12/03/2023
This patient summarizes the RCOG green top guideline 37a..recommendations of use of thromboprophylaxis in pregnancy
Mrs Karmakar .. 39 years..previous intra uterine fetal death.. presented with desire to be a mother.
But infertility was the least of her problems.
She was a patient of hepatic cirrhosis. T. Bilirubin was 4.6. Sgpt and Sgot at 1000. Ascitis present.
Combined with liver disorder.. was her problem of recurrent venous thrombosis. She had her right leg amputation 4 years back because of deep vein thrombosis (DVT) and subsequent gangrene. She was antiphospholipid antibody positive (APLA) , anti cardiolipin positive.
She became pregnant following ovulation induction. LMWH in 75% higher doses and aspirin was initiated immediately.
Problem was I was giving high doses of anticoagulants to a patient of hepatic cirrhosis .. who already had multiple sites of varices.
Regardless LMWH was continued till the day before her Cesarean. 4 units of FFP was given before OT. Heparin had to be re-initiated immediately 12 hours after her anasthesia. Patient was given hepamerz and anti-embolic stocking.
With hepatic function deranged, and high dose anticoagulants, excessive intra operative bleeding and postpartum hemorrhage (PPH) was always going to be a challenge. So surgical devascularisation of uterus was done intraoperatively.
Patient was discharged without any complications. Now she has been shifted to Warfarin. INR maintained @ 2.2
