VENOUS
THROMBOEMBOLIC
DISEASE
Department of Obstetrics and Gynaecology
UWI
Introduction
• Pregnancy is a hypercoagulable state with up to a fivefold increased risk of
deep vein thrombosis (DVT) and pulmonary embolism (PE).
• The greatest risk of a venous thromboembolism (VTE) is during the first few
weeks postpartum, especially following a caesarean delivery.
• 1. Pregnancy-induced changes in coagulation factors that favour clotting
include a decrease in protein S and increases in fibrinogen; factors VI, VII,
and X; and von Willebrand factor.
• 2. Venous stasis results from compression of the pelvic veins by the gravid
uterus, as well as endocrine-mediated venodilation, often aggravated by
decreased mobility.
• 3. Delivery, especially an operative delivery, can cause endothelial injury to
uteroplacental and pelvic vessel
• Thus, all three elements of the Virchow triad (stasis, endothelial injury, and
hypercoagulability) are present and predispose the pregnant woman to
VTE.
• Additional important risk factors are previous history of a DVT or PE,
acquired or inherited thrombophilias, smoking, and prolonged immobility
as a result of prescribed bed rest for certain obstetric complications.
Pulmonary
Embolus
• PE is the leading ‘direct’ cause of
maternal death in many countries.
• Embolism occurs in <0.3%, with a
mortality of 3.5%
• Chest pain and dyspnoea are
common
• Key signs are a tachycardia, raised
respiratory rate and jugular venous
pressure (JVP), and chest
abnormalities
• Diagnosis is as in the non-pregnant
woman using a chest X-ray, arterial
blood gas analysis and computed
tomography (CT) or with perfusion
― ventilation (VQ) scanning.
• The ECG changes of normal
pregnancy can mimic a pulmonary
embolus.
Deep vein thrombosis (DVT):
• occurs in about 0.1% of pregnant women.
• Thromboses are more often iliofemoral and on the left.
• Doppler examination and occasionally a venogram or
pelvic MRI is used.
Cerebral venous thrombosis:
• occurs in 1 in 10 000 pregnancies, particularly during the
puerperium, and presents as headache and or stroke.
• Imaging with MRI is best.
Management of VTE in pregnancy
• A thrombophilia screen should be considered before
treatment with subcutaneous LMWH
• Dosing is weight based and can be adjusted according to
the anti-Factor Xa level; more is needed than in non-
pregnant women as clearance is more rapid
• If possible, treatment is stopped shortly before labour,
but is restarted and continued into the puerperium
• Warfarin is teratogenic, may cause fetal bleeding and is
seldom used antenatally
• Both LMWH and warfarin may be used in breastfeeding
Thromboprophylaxis
• Because of the importance of pulmonary embolism as a cause of maternal death,
thromboprophylaxis is used frequently
• Every woman requires an early antenatal risk assessment, which is reviewed
according to subsequent events, such as caesarean delivery or hospitalisation.
Prophylaxis with LMWH
• Maternal weight determines dosage; it is essential this is weight adjusted.
Antenatal prophylaxis is restricted to women at very high risk, such as a
previous thrombosis, particularly if unprovoked or with a thrombophilia, or
those with intermediate risk factors such as medical comorbidities, or if there
are 3–4 more minor risk factors
Postpartum prophylaxis is more frequently used. If it has been used
antenatally it is continued. If there is a major or intermediate risk factor, or
two or more minor risk factors, LMWH is prescribed for at least 10 days. LMWH
can usually be given within 12 hours of caesarean section or vaginal delivery.
Non-pharmacological
• General measures are required for all: mobilization and
maintenance of hydration
• Compression stockings are useful for those where LMWH
is contraindicated (e.g. during/ immediately post
surgery).
