Florida Perinatal Quality Collaborative

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Venous Thromboembolism

Key Points

  1. Stabilize and Transfer if necessary
  2. Virchow’s triad is present in pregnancy and postpartum
  3. High suspicion is essential. Monitor signs and symptoms including unilateral leg pain, swelling, shortness of breath, and low O2 saturation
  4. Imaging: lower extremity venous doppler, V/Q scan, CT angiogram
  5. Treatment: Heparin (low molecular weight, unfractionated)

Synopsis

The risk of venous thromboembolism (VTE) increases during pregnancy and postpartum. A deep vein thrombosis (DVT) will often present with unilateral extremity swelling or pain and the skin may be erythematous and warm to palpation. Approximately 75-80% of pulmonary embolisms are caused by DVT. Symptoms include shortness of breath, chest pain that worsens with deep inspiration, hemoptysis, and palpitations. On evaluation, tachycardia and lowered oxygen saturation can be seen. Clinicians need to have a high index of suspicion. Workup includes a venous duplex ultrasound of the affected area, a ventilation-perfusion (v/q) scan, or a CT angiogram. Once the VTE is confirmed or highly suspected, unfractionated heparin should be started per protocol.

Management

Heparin Dose Level Dose
LMW heparin Therapeutic Enoxaparin 1 mg/kg SC every 12 hours
Dalteparin 100 units/kg SC every 12 hours
Unfractionated heparin Therapeutic Can be given as a continuous IV infusion or an SC dose every 12 hours. Titrated to keep the aPTT in the therapeutic range.
  1. Baseline labs include a Complete Blood Count, Creatinine, and PT/PTT/INR/ Fibrinogen.
  2. Complications: Protamine Sulfate can reverse unfractionated heparin and can potentially reverse the bleeding effect with LMW heparin
  3. Complications: new-onset thrombocytopenia with the initiation of heparin can be due to Heparin Induced Thrombocytopenia (HIT). Workup includes laboratory assessment for Heparin PF4 Antibody testing, trending platelets, and monitoring for signs of thrombosis and bleeding. Discontinue the heparin and switch to a non-heparin anticoagulant. Consider mechanical prophylaxis.