Venous Thromboembolism in the Context of Pregnancy

Publication Date: November 27, 2018
Last Updated: March 14, 2022

Recommendations

Treatment of acute VTE and superficial vein thrombosis

For pregnant women with acute VTE, the American Society of Hematology (ASH) guideline panel recommends antithrombotic therapy compared with no antithrombotic therapy. (1⊕⊕⊕⊕)
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For pregnant women with acute VTE, the ASH guideline panel recommends low-molecular-weight heparin (LMWH) over unfractionated heparin (UFH). (1⊕⊕⊕o)
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For pregnant women with proven acute superficial vein thrombosis, the ASH guideline panel suggests using LMWH over not using any anticoagulant. (2⊕⊕oo)
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For pregnant women with acute VTE treated with LMWH, the ASH guideline panel suggests either once-per-day or twice-per-day dosing regimens. (2⊕ooo)
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For pregnant women receiving therapeutic-dose LMWH for the treatment of VTE, the ASH guideline panel suggests against routine monitoring of anti-FXa levels to guide dosing. (2⊕⊕oo)
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For pregnant women with acute lower-extremity deep vein thrombosis (DVT), the ASH guideline panel suggests against the addition of catheter-directed thrombolysis therapy to anticoagulation. (2⊕⊕oo)
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For pregnant women with acute pulmonary embolism and right ventricular dysfunction in the absence of hemodynamic instability, the ASH guideline panel suggests against the addition of systemic thrombolytic therapy to anticoagulation compared with anticoagulation alone. (2⊕⊕oo)
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For pregnant women with acute pulmonary embolism and life-threatening hemodynamic instability, the ASH guideline panel suggests administering systemic thrombolytic therapy in addition to anticoagulant therapy. (2⊕ooo)
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For pregnant women with low-risk acute VTE, the ASH guideline panel suggests initial outpatient therapy over hospital admission. (2⊕⊕oo)
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Management of anticoagulants around the time of delivery

For pregnant women receiving therapeutic-dose LMWH for the management of VTE, the ASH guideline panel suggests scheduled delivery with prior discontinuation of anticoagulant therapy. (2⊕⊕oo)
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For pregnant women receiving prophylactic-dose LMWH, the ASH guideline panel suggests against scheduled delivery with discontinuation of prophylactic anticoagulation compared with allowing spontaneous labor. (2⊕ooo)
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Anticoagulant use in breastfeeding women

For breastfeeding women who have an indication for anticoagulation, the ASH guideline panel recommends using UFH, LMWH, warfarin, acenocoumarol, fondaparinux, or danaparoid as safe options. (1⊕⊕oo)
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For breastfeeding women who have an indication for anticoagulation, the ASH guideline panel recommends using UFH, LMWH, warfarin, acenocoumarol, fondaparinux, or danaparoid as safe options. (1⊕ooo)
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Prevention of VTE

For unselected women undergoing assisted reproductive therapy, the ASH guideline panel suggests against prophylactic antithrombotic therapy to prevent VTE. (2⊕⊕oo)
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For women undergoing assisted reproductive therapy who develop severe ovarian hyperstimulation syndrome, the ASH guideline panel suggests prophylactic antithrombotic therapy to prevent VTE. (2⊕⊕oo)
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For women not already receiving long-term anticoagulant therapy who have a history of VTE that was unprovoked or associated with a hormonal risk factor, the ASH guideline panel recommends antepartum anticoagulant prophylaxis over no anticoagulant prophylaxis. (1⊕⊕oo)
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For women not already receiving long-term anticoagulant therapy who have a history of prior VTE associated with a nonhormonal temporary provoking risk factor and no other risk factors, the ASH guideline panel suggests against antepartum anticoagulant prophylaxis. (2⊕⊕oo)
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For women not already receiving long-term anticoagulant therapy who have a history of VTE, the ASH guideline panel recommends postpartum anticoagulant prophylaxis. (1⊕⊕oo)
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For women who are heterozygous for the factor V Leiden or prothrombin mutation and in those who have protein C or S deficiency, regardless of family history of VTE, the ASH guideline panel suggests against using antepartum antithrombotic prophylaxis to prevent a first venous thromboembolic event. (2⊕ooo)
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For women who have no family history of VTE but have antithrombin deficiency or are homozygous for the prothrombin gene mutation, the ASH guideline panel suggests against using antepartum antithrombotic prophylaxis to prevent a first venous thromboembolic event. (2⊕ooo)
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For women with antithrombin deficiency who have a family history of VTE and for those who are homozygous for the factor V Leiden mutation or who have combined thrombophilias, regardless of family history of VTE, the ASH guideline panel suggests antepartum antithrombotic prophylaxis to prevent a first venous thromboembolic event. (2⊕ooo)
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For women without a family history of VTE who are heterozygous for the factor V Leiden mutation or prothrombin mutation or who have antithrombin, protein C, or protein S deficiency, the ASH guideline panel suggests against antithrombotic prophylaxis in the postpartum period to prevent a first venous thromboembolic event. (2⊕ooo)
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For women with a family history of VTE who are heterozygous for the factor V Leiden mutation or prothrombin mutation, the ASH guideline panel suggests against postpartum antithrombotic prophylaxis to prevent a first venous thromboembolic event. (2⊕ooo)
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For women with a family history of VTE who have antithrombin deficiency, the ASH guideline panel recommends postpartum antithrombotic prophylaxis to prevent a first venous thromboembolic event. (1⊕⊕⊕o)
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For women with a family history of VTE who have protein C or protein S deficiency, the ASH guideline panel suggests postpartum antithrombotic prophylaxis to prevent a first venous thromboembolic event. (2⊕ooo)
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For women with combined thrombophilias or who are homozygous for the factor V Leiden mutation or prothrombin gene mutation, regardless of family history, the ASH guideline panel suggests postpartum antithrombotic prophylaxis to prevent a first venous thromboembolic event. (2⊕ooo)
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For women with no or 1 clinical risk factor (excluding a known thrombophilia or history of VTE), the ASH guideline panel suggests against antepartum or postpartum prophylaxis. (2⊕⊕oo)
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For pregnant women who require prophylaxis, the ASH guideline panel suggests against intermediate-dose LMWH prophylaxis compared with standard-dose LMWH prophylaxis during the antepartum period. (2⊕ooo)
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For women who require prophylaxis, the ASH guideline panel suggests either standard- or intermediate-dose LMWH prophylaxis during the postpartum period. (2⊕ooo)
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Diagnosis of VTE

For pregnant women with suspected pulmonary embolism, the ASH guideline panel suggests ventilation-perfusion (V/Q) lung scanning over computed tomography (CT) pulmonary angiography. (2⊕⊕oo)
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For pregnant women with suspected DVT, the ASH guideline panel suggests additional investigations, including serial compression ultrasound or magnetic resonance venography compared with no further investigations after an initial negative ultrasound with imaging of the iliac veins. (2⊕⊕oo)
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Recommendation Grading

Disclaimer

Overview

Title

Venous Thromboembolism in the Context of Pregnancy

Authoring Organization

Publication Month/Year

November 27, 2018

Last Updated Month/Year

June 9, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and others in decisions about the prevention and management of pregnancy-associated VTE.

Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Prevention, Treatment

Diseases/Conditions (MeSH)

D054556 - Venous Thromboembolism, D020246 - Venous Thrombosis, D011247 - Pregnancy, D011250 - Pregnancy Complications, Hematologic

Keywords

anticoagulation, pregnancy, Venous Thromboembolism, Anticoagulation

Source Citation


Blood Adv (2018) 2 (22): 3317–3359.
https://doi.org/10.1182/bloodadvances.2018024802