Pulmonary embolism special scenario pregnancy

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Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

The intial diagnostic test in a pregnant woman suspected to have a pulmonary embolism (PE) depends on the presence or absence of leg symptoms suggestive of deep vein thrombosis (DVT). Compression ultrasonography is not the routine initial method of evaluation in a suspected PE during pregnancy unless the patient has coexisting symptoms and signs of DVT.[1] In case the compression ultrasound is negative for DVT and there is persistent clinical suspicion of PE, the negative ultrasound does not rule out PE and additional imaging tests are required.[1] If leg symptoms are absent in a pregnant woman suspected to have PE, a chest X-ray is the initial imaging modality.[1] When anticoagulation is indicated for the prevention or treatment of venous thromboembolism in pregnancy, low molecular weight heparin (LMWH) should be administered instead of vitamin K antagonists (VKA).[2] In fact, VKA can cross the placenta and lead to embryopathy as well as fetal loss. Some of the teratogenic effect of VKA include midfacial hypoplasia, stippled epiphysis, and limb hypoplasia.[2][3][4] The teratogenic effect of VKA is particularly important during the first trimester of pregnancy.[2]

2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)[2]

Maternal Complications of Anticoagulant Therapy

Class I
"1. For pregnant patients, we recommend LMWH for the prevention and treatment of VTE, instead of UFH. (Level of Evidence: B)"

Fetal Complications of Antithrombotic Therapy During Pregnancy

Class I
"1. For women receiving anticoagulation for the treatment of VTE who become pregnant, we recommend LMWH over vitamin K antagonists during the first trimester (Level of Evidence: A), in the second and third trimesters (Level of Evidence: B), and during late pregnancy when delivery is imminent (Level of Evidence: B). '"
"2. For pregnant patients, we recommend LMWH for the prevention and treatment of VTE, instead of UFH. (Level of Evidence: B)"
"3. For pregnant women, we recommend avoiding the use of oral direct thrombin (eg, dabigatran) and anti-Xa (eg, rivaroxaban, apixaban) inhibitors. (Level of Evidence: C)"
Class II
"1. For women requiring long-term vitamin K antagonists who are attempting pregnancy and are candidates for LMWH substitution, we suggest performing frequent pregnancy tests and substituting LMWH for vitamin K antagonists when pregnancy is achieved rather than switching to LMWH while attempting pregnancy. (Level of Evidence: C)"
"2. For pregnant women, we suggest limiting the use of fondaparinux and parenteral direct thrombin inhibitors to those with severe allergic reactions to heparin (eg, HIT) who cannot receive danaparoid. (Level of Evidence: C)"

Use of Anticoagulants in Breast-feeding Women

Class I
"1. For lactating women using warfarin, acenocoumarol, or UFH who wish to breast-feed, we recommend continuing the use of warfarin, acenocoumarol, or UFH. (Level of Evidence: A) '"
"2. For lactating women using LMWH, danaparoid, or r-hirudin who wish to breast-feed, we recommend continuing the use of LMWH, danaparoid, or r-hirudin. (Level of Evidence: B) '"
"3. For breast-feeding women, we recommend alternative anticoagulants rather than oral direct thrombin (eg, dabigatran) and factor Xa inhibitors (eg, rivaroxaban, apixaban). (Level of Evidence: C) '"
Class II
"1. For breast-feeding women, we suggest alternative anticoagulants rather than fondaparinux. (Level of Evidence: C)"
"2. For lactating women using low-dose aspirin for vascular indications who wish to breast-feed, we suggest continuing this medication. (Level of Evidence: C)"

VTE in Patients Using Assisted Reproductive Technology

Class I
"1. For women undergoing assisted reproduction, we recommend against the use of routine thrombosis prophylaxis. (Level of Evidence: B)"
Class II
"1. For women undergoing assisted reproduction who develop severe ovarian hyperstimulation syndrome, we suggest thrombosis prophylaxis (prophylactic LMWH) for 3 months postresolution of clinical ovarian hyperstimulation syndrome rather than no prophylaxis. (Level of Evidence: C)"

VTE Following Cesarean Section

Class I
"1. For women undergoing cesarean section without additional thrombosis risk factors, we recommend against the use of thrombosis prophylaxis other than early mobilization. (Level of Evidence: B)"
Class II
"1. For women at increased risk of VTE after cesarean section because of the presence of one major or at least two minor risk factors, we suggest pharmacologic thromboprophylaxis (prophylactic LMWH) or mechanical prophylaxis (elastic stockings or intermittent pneumatic compression) in those with contraindications to anticoagulants while in hospital following delivery rather than no prophylaxis. (Level of Evidence: B)"
"2. For women undergoing cesarean section who are considered to be at very high risk for VTE and who have multiple additional risk factors for thromboembolism that persist in the puerperium, we suggest that prophylactic LMWH be combined with elastic stockings and/or intermittent pneumatic compression over LMWH alone. (Level of Evidence: C)"
"3. For selected high-risk patients in whom significant risk factors persist following delivery, we suggest extended prophylaxis (up to 6 weeks after delivery) following discharge from the hospital. (Level of Evidence: C)"

Treatment of Proven Acute VTE During Pregnancy

Class I
"1. For pregnant women with acute VTE, we recommend therapy with adjusted-dose subcutaneous LMWH over adjusted-dose UFH. (Level of Evidence: B)"
"2. For pregnant women with acute VTE, we recommend LMWH over vitamin K antagonist treatment antenatally. (Level of Evidence: A)"
"3. For pregnant women receiving adjusted-dose LMWH therapy and where delivery is planned, we recommend discontinuation of LMWH at least 24 h prior to induction of labor or cesarean section (or expected time of neuraxial anesthesia) rather than continuing LMWH up until the time of delivery. (Level of Evidence: B)"
Class II
"1. For pregnant women with acute VTE, we suggest that anticoagulants should be continued for at least 6 weeks postpartum (for a minimum total duration of therapy of 3 months) in comparison with shorter durations of treatment. (Level of Evidence: C)"

Prevention of VTE in Pregnant Women With Prior DVT or PE

Class II
"1. For all pregnant women with prior VTE, we suggest postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than no prophylaxis. (Level of Evidence: B)"
"2. For pregnant women at low risk of recurrent VTE (single episode of VTE associated with a transient risk factor not related to pregnancy or use of estrogen), we suggest clinical vigilance antepartum rather than antepartum prophylaxis. (Level of Evidence: C)"
"3. For pregnant women at moderate to high risk of recurrent VTE (single unprovoked VTE, pregnancy- or estrogen-related VTE, or multiple prior unprovoked VTE not receiving long-term anticoagulation), we suggest antepartum prophylaxis with prophylactic- or intermediate-dose LMWH rather than clinical vigilance or routine care. (Level of Evidence: C)"
"4. For pregnant women receiving long-term vitamin K antagonists, we suggest adjusted-dose LMWH or 75% of a therapeutic dose of LMWH throughout pregnancy followed by resumption of long-term anticoagulants postpartum, rather than prophylactic-dose LMWH. (Level of Evidence: C)"

Prevention of VTE in Pregnant Women With Thrombophilia and No Prior VTE

Class II
"1. For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and have a positive family history for VTE, we suggest antepartum prophylaxis with prophylactic- or intermediate-dose LMWH and postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than no prophylaxis. (Level of Evidence: B)"
"2. For pregnant women with all other thrombophilias and no prior VTE who have a positive family history for VTE, we suggest antepartum clinical vigilance and postpartum prophylaxis with prophylactic- or intermediate-dose LMWH or, in women who are not protein C or protein S|S]] deficient, vitamin K antagonists targeted at INR 2.0 to 3.0 rather than routine care. (Level of Evidence: C)"
"3. For pregnant women with no prior history of VTE who are known to be homozygous for factor V Leiden or the prothrombin 20210A mutation and who do not have a positive family history for VTE, we suggest antepartum clinical vigilance and postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or vitamin K antagonists targeted at INR 2.0 to 3.0 rather than routine care. (Level of Evidence: B)"
"4. For pregnant women with all other thrombophilias and no prior VTE who do not have a positive family history for VTE, we suggest antepartum and postpartum clinical vigilance rather than pharmacologic prophylaxis. (Level of Evidence: C)"

Thrombophilia and Pregnancy Complications

Class I
"1. For women with recurrent early pregnancy loss (three or more miscarriages before 10 weeks of gestation), we recommend screening for APLAs. (Level of Evidence: B)"
"2. For women who fulfill the laboratory criteria for APLA syndrome and meet the clinical APLA criteria based on a history of three or more pregnancy losses, we recommend antepartum administration of prophylactic- or intermediate-dose UFH or prophylactic LMWH combined with low-dose aspirin, 75 to 100 mg/d, over no treatment. (Level of Evidence: B)"
Class II
"1. For women with a history of pregnancy complications, we suggest not to screen for inherited thrombophilia. (Level of Evidence: C)"
"2. For women with inherited thrombophilia and a history of pregnancy complications, we suggest not to use antithrombotic prophylaxis. (Level of Evidence: C)"

Management of Women With a History of Preeclampsia or Recurrent Fetal Loss and No Thrombophilia

Class I
"1. For women considered at risk for preeclampsia, we recommend low-dose aspirin throughout pregnancy, starting from the second trimester, over no treatment. (Level of Evidence: B)"
"2. For women with two or more miscarriages but without APLA or thrombophilia, we recommend against antithrombotic prophylaxis. (Level of Evidence: B)"

Maternal and Fetal Risks Related to Anticoagulation During Pregnancy for Mechanical Prosthetic Valves

Class I
"1. For pregnant women with mechanical heart valves, we recommend one of the following anticoagulant regimens in preference to no anticoagulation (Level of Evidence: A):

(a) Adjusted-dose bid LMWH throughout pregnancy. We suggest that doses be adjusted to achieve the manufacturer’s peak anti-Xa LMWH 4 h postsubcutaneous-injection or

(b) Adjusted-dose UFH throughout pregnancy administered subcutaneously every 12 h in doses adjusted to keep the mid-interval aPTT at least twice control or attain an anti-Xa heparin level of 0.35 to 0.70 units/mL or

(c) UFH or LMWH (as above) until the 13th week, with substitution by vitamin K antagonists until close to delivery when UFH or LMWH is resumed."

References

  1. 1.0 1.1 1.2 Leung AN, Bull TM, Jaeschke R, Lockwood CJ, Boiselle PM, Hurwitz LM; et al. (2011). "An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy". Am J Respir Crit Care Med. 184 (10): 1200–8. doi:10.1164/rccm.201108-1575ST. PMID 22086989.
  2. 2.0 2.1 2.2 2.3 Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO; et al. (2012). "VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e691S–736S. doi:10.1378/chest.11-2300. PMC 3278054. PMID 22315276.
  3. Born D, Martinez EE, Almeida PA, Santos DV, Carvalho AC, Moron AF; et al. (1992). "Pregnancy in patients with prosthetic heart valves: the effects of anticoagulation on mother, fetus, and neonate". Am Heart J. 124 (2): 413–7. PMID 1636585.
  4. Chan WS, Anand S, Ginsberg JS (2000). "Anticoagulation of pregnant women with mechanical heart valves: a systematic review of the literature". Arch Intern Med. 160 (2): 191–6. PMID 10647757.



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