Tre a t i n g Ve n o u s

T h ro m b o e m b o l i s m
i n P re g n a n c y
a,b b,c,
Annemarie E. Fogerty, MD , Jean M. Connors, MD *

KEYWORDS
 Venous thromboembolism  Pregnancy  Diagnostic testing
 Heparin

INCIDENCE

The likelihood for venous thromboembolism (VTE) in pregnancy is increased fourfold

to fivefold, with an estimated incidence of 0.76 to 1.72 per 1000 pregnancies.1,2 Two
thirds of deep vein thromboses (DVT) occur antepartum and are distributed evenly
between trimesters, while approximately 50% of pulmonary emboli (PE) occur
postpartum.2–5 Estimates of death for PE are 1.1 to 1.5 per 100,000 deliveries in the
United Sates and Europe.2,6 While there is decreased blood flow velocity in the distal
legs as pregnancy progresses, the fact that DVTs are evenly distributed between
trimesters argues that hormonal or coagulation changes inherent to pregnancy are
the primary drivers of increased VTE risk.

COAGULATION CHANGES DURING PREGNANCY

Changes during normal pregnancy promote coagulation, decrease anticoagulation,

and inhibit fibrinolysis.7,8 Specifically there is a marked increase in coagulation factors
II, VII, VIII, IX, and X, as well as von Willebrand factor. There is also a decrease of phys-
iologic anticoagulants, with protein S levels falling to 40% to 60%, starting in the first
trimester and remaining decreased for 3 months postpartum. This change is attribut-
able to an estrogen-induced decrease in total protein S and an increase in C4b, which
binds protein S. The combined impact of decreased protein S and increased Factor
VIII leads to increased resistance to activated protein C.

a
Department of Hematology/Oncology, Massachusetts General Hospital Cancer Center, 55
Fruit Street, Yawkey 7B, Boston, MA 02114, USA
b
Harvard Medical School, Boston, MA, USA
c
Division of Hematology, Department of Medicine, Brigham and Women’s Hospital and Dana
Farber Cancer Institute, 75 Francis Street, Boston, MA 02115, USA
* Corresponding author. Division of Hematology, Department of Medicine, Brigham and
Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA.
E-mail address: [email protected]

Hematol Oncol Clin N Am 25 (2011) 379–391

doi:10.1016/j.hoc.2011.02.004 hemonc.theclinics.com
0889-8588/11/$ – see front matter Ó 2011 Published by Elsevier Inc.
380 Fogerty & Connors

DIAGNOSIS: LABORATORY ANALYSIS

As pregnant women are at increased risk, clinicians should exercise a heightened

suspicion for VTE. Making the diagnosis, however, can be complicated by the fact
that reasonable alternatives to VTE also exist at higher frequencies in pregnant
women. The traditional signs of VTE, such as an edematous or tender extremity, chest
wall pain, shortness of breath, tachypnea, or tachycardia can occur in healthy preg-
nancies. To complicate matters further, the D-dimer test, which is commonly used
in nonpregnant patients to indicate VTE probability, is often elevated in healthy preg-
nancies. Therefore, as highlighted in the following two studies, the D-dimer is not a reli-
able marker for determining the likelihood of gestational VTE.
In a prospective study of 800 women,9 who had 391 with uncomplicated pregnan-
cies, vaginal deliveries and uneventful postpartum periods were analyzed. The
D-dimer concentration increased progressively throughout gestation, peaking on
postpartum day 1 and decreasing starting on postpartum day 2. A D-dimer level of
0.5 mg/L or greater is the generally accepted threshold for determining high proba-
bility versus low probability for VTE in nonpregnant patients. Between gestational
weeks 13 and 20, however, more than 25% of included pregnant patients had D-dimer
levels that exceeded 0.5 mg/L. After week 36, virtually all pregnant patients had
D-dimer levels greater than 0.5 mg/L. These patients had no complaints consistent
with symptoms of VTE.
Similar findings were seen by Kovac and colleagues,10 who collected D-dimer
values prospectively in 89 healthy pregnancies and compared these with the D-dimer
values of 12 pregnant women clinically suspected to have VTE. Among the women
with healthy pregnancies, 84% had normal D-dimer levels in the first trimester. The
number of women with normal D-dimer values decreased to 33% in the second
trimester and was only 1% in the third trimester. Women with positive ultrasound find-
ings for VTE, however, had a statistically significant elevation in the D-dimer level
compared with controls. Thus, the investigators proposed new values for D-dimer
thresholds in pregnancy that should vary with trimesters: 286, 457, and 644 ng/mL
in the first, second, and third trimesters, respectively. This increased D-dimer
threshold is intended to reflect the natural increase in D-dimer during gestation. This
approach has not yet been validated.

DIAGNOSIS: RADIOLOGIC STUDIES

Given the lack of reliability in pregnancy, D-dimer levels should not be used indepen-
dently to diagnose or exclude VTE. The clinician therefore must also be aware of the
risks and sensitivity of radiographic studies used to assess VTE in pregnancy.
Compression duplex ultrasonography of the legs is noninvasive and considered safe
in pregnancy. Given the safety profile, it should be the first test obtained for any pregnant
woman presenting with symptoms suggestive of VTE. Its limitations are that efficacy has
not been clearly defined in the pregnant population. In addition, pregnant women may
also develop iliac vein thrombosis, which would not be detected on traditional compres-
sion duplex ultrasonography. These women typically present with back pain and
swelling of the entire lower limb. If a DVT is diagnosed, treatment with therapeutic anti-
coagulation should be started. If clinical suspicion is high for DVT but the initial ultra-
sound result is negative, the ultrasound scan should be repeated in 1 week.
Ultrasonography should also be repeated in 1 week if a superficial thrombosis is present
but the ultrasonogram is negative for DVT. If there is concern for iliac vein thrombosis,
magnetic resonance venography or pulsed Doppler study is recommended.
 VTE in Pregnancy 381

If a PE is suspected clinically, examination of the lower extremities with duplex ultra-

sonography should still be the first diagnostic test performed. A definitive DVT is
treated with the same intensity and duration of anticoagulation as a PE, and therefore
radiologic confirmation of a PE is not required. Alternatively, if a PE is suspected but
the ultrasonogram is negative for DVT, further testing is required.
The majority of trials establishing the use of radionuclide imaging to diagnose PE
excluded pregnant subjects. One small study11 examined 120 pregnant patients
with ventilation perfusion scans (VQ scans) to evaluate symptoms suggestive of PE.
Eight of these women were already receiving anticoagulation at the time of the study.
Of the remaining cases, 73.5% of the VQ scans were normal, 24.8% were nondiag-
nostic, and 1.8% were of high probability for PE. Images were evaluated by 2 indepen-
dent experts. The women with normal or nondiagnostic images were not treated with
anticoagulation, and the patients were followed for a mean of 20.6 months. During this
follow-up interval, there was no subsequent diagnosis of PE.
This study11 also examined pregnancy outcomes in the women who had undergone
VQ scanning. A low number of adverse pregnancy outcomes such as early or late
pregnancy loss were reported for all stages of pregnancy. A low incidence of congen-
ital structural anomalies and developmental disorders in early childhood were noted.
None of these were felt to be attributable to exposure from VQ scanning. There were
no childhood cancers or leukemia reported in this small study. Therefore, use of VQ
scanning in these pregnant subjects was not associated with any increased risk of
poor fetal outcome.
While VQ scanning has an acceptable safety profile in pregnancy, this same study
highlights that one-fourth of cases will be nondiagnostic. In fact, VQ scans are known
to be negative in 73% to 92% of pregnant women suspected to have PE.12,13 When
a VQ scan is nondiagnostic a computed tomography (CT) scan is often required, which
ultimately exposes the patient to more total radiation than if the CT scan was the first diag-
nostic test performed. Another advantage of the CT scan is that unlike the VQ scan, CT
provides alternative diagnostic information, such as evidence of pneumonia, pulmonary
edema, or aortic dissection, when PE is not confirmed. Therefore, the CT scan is the
preferred tool for evaluating respiratory complaints or diagnosing PE in pregnancy.
One noninferiority randomized trial14 directly compared CT and VQ scans in assess-
ing patients with high clinical suspicion for PE, based on the Wells Clinical Criteria and
a positive D-dimer test. Patients with high clinical suspicion for PE but with negative or
nondiagnostic images also underwent ultrasound evaluation of the legs. Although
pregnant women were excluded, these data demonstrate that CT is not inferior to
VQ scanning for ruling out PE. Of the 701 patients randomized to undergo CT,
19.2% were diagnosed with PE or DVT, versus 14.2% of the 716 patients randomized
to the VQ arm. The difference in the percentage of VTE diagnosis was statistically
significant between the two groups, raising some concern that the CT scan may be
diagnosing clinically insignificant events. The primary outcome of this study was the
subsequent development of symptomatic PE or proximal DVT among the patients
with an initial negative image and an excluded PE diagnosis. Of these patients,
1.0% of the VQ scan patients versus 0.4% of the CT scan patients were ultimately
diagnosed with VTE in the 3-month follow-up period, including one fatal PE in the
VQ scan group. This difference was not statistically significant. Of note, 54.2% of
patients in the VQ scan arm had nondiagnostic images. Among this group, 7.0%
were ultimately diagnosed with VTE after further testing (initial ultrasound scans of
the lower extremities, CT scan, or conventional pulmonary angiography), suggesting
that clinicians in the study lacked confidence in a nondiagnostic VQ scan when there
was high clinical suspicion of PE. Alternatively, in only 3 cases was a VQ scan ordered
382 Fogerty & Connors

following a negative CT scan in a patient with high clinical suspicion of PE; in all of
these cases, the VQ scan was also negative.14 Although these results support that
fact that the VQ scan and CT scan are equivalent in diagnosing PE in the appropriate
high-risk clinical group, the assignment of high risk was determined based on D-dimer
testing and the Wells Clinical Criteria for PE. As previously described, these two
metrics are different in the pregnant and nonpregnant populations, and therefore
the authors’ recommendation favoring CT over VQ scan when chest imaging is
required to assess for PE in pregnancy.
Despite this recommendation, there are no published data documenting the spec-
ificity and sensitivity of diagnosing PE by CT in pregnant patients. There is also theo-
retical concern that the hyperdynamic circulation and increased plasma volume of
pregnancy may decrease the sensitivity. In addition, there is concern that ionizing radi-
ation may increase the risk of fetal malignancy or other birth defects; therefore, appro-
priate radiation reduction strategies should be exercised. There are insufficient data
on the safety of gadolinium in pregnant patients to recommend magnetic resonance
angiographic techniques in assessing gestational VTE.
Despite the theoretical concern of using ionizing radiation in pregnant women, the
2004 American Congress of Obstetricians and Gynecologists (ACOG) committee
guidelines state that fetal risks from radiation exposure are negligible when doses
are less than 0.05 Gy. Doses of 0.1 Gy and higher were determined to result in
a combined increased risk of organ malformation or childhood cancers of approxi-
mately 1%. The guidelines further estimate that the combined radiation from chest
radiography, CT, and pulmonary angiography expose the fetus to around 1.5 mGy
of radiation, which is well below the 0.05 Gy dose recommendation.15
Other published estimates of fetal exposure from maternal CT scanning when dose
reduction methods are employed confirm that the overall dose is low.16,17 Most of the
literature on childhood cancers and in utero radiation exposure are case reports.
These reports were reviewed by Ginsberg and colleagues18 who found a small, but
statistically significant increased relative risk of childhood cancer when exposed to
0.05 Gy. In the cases reviewed, however, there was no increase in pregnancy loss
or growth retardation.
Another study measured the amount of radiation to which a fetus would be exposed
during CT pulmonary angiography scans by using an anthropomorphic phantom to
represent the chest and gravid abdomen of a woman in late gestation. Three different
helical scanners were studied, and estimated fetal doses ranged from 60 to 230 mGy.
Strategies for reducing fetal exposure were variably effective: milliampere modulation,
shielding with a lead coat, and using a 5-cm shorter scan length. These strategies
reduced fetal exposure by 10%, 35%, and 56% respectively.19 Decreasing scan
length by 5 cm excludes the bases of the lungs and therefore prevents examination
of the subsegmental arteries. This strategy is predicated on the notion that thrombosis
of the subsegmental vessels is associated with less morbidity and mortality.
In a 2009 quality initiatives report, The Radiological Society of North America lists
methods to reduce the radiation dose of the maternal breasts and fetus at CT pulmo-
nary angiography (CTA).20 These methods include lead shielding, a thin-layer bismuth
breast shield, reduction in tube current and voltage, increase in pitch, increase in
detector collimation thickness, reduction of Z-axis, oral barium preparation, elimina-
tion of lateral scout image, fixed injection timing rather than test run, and elimination
of any additional CT sequences. Although there is less breast radiation exposure
during VQ scans than with CTA, as discussed earlier VQ scans yield more nondiagnos-
tic results. Using VQ scans as the initial diagnostic approach may therefore necessi-
tate a second diagnostic scan using CTA, which results in more overall radiation. The
 VTE in Pregnancy 383

chest CTA results in 0.02 to 0.06 Gy breast radiation, which can be reduced by 50%
with use of breast shields.21,22 There have been no studies that document whether the
breast tissue in pregnant women is more vulnerable to radiation damage than in
nonpregnant women of the same age.
In summary, the risk of an undiagnosed and therefore untreated VTE in pregnancy is
much higher than the risk introduced by using appropriate diagnostic tools in the preg-
nant patient. Clinical judgment is of chief importance and, when necessary, appro-
priate expert consultation should be sought to evaluate a pregnant woman
presenting with signs suggestive of VTE. Obvious care should be taken to minimize
the risks and exposure involved in diagnostic testing. Pregnant women suspected
to have VTE should first undergo compression ultrasonography of the lower extremi-
ties to assess for DVT. If the ultrasonogram is negative in a patient with suspected DVT
or superficial thrombophlebitis, the ultrasound scan should be repeated in 1 week. If
the ultrasonogram is negative for DVT and PE is suspected, pulmonary imaging with
CTA should be performed with radiation-minimizing practices. If VTE is diagnosed
by positive extremity ultrasonogram but respiratory symptoms persist after appro-
priate treatment with anticoagulation, diagnostic chest imaging should be performed
to investigate for alternative diagnoses. Our strategy for evaluation of symptoms
suggestive of VTE in a pregnant patient is summarized in Fig. 1.

TREATMENT GUIDELINES

The most recent guidelines from the American College of Chest Physicians (ACCP)23
and the American Journal of Obstetrics and Gynecology Consensus Report24 outline
treatment recommendations for VTE in pregnancy. Women who develop VTE at any
point during gestation require anticoagulation for the remainder of the pregnancy
and for 6 to 8 weeks postpartum. Treatment should be continued beyond 2 months

Suspected DVT or PE

Lower extremity compression ultrasound

Negative, but high Positive Negative, but superficial

suspicion for PE thrombophlebitis present
or high suspicion for DVT

Perform chest CTA Repeat lower extremity

ultrasound in one week

Negative Positive Positive Negative

Consider Anticoagulate with therapeutic dosing of LMWH Consider alternative

alternative diagnosis, or assess for
diagnosis iliac vein thrombosis

Fig. 1. Approach to diagnosis of suspected VTE in pregnancy.

384 Fogerty & Connors

postpartum if necessary to complete a minimum of 6 months’ total anticoagulation.

Treatment for VTE is full-intensity anticoagulation, usually with low molecular weight
heparin (LMWH), adjusted for weight changes throughout pregnancy. Fondaparinux,
a pentasaccharide anticoagulant, has also been used in pregnancy, although the pub-
lished case reports are limited25,26 to a small number of women unable to tolerate
LMWH. Although there have been no adverse outcomes, more data are needed to
document safety and efficacy of fondaparinux in pregnancy. Direct thrombin inhibitors
have been demonstrated to cross the placenta in animal models, albeit with low trans-
ference, and therefore are not used in pregnant humans.27 Similarly, the new oral Xa
inhibitor agents available for use in treating VTE in Europe and Canada have not been
used in pregnant women.
The majority of pregnant patients with VTE can be safely treated at home. Their
weight needs to be regularly monitored and the LMWH dose should be adjusted
accordingly. The pharmacokinetics of LMWH have not been clearly defined in preg-
nancy, and may be variable between women. The half-life of LMWH has been demon-
strated to be shorter in pregnancy, likely due to increased renal clearance.28 Routine
monitoring of anti-Xa levels, however, is not usually performed. Exceptions are made
for patients with renal insufficiency or obesity. In such patients anti-Xa levels should be
checked for each dose change, change in creatinine clearance, or other parameters
affecting levels, and at least once each trimester to ensure that the patient is in the
desired therapeutic range.29 Additional information on treatment in patients with renal
insufficiency is given later in a separate section. Compression stockings are recom-
mended to prevent postphlebitic syndrome in any DVT diagnosis.
While many studies have supported the safety of both unfractionated heparin (UFH)
and LMWH in pregnancy, LMWH is preferred because it requires less monitoring and
is associated with less bone loss, and there have been no documented cases of
heparin-induced thrombocytopenia when used in pregnancy.30

Warfarin
Women receiving warfarin for VTE diagnosed before pregnancy should be transitioned
to a heparin product once pregnancy is confirmed. Women receiving warfarin for
reasons other than VTE (such as mechanical heart valves) are outside the scope of
this review and are not necessarily transitioned to heparin for the entire pregnancy.
Warfarin is not used for treatment of VTE in pregnancy because birth defects have
been reported in 5% to 10% of children exposed to warfarin in utero between weeks
6 and 12. Warfarin also crosses the placenta and may therefore anticoagulate the
fetus, posing the potential risk of fetal intracranial hemorrhage during delivery.23,31,32
Women taking warfarin for VTE who desire pregnancy should be advised to check
pregnancy tests frequently, and contact their medical team with a positive test to dis-
continue warfarin and start heparin at that time. These women do not require transi-
tioning from warfarin to heparin prior to a confirmed pregnancy. Women can safely
receive warfarin postpartum.

LMWH Versus Heparin: Osteopenia

Long-term use of UFH at treatment doses is known to cause osteopenia. There is less
risk associated with use of LMWH. One study33 examined bone health in 184 pregnant
women who received long-term subcutaneous prophylaxis with UFH twice daily
because of increased risk of VTE. The mean heparin dose was 19,100 IU in
a 24-hour period, and the average duration of exposure was 25 weeks. Symptomatic
osteoporotic fractures of the spine occurred in 4 women postpartum, which
 VTE in Pregnancy 385

represented 2.2% of the total group studied. The mean heparin dose for these 4
women was 24,500 IU in 24 hours.
It is possible that the osteopenia secondary to UFH is reversible. In one study,34 70
pregnant women received UFH subcutaneously for either treatment of or thrombopro-
phylaxis against VTE. Sixty-eight of these women underwent spine and hip radio-
graphs in the first week postpartum. Twelve of these women (17%) had osteopenia;
2 (3%) had multiple fractures. Reexamination 6 to 12 months later showed that the
osteopenia was reversed in most cases. A second part of this study repeated the
radiographs 3 years after gestational UFH exposure. Among the 18 women included
in this delayed investigation, there was no osteopenia documented.
There is less concern for osteopenia when using LMWH as compared with UFH.
One larger study35 undertaken to determine the effectiveness of antepartum LMWH
on pregnancy outcomes included a substudy of 77 patients to evaluate the rate of
osteoporosis associated with gestational LMWH exposure. The women received dal-
teparin and underwent bone mineral density testing. In total, 62 patients were
analyzed. The intervention group received dalteparin antepartum and postpartum
(mean of 212 total days); the control group received dalteparin only postpartum
(mean of 38 days). There was no difference in mean bone mineral densities between
the groups. Similar findings were seen in a trial of 44 pregnant women randomized to
receive LMWH (dalteparin) once daily or UFH twice daily because of history of
previous or current VTE.36 Bone mineral density was collected from each group, as
well as from pregnant women who did not receive any anticoagulation. The mean
bone mineral density was significantly lower in the UFH group than in the LMWH
and non-anticoagulated groups. A large meta-analysis30 including 64 studies and
2777 total pregnancies in which LMWH was used reported one case of documented
osteoporosis and postpartum vertebral fracture. This woman had received high-dose
dalteparin for 36 weeks.

Bleeding
The more commonly cited concern for use of heparin products in pregnancy is
bleeding. Neither UFH37 nor LMWH cross the placenta. Anti-Xa levels have been
measured in fetal blood from mothers receiving LMWH, and showed no activity.38,39
A meta-analysis frequently cited in support of thromboprophylaxis30 included 64
studies and 2777 total pregnancies in which LMWH was used, for both treatment
and prophylaxis. The prophylaxis group had widely variable indications for use, but
in total there was a reported VTE rate of 0.84%. Given the heterogeneous diagnoses
of included women, this study does not support the efficacy of LMWH for prophylaxis;
however, it can be used to assess the safety profile of LMWH in pregnancy. The overall
hemorrhage rate was 1.99%: 0.42% antenatal, 0.92% postpartum, and 0.65% wound
hematomas.

Thrombolytic Therapy
As in nonpregnant patients, the use of thrombolytic drugs in pregnancy should be
reserved for treatment of those patients with significant hemodynamic instability or
compromise. In a review of 28 cases using thrombolysis in pregnancy,40 7 women
received treatment for PE and 3 women for DVT. The complication rate was similar
to that of nonpregnant patients. Another publication41 reviewed use of thrombolytic
medications in 172 pregnant women, with varied indications. In total there were
1.2% maternal deaths, 5.8% pregnancy losses, and 8.1% hemorrhagic complica-
tions. It has yet to be determined whether the observed pregnancy specific
386 Fogerty & Connors

complications such as preterm labor, pregnancy loss, or placental abruption were

caused by underlying PE, thrombolytic therapy, both, or neither.

Special Circumstances: Renal Insufficiency and Obesity

Pregnant women with renal insufficiency require close monitoring with anti-Xa levels
when using either UFH or LMWH. The trough anti-Xa level should be collected just
before the next dose is administered. Once a stable dosing schedule is determined
by this method, anti-Xa levels should be repeated for any change in weight, anticoag-
ulant dose, or creatinine clearance.
Anti-Xa level is preferred over partial thromboplastin time (PTT), as the PTT in preg-
nancy is influenced by factors other than anticoagulation alone. PTT can be attenuated
by increased fibrinogen and Factor VIII activity. Thus, a pregnant patient would require
a higher heparin dose to achieve the same PTT level, which may result in overdosing.
This process was demonstrated in one study42 where known concentrations of UFH
were added to the in vitro plasma samples of 13 pregnant women in their third trimes-
ters and compared with plasma samples of 15 nonpregnant women. The PTT and anti-
Xa activities were measured at increasing UFH concentrations. The anti-Xa levels
more accurately correlated with change in heparin concentrations. Therefore, the
anti-Xa level is preferred for monitoring UFH.

PERIPARTUM MANAGEMENT

Balancing the bleeding risks of delivery and associated procedures with the risk of
recurrent VTE is most difficult during the peripartum time period, as the timing of onset
of spontaneous labor is unpredictable. Anticoagulation therapy is usually altered
during the last weeks of pregnancy to minimize bleeding risks and allow for neuraxial
anesthesia if desired or necessary. Collaboration between obstetricians, hematolo-
gists, and anesthesiologists is required to determine optimal management of antico-
agulation at the time of labor and delivery, and the use of regional anesthesia in
a pregnant woman with VTE.
For pregnant women with VTE diagnosed longer than 4 weeks before estimated
delivery, LMWH anticoagulation should be held 24 hours before scheduled delivery
and restarted immediately after hemostasis is assured. While there is obvious concern
about excessive maternal bleeding, studies do not necessarily support this concern.
One small study43 reviewed 41 total pregnancies managed with LMWH, where
87.5% of included subjects received only prophylactic dosing of 40 mg enoxaparin
daily. Women received LMWH throughout gestation, labor, and delivery, and immedi-
ately postpartum. There were no reports of excessive bleeding in these patients,
including the small number of therapeutically anticoagulated mothers. There were
no cases of intraventricular hemorrhage in the neonates. For most women on full-
intensity anticoagulation, simply holding the LMWH for 24 hours is sufficient if sched-
uled induction or cesarean section is planned for obstetric purposes.
In the immediate 2- to 4-week period after VTE diagnosis, there is a high rate of
mortality if therapeutic anticoagulation is stopped or actively reversed. Therefore, it
is unfavorable for women diagnosed with VTE within 4 weeks of expected delivery
to have therapeutic anticoagulation held for 24 hours for the purposes of labor and
delivery. In this circumstance, use of continuous intravenous UFH and should be
considered. The intravenous UFH can be stopped 4 to 6 hours before delivery or
when the patient goes into labor, with the PTT and anti-Xa levels used to monitor
the coagulation status. In patients with extensive DVT or PE, consideration for
 VTE in Pregnancy 387

scheduled induction of labor or cesarean delivery should be considered to minimize

the duration of time without anticoagulation.
Use of inferior vena cava (IVC) filters in patients with DVT to permit reversal of anti-
coagulation for labor is controversial and is generally not advised, as the data for
nonpregnant patients suggests that IVC filters have limited efficacy in preventing
PE. In particular, one review cataloged the complications involved in IVC filter
placement,44 with the most significant early complication being insertion site throm-
bosis at 8.5%. However, over a course of 15 months of follow-up, the risk for recurrent
DVT was 21%, recurrent PE 3%, IVC thrombosis 2% to 10%, and postthrombotic
syndrome 15% to 40%. Another retrospective study45 showed that IVC filter place-
ment in a patient who can tolerate anticoagulation offers no benefit in recurrent
DVT, PE, or mortality. Given the potential complications of IVC filter placement and
risk for long-term sequelae if the filter is unable to be removed, the overall low risk
for bleeding even in fully anticoaugulated mothers, and the option of limiting the
time without anticoagulation to several hours, the authors do not recommend routine
use of IVC filters.
UFH has a shorter half life than LMWH: 1.5 hours for UFH versus 3 to 6 hours after
a single dose of LMWH.46,47 The half-life of enoxaparin may increase to 7 hours after
repeated dosing. This feature is the rationale behind the common practice of transi-
tioning a woman from LMWH to UFH at approximately 36 weeks’ gestation. There
is also the perceived appeal of being able to use protamine to reverse UFH for
a laboring mother who is anticoagulated. However, the impact of protamine on the
fetus has not been widely studied. There is one case report48 of significant respiratory
depression in a neonate born at 39.5 weeks where the mother received 25 mg of prot-
amine. Therefore, the use of protamine should be reserved for cases of significant
bleeding and not reflexively given to all anticoagulated mothers receiving heparin.
Recently the American Society of Regional Anesthesia and Pain Medicine
(ASRAPM) published evidence-based guidelines for use of regional anesthesia in
patients receiving antithrombotic therapy.49 There is limited literature specific to the
use of regional anesthesia in pregnant patients and, as such, the obstetric guidelines
are based on data adopted from other surgical literature. This publication notes that
there have been no published case reports of spinal hematoma in a pregnant patient
receiving antithrombotic therapy at the time of delivery, with or without the use of neu-
raxial blockade. These guidelines advocate the use of UFH or LMWH by gestational
week 36 for the rare patient managed with oral anticoagulants. The guidelines further
suggest discontinuing LMWH at least 36 hours before induction of labor or cesarean
section, and substituting UFH (either intravenously or subcutaneously) if needed. If
intravenous heparin is instituted, it should be held 4 to 6 hours before anticipated
delivery with PTT monitoring to ensure acceptable range. Based on this recommenda-
tion, many practitioners choose to transition a pregnant patient from LMWH to UFH at
36 weeks, particularly in cases of anticipated spontaneous labor. For scheduled
induction of labor and cesarean sections, however, use of LMWH can be continued
beyond 36 weeks.
The ASRAPM guidelines also present recommendations for the timing of neuraxial
anesthesia when a patient is receiving prophylactic UFH or LMWH. In general, guide-
lines recommend delaying needle placement until 4 to 12 hours after the last dose of
UFH, and waiting at least 1 hour after catheter removal before resuming heparin. For
women receiving therapeutic dosing of LMWH, the guidelines recommend delaying
needle placement until 24 hours after the last administered dose. There is no single
rule regarding the safety of using epidural anesthesia and the exact timing of discon-
tinuation of anticoagulation for all pregnant women, and decisions must be made in
388 Fogerty & Connors

collaboration with hematologists, obstetricians, and anesthesiologists in the best

interest of the individual patient.

POSTPARTUM MANAGEMENT

After hemostasis is assured and epidural catheters safely removed, women should be
restarted on anticoagulation. Treatment should be continued for a minimum of 6
weeks following a vaginal delivery and 8 weeks following a cesarean delivery, but
extended as needed to complete a total of 6 months of anticoagulation from the
date of the VTE diagnosis. Therapeutic anticoagulation with either heparin or warfarin
is safe in nursing mothers.

SUMMARY

Clinicians should exercise a heightened level of suspicion for VTE in pregnant women,
as they are at increased risk for VTE but can present with symptoms that can have
multiple etiological factors. Although the D-dimer assay has limited diagnostic value
in pregnancy, the use of compression ultrasonography, VQ, and pulmonary CT can
be used safely. The authors’ preferred diagnostic approach is to start with a lower
extremity ultrasonogram in women with suspected VTE, reserving use of pulmonary
CT for negative ultrasound results or persistent pulmonary complaint after starting
anticoagulation in women with documented DVT. Treatment is full-intensity anticoa-
gulation with a heparin product for the remainder of pregnancy and 6 to 8 weeks post-
partum, to complete a minimum of 6 months. LMWH has been documented to be safe
in pregnancy, with minimal side effects. The most difficult aspect of treating VTE in
pregnancy is planning the interruption of anticoagulation for labor and delivery. Deci-
sions on the exact plan for management of anticoagulation in preparation for labor and
delivery should be made on an individual case basis with input from all members of
a multidisciplinary team involving obstetricians, hematologists, and anesthesiologists.

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