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    It’s a new era in anticoagulant therapy

     

     

    Dr. Lockwood, editor in chief, is Dean of the College of Medicine and Vice President for Health Sciences at The Ohio State University, Columbus, Ohio. Contact him at [email protected].

     

    A 36-year-old G3P3002 presents with a very swollen erythematous left leg 2 days after discharge following a cesarean delivery for arrest of descent, macrosomia, and chorioamnionitis. She had diet-controlled gestational diabetes, her body mass index (BMI) is 35, and she has bilateral lower extremity varicose veins and clear evidence of superficial thrombophlebitis in the left leg. Compression venous ultrasound (CU/S) reveals a large femoral vein thrombosis extending into the pelvis.

    The patient is begun on enoxaparin 1 mg/kg subcutaneously twice daily. However, because of evidence of possible iliofemoral arterial compromise, she undergoes thrombolytic therapy with alteplase (Activase) 100 mg IV given over 2 hours. About 8 hours later, the patient experiences a significant postpartum hemorrhage requiring multiple transfusions and uterotonic therapy. She does not plan to breastfeed, was noncompliant with glucose monitoring during the pregnancy and, in view of her recent history, is very concerned about having another hemorrhage. Therefore, she is begun on apixaban (Eliquis) 5 mg orally twice a day.

    Although this particular presentation is rather complex and relatively uncommon, venous thrombosis is not uncommon. It behooves ob/gyn practitioners to keep current with the latest agents and strategies for treating venous thromboembolic (VTE) events in both pregnant and nonpregnant women.

    Prevalence

    The past few decades have witnessed an increase in the occurrence of antepartum VTE and a decrease in the prevalence of postpartum thrombotic events.1,2 I suspect this paradox reflects the opposing influences of the obesity epidemic and the increased use of puerperal prophylaxis. In nonpregnant adult women, occurrence of VTE rises exponentially with age.

    The annual incidence of acute pulmonary embolism (PE) and deep venous thrombosis (DVT) increases from 7 and 14 per 100,000, respectively, in women aged 30–39 years, to 62 and 99 per 100,000 at ages 60–69 years, to 140 and 303 per 100,000 for women aged ≥80 years.3  The lifetime risk of VTE is about 5%.4

    Superficial thrombophlebitis is relatively common in pregnant and nonpregnant older women with varicose veins, and is associated with coexistent DVT in about 10% of cases,5 and up to 53% when the saphenous vein is affected.6

     

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...

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