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Pregnancy and Venous Thromboembolism: Prevention, Diagnosis, Treatment

A new guideline about the prevention, diagnosis, and treatment of DVT and PE associated with pregnancy was published today by ACOG (American College of Obstetricians and Gynecologists) in its respected series of Practice Bulletins.  The bulletin includes detailed reference to thromboprophylaxis in pregnant women with thrombophilia.  Unfortunately, the guidline is not publically available – access requires a subscription to the journal Obstetrics & Gynecology.  However, the key points are as follows:

A.   DIAGNOSIS

  • Doppler ultrasound is the diagnostic tool for suspected DVT.
  • If Doppler ultrasound is negative or equivocal, MRI of the leg/pelvis is recommended.
  • D-dimer test is not helpful.
  • VQ scan or chest CTA are the diagnostic tools of choice, both associated with relatively low radiation exposure for the fetus.
B.  PROPHYLAXIS
  • Two easy to use, comprehensive, practical tables (ACOG table 2 and 3) are provided in the Bulletin with thromboprophylaxis recommendations as to which patient to treat (table 2) and what drugs and doses to use (table 3).  These take reference to pregnancies in women with and without thrombophilia, with and without previous thrombotic event, and the ante- and postpartum management.
  • For routine prophylactic LMWH dosing, anti-Xa level monitoring is not needed.
  • For full dose LMWH therapy, it is not clear whether anti-Xa monitoring is beneficial and LMWH dose adjustment based on anti-Xa levels is needed.
  • Women on prophylactic or therapeutic LMWH may be converted from LMWH to the shorter half-life unfractionated heparin in the last month of pregnancy or sooner if delivery appears imminent (to allow for safer epidural analgesia).
C.  DELIVERY
  • Neuraxial blockade should be withheld for 10-12 hours after the last prophylactic dose of LMWH or 24 hours after the last therapeutic dose of LMWH.
  • If anticoagulation is needed in the postpartum period, it should be resumed no sooner that 4-6 hours after vaginal delivery or 6-12 hours after C-section, to minimize bleeding.  Pneumatic compression devices should be used peripartum until anticoagulation is restarted.
  • C-section:
    • All women undergoing C-section delivery should have pneumatic compression devices placed BEFORE delivery (unless they are on pharmacologic VTE prophylaxis already).
    • Women undergoing C-section who have additional VTE risk factors may require LMWH or unfractionated heparin prophylaxis in addition to pneumatic compression devices.
D.  POSTPARTUM
  • Breast feeding is fine on LMWH, unfractionated heparin and warfarin, as they do not accumulate in breast milk.

Reference

Thromboembolism in Pregnancy. Obstetrics & Gynecology. 118(3):718-729, September 2011.  Practice bulletin # 123.

Disclosures:  I have no financial conflict of interest relevant to this post.

Last updated: August 24th, 2011

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