Deep vein thrombosis and pulmonary embolism in pregnancy: Prevention
- David R Schwartz, MD
David R Schwartz, MD
- Associate Professor of Clinical Medicine
- Section Chief, Critical Care
- NYU Medical Center
- Atul Malhotra, MD
Atul Malhotra, MD
- Kenneth M Moser Professor, Department of Medicine
- University of California, San Diego
- Steven E Weinberger, MD
Steven E Weinberger, MD
- Adjunct Professor of Medicine
- University of Pennsylvania School of Medicine
- Executive Vice President and CEO Emeritus
- American College of Physicians
- Section Editors
- Lawrence LK Leung, MD
Lawrence LK Leung, MD
- Editor-in-Chief — Hematology
- Section Editor — Disorders of Hemostasis and Coagulation
- Professor of Medicine
- Stanford University School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Jess Mandel, MD
Jess Mandel, MD
- Section Editor — Pulmonary Vascular Disease
- Professor of Medicine
- University of California, San Diego
Pregnancy and the puerperium are well-established risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE), which are collectively referred to as venous thromboembolic disease (VTE). The need for thromboprophylaxis should be assessed antepartum, postpartum and at any time the patient transitions from the outpatient to the inpatient setting. When it is determined that thromboprophylaxis is warranted, an appropriate strategy should be selected and prescribed.
Thromboprophylaxis can be pharmacologic (ie, anticoagulation) or mechanical (eg, intermittent pneumatic compression devices or graduated compression stockings). Indications, method and duration of thromboprophylaxis in pregnant women are the major focuses of this topic. Issues concerning the use of anticoagulants during pregnancy and prevention of VTE in medical, surgical, and gynecologic patients are discussed separately. (See "Use of anticoagulants during pregnancy and postpartum" and "Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults" and "Prevention of venous thromboembolic disease in surgical patients".)
Pregnancy and the puerperium are risk factors for the development of venous thromboembolism (VTE). This risk is thought to be due to venous stasis of the lower extremities, endothelial injury and the hypercoagulable state that occurs during pregnancy. The incidence VTE is increased throughout all trimesters of pregnancy but is highest during the postpartum period. Factors that may further augment the risk include a prior history of VTE, hospitalization for an acute illness or cesarean delivery, and the presence of an inherited thrombophilia (eg, factor V Leiden mutation prothrombin gene mutation, antithrombin III, protein C, or protein S deficiencies). (See "Deep vein thrombosis in pregnancy: Epidemiology, pathogenesis, and diagnosis", section on 'Pathogenesis'.)
Although pregnancy and the puerperium are risk factors for the development of VTE, the vast majority of pregnant women do not require thromboprophylaxis. However, thromboprophylaxis is typically targeted at those who are considered to be at greatest risk for the development of VTE during the antepartum and postpartum periods. The indications for thromboprophylaxis in this particular population of patients are discussed in this section.
Outpatient thromboprophylaxis — The indications for thromboprophylaxis differ for antepartum and postpartum women.
- 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; 141:e691S.
- American College of Obstetricians and Gynecologists Women's Health Care Physicians. ACOG Practice Bulletin No. 138: Inherited thrombophilias in pregnancy. Obstet Gynecol 2013; 122:706.
- Haemostasis and Thrombosis Task Force, British Committee for Standards in Haematology. Investigation and management of heritable thrombophilia. Br J Haematol 2001; 114:512.
- Pabinger I, Grafenhofer H, Kaider A, et al. Risk of pregnancy-associated recurrent venous thromboembolism in women with a history of venous thrombosis. J Thromb Haemost 2005; 3:949.
- Roeters van Lennep JE, Meijer E, Klumper FJ, et al. Prophylaxis with low-dose low-molecular-weight heparin during pregnancy and postpartum: is it effective? J Thromb Haemost 2011; 9:473.
- Dargaud Y, Rugeri L, Vergnes MC, et al. A risk score for the management of pregnant women with increased risk of venous thromboembolism: a multicentre prospective study. Br J Haematol 2009; 145:825.
- Pettilä V, Kaaja R, Leinonen P, et al. Thromboprophylaxis with low molecular weight heparin (dalteparin) in pregnancy. Thromb Res 1999; 96:275.
- Bain E, Wilson A, Tooher R, et al. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. Cochrane Database Syst Rev 2014; :CD001689.
- Kamel H, Navi BB, Sriram N, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med 2014; 370:1307.
- Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med 2008; 359:2025.
- Heit JA, Kobbervig CE, James AH, et al. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med 2005; 143:697.
- Simpson EL, Lawrenson RA, Nightingale AL, Farmer RD. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. BJOG 2001; 108:56.
- Sultan AA, West J, Tata LJ, et al. Risk of first venous thromboembolism in and around pregnancy: a population-based cohort study. Br J Haematol 2012; 156:366.
- Stein PD, Hull RD, Kayali F, et al. Venous thromboembolism in pregnancy: 21-year trends. Am J Med 2004; 117:121.
- http://www.nice.org.uk/nicemedia/live/12695/47195/47195.pdf (Accessed on November 15, 2013).
- Heit JA, Melton LJ 3rd, Lohse CM, et al. Incidence of venous thromboembolism in hospitalized patients vs community residents. Mayo Clin Proc 2001; 76:1102.
- Abdul Sultan A, West J, Tata LJ, et al. Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England. BMJ 2013; 347:f6099.
- Lindqvist P, Dahlbäck B, Marŝál K. Thrombotic risk during pregnancy: a population study. Obstet Gynecol 1999; 94:595.
- Norgren L, Austrell C, Nilsson L. The effect of graduated elastic compression stockings on femoral blood flow velocity during late pregnancy. Vasa 1995; 24:282.
- Friederich PW, Sanson BJ, Simioni P, et al. Frequency of pregnancy-related venous thromboembolism in anticoagulant factor-deficient women: implications for prophylaxis. Ann Intern Med 1996; 125:955.