests. If the platelet count and blood clotting rate change, the attending physician should reduce the dosage.

Special instructions and precautions

When injecting Fraxiparine or Clexane, you should not immediately release the skin. Once the contents of the syringe have been completely injected, you can smooth out the fold. Rubbing the injection site is prohibited. It is only slightly moistened with formic alcohol.

Special instructions for injections in the stomach include adhering to the expiration date of the drug. Most often it is 30 days. During this time, all doses should be used. Injections should be stored in a cool and dark place. A refrigerator is perfect for this purpose.

Heparin injections in the abdomen: Clexane and Fraxiparine during pregnancy

Both drugs are available in disposable syringes packed in a blister. Each contains the dosage required for one injection.

Fraxiparine is not recommended in the first trimester. In 2 and 3 it is used to prevent venous thrombosis. It is not used as a treatment course. For women who plan to receive pain relief through epidural anesthesia during labor, Fraxiparine should be stopped 12 hours before the expected time of delivery.

Low molecular weight heparins cannot be taken simultaneously with non-steroidal anti-inflammatory drugs, aspirin, and dextran. Concomitant use enhances the anticoagulant effect and may lead to bleeding.

How do pregnant women get an injection in the stomach?

The drug is available in a syringe, which is completely ready for use.

• Be sure to wash your hands. Before administration, the skin of the anterolateral abdominal area should be wiped with cotton wool soaked in an antiseptic.
• For convenience, you need to sit on a hard, flat surface. In a lying position, the skin will not be stretched, it is easier to grasp it with your fingers.
• Release the syringe from the packaging and grab the fold on the side of the abdomen with two fingers.
• The needle is inserted strictly perpendicular to the surface of the abdomen. The injection must occur intradermally; intramuscular injection is prohibited.
• The entire dose of the drug is administered completely. Only after this the skin is released.

The injection site should not be rubbed. To prevent post-injection complications, the injection site is alternated on the right and left.

Sometimes hematomas and swelling may occur at the injection site. If an allergic reaction or dermatitis occurs, you should discard the drug. In most cases, if an allergy to Clexane occurs, a similar reaction to Fraxiparine may develop, despite their differences in the active substance.

Yulia Shevchenko, obstetrician-gynecologist, especially for Mirmam.pro