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Helen Feltovich, MD, Maternal-Fetal Medicine
Intermountain Healthcare, Provo, UT
At our institution, we fully anticoagulate a patient who gets a clot in pregnancy throughout pregnancy and for at least three months postpartum (PP), usually six months PP. We know from studies of clot incidence that there is still signal related to the increased incidence surrounding pregnancy as far out as three months. We do not image them until we are making a decision to stop anticoagulation and that is usually six months PP. I say “we,” but at that time it is our Heme/Coag team who is making the decision. They will also check a d-dimer and assess other risk factors when deciding whether to stop or continue. In Europe, our heme/epi colleagues are concerned about the high rate of recurrence among their patients who receive low dose anticoag for a history of clot, let alone for a clot during that pregnancy. I just have been asked to participate on a steering committee for an international randomized trial of low vs. full dose anticoag for women with a history of clot. My impression is that the risk of recurrent clot is MUCH higher among women who have had a clot during that pregnancy. I am just not comfortable reducing a woman’s anticoag to a low dose when she has had a clot during pregnancy, especially when all the risk factors that gave her a clot in the first place are still present. Then, PP, her risk increases another 5- to 20-fold higher than it was during pregnancy.
Andra James, MD, MPH
Founder of the Women’s Hemostasis and Thrombosis Clinic
Duke University Medical Center
Associate Professor of Obstetrics & Gynecology
Duke University School of Medicine
Providers at an HTC
The baby is, as you say, at 50/50 risk for VWD, but not severe – only mild or mod. The OB should avoid operative vaginal delivery and scalp electrode. (No one does scalp sampling any more.) If the patient is in the third stage of labor and at a point of “no return” with fetal distress, the OB should choose forceps over vacuum, otherwise have a low threshold for C/S. Otherwise, C/S should be used for obstetric reasons only.
The OB should get two tubes of cord blood, light blue topped, so that studies can be run on the infant. Is it a girl or boy? If a boy, circumcision should be postponed until his status is known with respect to VWF/FVIII.
Caroline Cromwell, Assistant Professor Hematology
Mount Sinai School of Medicine
In general, combined oral contraceptives increase risk of thrombosis in susceptible women. Medroxyprogesterone acetate (DMPA) has also been shown to increase risk of thrombosis about 2-fold (so similarly). We usually recommend levonorgestrel releasing IUD or copper IUD for patients where we are concerned about thrombosis risk. The other alternative for an oral agent is the mini-pill, but some women don’t tolerate side effects. If the patient chooses barrier methods, be sure she uses two things (e.g., condoms and spermicide).
Mary Cushman, MD, M.Sc.
Professor of Medicine, Hematology/Oncology Division
Department of Medicine
Professor of Pathology
University School of Vermont
Paulette Bryant MD
This is a complicated clinical scenario. In addition, there is very little published literature in this area. However, we have been concerned about the potential hemodynamic/intravascular pressure shifts that may exist during exchange and the impact on the fetus. We have used straight transfusions during the pregnancy then resumed exchanges postpartum. However, our patients did not have other thrombotic risk factors and they did well. I understand your concern regarding thrombotic risk and potential compromise to fetal growth. I like your plan to continue exchanges and monitor closely.
Sickle cell disease is a high-risk thrombophilia, as pointed out by Sophie Lanzkron and colleagues in their recent articles. Given this patient’s additional risks of pregnancy, FVL, low protein S and history of stroke, I would think that at least low-dose LMWH plus ASA, or a moderate dose of LMWH, with heparin in the peripartum period should be considered, in addition to the standard treatment you and Kim have discussed.
What a challenging case!