Successful Use of Argatroban During the Third Trimester of Pregnancy: Case Report and Review of the Literature
Department of Pharmacy, The Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA. Pharmacotherapy
(Impact Factor: 2.66).
01/2009; 28(12):1531-6. DOI: 10.1592/phco.28.12.1531
Direct thrombin inhibitors are commonly used anticoagulants in patients with known or suspected heparin-induced thrombocytopenia (HIT). All three direct thrombin inhibitors available in the United States-argatroban, bivalirudin, and lepirudin-are pregnancy category B drugs based on animal studies, but little data are available on the safety of these agents during human pregnancy. Whereas several case reports support the safe use of lepirudin, only one case report has been published with argatroban and none with bivalirudin. We describe a 26-year-old pregnant woman with portal vein thrombosis and thrombocytopenia treated with argatroban for possible HIT during her last trimester. An argatroban infusion was started at 2 microg/kg/minute during her 33rd week of pregnancy, with the dosage titrated based on the activated partial thromboplastin time; infusion rates ranged from 2-8 microg/kg/minute. Treatment continued until her 39th week of pregnancy, when labor was induced. Argatroban therapy was discontinued 7 hours before epidural anesthesia. The patient successfully delivered a healthy male newborn, devoid of any known adverse effects from argatroban. The infant was found to have a small ventricular septal defect and patent foramen ovale at birth, but it is unlikely that these were caused by argatroban since organogenesis occurs in the first trimester. Even though the cause of this patient's thrombocytopenia was later determined to be idiopathic thrombocytopenic purpura, this is an important case that adds to the literature on use of argatroban during pregnancy.
Available from: Simon J Davidson
- "There are a small number of case reports documenting the use of argatroban in pregnacy (Young et al, 2008; Ekbatani et al, 2010; Tanimura et al, 2012). In two of these cases, argatroban was used in combination with fondaparinux with successful pregnacy outcomes (Ekbatani et al, 2010; Tanimura et al, 2012), and in another, argatroban was used continuously for 6 weeks, again with a good pregnancy outcome (Young et al, 2008). The option for subcutaneous injection favours the use of danaparoid and fondaparinux, especially in situations where prolonged anticoagulation is required; there are encouraging data using the latter in pregnancy (Knol et al, 2010). "
Available from: Krzysztof Jankowski
- "This agent, however, can cross the placenta . Young et al described a pregnant woman with portal vein thrombosis and thrombocytopenia treated with argatroban for suspected HIT during the third trimester, but there exists only limited human data describing use of this agent during pregnancy . Fondaparinux is another potential therapeutic option for HIT. "
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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.
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.
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ABSTRACT: Unfractionated heparin and low-molecular-weight heparin are currently the anticoagulants of choice for the prevention of recurrent thromboembolic disease during pregnancy. However, heparin-induced thrombocytopenia contraindicates the use of unfractionated heparin and low-molecular-weight heparin. We describe a patient who was admitted to our hospital with deep vein thrombosis at 18 weeks of gestation and who developed heparin-induced thrombocytopenia during her antenatal care. Therapeutic anticoagulation was initially achieved with argatroban, then changed to fondaparinux. During early labor, fondaparinux was discontinued and intravenous argatroban was substituted. Argatroban was discontinued during transition to active labor. After return of a normal partial thromboplastin time, combined spinal-epidural analgesia was induced for routine completion of labor and vaginal delivery. We discuss the decisions made in the maintenance of this patient's anticoagulation during the peripartum period as well as timing of her neuraxial labor analgesia.
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