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Deep venous thrombosis in pregnancy: incidence, pathogenesis and endovascular management

Women are at increased risk of VTE during pregnancy and the postpartum period. Treatment and prevention of VTE in this patient population is complicated by the need to consider fetal, as well as maternal wellbeing when making management decisions. Although our knowledge of risk factors for pregnancy related VTE, the safe and effective use of anticoagulants in this patient population, as well as the use of IVC filters and catheter directed therapies continues to grow, there are still important gaps. The lack of high quality research and conclusive trial data demonstrating the safety and efficacy of treatment options for VTE during pregnancy highlights the need for prospective trials with larger…

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 How I treat venous thromboembolism in pregnancy

Evidence-based guideline recommendations are often extrapolated from nonpregnant women and thus weak or conditional, resulting in wide variation of practice. In women with suspected PE, the pregnancy-adapted YEARS algorithm is safe and efficient, rendering computed tomographic pulmonary angiography to rule out PE unnecessary in 39%. Low molecular weight heparin (LMWH) in therapeutic doses is the treatment of choice during pregnancy, and anticoagulation (LMWH or vitamin K antagonists [VKAs]) should be continued until 6 weeks after delivery, with a 3-month minimum total duration. LMWH or VKA use does not preclude breastfeeding.

 Venous Thromboembolism in Pregnancy: Challenges and Solutions

Among the anticoagulation options are low-molecular-weight heparins (LMWHs), unfractionated heparins (UFHs), and Warfarin which should be used postpartum only. LMWHs are preferred over UFH as the first-line treatment for preventing and treating VTE in pregnancy

Articles of Interest

Deep venous thrombosis in pregnancy: incidence, pathogenesis and endovascular management

Deep venous thrombosis (DVT) during pregnancy is associated with high mortality, morbidity, and costs. Pulmonary embolism (PE), its most feared complication, is the leading cause of maternal death in the developed world. DVT can also result in long-term complications that include postthrombotic syndrome (PTS) adding to its morbidity. Women are up to 5 times more likely to develop DVT when pregnant. The current standard of care for this condition is anticoagulation.

Early diagnosis of iliofemoral DVT in pregnancy in the emergency department

Clinicians need to be aware of the presentation of iliofemoral DVTs in pregnancy. Groin or pelvic pain is a common condition in pregnancy, the causes of which include symphysis pubis dysfunction, which occurs after the 12th week, and urinary tract infection, and early in pregnancy ectopic pregnancy may present this way. This symptom appearing for the first time in pregnancy or puerperium needs careful assessment, which should include assessment for DVT.

Early diagnosis of iliofemoral DVT in pregnancy in the emergency department

The case of a 26-year-old woman who was 23 weeks pregnant is described; the patient presented, on a weekend, to the emergency department (ED) with left groin pain. There were few clinical signs of deep venous thrombosis (DVT) but ED ultrasound (US) showed a left external iliac vein thrombus. This is a new technique in the ED. Not only does this case show the importance of using this technique in the ED, but it also shows the importance of correct training in how to examine for thrombus in the external iliac vein in the pregnant patient.

Management of Deep Vein Thrombosis in the Emergency Department

The management of patients presenting to the ED with deep vein thrombosis (DVT) has changed in several ways over the last decade, and emergency clinicians have more tools to manage a safe and cost-effective disposition.

Pulmonary Embolism in Pregnancy: Diagnostic Dilemmas

Compression ultrasound is the test of choice to diagnose DVT in pregnant women. The rationale for performing a leg ultrasound in a pregnant woman with suspected DVT is that if DVT is confirmed, this leads to the same therapy as PE, and consequently chest imaging can be avoided altogether. This has the benefit of avoiding unnecessary radiation.

Venous Thromboembolism in Pregnancy: Challenges and Solutions

Managing VTE in pregnancy is challenging due to the complexity of balancing the risks and benefits of anticoagulant therapy for both the mother and the fetus. A multidisciplinary approach involving obstetricians, hematologists, and neonatologists...

Resources

Enoxaparin (Lovenox)

Therapeutic enoxaparin = 1.5mg/kg/day or 1mg/kg/bid. Prophylactic enoxaparin = 40mg/day. Dose adjustment required/precaution advised for CrCl < 30mL/min. Dose adjustment required/precaution advised for obese patients with a BMI ≥ 40 kg/m2. Consider enoxaparin 0.75 mg/kg bid (therapeutic dosing) and enoxaparin 0.5 mg/kg (prophylactic dosing). Consider anti-Xa monitoring. Round all enoxaparin doses to the nearest injection syringe availability. Do not have patients displace or “squirt out” some of the medication prior to administration.