How I treat pregnancy-related VTE and a summary of alternatives
| . | Our approach in most patients . | Our alternatives (not exhaustive) . |
|---|---|---|
| Diagnosis of suspected DVT | Single whole-leg CUS with visualization of the iliac vein | If clinical suspicion is high, repeat CUS after 3-7 d |
| Diagnosis of suspected PE | Pregnancy-adapted YEARS algorithm (Figure 1) | YEARS algorithm with bilateral CUS of the legs if no signs of DVT |
| Initial treatment of VTE in pregnancy | Therapeutic-dose LMWH in a once-daily regimen based on actual body weight and peak anti-Xa levels 4 h after injection (instruct women to inject LMWH in the morning) | Temporary vena cava filter only in women with an absolute contraindication for anticoagulation |
| Infrequent monitoring of platelets and anti-Xa levels (every 6 to 8 wk, combined with obstetric follow-up) | ||
| Management of delivery | If no obstetric indication for a planned delivery, wait for spontaneous delivery | Planned delivery in women with recent VTE (4 wk before expected delivery); consider switching LMWH to twice-daily regimen of therapeutic-dose LMWH |
| Counsel women about possibly not being able to receive neuraxial analgesia but alternative methods instead if necessary | UFH IV with aPTT monitoring in women with acute VTE (ie, in recent 2 wk) who have to deliver; stop UFH 4 h before delivery; neuraxial anesthesia is possible | |
| As soon as spontaneous labor starts, no LMWH injections; active management of third stage of labor | ||
| Postpartum management | Restart LMWH 12 to 24 h after delivery, depending on amount of blood loss and adequate hemostasis; continue LMWH for the rest of the anticoagulation period | Start VKAs 24 to 48 h after restarting LMWH if hemostasis is adequate and measure INR 3 d after starting VKAs; stop LMWH if INR is >2.0 |
| Breastfeeding is not contraindicated with LWMH or VKAs | DOACs are an option if not breastfeeding and long-term treatment is intended | |
| Duration of anticoagulation until 6 wk postpartum or longer to guarantee a minimum total duration of 3 mo if VTE occurred in late pregnancy | ||
| Prevention of recurrent VTE in pregnancy | In women with unprovoked or hormone-related first episode of VTE who do not use anticoagulants outside pregnancy, antepartum and postpartum LMWH prophylaxis; include in Highlow study | |
| In women with a first episode of VTE related to a major provoking risk factor and without concomitant hormonal risk factor, postpartum LMWH prophylaxis only | ||
| In women who use long-term anticoagulation (DOAC) for VTE outside pregnancy, switch to VKAs preconceptionally and to LMWH with vitamin K supplements as soon as pregnancy test is positive |
| . | Our approach in most patients . | Our alternatives (not exhaustive) . |
|---|---|---|
| Diagnosis of suspected DVT | Single whole-leg CUS with visualization of the iliac vein | If clinical suspicion is high, repeat CUS after 3-7 d |
| Diagnosis of suspected PE | Pregnancy-adapted YEARS algorithm (Figure 1) | YEARS algorithm with bilateral CUS of the legs if no signs of DVT |
| Initial treatment of VTE in pregnancy | Therapeutic-dose LMWH in a once-daily regimen based on actual body weight and peak anti-Xa levels 4 h after injection (instruct women to inject LMWH in the morning) | Temporary vena cava filter only in women with an absolute contraindication for anticoagulation |
| Infrequent monitoring of platelets and anti-Xa levels (every 6 to 8 wk, combined with obstetric follow-up) | ||
| Management of delivery | If no obstetric indication for a planned delivery, wait for spontaneous delivery | Planned delivery in women with recent VTE (4 wk before expected delivery); consider switching LMWH to twice-daily regimen of therapeutic-dose LMWH |
| Counsel women about possibly not being able to receive neuraxial analgesia but alternative methods instead if necessary | UFH IV with aPTT monitoring in women with acute VTE (ie, in recent 2 wk) who have to deliver; stop UFH 4 h before delivery; neuraxial anesthesia is possible | |
| As soon as spontaneous labor starts, no LMWH injections; active management of third stage of labor | ||
| Postpartum management | Restart LMWH 12 to 24 h after delivery, depending on amount of blood loss and adequate hemostasis; continue LMWH for the rest of the anticoagulation period | Start VKAs 24 to 48 h after restarting LMWH if hemostasis is adequate and measure INR 3 d after starting VKAs; stop LMWH if INR is >2.0 |
| Breastfeeding is not contraindicated with LWMH or VKAs | DOACs are an option if not breastfeeding and long-term treatment is intended | |
| Duration of anticoagulation until 6 wk postpartum or longer to guarantee a minimum total duration of 3 mo if VTE occurred in late pregnancy | ||
| Prevention of recurrent VTE in pregnancy | In women with unprovoked or hormone-related first episode of VTE who do not use anticoagulants outside pregnancy, antepartum and postpartum LMWH prophylaxis; include in Highlow study | |
| In women with a first episode of VTE related to a major provoking risk factor and without concomitant hormonal risk factor, postpartum LMWH prophylaxis only | ||
| In women who use long-term anticoagulation (DOAC) for VTE outside pregnancy, switch to VKAs preconceptionally and to LMWH with vitamin K supplements as soon as pregnancy test is positive |
Our approach and alternatives are justified in the full text.
aPTT, activated partial thromboplastin time; INR, international normalized ratio.