What are the ACOG guidelines on the diagnosis and management of thromboembolism during pregnancy?

Updated: Sep 18, 2020
  • Author: Daniel R Ouellette, MD, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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In 2011, the American College of Obstetricians and Gynecologists (ACOG) published a practice bulletin on the diagnosis, management, and prevention of thromboembolism during pregnancy. The key recommendations included the following [114] :

  • Compression ultrasonography of the proximal veins is the recommended initial diagnostic test when signs or symptoms suggest new-onset deep veinous thrombosis (DVT) (level A).
  • Women with a history of thrombosis who have not been thoroughly evaluated for possible underlying causes should receive testing for antiphospholipid antibodies, as well as for inherited thrombophilias (level C).
  • Heparin compounds are preferred for anticoagulation (level B).
  • Anticoagulation is recommended for women with acute thromboembolism during the current pregnancy or those at high risk of venous thromboembolism (VTE), such as women with mechanical heart valves (level C).
  • In the last month of pregnancy, or sooner if delivery appears imminent, women receiving either therapeutic or prophylactic anticoagulation may be converted from low-molecular-weight heparin (LMWH) to unfractionated heparin (UFH), which has a shorter half-life (level C).
  • Neuraxial blockade should be withheld for 10-12 hours after the last prophylactic dose of LMWH or 24 hours after the last therapeutic dose of LMWH (level C).
  • For all women not already receiving thromboprophylaxis, placement of pneumatic compression devices before cesarean delivery is recommended. However, an emergency cesarean delivery should not be delayed for the placement of compression devices (level C).
  • To minimize postpartum bleeding complications, a reasonable strategy is to resume anticoagulation therapy no sooner than 4-6 hours after vaginal delivery or 6-12 hours after cesarean delivery (level B).
  • For women in whom restarting anticoagulation is planned after delivery, pneumatic compression devices should be left in place until the woman is ambulatory and anticoagulation therapy is resumed (level C).
  • Warfarin, LMWH, and UFH are compatible with breastfeeding because they do not accumulate in breast milk and do not lead to anticoagulation in the infant (level B).

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