Managing anticoagulation peripartum

Due to the elevated thrombosis risk during pregnancy, anticoagulants are among the most common medications prescribed during gestation. For patients on anticoagulation antepartum, planning for delivery in advance is central to a safe and patient-centered delivery. Peripartum anticoagulation management must balance the benefits of continued therapy against the risks of postpartum hemorrhage and potential limitations in offering neuraxial anesthesia. Key considerations for delivery planning for patients on anticoagulation include the following: (1) prophylactic versus therapeutic dosing; (2) mode of delivery (vaginal vs cesarean); (3) scheduled vs spontaneous delivery; (4) specific indications for neuraxial anesthesia (eg, twin gestation and difficult airway); (5) the patient's valuation of neuraxial anesthesia; and (6) time since diagnosis of venous thromboembolism where applicable. Optimal patient management requires prenatal collaboration among thrombosis experts, obstetricians, and anesthesiologists to develop a personalized plan for delivery that balances risk of thrombosis, the potential for hemorrhagic complications, and patient preferences. This includes evaluating whether a patient on low-molecular-weight heparin should switch prior to delivery to subcutaneous unfractionated heparin for prophylaxis or unfractionated heparin continuous infusion, for those at high risk from a break in therapeutic anticoagulation. We also review postpartum anticoagulation options, emphasizing the importance of adherence during this high-risk period. Our discussion is limited to anticoagulation indicated for venous thromboembolism.