Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period

Abstract

Venous thromboembolism (VTE) in pregnancy and the postpartum is an important cause of maternal morbidity and mortality; yet, there are few robust data from clinical trials to inform an approach to diagnosis and management. Failure to investigate symptoms suggestive of pulmonary embolism (PE) is a consistent finding in maternal death enquiries, and clinical symptoms should not be relied on to exclude or diagnose VTE. In this consensus statement, we present our recommendations for the diagnosis and management of acute deep venous thrombosis (DVT) and PE. All women with suspected DVT in pregnancy should be investigated with whole leg compression ultrasonography. If the scan is negative and significant clinical suspicion remains, then further imaging for iliofemoral DVT maybe required. Imaging should be undertaken in all women with suspected PE, as the fetal radiation exposure with both ventilation/perfusion scans and CT pulmonary angiography is within safe limits. Low-molecular-weight heparin (LMWH) is the preferred therapy for acute VTE that occur during pregnancy. In observational cohort studies, using once-daily regimens appears adequate, in particular with the LMWH tinzaparin; however, pharmacokinetic data support twice-daily therapy with other LMWH and is recommended, at least initially, for PE or iliofemoral DVT in pregnancy. Treatment should continue for a minimum duration of six months, and until at least six weeks postpartum. Induction of labour or planned caesarean section maybe required to allow an appropriate transition to unfractionated heparin to avoid delivery in women in therapeutic doses of anticoagulation.

Takotsubo cardiomyopathy after cesarean: A case report and published work review of pregnancy‐related cases

“…Clinical guidelines for pregnancy recommend appropriate imaging to diagnose PTE . Computed tomography pulmonary angiography is generally preferred because of the relatively high diagnostic accuracy for PTE .…”

Deep venous thrombosis and pulmonary embolism in obese women

“…Management may involve thrombolytic therapy or surgical embolectomy and requires a multidisciplinary resuscitation team including senior physicians, obstetricians and radiologists. Postnatal anticoagulant therapy should be continued for at least 6 months and until at least 6 weeks post partum [58,62].…”

Recommendations for Thrombopropylaxis in Obstetrics and Gynaecology-A SASOG Guideline

“…Recommendations presented are in accordance with the more comprehensive evidence-based guidelines namely the 9th edition of the American College of Chest Physicians (ACCP), [4] the Green Top guidelines of the Royal College of Obstetricians and Gynaecologists (RCOG), [5] the American College of Obstetricians and Gynecologists (ACOG), [6] the Society of Obstetricians and Gynaecologists of Canada (SOGC), [7] Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) [8] and the European Society of Regional Anaesthesia (ESRA) Guidelines on Anticoagulation and Regional Anaesthesia. [9] Many of these recommendations are formulated in the absence of strong evidence and the guidelines were also prepared in conjunction with systematic reviews and observational studies.…”