Anticoagulants help preventing blood clot formation in the vessels. Their indications in pregnancy and/or in the puerperium period are found in women who are at high risk for deep vein thrombosis and women with prosthetic heart valves, atrial fibrillation, cere- bral venous sinus thrombosis, previous miscarriages, left ventricular dysfunction.
Low molecular weight heparins (LMWHs), unfractionated heparin (UFH), vita- min K antagonists, and direct thrombin and factor Xa inhibitors are the preferred agents for anticoagulant therapy. The American Society of Regional Anaesthesia and Pain Medicine (ASRA) and the European Society of Anaesthesiologists (ESA) published similar consensus guidelines in 2010 [51, 52]. They both recommended that neuraxial anesthesia in patients using prophylactic UFH up to 5000 units twice daily is safe and no further testing is required before neuraxial anesthesia tech- niques. Doses of over 5000 units twice a day require documentation of a normal PTT before placement. A platelet count should be checked to exclude heparin- induced thrombocytopenia after a 4-day course of heparin therapy [50].
Neuraxial anesthesia should be withheld for either 12 or 24 h from the last injec- tion of LMWH depending on whether the patient is receiving prophylactic or thera- peutic doses of LMWH, respectively. If the patient has an epidural catheter placed, LMWH administration should be delayed for 4 h after catheter removal [50].
If a pregnant woman is taking the newer oral anticoagulants, such as dabigatran or rivaroxaban, neuraxial placement should be delayed by 5 and 3 days, respec- tively [43].
Key Learning Points
• The management of the coagulation defects in pregnant patients requires multidisciplinary approach including anesthesiologist, hematologist, and obstetricians.
• Women whom have known or suspected disorder of coagulation during pregnancy should be evaluated at antepartum period.
• Women whose first manifestation of coagulation disturbance is obstetric hemorrhage should receive standard treatment for hemorrhage and subse- quently should be evaluated for disorders of coagulation.
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© Springer International Publishing AG, part of Springer Nature 2018 B. Gunaydin, S. Ismail (eds.), Obstetric Anesthesia for Co-morbid Conditions, https://doi.org/10.1007/978-3-319-93163-0_12
S. Gupta (*)
Department of Anaesthesiology and Critical Care, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India
A. Grewal
Department of Anaesthesiology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
12
Pregnant Patients on Anticoagulants
Sunanda Gupta and Anju Grewal