Table 1 How I treat pregnancy-related... | American Society of Hematology

Table 1

How I treat pregnancy-related VTE and a summary of alternatives

	My approach in most patients	My alternatives (not exhaustive)
Diagnosis of suspected DVT or PE	Imaging of proximal leg veins with compression ultrasound (CUS) If suspected PE, and CUS-negative, spiral multislice detector CT scanning of the lungs	Immediate CT scanning of the lungs If suspected PE, algorithm of initial CUS, if negative V/Q scanning of the lungs, followed by pulmonary angiography if V/Q scan nondiagnostic
Initial treatment of VTE in pregnancy	Twice-daily therapeutic dose of LMWH subcutaneously at a starting dose based on actual body weight; if uncomplicated, continuation with therapeutic dose LMWH in a once-daily regimen, based on actual body weight and peak anti-Xa levels 4 hours after injection (instruct women to inject LMWH in the morning). Infrequent monitoring of platelets and anti-Xa levels (every 6-8 weeks, combined with obstetric follow-up). Multidisciplinary plan for delivery. Counsel women about not being able to receive neuraxial anesthesia but alternative methods instead if necessary.	Continuation with twice-daily regimen of therapeutic dose LMWH, in women with increased bleeding risk or imminent delivery. Unfractionated heparin intravenously with close APTT monitoring, in women with increased bleeding risk or imminent delivery. Temporary vena cava filter in women with an absolute contraindication for anticoagulation.
Management of delivery	As soon as spontaneous labor starts, no LMWH injections. Avoid neuraxial anesthesia. Active management of third stage of labor.	Switch to twice-daily regimen of therapeutic dose LMWH from gestational age of 37 weeks, in women with increased bleeding risk. Planned delivery in women with recent VTE (4 weeks before expected delivery); consider switching LMWH to unfractionated heparin intravenously with APTT monitoring in women with acute VTE (ie, in recent 2 weeks) who have to deliver. Stop unfractionated heparin 4 hours before delivery. Neuraxial anesthesia is possible. Consider temporary inferior vena cava filter.
Postpartum management	Restart LMWH 6-12 hours after delivery, depending on amount of blood loss and adequate hemostasis. Continue until INR is > 2.0 on 2 consecutive occasions. Start vitamin K antagonists one day after restarting LMWH if hemostasis is adequate. Breastfeeding is not contraindicated. Duration of anticoagulation until 6 weeks postpartum or longer to guarantee a minimum total duration of 3 months if VTE occurred in late pregnancy.	Continue LMHW for the rest of the anticoagulation period, if preferred by the patient.

	My approach in most patients	My alternatives (not exhaustive)
Diagnosis of suspected DVT or PE	Imaging of proximal leg veins with compression ultrasound (CUS) If suspected PE, and CUS-negative, spiral multislice detector CT scanning of the lungs	Immediate CT scanning of the lungs If suspected PE, algorithm of initial CUS, if negative V/Q scanning of the lungs, followed by pulmonary angiography if V/Q scan nondiagnostic
Initial treatment of VTE in pregnancy	Twice-daily therapeutic dose of LMWH subcutaneously at a starting dose based on actual body weight; if uncomplicated, continuation with therapeutic dose LMWH in a once-daily regimen, based on actual body weight and peak anti-Xa levels 4 hours after injection (instruct women to inject LMWH in the morning). Infrequent monitoring of platelets and anti-Xa levels (every 6-8 weeks, combined with obstetric follow-up). Multidisciplinary plan for delivery. Counsel women about not being able to receive neuraxial anesthesia but alternative methods instead if necessary.	Continuation with twice-daily regimen of therapeutic dose LMWH, in women with increased bleeding risk or imminent delivery. Unfractionated heparin intravenously with close APTT monitoring, in women with increased bleeding risk or imminent delivery. Temporary vena cava filter in women with an absolute contraindication for anticoagulation.
Management of delivery	As soon as spontaneous labor starts, no LMWH injections. Avoid neuraxial anesthesia. Active management of third stage of labor.	Switch to twice-daily regimen of therapeutic dose LMWH from gestational age of 37 weeks, in women with increased bleeding risk. Planned delivery in women with recent VTE (4 weeks before expected delivery); consider switching LMWH to unfractionated heparin intravenously with APTT monitoring in women with acute VTE (ie, in recent 2 weeks) who have to deliver. Stop unfractionated heparin 4 hours before delivery. Neuraxial anesthesia is possible. Consider temporary inferior vena cava filter.
Postpartum management	Restart LMWH 6-12 hours after delivery, depending on amount of blood loss and adequate hemostasis. Continue until INR is > 2.0 on 2 consecutive occasions. Start vitamin K antagonists one day after restarting LMWH if hemostasis is adequate. Breastfeeding is not contraindicated. Duration of anticoagulation until 6 weeks postpartum or longer to guarantee a minimum total duration of 3 months if VTE occurred in late pregnancy.	Continue LMHW for the rest of the anticoagulation period, if preferred by the patient.