Venous thromboembolism (VTE), manifests as either deep vein thrombosis (about 80%) or pulmonary embolism (about 20%) in pregnancy and is a major cause of mortality and severe maternal morbidity. The risk for VTE increases above that of non-pregnant women during the first trimester, with the highest risk being in the first week postpartum. Almost all cases are considered potentially preventable with identification of an individual woman’s risk profile, typically consider ‘low’, ‘medium’, or ‘high risk’. Various professional organizations have promoted different risk stratification rubrics and guidelines for prophylaxis of or treatment of VTE during and after pregnancy. The CMQCC created a toolkit to help providers with risk assessment and suggested prophylaxis, representing a consensus summary of ACOG and ACCP guidelines.
Low Risk (Surveillance with no treatment recommended)
Medium Risk (Prophylactic dose Low Molecular Weight Heparin [LMWH] or unfractionated heparin [UFH])
Note: ACOG recommends the use of prophylactic, intermediate dose or adjusted dose LMWH/UFH for history of single unprovoked DVT (including DVT in prior pregnancy or related to hormonal contraceptive use) – see ACOG dosing below
High Risk (Therapeutic dose with LMWH or UF Heparin)
Note: MFM and/or Hematology Specialist Co-Management Recommended for ‘High Risk’
Note: Anti-Xa level testing is available to monitor activity of LMWH agents, but 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)
Note: CMQCC defines prophylactic LMWH dosing as fixed dose enoxaparin 40 mg SC every 24 hours and therapeutic LMWH as enoxaparin 1 mg/kg SC every 12 hours | Low-dose UFH is defined as UFH 5000 units SC every 12 hours | Therapeutic dose is defined as enoxaparin, 1mg/kg SC every 12 hours, adjusted to target Xa 0.6 to 1.0 units/mL 4 to 6 hours after injection with acute VTE
Note: LMWH cannot be reversed and its use proximate to labor and delivery precludes the administration of neuraxial anesthesia | There are pros and cons of the options to discuss with patients in this setting
CMQCC Venous Thromboembolism Toolkit
ACOG Practice Bulletin 196: Thromboembolism in Pregnancy
ACOG District II/Safe Motherhood Initiative: Maternal Safety Bundle for Venous Thromboembolism
ACOG Practice Bulletin 197: Inherited Thrombophilias in Pregnancy
CMQCC Maternal VTE Patient Education Handout
Maternal Fetal Medicine Specialist Locator-SMFM
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