anticoagulation in pregnancy

Q: 28 year old female with 20 weeks pregnancy is admitted to ICU with pulmonary embolism. Patient developed Heparin Induced Thrombocytopenia (HIT) with heparin infusion and was switched to bivalirudin. Patient can be transitioned to which of the following with relative safety?

A) Subcutaneous (SQ) full dose enoxaparin
B) Warfarin
C) Dabigatran 
D) Apixaban 
E) Subcutaneous (SQ) fondaparinux


Answer: E

Objective of the above question is to highlight the point that fast getting popular direct oral anticoagulants (DOACs) i.e. dabigatran, apixaban, edoxaban, or rivaroxaban are not safe in pregnancy or breastfeeding.  (Choices C and D)

Warfarin is well known to be avoided in pregnancy. (Choice B)

Once the suspicion or diagnosis of HIT is made, any kind of heparin should be avoided like enoxaprin. (Choice A)

Fondaparinux is a synthesized version of the active pentasaccharide subunit of heparin, with the property of no interaction with platelet factor 4, and can be used safely in pregnancy and HIT. (Choice E)


#pharmacology
#hematology
#Ob-Gyn


References: 

1. Wijesiriwardana A, Lees DA, Lush C. Fondaparinux as anticoagulant in a pregnant woman with heparin allergy. Blood Coagul Fibrinolysis 2006; 17:147–149. 

2.  Lameijer H, Aalberts JJJ, van Veldhuisen DJ, Meijer K, Pieper PG. Efficacy and safety of direct oral anticoagulants during pregnancy; a systematic literature review. Thromb Res. 2018 Sep;169:123-127.