How to manage colostrum-associated hypercoagulability in mothers and newborns?

From the Guidelines

Managing colostrum-associated hypercoagulability in mothers and newborns requires careful monitoring and preventive measures rather than routine medication. For mothers, early ambulation after delivery, adequate hydration, and compression stockings are recommended to prevent thrombotic events [ 1 ]. In cases of high-risk mothers (with previous thrombotic history or known thrombophilia), prophylactic low molecular weight heparin such as enoxaparin 40mg subcutaneously daily may be considered, typically continuing for 6 weeks postpartum [ 1 ]. Some key points to consider in the management of these patients include:

• The use of fondaparinux or parenteral direct thrombin inhibitors should be reserved for women with heparin-induced thrombocytopenia (HIT) [ 1 ]
• The oral direct thrombin inhibitors and factor Xa inhibitors should also be avoided in pregnancy owing to the lack of safety data [ 1 ]
• Antepartum prophylaxis is suggested for pregnant women at increased risk: previous unprovoked VTE, pregnancy or estrogen-related VTE, homozygous factor V Leiden or prothrombin G20210A, or antiphospholipid antibody syndrome [ 1 ] For newborns, no routine anticoagulation is needed as the hypercoagulable state is usually transient and physiologic [ 1 ]. Instead, focus on ensuring adequate hydration and monitoring for any signs of thrombosis such as limb swelling, discoloration, or unexplained irritability. The hypercoagulable state occurs because colostrum contains high levels of tissue factor and other procoagulant substances that temporarily increase coagulation potential. This is actually a protective evolutionary mechanism to prevent excessive bleeding during the perinatal period. Most cases resolve spontaneously as mature milk replaces colostrum within the first week of life, and the infant's coagulation system achieves better balance. In the event of bleeding associated with low molecular weight heparin, equimolar concentrations of protamine sulfate can be used to neutralize anti-IIa activity [ 1 ].

From the Research

Management of Colostrum-Associated Hypercoagulability

• The management of colostrum-associated hypercoagulability in mothers and newborns is crucial to prevent thrombotic complications 2, 3, 4.
• Pregnancy itself increases the risk of thromboembolic complications due to hypercoagulability, which is present as early as the first trimester 2.
• Factors that further increase the risk of thromboembolism in pregnancy include a history of thrombosis, inherited and acquired thrombophilia, certain medical conditions, and complications of pregnancy and childbirth 2.
• Anticoagulant treatment and prophylaxis, such as low-molecular-weight heparin (LMWH), are used to prevent thromboembolic events in high-risk pregnancies 3, 4.
• The use of unmonitored intermediate-dose LMWH in pregnant women with previous thrombotic events has been shown to be safe and effective in preventing recurrent venous thromboembolic events 3.

Prevention of Thrombotic Events

• The primary prevention of thrombotic events in people with antiphospholipid antibodies is unclear, and there is insufficient evidence to demonstrate the benefit or harm of using anticoagulants with or without antiplatelet agents 5.
• The incidence of minor bleeding, such as nasal bleeding and menorrhagia, was increased in people with antiphospholipid antibodies treated with anticoagulant combined with antiplatelet agents compared to antiplatelet agents alone 5.
• The follow-up of fibrinolytic markers could represent a useful diagnostic tool for the termination of pregnancy and the prevention of thrombotic events 6.

Hypercoagulability During Pregnancy

• Hypercoagulability during pregnancy is a thrombophilic state that requires an even balance of coagulation and fibrinolysis to secure stabilization of the basal plate and adequate placental perfusion 6.
• A decrease in free protein S and fibrinolysis activities and an increase in Factor VII, Factor VIII, prothrombin fragment 1+2, and D-dimer were observed in pregnant women during the follow-up of gestation 6.
• An excessive hypercoagulable state is associated with the termination of pregnancy, resulting in a moderate risk for thrombosis during the different trimesters of pregnancy 6.