Anesth Analg 2006;102:1902-1903
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000215133.89323.61
LETTER TO THE EDITOR
Activated Recombinant Factor VII to Reverse Oral Anticoagulants for Emergent Cesarean Delivery
Laura Morante, MD,
Emilia V. Guasch, MD, PhD,
Francisco Palacio, MD, and
Fernando Gilsanz, MD, PhD
Department of Anesthesia; Universidad Autónoma Madrid; Servicio de Anestesia-Reanimación; Hospital Universitario La Paz; Madrid, España; emiguasch{at}hotmail.com
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.
References
- Ahonen J, Jokela R. Recombinant factor VIIa for life threatening post-partum haemorrhage. Br J Anaesth 2005;94:592–5.[Abstract/Free Full Text]
- Uhlmann EJ, Eby CS. Recombinant activated factor VII for non-hemophiliac bleeding patients. Curr Opin Hematol 2004;11:198–204.[Web of Science][Medline]
- Kubisz P, Stasko J. Recombinant activated factor VII in patients at high risk of bleeding. Hematology 2004;9:317–32.[Medline]
- Pavankumar P, Venugopal P, Kaul U, et al. Pregnancy in patients with prosthetic cardiac valve: a 10-year experience. Scand J Thorac Cardiovasc Surg 1988;22:19–22.[Web of Science][Medline]
- Lecuru F, Desnos M, Taurelle R. Anticoagulant therapy in pregnancy: report of 54 cases. Acta Obstet Gynecol Scand 1996;75:217–21.[Web of Science][Medline]
- Heuer L, Blumenberg D. Recombinant factor VIIa: a new option in intractable bleeding? Int J Int Care 2003;10:73–79.
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