Clexane/Heparin and giving birth

[joeschmoesmum]

I am 31 weeks into quite an eventful pregnancy (following several miscarriages and other gynae mishaps) and have only just started discussing delivery with my OB (not in the UK).

I was on heparin, I stopped injecting when I went into labour. As long as your last injection was 12 hours prior to any need for painkillers you can have an epidural, although you might decide that the placenta injection is a good idea to reduce risk of pph.

I was told to stop doing injections as soon as I went into labour and do a "catch-up" as soon as I could post-birth (by haemotologist). Much horror among MWs / Drs when I told them this was what I was doing / had done as per advice as they thought it would cause a pph (each time!). With nr 1 had 6 months blood thinners after. With nr2 had 6 weeks. With nr 3 was told my bloods were fine 3 days after and I could stop! Also told (each time) there was no chance of an epidural and if I needed a section it would be a GA. Was also told with first that I couldn't drink. Other two was told it didn't matter. First time was a subject of much interest. By nr 3 it was the other end of the scale.

Thanks for that - I was told 24 hrs not 12, for some reason, which is what worried me. Did you end up delivering naturally with an epidural in the end? (I'm also meant to continue injections for 6-8 weeks after, yomellamoHelly. Did you have any pph issues?
ohthegoats can you tell me more about the placenta injection please? Thank you!

I was on clexane throughout my first pregnancy and am currently 22 weeks and on it again, as I have mthfr and have miscarried previously.
I had a c section at 39+2 and was told to not do my injection the day before (4pm) then come into hospital at 8am. I was then put further and further down the list (because of emergencies, quite reasonably) and didn't end up going into theatre till 4pm. My consultant remarked that the later the better because of the clexane.
Also, I had a spinal anaesthetic rather than a GA.

I had a dvt at 34 weeks and was then on clexane injections until the birth. My consultant recommended induction so they could manage my blood when I came off the injections (24 hours before) and so that I could have an epidural.
Things didn't go to plan, as the pessary didn't work so I was given another clexane injection the next morning with a view to trying again the next day. However, I then went into labour on the same day (I.e. With clexane in my system - the thing they'd tried to avoid) and ended up giving birth with just g&a.
However, the birth was very positive and the hospital were fab so it went well! I was then on clexane for 6 months post birth, but that was just because my dvt was so huge :-(

I've had two pregnancies (last one 7yrs ago, 6yrs between DCS) on heparin (fragmin) - first DC I was told to stop the fragmin 24hr before I was due to be induced...
Second DC no induction planned told to stop at first sign of labour - so when I had the show - two days before giving birth.
Was told I wouldn't be allowed an epidural for either (emcs would have to be GA) but they were much less concerned about fragmin than the Aspirin I was also taking ... memory a bit hazy but have a feeling I had to stop 2 or 3 weeks before due date - that was much more likely to lead to pph.
Straight back onto the fragmin after birth and aspirin 24 hrs later. Continue for 6 weeks - unless moving back onto eg warfarin - a haemotogist told me that after birth was statistically a higher risk period for getting a maternal DVT than pregnancy but that may be skewed data due to at one time it was not considered to be important.
Had no problems - standard deliveries, just G&A
I was still bleeding lightly at 6 weeks with DC2 (can't remember for DC1) and GP said an infection but actually speaking to someone else they had the same experience...so not sure...

Hi op, I was on warfarin during pregnancy, was moved to heparin a few weeks before end of pregnancy. I stopped heparin when I first felt labour begin, followed the 12-hour rule. Had an epidural and ventouse delivery. All was fine. Had to return to warfarin for almost a year afterwards

I had both labours induced on my due date, I just didn't inject that morning. By the time I was in active labour I could have had an epi but I didn't either time. Did six weeks clexane after each birth. I think it will depend on why you are on clexane. If like me and it is "just" a blood issue related to miscarriage then the dose is low and is a "just in case" medication. You would likely have induction recommended and missing one or two injections while you deliver is not a big deal.
If you have had a DVT, I think there are more serious considerations and risks.

I was on Clexane from 11 weeks due to two DVTs and clots in both lungs. I had also had a stroke. My delivery was very different to those above. As PP stated, I think the management of your delivery varies a little bit depending on the medical reason behind why you are taking Heparin.

My only advice is to make sure you and your birth partner(s) have memorised your birth plan. If you have a longer labour and it's more complex, you will go thru several midwives and it's best to triple check everything with everyone new.

Sakura sorry were you on Warfarin before you were pregnant? Did you not know you were pregnant? Was this a long time ago?
(I've read a paper on this published in 1981! Really not a recent thing!)

Being on warfarin during pregnancy is a really, really bad idea - especially in the early stages!
Sorry to draw attention to it - but seeing as this may be read by people who have blood issues and on long term anitcoagulants who might be planning a pregnancy had to bring it up.

mdpis3 I was on Fragmin due to having DVT /PEs outside pregnancy in the past and testing positive for APS a number of years before. I had been on warfarin for years then aspirin for several years.
Not sure if I was tested again in pregnancy -it wouldn't matter - the tests are a bit hit and miss and pregnancy carries an increased risk of clotting so I was treated as if I tested positive...classed as high risk.

I think the difference is that they are constantly investigating/tweaking the best way of treating patients, weighing up the risks - as well as different specialists have different views.
I know for DD1 I was treated as advised by my old consultant - one of this country's leading experts on blood clotting and pregnancy - who I trust absolutely - induction before due date recommended. (DD appeared on her own just before!)

For DD2 (6 yrs later/7 yrs ago ) I was worried that I wasn't down to be induced - (especially cos I knew my general obstetric consultant had a reputation for thinking induction caused more problems than it was worth) - but found the general consensus (including from my old consultant) was not to induce if possible ...
Now it might be different again...

I think fragmin/clexane they are less worried cos there is an 'antidote' to it - not instant but ...(there is for warfarin too - there isn't one for aspirin afaik) and fragmin doesn't stay in your body very long...about 12hrs (Reason you (or I at least) do two injections a day rather than one big one...although for my recent clot I only had one big one a day

Actually that's another difference - fragmin was the low molecular weight heparin of choice when I was pregnant - now I believe it clexane ..they have been both been around similar amounts of time, cost about the same, both anti factor Xa but are slightly different molecules...

Thank you all for your wisdom! I am hoping for an unmediated birth (as much as possible) but would have liked the option of an epidural (especially as I don't have the option of gas and air). But your experiences are all encouraging.
I am scared of a cesarean under general, but I guess we will see if it will be needed. I am being monitored closely and baby is breech at the moment, but will hopefully turn soon. Otherwise it's all a moot point anyway...

Thank you all for your wisdom! I am hoping for an unmediated birth (as much as possible) but would have liked the option of an epidural (especially as I don't have the option of gas and air). But your experiences are all encouraging.
I am scared of a cesarean under general, but I guess we will see if it will be needed. I am being monitored closely and baby is breech at the moment, but will hopefully turn soon. Otherwise it's all a moot point anyway...

I'm an anaesthetist. We advise women on prophylactic doses of clexane (so probably 40mg once a day) that they can't have an epidural until 12 hours after the clexane. If they are on a therapeutic dose (1mg/kg twice a day or 1.5mg/kg once a day) then it's 24 hours.

I was induced at 38 weeks due to having a dvt at 28 weeks and on twice daily treatment dose of Clexane. I was told to stop injections on the day of going in to be induced. I went it to labour 3 days later after 4 pessaries, I had an epidural and it was amazing. I didn't feel a thing and after all the horrible things we went through in pregnancy it was nice to have one less thing to worry about. Delivery was complicated but would have been anyway. Good Luck!

Unlucky83 - sorry, only just saw your msg. I was on warfarin during pregnancy from around 24 weeks, not any earlier.

No problem - just relieved to hear that Sakura

(Did want to ask if your baby was ok too but felt that might be tactless)

Aw, thanks, she's ten years old now and luckily it's all a distant memory .

Interesting to see all the different experiences. I was on clexane from 4wks pregnant until 6 wks pp due to previous pulmonary embolism. I was induced ostensibly to control the birth and avoid a Caesarian. Ironically I ended up with an emcs anyway after scheduled induction being delayed by 5 days due to more urgent cases.

Anyway, think it was most important to get clexane in me ASAP after the birth than anything else. However after a day or two without whilst waiting I did have some more and then would not have been able to have an epidural for a while as other posters have mentioned.

4 years on all is well although I do think with hindsight things could've been better managed.

I was on Clexane for repeat MC. If you have sticky blood the current protocol in the uk is to take you off it at 35-6 weeks (as the placenta won't grow after that) and induce if 2 weeks over. That is if not on Clexane for dvt but for APS.
I gave birth with only midwives in a pool.

A welcome break after a high risk pregnancy!

My situation is a little complicated because although I have had recurrent mc and the clexane has helped with that, I am also on it for another thrombophilia factor that makes me more likely to get pulmonary embolism, stroke etc. That's the reason they want to keep me on it as long as possible, and start me back on within 24 of birth and for 6-8 weeks postpartum.
I guess an induction is the safest option in a way, but terrified of intervention which I know is more likely with an induction... Eeek! Thanks all for sharing your experiences!

Had a dvt a few days after ds2 was born so although I don't know about managing things for birth, I do know about afterwards in the longer term.

I was given 2 weeks of heparin injections whilst taking warfarin to get me started and then left with warfarin. I ended up taking it for about 10 months as the doctors really struggled to get my inr under control and even when it was slipping they wouldn't let me take more warfarin, then it would slip dangerously low and I'd be back having injections again and restarting the cycle

It wasn't until right at the very end of my time taking warfarin that I discovered that there were special protocols that had been developed for people taking warfarin after being pregnant as all the hormones can screw around with normal absorption levels so the normal protocols dont work as well.

I don't think they were very well known (6 years ago) when I had ds - my gp didn't know about them and was going to look into it but it was the hospital lab that was giving me the dose to take and they weren't interested.
However I would say if you do take warcarin afterwards and do start to have problems with your inr then kick up a fuss and make sure that they are following a proper post partum protocol rather than end up like me, having extra jabs and months of extra warfarin to compensate!

(and can I just be very cheeky and hijack the thread to find out how many of you took warfarin post partum and also breast fed? I was assured that It was completely safe to do so but ds2 has ended up being healthy but tiny for his age which you wouldn't have predicted from dp's and my heights. So I was just wondering if anyone else had noticed anything similar a few years down the line?

Sorry op, just curious and thre aren't many threads where lots of others have had blood thinners!)

I don't know about bf and warferin bur small stature can be a side effect of higher dose Clexane when pregnant so there could be a link? Healthy just not tall.

Didn't know about the side effects of LMW heparin (clexane) and height - both my DDs (using fragmin during pregnancy) are normal height - DD2 taller than normal if anything...in fact i didn't think Heparin passed through the placenta...
I know I insisted my DDs had their vit K post birth injections (for bleeding) - even though as far as I recall it was actually an irrational thing for me to be worried about....

Warfarin and bf - don't really know anything about - but sure it is reported as not being detectable in breast milk and therefore safe.
My memory isn't what it was - and too tired to look it up now - but as far as remember Warfarin acts as a vit K 'antagonist' - so effectively depletes Vit K in your blood (why you have to have stable amounts of green leafy vegs in your diet - you eat more and your INR goes down as your vit K levels rise).
Honestly unstable INR is quite common - I've been back on Warfarin since July and still on weekly tests -my INR is up and down like a yo yo - when I was talking to one of the nurses about it she said maybe it was because the wind had changed direction - it really is that variable - so many factors effect it.

Anyway Vit K is involved in the clotting cascade but also with 'fixing' calcium in your bones (very simplistic way of describing it) - so maybe your breast milk contains less calcium and/or vit K so restricts bone growth...but that is a maybe...and a pretty big one ..
and I don't know how old your Ds2 is but I know some 'short for their age' children shoot up during their teens ...

It's a very mild side effect in some cases. Not a clinical problem, thankfully! Moot point with me as I'm 5"1 and DH 5"7 so dd isn't going to be supermodel height!

DD is 6. She was the longest baby born at the hospital in 2008 and wears age 10-11 clothes. DH is 6'6" and I am 5'8". I have spent years (and thousands of pounds) researching the issues surrounding my pregnancy and my daughters birth and I haven't come across a delay in growth being common amongst Enoxaparin babies.