SLE with antiphospholipid syndrome on warfarin for mastectomy34-year-old woman, 62 kg, for mastectomy and axillary surgery for breast cancer

The patient

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1. Consider

   What are the issues?

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   • A 34-year-old with lupus nephritis plus antiphospholipid syndrome after a stroke, for time-sensitive mastectomy. Patient
   • I review her lupus by system: kidneys, heart, lungs and blood, and look for an active flare. Disease
   • Her prolonged APTT is the antibody acting on the test; she clots, she doesn't bleed.
   • Antiphospholipid syndrome with a past stroke puts her at high thrombotic risk.
   • Lupus nephritis with clearance of 40: no nephrotoxic drugs, and doses adjusted.
   • Her antibodies raise ischaemia risk and hydroxychloroquine can affect the heart, so she has an ECG.

2. Prepare

   How will you manage her anticoagulation and medicines?

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   • Warfarin stopped 5 days before, bridged with therapeutic low-molecular-weight heparin. (Disease)
   • Enoxaparin 1 mg/kg 12-hourly; last dose 24 hours before surgery, halved for her clearance of 40.
   • Anti-Xa levels guide her dose, peak 0.5–1 U/mL at 3–4 hours; her APTT cannot.
   • I treat axillary surgery as moderate stress: on surgery day, hydrocortisone 50–75 mg IV, tapered over 1–2 days.
   • Full blood count for her anaemia; echo only if a murmur, fever or falling exercise tolerance appears.

3. Plan

   What is your plan around surgery?

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   • Calf compression on before induction and kept on until she is up and moving. Disease
   • The gap off anticoagulation kept short: heparin restarts once the surgeon accepts the bleeding risk. After surgery
   • Warfarin restarts 12–24 hours after surgery, since it takes days to work.
   • No NSAIDs for her kidneys; paracetamol and titrated opioid instead.
   • Unexplained low pressure on her steroids: I give hydrocortisone 100 mg for adrenal crisis. Disease

4. Crisis

   On day two, before heparin restarts, her left leg is cold, pale and painful with no foot pulses. BP 138/84, HR 104. What do you do?

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   • Acute arterial occlusion: thrombosis while her anticoagulation is paused. Crisis
   • Urgent vascular surgery review; how fast she is revascularised decides the limb.
   • Unfractionated heparin now, agreed with her breast surgeon, to stop the clot propagating.
   • Heparin monitored by anti-Xa, because her APTT is already prolonged.
   • New neurology, chest pain or falling urine means catastrophic APS: ICU and haematology now.
   • Restart and long-term plan agreed with haematology and vascular surgery. After surgery