Venous Thromboembolic Disease in Pregnancy

Venous thromboembolic disease (VTE), which includes both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity and mortality in pregnant women. Occurring in 1 to 2 women per 1000 deliveries,[1] VTE is responsible for 9% to 13% of maternal deaths.[2],[3] Because of changes in maternal coagulation, venous stasis, decreased maternal mobility, and birth-related endothelial damage, the relative risk of VTE in pregnancy and in the postpartum period is 5-fold greater than in the nonpregnant adult.[4] Diagnosing PE poses significant challenges in pregnancy, in part because the complaint of shortness of breath is so common. OB/GYN hospitalists have opportunities to influence outcomes from VTE at various levels in the health care system. At the individual patient level, OB/GYN hospitalists may be the first physicians to encounter the peripartum woman with life-threatening VTE, and their ability to rapidly diagnose, initiate therapy, and mobilize consultants is critical to reducing maternal mortality. VTE is thought to be the single cause of death most amenable to reduction by systematic change in practice, and OB/GYN hospitalists are well-positioned to influence care at a system level by leading or contributing to initiatives such as those that increase rates of VTE screening or the appropriate use of VTE prophylaxis.

Knowledge

OB/GYN hospitalists should be able to:

  • Describe VTE pathophysiology in pregnancy and the postpartum period and the factors that increase its incidence, including a hypercoagulable state, venous stasis, decreased maternal mobility, and birth-related endothelial damage.
  • List the risk factors and clinical conditions that increase the likelihood of VTE in pregnancy and the mechanisms by which each leads to venous thromboembolism.
  • Discuss the recommendations for screening for VTE risk in pregnancy and list resources for obtaining risk assessment tools.
  • Explain the indications and contraindications for mechanical prophylaxis in pregnant hospitalized patients.
  • Explain the indications, contraindications, dosing regimens, adverse effects, and mechanism of action of the pharmacologic agents used for VTE prophylaxis in pregnant patients, including low-molecular weight heparins, unfractionated heparins, warfarin, and fondaparinux.
  • Describe the various clinical signs and symptoms of VTE (DVT and PE) in pregnant women and how they may differ in location from VTE in nonpregnant adults.
  • Describe the indications and limitations of the diagnostic tests used to identify DVT and PE in pregnancy and the postpartum period.
  • Describe the indications for fibrinolytic therapy in life-threatening or limb-threatening VTE and risks associated with this therapy.
  • Explain the indications, contraindications, dosing regimens, adverse effects and mechanism of action of the pharmacologic agents used to treat VTE, including low-molecular weight heparins, unfractionated heparins, warfarin, direct factor Xa inhibitors, and direct thrombin inhibitors.
  • Explain the impact of changes in maternal physiology on the pharmacokinetics of heparins and the recommended therapeutic drug monitoring for both therapeutic and prophylactic regimens in pregnancy.
  • Discuss the pros and cons of continuing low-molecular weight heparin until delivery versus transitioning to unfractionated heparin at 36 weeks of gestation.
  • Discuss the standard recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial analgesia both before and after delivery.
  • Describe the options for reversal of anticoagulation if required.
  • Discuss the safety of anticoagulant medications in breastfeeding patients.

Skills

OB/GYN hospitalists should be able to:

  • Elicit a thorough and relevant medical history, including risk factors and symptoms for VTE in pregnant women.
  • Perform an appropriate physical examination to identify clinical signs associated with VTE.
  • Perform VTE risk assessment in all hospitalized obstetric patients and initiate indicated prophylactic measures.
  • Develop an appropriate differential diagnosis for pregnant patients who present with signs or symptoms of PE.
  • Order and interpret the appropriate diagnostic tests tailored to the patient’s presentation.
  • Recognize the signs and symptoms of a life-threatening pulmonary embolus and initiate timely evaluation and treatment.
  • Engage consultants and coordinate a multidisciplinary approach, including the patient, those who support the patient, critical care specialists, hematologists, perinatologists, and others, when indicated.
  • Synthesize history, physical examination findings, laboratory and imaging results, consultant recommendations, and patient input to formulate an evidence-based, patient-centered management plan.
  • Communicate with patients and families regarding:
  • the natural history of, risk factors for, and prevention of VTE in pregnancy;
  • tests and procedures used to diagnose VTE in pregnancy, the maternal and fetal risks and benefits associated with those procedures, and obtain relevant informed consent; and
  • the prescribed anticoagulation therapy, including the specific dosing regimen, need for therapeutic drug monitoring, potential adverse effects, and the treatment plan after hospital discharge.
  • Formulate and communicate a clear discharge plan for patients started on anticoagulation, including medications, outpatient testing, follow-up appointments, and plan for delivery and postpartum management.
  • In the medical record, document history, examination findings, results of testing, diagnosis, discussion with the patient, care options, and management plan.

Self-Awareness and Collaborative Attitudes

OB/GYN hospitalists should be able to:

  • Provide evidence-based, patient-centered care to patients to prevent, diagnose, and treat VTE.
  • Collaborate and communicate effectively within a multidisciplinary team, including the patient, those who support the patient, anesthesiologists, interventional radiologists, vascular surgeons, hematologists, and medical intensive care staff, to optimize outcomes and the patient experience.
  • Use resources in a timely and appropriate manner and transfer to a higher level of care when indicated.

System Organization and Improvement

OB/GYN hospitalists should be able to:

  • Lead, coordinate, and/or participate in departmental initiatives to implement screening and prevention protocols for pregnant women admitted to the antepartum and postpartum services.
  • Lead, coordinate, and/or participate in clinical education programs to improve knowledge of VTE risk, preventive measures, anticoagulation therapies, current regimens, and therapeutic drug monitoring guidelines.
  • Lead, coordinate, and/or participate in multidisciplinary teams to develop or improve early treatment protocols for women with life-threatening VTE.
  • Lead, coordinate, and/or participate in implementing systems to monitor process and outcome metrics and assess for complications from pharmacologic prophylaxis to ensure high-quality, safe, and evidence-based health care delivery to pregnant patients regarding VTE prevention and treatment.
  • Lead, coordinate, and/or participate in outcomes research to evaluate diagnostic and management strategies for pregnant women with VTE.

References

  1. McLean K, Cushman M. Venous thromboembolism and stroke in pregnancy. Hematology Am Soc Hematol Educ Program. 2016;2016(1):243-250.  [PMID:27913487]
  2. Berg CJ, Callaghan WM, Syverson C, et al. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol. 2010;116(6):1302-1309.  [PMID:21099595]
  3. Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol. 2008;199(1):36.e1-5; discussion 91-2. e7-11.  [PMID:18455140]
  4. Heit JA, Kobbervig CE, James AH, et al. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann Intern Med. 2005;143(10):697-706.  [PMID:16287790]
Last updated: August 30, 2021