VTE, Thrombophilia, Antithrombotic Therapy, And Pregnancy

Publication Date: February 1, 2012
Last Updated: March 14, 2022

Recommendations

Maternal Complications of Anticoagulant Therapy

For pregnant patients, we recommend LMWH for the prevention and treatment of VTE, instead of UFH. (1, B)
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Fetal Complications of Antithrombotic Therapy During Pregnancy

For women receiving anticoagulation for the treatment of VTE who become pregnant,
  • we recommend LMWH over vitamin K antagonists during the first trimester.
(1, A)
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  • in the second and third trimesters,
(1, B)
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  • and during late pregnancy when delivery is imminent.
(1, A)
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For women requiring long-term vitamin K antagonists who are attempting pregnancy and are candidates for LMWH substitution, we suggest performing frequent pregnancy tests and substituting LMWH for vitamin K antagonists when pregnancy is achieved rather than switching to LMWH while attempting pregnancy. (2, C)
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For pregnant women, we suggest limiting the use of fondaparinux and parenteral direct thrombin inhibitors to those with severe allergic reactions to heparin (eg, HIT) who cannot receive danaparoid. (2, C)
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For pregnant women, we recommend avoiding the use of oral direct thrombin (eg, dabigatran) and anti-Xa (eg, rivaroxaban, apixaban) inhibitors. (1, C)
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Use of Anticoagulants in Breast-feeding Women

For lactating women using warfarin, acenocoumarol, or UFH who wish to breastfeed, we recommend continuing the use of warfarin, acenocoumarol, or UFH. (1, A)
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For lactating women using LMWH, danaparoid, or r-hirudin who wish to breast-feed, we recommend continuing the use of LMWH, danaparoid, or r-hirudin. (1, B)
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For breast-feeding women, we suggest alternative anticoagulants rather than fondaparinux. (2, C)
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For breast-feeding women, we recommend alternative anticoagulants rather than oral direct thrombin (eg, dabigatran) and factor Xa inhibitors (eg, rivaroxaban, apixaban). (1, C)
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For lactating women using low-dose aspirin for vascular indications who wish to breastfeed, we suggest continuing this medication. (2, C)
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VTE in Patients Using Assisted Reproductive Technology

For women undergoing assisted reproduction, we recommend against the use of routine thrombosis prophylaxis. (1, B)
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For women undergoing assisted reproduction who develop severe ovarian hyperstimulation syndrome, we suggest thrombosis prophylaxis (prophylactic LMWH) for 3 months postresolution of clinical ovarian hyperstimulation syndrome rather than no prophylaxis. (2, C)
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VTE Following Cesarean Section

For women undergoing cesarean section without additional thrombosis risk factors, we recommend against the use of thrombosis prophylaxis other than early mobilization. (1, B)
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For women at increased risk of VTE after cesarean section because of the presence of one major or at least two minor risk factors, we suggest pharmacologic thromboprophylaxis (prophylactic LMWH) or mechanical prophylaxis (elastic stockings or intermittent pneumatic compression) in those with contraindications to anticoagulants while in hospital following delivery rather than no prophylaxis. (2, B)
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For women undergoing cesarean section who are considered to be at very high risk for VTE and who have multiple additional risk factors for thromboembolism that persist in the puerperium, we suggest that prophylactic LMWH be combined with elastic stockings and/or intermittent pneumatic compression over LMWH alone. (2, C)
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For selected high-risk patients in whom significant risk factors persist following delivery, we suggest extended prophylaxis (up to 6 weeks after delivery) following discharge from the hospital. (2, C)
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Treatment of Proven Acute VTE During Pregnancy

For pregnant women with acute VTE, we recommend therapy with adjusted-dose subcutaneous LMWH over adjusted-dose UFH. (1, B)
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For pregnant women with acute VTE, we recommend LMWH over vitamin K antagonist treatment antenatally. (1, A)
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For pregnant women with acute VTE, we suggest that anticoagulants should be continued for at least 6 weeks postpartum (for a minimum total duration of therapy of 3 months) in comparison with shorter durations of treatment. (2, C)
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For pregnant women receiving adjusted dose LMWH therapy and where delivery is planned, we recommend discontinuation of LMWH at least 24 h prior to induction of labor or cesarean section (or expected time of neuraxial anesthesia) rather than continuing LMWH up until the time of delivery. (1, B)
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Prevention of VTE in Pregnant Women With Prior DVT or PE

For all pregnant women with prior VTE, we suggest postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than no prophylaxis. (2, B)
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For pregnant women at low risk of recurrent VTE (single episode of VTE associated with a transient risk factor not related to pregnancy or use of estrogen), we suggest clinical vigilance antepartum rather than antepartum prophylaxis. (2, C)
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For pregnant women at moderate to high risk of recurrent VTE (single unprovoked VTE, pregnancy- or estrogen-related VTE, or multiple prior unprovoked VTE not receiving longterm anticoagulation), we suggest antepartum prophylaxis with prophylactic- or intermediate-dose LMWH rather than clinical vigilance or routine care. (2, C)
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For pregnant women receiving long-term vitamin K antagonists, we suggest adjusted-dose LMWH or 75% of a therapeutic dose of LMWH throughout pregnancy followed by resumption of long-term anticoagulants postpartum, rather than prophylactic-dose LMWH. (2, C)
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Prevention of VTE in Pregnant Women With Thrombophilia and No Prior VTE

For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and have a positive family history for VTE, we suggest antepartum prophylaxis with prophylactic- or intermediate-dose LMWH and postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than no prophylaxis. (2, B)
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For pregnant women with all other thrombophilias and no prior VTE who have a positive family history for VTE, we suggest antepartum clinical vigilance and postpartum prophylaxis with prophylactic- or intermediate-dose LMWH or, in women who are not protein C or S defi - cient, vitamin K antagonists targeted at INR 2.0 to 3.0 rather than routine care. (2, C)
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For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and who do not have a positive family history for VTE, we suggest antepartum clinical vigilance and postpartum prophylaxis for 6 weeks with prophylactic- or intermediatedose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than routine care. (2, B)
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For pregnant women with all other thrombophilias and no prior VTE who do not have a positive family history for VTE, we suggest antepartum and postpartum clinical vigilance rather than pharmacologic prophylaxis. (2, C)
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Thrombophilia and Pregnancy Complications

For women with recurrent early pregnancy loss (three or more miscarriages before 10 weeks of gestation), we recommend screening for APLAs. (1, B)
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For women with a history of pregnancy complications, we suggest not to screen for inherited thrombophilia. (2, C)
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For women who fulfi ll the laboratory criteria for APLA syndrome and meet the clinical APLA criteria based on a history of three or more pregnancy losses, we recommend antepartum administration of prophylactic- or intermediatedose UFH or prophylactic LMWH combined with low-dose aspirin, 75 to 100 mg/d, over no treatment. (1, B)
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For women with inherited thrombophilia and a history of pregnancy complications, we suggest not to use antithrombotic prophylaxis. (2, C)
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Management of Women With a History of Preeclampsia or Recurrent Fetal Loss and No Thrombophilia

For women considered at risk for preeclampsia, we recommend low-dose aspirin throughout pregnancy, starting from the second trimester, over no treatment. (1, B)
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For women with two or more miscarriages but without APLA or thrombophilia, we recommend against antithrombotic prophylaxis. (1, B)
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Maternal and Fetal Risks Related to Anticoagulation During Pregnancy for Mechanical Prosthetic Valves

For pregnant women with mechanical heart valves, we recommend one of the following anticoagulant regimens in preference to no anticoagulation.
  • a. Adjusted-dose bid LMWH throughout pregnancy. We suggest that doses be adjusted to achieve the manufacturer’s peak anti-Xa LMWH 4 h postsubcutaneous-injection or
  • b. Adjusted-dose UFH throughout pregnancy administered subcutaneously every 12 h in doses adjusted to keep the mid-interval aPTT at least twice control or attain an anti-Xa heparin level of 0.35 to 0.70 units/mL or
  • c. UFH or LMWH (as above) until the 13th week, with substitution by vitamin K antagonists until close to delivery when UFH or LMWH is resumed.
(1, A)
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In women judged to be at very high risk of thromboembolism in whom concerns exist about the effi cacy and safety of UFH or LMWH as dosed above (eg, older generation prosthesis in the mitral position or history of thromboembolism), we suggest vitamin K antagonists throughout pregnancy with replacement by UFH or LMWH (as above) close to delivery rather than one of the regimens above. (2, C)
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For pregnant women with prosthetic valves at high risk of thromboembolism, we suggest the addition of low-dose aspirin, 75 to 100 mg/d. (2, C)
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Recommendation Grading

Overview

Title

VTE, Thrombophilia, Antithrombotic Therapy, And Pregnancy

Authoring Organization

American College of Chest Physicians

Publication Month/Year

February 1, 2012

Last Updated Month/Year

May 15, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The use of anticoagulant therapy during pregnancy is challenging because of the potential for both fetal and maternal complications. This guideline focuses on the management of VTE and thrombophilia as well as the use of antithrombotic agents during pregnancy.

Target Patient Population

Pregnant patients requires anticoagulant therapy

Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D054556 - Venous Thromboembolism, D000925 - Anticoagulants, D011247 - Pregnancy, D011250 - Pregnancy Complications, Hematologic, D013923 - Thromboembolism, D019851 - Thrombophilia

Keywords

anticoagulation, pregnancy, antiplatelet agents, Antithrombotic Agents, Venous Thromboembolism, thrombophilia, Anticoagulation

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
343
Literature Search Start Date
January 1, 2005
Literature Search End Date
January 1, 2010