Management of Pregnant Women with Coagulation Disorders or High Thromboembolic Risk
Introduction to Anticoagulation in Pregnancy
- The American Society of Hematology recommends antepartum prophylactic anticoagulation with Low Molecular Weight Heparin (LMWH) for pregnant women with a history of unprovoked or hormone-associated Venous Thromboembolism (VTE), and all women with prior VTE should receive postpartum anticoagulation for at least 6 weeks 1, 2
Acute VTE Treatment in Pregnancy
- LMWH is the anticoagulant of choice over unfractionated heparin for treating acute VTE during pregnancy, with either once-daily or twice-daily dosing acceptable 2
- Continue therapeutic anticoagulation throughout pregnancy and for at least 6 weeks postpartum (minimum total duration of 6 months) 2
Primary Prevention Based on VTE History
- For women with a history of unprovoked or hormone-associated VTE, strongly recommend antepartum prophylactic LMWH throughout pregnancy 1, 3
- For women with a history of VTE, strongly recommend postpartum anticoagulation for at least 6 weeks 1, 2
- The recurrence risk is 3.6% for unprovoked VTE and 6.4% for hormone-associated VTE without prophylaxis 3
Primary Prevention Based on Thrombophilia Type
- For women with antithrombin deficiency, strongly recommend postpartum prophylaxis for women with a family history of VTE 1, 2
- For women with homozygous Factor V Leiden, suggest antepartum prophylaxis regardless of family history 4, 5
- For women with homozygous prothrombin gene mutation, suggest postpartum prophylaxis for 6 weeks regardless of family history 4, 5
Additional Risk Factor Assessment for Postpartum Prophylaxis
- Consider postpartum prophylaxis (at least 10 days, extend to 6 weeks with family history of VTE) if ≥2 of the following are present: BMI ≥30 kg/m², smoking >10 cigarettes/day, preeclampsia, intrauterine growth restriction, placenta previa, emergency cesarean section, blood loss >1L or transfusion requirement, preterm delivery, stillbirth, or maternal comorbidities 6
Anticoagulant Selection and Safety
- LMWH (enoxaparin, dalteparin) is preferred over UFH due to ease of use, lower adverse event rates, and no need for monitoring 2
- UFH, LMWH, warfarin, acenocoumarol, fondaparinux, and danaparoid are safe options during breastfeeding 1, 2
Peripartum Anticoagulation Management
- For women on therapeutic-dose LMWH, suggest scheduled delivery with prior discontinuation of anticoagulation 2
- For women on prophylactic-dose LMWH, suggest against scheduled delivery with discontinuation 1, 2