how to inject heparin during pregnancywhat aisle are prunes in at kroger

Heparin Sodium Injection, USP is a sterile solution of heparin sodium derived from porcine intestinal mucosa, standardized for use as an anticoagulant. She likes to write research-based articles that are informative and relevant. It is known as Low Molecular Weight Heparin (LMWH). Do not inject this medication into a muscle. Thrombosis. Cochrane Database of Systematic Reviews 2013, Issue 3. However, all these adverse effects are caused due to Unfractionated Heparin and other blood thinners. The dose and length of. 4 0 obj endobj Heparin Use in Pregnancy. Againsure wish I had gotten some guidance from my dr. And, I thank you in advance for any guidance you ladies can give me! Warfarin is contraindicated during pregnancy, but is safe to use postpartum and is compatible with breastfeeding. I tend to insert the needle and inject the heparin slow too. UpToDate, electronic clinical resource tool for physicians and patients that provides information on Adult Primary Care and Internal Medicine, Allergy and Immunology, Cardiovascular Medicine, Emergency Medicine, Endocrinology and Diabetes, Family Medicine, Gastroenterology and Hepatology, Hematology, Infectious Diseases, Nephrology and Hypertension, Neurology, Obstetrics, Gynecology, and Women . There may be an increased tendency to bleeding. If the embolus lodges in the lung this is known as a pulmonary embolus (PE). It is given by injection just under the skin or . LEE T. DRESANG, MD, PAT FONTAINE, MD, MS, LARRY LEEMAN, MD, MPH, AND VALERIE J. But the good news is, blood clots may be preventable and treated if discovered early. Heparin. This condition is not that serious and is reversible through treatment. If another cause of recurrent miscarriage is identified, your doctor can recommend another treatment that's more specific to your situation. Your doctor can discuss the costs and benefits of taking heparin to help you understand what side effects to look out for and decide whether it's right for you. No adverse effects on any babies have been reported. Repeated miscarriages. KING, MD, MPH. It has been found that complications with regard to CNS (Central Nervous System) are caused in the foetus. I've read on here that it's necesary to change injection sites, but my dr. didn't say anything about that. Expecting or recently had a baby? Venography still serves as the definitive test for diagnosing DVT19 and may be used in clinical situations where noninvasive tests are equivocal, empiric anticoagulation is relatively contraindicated, and clinical suspicion is high.24, Figure 2 outlines a diagnostic approach for suspected PE based on expert opinion derived from studies mostly involving nonpregnant patients.2427, With low or moderate clinical suspicion, a negative highly sensitive d-dimer test rules out PE.25,28 If d-dimer testing is positive, or if clinical suspicion is high, additional testing is needed. Copyright 2023 American Academy of Family Physicians. 2.1 Preparation for Administration. Using heparin during pregnancy is not without risk. Some women might already be taking the injections, and some might begin during their term of pregnancy. Studies reported only as abstracts were eligible for inclusion and would have been placed in studies awaiting assessment, pending the full publication of their results. Warfarin (Coumadin) is not safe during pregnancy. However, this review found no randomised controlled trials to show which methods of receiving subcutaneous heparin are effective and safe for pregnant women. Clinical suspicion is confirmed in 10 percent of pregnant women, compared with 25 percent of nonpregnant patients.17 Typical symptoms are unilateral leg pain and swelling. These documents share important information about blood clot signs and symptoms, and risks for blood clots in pregnant women or women who just delivered a baby. And she would like to continue creating content on health and lifestyle. Wipe the area with alcohol. Heparin is an anticoagulant, which prevents blood clotting. 2010-2023 Parenting.FirstCry.com. Therefore, we performed a literature review of fetal/infant outcomes following anticoagulant therapy during pregnancy. Of clinically suspected PE, only 4 percent are confirmed in pregnant patients, versus 30 percent in nonpregnant patients.17, Figure 1 presents an approach to the diagnosis and treatment of DVT in pregnancy derived from studies of non-pregnant patients.19,20 In nonpregnant women, a negative (low) d-dimer test combined with a low clinical probability score has a negative predictive value higher than 99.5 percent when a highly sensitive assay (e.g., enzyme-linked immunosorbent assay, latex turbidimetric assay) is used.19,20 However, d-dimer values increase progressively throughout pregnancy, and the ranges for normal values by gestational week are not yet universally established.21,22 Although a low d-dimer may be helpful in ruling out DVT, a positive (high) d-dimer result will be common during pregnancy and always requires confirmatory testing.12,20. A DVT can limit blood flow through the vein, causing swelling and pain, but there is a risk that it can break off and travel through the blood stream. All rights reserved. % This medicine, injected under the skin, is used to prevent or treat blood clots during and after pregnancy. Was told to change injection sites because a small lump/bump can develop and will not go away. dontletitbeabouttom 2 yr. ago. The LMWH comes in preloaded syringes. CDC is not responsible for Section 508 compliance (accessibility) on other federal or private website. No trials met the inclusion criteria for the review. If a very small amount passed into breast milk it is broken down by stomach acids therefore any absorption by a breast fed baby is negligible. Clinical symptoms of deep venous thrombosis may be subtle and difficult to distinguish from gestational edema. Blood Clot Prevention Checklist for Pregnant Women, Blood Clot Risk Checklist for Pregnant Women, This Is Serious (Duke Haemostasis Center), Join the Public Health Webinar Series on Blood Disorders. (I tried it). UFH is considered an acceptable alternative.32 Table 1 recommends dosages and monitoring.10,12,32,41 For postpartum DVT or PE, warfarin may be started concomitantly with heparin.42 LMWH or UFH should be continued until an international normalized ratio of 2.0 to 3.0 is achieved for two consecutive days.42 Post-thrombotic syndrome can be prevented if compression stockings are worn for at least one year starting in the first month after a DVT.1, Intrapartum management may vary depending on the indication for anticoagulation and whether therapeutic or prophylactic doses have been used.10 Expert guidelines suggest that women receiving adjusted-dose LMWH or UFH be instructed to discontinue heparin injections at the onset of labor to prevent anticoagulant complications during delivery.12,32 When delivery is predictable, as for elective induction or planned cesarean birth, LMWH or UFH should be discontinued 24 hours before delivery.12,32 For high-risk patients, such as those with mechanical heart valves or recent VTE, the American College of Obstetricians and Gynecologists (ACOG) recommends switching to intravenous heparin at the onset of labor.10 The short half-life of intravenous UFH allows discontinuation four to six hours before the anticipated time of delivery.10,32 To minimize spinal and epidural hematoma risk, the ACOG and the American Society of Regional Anesthesia advise avoiding regional anesthesia for 24 hours after the last LMWH dose for women on twice daily therapeutic doses of enoxaparin (Lovenox), and for 12 hours after the last dose of LMWH for women receiving daily prophylactic dosing.10, Evidence is insufficient to recommend for or against an inferior vena cava filter if anticoagulation is contraindicated or repeat PE occurs despite adequate anticoagulation.1, Systematic reviews of observational studies have found VTE prophylaxis with LMWH to be safe and effective in pregnancy, but there are no randomized controlled trials confirming this.35,42 Table 2 lists representative prophylactic doses of LMWH and subcutaneous UFH.6,43 Table 3 summarizes recommendations for the type and duration of prophylaxis based on specific clinical risk factors.5,10,15,32,39,40 Consultation should be considered for high-risk thrombophilias such as antithrombin deficiency.6, Low-dose aspirin (75 to 81 mg) is sometimes used for women with an increased risk of thrombosis that does not meet the threshold for prophylactic heparin (e.g., a woman with a mild thrombophilia and no history of VTE).6 Due to the lack of studies of aspirin for this indication, such treatment is of unknown benefit; however, low-dose aspirin is safe to use during pregnancy.32, Postpartum thromboprophylaxis is not routinely indicated following vaginal delivery,42 but may become necessary because of labor-related risk factors, such as prolonged labor, mid-forceps delivery, and immobility after delivery.6, Unless other VTE risk factors are also present, women who undergo a scheduled cesarean delivery are not routinely placed on pharmacologic VTE prophylaxis.44 However, mechanical prophylaxis with pneumatic compression stockings has been shown to provide effective post-cesarean thromboprophylaxis.45 Graduated compression stockings provide effective prophylaxis in nonpregnant postoperative patients.46 A decision analysis comparing pneumatic compression stockings with no intervention for post-cesarean VTE prophylaxis found the former to be cost-effective.47. 3 www.leicestershospitals.nhs.uk Instructions: Make sure you have a sharps box and cotton wool ball ready for after the injection. I mostly stick to my sides/love handles. The best places for you to inject into are: The U-shape area around your belly button. An increased risk of a clot forming during pregnancy or after birth, e.g. Another thingsince I didn't know it was necessary to change sites, I've been giving the injections primarily on my left side (because it doesn't hurt as much on that side, for whatever reason). Symptoms of dyspnea are nonspecific in pregnancy. Stop Lovenox or Dalteparin for 12 hours and begin unfractionated heparin at 10,000 u q 12 hours. Do not rub the area. You are at increased risk for developing a blood clot. Heparin is given by injection or drip into a vein (intravenously) or by injection under the skin (subcutaneously) to treat and prevent these types of blood clots. Several methods of administering heparin (UFH or LMWH) subcutaneously have been introduced to prevent adverse pregnant outcomes. Some women may not self-administer heparin and must rely on others to give them their injections otherwise they stop using the heparin, thus exposing themselves to an increased risk of VTE. In extreme conditions, death has also been recorded. I went through a bruising period of a few weeks, but honestly haven't had one in a long time. All these medications are safe for both the mother and the baby. Also, you want to stay at least 2 inches AWAY from your belly button to avoid the higher concentration of veinswhich can lead to bruising and swelling. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2013) and reference lists of retrieved studies. Heparin is extensively a protein-bound medication. <> The CDC recommends that women drink 10 glasses of liquid every day during pregnancy and 12 to 13 glasses every day while breastfeeding. your doctor. Low-molecular-weight heparin has largely replaced unfractionated heparin for prophylaxis and treatment in pregnancy. I wouldn't inject where the bruise is cause that would probably hurt pretty bad. CDC twenty four seven. You may be advised to start treatment with injections of heparin (an anticoagulant) to 'thin the blood'. Also Read:Blood Clot in the Uterus During Pregnancy: Causes, Complications & Treatment. . The three most common reasons for women starting heparin during pregnancy or after the birth are: For pregnant women and women who have given birth, heparin is the anticoagulant of choice and is recommended by the Royal College of Obstetricians and Gynaecologists. As the risk of losing blood is high during and post-pregnancy stages, heparin is considered largely effective in stopping blood clots. It is used to treat and prevent deep vein thrombosis (DVT) and pulmonary embolism (PE) including during pregnancy and following certain types of surgery. Heparin Sodium Market - Covid-19 Impact and Recovery Analysis: We have been tracking the direct impact of COVID-19 on this market, as well as the indirect impact from other industries. After deep subcutaneous (intrafat) injections, tests for adequacy of dosage are best performed on samples drawn 4 to 6 hours after the injection. A family or personal history of blood clots or a blood clotting disorder, Prolonged immobility (not moving a lot), such as during bed rest or recovery after delivery, Complications of pregnancy and childbirth, Certain long-term medical conditions, such as heart or lung conditions, or diabetes, Know the signs and symptoms of blood clots, A blood clot occurring in the legs or arms is called deep vein thrombosis (DVT). It does not cross the placenta, and therefore is considered to be safe. Carefully remove the cap from the needle connected to the syringe filled with the drug Clexane. This for me meant I was included early so they could manage it. Let your provider know if you or anyone else in your family has ever had a blood clot. Heparin is also known as: Heparin Sodium Pregnancy Warnings Breastfeeding Warnings Heparin Pregnancy Warnings Animal studies have revealed increased resorptions at doses approximately 10 times higher than the maximum human daily dose based on body weight. Keep reading to know whether the use of heparin during pregnancy is safe or not. Clexane during pregnancy, birth and afterbirth. Also, heparin is usually administered around the abdomen area where the fatty layers of the stomach do not permit the needle to get close to the foetus and harm it. 5 For individuals with antiphospholipid syndrome, the benefits of heparin usually outweigh the risks. Sasaki H, Yonemoto N, Hanada N, Mori R. Methods for administering subcutaneous heparin during pregnancy. It is a physically and emotionally painful journey but it will be worth it all when the sweet bundle of joy arrives at the end of it all. The specific form of thrombophilia that's most often tied to miscarriage is calledantiphospholipid syndrome. It crosses the placenta and increases the risk of miscarriage, stillbirth, embryopathy (nasal hypoplasia or stippled epiphyses), central nervous system abnormalities, and maternal and fetal hemorrhage.32 Warfarin is compatible with breastfeeding.32, Data derived from nonpregnant populations suggest that therapeutic anticoagulation following a first episode of VTE should continue for at least six months from diagnosis.38 Current recommendations for the duration of treatment in pregnancy range from three to six months, including six weeks postpartum.10,12,32 Long-term (i.e., longer than 12 months) anticoagulation is indicated for women with VTE and antiphospholipid antibody syndrome, or two or more thrombophilias,39 and for women with any thrombophilia and recurrent thrombotic events.40. Cookies used to make website functionality more relevant to you. Therefore it is considered that heparin is safe for you to have whilst you are breastfeeding. By clicking Accept All Cookies, you agree to the storing of cookies on your device to enhance site navigation, analyze site usage, and assist in our marketing efforts. A clot arising during this or a previous pregnancy. There is another kind of heparin, which has been recently recommended by doctors to pregnant women and in general to stop blood clots. It is important that you change the site each time. To compare the effectiveness and safety of different methods of administering subcutaneous heparin (UFH or LMWH) to pregnant women. Campaign digital content is provided in ways that make it easy for you to share with friends and family and across your social media networks. 2013;2013:1-9. doi:10.1155/2013/516420, Kaandorp SP, Goddijn M, Van der post JA, et al. It will depend on why you are receiving heparin as to when your injections will start. And then administer the injection ask your Dr he could prescribe it. Could be that I am a bigger girl but I have found that the heparin shots are much easier than the lovenox shots. Do not administer Heparin Sodium Injection by intramuscular injection because of the risk of hematoma at the injection site [see Adverse Reactions (6)]. (AND I had some NASTY ones during that time--unfortunately, it is very normal)!! She was on Lovenox for all three of her pregnancies. We use cookies to improve your experience on our site. . stream Although receiving subcutaneous heparin (either unfractionated heparin (UFH) or low molecular weight heparin (LMWH)) is the main option in the prevention of VTE during pregnancy, the management of thromboprophylaxis in pregnant women has mostly relied on the evidence from non-pregnant participants. Warfarin is contraindicated during pregnancy, but is safe to use postpartum and is compatible with breastfeeding. Pain with foot dorsiflexion (Homans' sign) is neither sensitive nor specific for diagnosing DVT in patients who are not pregnant;18 however, data are lacking for this in patients who are pregnant. VTE includes deep vein thrombosis (DVT) and pulmonary embolism (PE). She has written articles on pregnancy, parenting, and relationships. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. If you need to go back and make any changes, you can always do so by going to our Privacy Policy page. Push down on the plunger slowly as far as it will go. Most commonly, venous thrombosis occurs in the deep veins in the legs, thighs or pelvis and this is called a deep vein thrombosis or a DVT. I lie down and then just squeeze an inch of skin/fat and inject at a 45 degree angle. (I'm not sure if you are supposed to do so, but it seems to help me sometimes). The effectiveness and safety of different methods administering subcutaneous heparin (UFH or LMWH) during pregnancy have not been systematically evaluated. Heparin is most often prescribed to prevent blood clots or miscarriages, and is usually given as a subcutaneous injection. The effect of unfractionated heparin in assisted reproductive technology (ART) cycles is prevention of thrombosis in implantation site . Table 1 lists a typical therapeutic LMWH dose.10,12,32,41 The optimal monitoring protocol with LMWH is controversial. This means that is slows down blood clotting or "thins" the blood. During pregnancy, a womans blood clots more easily to lessen blood loss during labor and delivery. All rights reserved. I hardly bruise at all. : CD009136. Heparin Use During Pregnancy Information for pregnant women or women who have given birth who are receiving low molecular weight heparin Heparin is an anticoagulant drug. N Engl J Med. We're thinking of having a doula which sounds like such a silly posh person thing to do, we're not posh but I really feel like I could do with having an experienced advocate in there with me at the sharp end. I found this out when I was giving my husband his Enbrel- this one get refrigerated- my hands were full so I stuck the syring in my bra (haha) so it wouldn't break in my pocket and he said that it was the least painful injection ever. Heparin, sometimes called "standard heparin," is available as a liquid solution injected directly into the blood (intravenous or "IV") and only given to hospitalized patients, for instance . The only slight difficulty was that you can't have an epidural within 24 hours of your last heparin injection. Anticoagulation options include low-molecular-weight heparins (LMWHs), unfractionated heparin (UFH), and warfarin (Coumadin; postpartum only). Arterial blood gas monitoring (with the patient sitting upright for greatest accuracy), chest radiography, and electrocardiography (looking for right ventricular hypertrophy) can be done in unstable and immobile patients and may help diagnose PE or suggest other conditions. A management plan for the heparin will be made which should be kept in your obstetric notes and a copy will be kept in your medical notes. From what I hear though, some really like it. I don't really have alot more to add than the previous posters but, I have beenon heaprin now for almost 5 wks and at first i was bruising very badly and was using my inner thighs (while sitting down) as my injection sites. These cookies may also be used for advertising purposes by these third parties. This medication is given by injection into a vein or under the skin as directed by your doctor. Regardless of the reason, women who use opioids during pregnancy should be aware of the possible risks during pregnancy, as well as her . Now that is the way we do all of them! BabyCenter may earn a commission from shopping links. I tried it a couple times, but I lack the patience. Very rarely there may be allergic type reactions at the injection site or in the body generally, increased blood potassium level, an immune reaction called HIT (heparin induced thrombocytopenia) or possibly bone thinning. How should this medicine be used? Anticoagulant therapy during pregnancy is indicated for the treatment and prophylaxis of venous thromboembolic disease and for the prevention and treatment of systemic embolism associated with valvular heart disease and/or . If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. I took heparin during my pregnancies (after having a DVT). Heparin is only recommended for use during pregnancy when benefit outweighs risk. How Heparin Helps Prevent Recurrent Miscarriages. Rubbing increases the chance for bruising and bleeding. As far as the bruise/swelling, it probably won't be your last one, but hopefully it will get better! Your risk of developing a thrombosis will be assessed in pregnancy and after the birth of your baby. The nurse that taught both myself and my husband to inject myself had that happen to her. Heparin is broken down by stomach acids and so cannot be taken by mouth. Remove the cap from needle and gently pick up a well-defined fold of skin. You also acknowledge that owing to the limited nature of communication possible on The campaign web portal provides people with lifesaving information about blood clots, including the factors that increase the risk for blood clots, as well as their signs, symptoms, and prevention. IJMS. It is partially broken down and metabolized both by the liver and the reticuloendothelial system. This is called an embolus. Copyright 2008 by the American Academy of Family Physicians. For patients with diagnosed underlying health conditions, treatment can be tailored to improve the chance of a successful pregnancy. Every story is different, but below . It was commented on recently (last week) so it should not be too far back. Good luck and congrats!!!! Blood Clot in the Uterus During Pregnancy: Causes, Complications & Treatment, 170 Baby Boy & Girl Name That Mean 'Gift from God', 600+ Unique & Cute Nicknames for Boys & Girls, Protecting Adolescents From Common Food and Waterborne Diseases, Why an Ideal pH 5.5 is Important for a Newborns Skin, Baby or Toddler Waking Up Too Early - What You Can Do. Grasp the tip of the Needle-Trap and bend it away from the syringe. DVT Elastic compression stockings have a protective effect against DVT but can be uncomfortable to wear and are not protective against thrombosis anywhere else but the legs. Methods of receiving heparin subcutaneously include giving an injection at regular intervals, or using an indwelling catheter and an infusion pump. 2010;362(17):1586-96. doi:10.1056/NEJMoa1000641. Quasi-randomised studies and cross-over trials were not eligible for inclusion.. Methods of administering subcutaneous heparin include intermittent injections versus indwelling catheters or programmable (auto) external infusion pumps, or any other devices to facilitate the subcutaneous administration of heparin (UFH or LMWH) during pregnancy. These injections are often provided alongside a low dose of "baby" aspirin. Staying hydrated during pregnancy helps prevent clots by keeping the blood from getting too thick, Roshan said. Some women might already be taking the injections, and some might begin during their term of pregnancy. Is It Safe to Use Heparin During Pregnancy? While multiple contributing factors may be involved, sadly about 50% to 75% of the time, there is no known cause for recurrent miscarriages. Pregnant women may also experience less blood flow to the legs later in pregnancy because the blood vessels around the pelvis are pressed upon by the growing baby. There are different types of heparin. All randomised controlled trials (individual and cluster) comparing the effectiveness and safety of different methods of administering subcutaneous heparin (UFH or LMWH) during pregnancy. Before you handle the syringe or vial of heparin, you should wash your hands thoroughly. It is considered safe since it does not penetrate the placenta. alone. Depo-Provera typically suppresses ovulation, keeping your ovaries from releasing an egg. No. Myeloproliferative neoplasms (MPN) such as essential thrombocythemia (ET) and polycythemia vera (PV) are rare during pregnancy. Thank you, {{form.email}}, for signing up. The use of heparin and oral anticoagulants during pregnancy is problematic because these drugs have the potential to produce adverse effects in the mother and fetus. Heparin injection during pregnancy is usually administered to control blood clotting. Methods of receiving heparin subcutaneously include giving an injection at regular intervals, or using an indwelling catheter and an infusion pump. Women are especially at risk for blood clots during pregnancy, childbirth, and the three-month period after delivery. Pregnant women with a history of venous thromboembolism (VTE), antithrombin deficiency, or other risk factors for VTE, need heparin (unfractionated heparin (UFH) or low-molecular weight heparin (LMWH)) prophylaxis, mainly through administering subcutaneously. 1997-2023 BabyCenter, LLC, a Ziff Davis company. During pregnancy, progesterone plays an important role, especially early in the first trimester. :) I do heparin twice a day, on my morning injection I do the left side and in the evening I do the right side. Before choosing a course of action, your doctor will evaluate the potential causes of your repeated miscarriages. A couple minor inconveniences to your day! Aspirin plus heparin or aspirin alone in women with recurrent miscarriage. Due to the risks and uncertain benefits, heparin treatment is recommended only for those with a confirmed diagnosis of antiphospholipid syndrome or an inherited thrombophilia disorder. According to this study: In women who have a history of venous thromboembolism, weight-adjusted intermediate-dose low-molecular-weight heparin during the combined antepartum and postpartum periods didn't reduce the risk of recurrence compared with fixed low-dose low-molecular-weight heparin.Further study is needed to determine whether intermediate-dose low-molecular-weight heparin may be more . Now that my belly is a lot bigger, I inject into my love handles or side of upper thigh (do that while sitting). It's best to use one of the following areas (see Figure 1): Your abdomen (belly), except for the 2-inch (5-centimeter) area around your belly button The middle front or middle outside of your thighs Another possible cause of recurrent miscarriage is a group of medical conditions that increase blood clotting, called thrombophilia disorders. Visiting and Attending Maternity Services, Covid during Pregnancy, Labour and After Birth, Southmead Hospital Charity - Supporting Maternity, Active Birth & Positions for Labour Video, Emergency Parking at Cossham Birth Centre Video, Short Stay Parking at Central Delivery Suite Video, Labour Room, Central Delivery Suite Video. 2 Remove the cap and roll the vial. While working as an intern for an English daily, she realised that she likes writing above anything else. Pick up the syringe. Are the heparin injections more painful than the progesterone? <>/PageLabels 375 0 R>> 1. It is important that the heparin is given at the same time of day (within two hours) and it is recommended that it be given in the morning if the blood tests to monitor it are needed. Research supports this through various experiments conducted on animals and their results. . Is this normal? Thromboprophylaxis during pregnancy By subcutaneous injection Adult 5000-10 000 units every 12 hours, to be administered with monitoring, Important: prevention of prosthetic heart-valve thrombosis in pregnancy calls for specialist management. The welcome thread at the top of page one has lots of tips in it. Check APTT or antifactor Xa level once in 7 days. 2Li{.2e|s;G ;`%A. Hold the syringe like a pencil in one hand, keeping your fingers off the plunger. Women may use opioids as prescribed, may misuse prescription opioids, may use illicit opioids such as heroin, or may use opioids as part of medication-assisted treatment for opioid use disorder.

Tbc Enhancement Shaman Pvp Guide, Murchison Family Net Worth, Honey Baked Ham Mac And Cheese Recipe, Articles H