Management of active bleeding in patients receiving anticoagulation

Management of AF in pregnancy

1-Rate vs. Rhythm control?

Answer: Rhythm control is preferred over rate control to avoid side effects of the drugs(Rhythm control is usually achieved by DC cardioversion).

2-Drugs used for rate control :

-Selective B1 blockers(metoprolol or bisoprolol) (class I)
-Calcium channel blockers(Verapamil)(class IIa)
-Digoxin (class IIa)

3-Drugs used for Rhythm control:

-Sotalol
-Propafenone or flecainide (for structually normal heart or pre-excitation)

NB:Amiodarone is contraindicated with pregnancy

4-Drugs used for anticoagulation:

Either therapeutic weight based LMWH or warfarin based on stage of pregnancy

NB:NOACs are contraindicated in pregnancy and lactation

I-First trimester:

LMWH or warfarin if dose less than 5mg

II-Second trimester until 36 weeks:

Warfarin

III-After 36 weeks to 36 hours before delivery:

LMWH

IV-36 hours before and After deliverly:

UFH infusion
(stop 6 hours before delivery)

(instead of the UFH strategy, you can stop LMWH 24 hours before delivery if low risk for thromboembolism)

5-The decision for giving anticoagulation is based on CHADS-VASc score

Reference: ESC guidelines for management of CVD with pregnancy 2018
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By Dr Ahmed Mohsen

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