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Use of fondaparinux in a pregnant woman with pulmonary embolism and heparin-induced thrombocytopenia.

Ciurzyński M, Jankowski K, Pietrzak B, Mazanowska N, Rzewuska E, Kowalik R, Pruszczyk P - Med. Sci. Monit. (2011)

Bottom Line: We present a case of a 24-year-old female presenting for care at 34 weeks of gestation with acute pulmonary embolism treated initially with unfractionated heparin (UFH) and low molecular weight heparin (LMWH), who developed HIT.She was then successfully treated with fondaparinux.To the best of our knowledge, this is one of the first case reports describing a successful use of fondaparinux in the treatment of HIT in a third-trimester pregnant woman, providing a novel approach for this subset of patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland. michal.ciurzynski@wum.edu.pl

ABSTRACT

Background: A serious complication of heparin treatment, heparin-induced thrombocytopenia (HIT) is rarely observed in pregnant women. Drug therapy during pregnancy should always be chosen to minimize fetal risk. The management of HIT in pregnancy represents a medical challenge. Unlike heparins, the anticoagulants used in patients with HIT do cross the placenta, with unknown fetal effects.

Case report: We present a case of a 24-year-old female presenting for care at 34 weeks of gestation with acute pulmonary embolism treated initially with unfractionated heparin (UFH) and low molecular weight heparin (LMWH), who developed HIT. She was then successfully treated with fondaparinux.

Conclusions: To the best of our knowledge, this is one of the first case reports describing a successful use of fondaparinux in the treatment of HIT in a third-trimester pregnant woman, providing a novel approach for this subset of patients.

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Related in: MedlinePlus

Transthoracic echocardiography showing saddle pulmonary thromboembolus.
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f1-medscimonit-17-5-cs56: Transthoracic echocardiography showing saddle pulmonary thromboembolus.

Mentions: A 24-year-old female (gravida 1, para 1) at 34 weeks of gestation was referred from another hospital to the Intensive Care Unit due to acute PE. One month before the hospitalization, the patient was prescribed bed-rest due to threatened premature labour. Several days before admission, she fainted and experienced severe dyspnoea. Spiral computed tomography performed in a regional hospital detected bilateral proximal pulmonary artery thromboemboli. Transthoracic echocardiography revealed right ventricular dysfunction – enlarged right ventricle (33 mm), paradoxical movement of the intraventricular septum, McConnell sign, shortened acceleration time (50 ms) and a transtricuspid pressure gradient value of 30 mmHg. Moreover, saddle pulmonary embolus was revealed (Figure 1). On admission to the Intensive Care Unit, she was moderately dyspneic, with preserved systemic blood pressure (110/70 mmHg) and moderate tachycardia 98/min. D-dimer plasma level was 5226 μg/ml (normal values <500 μg/ml, Vidas Bio-Merieux), while plasma cardiac troponin level and renal and hepatic functions were normal. Therefore, a diagnosis of intermediate-risk acute PE was made. Initially, for 4 days the patient was treated with APTT adjusted intravenous infusion of unfractionated heparin (UFH) followed by a 2-day treatment with enoxaparin in a dose of 1 mg/kg. The initial platelet count was 200×109/L. Platelet count was monitored every other day during the first days of therapy and always exceeded 100×109/L. However, on the seventh day of anticoagulation therapy, a rapid decline in the platelet count, reaching 44×109/L, was observed. LMWH was stopped immediately. The following causes of thrombocytopenia in our pregnant patient were considered: heparin-induced thrombocytopenia (HIT), thrombotic thrombocytopenic purpura (TTP), disseminated intravascular coagulation (DIC), preeclampsia-eclampsia and HELLP syndrome. HIT was diagnosed on the basis of antiplatelet-heparin binding antibodies presence in serum (GTI Diagnostics’ PF4 Enhanced Solid Phase ELISA), while other causes were excluded. Treatment with subcutaneous fondaparinux injections in a daily dose of 7.5 mg was commenced. Over the next few days, the platelet count decreased further, with a nadir of 19×109/L. However, after 10 days the platelet count started to increase progressively (Figure 2). No recurrence of venous thromboembolism or bleeding occurred. At 37 weeks of gestation, 24 hours before an elective caesarean delivery, fondaparinux injections were discontinued. At that time, platelet count was 200×109/L and no signs of right ventricular dysfunction were present on echocardiography. The patient successfully underwent an elective caesarean section under general anesthesia and a healthy female newborn weighting 2620 g was delivered. The course of the surgery was uneventful and no excessive bleeding was observed. Peritoneal drainage and skin closure with interrupted sutures were used as precautionary measures. The newborn suffered from no complications and had a normal platelet count (201 to 313×109L).


Use of fondaparinux in a pregnant woman with pulmonary embolism and heparin-induced thrombocytopenia.

Ciurzyński M, Jankowski K, Pietrzak B, Mazanowska N, Rzewuska E, Kowalik R, Pruszczyk P - Med. Sci. Monit. (2011)

Transthoracic echocardiography showing saddle pulmonary thromboembolus.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3539579&req=5

f1-medscimonit-17-5-cs56: Transthoracic echocardiography showing saddle pulmonary thromboembolus.
Mentions: A 24-year-old female (gravida 1, para 1) at 34 weeks of gestation was referred from another hospital to the Intensive Care Unit due to acute PE. One month before the hospitalization, the patient was prescribed bed-rest due to threatened premature labour. Several days before admission, she fainted and experienced severe dyspnoea. Spiral computed tomography performed in a regional hospital detected bilateral proximal pulmonary artery thromboemboli. Transthoracic echocardiography revealed right ventricular dysfunction – enlarged right ventricle (33 mm), paradoxical movement of the intraventricular septum, McConnell sign, shortened acceleration time (50 ms) and a transtricuspid pressure gradient value of 30 mmHg. Moreover, saddle pulmonary embolus was revealed (Figure 1). On admission to the Intensive Care Unit, she was moderately dyspneic, with preserved systemic blood pressure (110/70 mmHg) and moderate tachycardia 98/min. D-dimer plasma level was 5226 μg/ml (normal values <500 μg/ml, Vidas Bio-Merieux), while plasma cardiac troponin level and renal and hepatic functions were normal. Therefore, a diagnosis of intermediate-risk acute PE was made. Initially, for 4 days the patient was treated with APTT adjusted intravenous infusion of unfractionated heparin (UFH) followed by a 2-day treatment with enoxaparin in a dose of 1 mg/kg. The initial platelet count was 200×109/L. Platelet count was monitored every other day during the first days of therapy and always exceeded 100×109/L. However, on the seventh day of anticoagulation therapy, a rapid decline in the platelet count, reaching 44×109/L, was observed. LMWH was stopped immediately. The following causes of thrombocytopenia in our pregnant patient were considered: heparin-induced thrombocytopenia (HIT), thrombotic thrombocytopenic purpura (TTP), disseminated intravascular coagulation (DIC), preeclampsia-eclampsia and HELLP syndrome. HIT was diagnosed on the basis of antiplatelet-heparin binding antibodies presence in serum (GTI Diagnostics’ PF4 Enhanced Solid Phase ELISA), while other causes were excluded. Treatment with subcutaneous fondaparinux injections in a daily dose of 7.5 mg was commenced. Over the next few days, the platelet count decreased further, with a nadir of 19×109/L. However, after 10 days the platelet count started to increase progressively (Figure 2). No recurrence of venous thromboembolism or bleeding occurred. At 37 weeks of gestation, 24 hours before an elective caesarean delivery, fondaparinux injections were discontinued. At that time, platelet count was 200×109/L and no signs of right ventricular dysfunction were present on echocardiography. The patient successfully underwent an elective caesarean section under general anesthesia and a healthy female newborn weighting 2620 g was delivered. The course of the surgery was uneventful and no excessive bleeding was observed. Peritoneal drainage and skin closure with interrupted sutures were used as precautionary measures. The newborn suffered from no complications and had a normal platelet count (201 to 313×109L).

Bottom Line: We present a case of a 24-year-old female presenting for care at 34 weeks of gestation with acute pulmonary embolism treated initially with unfractionated heparin (UFH) and low molecular weight heparin (LMWH), who developed HIT.She was then successfully treated with fondaparinux.To the best of our knowledge, this is one of the first case reports describing a successful use of fondaparinux in the treatment of HIT in a third-trimester pregnant woman, providing a novel approach for this subset of patients.

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland. michal.ciurzynski@wum.edu.pl

ABSTRACT

Background: A serious complication of heparin treatment, heparin-induced thrombocytopenia (HIT) is rarely observed in pregnant women. Drug therapy during pregnancy should always be chosen to minimize fetal risk. The management of HIT in pregnancy represents a medical challenge. Unlike heparins, the anticoagulants used in patients with HIT do cross the placenta, with unknown fetal effects.

Case report: We present a case of a 24-year-old female presenting for care at 34 weeks of gestation with acute pulmonary embolism treated initially with unfractionated heparin (UFH) and low molecular weight heparin (LMWH), who developed HIT. She was then successfully treated with fondaparinux.

Conclusions: To the best of our knowledge, this is one of the first case reports describing a successful use of fondaparinux in the treatment of HIT in a third-trimester pregnant woman, providing a novel approach for this subset of patients.

Show MeSH
Related in: MedlinePlus