Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Apply first prenatal visit risk assessment to your practice
2. Discuss the ACOG definitions for anticoagulation regimens for the prevention and treatment of maternal VTE

Estimated time to complete activity: 0.5 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 08.10.23 through 08.10.25, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.5 contact hours.

Designated for 0.5 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY

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.

CMQCC RISK STRATIFICATION RECOMMENDATIONS:

Standardize Risk Assessment Screening at First Prenatal Visit

Low Risk (Surveillance with no treatment recommended)

• Low risk thrombophilia (isolated) or with VTE in first degree relative prior to age 50 years
  • Low risk thrombophilias
    • Heterozygous for Factor V Leiden or Prothrombin gene mutation
    • Protein S or Protein C Deficiency
• Prior provoked VTE
  • VTE associated with a temporary risk factor for example
    • Major/orthopedic surgery 
    • Indwelling catheter 
    • Prolonged immobilization 

Medium Risk (Prophylactic dose Low Molecular Weight Heparin [LMWH] or unfractionated heparin [UFH])

• Prior VTE idiopathic 
• Prior VTE with pregnancy or use of estrogen containing oral contraceptives 
• Prior VTE with low-risk thrombophilia (see above)
• High risk thrombophilia with or without family history of VTE

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)

• Current VTE or other conditions requiring therapeutic dose of anticoagulation 
• Multiple prior VTE episodes 
• Prior VTE with high-risk thrombophilia 
• Prior VTE with APS 

Note: MFM and/or Hematology Specialist Co-Management Recommended for ‘High Risk’

ANTICOAGULATION REGIMENS (ACOG): 

LMWH – PROPHYLACTIC

• Enoxaparin, 40 mg SC once daily 
• Dalteparin, 5,000 units SC once daily 
• Tinzaparin, 4,500 units SC once daily 
• Nadroparin, 2,850 units SC once daily

LMWH-INTERMEDIATE DOSE

• Enoxaparin, 40 mg SC every 12 hours
• Dalteparin, 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 SC every 12 hours

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)

UFH – PROPHYLACTIC  

• UFH, 5,000 to 7,500 units SC every 12 hours in first trimester 
• UFH, 7,500 to 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 to 2.5) 6 hours after the injection  

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

KEY POINTS:

• CMQCC suggests several approaches from women on LMWH thromboprophylaxis at 36 weeks
  • Continue LMWH (Enoxaparin 40 mg SC daily or LMWH BID)
  • Transition to low-dose unfractionated heparin (5000 units SC BID)
  • Transition to UFH 10,000 units SC BID (ACOG recommendation)
  • Therapeutic IV infusion of UFH

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

• 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 pre-pregnancy or early in pregnancy and repeated if complications develop, particularly those necessitating hospitalization or prolonged immobility  
• At the first prenatal visit perform a risk assessment for VTE to determine if your patient requires surveillance or anticoagulation
• CMQCC has created a toolkit to assist providers in risk stratification and management
• Agents for VTE prophylaxis include UFH and LMWH, with escalating dose depending on risk factors and prior history
• ACOG and CMQCC have provided guidance on dosing regimens and surveillance
• Consultation and ongoing collaboration with Anesthesia service is strongly recommended 

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

ACOG Practice Bulletin 197: Inherited Thrombophilias in Pregnancy

CMQCC Maternal VTE Patient Education Handout

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

Related ObG Topics:

The CMQCC Toolkit: Venous Thromboembolism and Antepartum Admission (Non-Delivery)

The CMQCC Toolkit: Venous Thromboembolism Prevention and Management at Delivery

ACOG Guidance on Thrombophilia in Pregnancy

Which Thrombophilias in Pregnancy Warrant Thromboprophylaxis? 

SMFM Guidance: VTE Prophylaxis and Cesarean Delivery

What is the Risk for Venous Thromboembolism Following Cesarean Section?

The CMQCC Toolkit: Pregnancy Related Risk Factors & Thrombophilia Defined

MTHFR Polymorphism Testing – The Evidence Isn’t There