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Prepublished online as a Blood First Edition Paper on July 12, 2002; DOI 10.1182/blood-2002-03-0965.
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Blood, 15 November 2002, Vol. 100, No. 10, pp. 3470-3478
HOW I TREAT
How we manage venous thromboembolism during pregnancy
Shannon M. Bates and
Jeffrey S. Ginsberg
From the Department of Medicine, McMaster University,
Hamilton, ON, Canada.
During pregnancy, physiologic and anatomic changes can
complicate the diagnosis of venous thromboembolism (VTE) as well as the
management of patients with a high risk of or established VTE. As in
nonpregnant subjects, clinical diagnosis of VTE by itself is unreliable
and accurate objective testing is essential. Few diagnostic studies of
VTE have been performed in pregnant women and, therefore, approaches
are largely extrapolated from those used in nonpregnant subjects with
modifications to limit the radiation exposure and overcome the
limitations of diagnostic testing in pregnancy. Therapy of established
VTE during pregnancy consists of therapeutic doses of unfractionated
heparin (UFH) or low-molecular-weight heparin (LMWH), generally given
throughout pregnancy subcutaneously and for 4 to 6 weeks after
childbirth. A key unresolved issue includes the optimum dosing of LMWH
therapy. Maternal warfarin can be safely used after childbirth because it is safe to use in the breast-fed infant of a mother receiving warfarin. Finally, pregnant women with prior VTE (with or without a
hypercoagulable state) have an increased risk of recurrent venous thrombosis. A recent study has demonstrated that for women with a
single episode of prior VTE, many can be managed without
anticoagulants. However, for many, anticoagulant therapy with
prophylactic UFH or LMWH is a reasonable option.
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