Blood thinners during pregnancy - any advice/experience on birth plan?

[OneAmberDeer]

I’m currently 15 weeks pregnant and have been taking injectable blood thinners since I got a positive pregnancy test. This is due to a blood clot I had in my arm about 10 years ago, when scans showed that my veins are more compressed than usual, so I’m more prone to getting blood clots in my arms. This is my second pregnancy (first ended in a missed miscarriage at 10 weeks back in November).
I had my first NHS high-risk appointment recently and was a bit surprised that the obstetrician and haematologist pushed me quite hard towards a natural birth. From my research, I had expected them to suggest an induction or elective c-section, because you can control when you come off your blood thinners and then restart them quickly after birth. The haematologist pointed out that the risk of blood clots after a C-section is higher so they wouldn’t recommend it, which is fair. But she also mentioned all kinds of scary things for a natural birth (risk of haemorrhage, limited pain relief options, possibility of having to go under general anaesthetic if I needed an emergency c-section) that sound far from ideal. She said that if labour progressed slowly we should be OK, and the blood thinners would be out of my system. But obviously I’m aware that birth rarely goes to plan, and there’s no way to guarantee it would progress slowly.
Before this appointment I was leaning towards an elective c-section because the element of control over when I’d be on/off medication appealed to me. But I don’t know if I’d be stupid to go against medical advice.
Does anyone have experience of this who can tell me what they decided, or anyone else going through a similar decision?

Sorry don’t have experience of this but I’ve been put on blood thinner injections so interested to follow and see what others say!

I’m 15+2 currently and put on aspirin and tinzaparin due to higher risk pre eclampsia and blood clots. When I had an OB call with consultant (not due to being high risk but as this is an ivf pregnancy) she asked if I’d had any thoughts on how I’d like to give birth (if that’s any help at all? I.e. not advising any way at all) and, with what it’s taken to get here and an ivf miscarriage last year I just said not yet, taking it week by week and not thought that far ahead yet! But from what I’d read online I presumed if we get there then it would be induction or elective c section too xx

It very much depends on the dose of blood thinners you are on...

I had a blood clot (pulmonary embolism) in my first pregnancy at 36 weeks. Because there was already a clot there, I was put on a very high dose of blood thinners (100mg twice a day from memory, although take that with a pinch of salt as baby brain is a thing) and because of that was induced at 39 weeks. This was to avoid an emergency c section or difficult birth with uncontrolled bleeding, so I stopped taking blood thinners 24 hours before I went in for my induction.

For my second pregnancy, I was put on a preventative dose of 10mg once a day. No special arrangements were made for the birth, I just didn't take my thinners once contractions started.

Both times a C section was to be an absolute last resort because of my apparent tendency to throw clots while pregnant, and the increased risk post surgery.

Feel free to ask any questions I havent answered!

anaesthetist pov... this is a really pretty common scenario (and you're pretty early on and lots of things can change what the best decision might be as pregnancy progresses).

If you're on a preventative dose (which it sounds like), the usual advice re. the anaesthetic/analgesic options is that there has to be 12 hours since the last dose before siting an epidural or spinal injection. For a lot of first time labourers that gives plenty of time if you just stop taking the meds as soon as the contractions get started (and it's a really good idea to be in contact with the maternity triage/equivalent so they can advise a bit more specifically when it does sound like things are getting started).

If it's a treatment dose (doesn't sound like it) then 24 hours gap is the usual rule.

It may be worth finding out early what other analgesia options are available for women in active labour who can't have an epidural (remifentanil can be useful in this sort of scenario either until it's safe to site an epidural or for the whole labour).

A preventative dose of blood thinners probably isn't going to be the thing that's a big decider in whether someone has a huge PPH or not and there are some drugs that can be used to reduce the chance of that if women do deliver within the timeframe of the blood thinner being active.

Having surgery does increase the risk of developing clots, so that's why the surgeons often suggest that a section might not be the best option unless its really, really necessary. Ultimately though the decision is based on lots of different factors as well as your preference.

Would be interested to hear what you’re recommended too!

Ah ok that’s interesting to hear, I hadn’t even thought about the dosage! I believe I’m on 40mg, so somewhere in between where you were for your pregnancies. Good to know you were able to have a natural birth on blood thinners without issue.

Thank you, this is an extremely helpful perspective! It hadn’t occurred to me that the dosage could differ so much and could change the recommendation.
I did wonder if, because the clots are in my upper body, my risk of clots after surgery might be lower, since it seems like a bit cause is that inactivity after surgery is a big cause of DVTs, which may be less applicable to AVTs. But either way, your suggestion about asking about different analgesia options is really useful and I will definitely take to my next appointment!

Hello, congratulations on your pregnancy! Are you on Dalteparin (not sure that is correct spelling!) I had a clot and PE at 9 weeks pregnant and was put on these injections daily throughout pregnancy and beyond. I was monitored and plan was for me to be induced at 38 weeks, this was so they could control when I took my blood thinner. In the end my waters broke the day I was to be induced, they were then able to leave me for 24 hours to get into established labour, if that had not happened I was going to be induced. I was also told that depending on when I had my last blood thinner that epidural would not be an option and I would need to be put under if a section was needed. In the end everyone was ok but I do remember being a bit scared before just in case I felt I needed an epidural or a section.

I have blood thinners (DVT) during my pregnancy and I'm allergic to anaesthetic. I stopped the blood thinners the day before. They put an epidural in on the morning and then started me off, I was 37 weeks. It took 4 days to have the baby normally and then I was put back on blood thinners. Everything was pretty normal.

Hi, congratulations on your pregnancy! I'm also on blood thinners - Fragmin - for my latest pregnancy due to post-partum PE after my last birth 3 yrs ago (long labour, emergency C section along with loads of other complications 🥲). Still very early - just 8 weeks ish. This time I'm hoping for an elective section to avoid the events that happened to me last time but I'm interested to see whether the doctor recommends a VBAC or not!

Hello.
I had these for my kids 8 and 6 years ago.
For my 8yo they basically said that I needed to go 12 hours after an injection in order to have the epidural. They advised that if I needed an emergency c section in a smaller amount of time that I would have a c section under GA. The consultant was pretty relaxed about this happening and mostly wanted to make sure that my husband didnt panic if the baby subsequently needed help breathing as apparently this is normal if you are born under GA. I ended up being induced so just stopped 12 hrs before going in. Gave birth naturally, all fine

Dc2 the guidance had changed and they said to stop the injections at (maybe) 38 weeks (or maybe 39?) As they felt the risk of 1 week of no blood thinners was very low. She was born very quickly/vaginally/all fine.

One thing I do remember though is with DC1 the anethestist was VERY cautious anyway about the epidural and phoned my consultant (at 3am) to check he was happy for me to have it and then to do something else (increase the dose?), so that was obvs annoying as I had to wait a bit longer when I really wanted it.

I had the jabs for 6 weeks after with times. I remember the clexane needles were the best ones!

Another thing is I wasnt allowed to keep the umbilical cord attached to long/had to have the injection to make the planta come put quickly as they were more aware of risks with those things than normal iyswim

Thank you! I’m on enoxaparin. Glad everything was ok for you in the end

Thank you! Sorry to hear you went through that. Do you know the cause of your clot last time? Was it exclusively to do with having a c-section, or were there other factors?

surgery generally is an inflammatory, pro-coagulant event that can increase the risk of clots anywhere so the risk remains higher even if it's 'only' been a history of upper limb clots in the past. Pregnancy is also a pro-coagulant state normally.

Using the usual pregnancy venous-thromboembolism risk scoring systems (which are easily googleable), simply having had an clot that wasn't provoked by surgery is enough to put someone into a 'high risk' VTE category. An elective section scores slightly lower than an emergency section, but both are lower risk than having had a previous clot.

Not for me but my mum had a DVT during pregnancy so was on injectable blood thinners twice a day when she had my brother, had a natural birth no issues.

They tried to explain that mine was a mixture of things, PPH after my emergency section and 4 blood transfusions made my blood thicker and where I was very unwell with an infection and fluid on my lungs etc that meant I was lying down a lot and wasn't moving around as much! It sounds like I got unlucky 🥲

15 years ago, but... I was on Clexane (Heparin) throughout pregnancy due to IgG cardiolipin antibodies, and the dose was increased during pregnancy from 20mg to 80mg which I understood was pretty high.

I was advised to choose the biggest hospital locally in which to give birth in case of complications, and that I would have to wait 24h after my last injection before I could have an epidural. I don't remember discussing the option of an elective C-section.

However, it was all taken out of my hands when I went to be checked out for spotting at 6 months pregnant and ended up having a placental abruption requiring an emergency C-section - with GA, obviously. DD was born at 29 weeks and we were both fine, thankfully!

Hi, I've got a blood clotting condition and have had 2 pregnancies on clexane and I'm currently pregnant with my 3rd and I still have some of the same anxieties as you.

In all honesty no midwives or doctors I've spoken to have ever shown any concern or worry and have always been really reassuring when I've been panicking about the risks of being on blood thinners and going into labour. I was always told that especially with my first the likelihood was I'd have plenty of 'build up' before being in established labour so hopefully the blood thinners would be well out my system. With my second I was told if the worse was to happen and I did go into labour soon after taking my clexane then there's medicines they can give to reverse the effects slightly to reduce the risk of bleeding. But if I needed a C-section it would be under general. They also said if things happened quickly I probably wouldn't get to the point of needing an epidural anyway as I'd cope without (not sure if that's reassuring or not 😂 I've had 1 with an epidural and 1 without and I know which one I would prefer...).

I was told to inject in the morning towards the end of my pregnancy as most women go into labour during the night so if I woke up and there were no signs of labour I'd probably/hopefully be ok (although I did feel like a ticking time bomb every time id injected).

As it turned out in both my pregnancies I ended up being induced at 41 weeks so I was able to stop the blood thinners beforehand. No one has ever suggested a planned induction was necessary because of the blood thinners but I am going to query it this time because both my labours have been quick and I still have some worries/anxieties despite everyone always being really reassuring about it. I'd rather it be planned/controlled if possible but I don't know if they will agree!

Good luck - I hope it all works out well for you :)