Heparin Resistance due to an Acquired Antithrombin Deficiency in a Patient With Sickle Cell Disease During a Pregnancy Complicated by Bilateral Pulmonary Emboli: A Case Report

Abstract

We report a 31-year-old woman with sickle beta thalassemia zero who presented at 21 weeks gestational age with multiple bilateral pulmonary emboli and no hemodynamic instability. Acquired antithrombin deficiency was suspected due to a refractory response to therapeutic anticoagulation with enoxaparin, unfractionated heparin, and fondaparinux, and a reduced antithrombin antigen level. At 26 4/7 weeks, she developed signs concerning for increased pulmonary clot burden. To avoid the use of alternative anticoagulants that may cross the placenta and impact the fetus, a planned cesarean delivery was performed without complication at 27 weeks gestation. Both mother and child experienced successful long-term outcomes.

Viscoelastic testing in benign hematologic disorders: Clinical perspectives and future implications of point‐of‐care testing to assess hemostatic competence

“…The more common coagulopathic presentation of systemic autoimmune diseases is a hypercoagulable state. It is well described that systemic lupus erythematosus patients can develop specific antibodies such as lupus anticoagulant, antiphospholipid syndrome, antiprothrombin, and No abnormal variables documented CT: # 154,155 CFT: # [154][155][156] A: " 155 MCF: " [154][155][156][157] VET variables were more hypercoagulable in splenectomized thalassemic patients compared to nonsplenectomized 154,156,157 There is no predisposition to hypercoagulability in children with hereditary spherocytosis unless the child has had a splenectomy 158 Sickle cell disease R: # [159][160][161] K: # 160,161 A: " 159,160 MA: " 159,160 CI: " 159,160 CT: # 162 MCF: " 162,163 Sickle 162,163 No difference in VET variables between SCT and NC 161 Treatments guided by VETs:…”

“…• Heparin/protamine 162,163 • Chronic transfusion therapy 159 • Exchange blood transfusion 160 • Hydroxyurea therapy 159 • Hydroxycarbamide 160 • Ameliorating therapy 160 HbSC anticardiolipin; these antibodies often result in coagulopathies. These antibodies or the disease itself pose a risk for venous thomboembolic events and pregnancy-related complications.…”

“…Pregnant sickle cell patients who anticoagulated during pregnancy required ROTEM guided reversal of LMWH and unfractionated heparin because the patients were unexpectedly hypercoagulopathic 162,163 …”

“…Treatments guided by VETs: Heparin/protamine 162,163 Chronic transfusion therapy 159 Exchange blood transfusion 160 Hydroxyurea therapy 159 Hydroxycarbamide 160 Ameliorating therapy 160 …”