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Multidisciplinary Management of a Pregnant Patient Undergoing Cesarean Section on Dual Antiplatelet Therapy (DAPT) within 1 Month of Intracranial Stent Placement on Cangrelor
Abstract Number: RF1AA-140
Abstract Type: Case Report Case Series
Introduction: The recommended duration of DAPT after intracranial stent placement presents a dilemma for pregnant patients with recent stenting who require urgent or emergent obstetrical surgery. If DAPT is discontinued, the risk of stent thrombosis is increased, which could result in stroke or death (1). We present the case of a pregnant patient with recent stent placement (less than 1 month) on DAPT who underwent successful c-section with DAPT therapy bridged using cangrelor, an IV P2Y12 receptor inhibitor antiplatelet agent.
Case: A 34-year-old G1P0 at 31.4 weeks presented to the emergency department with a sudden onset headache and left hemiparesis and neglect. She had a history of polycystic ovarian syndrome and morbid obesity. A non-contrast brain MRI revealed findings concerning for a right MCA stroke. An MRA of the patient’s head and neck showed an occlusion of the M1 branch of the MCA. The patient was taken to the angiography suite where thrombectomy was performed and two balloon mounted stents were deployed in the right ICA communicating branch for successful recanalization. Aspirin and clopidogrel were started to prevent stent thrombosis. The patient’s symptoms resolved.
During the patient’s hospitalization her blood pressure was noted to be elevated and her platelet count dropped from the 120s to 90s, concerning for cHTN with SIPE with severe features versus gestational thrombocytopenia. Given the inability to distinguish between the two diagnoses, the decision was made to deliver the baby at 35.3 weeks. The patient elected to have a general anesthetic, as she did not want to labor without a neuraxial block.
A multidisciplinary team consisting of anesthesiology, MFM, neurology, and hematology met, and the decision was made to discontinue the patient’s clopidogrel 5 days prior to delivery while bridging her with cangrelor, an IV P2Y12 receptor inhibitor with a 6-minute half-life. On the day of the patient’s c-section, the cangrelor infusion was discontinued during induction. A live male infant was delivered with APGARs of 8 and 9. The cangrelor infusion was restarted when hemostasis was achieved, and the uterus was noted to have good tone. EBL was 400 cc. The patient underwent continuous intraoperative EEG and EMG to monitor neurological status. A stroke team was notified and available in the event that a change in neurological status was seen. Postoperatively the patient was loaded with clopidogrel and the cangrelor infusion was discontinued. The patient was discharged on post-op day 3.
Discussion: This case is the only report of a c-section performed in the setting of aspirin and cangrelor use in a patient with stent placement. It highlights the importance of a multidisciplinary approach to the pregnant stroke patient. Our strategy is a potential option for pregnant patients on DAPT who are high thrombotic and high bleed-risk, yet require obstetrical surgery.
J Am Coll Cardiol. 2009;53(16):1399.