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Overview of prevention of venous thrombosis in pregnant and postpartum women
Robert D Auerbach, MD
Charles J Lockwood, MD
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INTRODUCTION — Virchow's classic triad of stasis, hypercoagulability, and vascular trauma is present during pregnancy. Stasis results from compression via the gravid uterus and via estradiol-mediated increase in deep venous capacitance [1]. Hypercoagulability is a result of an increase in coagulation factors (I, II, VII, VIII, IX, X), a decrease in protein S, an increase in resistance to activated protein C, and an increase in fibrinolytic inhibitors (plasminogen activator inhibitor type-1 and type-2) [2-4]. Vascular trauma may occur during childbirth, particularly following operative vaginal or cesarean delivery. Because of these changes, pregnancy is associated with a risk of thrombosis three- to ten-fold higher than the risk in nonpregnant women (incidence of pregnancy-related venous thromboembolism 0.71 to 1.72 per 1000 pregnancies, mortality 1.1 per 100,000 deliveries) [5-8]. Manifestations of maternal thrombotic events include superficial and deep vein thrombosis, pulmonary embolus, septic pelvic thrombophlebitis, and ovarian vein thrombosis.
Indications for and use of anticoagulation to prevent thrombotic complications in pregnant and postpartum women will be discussed here. Anticoagulation of women with prosthetic heart values, acute venous thrombosis, pulmonary embolism, previous thromboembolism, and recurrent pregnancy loss are reviewed separately. (See "Anticoagulation during pregnancy", see "Management of pregnant women with prosthetic heart valves", see "Deep vein thrombosis and pulmonary embolism in pregnancy" and see "Evaluation and management of couples with recurrent pregnancy loss").
RISK FACTORS FOR THROMBOEMBOLISM — Risk factors associated with venous thromboembolism (VTE) are shown in Table 1 (show table 1) [5,9-14]. The magnitude of risk attributable to these factors is difficult to quantify and often not consistent across studies. The risk of thrombosis in pregnant patients with thrombophilias depends upon the thrombophilia (show table 2). The most important determinant of VTE risk in thrombophilic pregnant patients is a personal or family history of VTE [15]. For women with a previous VTE, the best estimate for risk of recurrence during pregnancy in untreated women is 2.4 percent (95% CI 0.2-6.9 percent) versus about 0.1 percent in the general obstetrical population [6,16]. The best estimate of the overall incidence of post-cesarean delivery thrombosis is 0.9 percent [11].
INDICATIONS FOR VTE PROPHYLAXIS — VTE has become the leading cause of maternal mortality in developed countries [17,18] and serious long-term maternal morbidity from chronic venous insufficiency may occur in survivors [19]. Nevertheless, there are few data from randomized trials on which to base recommendations for VTE prophylaxis. Guidelines based mainly on expert opinion have been produced by the Royal College of Obstetricians and Gynaecologists (RCOG) in the United Kingdom [20], the American College of Chest Physicians [21], and the British Society for Haematology [22].
Antepartum VTE prophylaxis — Thromboprophylaxis is recommended throughout pregnancy for women at high risk of VTE, unless the risk factor can be removed. It should begin as early in pregnancy as is practical since the frequency of VTE is similar in each trimester [23]. Candidates for antepartum prophylaxis include:
Selected women with highly thrombogenic acquired or inherited thrombophilias or those with lesser thrombogenic thrombophilias and a personal or strong family history of VTE (show table 3) (See "Inherited thrombophilias in pregnancy" section on Indications for treatment).
Women with idiopathic VTE during a previous pregnancy or in the nonpregnant state. (See "Anticoagulation during pregnancy" section on Venous thromboembolism).
By comparison, women with a single prior VTE outside of pregnancy and related to a nonrecurring (temporary) risk factor, such as an recent major surgery, trauma, or immobilization, are at low risk of recurrence during pregnancy in the absence of an underlying thrombophilia, family history of VTE in a first degree relative, or VTE in an unusual location (eg, axillary vein) [16]. Therefore, routine antepartum anticoagulation is not necessary in these women. However, prophylaxis should be administered postpartum when the risk of thrombosis is higher than the antepartum risk (see "Postpartum management" below) [21,23].
There is no consensus as to whether VTE related to use of oral contraceptive pills should be categorized as a nonrecurring risk factor with low risk of recurrence during pregnancy [16] or hormonally mediated with high risk of recurrence during pregnancy.
Women who have risk factors (show table 1), alone or in combination, that in the ju
ment of the clinician significantly increases their risk of antepartum VTE. (See "Prevention of venous thromboembolic disease").
Postpartum VTE prophylaxis
All women who received antepartum prophylaxis (except if the only indication is previous adverse pregnancy outcome)
All women with a prior VTE
Women with inherited lower risk thrombophilias (heterozygotes for factor V Leiden, prothrombin G20210A mutation, protein C or S deficiency; hyperhomocysteinemia unresponsive to folate therapy) but no personal history of VTE who undergo cesarean delivery [24] and, possibly, if they have a first degree relative with VTE or additional risk factors for thrombosis (show table 1). These women do not typically require antepartum prophylaxis because their risk of thromboembolism antepartum is likely less than 1 percent [25]. (See "Inherited thrombophilias in pregnancy").
Women who are at high risk of VTE because of one or more risk factors from Table 1 (show table 1)
Postpartum management of these women is discussed below (see "Postpartum management" below).
Cesarean delivery — Cesarean delivery is associated with a three- to five-fold increase in risk of thromboembolism compared to vaginal birth [11,26]. In three large series, 30, 67, and 76 percent of postpartum deaths due to pulmonary embolus occurred in women who delivered by cesarean section [5,14,27]. For this reason, thromboprophylaxis has been advocated for women undergoing transabdominal delivery.
However, selection of appropriate candidates for thromboprophylaxis is controversial. The benefit of prevention of VTE related morbidity and mortality needs to be balanced against the morbidity and cost of pharmacologic therapy and compared against alternative therapies (compression stockings or boots) or no therapy (see "Nonpharmacologic alternatives" below).
In 1995, the RCOG recommended heparin prophylaxis based on risk status (show table 4). However, 20 percent of women who developed VTE postpartum had no recognizable risk factors and only 30 percent of at-risk women received thromboprophylaxis [22]. As a result, in 2001 the RCOG recommended heparin prophylaxis for all women undergoing cesarean delivery.
By comparison, a 2001 Cochrane review on use of prophylaxis for prevention of VTE in pregnancy concluded there was insufficient evidence on which to base a recommendation [28]. Only two small randomized studies comparing use of heparin (unfractionated or LMWH) to placebo in women undergoing cesarean delivery were available [29,30].
Since the benefit of routine thromboprophylaxis has not been proven and since minor bleeding (impaired surgical hemostasis, wound hematoma) is more common in patients receiving these drugs [31], most clinicians do not recommend routine use of heparin thromboprophylaxis in all women undergoing cesarean delivery. In pregnancy, one cohort study suggested that use of graduated elastic compression stockings reduced the prevalence of postpartum VTE from 4.3 percent to 0.9 percent [32].
Pneumatic boots do not increase the risk of bleeding complications and may be more efficacious than compression stockings [33]; however, their efficacy in this patient population has also not been proven, nor has the cost-benefit been evaluated.
Given their safety and potential efficacy, we suggest that clinicians use these devices in all patients undergoing a cesarean delivery who have additional risk factors for VTE. (See "Prevention of venous thromboembolic disease" sections on Intermittent leg compression and graduated compression stockings).
Vaginal delivery — There are no data on which to base recommendations for postpartum prophylaxis after vaginal delivery in women with no history of VTE or thrombophilia. The RCOG has opined that clinical ju
ment should be used in deciding whether an individual patient receives postpartum thromboprophylaxis [23]. They suggested that women with combinations of risk factors (show table 1) should be considered for a three- to five-day course of LMWH postpartum, and possibly antepartum therapy as well. We suggest a short-term intervention for prophylaxis of VTE in nonambulatory women with risk factors for thrombosis (see "Postpartum management" below).