How to reverse enoxaparin (Lovenox) in postpartum hemorrhage?

From the Guidelines

Protamine sulfate is the recommended reversal agent for enoxaparin (Lovenox) in postpartum hemorrhage.

Reversal Protocol

• The dosage of protamine sulfate is based on the timing of the last enoxaparin dose, with a dose of 1 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) if administered within 8 hours of the last dose, and 0.5 mg IV per 1 mg enoxaparin (up to 50 mg in a single dose) if administered within 8-12 hours of the last dose 1.
• Protamine sulfate has minimal utility in reversal more than 12 hours from dosing 1.

Important Considerations

• It is essential to discuss with the primary service managing the anticoagulation prior to fully reversing a patient’s anticoagulation 1.
• The choice of reversal agent and dosage should be based on the severity of bleeding and the specific anticoagulant used 1.

From the Research

Reversing Enoxaparin in Postpartum Hemorrhage

• There is no direct evidence on how to reverse enoxaparin (Lovenox) in postpartum hemorrhage from the provided studies 2, 3, 4, 5, 6.
• However, the studies suggest that enoxaparin is used to prevent pregnancy-associated venous thromboembolism (PA-VTE) and that the timing of postpartum enoxaparin administration may influence hemorrhagic outcomes 4.
• One study found that discontinuing low molecular weight heparin (LMWH) more than 12 hours before delivery is safe in relation to maternal hemorrhagic complications 2.
• Another study reported that postpartum hemorrhage is common in women receiving thromboprophylaxis with enoxaparin, but the data do not suggest an urgent need to consider higher doses of enoxaparin for thromboprophylaxis in this clinical setting 3.
• The appropriate time to restart anticoagulation in the postpartum period is not known, but one study found that severe postpartum hemorrhage is an infrequent complication when enoxaparin is administered to hemostatically intact women between 5 and 24 hours following a vaginal delivery or 12-36 hours following cesarean section 4.

Enoxaparin Administration Protocols

• Weight-based enoxaparin administration was superior to fixed-dose enoxaparin administration in achieving an anti-Xa prophylactic range 5, 6.
• One study found that postpartum enoxaparin administration at 1 mg/kg was superior to weight categories in reaching anti-Xa prophylactic levels without leading to serious adverse effects 5.
• Another study reported that weight-based dosing was more effective than fixed enoxaparin dosing in achieving prophylactic peak anti-Xa levels after cesarean delivery 6.