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A Laboring Patient with Recent Pulmonary Embolism: Anticoagulation for the Full Term Parturient
Abstract Number: F4C-6
Abstract Type: Case Report/Case Series
Introduction: Pregnancy is a well-known risk factor for venous thromboembolism (VTE) occurring in approximately 1:1600 pregnancies and accounts for 20-30% of maternal deaths. As many parturients require anticoagulation, the Society of Obstetric Anesthesia and Perinatology (SOAP) released a statement on the anesthetic management of pregnant or postpartum women receiving anticoagulation which is based on expert consensus and published evidence. This statement recognizes the lack of literature regarding parturients who require therapeutic heparin infusions during delivery and currently recommend following PTT 4 hours after discontinuation. In our case, we discuss planning for a laboring patient requiring a heparin infusion during a vaginal delivery due to acute pulmonary embolus.
Case: Our patient is a 19yo G1P0 at 39.6 weeks with a PMH of asthma, gestational thrombocytopenia and new onset sub-segmental PE with sx of SOB and leg swelling (LE dopplers negative). Due to her gestational age, the MFM and Anesthesiology services met to determine the plan for her delivery with considerations for anticoagulation continuation, monitoring, discontinuation and contingency planning for reversal if necessary. At 40 wks GA, induction of labor was planned with a therapeutic heparin infusion. After progression to active labor, the heparin drip would be stopped, the PTT would be checked every hour with plan to place epidural when PTT no longer therapeutic. After delivery the catheter would be removed with a plan to restart heparin 4 hours later. If the patient required an emergency cesarean delivery while on heparin, general anesthesia would be necessary and the patient would be given protamine (0.5mg per 100 unit heparin) to minimize blood loss during surgery. If indicated by PTT or surgical bleeding, a second dose would be administered. Fortunately, our patient achieved active labor, the heparin was discontinued and PTT normalized within 1.5 hours, an epidural was placed and she delivered vaginally with no additional bleeding.
Discussion: This case report is a unique example of how to provide anticoagulation to a full term parturient with an acute pulmonary embolism. The SOAP consensus statement provides guidelines for thromboprophylaxis however limited case reports are available addressing this unique clinical scenario. Although guidelines recommend checking PTT 4 hours after stopping heparin drip, the PTT may decrease to sub-therapeutic levels much faster in pregnant patients due to increased GFR; allowing epidural placement much sooner. Our patient’s PTT normalized with 2 hours. Coordination of anticoagulation with administration of anesthetics must be well planned and discussed to provide safety and comfort to this patient population.
James, A. (2011)Obstetrics and Gynecology, 118(3), 718-29.
Leffert,L., Butwick, A., et al. (2017). Anesthesia and Analgesia, 01 November 2017.