BACKGROUND AND PURPOSE:

• It is unclear which of the following options for pregnant women using low weight molecular heparin (LMWH) is associated with better perinatal outcomes, including the best chance of having neuraxial analgesia
  • Scheduled delivery 12 hours following termination of anticoagulant treatment vs
  • Spontaneous onset of delivery
• Neuraxial anesthesia is generally available to patients if the time from last prophylactic LMWH dose ≤10 to 12 hours
• Rottenstreich et al. (BJOG, 2020) examined the outcomes of planned induction of labor vs spontaneous onset of labor among women using LMWH

METHODS:

• Retrospective cohort study
• Participants
  • Use of prophylactic LMWH therapy during pregnancy
  • Vaginal delivery from 2018 to 2019
• Exposures
  • Planned induction of labor
  • Spontaneous onset of labor
• Primary outcome
  • Duration of anticoagulation interruption
  • Eligibility to receive neuraxial anesthesia

RESULTS:

• 199 women | >90% considered at risk for postpartum VTE and were given postpartum thromboprophylaxis
  • Spontaneous onset of labor: 39.2%
  • Planned induction: 60.8%
• Women who presented with spontaneous onset of labor had a shorter
  • Median admission-to-delivery interval (P < 0.001)
    • Spontaneous: 4.7 hours
    • Planned: 29.3 hours
  • Last LMWH injection to delivery interval (P <0.001)
    • Spontaneous: 25.8 hours
    • Planned: 48.2 hours
  • LMWH injection to the first postpartum LMWH injection interval (P <0.001)
    • Spontaneous: 41.2 hours
    • Planned: 63.7 hours
• Eligibility for neuraxial analgesia was higher among the planned group (P <0.001)
  • Spontaneous: 88.5%
  • Planned: 100%
• Rates of the following were similar between the groups
  • Postpartum hemorrhage
  • Blood transfusion
• Thrombotic events were documented among women in the planned group but there was no statistical difference between groups (P=0.16)
  • Spontaneous: no events
  • Planned: 3.3% (4 women)

CONCLUSION:

• The planned induction group experienced postpartum thrombotic events (though not statistically significant)
  • The authors hypothesize that this may be due to the prolonged duration of anticoagulation interruption
• There were comparable rates of bleeding complications between the groups
• Most women (almost 90%) in the spontaneous onset of labor group were eligible to receive neuraxial anesthesia because time from last LMWH injection until active labor was >12 hours
• The authors state that while prospective studies are needed

The risk of not being eligible for neuraxial anaesthesia following spontaneous onset of labour was relatively low

Thus, we do not support the routine offering of induction of labour solely due to the use of prophylactic anticoagulation therapy

A multidisciplinary, individualised approach should be implemented

Learn More – Primary Sources:

Planned induction versus spontaneous delivery among women using prophylactic anticoagulation therapy: a retrospective study

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