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Presentation Details
| Optimizing Anticoagulant Strategies in Pregnancy-Associated HIT and Acute Stroke in a Real-World Community Setting Pedrom Farid1, 2, 3, Marco A Herrera Quijano1, 2, 3, Omar Samarraie2, Andrea Cervi1, 2, 3. 1Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.2University of Windsor, Windsor, ON, Canada.3Windsor Regional Hospital, Windsor, ON, Canada |
Abstract
Introduction: Heparin-induced thrombocytopenia (HIT) is an uncommon but serious immune-mediated complication of heparin therapy, and its occurrence during pregnancy is exceedingly rare, particularly following exposure to low-molecular-weight heparin (LMWH) as opposed to unfractionated heparin (UFH). Management is challenging due to the restricted anticoagulant options in pregnancy and risks to both maternal and fetal health. We describe a case illustrating the intersection of pregnancy and HIT, presenting with acute basilar artery thrombosis and managed entirely within a regional community hospital system. Case Presentation: A 30-year-old gravid 1 para 0 woman with a history of unprovoked lower-extremity deep vein thrombosis (DVT), maintained on rivaroxaban for secondary prophylaxis, was transitioned to LMWH (enoxaparin) at 7 weeks’ gestation. Twelve days later, she presented with an acute posterior circulation stroke due to mid-distal basilar artery occlusion and underwent urgent endovascular thrombectomy (EVT), an intervention rarely described in early pregnancy. At presentation, she was thrombocytopenic (platelets 85 × 10^9/L), and testing confirmed HIT through a positive platelet factor 4 enzyme immunoassay followed by a confirmatory serotonin release assay. Enoxaparin was discontinued, and argatroban was initiated post-EVT, followed by transition to subcutaneous danaparoid and ultimately fondaparinux for ongoing anticoagulation through pregnancy. At 39+1 weeks’ gestation, she underwent induction of labor resulting in the delivery of a healthy female infant. She received intermediate-dose fondaparinux for six weeks postpartum. Discussion: HIT in pregnancy poses significant therapeutic challenges, requiring rapid diagnosis and thoughtful anticoagulant selection to optimize maternal and fetal outcomes. In this case, rapid neurologic deterioration necessitated urgent thromboreduction via endovascular thrombectomy, marking the first documented instance of EVT in the first trimester for HIT-associated ischemic stroke. Subsequent anticoagulation required individualized selection and multidisciplinary oversight. Fondaparinux was ultimately chosen given its subcutaneous dosing, tolerability, and limited requirement for laboratory monitoring, despite sparse safety data in pregnancy. A notable feature of this case is its complete management within a community hospital system, enabling continuity of care, postpartum support, and access to local rehabilitation without tertiary transfer. This case demonstrates that, when supported by coordinated multidisciplinary expertise, community hospitals can effectively deliver highly specialized, patient-centered thrombosis care.
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No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author.