Deep Vein Thrombosis and Pulmonary Embolus in Pregnancy is a topic covered in the 5-Minute Clinical Consult.
Blood clots formed in the deep veins of the lower extremities (deep vein thrombosis [DVT]) or pelvis (iliac vein thrombosis) are at risk of traveling to the lung, causing a pulmonary embolism (PE).
Risk of VTE events is similar in all trimesters.
Obstetric risk factors include twin (and other multiple gestation), preeclampsia, cesarean section, prolonged labor (>24 hours), operative delivery, severe postpartum hemorrhage.
Transient and potentially recurring risk factors include assisted reproductive technology (ART), in vitro fertilization (IVF), ovarian hyperstimulation syndrome (OHSS), any surgery during pregnancy, hyperemesis, dehydration, bed rest >3 days, systemic infection, long distance travel (>4 hours).
Risk of VTE is higher in the postpartum period; interestingly, 2/3 of DVTs happen antepartum and 60% of PEs postpartum. Postpartum incidence of VTE is 10 to 20 times higher than in the nonpregnant state and is especially high after cesarean.
Screening for thrombophilias even after diagnosis of VTE during pregnancy is not recommended (2)[C].
Antepartum thromboprophylaxis for high-risk thrombophilia with family history of VTE, ≥2 prior VTE (unprovoked, pregnancy, or estrogen related) (2). If no family history, suggest postpartum prophylaxis for 6 weeks only with prophylactic or intermediate dose low-molecular-weight heparin (LMWH) (2)[B].
Anticoagulation may not be required if prior VTE was not pregnancy related and associated with a risk factor no longer present.
Consider thromboprophylaxis for past single episode of idiopathic VTE, low-risk thrombophilia with past VTE, morbid obesity (BMI >40), bedridden patients, and assisted reproduction technologies (2)[C].
DVT prophylaxis both during and following cesarean delivery in the general population may be limited to pneumatic compression devices; however, in morbidly obese women (BMI ≥40), weight-based dosing of enoxaparin should be utilized postoperatively throughout the remainder of hospitalization (2)[B].
Stephens, Mark B., et al., editors. "Deep Vein Thrombosis and Pulmonary Embolus in Pregnancy." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816908/all/Deep_Vein_Thrombosis_and_Pulmonary_Embolus_in_Pregnancy.
Deep Vein Thrombosis and Pulmonary Embolus in Pregnancy. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816908/all/Deep_Vein_Thrombosis_and_Pulmonary_Embolus_in_Pregnancy. Accessed April 18, 2019.
Deep Vein Thrombosis and Pulmonary Embolus in Pregnancy [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 18]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/816908/all/Deep_Vein_Thrombosis_and_Pulmonary_Embolus_in_Pregnancy.