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....................................................................................................................................... Monitoring (see section 12).

UFH: Typically, UFH is used in the acute treatment of massive pulmonary emboli. For details on management, see section 12. Thrombolysis: Thrombolytics should only be used in patients with severe hypotension or shock405 (see section 12). When thrombolysis has been given, the loading dose of UFH should be omitted and an infusion started at a rate of 18 U/kg/h. After stabilization of the patient, UFH can be switched to LMWH. Fondaparinux: Fondaparinux (7.5 mg once a day in normalweight pregnant women) can be considered if there is an allergy or adverse response to LMWH (see section 12). Vena cava filters: Indications for vena cava filters are the same as in non-pregnant patients. However, there is limited experience with their use and the risk associated with the procedure may be increased.405,414 Post-partum management: In patients with recent PE, prepartum heparin treatment should be restarted 6 h after a vaginal birth and 12 h after a caesarean delivery, if no significant bleeding has occurred, with subsequent overlap with VKAs for at least 5 days. VKAs may be started on the second day after delivery and continued for at least 3 months, or for 6 months if PE occurred late in pregnancy. The INR should be between 2 and 3 and needs regular monitoring, ideally every 1–2 weeks. VKAs do not enter the breast milk in active forms and are safe for nursing mothers.

11.4.2 Acute deep vein thrombosis 11.4.2.1 Clinical presentation Leg swelling is a frequent finding in pregnancy, giving rise to the suspicion of DVT. Since DVT is left-sided in >85% of cases, due to compression of the left iliac vein by the left iliac artery and the gravid uterus, swelling of the left leg is more suspicious. Iliac vein thrombosis may manifest with isolated pain in the buttock, groin, flank, or abdomen. Three clinical variables-left leg presentation, >2 cm calf circumference difference, and first trimester-allowed a negative predictive value of 100% (95% CI 95.8–100%) if none of the three variables was present and ultrasound of the legs was negative.415 However, this clinical decision rule needs to be validated in prospective studies.

11.4.2.2 Diagnosis D-dimer: See section 11.4.1.2. Compression ultrasound leg vein imaging: Compression ultrasound is the diagnostic imaging procedure of choice for suspected DVT in pregnancy with a high sensitivity and specificity for proximal DVT, but less so for distal and pelvic DVTs. Serial compression ultrasound evaluations at days 0, 3, and 7 in pregnancy give a high negative predictive value of 99.5% (95% CI 97–99%).416

Women with a suspected DVT in pregnancy can be evaluated with D-dimer testing (see above) and compression ultrasonography. If a proximal DVT is detected, treatment should be continued. If the initial compression ultrasound is negative, then magnetic resonance venography may be considered to exclude a pelvic DVT. If the clinical suspicion is high and the initial compression ultrasonography negative, then anticoagulation should be continued and compression ultrasonography repeated on days 3 and 7. If the initial clinical suspicion is low, then anticoagulation can be stopped and compression ultrasonography repeated on days 3 and 7. If compression ultrasonography is persistently negative, a DVT can be excluded.

11.4.2.3 Treatment In acute DVT, treatment with therapeutic doses of weight adjusted LMWH should be given twice daily (see treatment of PE).

11.5 Recommendations

11.5.1 Management of delivery In women on therapeutic LMWH, delivery should be planned at around 39 weeks to avoid the risk of spontaneous labour while fully anticoagulated, as LMWH can only be partially reversed with protamine sulfate. In high-risk women on therapeutic LMWH, LMWH should be converted to UFH at least 36 h prior to delivery and the infusion stopped some 4–6 hours prior to anticipated delivery. A normalized aPTT should guide the use of regional anaesthesia. In low-risk women on therapeutic LMWH or women on high dose prophylaxis, assuming a typical twice-a-day regimen, the evening LMWH dose should be omitted and induction or caesarean section performed the next morning, with regional anaesthesia started more than 24 h after the last dose of LMWH and if no other drugs with impairment of coagulation are used. Therapeutic anticoagulation is associated with an increased risk of post-partum haemorrhage, so the third stage of labour should always be actively managed with modified dose oxytocin. Recently, the effect of adding 2 IU oxytocin over 5 min to a standard treatment of lowdose infusion for 4 h [10 U of oxytocin in 500 mL of normal saline given i.v. at 36 mL/h for 4 h (12 mU/min)] was analysed. The addition of 2 IU of oxytocin was not associated with any greater derangement in cardiovascular measures, but with a significantly lower volume of blood loss.105 We would advise using this regimen. Downloaded from academic.oup.com/eurheartj/article/39/34/3165/5078465 by guest on 07 October 2026