Prevention in Pregnancy and Puerperium
Dr (Mrs.) V BAGRI BUCKTOWAR,
Obstetrician and Gynaecologist
MBBS, MD, DGO, DPM, Dip USG.
When you have completed this course you will be able to:
• describe the normal mechanism of coagulation and how
this alters in pregnancy.
• describe the epidemiology, pathophysiology and risk factors
in venothromboembolism in pregnancy.
• conduct prenatal counselling and the subsequent
management of those women with thromboembolic
• recognise who needs to be given thromboprophylaxis to
Embolus lodged in
• Pregnancy is a prothrombotic state.
• The relative risk of VTE in pregnancy is increased four to six
fold and this is increased further postpartum.
• Although the risk of VTE is higher in the puerperium ,the
antenatal period is longer and antepartum deaths from VTE
occur as commonly as postpartum deaths.
• VTE remains the leading cause of direct maternal death.
• Women giving birth are now older, have preexisting health
problems and rates of obesity in the pregnant population is
on the rise
Incidence of VTE in pregnancy (DVT, PE, CVT)
• The incidence of non-fatal PE and DVT in pregnancy is 0.1%
• DVT accounts for 75% of pregnancy associated VTE and PE about 25%
• The risk of DVT after caesarean section is around 1-2%
• The incidence of CVT during pregnancy and puerperium in developed countries is
11.6 per 100,000 deliveries per year.
• In pregnancy, DVT is more likely to be more proximal (involving the iliac and
iliofemoral veins)and in the left leg as the left iliac vein is compressed by the right
iliac artery and 5th lumbar veretebra
Reference-Handbook of Obstetric Medicine :Catherine Nelson-Piercy 2015
DVT Pregnant % Non-pregnant %
Left sided 85 55
Ilio-femoral 72 9
Morbidity following DVT
• Post thrombotic syndrome (PTS) is characterised by chronic
persistent leg swelling, pain, a feeling of heaviness, dependant
cyanosis, telangiectasis, chronic pigmentation, eczema, associated
varicose veins and in the most severe cases, venous ulceration.
There is no role of compression stockings in the prevention of post-
• Venous insufficiency resulting in pigmentation and venous leg
• Pulmonary hypertension in 3–4% following pulmonary embolism.
• Recurrent DVT – the incidence of a recurrent DVT outside
pregnancy is 3.7% but in pregnancy this increases to 10.9%.
There needs to be a balance between thrombosis and fibrinolysis
• In pregnancy, there are changes in both the clotting and fibrinolysis system. The
purpose of these changes is to safeguard against bleeding after delivery, but the
associated consequence is that there is an increased risk of thrombosis.
Blood concentrations of clotting factors in pregnancy
von Willebrand factor
Stays the same
Trend changes in the constituents of
blood in a normal pregnancy
Pregnancy predisposes to thrombosis
as explained below:
• pregnancy is a physiologically
hypercoagulable state - this risk is
present from the first trimester up
to 6 weeks postpartum.
• Although the risk persists until 12
weeks the absolute risk beyond 6
weeks is low.
• Fibrinogen levels rise by up to 50%
while fibrinolytic activity is
• Antithrombin and protein S levels
decrease thus altering the balance
Pregnancy fulfills all the 3 criteria of Virchow’s Triad!
Prepregnancy and antenatal risk assessment
Q: What are the risk factors for venous thromboembolism (VTE) in pregnancy
and puerperium?what is the magnitude of risk for these factors?
All women should undergo a documented assessment of risk factors for VTE in early
pregnancy or prepregnancy.
Risk assessment should be repeated if the woman is admitted to hospital for any reason
or develops other intercurrent problems.
Risk assessment should be repeated again intrapartum or immediately postpartum.
Any woman with four or more current risk factors (other than
previous VTE or thrombophilia)-prophylactic (LMWH) throughout the antenatal period
and prophylactic LMWH for 6 weeks postnatally.
Any woman with three current risk factors (other than previous VTE or thrombophilia)
prophylactic LMWH from 28 weeks and require prophylactic LMWH for 6 weeks
Any woman with two current risk factors (other than previous VTE or thrombophilia) -
prophylactic LMWH for at least 10 days postpartum. [New 2015]
Risk factors for venous thromboembolism in
pregnancy and the puerperium
Risk factors for venous thromboembolism in
pregnancy and the puerperium-contd.
Obstetric thromboprophylaxis -Risk assessment and management
Obstetric thromboprophylaxis - risk assessment and management-
NUMERICAL SCORING SYSTEM
Risk factors for VTE-pre-existing risk factors
NUMERICAL SCORING SYSTEM
Risk factors for VTE-Obstetric risk factors
NUMERICAL SCORING SYSTEM
Risk factors for VTE-transient risk factors
Risk assessment for venous thromboembolism (VTE)
• A thrombophilia is defined as a predisposition to thrombosis, secondary to
any persistent or identifiable hypercoagulable state. This can be inherited or
• Present in about 5% of the population
• Not all thrombophilias carry the same risk and risk assessment should
therefore be stratified. Thromboprophylaxis should be offered depending on
the score after considering other risk factors.
• Antithrombin deficicency
• Protien C deficiency
• Protien S deficiency
• Factor V Leiden
• Prothrombin gene mutation
The most common acquired thrombophillia is Antiphospholipid syndrome.
Summary of revised classification criteria for APS
Risks of APS
The risks to pregnancy include:
• pregnancy loss
• fetal growth restriction
• preterm delivery
• thrombosis – deep vein thrombosis/pulmonary
Management of women with APS and a previous thrombotic event
• a change from warfarin should be made once a positive pregnancy test is
• It is important to emphasise the necessity of an early pregnancy test, to
ensure a change to heparin before 6 weeks of gestation to minimise the
risk of warfarin embryopathy.
• The dose of heparin should be at intermediate or therapeutic levels,
depending on assessment of overall risk
• In those women not on anticoagulation, a high prophylactic or
intermediate dosage should be commenced early in the first trimester on
confirmation of a viable pregnancy and continued untill 6 weeks
• Low dose Aspirin (75-150mg) should be started from 12 weeks, preferably
• Women need to be managed in a multidisciplinary team comprising of an
obstetrician, rheumatologist, haematologist and anaesthetist.
Management of women with APS and no previous thrombotic event
• Persistent Antiphospholipid antibodies in women without previous VTE
should be considered for antenatal or postnatal thromboprophylaxis.
Testing for thrombophilia in women with
Q:Which women with prior VTE require thrombophilia
Women with a family history of VTE .
Women with an unprovoked VTE should be tested
for the presence of antiphospholipid antibodies.
• Women with previous VTE associated with antithrombin
deficiency (who will often be on long-term oral anticoagulation)
should be offered thromboprophylaxis with higher dose LMWH
(either 50%, 75% or full treatment dose) antenatally
• for 6 weeks postpartum or until returned to oral anticoagulant
therapy after delivery.
• Women with previous VTE associated with other heritable
thrombophilia should be offered standard doses of
• Management should be undertaken in collaboration with a
haematologist with expertise in thrombosis in pregnancy.
• Antenatal anti-Xa monitoring and the antithrombin replacement at
initiation of labour or prior to caesarean section. [New 2015]
Asymptomatic heritable thrombophilia
Q: How should women with asymptomatic thrombophilia be treated?
Women should be stratified according to level of risk associated with their
thrombophilia and the family history or other risk factors. [New 2015]:
1.Women with asymptomatic antithrombin, protein C or S deficiency
2.those with more than one thrombophilic defect (including homozygous factor V
Leiden, homozygous prothrombin genemutation and compound heterozygotes)
should be referred to a local expert and antenatalprophylaxis considered. and 6 wks
postnatal prophylaxis even in the absence of additional risk factors. [New 2015]
In the presence of:
three other risk factors- antenatal thromboprophylaxis
two other risk factors: thromboprophylaxis from 28 weeks
one other risk factor: postnatal thromboprophylaxis for 10 days should be
considered. [New 2015]
Q:How should women with antiphospholipid
antibodies be treated?
• Persistent antiphospholipid antibodies (lupus
anticoagulant and/or anticardiolipin and/or
β2-glycoprotein 1 antibodies) in women without
previous VTE should be considered for
antenatal or postnatal thromboprophylaxis. [New
Thrombophilias –key points
• Thrombophilias may be acquired or congenital and vary in their degree of
• Thrombophilias increase the risk of VTE but most carriers never
experience a deep vein thrombosis or pulmonary embolism.
• Initiation and intensity of anticoagulant therapy following a diagnosis of
acute venous thrombosis should be the same in woman with and without
• Antithrombin III, compound thrombophilias and homozygosity for FVL and
G20210A prothrombin gene mutation are the most thrombogenic.
• Thrombophilias are also associated with fetal loss, placental abruption and
Previous VTE/recurrent VTEs
Q: How should women with previous VTE be managed in pregnancy?
Single previous VTE
• prepregnancy counselling and a prospective management plan for thromboprophylaxis
in pregnancy made.
• Referral at the earliest opportunity in pregnancy to a clinician with expertise in
thrombosis in pregnancy.
• Thromboprophylaxis with LMWH throughout the antenatal period. [New 2015]
Q: What extra advice is needed for women with previous recurrent VTE?
• Clinician with expertise in haemostasis and pregnancy should be involved. [New 2015]
these women require higher doses of LMWH. [New 2015]
Women on long-term warfarin or other oral anticoagulants should be counselled about
the risks of these agents to the fetus and advised to stop their oral anticoagulant
therapy and change to LMWH as soon as pregnancy is confirmed, ideally within 2
weeks of the missed period and before the sixth week of pregnancy. [New 2015]
Women not on warfarin or other oral anticoagulants should be advised to start LMWH
as soon as they have a positive pregnancy test. [New 2015]
Stratification of women with previous VTE
Q: How should women with previous VTE be stratified to determine
management in pregnancy?
Q: When should thromboprophylaxis be started?
Women with VTE associated with either antithrombin deficiency or APS or with recurrent
VTE (who will often be on long-term oral anticoagulation) should be offered
thromboprophylaxis with higher dose LMWH (either 50%, 75% or full treatment dose)
antenatally and for 6 weekspostpartum or until returned to oral anticoagulant therapy after
Women in whom the original VTE was unprovoked/idiopathic or related to estrogen
(estrogen-containing contraception/pregnancy) or related to a transient risk factor should be
offered thromboprophylaxis with LMWH throughout the antenatal period.
In women in whom the original VTE was provoked by major surgery from which they have
recovered and who have no other risk factors, thromboprophylaxis with LMWH can be
withheld antenatally until 28 weeks provided no additional risk factors are present (in which
case they should be offered LMWH). They require close surveillance for the development of
other risk factors.
First trimester risk factors
Q:What are the first trimester risk factors for VTE and how
should they be managed?
Women admitted with hyperemesis should be considered for
thromboprophylaxis with LMWH and can discontinue thromboprophylaxis
when the hyperemesis resolves. [New 2015]
Women with ovarian hyperstimulation syndrome should be considered for
thromboprophylaxis with LMWH in the first trimester. [New 2015]
Women with an IVF pregnancy and three other risk factors should be
considered for thromboprophylaxis with LMWH starting in the first
Q:When should thromboprophylaxis be interrupted
• LMWH should be stopped by the pt. if they have any vaginal bleeding or once labour begins.
She should continue to wear support stockings in labour and remain hydrated.
• If a patient anticoagulated with LMWH has required a caesarean section, consideration
should be given to insertion of wound drains.
• However, bleeding complications are very uncommon with LMWH.
• There is a 2% chance of wound haematoma with both LMWH and UH, so staples or
interrupted skin sutures should be used.
• Women at high risk of haemorrhage including major antepartum haemorrhage,
coagulopathy, progressive wound haematoma, suspected intra-abdominal bleeding and
postpartum haemorrhage may be managed with anti-embolism stockings (AES), foot
impulse devices or intermittent pneumatic compression devices.
• Unfractionated heparin (UFT) may also be considered.
• If a woman develops a haemorrhagic problem while on LMWH the treatment should be
stopped and expert haematological advice sought.
• Thromboprophylaxis should be started or reinstituted as soon as the immediate risk of
haemorrhage is reduced.
Thromboprophylaxis and the use of
• Regional techniques should be avoided if possible until at least 12 hours
after the previous prophylactic dose of LMWH.
• LMWH should not be given for 4 hours after use of spinal anaesthesia or
after the epidural catheter has been removed and the catheter should not
be removed within 12 hours of the most recent injection.
• When a woman presents while on a therapeutic regimen of LMWH,
regional techniques should be avoided if possible for at least 24 hours after
the last dose of LMWH.
• Elective caesarean -thromboprophylactic dose of LMWH on the day prior
to delivery and, on the day of delivery, any morning dose should be
omitted and the operation performed that morning.
• The first thromboprophylactic dose of LMWH should be given as soon as
possible after delivery provided there is no PPH and regional analgesia has
not been used. [New 2015]
Cautionary use of regional analgesia
techniques in pregnant women on LMWH
Regional analgesia in pregnant women on LMWH
Timing to avoid epidural
can be given
On prophylactic LMWH ≥12 hours after last dose
On therapeutic LMWH ≥24 hours after last dose
Epidural catheter removal
On LMWH 12 hours after last dose
Next dose LMWH ≥4 hours after removal
Thromboprophylaxis after delivery-Assessment of risk
Q:What are the risk factors for VTE after delivery?
1. Class 3 obesity (BMI greater than or equal to 40 kg/m2) - prophylactic LMWH in doses
appropriate for their weight for 10 days after delivery. [New 2015]
2. Women with two or more persisting risk factors -LMWH in prophylactic doses appropriate
for their weight for 10 days after delivery. [New 2015]
3. Previous VTE-All women with a previous history of confirmed VTE should be offered
thromboprophylaxis with LMWH or warfarin for at least 6 weeks postpartum regardless of
the mode of delivery.
4. Asymptomatic thrombophilia- Women with thrombophilia without previous VTE should be
stratified according to both the level of risk associated with their thrombophilia and the
presence or absence of a family history or other risk factors. [New 2015]
5. Women with a family history of VTE and an identified thrombophilia should be considered
for 6 weeks’ postnatal thromboprophylaxis.
6. Caesarean section- All women who have had caesarean sections should be considered for
thromboprophylaxis with LMWH for 10 days after delivery .
Q: For how long should thromboprophylaxis be
continued after delivery?
• Risk assessment should be performed in each woman at least
once following delivery and before discharge.
• Thromboprophylaxis should be continued for 6 weeks in high-risk
women and for 10 days in intermediate-risk women [New 2015]
• In women with additional persistent (lasting more than 10 days
postpartum) risk factors, such as prolonged admission, wound
infection or surgery in the puerperium, thromboprophylaxis
should be extended for up to 6 weeks or until the additional risk
factor/s is/are resloved.
Q:Which agents should be used for thromboprophylaxis?
• Heparin does not cross the placenta, hence there are no fetal adverse effects.
• It prevents clot formation and propagation. LMWH use is preferred in pregnancy for thromboprophylaxis
and treatment of VTE.
• It is an effective anticoagulant, is easy to administer, has less side effects and less maternal bleeding risk
than unfractionated heparin, and levels do not need to be routinely monitored.
• LMWHs are the agents of choice for antenatal and postnatal thromboprophylaxis.
• It is only necessary to monitor the platelet count if the woman has had prior exposure to unfractionated
• Monitoring of anti-Xa levels is not required when LMWH is used for thromboprophylaxis.
• Doses of LMWH should be reduced in women with renal impairment. LMWH is safe in breastfeeding.
Side effects of LMWH
• osteoporosis 1/500 fracture rate – can be severe (e.g. vertebral collapse)
• injection site bruising
• thrombocytopenia – very rare idiosyncratic reaction. Platelet count does not need to be checked unless
patient received UFH before LMWH.
Unfractionated heparin (UFH) and Warfarin
UFH needs to be administered as an infusion for treatment and has more side
effects than LMWH:
• symptomatic vertebral fractures 2%
• allergic reactions
• heparin-induced thrombocytopenia.
Warfarin is an excellent anticoagulant but is not used for the treatment of
antenatal VTE due to its placental passage, which can result in:
• warfarin embryopathy
• fetal bleeding especially intracerebral
• neonatal haemorrhage following delivery.
• There is an increased risk of maternal bleeding, particularly retroplacental
with warfarin use.
More about warfarin embryopathy
• Warfarin is teratogenic and should
be avoided in the first trimester.
• The period of risk is 6–12 weeks so
must be replaced within 2 weeks
of missed period.
• Risk is dose dependent and is
greater if dose is >5 mg per day.
• It can cause chondrodysplasia
punctate, nasal hypoplasia,
chondral calcification, short
proximal limbs and phalanges.
• Women should be offered a choice
of LMWH or oral anticoagulant for
• Postpartum warfarin should be
avoided until at least the fifth day
and for longer in women at
increased risk of postpartum
Characteristics of anticoagulants used to treat VTE
LMWH Anti-Xa* BMI No No 0.04%
Keep APTT 1.5–2.0x
No No 2%
Warfarin INR Keep INR 2.0–3.0 Yes Yes 0
•level only performed if extremes of bodyweight (less than 50 kg or more than 90 kg) or
other complicating risk factors e.g. recurrent VTE or renal impairment. Aim for peak level
3 hour post injection of 0.5–1.2 u/ml.
•Nelson-Piercy C. Handbook of Obstetric Medicine. 5th ed. Taylor & Francis Group; 2015.
Role of newer agents
• Consideration should be given
to the use of newer
argatroban or r-hirudin) in
pregnant women who are
unable to tolerate heparin
(LMWH or unfractionated
heparin) or danaparoid and
who require continuing
• Non-vitamin K antagonist oral
anticoagulants (NOACs e.g.
betrixaban and dabigatran) are
likely to cross the placenta and
should therefore be avoided in
pregnancy and puerperium.
• Aspirin inhibits platelet
• Platelets play a small role in
• Any benefit of aspirin in VTE
prevention appears uncertain
and significantly less than that
• Aspirin is not recommended
for thromboprophylaxis in
Q:Which agents should be used for
In women at very high risk of thrombosis, UFH may be used
peripartum inpreference to LMWH where there is an increased risk
of haemorrhage or where regional anaesthetic techniques may be
• If UFH is used after caesarean section (or other surgery), the
platelet count should be monitored every 2–3 days from days 4–14
or until heparin is stopped. [New 2015]
Potential use of danaparoid should be in conjunction with a
consultant haematologist with expertise in haemostasis and
Q:Which agents should be used for
Reserved for women intolerant of heparin compounds.
Fondaparinux use in pregnancy should be in
conjunction with a consultant haematologist with
expertise in haemostasis and pregnancy.
• Low-dose aspirin
× Aspirin is not recommended for thromboprophylaxis in
obstetric patients. [New 2015]
Q:Which agents should be used for
• Warfarin use in pregnancy is restricted to the few situations where heparin
is considered unsuitable, e.g. some women with mechanical heart valves.
• Women receiving long-term anticoagulation with warfarin can be converted
from LMWH to warfarin postpartum when the risk of haemorrhage is
reduced, usually 5–7 days after delivery.
• Warfarin is safe in breastfeeding.
• Dextran should be avoided antenatally and intrapartum because of the risk
of anaphylactoid reaction.
• Oral thrombin and Xa inhibitors
• Non-vitamin K antagonist oral anticoagulants (NOACs) should be avoided
in pregnant women.[New 2015] and is not currently recommended in
women who are breastfeeding. [New 2015]
Thromboprophylactic doses for
antenatal and postnatal LMWH
Contraindications/cautions to LMWH use
Q: Which women should not be given thromboprophylaxis with
Q: If LMWH is contraindicated? What should be
LMWH should be avoided, discontinued or postponed in
women at risk of bleeding after careful consideration of the
balance of risks of bleeding and thrombosis.
Women with previous or current allergic reactions to
LMWH should be offered an alternative preparation or
alternative form of prophylaxis. [New 2015]
Further advice may be sought from a haematologist with
expertise in the management of thrombosis and bleeding
disorders in pregnancy.
Anti-embolism stockings/Graduated Elastic compression
In addition to starting anticoagulation, the leg should be elevated and GECS should be applied to
reduce oedema. Mobilisation with GECS should be encouraged.
Appropriate size, properly applied, anti-embolism stockings (AES) providing graduated
compression with a calf pressure of 14–15 mmHg is recommended in pregnancy and the
puerperium for women who are hospitalised and have a C/I to LMWH.
These include women who are hospitalised post-
caesarean section (combined with LMWH) and
considered to be at particularly high risk of
more than four risk factors antenatally,
more than two risk factors postnatally)
women travelling long distance for more than 4
hours. [New 2015]
Graduated elastic compression stockings-contd.
• The mechanism of action of GECS is uncertain, but studies have shown that they improve
venous emptying, and increase the blood flow while decreasing the lumen diameter of the
superficial femoral and common femoral vein.
• As most DVT in pregnant women are ileofemoral, properly applied full length GECS are
ideal but if they are ill-fitted or compliance is poor knee length should be considered.
Contraindications to use:
• suspected or proven peripheral arterial disease
• fragile tissue paper skin, dermatitis, gangrene or recent skin graft
• known allergy to material
• peripheral neuropathy
• peripheral arterial bypass grafting
• major limb deformity or unusual leg size or shape
• severe leg oedema
Use with caution in cases of:
• venous ulcers or wounds
Flying in pregnancy
• Although the absolute risk of DVT is small, this risk is likely
to be increased by air travel owing to immobility by
approximately three-fold, with an 18% higher risk of VTE for
each 2-hour increase in flight duration.
• It is now recognised that the risk of VTE is associated with all
• With regard to minimising the risk of DVT, appropriate
general advice would be:
have an aisle seat to facilitate movement
take regular walks around the cabin
carry out in-seat exercises every 30 minutes on a medium or
long haul flight
maintain good fluid intake and minimise caffeine and
for medium- to long-haul flights(lasting > 4hrs) wear
appropriate-sized GEC stockings
LMWH prophylaxix is advised starting from the day of travel
in those with other risk factors of VTE if not already on it.
Contraception and VTE
• Concerns about the role of hormonal contraceptives in mediating thrombosis risk
have been ongoing since the introduction of hormonal contraceptives in the 1960s.
thromboembolism CHC POP IMP DMPA LNG-IUS Cu-IUD
History of VTE 4 2 2 2 2 1
Current VTE (on
anticoagulation) 4 2 2 2 2 1
• Emergency contraception (CU -IUD, Ulipristal acetate, Levonorgestrel) is UKMEC 2
in woman with history of VTE or current VTE.
UK Medical eligibility criteria for contraceptive use
WHAT NICE GUIDELINE RECOMMENDS:
• Interventions for pregnant women and women who gave birth or had a
miscarriage or termination of pregnancy in the past 6 weeks
• Consider LMWH for all women who are admitted to hospital if they are
pregnant or gave birth, had a miscarriage or had a termination of
pregnancy in the past 6 weeks, and whose risk of VTE outweighs their
risk of bleeding. 
• Do not offer VTE prophylaxis to women admitted to hospital or a
midwife-led unit who are in active labour. 
• Stop pharmacological VTE prophylaxis when women are in labour. 
• If using LMWH in pregnant women, start it as soon as possible and within
14 hours of the risk assessment being completed and continue until the
woman is no longer at increased risk of VTE or until discharge from
NICE GUIDELINE RECOMMENDS: Contd.
• If using LMWH in women who gave birth or had a miscarriage or
termination of pregnancy, start 4 to 8 hours after the event unless
contraindicated and continue for a minimum of 7 days. 
• Consider combined prophylaxis with LMWH plus mechanical
prophylaxis for pregnant women or women who gave birth or had a
miscarriage or termination of pregnancy in the past 6 weeks and who
are likely to be immobilised, or have significantly reduced mobility for
3 or more days after surgery, including caesarean section:
Use intermittent pneumatic compression as first-line treatment.
If contraindicated, use anti-embolism stockings.
Continue until the woman no longer has significantly reduced mobility
or until discharge from hospital. 
ACOG guidelines recommends
• women with antithrombin deficiency alone do not need antenatal
prophylaxis whilst most clinicians in the UK would advise it.
• That having been said, hereditary thrombophilia screens should
not be routinely undertaken in pregnancy given the high risk of
thrombosis in antithrombin deficiency.
• However if there is a strong suspicion or family history this may be
• should be interpreted by an experienced haematologist.
• NOTE: Protein C, Protein S and antithrombin III are all altered by
• Pregnancy is a risk factor for venous thromboembolism (VTE), an important cause of
maternal morbidity and mortality. Although there is a 4–5-fold increased risk compared to
that of nonpregnant women of the same age, the absolute risk is low at no more than two
episodes of VTE per 1000 pregnancies.
• There is uncertainty about which women require thromboprophylaxis during pregnancy or
postpartum because of a lack of data from appropriate clinical trials.
• For this reason, recommendations for prophylaxis should be made only after explaining the
available evidence to the patient and taking into account her perception of the balance of
risk and benefit in thromboprophylaxis.
• The aim of these recommendations is to provide clinicians with practical advice to assist in
decisions regarding thromboprophylaxis in women considered to be at risk of VTE during
pregnancy and the postpartum.VTE is a common cause of maternal mortality.
• All women must be risk assessed for VTE at booking, on admission, in labour and
• The first line choice for pharmacological thromboprophylaxis and/or therapy is LMWH.
• Unfractionated heparin (UFH) is used in cases of massive PE, or in cases where rapid
reversibility is required.
• Warfarin is not recommended antenatally other than in specific circumstances. It can be
used for postnatal anticoagulation.
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Notas del editor
Venous thromboembolic disease (VTE) is caused by a blood clot developing in the venous system, usually in the deep veins (deep vein thrombosis [DVT]).
This will cause local symptoms of pain and swelling. If a portion or all of this blood clot detaches, it will travel through the venous system, through the heart and into the pulmonary arterial system where it will lodge. Pulmonary embolus (PE), generally presents with symptoms of chest pain, shortness of breath, and, if sufficiently large, can be fatal.
17.8% of Mauritians are obese, among 6.5% are men and 11.3% are women
If the known low-risk thrombophilia is in a woman with a family history of VTE in a first-degree relative postpartum thromboprophylaxisshould be continued for 6 weeks.
BMI ≥ 30 = 1; BMI ≥ 40 = 2
All women should undergo a documented assessment of risk factors for venous thromboembolism inearly pregnancy or pre-pregnancy. Risk assessment should be repeated if the woman is admitted tohospital for any reason or develops other intercurrent problems. Risk assessment should be repeatedagain intrapartum or immediately postpartum. ACTION: Service managers, health professionals
Reassessment of VTE risk after miscarriage or ectopic pregnancy to consider whether thromboprophylaxisis required is as important as reassessment of risk after giving birth. ACTION: Service managers, healthprofessionals.
Summary of guideline for thromboprophylaxis in women with previous VTE and/orthrombophilia
THESE PATIENTS will often be on long-term oral anticoagulation)
It is likely that these women will be on long-term anticoagulation, although this depends on the circumstances of the thrombotic event. If there was clearly a temporary provoking factor, they may have had a limited duration of anticoagulation.
Prior to testing for thrombophilia, women should be counselled regarding the implications for themselves and family members of a positive or negative result. The results should be interpreted by clinicians with specific expertise in the area.
Heterozygosity for factor V Leiden or prothrombin gene mutation or antiphospholipid antibodies areconsidered as risk factors for thrombosis in asymptomatic women (see Appendix I).
Antenatal thromboprophylaxis for those with previous VTE should begin as early in pregnancy as practical. [New 2015] Women without previous VTE and without particular first trimester risk factors or admission to hospital, but with four other risk factors, should be considered for antenatal prophylaxis throughout pregnancy. [New 2015] Women without previous VTE and without particular first trimester risk factors or admission to hospital, but with three other risk factors, can start antenatal prophylaxis at 28 weeks of gestation.[New 20
All VTE risk assessment should be individualised. The knowledge of thrombophilia is only a single risk factor and must be viewed in context with the rest of the patient's risk factors. For example, a small, thin primigravida who has factor V Leiden (heterozygote) does not need antenatal prophylaxis although this could be considered postnatally, particularly if there are additional VTE risk factors. Conversely, a woman (para 5) with a BMI of 40 with factor V Leiden (heterozygote) would be advised to have LMWH both antenatally and for 6 weeks postnatally.
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