PROTOCOL FOR ANTICOAGULATION DURING DENTAL EXTRACTION AND OTHER PROCEDURES
Whenever the patient has to undergo procedures such as dental extraction, eye operations and other minor or major surgeries and he/she is taking oral anticoagulation for obligatory reasons, it is wise to follow the protocol given below:
This protocol is not a final protocol and will have to be tailored to the individual patient. It is merely a guideline.
- The patient must be put on parenteral Heparin or low molecular weight heparin in adequate doses if the INR of prothrombin time is more than 1.5. In case the INR is less than 1.5, one may proceed with the surgery/procedure immediately. Oral anticoagulant tablets must be stopped during this period.
- Daily monitoring of the INR is essential till the INR reduces below the 1.5 level and thereafter the surgery can be planned.
- On the day of procedure, the injection Heparin or low molecular weight heparin should be stopped and the procedure should be undertaken. In patients with prosthetic valves or valve repairs or mild cardiac defects, one must remember to give parenteral antibiotics for infective endocarditis prophylaxis, although this step has nothing to do with anticoagulation.
- In the evening of the operation or when the potential of bleeding is over, we should restart the injectable Heparin. One can also start the oral anticoagulation tablets SIMULTANEOUSLY as the tablets will take about 36 hours to start acting.
- Daily monitoring of the INR is essential till the patient reaches an INR of 1.5 or higher and at that point, one can discontinue the injectable Heparin.
PROTOCOL FOR MANAGEMENT OF ORAL ANTICOAGULATION IN A PREGNANT PATIENT.
- Oral anticoagulation is used for valve and other lesions including deep vein thrombosis and sometimes these patients get pregnant.
- In the first trimester [the first three months], as soon as the patient detects that she is pregnant and gets it confirmed by tests and visits an obstetrician, the whole program of anticoagulation changes. At first, we must educate the female patient who is in childbearing age group and who is expecting a pregnancy about the need to meet her obstetrician as soon as possible after her monthly menstrual cycle is missed. The earlier the program of anticoagulation is changed the better it is for the baby.
- As soon as pregnancy is confirmed, we must advise the stoppage of oral anticoagulation and start the patient on injectable Heparin/low molecular heparins. The first trimester is a period of organogenesis and there are various papers in the past that prove the existence of fetal warfarin syndrome. Although the syndrome is not described, it is wiser to be more careful.
- Oral anticoagulation is stopped and the patient is started on injectable drugs. The monitoring may be done with APTT test, although we do not advise it outside the hospital due to its poor sensitivity.
- Injectable forms of Heparin are continued though out the first trimester which is the period of organogenesis and proper formation of the organs.
- After the completion of the first trimester the patient should be restarted on oral anticoagulants and this period should be monitored with prothrombin and INR. One should remember that the requirement of oral anticoagulant may vary from the pre-pregnancy level as now the whole blood and extra-cellular fluid levels as well as the levels of carrier plasma proteins is totally different. Daily monitoring of INR should be done till the INR > 1.5 and thereafter it should be done after 3 days, after one week, then with 2 weeks gap and then on monthly basis. Injectable heparin should be discontinued once the INR reaches level of 1.5 or above
- Oral anticoagulation should be continued till the pregnancy is at term and when the patient is planned for delivery, the oral anticoagulation should be stopped and injectable Heparin should be restarted and when the delivery is induced, the Heparin should be stopped before induction of the labour.
- After delivery is over, the oral anticoagulation can be restarted on the strict condition of there will not be any breast feeding as the medicine can be secreted in the breast milk and the baby may get problems of bleeding including the dangerous condition of brain bleed. Suppression of lactation will be carried out by medical advice of the gynaecologist.
- As there have been reports of the anomalies in the foetus [birth defects], it is advisable that the foetal scans should be done more often than usual pregnancy scan schedules. Also, there is a potential of bleeding behind the placenta if the anticoagulation becomes erratic during pregnancy.
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