Deep vein thrombosis in pregnancy: Epidemiology, pathogenesis, and diagnosis
- 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
- 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 (postpartum period) are well-established risk factors for venous thromboembolism (VTE), which occurs with a prevalence of 1 in 1600 [1-7]. The overlap with symptoms of pregnancy may impair clinical suspicion making diagnosis of VTE more challenging.
VTE can manifest during pregnancy as an isolated lower extremity deep vein thrombosis (DVT) or clot can break off from the lower extremities and travel to the lung to present as a pulmonary embolus (PE) [8-10]. PE is the seventh leading cause of maternal mortality, responsible for 9 percent of maternal deaths [11-13]. Thus, the detection of DVT during pregnancy is critical to preventing deaths from PE.
The epidemiology, pathogenesis, and diagnosis of DVT during pregnancy and the puerperium will be reviewed here. The epidemiology, pathogenesis, and diagnosis of PE, as well as the prevention and treatment of DVT and PE during pregnancy are discussed separately. (See "Pulmonary embolism in pregnancy: Epidemiology, pathogenesis, and diagnosis" and "Deep vein thrombosis and pulmonary embolism in pregnancy: Prevention" and "Deep vein thrombosis and pulmonary embolism in pregnancy: Treatment" and "Use of anticoagulants during pregnancy and postpartum".)
The overall prevalence of venous thromboembolism (VTE) in pregnancy is low. In the United States, VTE is diagnosed during 1 in 500 to 2000 pregnancies (absolute incidence; 0.025 to 0.1 percent) [1-6]. In a retrospective case-control study of 395,335 pregnant women at 24 weeks of gestation, the incidence of VTE was 85 per 100,000 pregnancies . A population-based inception cohort study over a 30 year period detected an overall incidence of VTE of 200 per 100,000 woman-years . DVT was three times more common than PE .
Similar rates are observed in Europe [2,5]. In one retrospective study of over 72,000 deliveries, the incidence of DVT was 0.71 per 1000 deliveries (95% CI 0.5-0.9) with 0.5 (95% CI 0.34-0.66) and 0.21 (95% CI 0.11-0.31) occurring antenatally and postnatally, respectively . The incidence of PE was 0.15 per 1000 deliveries (95% CI 0.06-0.24) with 0.07 (95% CI 0.01-0.13) and 0.08 (95% CI 0.02-0.14) occurring antenatally and postnatally, respectively .
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- RISK FACTORS
- Timing during pregnancy
- Anatomic location of deep vein thrombosis (DVT)
- Inherited thrombophilias
- Endothelial injury
- CLINICAL PRESENTATION
- LABORATORY TESTING
- Compression ultrasonography
- Serial compression ultrasonography
- Magnetic resonance venography
- Ascending contrast venography
- DIAGNOSTIC ALGORITHM
- Pretest probability
- - Wells score
- - LEFt clinical prediction rule
- - D-dimer
- Compressive ultrasound and subsequent testing
- - Positive CUS
- - Negative CUS
- DIFFERENTIAL DIAGNOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS