Deep vein thrombosis in pregnancy- Management

Deep vein thrombosis (DVT) and acute pulmonary embolism (PE) are two manifestations of venous thromboembolism (VTE). The risk of VTE is increased in pregnancy by about five times because of a more hyper-coagulable state. VTE contributes to significant maternal morbidity and mortality. The mainstay of therapy for DVT is anticoagulation, provided there is no contraindication.

Clinical presentation

• Pain on the affected limb

• Swelling or redness of the calf or thigh

• Homan’s sign (pain in the calf in response to dorsiflexion of the foot)

Investigations

• Venous doppler ultrasound

• Venography (CT MRI)

• Fibrin degradation product (FDP) or D-dimer

Prevention of DVT

• Early passive and active ambulation in women undergoing major obstetric surgery

• Compressive stockings in women ≥100 kg undergoing obstetric surgery

• LMWH prophylaxis 5000 IU within 1 hour post-surgery to at risk women

Pharmacological treatment

• Unfractionated heparin (SC) 5,000 bolus and subsequent 15,000–20,000 doses at 12 hourly intervals (under supervision of a specialist)

• Low molecular weight heparin (SC) 1 mg/kg 12 hourly

• Warfarin (PO) 5 mg 24 hourly (in delivered women); consider bridging warfarin with heparin for 5 days as it takes longer to act. Warfarin to be continued up to 6 weeks postpartum.

Note:

Check PTT every 4 hours and PTT should be maintained at 1.5–2.5 × control. Once steady state has been achieved, measure PTT levels daily. Change heparin to SC route after 5–10 days.

Referral

Immediate referral to a hospital with expertise and monitoring of the treatment through laboratory testing is recommended.