Deep vein thrombosis and pulmonary embolism in pregnancy: Treatment

INTRODUCTION

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). Treatment of VTE in pregnant patients is unique in several ways. (See "Anticoagulation during pregnancy".)

• Warfarin is generally not used, particularly in the first trimester, because it may be teratogenic.
• Synthetic heparin pentasaccharides (eg, fondaparinux, idraparinux) are avoided because there is a paucity of safety data for these agents.
• Monitoring of anticoagulant activity tends to be more vigilant because less is known about the appropriate dosing of anticoagulants during pregnancy.

Treatment of VTE during pregnancy and the puerperium will be reviewed here [1-6]. The epidemiology, pathogenesis, diagnosis, and prevention of VTE during pregnancy and the puerperium are discussed separately. (See "Deep vein thrombosis and pulmonary embolism in pregnancy: Epidemiology, pathogenesis, and diagnosis" and "Deep vein thrombosis and pulmonary embolism in pregnancy: Prevention".)

GENERAL APPROACH

Initial management of suspected VTE depends upon the degree of clinical suspicion for acute PE, whether there are contraindications to anticoagulation, and whether PE, DVT, or both are suspected:

• When there is a high clinical suspicion for acute PE, empiric anticoagulant therapy is indicated prior to the diagnostic evaluation. Anticoagulant therapy is discontinued if VTE is excluded.
• When there is low or moderate clinical suspicion for PE, empiric anticoagulant therapy prior to diagnostic evaluation is determined on a case-by-case basis.
• For those patients in whom PE is suspected but anticoagulant therapy is contraindicated, diagnostic evaluation should be expedited. Anticoagulation-independent therapy (eg, inferior vena cava filter) is indicated if VTE is confirmed.
• When there is suspicion for DVT alone (no clinical evidence or suspicion of acute PE), anticoagulant therapy is generally withheld until VTE is confirmed, assuming that diagnostic evaluation can be performed in a timely fashion.