Management of Pulmonary Embolism in Pregnancy

Anticoagulation in Pregnancy with PE

The European Society of Cardiology recommends that NOACs (including apixaban) are explicitly contraindicated during pregnancy and lactation according to current guidelines 1, 2, 3
Therapeutic, fixed doses of LMWH based on early pregnancy weight are the recommended treatment for PE in pregnant women without hemodynamic instability, as suggested by the European Heart Journal 1, 4, 3
LMWH should be administered throughout the entire pregnancy, as recommended by the European Heart Journal 5
Unfractionated heparin (UFH) may be considered as an alternative, particularly in situations requiring rapid reversal, according to the European Heart Journal 3

For confirmed PE in pregnancy, immediately discontinue apixaban and switch to therapeutic fixed-dose LMWH based on early pregnancy weight, as recommended by the European Heart Journal 1, 2, 3
Perform formal diagnostic assessment with validated methods if PE is suspected during pregnancy, as suggested by the European Heart Journal 2, 4

Continue anticoagulant therapy with LMWH throughout pregnancy, as recommended by the European Heart Journal 5
After delivery, heparin treatment may be replaced by anticoagulation with vitamin K antagonists (VKAs), according to the European Heart Journal 6
Anticoagulant treatment should be administered for at least 3 months after delivery, as suggested by the European Heart Journal 6

Discontinue LMWH at the onset of regular uterine contractions, as recommended by the European Heart Journal 7
Do not insert a spinal or epidural needle within 24 hours since the last LMWH dose, according to the European Heart Journal 1, 4
Close collaboration between obstetrician, anesthetist, and attending physician is recommended, as suggested by the European Heart Journal 6

VKAs can be given to breastfeeding mothers after delivery, according to the European Heart Journal 6
Assess the need for extended anticoagulation based on risk factors for recurrence, as recommended by the European Heart Journal 2, 4

Mistakenly continuing apixaban during pregnancy instead of switching to LMWH, as warned by the European Heart Journal 1, 2, 4
Failure to adjust LMWH dosing based on weight changes during pregnancy, according to the European Heart Journal 3
Inadequate planning for labor and delivery anticoagulation management, as cautioned by the European Heart Journal 7, 6

The European Society of Cardiology recommends basing the decision to start empirical anticoagulation on clinical probability assessment using either clinical judgment or a validated prediction rule 8
For pregnant women with suspected pulmonary embolism, formal diagnostic assessment with validated methods is recommended 9, 10
D-dimer measurement and clinical prediction rules should be considered to rule out pulmonary embolism during pregnancy or post-partum period 9
In pregnant patients with symptoms of deep vein thrombosis, venous compression ultrasonography should be considered to avoid unnecessary radiation 9

The European Heart Journal recommends initiating intravenous unfractionated heparin without delay, including a weight-adjusted bolus injection, for high clinical probability or hemodynamic instability 8
For high-risk pulmonary embolism with hemodynamic instability, consider thrombolysis or surgical embolectomy 9
Bedside echocardiography or emergency computed tomography pulmonary angiography should be performed for diagnosis depending on availability and clinical circumstances 11

The European Heart Journal recommends low-molecular-weight heparin as the preferred anticoagulant for pregnant women with confirmed pulmonary embolism 12
For high-risk pulmonary embolism near delivery, unfractionated heparin infusion should be converted from low-molecular-weight heparin at least 36 hours prior to anticipated delivery 9
Unfractionated heparin infusion should be stopped 4-6 hours prior to anticipated delivery 9
Do not administer low-molecular-weight heparin within 4 hours of removal of an epidural catheter 10

Anticoagulant treatment should be administered for at least 6 weeks after delivery with a minimum overall treatment duration of 3 months 9
After delivery, heparin treatment may be replaced by vitamin K antagonists 13
Vitamin K antagonists can be given to breastfeeding mothers 9

A team of multidisciplinary colleagues should collaborate in planning ante-, peri-, and post-partum care pathways 9