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Activated Recombinant Factor VII to Reverse Oral Anticoagulants for Emergent Cesarean Delivery

2006; Lippincott Williams & Wilkins; Volume: 102; Issue: 6 Linguagem: Inglês

10.1213/01.ane.0000215133.89323.61

1526-7598

Laura Morante, Emilia V. Guasch, F. Palacio, F. Gilsanz,

Maternal and fetal healthcare

To the Editor: Activated recombinant factor VII (rfVIIa) has been used in the treatment of obstetric hemorrhage (1–3) but not for the peripartum reversal of warfarin effects. A 32-yr-old, 34th week pregnant woman was treated with acenocoumarol (a coumarin with a short half-life) because of an aortic and mitral metallic heart valve prostheses. She presented to the hospital with vaginal bleeding. Her arterial blood pressure, hemoglobin, and hematocrit were normal. On admission, her International Normalized Ratio (INR) was increased to 3.2. A cesarean delivery became necessary and rfVIIa 96 μg/kg (Novoseven®; Novo Nordisk, Bagsvaerd, Denmark) was given before surgery. The INR was measured at 0.8 <30 min after treatment with rfVIIa. The cesarean delivery was performed under general anesthesia and was uneventful for mother and baby. Unfractionated heparin was instituted 4 h after surgery and acenocoumarol was reintroduced on the second day. Her INR was measured at 2.2 12 h after surgery. The patient was discharged from hospital in good condition on the seventh day after surgery. Pregnancy with anticoagulation is common. Most of complications occur peripartum when the timing of anticoagulant reversal and birth can be difficult to coordinate (4,5). Normal coagulation status can take more than 24 h after cessation of oral coumarin or treatment with vitamin K (which should never be given to patients with mechanical heart valves). Fresh-frozen plasma has been used for rapid reversal of anticoagulation in the setting of an obstetrical emergency, but there are risks with transfusion of pooled blood products. Prothrombin complex has also been used, but it is associated with a more frequent incidence of thrombosis than treatment with rfVIIa (6). Hemostatic monitoring can be difficult with rfVIIa, and its effect is best judged clinically (6). Obstetric patients are at high risk for prothrombotic events and must be specially watched. Supra-physiologic correction is dose-dependant and can be sustained for 6 h (3, 7). Treatment with rfVIIa may be a reasonable alternative to pooled plasma for rapid reversal of oral anticoagulation in a patient requiring emergency surgery. Laura Morante, MD Emilia V. Guasch, MD, PhD Francisco Palacio, MD Fernando Gilsanz, MD, PhD Department of Anesthesia Universidad Autónoma Madrid Servicio de Anestesia-Reanimación Hospital Universitario La Paz Madrid, España [email protected]