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The CMQCC Toolkit: Pregnancy Related Risk Factors & Thrombophilia Defined

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Learning Objectives and CME/Disclosure Information

SUMMARY:  

The CMQCC Task Force has released guidance on the prevention of PE and DVT in pregnancy.  The document also helps clarify terminology to provide clarity when performing risk assessment at various time points in pregnancy (see ‘Related ObG Topics’ below). In addition, the CMQCC Task Force provides the  anti-coagulation regimens recommended by ACOG.

Risk Factors  

FAMILY HISTORY of VTE 

  • VTE occurring in a first-degree relative prior to age 50 

HIGH RISK THROMBOPHILIA   

  • Antithrombin III deficiency 
  • Antiphospholipid syndrome (APS)  
    • Requires at least one clinical and one laboratory criteria be met  
  • Factor V Leiden or Prothrombin pathogenic variant  
    • Homozygosity or compound heterozygosity 

LOW RISK THROMBOPHILIA

  • Factor V Leiden or Prothrombin pathogenic variant  
    • Heterozygote state  
  • Protein C or S deficiency 

Anticoagulation Regimens (ACOG) 

LMWH – PROPHYLACTIC DOSE

  • Enoxaparin, 40 mg SC once daily 
  • Dalteparin, 5,000 units SC once daily 
  • Tinzaparin, 4,5000 units SC once daily 
  • Nadroparin, 2,850 units SC once daily

LMWH – INTERMEDIATE DOSE

  • Enoxaparin, 40 mg SC every 12 hours
  • Dateparin, 5,000 units SC every 12 hours

LMWH – ADJUSTED DOSE (THERAPEUTIC) 

  • Enoxaparin, 1mg/kg SC every 12 hours 
  • Dalteparin, 200 units/kg SC once daily 
  • Tinzaparin, 175 units/kg SC once daily 
  • Dalteparin, 100 units/kg every 12 hours

UFH – PROPHYLACTIC 

  • UFH, 5,000-7,500 units SC every 12 hours in first trimester 
  • UFH, 7,500-10,000 units SC every 12 hours in the second trimester 
  • UFH, 10,000 units SC every 12 hours in the third trimester, unless the aPTT is elevated 

UFH – ADJUSTED DOSE (THERAPEUTIC)

  • UFH, 10,000 units or more SC every 12 hours in doses adjusted to target aPTT in the therapeutic range (1.5-2.5) 6 hours after the injection   

POSTPARTUM ANTICOAGULATION  

  • Prophylactic, intermediate or adjusted dose LMWH for 6-8 weeks as indicated
  • Oral anticoagulants may be considered postpartum based upon planned duration of therapy, lactation and patient preference

SURVEILLANCE

  • Clinical vigilance and appropriate objective investigation of women with symptoms suspicious of deep vein thrombosis or pulmonary embolism
  • VTE risk assessment should be performed prepregnancy or early in pregnancy and repeated if complications develop, particularly those necessitating hospitalization or prolonged immobility  

Notes:  

  • Anti-Xa level testing is available to monitor activity of LMWH agents 
  • CMQCC defines ‘LMWH therapeutic dose’ as enoxaparin, 1mg/kg SC every 12 hours, adjusted to target Xa 0.6-1.0 units/mL 4-6 hours after injection with acute VTE
  • aPTT testing is used to determine UFH dosing, not LMWH activity 
  • Anti-Xa level testing is not currently mandated due to cost, inconvenience and lack of high quality data 
  • Dose adjustment may be considered with extremes of body weight (< 50 kg or > 90 kg)
  • Consultation and ongoing collaboration with Anesthesia is strongly recommended 

CMQCC Maternal VTE Patient Education Handout

CMQCC Maternal VTE Patient Education Handout

Learn More – Primary Sources:

CMQCC Venous Thromboembolism Toolkit

ACOG Practice Bulletin 196: Thromboembolism in Pregnancy

ACOG District II/Safe Motherhood Initiative: Maternal Safety Bundle for Venous Thromboembolism

International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS)

Locate a genetic counselor or genetics services:

Genetic Services Locator-ACMG

Genetic Services Locator-NSGC

Genetic Services Locator-CAGC

Locate a Maternal Fetal Medicine Specialist

Maternal Fetal Medicine Specialist Locator-SMFM

Take a post-test and get CME credits

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Related ObG Topics:

The CMQCC Toolkit: Venous Thromboembolism in Early Pregnancy
The CMQCC Toolkit: Venous Thromboembolism and Antepartum Admission (Non-Delivery)
The CMQCC Toolkit: Venous Thromboembolism Prevention and Management at Delivery
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