title: Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period.
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.
authors.affiliation: National Women's Health, Auckland City Hospital, Grafton, New Zealand. claire.mclintock@adhb.govt.nz
authors.forename: Claire
authors.initials: C
authors.lastname: McLintock
authors.forename: Tim
authors.initials: T
authors.lastname: Brighton
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Chunilal
authors.forename: Gus
authors.initials: G
authors.lastname: Dekker
authors.forename: Nolan
authors.initials: N
authors.lastname: McDonnell
authors.forename: Simon
authors.initials: S
authors.lastname: McRae
authors.forename: Peter
authors.initials: P
authors.lastname: Muller
authors.forename: Huyen
authors.initials: H
authors.lastname: Tran
authors.forename: Barry N J
authors.initials: BN
authors.lastname: Walters
authors.forename: Laura
authors.initials: L
authors.lastname: Young
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use*; D005260:Female; D005338:Fibrin Fibrinogen Degradation Products / Q000032:analysis; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006801:Humans; D049590:Postpartum Period; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000175:diagnosis / Q000188:drug therapy; D011644:Puerperal Disorders / Q000175:diagnosis / Q000188:drug therapy; D011655:Pulmonary Embolism / Q000175:diagnosis / Q000188:drug therapy; D054556:Venous Thromboembolism / Q000175:diagnosis / Q000188:drug therapy; D020246:Venous Thrombosis / Q000175:diagnosis / Q000188:drug therapy
chemical_list: D000925:Anticoagulants; D005338:Fibrin Fibrinogen Degradation Products; D006495:Heparin, Low-Molecular-Weight; C036309:fibrin fragment D