Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
Overview
Overview
The intial diagnostic test in a pregnant woman suspected to have a pulmonary embolism (PE) depends on the presence or absence of leg symptoms suggestive of deep vein thrombosis (DVT). Compression ultrasonography is not the routine initial method of evaluation in a suspected PE during pregnancy unless the patient has coexisting symptoms and signs of DVT.[1] In case the compression ultrasound is negative for DVT and there is persistent clinical suspicion of PE, the negative ultrasound does not rule out PE and additional imaging tests are required.[1] If leg symptoms are absent in a pregnant woman suspected to have PE, a chest X-ray is the initial imaging modality.[1] When anticoagulation is indicated for the prevention or treatment of venous thromboembolism in pregnancy, low molecular weight heparin (LMWH) should be administered instead of vitamin K antagonists (VKA).[2] In fact, VKA can cross the placenta and lead to embryopathy as well as fetal loss. Some of the teratogenic effect of VKA include midfacial hypoplasia, stippled epiphysis, and limb hypoplasia.[2][3][4] The teratogenic effect of VKA is particularly important during the first trimester of pregnancy.[2]
2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)[2]
2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)[2]
Maternal Complications of Anticoagulant Therapy
Fetal Complications of Antithrombotic Therapy During Pregnancy
Use of Anticoagulants in Breast-feeding Women
| Class I
|
| “1. For lactating women using warfarin, acenocoumarol, or UFH who wish to breast-feed, we recommend continuing the use of warfarin, acenocoumarol, or UFH. (Level of Evidence: A) ‘“
|
| “2. For lactating women using LMWH, danaparoid, or r-hirudin who wish to breast-feed, we recommend continuing the use of LMWH, danaparoid, or r-hirudin. (Level of Evidence: B) ‘“
|
| “3. For breast-feeding women, we recommend alternative anticoagulants rather than oral direct thrombin (eg, dabigatran) and factor Xa inhibitors (eg, rivaroxaban, apixaban). (Level of Evidence: C) ‘“
|
VTE in Patients Using Assisted Reproductive Technology
| Class II
|
| “1. For women undergoing assisted reproduction who develop severe ovarian hyperstimulation syndrome, we suggest thrombosis prophylaxis (prophylactic LMWH) for 3 months postresolution of clinical ovarian hyperstimulation syndrome rather than no prophylaxis. (Level of Evidence: C)”
|
VTE Following Cesarean Section
Treatment of Proven Acute VTE During Pregnancy
| Class II
|
| “1. For pregnant women with acute VTE, we suggest that anticoagulants should be continued for at least 6 weeks postpartum (for a minimum total duration of therapy of 3 months) in comparison with shorter durations of treatment. (Level of Evidence: C)”
|
Prevention of VTE in Pregnant Women With Prior DVT or PE
| Class II
|
| “1. For all pregnant women with prior VTE, we suggest postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than no prophylaxis. (Level of Evidence: B)”
|
| “2. For pregnant women at low risk of recurrent VTE (single episode of VTE associated with a transient risk factor not related to pregnancy or use of estrogen), we suggest clinical vigilance antepartum rather than antepartum prophylaxis. (Level of Evidence: C)”
|
| “3. For pregnant women at moderate to high risk of recurrent VTE (single unprovoked VTE, pregnancy– or estrogen-related VTE, or multiple prior unprovoked VTE not receiving long-term anticoagulation), we suggest antepartum prophylaxis with prophylactic- or intermediate-dose LMWH rather than clinical vigilance or routine care. (Level of Evidence: C)”
|
| “4. For pregnant women receiving long-term vitamin K antagonists, we suggest adjusted-dose LMWH or 75% of a therapeutic dose of LMWH throughout pregnancy followed by resumption of long-term anticoagulants postpartum, rather than prophylactic-dose LMWH. (Level of Evidence: C)”
|
Prevention of VTE in Pregnant Women With Thrombophilia and No Prior VTE
| Class II
|
| “1. For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and have a positive family history for VTE, we suggest antepartum prophylaxis with prophylactic- or intermediate-dose LMWH and postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than no prophylaxis. (Level of Evidence: B)”
|
| “2. For pregnant women with all other thrombophilias and no prior VTE who have a positive family history for VTE, we suggest antepartum clinical vigilance and postpartum prophylaxis with prophylactic- or intermediate-dose LMWH or, in women who are not protein C or protein S|S]] deficient, vitamin K antagonists targeted at INR 2.0 to 3.0 rather than routine care. (Level of Evidence: C)”
|
| “3. For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and who do not have a positive family history for VTE, we suggest antepartum clinical vigilance and postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than routine care. (Level of Evidence: B)”
|
| “4. For pregnant women with all other thrombophilias and no prior VTE who do not have a positive family history for VTE, we suggest antepartum and postpartum clinical vigilance rather than pharmacologic prophylaxis. (Level of Evidence: C)”
|
Thrombophilia and Pregnancy Complications
| Class I
|
| “1. For women with recurrent early pregnancy loss (three or more miscarriages before 10 weeks of gestation), we recommend screening for APLAs. (Level of Evidence: B)”
|
| “2. For women who fulfill the laboratory criteria for APLA syndrome and meet the clinical APLA criteria based on a history of three or more pregnancy losses, we recommend antepartum administration of prophylactic- or intermediate-dose UFH or prophylactic LMWH combined with low-dose aspirin, 75 to 100 mg/d, over no treatment. (Level of Evidence: B)”
|
Management of Women With a History of Preeclampsia or Recurrent Fetal Loss and No Thrombophilia
| Class I
|
| “1. For pregnant women with mechanical heart valves, we recommend one of the following anticoagulant regimens in preference to no anticoagulation (Level of Evidence: A):
(a) Adjusted-dose bid LMWH throughout pregnancy. We suggest that doses be adjusted to achieve the manufacturer’s peak anti-Xa LMWH 4 h postsubcutaneous-injection or
(b) Adjusted-dose UFH throughout pregnancy administered subcutaneously every 12 h in doses adjusted to keep the mid-interval aPTT at least twice control or attain an anti-Xa heparin level of 0.35 to 0.70 units/mL or
(c) UFH or LMWH (as above) until the 13th week, with substitution by vitamin K antagonists until close to delivery when UFH or LMWH is resumed.”
|
References
References
- ↑ 1.0 1.1 1.2 Leung AN, Bull TM, Jaeschke R, Lockwood CJ, Boiselle PM, Hurwitz LM; et al. (2011). “An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy”. Am J Respir Crit Care Med. 184 (10): 1200–8. doi:10.1164/rccm.201108-1575ST. PMID 22086989.
- ↑ 2.0 2.1 2.2 2.3 Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO; et al. (2012). “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. 141 (2 Suppl): e691S–736S. doi:10.1378/chest.11-2300. PMC 3278054. PMID 22315276.
- ↑ Born D, Martinez EE, Almeida PA, Santos DV, Carvalho AC, Moron AF; et al. (1992). “Pregnancy in patients with prosthetic heart valves: the effects of anticoagulation on mother, fetus, and neonate”. Am Heart J. 124 (2): 413–7. PMID 1636585.
- ↑ Chan WS, Anand S, Ginsberg JS (2000). “Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature”. Arch Intern Med. 160 (2): 191–6. PMID 10647757.
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