What is the management plan for a 26-week pregnant woman with placenta previa, suspected partial placental abruption, antiphospholipid syndrome (APS) on Clexane (enoxaparin) + Aspirin, mild anemia, and prolonged partial thromboplastin time (PTT)?

Management of Placenta Previa with Suspected Partial Placental Abruption in a 26-week Pregnant Woman with APS

Immediate discontinuation of enoxaparin (Clexane) is essential, with hospitalization for intensive monitoring and management of this high-risk obstetric emergency.

Initial Assessment and Stabilization

• Admit to a tertiary care center with a dedicated multidisciplinary team including maternal-fetal medicine specialists, hematologists, anesthesiologists, and neonatologists 1
• Perform continuous electronic fetal monitoring to assess fetal wellbeing 2
• Establish two large-bore (14-16 gauge) intravenous lines for potential fluid resuscitation 2
• Position patient in left lateral tilt to optimize uteroplacental perfusion and venous return 2
• Administer oxygen supplementation to maintain maternal oxygen saturation >95% 2

Laboratory Evaluation

• Obtain complete blood count, comprehensive coagulation panel including fibrinogen, and type and cross-match 1
• Monitor fibrinogen levels closely - pregnancy normally has elevated fibrinogen (3.7-6.2 g/L in third trimester); levels <2 g/L with ongoing bleeding indicate severe coagulopathy 1
• Use PT/APTT ratios rather than absolute values, with a ratio ≥1.5 indicating coagulopathy (pregnancy normally has shortened PT/APTT) 1
• Consider thromboelastography or rotational thromboelastometry for rapid assessment of coagulation status if available 1

Management of Anticoagulation

• Discontinue enoxaparin (Clexane) immediately due to the risk of worsening hemorrhage 1, 3
• If emergency delivery is needed, consider protamine sulfate to partially reverse enoxaparin effects 1
• Discontinue aspirin due to increased bleeding risk with placental abruption 1, 3
• For patients with prolonged PTT from anticoagulation and active bleeding, administer fresh frozen plasma if clinically indicated 1

Blood Product Management

• Have O-negative blood immediately available if cross-matched blood is not yet ready 2
• For ongoing hemorrhage with hypofibrinogenemia (<2 g/L), administer cryoprecipitate or fibrinogen concentrate 1
• Maintain platelet count >75 × 10^9/L for obstetric patients with active bleeding 1
• If massive transfusion is required, use a 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets 1

Fetal Assessment and Delivery Planning

• Administer corticosteroids for fetal lung maturity (betamethasone or dexamethasone) 2
• At 26 weeks with placenta previa and abruption, prepare for possible emergency cesarean delivery 1
• If maternal condition is stable and fetal monitoring is reassuring, attempt to prolong pregnancy under close observation 1
• For severe or progressive abruption with fetal distress, proceed with immediate delivery regardless of gestational age 2

Monitoring and Ongoing Management

• Perform continuous cardiotocography for viable pregnancies (≥23 weeks) 2
• Monitor for signs of worsening abruption: increasing pain, uterine tenderness, vaginal bleeding, or abnormal fetal heart rate patterns 2
• Measure cumulative blood loss using volumetric and gravimetric techniques rather than estimation 1
• Maintain maternal temperature >36°C and avoid acidosis to optimize clotting function 1

Post-Stabilization Anticoagulation Plan

• After bleeding is controlled and patient is stable, discuss resumption of thromboprophylaxis with hematology 3
• For patients with APS and prior thrombosis, therapeutic anticoagulation should be resumed when safe, typically 12-24 hours after bleeding has stopped 1, 3
• Consider prophylactic rather than therapeutic anticoagulation in the immediate post-abruption period 3

Complications to Monitor

• Watch for development of disseminated intravascular coagulation (DIC), particularly with abruption 1
• Monitor for signs of HELLP syndrome, which can occur in patients with APS 4, 5
• Be vigilant for development of catastrophic antiphospholipid syndrome (CAPS), especially in the peripartum period 4

Pitfalls and Caveats

• Do not delay management of suspected placental abruption waiting for ultrasound confirmation, as ultrasound is not sensitive for abruption diagnosis 2
• Avoid relying solely on standard coagulation tests without considering pregnancy-specific reference ranges 1
• Remember that fibrinogen levels are normally elevated in pregnancy; normal non-pregnant values may indicate significant depletion 1
• Avoid vasopressors unless absolutely necessary for intractable hypotension unresponsive to fluid resuscitation, as they reduce uteroplacental perfusion 2