Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period

Authors

  • Claire MCLINTOCK,

    1. National Women’s Health, Auckland City Hospital, Grafton, Auckland, New Zealand
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  • Tim BRIGHTON,

    1. Department of Haematology, Prince of Wales Hospital, Sydney, New South Wales
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  • Sanjeev CHUNILAL,

    1. Clinical Haematology Department, Monash Medical Centre, Clayton
    2. Australian Centre for Blood Diseases, Monash University, Prahran, Victoria
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  • Gus DEKKER,

    1. Discipline of Obstetrics and Gynaecology, University of Adelaide, Lyell McEwin Hospital
    2. Department of Obstetrics and Gynaecology, Women’s and Children’s Hospital, Elizabeth Vale, North Adelaide, South Australia
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  • Nolan MCDONNELL,

    1. Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, and School of Women’s and Infants’ Health and School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
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  • Simon MCRAE,

    1. Department of Haematology, SA Pathology, Royal Adelaide Hospital
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  • Peter MULLER,

    1. Department of Perinatal Medicine, Women’s and Children’s Hospital, North Adelaide, South Australia
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  • Huyen TRAN,

    1. Clinical Haematology Department, Monash Medical Centre, Clayton
    2. Australian Centre for Blood Diseases, Monash University, Prahran, Victoria
    3. The Alfred Hospital, Prahran, Victoria
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  • Barry N.J. WALTERS,

    1. Obstetrics and Gynaecology Clinical Care Unit, King Edward Memorial Hospital for Women, Subiaco, Perth, Western Australia, Australia
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  • Laura YOUNG

    1. Department of Haematology, Auckland City Hospital
    2. Department of Molecular Medicine and Pathology, University of Auckland, Auckland, New Zealand
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Dr Claire McLintock, Haematologist and Obstetric Physician, Lead Clinician Obstetric Medicine, National Women’s Health, Auckland City Hospital, Level 9, Support Building, Park Rd, Grafton, Private Bag 92024, Auckland 1142, New Zealand. Email: claire.mclintock@adhb.govt.nz

Abstract

Venous thromboembolism (VTE) in pregnancy and the postpartum is an important cause of maternal morbidity and mortality; yet, there are few robust data from clinical trials to inform an approach to diagnosis and management. Failure to investigate symptoms suggestive of pulmonary embolism (PE) is a consistent finding in maternal death enquiries, and clinical symptoms should not be relied on to exclude or diagnose VTE. In this consensus statement, we present our recommendations for the diagnosis and management of acute deep venous thrombosis (DVT) and PE. All women with suspected DVT in pregnancy should be investigated with whole leg compression ultrasonography. If the scan is negative and significant clinical suspicion remains, then further imaging for iliofemoral DVT maybe required. Imaging should be undertaken in all women with suspected PE, as the fetal radiation exposure with both ventilation/perfusion scans and CT pulmonary angiography is within safe limits. Low-molecular-weight heparin (LMWH) is the preferred therapy for acute VTE that occur during pregnancy. In observational cohort studies, using once-daily regimens appears adequate, in particular with the LMWH tinzaparin; however, pharmacokinetic data support twice-daily therapy with other LMWH and is recommended, at least initially, for PE or iliofemoral DVT in pregnancy. Treatment should continue for a minimum duration of six months, and until at least six weeks postpartum. Induction of labour or planned caesarean section maybe required to allow an appropriate transition to unfractionated heparin to avoid delivery in women in therapeutic doses of anticoagulation.

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