Fruit of the Womb
Fruit of the Womb

Anticoagulation Therapy Does Not Mandate Cesarean Delivery

The following comment/question appeared recently on my post Recurrent Early Pregnancy Loss - 7 - Immunologic and Hematologic Causes. Since anticoagulation therapy for recurrent pregnancy loss, as well as genetic and autoimmune thrombophilias, with unfractionated and and low-molecular weight heparins appears to be growing in popularity, many readers with pregnancy problems may have an interest in my response...

Anonymous said...
In 2004, after the stillbirth of my first child at 22 weeks gestation, I was diagnosed with APS (Antiphospholipid Antibody Syndrome). I have a very good reproductive endocrinologist and perinatologist to work with me when I decide to become pregnant again. I know that I will have to follow the twice daily heparin injections. My question is, is a woman on this therapy always forced to have a c-section? I understand that the drugs are stopped 24 hours before the delivery, however I want to know if I can attempt to have a natural childbirth even with APS. Thanks for the advice...

Kenneth F. Trofatter, Jr., MD, PhD said...
To Anonymous Sept 17: You do NOT have to have a cesarean delivery just because you have antiphospholipid antibody syndrome. However, many women with APS will end up with one simply because, even with therapy, they are at increased risk for abnormalities of placentation that result in poor fetal growth (intrauterine growth restriction), hypertensive disorders of pregnancy (preeclampsia), or decreased placental reserve which can lead to nonreassuring fetal heart rate patterns ("fetal distress"), especially with uterine contractions. Incidentally, you do NOT have to stop therapy with unfractionated heparin 24 hours prior to delivery. You can take heparin until you actually present in labor and, if necessary, its effects can be 'reversed' with a drug called protamine sulfate.

If your doctor chooses to use 'low-molecular weight heparin' (such as enoxaparin), that does need to be stopped at least 24-48 hours prior to delivery because its effects cannot be readily reversed and that could increase your risk for bleeding problems. Indeed, many anesthesiologists will not consider using a regional anesthetic (an epidural or spinal anesthetic) unless you have been off enoxaparin for at least 48 hours due to the risk of subdural and epidural hematomas. In our practice, we generally stop enoxaparin at 34-36 weeks gestation and intentionally switch to heparin to avoid the risks of these bleeding complications and to allow the patients the benefits of regional anesthesia during labor and delivery.

Many women with APS will also be on low-dose aspirin therapy. Aspirin blocks platelet function on the other side of the coagulation system. Even the typical dose of only 81 mg can impair platelets for several days. Given the opportunity, I will often try to discontinue this 2-3 days prior to delivery as well. Thanks for reading and for a great question. I will feature this query in one of my daily blogs! Best regards, Dr T

Thu Sep 27, 01:25:00 PM 2007
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