Venous Thromboembolism During Pregnancy and the Postpartum Period: Risk Factors, Diagnostic Testing, and Treatment

Abstract

Importance: The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but pulmonary embolism is typically of greater concern as it contributes to far higher morbidity and mortality. Diagnosis and treatment of VTE during pregnancy differ substantially from the general nonpregnant population.Objective: This review describes the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of VTE during pregnancy and the postpartum period.Evidence Acquisition: First, we reviewed the VTE guidelines from professional societies in obstetrics, cardiology, hematology, emergency medicine, pulmonology, and critical care. Second, we examined references from these documents and used PubMed to identify recent articles that cited the guidelines. Finally, we searched PubMed and Google Scholar for articles published since 2018 that included terms for pregnancy and the epidemiology, risk factors, diagnostic imaging, or treatment of VTE.Results: Venous thromboembolism risk increases throughout pregnancy and peaks shortly after delivery. More than half of pregnancy-related VTE are associated with thrombophilia; other major risks include cesarean delivery, postpartum infection, and the combination of obesity with immobilization. Most VTE can be treated with low molecular weight heparin, but cases of limb-or life-threatening VTE require consideration of thrombolysis and other reperfusion therapies.Conclusions and Relevance: Venous thromboembolism is far more frequent in antepartum and postpartum women than age-matched controls, and clinical suspicion for VTE in this population should incorporate pregnancy-specific B.C.M. received support from the Oregon Emergency Care Research Multidisciplinary Training Program (5K12HL133115). K.J.G.

Rare deep vein thrombosis in pregnancy and puerperium 3 case series; upper extremities vein thrombosis, ovarian vein thrombosis, portal and superior mesenteric vein thrombosis

“…4 Pulmonary Embolism is associated with 15% of maternal mortality, therefore patients with risk factors such as previous history of VTE, thrombophilia including APS, or risk factors like obesity, and OHSS, should be carefully monitored. 2,5 Patients with a previous history of VTE or APS receive standard anticoagulation therapy in the postpartum period when the risk of hypercoagulability is increased. Therefore, in the first case, the patient received prophylactic therapy due to her previous history of thrombosis during the pregnancy.…”

Sex differences in guideline‐consistent diagnostic testing for acute pulmonary embolism among adult emergency department patients aged 18–49

“…PE is quite rare in adults less than 50 years old (approximately two cases per 100,000 person‐years at age 20 years compared to 60–80 cases per 100,000 person‐years at age 50 years), and incidence rises exponentially thereafter (500–600 cases per 100,000 person‐years at age 80 years) 38 . While population‐level data suggest a transient increase in PE incidence among women during the childbearing years, this is thought to be related primarily to OCPs and peripartum venous thromboembolism (VTE) 45 and has not been borne out in EM‐based studies 46 . Notably this pattern reverses between ages 40 and 50 years, as PE becomes more common in men and stays that way for the remainder of the lifespan 47 .…”

Oral Contraceptive Pills and Hypertension: A Review of Current Evidence and Recommendations

“…Rates of unintended pregnancies are approximately 65% among those with an income less than 100% of the federal poverty line and over 50% among those without a college education in the US. 100 Compared with non-Hispanic White individuals, non-Hispanic Black individuals report almost 2 times the prevalence of unintended pregnancies. 112,113 Given that differences in access to contraceptive methods likely contributes to some of these disparities, expanding current policies to allow over-the-counter OCP use could potentially reduce these gaps in unintended pregnancies.…”

“…[97][98][99] Furthermore, although risk of VTE is approximately 1.3 to 1.5 times higher among individuals using OCPs, risk is 3 to 10 times higher during pregnancy. 8,100 Therefore, the risks and benefits of OCP use must be weighed against those associated with unintended pregnancy and the availability of alternative contraceptive options.…”