When pregnancy, HIT, and stroke collide: Navigating complex thrombotic care in a community-based setting

Abstract Background: Heparin-induced thrombocytopenia (HIT) is an infrequent but life-threatening complication of heparin exposure, occurring rarely in pregnant patients. Management of HIT is complex due to the hypercoagulable state of pregnancy, limited anticoagulation options, and potential for adverse maternal and fetal outcomes. We present a case demonstrating the unique convergence of thrombophilia, pregnancy, and HIT manifesting as an acute basilar artery stroke, and managed entirely within a regional community hospital network. Case Presentation: A 30-year-old woman, gravida 1 para 0, with a history of unprovoked lower extremity deep vein thrombosis (DVT) on chronic rivaroxaban for secondary prophylaxis was transitioned to low-molecular-weight heparin (enoxaparin) upon confirmation of pregnancy at 7 weeks' gestation. Twelve days later, following a recent COVID-19 infection, she presented with an acute posterior circulation stroke due to a mid-distal basilar occlusion. She underwent urgent endovascular thrombectomy (EVT), a rarely reported intervention in early pregnancy. The patient was notably thrombocytopenic at the time of presentation (85 × 10^9/L platelets), which was confirmed as HIT through a positive platelet factor 4-heparin enzyme immunoassay and confirmatory serotonin release assay. Enoxaparin was discontinued, and argatroban was initiated post-EVT, later transitioning to subcutaneous danaparoid, and ultimately fondaparinux for the remainder of her pregnancy. She underwent an induction of labor and cesarean section at 39+1 weeks, giving birth to a healthy girl. She was maintained on intermediate-dose fondaparinux for six weeks postpartum. Discussion: Heparin-induced thrombocytopenia is rare in pregnancy, especially in the first trimester. HIT can be difficult to manage due to the limited availability of safe and effective anticoagulants. In this case, immediate thromboreduction following a basilar artery occlusion, which is an uncommon but life-threatening presentation of HIT, drove the acute management and prompted an emergency endovascular thrombectomy. To our knowledge, this is the first reported instance of EVT performed in the first trimester for stroke in the setting of confirmed HIT. Following the procedure, anticoagulation required careful titration and close multidisciplinary collaboration. Initial therapy was argatroban, which was transitioned to danaparoid, and later altered to fondaparinux, an agent not well studied in pregnancy but supported by limited case reports. Fondaparinux was chosen due to its availability, subcutaneous administration, the absence of routine laboratory monitoring requirements, and its favorable tolerability. Another important feature of this case is that it was successfully managed entirely within a regional community hospital system, allowing the patient to stay close to her family and access local rehabilitation services. This case report highlights the ability of community-based hospitals to provide high-acuity, patient-centered care through strong interdisciplinary collaboration.