Our practice at Parkland Hospital for many years for women with a history of prior VTE was to administer subcutaneous UFH, 5000 to 7500 units two to three times daily. With this regimen, the recurrence of documented deep-vein thrombosis embolization was rare. Beginning approximately 10 years ago, we have successfully used 40 mg enoxaparin given subcutaneously daily for thromboprophylaxis.
The risk for deep-vein thrombosis and especially for fatal thromboembolism rises manyfold in women following cesarean compared with that ater vaginal delivery. When considering that a third of women giving birth in the United States yearly undergo cesarean delivery, pulmonary embolism is understandably a major cause of maternal mortality (Creanga, 2017). hat said, the "lack
TABLE 52-6. Some Recommendations for Thromboprophylaxis during Pregnancy some experts." INR 2.0-3.0 x long-term therapy some experts" INR 2.0-3.0 x warfarin LMWH or 75% of anticoagulation
Associated with a high-Prophylactic, NSS Postpartum Prophylactic or risk thrombophiliad intermediate-, r anticoagulationC intermediate- anticoagulation or an LMWH or UFH x INR 2.0-3.0 x affected fi rst -d eg ree 6 weeksc 6 weeks relative Associated with a low-Prophylactic or NSS Postpartum Prophylactic or risk thrombophiliae intermed iate-dose anticoagulationc or intermediate-
INR 2.0-3.0 x
Two or more prior VTEs with or without thrombophilia 6 weeks INR 2.0-3.0 x 6 weeks Receiving long-term Therapeutic-dose Adjusted-dose Resumption of long-Resumption of anticoagulation LMWH or UFH LMWH or 75% of term anticoagulation long-term a therapeutic dose anticoagulation
No prior.VTE prophylactic or intermed iate-dose a nticoag u lation. dose LMWH or intermediate-dose LMWH warfarin target
LMWH or UFH INR 2.0-3.0 x mutation INR 2.0-3.0 x
TABLE 52-6. Continued mutation INR 2.0-3.0 x or S deficient,
INR 2.0-3.0
History of fE Prophylactic NSS Prophylactic NSS anticoagulation with a nticoag u lationC;
UFH or LMWH (?plus referral to specialist9
LMWH or UFH plus low-LMWH, both given pregnancy loss r dose aspirin if prior with 75-100 mg/ stillbirth9 aAmerican College of Obstetricians and Gynecologists, 2017a, c.
bAmerican College of Chest PhYSicians (Bates, 201n2).
(Postpartum treatment levels should be � antepartum treatment.
dAntithrombin deficiency; doubly heterozygous or homozygous for prothrombin 2021 OA and factor V Leiden.
eHeterozygous factor V Leiden or prothrombin 2021 OA; protein S or C deficiency.
fFirst-degree relative with fE at <50 years; other major thrombotic risk factors, e.g., obesity, prolonged immobility.
9Women with antiphospholipid syndrome should not use estrogen-containing contraceptives.
hTreatment is recommended if the diagnosis of antiphospholipid syndrome is based on three or more prior pregnancy losses.
LMWH = low-molecular-weight heparin; NSS = not specifically stated; UFH = unfractionated heparin; fE = venous thromboembolism.