title: Anticoagulant prescribing practices and anesthetic interventions among anticoagulated pregnant patients: a retrospective study.
abstract: BACKGROUND
  The peripartum management of anticoagulated patients poses important challenges for obstetric anesthesiologists, especially when deciding to perform neuraxial block. However, there is limited evidence evaluating anticoagulant prescribing practices and neuraxial block utilization in this setting. Our objective was to examine peripartum anticoagulant prescribing and anesthetic practices in a cohort of anticoagulated patients receiving subcutaneous enoxaparin, and subcutaneous or intravenous unfractionated heparin.
  
  
  METHODS
  We performed a retrospective study of anticoagulant prescribing patterns and anesthetic interventions among patients receiving enoxaparin and/or unfractionated heparin who delivered at a USA obstetric center over a seven-year period.
  
  
  RESULTS
  We identified 101 patients who received enoxaparin and/or unfractionated heparin before delivery. Thirty-nine (38.6%) patients received enoxaparin only, 41 (40.6%) patients received enoxaparin bridged to subcutaneous unfractionated heparin, 11 (10.9%) patients received enoxaparin and were converted to intravenous unfractionated heparin and 10 (9.9%) patients received only subcutaneous unfractionated heparin. The overall rate of neuraxial block utilization was 80.2%. The median [IQR] time-period between the last dose of enoxaparin and neuraxial block was significantly shorter for patients who received only enoxaparin vs. enoxaparin with subcutaneous unfractionated heparin (54h [12-192h] (n=26) vs. 216h [39-504h] (n=23), P=0.04). Among patients who received only subcutaneous unfractionated heparin, the time period between unfractionated heparin and neuraxial block was 24h [19-51h].
  
  
  CONCLUSIONS
  In this study, the neuraxial block rate was high among patients receiving enoxaparin and/or subcutaneous unfractionated heparin with patients undergoing relatively long periods off anticoagulation. Careful multidisciplinary planning is recommended for the peripartum management of anticoagulated pregnant patients.
authors.affiliation: Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA, USA. Electronic address: ajbut@stanford.edu.
authors.forename: A
authors.initials: A
authors.lastname: Butwick
authors.affiliation: NYU School of Medicine, New York, NY, USA.
authors.forename: C
authors.initials: C
authors.lastname: Hass
authors.affiliation: Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
authors.forename: J
authors.initials: J
authors.lastname: Wong
authors.affiliation: Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: D
authors.initials: D
authors.lastname: Lyell
authors.affiliation: Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Y
authors.initials: Y
authors.lastname: El-Sayed
mesh_terms: D000328:Adult; D000767:Anesthesia, Epidural / Q000706:statistics & numerical data*; D000773:Anesthesia, Obstetrical / Q000706:statistics & numerical data*; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D015331:Cohort Studies; D036861:Delivery, Obstetric; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D017984:Enoxaparin / Q000627:therapeutic use; D005260:Female; D006495:Heparin, Low-Molecular-Weight / Q000008:administration & dosage / Q000627:therapeutic use; D006801:Humans; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011247:Pregnancy; D012189:Retrospective Studies
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin; D006495:Heparin, Low-Molecular-Weight
keywords: Anesthesia; Anticoagulant drugs; Obstetrical; Pregnancy