Apixaban therapy in a pregnant woman with heparin-induced thrombocytopenia and venous thromboembolic events caused by congenital antithrombin deficiency: A case report

Heparin induced thrombocytopenia in pregnancy: A therapeutic challenge case report and literature review

The anticoagulants of choice for the prevention and treatment of venous thromboembolic disease during pregnancy are unfractionated heparin and low-molecular-weight heparin. Heparin-induced thrombocytopenia (HIT) is introduced as a rare but critical side effect of heparin products raising the thromboembolic event paradoxically. Here, we present a case of HIT in pregnancy with challenging management due to coincidence of lupus anticoagulant (LA) and limited anticoagulant options in the pharmaceutical market of our country of residence. We describe a 6-week pregnant patient with deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE), which developed HIT during antenatal care. Therapeutic anticoagulation was initiated with argatroban, then switched to apixaban due to limited access to argatroban. Another therapeutic challenge was the concurrent incidence of LA. The interdisciplinary care team decided on adding up warfarin and scheduled termination at 12 weeks regarding the hazardous condition of the patient. We also reviewed related case literature to convey a new insight into managing pregnancy-related HIT. HIT is a pro-coagulatory and lethal complication associated with heparin therapy that can be diagnosed by clinical suspicion, the 4T score system, and confirmatory laboratory analyses. Alternative anticoagulation is the cornerstone of the treatment and an interdisciplinary plan will be worthwhile to make the best clinical decision regarding the critical situation and least the thromboembolic events mortality during pregnancy.

An Open-Label, Single-Arm, Pilot Intervention Study to Assess the Efficacy and Safety of Apixaban in Heparin-Induced Thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction due to its related risk of life- and limb-threatening thrombosis. Apixaban is a direct factor Xa inhibitor that may be intended as an ideal alternative for the management of HIT. In this open-label, single-arm, pilot intervention study, the efficacy and safety of apixaban were evaluated in 30 patients over the age of 18 with clinically suspected HIT (4Ts score 4 points or greater). Patients with mechanical heart valves, chronic kidney disease, hepatic impairment, and active bleeding were excluded. In all patients with inclusion criteria, heparin or enoxaparin was discontinued and apixaban was started. The dose of apixaban for HIT suspected patients were defined based on the reason for anticoagulant therapy. Endpoints included confirmed thrombosis, mortality, and adverse treatment-related events. After Apixaban therapy, platelet counts normalized in all patients, none of the 30 subjects developed new, progressive, or recurrent thrombosis, and only 1/30 patients developed hemorrhagic events. Five patients (16.7%) died, but the reason for death was not linked to thrombosis, hemorrhage, or adverse effects of apixaban. Along with the available emerging data, our results propose that apixaban could be a safe and effective drug for the management of suspected HIT in clinically stable patients. This article is protected by copyright. All rights reserved.

Experience with direct oral anticoagulants in pregnancy - a systematic review

OBJECTIVES

The experience and use of the new direct oral anti coagulants (DOACs) in pregnancy is limited, but as they offer many practical advantages compared to low molecular weight heparin (LMWH), the pursue of their safety is challenging.

METHODS

Systematic review of studies in which DOACs were used during pregnancy and the puerperal period (PROSPERO registry-CRD42021237688). Searches were performed on MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library databases, until July 2021 and secondary sources using the MeSH terms 'pregnancy', 'pregnancy complications', 'venous thrombosis', 'congenital abnormalities', 'Factor Xa Inhibitors,' and names of specific DOACs. Search was limited to human studies, with English or French as languages of report.

RESULTS

Literature search yielded 1,989 results which, after duplicate exclusion, resulted in 672 publications. Studies were then screened using the specified eligibility criteria described and studies that did not meet the criteria were excluded, resulting in 21 full text studies to an in-depth analysis and data extraction. Overall, 339 cases of DOACs usage during pregnancy were reported until now. The data demonstrated 56% live births but a miscarriage rate of 22.2% and an elective termination of pregnancy in 21.8%; fetal abnormalities related to DOACs occurred in 3.6%. Our meta-analysis displayed a higher rate of fetal loss and fetal abnormalities with DOACs use compared to LMWH, notwithstanding similar bleeding complications.

CONCLUSIONS

The current information available for the 339 cases herein reported does not allow a conclusion that DOACs can be safely used in pregnancy.

[Direct oral anticoagulants and pregnancy]

The use of direct oral anticoagulants, apixaban, dabigatran and rivaroxaban, is increasing because of their simpler way of use than those of low molecular weight heparins and of antivitamines K anticoagulants. During pregnancy, although there is no warning signal to date, the data on their use are far from sufficient to allow the continuation or initiation of direct oral anticoagulant treatment in a pregnant women.