How I treat pregnancy-related venous thromboembolism

Abstract

Venous thromboembolism (VTE) complicates ϳ 1 to 2 of 1000 pregnancies, with pulmonary embolism being a leading cause of maternal mortality and deep vein thrombosis an important cause of maternal morbidity, also on the long term. However, a strong evidence base for the management of pregnancy-related VTE is missing. Management is not standardized between physicians, centers, and countries. The management of pregnancy-related VTE is based on extrapolation from the nonpregnant population, and clinical trial data for the optimal treatment are not available. Lowmolecular-weight heparin (LMWH) in therapeutic doses is the treatment of choice during pregnancy, and anticoagulation (LMWH or vitamin K antagonists postpartum) should be continued until 6 weeks after delivery with a minimum total duration of 3 months. Use of LMWH or vitamin K antagonists does not preclude breastfeeding.Whether dosing should be based on weight or anti-Xa levels is unknown, and practices differ between centers. Management of delivery, including the type of anesthesia if deemed necessary, requires a multidisciplinary approach, and several options are possible, depending on local preferences and patient-specific conditions. (Blood. 2011;118(20):5394-5400)

Treatment and diagnosis of pulmonary embolism in pregnancy

“…Nöroaksiyel blokaj uygulanan hastalarda DMAH'lar profilaktik dozda kateter çekildikten 12 saat sonra başlanabilirken, terapatik dozda ise 24 saatten önce DMAH başlanmamalıdır (45,46). DMAH'ların ya da varfarinin doğumdan sonra en az 6 hafta ya da total olarak en az 3 ay kullanılması önerilmektedir (28).…”

“…Gebelerde trombolitik tedavi gebe olmayan hastalarda kullanıldığında görülen kanama riskine benzer risk taşımaktadır (45,46). Gebelerde trombolitik ilaçların kullanımıyla ilgili büyük çalışmalar yoktur, bu nedenle bu konuda deneyim sınırlıdır.…”

“…Direkt trombin inhibitörleri (dabigatran) ve anti-Xa inhibitörleri (rivaroksaban, apiksaban gibi) ile gebelerde gelişen VTE durumlarında kullanımı ile ilgili bir veri olmadığından, bu ilaçların gebelerde kullanımı kontrendikedir (46).…”

Current challenges in diagnostic imaging of venous thromboembolism

“…Of note, although never studied specifically, the yield of CUS in patients presenting with PE symptoms during pregnancy without signs of DVT is likely low (Figure 4). 51 According to North American guidelines on diagnosis of PE in pregnancy, V-Q lung scintigraphy is to be considered as the first-line diagnostic test, especially in the presence of a normal chest x-ray, and…”

Non- Surgical Approach in a Case of Placenta Accreta Complicated by a Pulmonary Embolus

“…The risk of venous thromboembolism is 60 times greater in a post-partum woman compared to other women in the same age group. When pulmonary embolus (PE) is diagnosed in a patient, anticoagulation should be started immediately with heparin if the patient is pregnant and with warfarin if the patient is in the post-partum period, and should be continued for at least six weeks (3). in a patient with the placenta left in place during a cesarean section is presented here and the difficulties in the treatment of placenta accreta due to anticoagulant treatment, which was given for the treatment of PE, are discussed.…”