What are the blood thinner options for preventing strokes in pregnancy afterwards, specifically for patients with a history of stroke and requiring anticoagulation (anticoagulant) therapy?

From the Guidelines

Blood thinners after pregnancy-related strokes typically include low molecular weight heparin (LMWH) like enoxaparin (Lovenox) during pregnancy, transitioning to warfarin postpartum. For pregnant women who've had a stroke, enoxaparin is usually given at 1mg/kg twice daily or 1.5mg/kg once daily 1. After delivery, warfarin (Coumadin) with a target INR of 2-3 is often used for 3-6 months or longer depending on stroke cause and risk factors. Direct oral anticoagulants (DOACs) like apixaban (Eliquis) or rivaroxaban (Xarelto) are options after breastfeeding is complete but are contraindicated during pregnancy 1. The choice between medications depends on the stroke's cause, whether it was arterial or venous, and individual risk factors. Some key points to consider include:

• LMWH is an acceptable option to UFH and may avoid the problem of heparin-induced thrombocytopenia and osteoporosis associated with long-term heparin therapy 1.
• Low-dose aspirin (50 mg/d to 150 mg/d) appears safe after the first trimester 1.
• Women at high risk and with prior stroke or severe arterial thromboses were thought to be acceptable candidates for warfarin from 14 to 34 weeks’ gestation 1. Blood thinners work by preventing further clot formation, though they carry bleeding risks requiring regular monitoring. Women should also address underlying conditions like hypertension or diabetes and avoid estrogen-containing contraceptives which increase stroke risk. Regular follow-up with both neurology and obstetrics is essential for medication adjustments and monitoring 1.

From the Research

Strokes in Pregnancy and Blood Thinner Options

• Strokes during pregnancy and the postpartum period pose a significant risk to both the mother and the fetus, with increased risk of hemorrhagic strokes during pregnancy and all strokes during the puerperium 2.
• The use of anticoagulants during pregnancy is a complex issue, as pregnant women are prone to thromboembolism while also being at risk of bleeding, especially during delivery 3.
• Anticoagulant therapy during pregnancy may be necessary for the prevention and treatment of thrombotic events, preeclampsia, and pregnancy loss, with options including unfractionated heparin, low-molecular-weight heparin, warfarin, and aspirin 4.

Blood Thinner Options

• The decision to use antiplatelets and anticoagulants during pregnancy requires careful consideration of the benefits and risks, taking into account the potential teratogenicity and dosing considerations 5.
• Current guidelines support the selective use of aspirin, heparin, and warfarin in pregnant women, with the goal of balancing therapeutic benefit and maternal and fetal risks 5.
• In cases of acute stroke during pregnancy, intravenous thrombolysis may be considered if the benefit outweighs the risk, with a recommended diagnostic workup to guide decision-making 6.

Considerations for Anticoagulant Therapy

• The safety and efficacy of antithrombotic therapy during pregnancy and the peripartum period must be carefully assessed, taking into account the cardiovascular and obstetric indications, as well as the potential maternal and fetal side-effects 4.
• The use of anticoagulants during pregnancy requires special attention to both the woman and the unborn child, with careful monitoring and management to minimize risks 3.