Thromboembolic Disease
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
One previous deep vein thrombosis (DVT) or pulmonary embolism (PE)
The risk of TED should be discussed with the women at risk, ideally as pre- pregnancy counselling & with a prospective management plan. Women with a previous history of TED (except if related to a major surgical procedure & in the absence of other risk factors), should be offered thromboprophylaxis throughout pregnancy including the puerperium for at least 6 weeks post-partum regardless of the mode of delivery.
- Give heparin 5000 units SC twice daily (or enoxaparin 40 mg SC daily) up to delivery, & warfarin postpartum for 6 weeks. Adjust warfarin to an INR of 2.0 - 3.0
- Prescribe graduated elastic compression stockings
Two previous episodes of DVT or PE
- Consult with a haematologist, for thrombophilia screening (antithrombin III, protein C, protein S, antiphospholipid antibodies)
- Prescribe full anticoagulation with enoxaparin or heparin &/or warfarin as shown above
- Prescribe graduated elastic compression stockings
DVT or PE in the current pregnancy
A women with clinical signs & symptoms of thromboembolic disease should start treatment immediately while objective testing is performed unless treatment is contraindicated.
DVT
Iliofemoral/popliteal duplex ultrasound should be done where there’s a clinical suspicion of DVT. If the u/s is negative but the clinical suspicion very high, stop the anticoagulation treatment & repeat the test 3 – 7 days later.
PE
Women with signs/ symptoms of PE should have a Chest X-ray & ECG performed. A ventilation/perfusion (V/Q) scan or computerized tomography pulmonary angiogram (CTPA) should also be considered.
- Acutely ill patients should be managed in a high care area, with support & advice from internal medicine specialists
- LMWH should be commenced immediately until diagnosis is confirmed. It should be given according to women’s weight (1 mg/kg/dose 12 hourly)
- Treatment with therapeutic dose of LMWH should be continued during the remainder of the pregnancy & at least 6 weeks post-partum, or until at least 3 months of treatment has been completed.
- Prescribe graduated elastic compression stockings