The authors noted that UFH may also be administered during pregnancy and has a comparable safety profile to LMWH but requires activated partial thromboplastin time (aPTT) monitoring and is associated with a higher risk of HIT. One potential advantage of UFH is when rapid reversal of anticoagulant effect is needed; however, a twice-daily LMWH regimen may also be used in these patients, and in cases where rapid reversal is required, protamine sulfate may be administered. Vitamin K antagonists (VKA) are contraindicated in pregnancy because of teratogenic effects, but they can be safely administered during breastfeeding.

Direct oral anticoagulants (DOACs) are contraindicated during pregnancy and breastfeeding, but they are a suitable alternative in the postpartum setting, if women do not breastfeed and long-term use is intended. If a patient does become pregnant while receiving a DOAC, the authors recommended switching to LMWH immediately.

“In postpartum nonbreastfeeding patients, I do not have a preference for a specific DOAC,” commented Dr Middeldorp in an email interview.


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“Management of delivery, including the type of analgesia, requires a multidisciplinary approach and depends on local preferences and patient-specific conditions,” the authors wrote in their review. “Several options are possible and include waiting for spontaneous delivery with temporary interruption of LMWH.”

The risk of recurrent VTE in subsequent pregnancies is 6% to 10% without prophylaxis.6-8 As a result, prophylactic anticoagulant therapy is recommended in most women with a history of VTE.

To read the comprehensive list of recommendations containing qualifying remarks, readers should refer to the full publication in Blood.

Disclosure: Some guideline authors have declared affiliations with or received funding from the pharmaceutical industry. Please refer to the original study for a full list of disclosures.

References

  1. Middeldorp S, Ganzevoort W. How I treat venous thromboembolism in pregnancy. Blood. 2020;136(19):2133-2142. doi:10.1182/blood.2019000963
  2. Romualdi E, Dentali F, Rancan E, et al. Anticoagulant therapy for venous thromboembolism during pregnancy: a systematic review and a meta-analysis of the literature. J Thromb Haemost. 2013;11(2):270–81. doi:10.1111/jth.12085
  3. Bank I, Libourel EJ, Middeldorp S, Van Der Meer J, Büller HR. High rate of skin complications due to low-molecular-weight heparins in pregnant women. J Thromb Haemost. 2003;1(4):859–61. doi:10.1046/j.1538-7836.2003.t01-7-00115.x
  4. Schindewolf M, Gobst C, Kroll H, et al. High incidence of heparin-induced allergic delayed-type hypersensitivity reactions in pregnancy. J Allergy Clin Immunol. 2013;132(1):131–9. doi:10.1016/j.jaci.2013.02.047
  5. Chaudhary RK, Nepal C, Khanal N, et al. Management and outcome of heparin-induced thrombocytopenia in pregnancy: a systematic review. Cardiovasc Hematol Agents Med Chem. 2015;13(2):92–7. doi:10.2174/187152571302151217124957
  6. Brill-Edwards P, Ginsberg JS, Gent M, et al. Safety of withholding heparin in pregnant women with a history of venous thromboembolism. N Engl J Med. 2000;343(20):1439–44. doi:10.1056/NEJM200011163432002
  7. Pabinger I, Grafenhofer H, Kaider A, et al. Risk of pregnancy-associated recurrent venous thromboembolism in women with a history of venous thrombosis. J Thromb Haemost. 2005;3(5):949–54. doi:10.1111/j.1538-7836.2005.01307.x
  8. De Stefano V, Martinelli I, Rossi E, et al. The risk of recurrent venous thromboembolism in pregnancy and puerperium without antithrombotic prophylaxis. Br. J. Haematol. 2006;135(3):386–91. doi:10.1111/j.1365-2141.2006.06317.x