Managing Anticoagulation Peripartum.

Due to the elevated thrombosis risk during pregnancy, anticoagulants are amongst 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 1) prophylactic versus therapeutic dosing; 2) mode of delivery (vaginal vs cesarean); 3) scheduled vs spontaneous delivery; 4) specific indications for neuraxial anesthesia (e.g. twin gestation, difficult airway); 5) the patient's valuation of neuraxial anesthesia; 6) time since diagnosis of venous thromboembolism (VTE) where applicable. Optimal patient management requires prenatal collaboration between thrombosis experts, obstetrics, and anesthesia 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 (UFH) for prophylaxis or UFH 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 VTE.