A Avaliação e Manejo da
Trombose Pós-natal
M A Saxonhouse and D J Burchfield
Apresentação:Antenor Couto Neto, Márcio Teixeira
de Campos, Ciro Mendes Vargas, Leonardo Alves
Coordenação: Paulo R. Margotto
www.paulomargotto.com.br
Escola Superior de Ciências da Saúde
(ESCS)/SES/DF
8/7/2009
The evaluation and
management of postnatal
thromboses
M A Saxonhouse and D J Burchfield
Division of Neonatology, Department of
Pediatrics, University of Florida College of
Medicine, Gainesville, FL, USA
. E-mail: saxonma@peds.ufl.edu
Journal of Perinatology 2009: 29, 467–478
Ddos Márcio, Antenor, Leonardo e Ciro
Estudo de Caso

Um RN a termo, masculino, nascido por parto vaginal, foi admitido
em uma UTI neonatal devido a baixos valores de APGAR e
desconforto respiratório necessitando de ventilação mecânica. A
gestação foi complicada devido à diabetes, tratado com Glyburide*,
e corioamnionite evidenciado no momento do parto. Paciente iniciou
com ampicilina e gentamicina, e reposição volêmica. Paciente
melhorou nos dias posteriores e foi capaz de ser desmamado do
ventilador. O paciente tinha um cateter umbilical arterial que foi
removido no terceiro dia de vida. No quarto dia, as pernas do
paciente tinham um aspecto pálido. Ao exame físico, os MMII
estavam frios e com marcado decréscimo de pulsos nos pés. Nas
24 horas subseqüentes, houve um decréscimo significativo de
volume urinário. O US cardíaco e de grandes vasos demonstraram
um grande trombo na Aorta descendente, com muito pouco fluxo
renal e artérias ilíacas. A procura na literatura não revelou nenhum
guideline nível I para trombose em pacientes neonatais, e a
consideração atualmente é dada para trombectomia cirúrgica,
terapia anticoagulante ou terapia fibrinolítica.
Incidência da doença
tromboembólica neonatal
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Apesar do maior risco em neonatos, a
incidência varia quanto ao tipo e quanto a
intensidade da investigação.
Todos os três registros (instituições
internacionais) mostraram acometimento em
pré-termos e a termos, em sexo masculino e
feminino, 90% estavam relacionados com
cateteres venosos centrais.
A recorrência de tromboembolismo seguindo
eventos pós-natais sintomáticos varia entre 3,3
a 7%.
O sistema hemostático neonatal
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Os sistemas pró-coagulantes, anticoagulantes e
fibrinolítico são únicos e diferentes de outras
faixas etárias.
Estão em um relativo estado pró-trombólico,
balanceados com fatores que previnem eventos
tromboembólicos em neonatos a termo e
prematuros “relativamente bem”.
Quando esse balanço é desfeito o neonato
permanece com alto risco de desenvolver
tromboses. Infecções e cateteres aumentam o
risco.
Locais de
tromboembolismo no pósnatal, exames de imagem e
manejo
Trombose arterial
Trombose arterial iatrogênica:
 A maioria das tromboses arteriais são de origem
iatrogênica, por cateteres arteriais umbilicais,
cateteres periféricos e femurais arteriais.
 Um estudo recente evidenciou tromboses
arterial em 23,4% de 47 neonatos com
cateteres umbilicais. A maioria assintomáticos,
com diagnóstico através de USG Doppler.
 As complicações incluem isquemia mesentérica,
hipertensão, disfunção renal, falha cardíaca
congestiva.
 O estudo Cochrane recomenda posicionamento
alto do cateter umbilical.
Trombose arterial
Estudos evidenciam outros fatores
responsáveis pela formação de trombos.
 Infusão continua de heparina 1,0 U/ml.
 Retirar cateter se suspeita ou confirmação
de trombose.
 Melhor método diagnostico é angiografia
contrastada.
 USG subdiagnostifica
 Tipos específicos de tratamento: heparina,
fibrinolítico e cirurgia

Trombose arterial
Trombose arterial iatrogênica:
 Condição extremamente rara, geralmente
envolve a aorta e mimetiza uma doença
cardíaca congênita.
 Atentar para redução de pulso e
extremidades frias se ECOCARDIOGRAMA
não evidenciar lesão cardíaca e coactação
da aorta.
Trombose venosa
Trombose venosa relacionada a cateter (não
cardíaco)
 Trombose venosa sintomática tem incidência de
0,24/ 10000 admissões na UTI, a maioria está
relacionada a CV.
 Mecanismos: lesão de endotélio, alteração do
fluxo, infusão de substâncias e materiais
trombogênicos.
 Cateter umbilical geralmente substituído na 1ª
semana, risco de trombose de V. porta.
Trombose venosa
Quanto menor o tempo de permanência
do cateter menor o risco de trombose.
 Padrão ouro é o venograma, porém o
mais usado é o US ( falso negativos).
 Complicações da trombose venosa:
obstrução venosa crônica, quilo tórax,
hipertensão portal e embolismo.
 Manejo requer retirada do cateter( 3-5
dias de terapia anticoagulante).

Trombose venosa
Trombose intracardíaca e trombose em
crianças com doença cardíaca congênita
 Ceteter no AD leva a dano endocárdico,
tamponamento e/ou trombo intracardíaco.
 Cateter no AD deve ser evitado (usar rt-PA)
 Trombose é uma complicação comum em
crianças que sofreram reparo de doenças
cardíacas complexas.
 Diagnóstico por ECO.
Trombose venosa
Trombose venosa renal
 Incidência de 0,5/ 1000 admissões na UTI, (mais
comum das tromboses espôntaneas)
 70% unilateral, 64% Rim E, mais comum no sexo
masculino.
 Achados: hematúria macroscópica, massa
abdominal e/ou trobocitopenia.
 Complicação aguda mais comum é a hemorragia
adrenal e extensão do coagulo para VCI.
 Monitorização, terapia anticoagulante e
fibrinolítica.
Trombose venosa
Trombose venosa portal
 Tende a ser clinicamente silenciosa
 Principais fatores de risco são cateter
venoso umbilical e sepse/onfalite.
 A resolução espontânea é relativamente
comum.
 10 anos depois pode manifestar por
hipertensão porta sem doença hepática.
Trombose venosa
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Trombose de seios venosos cerebrais
Incidência de 0.67/100.000 por ano.
30% dos casos tem infarto e hemorragia
subsequente.
Os principais achados são febre, convulsões e
letargia.
Tratamento: Anticoagulação de 6 semanas a 3
mêses. Terapia fibrinolítica e cirurgia.
Monitorização radiológica.
Fatores de risco para
trombose pós natal
Fatores Adquiridos
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A presença de
cateter venoso
central e cateteres
arteriais são os
maiores riscos
adquirido para
trombose pós-natal.
Outros fatores de
riscos: Vários fatores
coexistentes.
Fatores de risco para o tromboembolismo
Fatores genéticos
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Os estudos genéticos
enfatizam mutações que
resultam em falta ou
deficência severa de
fatores inibidores de
hemostase.
Desordens homozigóticas
protrombóticas (proteína
C, S ou antitrombina)
Desordens
heterozigóticas
protrombóticas
Avaliação laboratorial para distúrbio protrombótico
Avaliação da trombose pós-natal
clinicamente sintomática
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É confuso devido limitado
número de estudos
Recomendado:
Detalhada história
familiar (desordens,
história gestacional, etc)
Extensiva pesquisa
laboratorial de desordem
protrombótica.
Avaliação laboratorial para distúrbio protrombótico
Manejo da trombose

A complicação mais temida na terapia antitrombótica é a hemorragia
intracraniana.

Contraindicações absolutas para a terapia antitrombótica: Cirurgias do
SNC, asfixia( nos primeiros 10 dias) sangramento ativo, procedimentos
invasivos dentro de 3 dias, convulsões
Contraindicações:plaquetopenia(abaixo de 50 mil/mm3), fibrinogênio
<100mg%, INR >2, deficiência severa de coagulação, alergia ao
agente entitrombótico
Monitorização laboratorial: vide tabela
Monitorização laboratorial durante a terapia
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antitrombótica
Terapia anticoagulante
HFH (heparina ultra-fracionada) X LMWH
(heparina de baixo peso molecular)


HFN:
Meia vida curta( ajuste e descontinuação),
afetada por baixos níveis de antitrombina e
clearence de heparina faz com que o recémnascido fique resistente.
Necessita de acesso IV.
Terapia anticoagulante
HFN X LMWH

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LMWH: heparina de baixo peso molecular
Ideal para uso neonatal
Risco reduzido de hemorragia
Não necessita acesso IV
Recomenda utilizar HFN apenas a curto prazo,
especialmente se a cirurgia é indicada nas
próximas 72h.
Se anticoagulação a longo prazo é desejada,
então LMWH é a escolha mais prática na UTI.
HFN
Uso em neonatos é recomendado para
grandes tromboses fatais ou não e
clinicamente significativas, com o objetivo
prevenir expansão do coagulo ou
embolismo.
 Independentemente da dose utilizada, a
meta de tratamento é manter um anti-fator
Xa (anti-FXa) no nível de 0,3 a 0,7 U/ml
(corresponde a TTPA de 60 a 85 s).

LMWH

Apesar das várias preparações todas
apresentam atividade contra FXa.

Sua administração pode ser através de
cateteres subcutâneos.
Agentes Trombolíticos
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Trombólise deve ser considerada apenas para
tratamento trombose arterial aguda.
O trombolítico de escolha deve ser o rt-PA
Possui meia-vida curta, pouca antigenicidade e
localizada ação fibrinolítica.
Terapia recomendada e doses dos agentes antitrombóticos neonatais
Futuro
A falta de estudos clínicos randomizados.
 A aplicação retrospectiva de dados e
relatórios para pode não ser reflexo da
população que está sendo cuidadas.
 Espera-se que as complicações possam
ser minimizados e os resultados posssam
ser melhorados.
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Abstract
In the pediatric population, neonates have the highest risk for
thromboembolism (TE), most likely due to the frequent use of
intravascular catheters. This increased risk is attributed to multiple
risk factors. Randomized clinical trials dealing with management of
postnatal thromboses do not exist, thus, opinions differ regarding
optimal diagnostic and therapeutic interventions. This review begins
with an actual case study illustrating the complexity and severity of
these types of cases, and then evaluates the neonatal hemostatic
system with discussion of the common sites of postnatal thrombosis,
perinatal and prothrombotic risk factors, and potential treatment
options. A proposed step-wise evaluation of neonates with
symptomatic postnatal thromboses will be suggested, as well as
future research and registry directions. Owing to the complexity of
ischemic perinatal stroke, this topic will not be reviewed.
Keywords:
postnatal thrombosis, anticoagulation, thrombolysis,
thromboembolism
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Consultem também:
Hemorragia intraventricular no
recém-nascido a termo
Autor(es): Paulo R. Margotto
Hemorragia intraventricular e
talâmica em um recém-nascido
a termo com aumento de
anticorpos antifosfolípides
Autor(es): Paulo R. Margotto
Obrigado!
Dr. Paulo R. Margotto; Ddos Márcio, Antenor, Leonardo e Ciro