Hematology and Oncology Book

Anemia

Cardiovascular Medicine

  • Thromboembolic Disease in Pregnancy

Coagulopathy

Hemolytic Disorders

Pharmacology

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Thromboembolic Disease in PregnancyAka: Deep Vein Thrombosis in Pregnancy, Deep Venous Thrombosis During Pregnancy, DVT in Pregnancy

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  1. See Also
    1. Deep Vein Thrombosis
    2. Pulmonary Embolism
    3. Pulmonary Embolism in Pregnancy
  2. Epidemiology
    1. Venous Thrombosis risk: 0.5 to 1.0 per 1000 pregnancies
    2. Thromboembolism risk is increased 5 fold in pregnancy
    3. DVT occurs equally in all trimesters
  3. Pathophysiology
    1. Hypercoagulation in pregnancy
      1. Procoagulants increase
        1. Factor II, Factor VII, Factor X and Fibrin
      2. Anticoagulants decrease
        1. Protein C resistance and decreased Protein S
    2. Venous Stasis increases in pregnancy
      1. Increased intravascular volume distends veins
      2. Inferior vena cava obstructed from uterus
    3. Vascular damage
      1. Related to vaginal and ceserean delivery
  4. Risk Factors
    1. Primary Thrombophilia (e.g. Factor V Leiden)
    2. Deep Vein Thrombosis history in past
    3. Mechanical heart valve
    4. Atrial Fibrillation
    5. Inflammatory Bowel Disease
    6. Nephrotic Syndrome
    7. Antiphospholipid Syndrome
    8. Prolonged immobilization (e.g. bed rest)
    9. Recent major surgery or trauma
    10. Age over 35 years
    11. Weight over 80 kg
    12. Multiparity over 4 deliveries
    13. Preeclampsia
    14. Current infection
  5. Symptoms
    1. Unilateral swelling and discomfort of one leg
  6. Signs
    1. See Deep Vein Thrombosis
    2. Lower leg circumference >2 cm difference is significant
    3. Superficial phlebitis may occur
    4. Iliofemoral or pelvic veins may be involved
  7. Radiology
    1. Perform late Pregnancy Testing in lateral decubitus
    2. Testing options
      1. Duplex Doppler Ultrasound (DDUS) or
      2. Impedence Plethysmography (IPG)
  8. Evaluation of suspected DVT
    1. Step 1: DDUS or IPG study (see radiology above)
      1. Positive for DVT: Anticoagulation
      2. Negative: Go to Step 2 if high clinical suspicion
    2. Step 2: Repeat DDUS or IPG study
      1. Positive for DVT: Anticoagulation
      2. Negative: Go to Step 3 if high clinical suspicion
    3. Step 3: Venography with abdominal shield or MRI
      1. Positive for DVT: Anticoagulation
      2. Equivocal: Anticoagulation if high clinical suspicion
  9. Prevention: DVT Prophylaxis
    1. Indications
      1. Mechanical Heart valve
      2. Rheumatic Heart Disease
      3. Atrial Fibrillation
      4. Antithrombin III deficiency
      5. Antiphospholipid Syndrome
      6. Prior Anticoagulation therapy
      7. Factor V Leiden Defect
      8. Prothrombin G20210A Mutation
    2. Protocol
      1. Unfractionated Heparin
        1. Low dose prophylaxis
          1. First trimester: 5000 to 7000 Units q12 hours
          2. Second trimester: 7500 to 10,000 Units q12 hours
          3. Third trimester: 10,000 Units q12 hours
            1. Unless aPTT elevated
        2. Adjusted dose prophylaxis to aPTT of 1.5 to 2.5
          1. Dose: 10,000 q8-12 hours
          2. Goal aPTT: 1.5 to 2.5 times normal
      2. Low Molecular Weight Heparin
        1. Low dose prophylaxis
          1. Dalteparin 5000 units qd to bid
          2. Enoxaparin 40 mg qd to bid
        2. Adjusted dose prophylaxis
          1. Dalteparin 5000 to 10,000 units q12 hours
          2. Enoxaparin 30 to 80 mg q12 hours
  10. Complications
    1. Pulmonary Embolism
  11. References
    1. (2000) ACOG Practice Bulletin 19:1-10

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