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Emerging Concepts in the Diagnosis and Management of Venous Thromboembolism During Pregnancy

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Abstract

Multiple changes in the coagulation system occur during pregnancy and account for the hypercoagulable state of pregnancy. Consequently, pregnant women are five times more likely to experience venous thromboembolism than non-pregnant women. Although the estimated rates of such events are low, venous thromboembolic disease is a leading cause of maternal death. The administration of intravenous or subcutaneous unfractionated heparin is the treatment and prophylaxis of choice. Warfarin is safe and efficacious following delivery, but should be avoided during pregnancy. LMWH is a promising alternative for treatment and prophylaxis, but further clinical experience is required.

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References

  1. Toglia MR, Weg JG. Venous thromboembolism during pregnancy. N Engl J Med 1996;335:108-114.

    Google Scholar 

  2. Atrash HK, Koonin LM, Lawson HW, et al. Maternal morbidity in the United States 1979-1986. Obstet Gynecol 1990;76:1055-1060.

    Google Scholar 

  3. Bates SM, Ginsberg JS. The special problems of thromboembolism in pregnancy. Intern Med 1997;121-133.

  4. Barbour LA. Current concepts of anticoagulation therapy in pregnancy. Obstet Gynecol Clin North Am 1997;24:499-521.

    Google Scholar 

  5. Bergqvist A, Bergqvist D, Holböök T. Deep vein thrombosis during pregnancy: A prospective study. Acta Obstet Gynecol Scand 1983;62:443-448.

    Google Scholar 

  6. Hellgren M, Nygards EB. Long-term therapy with subcutaneous heparin during pregnancy. Gynecol Obstet Invest 1982;13:76-89.

    Google Scholar 

  7. Tengborn L, Bergqvist D, Mätzsch T, et al. Recurrent thromboembolism in pregnancy and puerperium. Am J Obstet Gynecol 1985;28:107-118.

    Google Scholar 

  8. Ikard RW, Ueland K, Folse R. Lower limb venous dynamics in pregnant women. Surg Gynecol Obstet 1971;132:483.

    Google Scholar 

  9. Woodhams BJ, Candotti G, Shaw R, Kernoff PB. Changes in coagulation and fibrinolysis during pregnancy: evidence of activation of coagulation preceding spontaneous abortion. Thromb Res 1989;55:99-107.

    Google Scholar 

  10. Bremme K, Östlund E, Almqvist I, Heinonen K, Blombäck M. Enhanced thrombin generation and fibrinolytic activity in normal pregnancy and the puerperium. Obstet Gynecol 1992;80:132-137.

    Google Scholar 

  11. Cook G, Walker ID, McCall F, Conkie JA, Greer IA. Familial thrombophilia and activated protein C resistance: thrombotic risk in pregnancy. Br J Haematol 1994;87:873-875.

    Google Scholar 

  12. Friederich PW, Sanson BJ, Simioni P, et al. Frequency of pregnancy-related venous thromboembolism in anticoagulant factor-deficient women: Implications for prophylaxis. Ann Intern Med 1996;125:955-960.

    Google Scholar 

  13. Ginsberg JS, Hirsh J, Rainbow AJ, et al. Risks to the fetus of radiologic procedures used in the diagnosis of maternal venous thromboembolic disease. Thromb Haemost 1989;61:189.

    Google Scholar 

  14. Weinmann EE, Salzman EW. Deep-vein thrombosis. N Engl J Med 1994;331:1630-1641.

    Google Scholar 

  15. Nicholas GG, Lorenz RP, Botti JJ, Chez RA. The frequent occurrence of false-positive results in phleborheography during pregnancy. Surg Gynecol Obstet 1985;161:133-135.

    Google Scholar 

  16. Hull RD, Raskob GE, Carter CJ. Serial impedance plethysmography in pregnant patients with clinically suspected deep vein thrombosis. Clinical validity of negative findings. Ann Intern Med 1990;112:663.

    Google Scholar 

  17. Spritzer CE, Evans AC, Kay HH. Magnetic resonance imaging of deep venous thrombosis in pregnant women with lower extremity edema. Obstet Gynecol 1995;85:603-607.

    Google Scholar 

  18. Hull R, Hirsch J, Sackett DL, et al. Clinical validity of a negative venogram in patients with clinically suspected venous thrombosis. Circulation 1981; 64:622.

    Google Scholar 

  19. Ginsberg JS, Hirsh J, Rainbow AJ, Coates G. Risks to the fetus of radiologic procedures used in the diagnosis of maternal venous thromboembolic disease. Thromb Haemost 1989;61:189-196.

    Google Scholar 

  20. De Orme M, Lewis PJ, deSwiet M, et al. May mothers given warfarin breast-feed their infants? BMJ 1977;1:1564-1565.

    Google Scholar 

  21. Ginsberg JS, Hirsh J. Use of antithrombotic agents during pregnancy. Chest 1995;108(Suppl):305S-311S.

    Google Scholar 

  22. Dahlman T, Lindvall N, Hellgren M. Osteopenia in pregnancy during long-term heparin treatment: a radiological study post partum. Br J Obstet Gynaecol 1990;97:221-228.

    Google Scholar 

  23. Koopman MM, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The Tasman Study Group. N Engl J Med 1996;334:682.

    Google Scholar 

  24. Levine M, Gent M, Hirsh J, et al. A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep vein thrombosis. N Engl J Med 1996;334:677.

    Google Scholar 

  25. Nurmohamed MT, Rosendaal FR, Buller HR, et al. Low-molecular-weight heparin versus standard heparin in general and orthopedic surgery: A meta-analysis. Lancet 1992;340:152.

    Google Scholar 

  26. Simonneau G, Sors H, Charbonnier B, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. N Engl J Med 1997;337:663-669.

    Google Scholar 

  27. The Columbus Investigators. Low-molecular-weight heparin in the treatment of patients with venous thromboembolism. N Engl J Med 1997;337:657-662.

    Google Scholar 

  28. Omri A, Delaloye JF, Anderson H, et al. Low molecular weight heparin Novo (LHN-1) does not cross the placenta during the second trimester of pregnancy. Thromb Haemost 1989;61:55-56.

    Google Scholar 

  29. Rasmussen C, Wadt B, Jacobsen B. Thromboembolic prophylaxis with low molecular weight heparin during pregnancy. Int J Gynecol 1994;147:121-125.

    Google Scholar 

  30. Barbour LA, Pickard JA. Controversies in thromboembolic disease during pregnancy: A critical review. Obstet Gynecol 1995;86:621-633.

    Google Scholar 

  31. Hyers T, Hull RD, Wey JG. Antithrombotic therapy for venous thromboembolic disease. Chest 1995;108(suppl): S335-S351.

    Google Scholar 

  32. Levine MN, Goldhaber SZ, Gore JM, et al. Hemorrhagic complications of thrombolytic therapy in the treatment of myocardial infarction and venous thromboembolism. Chest 1995;108:S291-S301.

    Google Scholar 

  33. Turrentine MA, Braems G, Ramirez MM. Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Obstet Gynecol Surv 1995;50:534-541.

    Google Scholar 

  34. Hirsh J. Heparin. N Engl J Med 1991;324:1565-1574.

    Google Scholar 

  35. Hull RD, Raskob GE, Rosenbloom D, et al. Optimal therapeutic level of heparin therapy in patients with venous thrombosis. Arch Intern Med 1992;152:1589-1595.

    Google Scholar 

  36. Hirsh J, Raschke R, Warkentin TE, et al. Heparin: Mechanisms of action, pharmacokinetics, dosing considerations, monitoring, efficacy, and safety. Chest 1995;108(suppl):258-275.

    Google Scholar 

  37. Brancazio LR, Roperti KA, Stierer R, et al. Pharmacokinetics and pharmacodynamics of subcutaneous heparin during the early third trimester of pregnancy. Am J Obstet Gynecol 1995;173:1240-1245.

    Google Scholar 

  38. Anderson DR, Ginsberg JS, Brill-Edwards P, Demers C, Burrows RF, Hirsh J. The use of an indwelling Teflon catheter for subcutaneous heparin administration during pregnancy: A randomized crossover study. Arch Intern Med 1993;153:841-844.

    Google Scholar 

  39. Gillis A, Shushan A, Eldor A. Use of low molecular weight heparin for prophylaxis and treatment of thromboembolism in pregnancy. Int J Gynecol Obstet 1992;39:297-301.

    Google Scholar 

  40. Melissari E, Parker CJ, Wilson NV, et al. Use of low molecular weight heparin in pregnancy. Thromb Haemost 1992;68:652-656.

    Google Scholar 

  41. Jha R, Lindow SW, Masson EA, Atkin SL. High dose low-molecular-weight heparin (enoxaparin) for the treatment of recurrent thromboembolism in pregnancy. J Obstet Gynecol 1997;17:158.

    Google Scholar 

  42. Anand SS, Brimble S, Ginsberg JS. Management of iliofemoral thrombosis in a pregnant patient with heparin resistance. Arch Intern Med 1997;157:815-816.

    Google Scholar 

  43. Hyers TM, Hull RD, Weg JG. Antithrombotic therapy for venous thromboembolic disease. Chest 1995;108(suppl):335S-351S.

    Google Scholar 

  44. Scurr J, Stannard P, Wright J. Extensive thromboembolic disease in pregnancy treated with a Kimray Greenfield vena cava filter. Case report. Br J Obstet Gynaecol 1981;88:778.

    Google Scholar 

  45. Banfield PJ, Pittam M, Marwood R. Recurrent pulmonary embolism in pregnancy managed with the Greenfield vena caval filter. Int J Gynaecol Obstet 1990;33:275.

    Google Scholar 

  46. Dahlman TC, Hellgren MS, Blombäck M. Thrombosis prophylaxis in pregnancy with use of subcutaneous heparin adjusted by monitoring heparin concentration in plasma. Am J Obstet Gynecol 1989;161:420-425.

    Google Scholar 

  47. Horlocker TT. Central neural blockage for patients receiving anticoagulants. In: Barash PG, Cullen BF, Stoelling RK, eds. Clinical Anesthesia Updates, Vol 5. Philadelphia: J.B. Lippincott, 1994:1-9.

    Google Scholar 

  48. de Swiet M, Floyd E, Letsley E. Low risk of recurrent thromboembolism in pregnancy. Br J Hosp Med 1987;38:264.

    Google Scholar 

  49. Anderson DR, Ginsberg JS, Burrows R, Brill-Edwards P. Subcutaneous heparin therapy during pregnancy: a need for concern at the time of delivery. Thromb Haemost 1991;65:248-250.

    Google Scholar 

  50. De Stefano V, Leone G, Mastrangelo S, et al. Thrombosis during pregnancy and surgery in patients with congenital deficiency of antithrombin III, protein C, protein S. Thromb Haemost 1994;71:799.

    Google Scholar 

  51. Hellgren M, Tengborn L, Abildgaard U. Pregnancy in women with congenital antithrombin III deficiency: experience of treatment with heparin and antithrombin. Gynecol Obstet Invest 1982;14:127-141.

    Google Scholar 

  52. Finazzi G, Barbui T. Different incidence of venous thrombosis in patients with inherited deficiencies of antithrombin III, protein C and protein S. Thromb Haemost 1994;71:15-18.

    Google Scholar 

  53. Hirsh J, Hoak J. Management of deep vein thrombosis and pulmonary embolism. A statement for healthcare professionals. Circulation 1996;93:2212.

    Google Scholar 

  54. Guidelines on the prevention, investigation, and management of thrombosis associated with pregnancy. Maternal and Neonatal Haemostasis Working Party of the Haemostasis and Thrombosis Task. J Clin Pathol 1993;46:489.

    Google Scholar 

  55. Khamashta MA, Cuadrado MJ, Mujic F, Taub NA, Hunt BJ, Hughes GRV. The management of thrombosis in the antiphospholipid-antibody syndrome. N Engl J Med 1995;332:993-997.

    Google Scholar 

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Burns, M.M. Emerging Concepts in the Diagnosis and Management of Venous Thromboembolism During Pregnancy. J Thromb Thrombolysis 10, 59–68 (2000). https://doi.org/10.1023/A:1018750822218

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