Heparin induced thrombocytopenia in pregnancy: A therapeutic challenge case report and literature review

Abstract

The anticoagulants of choice for the prevention and treatment of venous thromboembolic disease during pregnancy are unfractionated heparin and low‐molecular‐weight heparin. Heparin‐induced thrombocytopenia (HIT) is introduced as a rare but critical side effect of heparin products raising the thromboembolic event paradoxically. Here, we present a case of HIT in pregnancy with challenging management due to coincidence of lupus anticoagulant (LA) and limited anticoagulant options in the pharmaceutical market of our country of residence. We describe a 6‐week pregnant patient with deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE), which developed HIT during antenatal care. Therapeutic anticoagulation was initiated with argatroban, then switched to apixaban due to limited access to argatroban. Another therapeutic challenge was the concurrent incidence of LA. The interdisciplinary care team decided on adding up warfarin and scheduled termination at 12 weeks regarding the hazardous condition of the patient. We also reviewed related case literature to convey a new insight into managing pregnancy‐related HIT. HIT is a pro‐coagulatory and lethal complication associated with heparin therapy that can be diagnosed by clinical suspicion, the 4T score system, and confirmatory laboratory analyses. Alternative anticoagulation is the cornerstone of the treatment and an interdisciplinary plan will be worthwhile to make the best clinical decision regarding the critical situation and least the thromboembolic events mortality during pregnancy.

The law of the critical illness and its far-reaching implications

“…Reality accommodates this consequence in those empirical findings of Nekooghadam et al in a 61-yearold patient whose returning results, upon presenting again after being discharged following near complete resolution of the signs and symptoms which were attributed to COVID-19 infection 3 weeks earlier, revealed a dramatic fall in hemoglobin and platelet count compared to values recorded on the discharge notes instead of nasopharyngeal swab positivity. 14 Following further workup of this patient in whom negativity was the outcome of the nasopharyngeal swab 14 despite the steep increase in hematological changes that indicates progressive worsening as the severity of the illness in COVID-19 patients increases, 15 severe acute leukemia was diagnosed and concern was expressed as to whether there is an association between COVID-19 infection and acute leukemia. 14 But in clinical reality, while insult abatement occurred despite a positive nasopharyngeal swab so that the discharge which was permitted by temporary exemption mechanisms appeared to be due to recovery, increasing severity was precipitated at the time of diagnosis with severe acute leukemia, despite a negative nasopharyngeal swab, because another insult which was not promptly abated like its predecessor, reinforced the pull of recovery failure on the trigger constituted by the SARS-CoV-2 etiological spectrum.…”

“…14 Following further workup of this patient in whom negativity was the outcome of the nasopharyngeal swab 14 despite the steep increase in hematological changes that indicates progressive worsening as the severity of the illness in COVID-19 patients increases, 15 severe acute leukemia was diagnosed and concern was expressed as to whether there is an association between COVID-19 infection and acute leukemia. 14 But in clinical reality, while insult abatement occurred despite a positive nasopharyngeal swab so that the discharge which was permitted by temporary exemption mechanisms appeared to be due to recovery, increasing severity was precipitated at the time of diagnosis with severe acute leukemia, despite a negative nasopharyngeal swab, because another insult which was not promptly abated like its predecessor, reinforced the pull of recovery failure on the trigger constituted by the SARS-CoV-2 etiological spectrum. Thus, the remission of leukemia that follows prompt abatement of the precipitating insult in patients who are concomitantly diagnosed with acute leukemia and pneumonia despite positive nasopharyngeal swabs, which may even be hypothesized to be an effect of SARS-CoV-2 infection, 16 must necessarily demonstrate the question of whether COVID-19 infection is associated with acute leukemia irrelevant on the path to be forged.…”

“…The diagnosis of normochromic microcytic anemia in the COVID-19 patient in whom Nekooghadam et al observed a dramatic fall in hemoglobin and platelet count 14 suggests that the size and hemoglobin content of red blood cells (RBC) in the peripheral blood are normal. But when recovery failure persists while an unabated insult confers the necessary status on the trigger due to the SARS-CoV-2 etiological spectrum which this failure pulls to precipitate increasing severity, the outcomes are worsened dramatically even when the size and hemoglobin content of RBC appear to be normal.…”