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Two Parturients Effectively Managed with Therapeutic Fondaparinux after Recurrent or Worsening Thrombosis on other Anticoagulation Therapy
Abstract Number: SU-12
Abstract Type: Case Report/Case Series
Introduction: Fondaparinux is a synthetic selective factor Xa inhibitor that can be used to prevent and treat venous thromboembolism (VTE) in patients that have failed or have contraindications to other therapies.(1,2) While fondaparinux use is becoming more prevalent in pregnant patients, there is still limited clinical experience.(2) We present the successful management of two parturients on fondaparinux with recurrent or worsening thrombosis on other therapies.
Case 1: A 22-year-old G1P0 at 31 weeks gestational age (GA) was diagnosed with a left lower extremity DVT and was started on enoxaparin 100mg daily. After developing worsening left leg pain, repeat imaging demonstrated extension of the DVT from the left common femoral vein to the distal iliac vein and IVC. At this time, enoxaparin 60mg BID was started, and she was transferred to our institution at 32 weeks GA. She was then transitioned to a heparin infusion. Given the worsening thrombosis she was placed on fondaparinux 7.5mg/day and a suprarenal IVC filter was placed. Fondaparinux was discontinued 4 days (5 half-lives of the drug) prior to her induction of labor at 37 weeks GA, and the heparin infusion was resumed. Prior to epidural placement, heparin was discontinued for 4 hours and a normalized PTT was verified. Heparin was resumed several hours after epidural placement; she had satisfactory labor analgesia and had an uncomplicated vaginal delivery.
Case 2: A 27-year-old G5P2 presented at 32 weeks GA with preeclampsia. She had history of right thoracic outlet syndrome and multiple right subclavian and axillary vein DVTs as well as VTE. She had recurrent DVTs while on therapeutic warfarin, enoxaparin, and rivaroxaban, and thus was placed on fondaparinux 7.5mg/day. Her fondaparinux was stopped for 4 days prior to scheduled induction of labor, and she was placed on heparin infusion during this interval. An epidural was placed 12 hours after discontinuation of heparin, and vaginal delivery was uncomplicated. Heparin infusion was restarted 6 hours PP prior to being transitioned back to fondaparinux 24 hours PP.
Discussion: The use of fondaparinux in pregnancy complicates the provision of neuraxial anesthesia and delivery; thus, careful planning is necessary to optimize patient care. Given its effects cannot be measured with lab testing, fondaparinux needs to be discontinued several days prior to neuraxial anesthesia.(2,3) In order to provide both patients with neuraxial anesthesia, current recommendations for fondaparinux were observed as it was discontinued for a 5 half-life interval in each patient, and not resumed until 24 hours after epidural removal.3 With thorough planning and close communication between providers, both patients successfully received neuraxial anesthesia and had uncomplicated deliveries after being anticoagulated with fondaparinux during pregnancy.
1. Thromb Res 2012;129:407-17.
2. Int J Obstet Anesth 2009;18:94-95
3. Reg Anesth Pain Med 2015;40:182-212