Thromboprophylaxis during the Pregnancy-Puerperal Cycle - Literature Review

Sanches, Suzanna Maria Viana; Cerqueira, Monique Magnavita Borba da Fonseca; Junqueira, Patrícia Lima; Gomez, Miriam Takayanagi

doi:10.1055/s-0040-1708096

home Sumário navigate_before Anterior Atual Seguinte navigate_next

home Sumário

Review Article • Rev Bras Ginecol Obstet. 42 (4) • Apr 2020 • https://doi.org/10.1055/s-0040-1708096 linkcopy

Thromboprophylaxis during the Pregnancy-Puerperal Cycle - Literature Review

Tromboprofilaxia no ciclo gravídico-puerperal - Revisão da literatura

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective To identify current strategies and recommendations for venous thromboembolism prophylaxis associated with the pregnancy-puerperal cycle, a condition of high morbidity and mortality among women.

Methods The literature search was performed between May and October 2019, using the PubMed database, including papers published in Portuguese, English and Spanish. The terms thromboembolism (Mesh) AND pregnancy (Mesh) OR postpartum (Mesh) were used as descriptors, including randomized controlled trials, meta-analyses, systematic reviews and guidelines published from 2009 to 2019, presenting strategies for prevention of thromboembolism during pregnancy and the postpartum.

Results Eight articles met the inclusion criteria. Many studies evaluated were excluded because they did not address prevention strategies. We compiled the recommendations from the American Society of Hematologists, the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynaecologists of Canada, the American College of Chest Physicians and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Conclusion: There are some gaps in the research, and clinical studies with appropriate methodology are needed to support decisions made regarding the risk of thromboembolism in the perigestational period. Thus, the attention of the professionals involved in the care of pregnant and postpartum women is crucial, as it is a condition associated with high morbidity and mortality.

Keywords
thromboembolism; thrombosis; pregnancy; postpartum; disease prevention

Authors/year	Country	Study design	Main findings
Bates et al (2018) ¹⁴-American Society of Hematology	USA	Guideline	The panel agreed on 31 recommendations related to the treatment of VTE and superficial vein thrombosis, diagnosis of VTE, and thrombosis prophylaxis
American College of Obstetricians and Gynecologists (2018) ¹⁵	USA	Guideline	Summarizes the available data to provide practical approaches
Stephenson et al (2016) ¹⁹	USA	Randomized controlled trial	Comparing two enoxaparin dosing strategies at achieving prophylactic anti-Xa levels in women with a body mass index (BMI) ⩾ 35 (kg/m2) postcesarean delivery, the authors found that weight-based dosing twice daily more effectively achieved prophylactic anti-Xa levels than fixed dosing daily
RCOG (2015) ¹³	UK	Guideline	Summarizes the available data and the quality of the evidence to provide practical approaches
Chan et al (2014) ¹⁶ -SOGC	Canada	Guideline	Summarizes the available data and the quality of the evidence to provide practical approaches
Bates et al (2012) ¹⁷ -ACCP	USA	Guideline	Summarizes the available data to provide practical approaches
McLintock et al (2012) ¹⁸ - RANZCOG	Australia/ New Zealand	Guideline	Compilation of recommendations from the Specialty Society Guidelines

Weight	Enoxaparin	Dalteparin
< 50Kg	20mg/day	2500 U/day
50-90 Kg	40 mg/day	5000 U/day
91-130 Kg	60mg/day	7500 U/day
131-170 Kg	80 mg/day	10,000 U/day
> 170 Kg	0,6mg/Kg/day	75 U/Kg/day
High prophylactic dosage for women between 50-90Kg	40mg 12/12h	5,000 U 12/12h

Regimen	Dosage
Prophylactic dosage	Enoxaparin 40 mg SC once a day Dalteparin 5,000 U SC once a day
Intermediate dosage	Enoxaparin 40 mg SC 12/12h Dalteparin 5,000 U SC 12/12h
Adjusted dosage (therapeutic)	Enoxaparin 1mg/Kg 12/12h Dalteparin 200 U/Kg once a day

Regimen	Dosage
Prophylactic UFH	5,000-7,500 U SC 12/12h in the 1^st trimester 7,500-10,000 U SC 12/12h in the 2^nd trimester 10,000 U 12/12h in the 3^rd trimester
Adjusted dosage (through aPTT) of UFH	10,000 U or more, SC 12/12h - adjusted for aPTT between 1.5-2.5x control 6 hours after injection

	ACOG	ACCP	ASH	RANZCOG	SOGC
Previous idiopathic VTE or associated to hormonal risk factor (estrogen)	Pharmacological prophylaxis during pregnancy and puerperium	Pharmacological prophylaxis during pregnancy and puerperium	Pharmacological prophylaxis during pregnancy and puerperium	Pharmacological prophylaxis during pregnancy and puerperium	Pharmacological prophylaxis during pregnancy and puerperium
Sole prior occurrence of VTE associated to a greater reversible risk factor (non-hormonal)/ without thrombophilia	Pregnancy: Monitoring Puerperium: Pharmacological prophylaxis in the case of additional risk factors (i.e. family history, caesarian section, etc.)	Pregnancy: Monitoring Puerperium: Pharmacological prophylaxis	Pregnancy: Monitoring Puerperium: Pharmacological prophylaxis	Pregnancy: Monitoring Puerperium: Pharmacological prophylaxis
Background of multiple thrombotic events	Pharmacological prophylaxis during pregnancy and puerperium	Pharmacological prophylaxis during pregnancy and puerperium		Pharmacological prophylaxis during pregnancy and puerperium	Pharmacological prophylaxis during pregnancy and puerperium
Low risk asymptomatic thrombophilia*1and negative family history for VTE	Monitoring during pregnancy and puerperium. Prophylaxis in puerperium if additional risk factors.	Monitoring during pregnancy and puerperium	Monitoring during pregnancy and puerperium
Low risk asymptomatic thrombophilia and positive family history for VTE	Monitoring or prophylaxis during pregnancy and pharmacological prophylaxis during puerperium	Monitoring during pregnancy and pharmacological prophylaxis during puerperium	If C and S deficiency does not indicate primary prophylaxis during pregnancy, only in the puerperium. If heterozygosis for FVL or mutant prothrombin does not indicate it.	Pregnancy: observation unless other risk factors Puerperium: consider prophylaxis especially if other risk factors
Low risk thrombophilia and sole prior occurrence of VTE (anticoagulation already concluded)	Prophylaxis during pregnancy and puerperium	Prophylaxis during pregnancy and puerperium			Prophylaxis during pregnancy and puerperium
High risk asymptomatic thrombophilia2and negative family history for VTE3	Prophylaxis during pregnancy and puerperium	Pregnancy: Monitoring Puerperium: LMWH prophylactic or therapeutic dosage or VKA (RNI:2-3) for 6 weeks	AT deficiency: monitoring during pregnancy and puerperium. Mutant prothrombin or homozygous V Leiden factor: monitoring in pregnancy and prophylaxis during puerperium		Pregnancy and puerperium: prophylaxis if any high-risk thrombophilia
Patient receiving anticoagulants and becomes pregnant	Pregnancy: adjusted dosage of LMWH or UFH Puerperium: therapeutic anticoagulation (VKA and LMWH may be used during breastfeeding)	Pregnancy: LMWH in therapeutic dosage or 75% of the dosage Puerperium: therapeutic anticoagulation (VKA and LMWH may be used during breastfeeding)	Pregnancy: LMWH in one dosage or twice a day Puerperium: UFH, LMWH, fondaparinux*4, warfarin or acenocoumarol are considered options by ASH (strong recommendation with very low level of evidence)	Pregnancy: therapeutic anticoagulation Puerperium: return to pre-pregnancy anticoagulation
Dosages of LMWH	Prophylactic, intermediate or adjusted dosage during pregnancy and puerperium	Prophylactic or intermediate dosage during pregnancy and puerperium	Pregnancy: ASH is in favor of the standard dosage and against the use of intermediate dosage Puerperium: standard or intermediate dosage	Prophylactic, intermediate or adjusted dosage during pregnancy and puerperium	Prophylactic, intermediate or adjusted dosage during pregnancy and puerperium

vertical_align_top show_chart

more_horiz close
- image
- translate
- link
- article
- vertical_align_top
- file_download
- show_chart
- image
- translate
- link
- article

location_on

Federação Brasileira das Sociedades de Ginecologia e Obstetrícia Av. Brigadeiro Luís Antônio, 3421, sala 903 - Jardim Paulista, 01401-001 São Paulo SP - Brasil, Tel. (55 11) 5573-4919 - Rio de Janeiro - RJ - Brazil
E-mail: editorial.office@febrasgo.org.br

rss_feed Acompanhe os números deste periódico no seu leitor de RSS

[TFN12] Abbreviations: ACCP, American College of Chest Physicians; RANZCOG, Royal Australian and New Zealand College of Obstetricians and Gynaecologists; SOGC, Society of Obstetricians and Gynaecologists of Canada; VTE, venous thromboembolism;