venous thromboembolism associated with pregnancy
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Etiology
(risk factors)
- history of venous thromboembolism (24.8)*
- family history of hypercoagulability
- recurrent fetal loss
- systemic lupus erythematosus (8.7)*
- heart disease (7.1)
- sickle cell disease (6.7)
- obesity (4.4)
- anemia (2.6)
- age > 35 years (2.1)
- hypertension (1.8)
- smoking (1.7)
- black race (1.4)[1]
* odds ratio in parenthesis
Pathology
- pregnancy is considered a hypercoagulable state
- risk of deep-vein thrombosis is increased in pregnancy (5-fold) & even more so in the puerperium[1][6]
- risk is greatest 1-6 weeks postpartum[1]
- risk returns to baseline 6-12 weeks postpartum[1]
- generally occurs in the left leg,
- generally proximal rather than distal
- increased risk of embolic complications
Genetics
- hereditary thrombophilias identified as high-risk* for first pregnancy-associated venous thromboembolism include:
- antithrombin deficiency (7.3% & 11.1)
- protein C deficiency (3.2% & 5.4%)
- protein S deficiency (0.9% & 4.2%)
- homozygous factor V Leiden (2.8% & 2.8%)[10]
* antepartum & postpartum absolute risks in parenthesis
* heterozygous factor V Leiden & prothrombin G20210A mutations with risks < 3%[10]
Laboratory
- evaluate risk factors for hypercoagulability
Radiology
- duplex doppler ultrasound for DVT
- initial diagnostic test prior to exposing pregnant patient to radiation[1]
- 50% of patients with pulmonary embolism have DVT on duplex ultrasound
- ventilation perfusion scanning* preferred procedure for evaluation of pulmonary embolism during pregnancy because of lower radiation exposure than pulmonary CT angiography[1][6]
- pulmonary CT angiography if ventilation perfusion scanning is equivocal[1]
* if doppler ultrasound shows DVT, treatment for pulmonary embolism is the same[11]
Complications
Management
- unfractionated heparin or LMW heparin
- antepartum[9]
- outpatient
- multiple prior VTEs or any VTE with high-risk thrombophilia
- therapeutic-dose anticoagulation
- unfractionated heparin or LMW heparin
- discontinue LMW heparin 24 hours before delivery[11]
- therapeutic-dose anticoagulation
- prior unprovoked VTE or estrogen-provoked VTE, or low-risk thrombophilia:
- prior provoked VTE or low-risk thrombophilia:
- no pharmacologic prophylaxis
- multiple prior VTEs or any VTE with high-risk thrombophilia
- inpatient
- consider prophylactic-dose anticoagulation for patients admitted for >= 72 hours not at high risk for bleeding or on verge of delivery
- outpatient
- postpartum
- inpatient
- prior VTE or thrombophilia:
- pneumatic compression while in bed plus therapeutic-dose anticoagulation
- after C section
- continue pneumatic compression until full ambulation
- add prophylactic-dose anticoagulation for women with VTE risk factors 6-12 hours after delivery & removal of epidural catheter or spinal needle
- consider opt-out (rather than opt-in) strategy for prophylactic-dose anticoagulation
- prior VTE or thrombophilia:
- outpatient
- multiple prior VTEs or VTE with high-risk thrombophilia:
- therapeutic-dose anticoagulation for 6 weeks
- all other women with prior VTE or low-risk thrombophilia:
- prophylactic-dose anticoagulation for 6 weeks[9]
- multiple prior VTEs or VTE with high-risk thrombophilia:
- inpatient
- therapeutic anticoagulation for high-risk pregnant women
- combined risk of > 3% may warrant prophylactic anticoagulation[10]
- LMW heparin generally preferred over unfractionated heparin[1][6]
- dalteparin of no benefit[5]
- at week 37, switch inpatient LMW heparin to unfractionated heparin to allow abrupt discontinuation of anticoagulation with regional anesthesia during delivery
- restart anticoagulation 6-12 hours after uncomplicated delivery
- restart 12 hours after epidural catheter removal[2]
- continue LMW heparin for 6 weeks postpartum
- avoid warfarin
- contraindicated during the 1st trimester of pregnancy
- contraindicated in pregnancy but can be used after delivery, including during breast-feeding[6]
- avoid direct thrombin inhibitors: dabigatran[5][11]
- no comment on other direct oral anticoagulants
- cesarean delivery increases risk for venous thromboembolism
- pneumatic compression devices should be used intraoperatively in patients who are not receiving anticoagulation[2]
- prophylaxis for venous thrombosis should be equally or more intense during the puerperium than during the antepartum period[2]
- treatment of DVT in pregnant women should continue for at least 3-6 months & for at least 6 weeks after delivery[1]
More general terms
- venous thromboembolism (VTE)
- pregnancy disorder; obstetric disorder; pregnancy complication
- hypercoagulability
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018.
- ↑ 2.0 2.1 2.2 2.3 ACOG Committee on Practice Bulletins-Obstetrics. Practice Bulletin No. 123: Thromboembolism in Pregnancy. Obstet Gynecol 2011 Sep; 118:718. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21860313
- ↑ Chunilal SD, Bates SM. Venous thromboembolism in pregnancy: diagnosis, management and prevention. Thromb Haemost. 2009 Mar;101(3):428-38. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19277402
- ↑ Bates SM, Jaeschke R, Stevens SM et al Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e351S-418S PMID: https://www.ncbi.nlm.nih.gov/pubmed/22315267 (corresponding NGC guideline withdrawn Dec 2017)
- ↑ 5.0 5.1 5.2 Rodger MA et al Antepartum dalteparin versus no antepartum dalteparin for the prevention of pregnancy complications in pregnant women with thrombophilia (TIPPS): a multinational open-label randomised trial. The Lancet, Early Online Publication, 25 July 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25066248 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960793-5/abstract
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Greer IA Pregnancy Complicated by Venous Thrombosis. N Engl J Med 2015; 373:540-547. August 6, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26244307 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcp1407434
- ↑ James AH. Prevention and treatment of venous thromboembolism in pregnancy. Clin Obstet Gynecol. 2012 Sep;55(3):774-87 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22828110
- ↑ Bates SM, Greer IA, Middeldorp S et al VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e691S-736S. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22315276 (corresponding NGC guideline withdrawn Dec 2017)
- ↑ 9.0 9.1 9.2 D'Alton ME, Friedman AM, Smiley RM et al National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. Obstet Gynecol. 2016 Oct;128(4):688-98. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27607857
- ↑ 10.0 10.1 10.2 10.3 Croles FN, Nasserinejad K, Duvekot JJ et al Pregnancy, thrombophilia, and the risk of a first venous thrombosis: Systematic review and bayesian meta-analysis. BMJ 2017 Oct 26; 359:j4452. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29074563 Free PMC Article
- ↑ 11.0 11.1 11.2 11.3 NEJM Knowledge+ Hematology
Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008 Nov 6;359(19):2025-33. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18987370 Review. No abstract available. https://www.nejm.org/doi/pdf/10.1056/NEJMra0707993