P011: PERIOPERATIVE MANAGEMENT OF ANTICOAGULATION OF PARTURIENT WITH GENETIC HYPERCOAGULABILITY AND HIT UNDERGOING CESAREAN DELIVERY
Michael Hsu, MD; Riann Ming, MD; Reine Zbeidy, MD; Rofayda Gad, MD; Daria Moaveni, MD; Selina Patel, MBBS; Jackson Memorial Hospital/ University of Miami
Fondaparinux is a drug which inhibits Xa and is used for prophylaxis and treatment of venous thromboembolism (VTE). It is recommended in pregnancy when heparin induced thrombocytopenia (HIT) has been diagnosed.1 We describe the management for cesarean delivery (CD) in a parturient receiving therapeutic fondaparinux. A 32 years old G5 P3 with a past medical history of hypercoagulable state secondary to methyl-N-tetrahydrofolate reductase and prothrombin gene mutations was referred for anesthetic evaluation at 32 weeks gestation. Her obstetric history was complicated by 3 previous CDs, premature delivery and presence of a uterine window. Following her last delivery 2 years prior, the patient developed bilateral pulmonary emboli (PE) in the immediate postpartum period. She developed HIT with both unfractionated heparin and low molecular weight heparin. Subsequent treatment with Rivaroxaban and Apixaban was also discontinued due to menorrhagia and anemia. Furthermore, the patient developed another PE while taking Rivaroxaban. She was finally commenced on Fondaparinux 7.5mg daily which she tolerated and continued during her current pregnancy. A multi-disciplinary team (MDT) meeting including obstetrics, obstetric anesthesia and hematology was arranged for delivery planning. Our hematology colleagues advised that fondaparinux was the only safe VTE prophylaxis in this patient given her intolerance to other agents, and that it should be discontinued for the shortest time interval. An elective CD was scheduled at 36 weeks. At 34 weeks, the patient was transitioned from a therapeutic dose of fondaparinux (7.5mg) to a prophylactic dose (2.5 mg), preparing for the possibility of premature emergency delivery. The fondaparinux was discontinued 48 hours prior to scheduled CD. On the day of scheduled CD, all coagulation tests (anti Xa levels, PT, APTT, INR and TEG) were within normal ranges. She underwent CD with general anesthesia. The surgery was uneventful with blood loss of 1L. Fondaparinux 2.5mg was restarted 12 hours postoperatively and was increased to 7.5mg after 24 hours. Her postpartum course was uncomplicated without recurrence of VTE. The peripartum management of patients receiving fondaparinux treatment must be individualized and MDT involvement is vital for safe delivery planning. The risks of VTE, hemorrhage and neuraxial hematoma must be balanced for each patient. This is a unique case where fondaparinux was the only VTE prophylaxis deemed safe in the postpartum period. Current guidance only supports administering fondaparinux postoperatively following uncomplicated neuraxial placement,2 which cannot be guaranteed. Although fondaparinux treatment does not preclude neuraxial placement, it may be best avoided in parturients for whom fondaparinux is deemed the only option for VTE prophylaxis.