Abstract: . . .  Haemostasis 1999;82: 1196-1197. Siragusa S., Cosmi B.,Piovella F.,Hirsh J. Ginsberg J.S. Low molecular weight heparins and unfractionated heparin in the treatment of patients with acute venous thromboembolism: results of a meta-analysis American Journal of Medicine 1996;11100:269-277. Wells P.S.,Kovacs M.J.,Bormanis J. et al Expanding eligibility for outpatient treatment of venous thrombosis and pulmonary embolism with low molecular weight heparin Archives of Internal Medicine 1998;158;1809-1812. Wells P.S., Anderson D.R., Ginsberg J. Assessment of deep venous thrombosis or pulmonary embolism by the combined use of clinical model and noninvasive diagnostic tests Seminars in Thrombosis and Haemostasis 2000;6:643-656. Date of issue October 2003 Recommended review date October 2005 Members of the working party Dr Mark Winter (Chairman), Consultant Haematologist, Canterbury Dr David Keeling, Consultant Haematologist, Oxford Dr Hannah Cohen, Consultant Haematologist, UCH, London Freda Sharpen, Anticoagulant Specialist Nurse, Manchester Professor Patrick Vallance, Clinical Pharmacologist, UCH, London Page 10 10 Appendix 1 CLINICAL CARE PATHWAY FOR DVT OUTPATIENT MANAGEMENT Clinical assessment for DVT Suitable for outpatient care? YES NO DVT confirmed? . . .
. . .  first trimester of pregnancy. There may be rare occasions where a pregnant patient may require warfarin during the second trimester but this should only be given in close collaboration with a consultant haematologist. LMWH should be administered for at least five days or until the INR has been in the therapeutic range for two successive days, whichever is the longer (grade C recommendation, level IV). This is because the INR in the early stages of warfarinisation is raised due to low levels of factor VII, but full anticoagulation is not achieved until the other vitamin K dependent clotting factors (II, IX and X) become depressed. This usually takes 3-5 days. A full blood count should be arranged after 5 days on LMWH and throughout the period of LMWH treatment - to exclude the possibility of heparin related thrombocytopenia. Patients with previous exposure to heparin within the past 100 days should also have a platelet count performed before the second dose of heparin. Oral anticoagulant treatment should be given according to thrombosis task force guidelines (Haemostasis and Thrombosis Task Force, 1998). A baseline INR should be carried out. The initiation of oral anticoagulant treatment may be carried out according to a nomogram (grade B recommendation, level IIB), an example of which is given as appendix 3. In most circumstances, the INR will need to be checked daily until . . .
--3000,2,750,3171,24938