How Do We Treat Pregnancy-Related Venous Thromboembolism?

Abstract

Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality during pregnancy and the postpartum period. Due to a lack of adequate study data, therapeutic strategies for pregnancy-related VTE are deduced from observational studies and extrapolated from recommendations for nonpregnant patients. Because heparins do not cross the placenta, weight-adjusted therapeutic-dose low-molecular-weight heparins (LMWHs) are the anticoagulant treatment of choice in cases of VTE during pregnancy. Once- and twice-daily dosing regimens are suitable. There is no evidence that measurement of factor Xa activities and consecutive LMWH dose adjustments improve clinical outcomes. There is no support for the routine use of vitamin K antagonists, direct oral thrombin or factor Xa inhibitors, fondaparinux, or danaparoid in uncomplicated pregnancy-related VTE. Management of delivery deserves special attention, and treatment strategies depend on the time interval between the diagnosis of acute VTE and the expected delivery date. In lactating women, an overlapping switch from LMWH to warfarin is possible. Anticoagulation should be continued for at least 6 weeks postpartum or for a minimum period of 3 months.

Zusammenfassung

Venöse Thromboembolien (VTE) sind eine der Hauptursachen für mütterliche Morbidität und Mortalität während der Schwangerschaft und postpartal. Aufgrund fehlender randomisierter kontrollierter Studien sind therpeutische Strategien vorzugsweise aus Beobachtungsstudien und aus Therapieempfehlungen für Nicht-Schwangere abgeleitet. Heparine sind nicht plazentagängig und gelten in der Schwangerschaft als sicher. Niedermolekulare Heparine (NMH) in gewichts-adaptierter volltherapeutischer Dosierung sind daher Mittel der Wahl für die VTE-Therapie in der Schwangerschaft. Dosisregime mit Einmal- oder Zweimalgabe sind möglich. In Abhängigkeit des Präparates wird das NMH ein- oder zweimal täglich subkutan appliziert. Da es keine Evidenz für einen Nutzen einer Dosisanpassung an anti-Faktor-Xa-Spiegel gibt, werden routinemäßige Spiegelkontrollen nicht empfohlen. Andere Antikoagulanzien wie Vitamin-K-Antagonisten, die direkten oralen Thrombin- und Faktor-Xa-Inhibitoren (DOAKs), Fondaparinux und Danaparoid haben in der VTE-Behandlung bei unkompliziertem Schwangerschaftsverlauf keinen Stellenwert. Das peripartale Vorgehen hängt wesentlich vom Zeitabstand zwischen VTE-Manifestation und dem Geburtszeitpunkt ab. In der Stillzeit kann die NMH-Therapie fortgeführt oder überlappend auf Warfarin umgestellt werden. Bei schwangerschafts-assoziierter VTE sollte eine Antikoagulation für die Mindestdauer von 3 Monaten und bis mindestens 6 Wochen postpartum fortgeführt werden.

Keywords

venous thromboembolism - deep vein thrombosis - pulmonary embolism - heparin - pregnancy - postpartum

Schlüsselwörter

venöse Thromboembolie - tiefe Venenthrombose - Lungenembolie - Heparin - Schwangerschaft - Stillzeit

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