# Presentation: 102552

## Needs of Special Populations

- Andra H. James MD, MPH
- Comprehensive Hemostasis and Thrombosis Center
- &
- Department of Obstetrics and Gynecology
- Duke University Medical Center

## Special Needs of Women

- Contraception
- Birth control pills increase the risk of thrombosis 3 to 4-fold
- Patches expose women to 60% more estrogen
- Progestin-only contraceptives do not increase the risk
- Menopausal symptoms
- Postmenopausal hormone therapy increases the risk of clots
- Progestin, in doses to treat abnormal bleeding increases the risk 5 to 6-fold
- Heavy menstrual bleeding
- May affect half of women on anticoagulants
- Hemorrhagic ovarian cysts

## Special Needs of Pregnant Women

- Women on warfarin must convert to heparin
- Women with a history of thrombosis will require heparin during pregnancy and for at least 6 weeks postpartum
- Women with thrombophilia are at risk for poor pregnancy outcome
- Women with thrombophilia and a history of poor pregnancy outcome will likely require heparin
- Women with thrombophilia but no history of thrombosis or poor pregnancy outcome do not require anticoagulation.

## Thromboses in Unborn Babies

- Vascular disruptions
- Renal veins
- Vena cavae
- Cerebral venous sinuses
- Umbilical veins
- Placental vessels

## Thromboses in Infants

- 80% catheter-related
- Lines in upper body
- Lines in umbilical vein
- 20% spontaneous
- Renal veins
- Cerebral veins
- Treat with anticoagulants or thrombolysis
- Neonatal purpura fulminans

## Special Needs of Children

- The coagulation system changes with age
- High circulatory demands
- Different illnesses and different medications
- Inability to cooperate
- Intravenous access
- No pediatric formulations of any anticoagulants
- No liquid warfarin or pediatric doses of pre-filled syringes
- Different diets and formulas contain different amounts of vitamin K
- Different level of understanding
- Dependent on their parents

## Assembling a Team to Meet the Needs of Individuals

- No specialist for venous thromboembolism
- Community hematologists devote 90% of their time to cancer patients
- The ideal team:
- Expert in coagulation
- Pharmacist knowledgeable in anticoagulation
- Nurse to educate the patient
- Primary provider

## Assembling a Team to Meet the Needs of Families

- Young adults and children with spontaneous DVT or PE often have thrombophilia
- Questions arise regarding:
- Whom to test
- Whom to treat
- Ideal team includes a knowledgeable genetic counselor

## Creating a Center that Meets the Needs of the Community

- Consultative services for inpatients and outpatients
- Direct care in complex cases
- Coagulation laboratory support
- Educational materials for patients
- Continuing medical education
- Websites
- Protocols
- Publications

## Meeting the Needs of the Nation

- Spyropoulos and Haire described the Clinical Thrombosis Center
- Needs of special populations were not considered
- In 2001, the CDC initiated a pilot program of thrombophilia centers to:
- Determine the value of a multi-disciplinary team in providing care to persons with coagulation disorders.
- Assess unmet needs and identify outreach strategies to improve access to care.
- Develop effective messages aimed at disease management and prevention.
- Foster the development of training programs to enhance provider skills.
- 8 receiving funding, networking and modeling care