From the Guidelines
Prescribing Eliquis (apixaban) 2.5mg twice daily for a 31-year-old female with recurrent pregnancy loss and stage 4 endometriosis is not recommended during pregnancy. Eliquis is contraindicated in pregnancy as it crosses the placental barrier and may increase bleeding risk for both mother and fetus 1. For women with recurrent pregnancy loss who need anticoagulation, low molecular weight heparin (LMWH) such as enoxaparin (Lovenox) is the preferred option as it does not cross the placenta. If anticoagulation is indicated based on confirmed thrombophilia or antiphospholipid syndrome, LMWH would typically be started when pregnancy is confirmed and continued throughout pregnancy and for 6 weeks postpartum, as suggested by the American Society of Hematology 2018 guidelines for management of venous thromboembolism in pregnancy 1.
The specific need for anticoagulation should be determined through comprehensive testing for thrombophilia, antiphospholipid antibodies, and other potential causes of recurrent pregnancy loss. While endometriosis itself is not an indication for anticoagulation, this patient should be evaluated by a maternal-fetal medicine specialist or reproductive endocrinologist to determine the appropriate management strategy for her specific situation. According to the American College of Chest Physicians, for pregnant women at moderate to high risk of recurrent VTE, antepartum prophylaxis with prophylactic- or intermediate-dose LMWH is suggested rather than clinical vigilance or routine care (Grade 2C) 1.
Key considerations for anticoagulation in pregnancy include:
- The risk of VTE and the potential benefits of anticoagulation
- The type and dose of anticoagulant used
- The duration of anticoagulation, which typically includes the entire pregnancy and 6 weeks postpartum
- The need for close monitoring and follow-up to minimize risks and optimize outcomes. It is essential to weigh these factors and consider the most recent and highest-quality evidence, such as the 2018 American Society of Hematology guidelines, when making decisions about anticoagulation in pregnant women with recurrent pregnancy loss and stage 4 endometriosis 1.
From the Research
Recurrent Pregnancy Loss and Endometriosis
- Recurrent pregnancy loss (RPL) is a distressing pregnancy disorder experienced by ~2.5% of women trying to conceive, and it can be caused by chromosomal errors, anatomical uterine defects, autoimmune disorders, and endometrial dysfunction 2.
- Endometriosis is a novel independent risk factor for venous thromboembolism (VTE) during pregnancy and post-partum, with an adjusted odds ratio of 2.70 (95% confidence interval, 1.21-6.00) 3.
Anticoagulant Therapy for RPL
- Anticoagulant therapy might reduce the number of miscarriages and adverse pregnancy outcomes in women with RPL and inherited thrombophilia 4.
- However, the evidence on the efficacy and safety of thromboprophylaxis with aspirin and heparin in women with RPL is limited, and large, randomized, placebo-controlled trials are needed to recommend the use of anticoagulants in this setting 5.
Use of Eliquis for RPL
- There is no direct evidence to support the use of Eliquis (apixaban) for preventing blood clotting in women with RPL and endometriosis.
- Low molecular weight heparin (LMWH) is commonly used for thromboprophylaxis in high-risk groups, but its effectiveness in women with RPL and inherited thrombophilia is still debated 4, 5.
Duration of Anticoagulant Therapy
- If anticoagulant therapy is initiated, it is typically continued until the end of pregnancy, but the optimal duration of therapy is not well established 4.
- The decision to use anticoagulant therapy and the duration of treatment should be individualized and based on a thorough assessment of the patient's risk factors and medical history.