Heparin

 Risk Factor: CM
 Class: HEMATOLOGICAL AGENTS / Anticoagulants

Contents of this page:

Fetal Risk Summary
Breast Feeding Summary
References
Questions and Answers

Fetal Risk Summary


No reports linking the use of heparin during gestation with congenital defects have been located. Other problems, at times lethal to the fetus or neonate, may be related to heparin or to the severe maternal disease necessitating anticoagulant therapy. Hall and co-workers (1) reviewed the use of heparin and other anticoagulants during pregnancy (167 References) (see also Coumarin Derivatives). They concluded from the published cases in which heparin was used without other anticoagulants that significant risks existed for the mother and fetus and that heparin was not a clearly superior form of anticoagulation during pregnancy. Nageotte and co-workers (2) analyzed the same data to arrive at a different conclusion.

Hall Nageotte Total number of cases
  • 120 Term liveborn-no complications 86
  • Premature-survived without complications 19
  • Liveborn-complications (not specified) 1
  • Premature-expired Heparin therapy appropriate* 10
  • Heparin therapy not appropriate* 4a Severe maternal disease making successful outcome of pregnancy unlikely 1b Spontaneous abortions Unknown cause 2
  • Maternal death due to pulmonary embolism
  • Stillbirths Heparin therapy appropriate* 17
  • Heparin therapy not appropriate* 7c Heparin and Coumadin used
  • *Appropriateness as determined by current standards aHypertension of pregnancy (4) bTricuspid atresia (1) cHypertension of pregnancy (6); proliferative glomerulonephritis (1) By eliminating the 15 cases in which maternal disease or other drugs were the most likely cause of the fetal problem, the analysis of Nageotte and co-workers results in a 13% (15 of 120) unfavorable outcome vs. the 22% (30 of 135) of Hall and associates. This new value appears to be significantly better than the 31% (133 of 426) abnormal outcome reported for coumarin derivatives (see Coumarin Derivatives). Furthermore, in contrast to coumarin derivatives in which a definite drug-induced pattern of malformations has been observed (fetal warfarin syndrome), heparin has not been related to congenital defects nor does it cross the placenta (3,4 and 5). Consequently, the mechanism of heparin's adverse effect on the fetus, if it exists, must be indirect. Hall and co-workers theorized that fetal effects may be caused by calcium (or other cation) chelation resulting in the deficiency of that ion(s) in the fetus. A more likely explanation, in light of the report of the Nageotte group, is severe maternal disease that could be relatively independent of heparin. Thus, heparin appears to have major advantages over oral anticoagulants as the treatment of choice during pregnancy (6,7,8,9,10,11,12 and 13).

    A retrospective study, published in 1989, lends support to the argument that heparin therapy is safe for the mother and fetus (14). A total of 77 women were treated with heparin during 100 pregnancies. In 98 pregnancies, therapy was administered for the prevention or treatment of venous thromboembolism, and in 2, treatment was because of prosthetic heart valves. In comparison with normal pregnancies, no difference was seen in the treated mothers in terms of prematurity, spontaneous abortions, stillbirths, neonatal deaths, or congenital malformations (6). Two bleeding episodes occurred, but there were no symptomatic thrombolic events.

    In a surveillance study of Michigan Medicaid recipients involving 229,101 completed pregnancies conducted between 1985 and 1992, 65 newborns had been exposed to heparin during the 1st trimester (F. Rosa, personal communication, FDA, 1993). Seven (10.8%) major birth defects were observed (three expected). Specific data were available for six defect categories, including (observed/expected) 4/0.6 cardiovascular defects, 0/0 oral clefts, 0/0 spina bifida, 1/0 polydactyly, 0/0 limb reduction defects, and 1/0 hypospadias. The data for total malformations and for cardiovascular defects are suggestive of possible associations, but other factors, most likely the mother's disease, but also possibly concurrent drug therapy and chance, are probably involved.

    Long-term heparin therapy during pregnancy has been associated with maternal osteopenia (15,16,17,18 and 19). Both low-dose (10,000 units/day) and high-dose heparin have been implicated, but the latter is more often related to this complication. One study found bone demineralization to be dose related, with more severe changes occurring after long-term therapy (>25 weeks) and in patients who had also received heparin in a previous pregnancy (18). The significant decrease in 1,25-dihydroxyvitamin D levels measured in heparin-treated pregnant patients may be related to the pathogenesis of this adverse effect (16,17). Similar problems have not been reported in newborns.

    Breast Feeding Summary


    Heparin is not excreted into breast milk because of its high molecular weight (15,000) (20).

    References

    1. Hall JG, Pauli RM, Wilson KM. Maternal and fetal sequelae of anticoagulation during pregnancy. Am J Med 1980;68:12240.
    2. Nageotte MP, Freeman RK, Garite TJ, Block RA. Anticoagulation in pregnancy. Am J Obstet Gynecol 1981;141:472.
    3. Flessa HC, Kapstrom AB, Glueck HI, Will JJ, Miller MA, Brinker B. Placental transport of heparin. Am J Obstet Gynecol 1965;93:5703.
    4. Russo R, Bortolotti U, Schivazappa L, Girolami A. Warfarin treatment during pregnancy: a clinical note. Haemostasis 1979;8:968.
    5. Moe N. Anticoagulant-therapy in the prevention of placental infarction and perinatal death. Obstet Gynecol 1982;59:4813.
    6. Hellgren M, Nygards EB. Long-term therapy with subcutaneous heparin during pregnancy. Gynecol Obstet Invest 1982;13:7689.
    7. Cohen AW, Gabbe SG, Mennuti MT. Adjusted-dose heparin therapy by continuous intravenous infusion for recurrent pulmonary embolism during pregnancy. Am J Obstet Gynecol 1983;146:4634.
    8. Howell R, Fidler J, Letsky E. The risks of antenatal subcutaneous heparin prophylaxis: a controlled trial. Br J Obstet Gynaecol 1983;90:11248.
    9. Vellenga E, van Imhoff GW, Aarnoudse JG. Effective prophylaxis with oral anticoagulants and low-dose heparin during pregnancy in an antithrombin III deficient woman. Lancet 1983;2:224.
    10. Bergqvist A, Bergqvist D, Hallbook T. Deep vein thrombosis during pregnancy. Acta Obstet Gynecol Scand 1983;62:4438.
    11. Michiels JJ, Stibbe J, Vellenga E, van Vliet HHDM. Prophylaxis of thrombosis in antithrombin III-deficient women during pregnancy and delivery. Eur J Obstet Gynecol Reprod Biol 1984;18:14953.
    12. Nelson DM, Stempel LE, Fabri PJ, Talbert M. Hickman catheter use in a pregnant patient requiring therapeutic heparin anticoagulation. Am J Obstet Gynecol 1984;149:4612.
    13. Romero R, Duffy TP, Berkowitz RL, Chang E, Hobbins JC. Prolongation of a preterm pregnancy complicated by death of a single twin in utero and disseminated intravascular coagulation: effects of treatment with heparin. N Engl J Med 1984;310:7724.
    14. Ginsberg JS, Kowalchuk G, Hirsh J, Brill-Edwards P, Burrows R. Heparin therapy during pregnancy: risks to the fetus and mother. Arch Intern Med 1989;149:22336.
    15. Wise PH, Hall AJ. Heparin-induced osteopenia in pregnancy. Br Med J 1980;281:1101.
    16. Aarskog D, Aksnes L, Lehmann V. Low 1,25-dihydroxyvitamin D in heparin-induced osteopenia. Lancet 1980;2:6501.
    17. Aarskog D, Aksnes L, Markestad T, Ulstein M, Sagen N. Heparin-induced inhibition of 1,25-dihydroxyvitamin D formation. Am J Obstet Gynecol 1984;148:11412.
    18. De Swiet M, Dorrington Ward P, Fidler J, Horsman A, Katz D, Letsky E, Peacock M, Wise PH. Prolonged heparin therapy in pregnancy causes bone demineralization. Br J Obstet Gynaecol 1983;90:112934.
    19. Griffiths HT, Liu DTY. Severe heparin osteoporosis in pregnancy. Postgrad Med J 1984;60:4245.
    20. O'Reilly RA. Anticoagulant, antithrombotic, and thrombolytic drugs. In Gilman AG, Goodman LS, Gilman A, eds. The Pharmacological Basis of Therapeutics. 6th ed. New York, NY:MacMillan, 1980:1350.

    Questions and Answers

    Has anyone ever taken heparin while they were pregnant?

    My ultrasound shows that i am about 5 1/2 to 6weeks preg and i was prescribed heparin b/c i have a clotting disorder that causes me to get blood clots. Of course i am trying to be very cautious about any medication during pregnancy especially your first tremester. So if anyone has taken it before can you please share your story with me? Thanks alot!!

    i used heparin in a pic line that i had for severe morning sickness. but i didn't take heparin for clotting. i am 16 weeks and baby is fine

    Are you (or have you been) pregnant and take heparin/lovenox?

    How is it going/how did it go?
    My doctor wants me to take 40 mg lovenox daily and a baby aspirin while pregnant to prevent blood clots. Sounds not-so-great. I obviously don't want to inject myself daily with shots in the stomach, but more than that I worry about the risks - clots, hemmorhage, osteoporosis!
    If you've taken this while pregnant please let me know about your experience.
    Thanks!

    I was on them when I was pregnant. I had a clot in my left thigh in my 26 week of pregnancy. When I got out of the hospital 6 days later I went on Lovenox twice daily until my 36 week. At that point was switched to Heparin for 2 weeks before my induction. Everything went fine. My baby was born healthy(she is 14 months old now) and I came through every thing without any other problems. As far as the side effects, i guess I wasn't in the position to worry about them, so I just didn't let myself think about it. Blood thinners saved my life and my babies life. I have Factor V Leiden so if I get pregnant again, I will go on the Lovenox for the entire pregnancy (except the last 2 weeks of course)

    As far as the injections. My husband did mine for which I am very grateful. I tried to do in the hospital myself but I just couldn't do it. Also, I was allowed to put my shots in my butt. That was much less painful for me than in the stomach. We tried them in the stomach but it just didn't work. I have always been pretty thin and I just didn't have the fat necessary in my stomach for it to really work there.

    I hope I answered your question. If I didn't feel free to contact me. I would love to help if I can.

    what doctor do i go to, to find heparin i have apls and trying to get pregnant?

    i need some sort of anticoagulant so i can have a baby i found out i have anti phospholipid syndrome which causes my misscarriages what doctor should i go to, to get the meds. GYNO? family doctor? i dont know where to go

    More than likely your OBGYN can help you. I have Factor V Leiden which is another clotting disorder. I have a 2 year old daughter and my disorder was discovered when I had a DVT in the 26 week of pregnancy with her. Now I am 17 weeks pregnant with baby #2. I am currently on on injection of Lovenox daily to prevent another clot. Lovenox is very similar to Heparin.

    My OBGYN takes care of my needs, but you might need a high risk doctor as well. I have one two but I will only see him for a ultrasound in a few weeks if all goes well. Thankfully my OB has experience with people like me, but not all OB do.

    If you have any questions. Please feel free to contact me.

    I am 9 wks 5 days pregnant. I have strokes and seizures. I have to take a shot of Heparin in my stomach twice?

    A day. The injections sites are very painful. I was wondering if there was anything I can put on them, or do to stop some of the pain. They are pretty bruised up, and I still have 7 months to do the injections. I am not complaining, this will all be worth it when my child is born. I already have a 4 yr old daughter and she is wonderful. I was just wondering if anyone knows of anything that may help. The pharmacy had to give me needles slightly larger than insulin needles, they aren't huge, but as I said the injection sites are very painful. Thankyou for any and all answers.

    I had to take heparin in my first pregnancy, Lovenox in my second.

    The shots are painful... but the pain lessens with time. Within a few months of starting the shots, I no longer felt the burning every time. Only if I moved to a new area. (I have a flab of belly-fat that kinda hangs off the bottom. Late in pregnancy, I started injecting in this flab, and felt the burning again.)

    There's not much that can be done for the bruising, I'm afraid. (Every time I saw a new practitioner -- for ultrasounds, non-stress tests, etc -- they'd send my husband out of the room & screen me for domestic violence!) Just try not to make it any worse by bumping your belly. (Do NOT try rubbing the bruises to make them go away, as with anticoagulants this only makes it worse.)

    Does your insurance cover Lovenox? It's a more expensive drug, but safer in pregnancy. Also, you only take it once a day, and there's FAR less bruising. (Unlike with heparin, I don't bruise every time I inject... maybe one out of four injections turns into a bruise.) It's at least worth checking with your insurance and doctor.

    Oh... and remember when your due-date rolls around that you can't have spinal anesthesia (spinal, epidural, etc) while on anticoagulents. Be sure to discuss your options with your doctor, so you're BOTH prepared.

    Good luck. And you're right -- this is such a small price to pay for a healthy baby. Here's wishing you an easy pregnancy!

    How to avoid Heparin, currently on Lovenox and pregnant?

    I am 34 weeks pregnant and currently taking 40 ml of Lovenox daily as a preventive measure. I have never had a blood clot but do have the prothrombin gene mutation and strong family history. Once I hit 36 weeks they want to switch me to Heparin so I will be allowed to have an epidural. An epidural is a MUST for me because I wanted to die with my first child at 2 cm and she was only 7.3 lbs. Recently there have been 81 deaths due to mismanufactured Heparin and I believe its even been taken off the shelf temporarily. If I stay on Lovenox I will have to be 24 hours without Lovenox before an epidural can be given. I do not want to risk this because at 34 weeks the baby measures 6lbs 11oz! (Yes, ouch. No, I do not have ges. diabeties) Anyway I was thinking I could lower the dosage of Lovenox to 20 ml daily so I would only have to wait 12 hours before an epidural. Of course I will ask my doctor at next visit but my ob is a a specialist in ob and not blood clots.

    Your advice please!

    Hi, I'm 34 weeks as well and on lovenox. I'm also scared to death to take herparin as I have read about the mismanufacturing by the "Chinese". This is the first I've heard about not getting the epidural if you have lovenox in your system. Guess the doctors didn't want me to know that? That's even more bad news since I really want to avoid heparin and really must have the epidural. I've have 2 kids 9.11lbs was my son's weight and 8.3lbs my daughters. I don't know what to do now...what information about the epidural and lovenox do you have?

    can anyone help me to get the details regarding heparin,anticoagulant?ie,do any harm for pregnant ladies.?

    my cousine is 3months pregnant,and now taking heparin injection for last 1month and may require for another 6months more.ie she nowadays taking those injections every day.Is that do any harm to her baby?.is there any other injection to replace this that will help her better?.She is taking this injection due to the clotting factor,ie cannot walk and leg getting fat.

    Heparin is a blood-thinning medication; it is usually prescribed for patients with a history of Deep Vein Thrombosis, as your cousin's symptoms suggest. Your cousin has a greater risk of hemorrhage than pregnant women who have no need to use this medication. She must be closely supervised by a doctor, preferably an Obstetrician that specializes in high-risk pregnancies. Of course, she shouldn't stop using this medication unless the doctor specifically instructs her to do so, because the risks of developing a blood clot which would put her life in danger, and her pregnancy as well.

    I am pregnant and need to take heparin, I am very scared I need help or support.?

    Do I need to be in bed all time or can I walk and do exercises.

    I am 12 weeks pregnant and have been on Heparin since about 4 weeks pregnant. I take a shot every morning (I give it to myself - not fun). My hemotologist informed me that because it is a low molecular weight heparin, there is no chance for the drug to cross the placenta (meaning it will not even reach the baby). I feel great, no side effects (and there really are not any expected while on heparin). You do not have to be in bed, you can do anything you normally do - but because you are pregnant just take it easy. My doctor recommended walking and pre-natal yoga for exercise. I know its a tad freaky to have to be on a blood-thinner while pregnant, but keep in mind, you are not alone, alot of women take heparin while pregnant. Good luck to you!

    Is it safe to take Heparin during pregnancy?

    Eventhough my doctor prescribed it to me, I always do my own research. I am 36 weeks pregnant and was taking Lovenox but have just been switched to Heparin. I read that Heparin is a pregnancy C category and the chance for fetal damage is unknown. Lovenox is a B category and does not cross the placent. Has anyone been taking Heparin and have had healthy babies with no delivery complications and also were you able to have an epidural?.Mainly, is it safe for the baby??

    according to this website
    http://safefetus.com/
    heparin is a category b drug as well.

    Have you during your pregnancy had to use heparin?

    I am almost 4 months pregnant. I was prescribed heparin which i have to inject myself 1 every 12 hours. I was wondering if any other women are on this too... or have been... and did you have your baby just fine? I am kinda worried it will hurt my baby so i wanted others information that have gone throught this or are going through the same thing.

    thanks in advance for ur answers

    I would hope that your doctor prescribed this knowing that you are pregnant, and that the benefits of the drug to you outweigh the potential risks to your baby. Keep in mind that there are many drugs that are safe to take during pregnancy, contrary to popular belief. Obviously, no drugs are better but sometimes they are necessary. Motherisk is a great source of information. Check out their website and call them. if you give them the name of the drug you are taking, they will give you all the information about it's safety/risks during pregnancy. Their website isn't the best, but I strongly urge you to call and speak to a counselor.

    I have never been on heparin, but before Christmas I had a bad flare-up of Crohn's disease and was on prednisone (a steroid drug) for 1.5 months, and also am on a 5-ASA drug called mezavent. Both are considered safe during pregnancy. The risk of the illness to me and my baby DEFINITELY outweigh any small, potential risk of the drug. I was unable to eat, had severe diarrhea and pain, and was becoming anemic. I am feeling much better now! And my baby is doing great.
    Good luck!

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