Deep vein thrombosis and pulmonary embolism in pregnancy: Treatment
- 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). Treatment of VTE in pregnant patients is unique in several ways. (See "Use of anticoagulants during pregnancy and postpartum".)
●Warfarin should be avoided, particularly in the first trimester, because it may be teratogenic.
●Fondaparinux, a synthetic heparin pentasaccharide, is generally avoided due to a paucity of safety data during pregnancy, with the only potential indication in the setting of heparin-induced thrombocytopenia (HIT).
●The direct oral anticoagulants, which include the oral direct thrombin inhibitors and the factor Xa inhibitors, should be avoided due to insufficient information about their safety when used during pregnancy.
●Monitoring of anticoagulant activity tends to be more vigilant because less is known about the appropriate dosing of anticoagulants during pregnancy.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- 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.
- Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med 2008; 359:2025.
- Bourjeily G, Paidas M, Khalil H, et al. Pulmonary embolism in pregnancy. Lancet 2010; 375:500.
- Brown HL, Hiett AK. Deep vein thrombosis and pulmonary embolism in pregnancy: diagnosis, complications, and management. Clin Obstet Gynecol 2010; 53:345.
- Arya R. How I manage venous thromboembolism in pregnancy. Br J Haematol 2011; 153:698.
- Middeldorp S. How I treat pregnancy-related venous thromboembolism. Blood 2011; 118:5394.
- Hirsh J, Bauer KA, Donati MB, et al. Parenteral anticoagulants: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:141S.
- van Dongen CJ, van den Belt AG, Prins MH, Lensing AW. Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane Database Syst Rev 2004; :CD001100.
- Romualdi E, Dentali F, Rancan E, et al. Anticoagulant therapy for venous thromboembolism during pregnancy: a systematic review and a meta-analysis of the literature. J Thromb Haemost 2013; 11:270.
- American College of Obstetricians and Gynecologists. Thromboembolism in pregnancy. ACOG Practice Bulletin 19. ACOG 2000; Washington, DC.
- Toglia MR, Weg JG. Venous thromboembolism during pregnancy. N Engl J Med 1996; 335:108.
- Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med 2003; 28:172.
- Dulitzki M, Pauzner R, Langevitz P, et al. Low-molecular-weight heparin during pregnancy and delivery: preliminary experience with 41 pregnancies. Obstet Gynecol 1996; 87:380.
- Lumpkin MM. FDA public health advisory. Anesthesiology 1998; 88:27A.
- Wysowski DK, Talarico L, Bacsanyi J, Botstein P. Spinal and epidural hematoma and low-molecular-weight heparin. N Engl J Med 1998; 338:1774.
- Bates SM, Ginsberg JS. How we manage venous thromboembolism during pregnancy. Blood 2002; 100:3470.
- Barbour LA. Current concepts of anticoagulant therapy in pregnancy. Obstet Gynecol Clin North Am 1997; 24:499.
- Ginsberg JS, Brill-Edwards P, Burrows RF, et al. Venous thrombosis during pregnancy: leg and trimester of presentation. Thromb Haemost 1992; 67:519.
- Schulman S, Rhedin AS, Lindmarker P, et al. A comparison of six weeks with six months of oral anticoagulant therapy after a first episode of venous thromboembolism. Duration of Anticoagulation Trial Study Group. N Engl J Med 1995; 332:1661.
- 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.
- Thomas LA, Summers RR, Cardwell MS. Use of Greenfield filters in pregnant women at risk for pulmonary embolism. South Med J 1997; 90:215.
- Milford W, Chadha Y, Lust K. Use of a retrievable inferior vena cava filter in term pregnancy: case report and review of literature. Aust N Z J Obstet Gynaecol 2009; 49:331.
- Zwaan M, Lorch H, Kulke C, et al. Clinical experience with temporary vena caval filters. J Vasc Interv Radiol 1998; 9:594.
- Köcher M, Krcova V, Cerna M, Prochazka M. Retrievable Günther Tulip Vena Cava Filter in the prevention of pulmonary embolism in patients with acute deep venous thrombosis in perinatal period. Eur J Radiol 2009; 70:165.
- McConville RM, Kennedy PT, Collins AJ, Ellis PK. Failed retrieval of an inferior vena cava filter during pregnancy because of filter tilt: report of two cases. Cardiovasc Intervent Radiol 2009; 32:174.
- Ahearn GS, Hadjiliadis D, Govert JA, Tapson VF. Massive pulmonary embolism during pregnancy successfully treated with recombinant tissue plasminogen activator: a case report and review of treatment options. Arch Intern Med 2002; 162:1221.
- Turrentine MA, Braems G, Ramirez MM. Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Obstet Gynecol Surv 1995; 50:534.
- Patterson DE, Raviola CA, D'Orazio EA, et al. Thrombolytic and endovascular treatment of peripartum iliac vein thrombosis: a case report. J Vasc Surg 1996; 24:1030.
- Roberts DH, Rodrigues EA, Ramsdale DR. Postpartum acute myocardial infarction successfully treated with intravenous streptokinase--a case report. Angiology 1993; 44:570.
- Cincotta RB, Davis SM, Gerraty RP, Thomson KR. Thrombolytic therapy for basilar artery thrombosis in the puerperium. Am J Obstet Gynecol 1995; 173:967.
- Fagher B, Ahlgren M, Astedt B. Acute massive pulmonary embolism treated with streptokinase during labor and the early puerperium. Acta Obstet Gynecol Scand 1990; 69:659.
- Hall RJ, Young C, Sutton GC, Cambell S. Treatment of acute massive pulmonary embolism by streptokinase during labour and delivery. Br Med J 1972; 4:647.
- Herrera S, Comerota AJ, Thakur S, et al. Managing iliofemoral deep venous thrombosis of pregnancy with a strategy of thrombus removal is safe and avoids post-thrombotic morbidity. J Vasc Surg 2014; 59:456.
- Funakoshi Y, Kato M, Kuratani T, et al. Successful treatment of massive pulmonary embolism in the 38th week of pregnancy. Ann Thorac Surg 2004; 77:694.
- Bloom AI, Farkas A, Kalish Y, et al. Pharmacomechanical catheter-directed thrombolysis for pregnancy-related iliofemoral deep vein thrombosis. J Vasc Interv Radiol 2015; 26:992.