In the US, thromboembolic disorders—deep venous thrombosis (DVT) or pulmonary embolism (PE)—are a leading cause of maternal mortality.
During pregnancy, risk is increased because
Venous capacitance and venous pressure in the legs are increased, resulting in stasis.
Pregnancy causes a degree of hypercoagulability.
However, most thromboemboli develop postpartum and result from vascular trauma during delivery. The risk of developing a thromboembolic disorder may be increased for about 6 weeks after delivery. Cesarean delivery also increases risk.
Symptoms of thrombophlebitis or their absence does not accurately predict the diagnosis, disease severity, or risk of embolization. Thromboembolic disorders can occur without symptoms, with only minimal symptoms, or with significant symptoms. Also, calf edema, cramping, and tenderness, which may occur normally during pregnancy, may simulate Homans sign.
Діагностика
Doppler ultrasonography or sometimes CT with contrast for DVT
Helical CT for PE
Diagnosis of DVT is usually by Doppler ultrasonography. In the postpartum period, if Doppler ultrasonography and plethysmography are normal but iliac, ovarian, or other pelvic venous thrombosis is suspected, CT with contrast is used.
Diagnosis of PE is increasingly being made by helical CT rather than ventilation-perfusion scanning because CT involves less radiation and is equally sensitive. If the diagnosis of PE is uncertain, pulmonary angiography is required.
Лікування
Similar to that in nonpregnant patients, except for avoidance of warfarin
For women with increased risk, prophylactic low molecular weight heparin throughout pregnancy and for 6 weeks postpartum
If DVT or PE is detected during pregnancy, the anticoagulant of choice is a low molecular weight heparin (LMWH). LMWH, because of its molecular size, does not cross the placenta. It does not cause maternal osteoporosis and may be less likely to cause thrombocytopenia, which can result from prolonged (≥ 6 months) use of unfractionated heparin. Warfarin crosses the placenta and may cause fetal abnormalities or death (see table Some Drugs With Adverse Effects During Pregnancy).
Indications for thrombolysis during pregnancy are the same as for patients who are not pregnant.
If PE recurs despite effective anticoagulation, surgery, usually placement of an inferior vena cava filter just distal to the renal vessels, is indicated.
If women developed DVT or PE during a previous pregnancy or have an underlying thrombophilic disorder, they are treated with prophylactic LMWH (eg, enoxaparin 40 mg subcutaneously once a day) beginning when pregnancy is first diagnosed and continuing until 6 weeks postpartum.
Ключові моменти
During pregnancy, risk of thromboembolic disorders is increased, but most thromboemboli develop postpartum and result from vascular trauma during delivery.
Symptoms of thrombophlebitis or their absence does not accurately predict the diagnosis, disease severity, or risk of embolization.
Diagnose deep vein thrombosis using Doppler ultrasonography, but postpartum, if Doppler ultrasonography and plethysmography findings are normal but pelvic venous thrombosis is suspected, do CT with contrast.
Diagnose pulmonary embolism using helical CT or, if needed, pulmonary angiography.
Low molecular weight heparin (LMWH) is the treatment of choice; warfarin should be avoided during pregnancy.
Treat high-risk women prophylactically with LMWH as soon as pregnancy is diagnosed and continue until 6 weeks postpartum.