Anticoagulation in Pregnancy and Post-partum: New Options

The ideal anticoagulant in pregnancy and postpartum is yet to be found. Vitamin K antagonists are cumbersome to use having multiple interactions with food and other drugs, requiring frequent laboratory monitoring and necessitating switch over to heparin in early pregnancy and around delivery. Direct Oral Anticoagulants (DOAC) are now therapeutic alternatives to Warfarin in the management of venous thromboembolism, non-valvular atrial fibrillation, and acute coronary syndromes. Their use in pregnancy and the postpartum period is to be explored. Our case is a 35-year, third gravida with two living issues with Rheumatic heart disease (severe mitral and tricuspid regurgitation, moderate pulmonary artery hypertension and chronic atrial fibrillation). She presented at 18 weeks’ gestation with active bleeding from a low-lying placenta. This being an unwanted pregnancy, she underwent hysterotomy with bilateral tubal ligation. Post procedure, warfarin was initiated in view of her chronic atrial fibrillation, and slowly titrated to a target an INR of 2-3. She developed spontaneous haemoperitoneum on warfarin therapy, which was conservatively managed. After resolution of haemoperitoneum, attempting to establish adequate anticoagulation on heparin and warfarin prolonged her hospital stay by an additional 3 weeks of hospital stay until dabigatran was initiated and the patient could be discharged. DOACs offer several advantages efficacy, safety, predictable pharmacokinetics. Although category C drugs in pregnancy, as data accumulates on exposures of these drugs in pregnancy, they may be a future therapeutic option which avoids many of the problems associated with current anticoagulation regimes.