• Jeanette R. BauchatEmail author
  • Joseph B. Bavaro


Pregnancy is a prothrombotic state with the potential to worsen underlying hypercoagulable states; thus, anticoagulation in pregnancy is not uncommon. Anesthetic consultation should be obtained for this patient population. Anesthesiologists must understand the mechanisms and types of anticoagulant medications used in pregnant women in order to assess and manage the risks associated with neuraxial techniques, postpartum hemorrhage, and cesarean delivery in the setting of sudden onset of labor. Proper consideration for timing of neuraxial techniques in the setting of anticoagulation is critical to a safe anesthetic outcome.


Anticoagulation, Anticoagulants, Neuraxial techniques, Pregnancy, Safety 


  1. 1.
    Greer IA. Thrombosis in pregnancy: maternal and fetal issues. Lancet. 1999;353(9160):1258–65.CrossRefGoogle Scholar
  2. 2.
    Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008;359(19):2025–33.CrossRefGoogle Scholar
  3. 3.
    McColl MD, Ramsay JE, Tait RC, Walker ID, McCall F, Conkie JA, et al. Risk factors for pregnancy associated venous thromboembolism. Thromb Haemost. 1997;78(4):1183–8.PubMedGoogle Scholar
  4. 4.
    Hellgren M, Blombäck M. Studies on blood coagulation and fibrinolysis in pregnancy, during delivery and in the puerperium. Gynecol Obstet Invest. 1981;12(3):141–54.CrossRefGoogle Scholar
  5. 5.
    Gordon MC. Maternal physiology. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: normal and problem pregnancies. 5th ed. Philadelphia: Churchill Livingstone; 2007. p. 55–84.CrossRefGoogle Scholar
  6. 6.
    Macklon NS, Greer IA, Bowman AW. An ultrasound study of gestational and postural changes in the deep venous system of the leg in pregnancy. Br J Obstet Gynaecol. 1997;104:191–7.CrossRefGoogle Scholar
  7. 7.
    Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ III. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med. 2005;143:697–706.CrossRefGoogle Scholar
  8. 8.
    Morris JM, Algert CS, Roberts CL. Incidence and risk factors for pulmonary embolism in the postpartum period. J Thromb Haemost. 2010;8(5):998–1003.PubMedGoogle Scholar
  9. 9.
    Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. 2015;125(1):5–12.CrossRefGoogle Scholar
  10. 10.
    Kamel H, Navi BB, Sriram N, Hovsepian DA, Devereux RB, Elkind MS. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med. 2014;370(14):1307–15.CrossRefGoogle Scholar
  11. 11.
    Blondon M, Harrington LB, Righini M, Boehlen F, Bounameaux H, Smith NL. Racial and ethnic differences in the risk of postpartum venous thromboembolism: a population-based, case-control study. J Thromb Haemost. 2014;12(12):2002–9.CrossRefGoogle Scholar
  12. 12.
    Sultan AA, Tata LJ, West J, Fiaschi L, Fleming KM, Nelson-Piercy C, et al. Risk factors for first venous thromboembolism around pregnancy: a population-based cohort study from the United Kingdom. Blood. 2013;121(19):3953–61.CrossRefGoogle Scholar
  13. 13.
    Simpson EL, Lawrenson RA, Nightingale AL, Farmer RD. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. BJOG. 2001;108(1):56–60.PubMedGoogle Scholar
  14. 14.
    Abdul Sultan A, West J, Tata LJ, Fleming KM, Nelson-Piercy C, Grainge MJ. Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England. BMJ. 2013;347:f6099.CrossRefGoogle Scholar
  15. 15.
    American College of Obstetricians and Gynecologists Women’s Health Care Physicians. ACOG Practice Bulletin No. 138: inherited thrombophilias in pregnancy. Obstet Gynecol. 2013;122(3):706–17.CrossRefGoogle Scholar
  16. 16.
    James A, Committee on Practice Bulletins—Obstetrics. Practice bulletin no. 123: thromboembolism in pregnancy. Obstet Gynecol. 2011;118(3):718–29.CrossRefGoogle Scholar
  17. 17.
    Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology. Expert consensus document on management of cardiovascular diseases during pregnancy. Eur Heart J. 2003;24(8):761–81.CrossRefGoogle Scholar
  18. 18.
    Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy. Chest. 2012;141(2 Suppl):e691S–736S.CrossRefGoogle Scholar
  19. 19.
    LeFevre ML, U.S. Preventive Services Task Force. Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;161(11):819–26.CrossRefGoogle Scholar
  20. 20.
    American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Task force on hypertension in pregnancy. Washington, DC. 2013.
  21. 21.
    Gordon JL, Fabian TC, Lee MD, Dugdale M. Anticoagulant and antiplatelet medications encountered in emergency surgery patients: a review of reversal strategies. J Trauma Acute Care Surg. 2013;75(3):475–86.CrossRefGoogle Scholar
  22. 22.
    Aspirin prescribing information. BAYER INC., CONSUMER CARE Mississauga, Canada.
  23. 23.
    Reaume KT, Regal RE, Dorsch MP. Indications for dual antiplatelet therapy with aspirin and clopidogrel: evidence-based recommendations for use. Ann Pharmacother. 2008;42(4):550–7.CrossRefGoogle Scholar
  24. 24.
    Hillis C, Crowther MA. Acute phase treatment of VTE: anticoagulation, including non-vitamin K antagonist oral anticoagulants. Thromb Haemost. 2015;113(6):1193–202.CrossRefGoogle Scholar
  25. 25.
    Heparin sodium injection. Pfizer Canada Inc. 17300 Trans Canada Highway Kirkland, Quebec H9J 2M5.
  26. 26.
    Fox NS, Laughon SK, Bender SD, Saltzman DH, Rebarber A. Anti-factor Xa plasma levels in pregnant women receiving low molecular weight heparin thromboprophylaxis. Obstet Gynecol. 2008;112(4):884–9.CrossRefGoogle Scholar
  27. 27.
    Coumadin (warfarin sodium) tablets prescribing information. Bristol-Myers Squibb, Princeton, NJ. Accessed 17 June 2016.
  28. 28.
    Praxbind prescribing information. Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT.
  29. 29.
    Hurst K, Lee R, Handa A. Quick reference guide to the new oral anticoagulants. J Vasc Surg. 2016;63(6):1653–7.CrossRefGoogle Scholar
  30. 30.
    Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology. 2004;101:950–9.CrossRefGoogle Scholar
  31. 31.
    Crawford JS. Some maternal complications of epidural analgesia for labour. Anaesthesia. 1985;40:1219–25.CrossRefGoogle Scholar
  32. 32.
    Bateman BT, Mhyre JM, Ehrenfeld J, Kheterpal S, Abbey KR, Argalious M, et al. The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium. Anesth Analg. 2013;116(6):1380–5.CrossRefGoogle Scholar
  33. 33.
    Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg. 1994;79(6):1165–77.CrossRefGoogle Scholar
  34. 34.
    Mammen EF, Comp PC, Gosselin R, Greenberg C, Hoots WK, Kessler CM, et al. PFA-100 system: a new method for assessment of platelet dysfunction. Semin Thromb Hemost. 1998;24(2):195–202.CrossRefGoogle Scholar
  35. 35.
    Klein SM, Slaughter TF, Vail PT, Ginsberg B, El-Moalem HE, Alexander R, et al. Thromboelastography as a perioperative measure of anticoagulation resulting from low molecular weight heparin: a comparison with anti-Xa concentrations. Anesth Analg. 2000;91(5):1091–5.CrossRefGoogle Scholar
  36. 36.
    Suchman AL, Mushlin AI. How well does the activated partial thromboplastin time predict postoperative hemorrhage? JAMA. 1986;256:750–3.CrossRefGoogle Scholar
  37. 37.
    Horlocker TT, Wedel DJ, Rowlingson JC, Enneking FK, Kopp SL, Benzon HT, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med. 2010;35(1):64–101.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Obstetric AnesthesiologyVanderbilt University Medical CenterNashvilleUSA
  2. 2.Department of AnesthesiologyNorthwestern University Feinberg School of MedicineChicagoUSA

Personalised recommendations