The prevention of pregnancy‐related venous thromboembolism

Abstract

SummaryPregnancy-related venous thromboembolism (VTE) remains one of the leading causes of maternal mortality and morbidity in the developed world. There is a lack of high-level data surrounding the use of thromboprophylaxis in pregnancy. In the UK, following the publication of the first Royal College of Obstetricians and Gynaecologists (RCOG) guideline for VTE prophylaxis during pregnancy and the puerperium in 2004, a fall in maternal deaths secondary to VTE was observed during the subsequent triennium (2006)(2007)(2008). For the first time since 1985, VTE was no longer the most common cause of maternal death. Low-molecular-weight-heparin (LMWH) is generally the agent of choice for thromboprophylaxis in this setting, and is considered safe and efficacious. The accurate risk stratification of women in order to allow the targeted provision of thromboprophylaxis is challenging. A number of international guidelines support risk assessment for pregnancyrelated VTE and the provision of LMWH for those who are deemed at sufficiently high risk. This review describes the importance of VTE in pregnancy and the puerperium, the part played by different risk factors and the role of thromboprophylaxis in this group of patients.

Pharmacology of Heparin and Related Drugs

“…Normal pregnancy presents as a hypercoagulable state and pregnancy-associated VTE remains a significant cause of maternal morbidity and mortality in developed countries (Kher et al, 2007;Lussana et al, 2012;Berresheim et al, 2014;Guimicheva et al, 2015), accounting for approximately 10% of maternal deaths (Marshall, 2014). Pregnancy places an estimated 4-to 5-fold increase in risk of VTE compared with the nonpregnant state, which rises further during the puerperium and can be compounded by underlying maternal risk factors (James, 2007;Lussana et al, 2012;Marshall, 2014).…”

Thrombophilia Screening: Universal, Selected, or Neither?

“…These patients may benefit from avoidance of modifiable acquired risk factors (ie, oral contraceptives) and from specific VTE prophylaxis in high-risk situations (ie, pregnancy, puerperium, immobility, trauma, surgery). 65 Testing asymptomatic women randomly before prescribing estrogen medications (oral contraceptives or hormone substitution) is not indicated. 40 Women with a previous VTE and/or positive familial history, though, should be tested.…”

Aspirin and heparin in pregnancy

“…Individually dosed LMWH is well tolerated and safe for prophylaxis and treatment of thromboembolic complications during pregnancy, delivery, and the post-partum period [62]. Vitamin K antagonists (VKAs) and LMWH are safe for breast-feeding [63,64].…”