Use of Lovenox ( Enoxaparin)

In Pregnancy

NURS247
08/12/2020
Rosaline Chirishian
Outline
• What is Lovenox?
• Doses
• Mechanism of action
• Indication
• Duration
• Side effects
• Surveillance
• Contraindications
• When to stop?
 What is Lovenox?
• Low Molecular Weight Heparin,
anticoagulant.

• It often is used during pregnancy as an

alternative to oral anticoagulants such as
warfarin (Coumadin), which cannot be safely
used during pregnancy as it causes birth
defects.

• Enoxaparin is a FDA pregnancy category B

drug which means Enoxaparin is not expected
to cause harm to an unborn baby when used
during pregnancy.
 Doses
Prophylactic Level Therapeutic level
• 40 mg Lovenox once • 1mg/kg sc every 12 hrs
daily
 Mechanism of Action
• The mechanisms of action of enoxaparin in pregnancy are
multiple and include anti-factor Xa (anti-Xa) activity in
maternal circulation, tissue factor pathway inhibitor release
from endothelial cells and thrombin inhibitors.
 Indication
• Women with atrial fibrillation • Prophylactic and treatment of
DVT and pulmonary embolism
• Post cerebral vein thrombosis
• Thrombophilias
• prophylaxis of venous
thromboembolism • Superficial vein
thrombophlebitis
• prevention of pregnancy loss in
thrombophilic women or miscarriage. • women with mechanical heart
valves
• prevention of late gestational
complication such as pre-eclampsia • arterial thrombosis
and intrauterine growth restriction.
 DVT

VTE
 Duration
• Most started the injections around the 12th to 20th week of pregnancy and
continued until week 37.

• Patients will receive a fixed dose of 40 mg of enoxaparin subcutaneous

daily. Treatment will start once positive pregnancy test and will be
continued until abortion or delivery (if premature), or 37 weeks
of pregnancy

• Anticoagulant therapy for treatment of VTE during pregnancy should be

continued throughout pregnancy and for at least 6 weeks postpartum for
a minimum duration of 3 months.
 Side effects
Enoxaparin does not cross the placenta and is safe for the fetus. Maternal side effects are
uncommon and include mild localized allergic reactions in 2% and increased
bleeding in 2%, which is dose dependent.

• Heparin-induced thrombocytopenia
• Fluid retention
• Fever
• Nausea
• Diarrhea
• Bleeding

• Lovenox multiple-dose vials contain benzyl alcohol as a preservative. Benzyl alcohol

has been associated with a fatal "gasping syndrome" in premature neonates. Lovenox
vials preserved with benzyl alcohol should be used with caution in pregnant women
and only if clearly needed because benzyl alcohol may cross the placenta.
 Surveillance
Therapeutic level • Prophylactic level
• Monitor anti Xa levels (0.6 No need to monitor regularly
to 1U/ml)
• Switch to UFH at 36 weeks
• Starts LMWH with warfarin
postpartum day 1
 Contraindications
• Medications that increase the risk of bleeding will add to the effects of
Lovenox and further increase the risk of bleeding. Such medications
include aspirin, clopidogrel Plavix, warfarin (coumadin)

• With nonsteroidal anti-inflammatory drugs such as Ibuprofen (Motril,

Advil), Naproxen (naprosyn), diclofenac (voltaren) and others.
 When to stop?
Stop
• Stop prophylactic dose 12 hrs prior to induction of labor or
c/section and may continue postpartum after 4 to 6 hours.

• Stop therapeutic dose 24 hrs prior induction of labor or

c/section and may continue postpartum after 6 to 12 hrs.

• It should be stopped 12 hrs before patient takes epidural or

spinal anesthesia as well.

• In postpartum, LMWH (4 to 5 days) + Warfarin (6 weeks).

Monitoring PT and INR ( 2 to 3).

• Warfarin is safe to take after pregnancy, even if you're

breastfeeding.
 References
• https://www.medicinenet.com/enoxaparin/art
icle.htm#what_else_should_i_know_about_e
noxaparin
• https://pubmed.ncbi.nlm.nih.gov/19803860/
• https://www.webmd.com/baby/news/201407
25/blood-thinner-doesnt-prevent-miscarriages
-study#1