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Prevention and Treatment of VTE and Pregnancy

NOMINATED TOPIC | January 12, 2018
Describe your topic.
VTE in Pregnancy
Describe why this topic is important.
Anticoagulant therapy is indicated during pregnancy for the prevention and treatment of VTE; for the prevention and treatment of systemic embolism in patients with mechanical heart valves; and, in combination with aspirin, for the prevention of recurrent pregnancy loss in women with antiphospholipid antibodies (APLAs). The use of anticoagulation for prevention of pregnancy complications in women with hereditary thrombophilia is becoming more frequent. Given the absence of proven-effective therapy in women with unexplained recurrent pregnancy loss, there is also growing pressure to intervene with antithrombotic therapy in affected women with no known underlying thrombophilia. The use of anticoagulant therapy during pregnancy is challenging because of the potential for fetal and maternal complications.
Tell us why you are suggesting this topic.
VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy has been the focus of 9 editions of evidence-based guidelines developed by the American College of Chest Physicians (CHEST), the last of which was published in 2012 and accepted by the National Guideline Clearinghouse. CHEST aims to update its guidelines every 5 years per the National Academy of Medicine (formerly IOM) and AHRQ standards, but due to increased demand for guidelines, has fallen short on this objective. Development of an evidence review on at least some, if not all, of the PICO’s described above would serve as the source document to facilitate the update of these guidelines.
Target Date.
 
Describe what you are doing currently and what you are hoping will change because of a new evidence report.
As described above, evidence reports form the basis of all CHEST clinical practice guidelines. If this topic is selected for an AHRQ evidence report, the results of that report will directly inform an update of the guideline on VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy. The original selection of this topic was due to professional demand based on inconsistent or lack of clear guidance based on current evidence. CHEST guidelines have been touted as a useful tool to assist in clinical decision-making, resulting in improved concordance between practice and the larger body of published evidence. In order to meet the National Academy of Medicine (formerly IOM) standards, it is imperative that an updated evidence report be developed to update the guidelines.
How will you or your group use the information from a new evidence report?
As described above, the evidence report will be directly used to inform the update of evidence-based guidelines on this topic.
How would you or your group plan to disseminate information from the report? Who would you plan to disseminate it to?
The report will be disseminated in the following ways: 1) communications to CHEST membership (nearly 19,000 healthcare providers) via electronic (ie eNews Alerts), print (ie CHEST Physician Newsletter), and social media. There will also be opportunities to inform providers about the report through our eLearning and Live Learning platforms, including our Annual Conference. Finally, the report will be referenced as the source document for the subsequent update of the guideline, furthering dissemination of the report as well as use of its contents in clinical practice.
Do you know of organizations that could use an evidence report to change clinical practice? Are you a part of, or have you been in contact with, any organizations that might implement the research findings of an evidence report?
CHEST serves as the primary organization that will directly use this evidence report to update our clinical practice guideline on VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy. Such guidelines have the opportunity to change clinical practice by improving clinical decisions in concordance with current evidence. Other organizations that would also benefit from this evidence report include: the American Thoracic Society, the American Society of Hematology, and the American College of Obstetricians and Gynocologists.
Information About You: (optional)
Provide a description of your role or perspective.
The American College of Chest Physicians (CHEST) is a professional society
If you are you making a suggestion on behalf of an organization, please state the name of the organization.
The American College of CHEST Physicians
Please tell us how you heard about the Effective Health Care Program.
CHEST has collaborated with AHRQ in the past on evidence reviews, most recently the VTE Prophylaxis in Orthopedic Surgery Update

We are suggesting the following PICO questions pertaining to the management of Venous thromboembolism (VTE) and thrombophilia during pregnancy as well as the use of antithrombotic agents in pregnant women.

Population Intervention Comparison Outcome
Safety and Adverse Outcome PICO Questions

Pregnant women

  • Unfractionated heparin
  • Low-molecular-weight heparin
  • Other relevant agents
  • No antithrombotic therapy or
  • Other antithrombotic therapy
  • Fetal hemorrhage
  • Pregnancy loss
  • Congenital malformations
  • Developmental delay
  • Levels or results of coagulation testing in umbilical cord blood
  • Birth weight (centile); number small for dates

Fetuses and children of women using antithrombotic therapy during pregnancy

  • Vitamin K antagonists
  • Unfractionated heparin
  • Low-molecular-weight heparin
  • Other relevant agents
  • No antithrombotic therapy exposure or
  • Other antithrombotic agent
  • Fetal hemorrhage
  • Pregnancy loss
  • Congenital malformations
  • Developmental delay
  • Levels or results of coagulation testing in umbilical cord blood
  • Birth weight (centile); number small for dates

Breast-fed infants of women receiving antithrombotic therapy

  • Vitamin K antagonists
  • Unfractionated heparin
  • Low-molecular-weight heparin
  • Other relevant agents
  • No antithrombotic therapy exposure or
  • Other antithrombotic agent
  • Infant hemorrhage
  • Levels or results of coagulation testing in breast milk
  • Levels or results of coagulation testing in plasma of breast-fed infants
Prevention & Risk PICO Questions

Women using assisted reproductive technology to become pregnant   

  • No prophylaxis   
  • No intervention
  • Proportion of pregnancies that are successful
  • DVT
  • Pulmonary embolism
  • Mortality
  • Major bleeding
  • Bleeding during oocyte retrieval and embryo transfer

Women using assisted reproductive technology to become pregnant   

  • Low-molecular-weight heparin
  • Unfractionated heparin
  • Graduated compression stockings
  •  Other relevant agents   
  • No prophylaxis or
  • Other intervention
  • DVT
  • Pulmonary embolism
  • Mortality
  • Major bleeding
  • Bleeding during oocyte retrieval and embryo transfer

Pregnant women undergoing cesarean section

  • No prophylaxis
  • No intervention   
  • DVT
  • Pulmonary embolism
  • Embolism
  • Mortality
  • Major bleeding
  • Epidural hematoma

Pregnant women undergoing cesarean section

  • Low molecular weight heparin
  • Unfractionated heparin
  • Graduated compression stockings
  • Intermittent pneumatic compression
  • Combined mechanical and pharmacologic prophylaxis
  • Other relevant agents
  • No prophylaxis or
  • Other antithrombotic strategy   
  • DVT
  • Pulmonary embolism
  • Mortality
  • Major bleeding: total
  • Major bleeding
  • Epidural hematoma

Pregnant women with prior VTE

  • No prophylaxis
  • No intervention
  • Symptomatic DVT, pulmonary embolism
  • Mortality
  • Major bleeding: total
  • Postthrombotic syndrome

Pregnant women with prior VTE    

 

 

  • No antepartum prophylaxis, postpartum only
    -All relevant agents considered
  • Antepartum and postpartum prophylaxis
    -All relevant agents considered
  • No prophylaxis
  • Symptomatic recurrent DVT or pulmonary embolism
  • Major bleeding: total
  • Postthrombotic syndrome

Pregnant women with thrombophilia and no prior VTE

  • No prophylaxis
  • No intervention 
  • Symptomatic DVT, pulmonary embolism
  • Mortality
  • Major bleeding

Pregnant women with thrombophilia and no prior VTE

  • No antepartum prophylaxis, postpartum only
    -Low-molecular-weight heparin
    -Unfractionated heparin
    -Other relevant agents
    -Graduated compression stockings
    -Combined mechanical and pharmacologic prophylaxis
  • Antepartum and postpartum prophylaxis
    -Similar agents as above    
  • No prophylaxis or
  • Other intervention 
  • Symptomatic DVT, pulmonary embolism
  • Mortality
  • Major bleeding

Pregnant women with thrombophilia  and a history of pregnancy complications

-Recurrent early pregnancy loss
-Late pregnancy loss (single)
-Late pregnancy loss (multiple)
-Pre-eclampsia
-Intrauterine growth restriction
-Placental abruption    

    

 

 

  • No prophylaxis
  • No intervention  
  • Recurrent pregnancy complication (as defined under patient population)
  • Symptomatic DVT, pulmonary embolism
  • Mortality
  • Major bleeding

Pregnant women with thrombophilia  (antiphospholipid antibodies vs congenital thrombophilia vs specific congenital thrombophilia) and a history of pregnancy complications

-Recurrent early pregnancy loss
-Late pregnancy loss (single)
-Late pregnancy loss (multiple)
-Preeclampsia
-Intrauterine growth restriction
-Placental abruption

  • Aspirin
  • Unfractionated heparin ( +/- aspirin)
  • Low-molecular-weight heparin (+/-aspirin)
  • No prophylaxis or
  • Other antithrombotic strategy
  • Recurrent pregnancy complication (as defined under patient population)
  • Symptomatic DVT, pulmonary embolism
  • Mortality
  • Major bleeding

Pregnant women with no known
thrombophilia and prior preeclampsia


Pregnant women with no known thrombophilia and at least two prior pregnancy losses

  • Aspirin
  • Unfractionated heparin (+/- aspirin)
  • Low-molecular-weight heparin (+/- aspirin)  
  • No prophylaxis
  • Recurrent preeclampsia
  • Recurrent pregnancy loss

Pregnant women with mechanical heart valves

  • No antithrombotic therapy
  • No intervention
  • Maternal thromboembolism
  • Major bleeding: total
  • Major bleeding: maternal death
  • Congenital malformations
  • Fetal/neonatal hemorrhage
  • Pregnancy loss

Pregnant women with mechanical heart valves

  • Vitamin K antagonists throughout pregnancy
  • Unfractionated heparin throughout pregnancy
  • Low-molecular-weight throughout pregnancy
  • Vitamin K antagonists substituted with unfractionated heparin during first trimester (at or before 6 wk)
  • Vitamin K antagonists substituted with low-molecular-weight heparin during first trimester (at or before 6 wk)
  • Vitamin K antagonists substituted with unfractionated heparin after 6 wk
  • Vitamin K antagonists substituted with low molecular weight heparin after 6 wk
  • Aspirin throughout pregnancy
  • No antithrombotic therapy or
  • Other antithrombotic strategy
  • Maternal thromboembolism
  • Major bleeding maternal death
  • Congenital malformations
  • Fetal/neonatal hemorrhage
  • Pregnancy loss
Treatment PICO Questions  

Pregnant women with proven acute VTE

  • Vitamin K antagonists
  • Unfractionated heparin
  • Low-molecular-weight heparin
  • Other relevant agents
  • No treatment or
  • Other antithrombotic therapy or
  • Therapy in nonpregnant population with acute VTE
  • Symptomatic recurrent DVT or pulmonary embolism
  • Fatal pulmonary embolism
  • Major bleeding
  • Postthrombotic syndrome

Pregnant women with proven acute VTE

  • Throughout pregnancy
  • Throughout pregnancy and 6 wk postpartum (at least 3 mo)
  • Throughout pregnancy and 6 wk postpartum (at least 6 mo)
  • Throughout pregnancy and indefinite postpartum
  • Other duration
  • Symptomatic recurrent DVT or pulmonary embolism
  • Fatal pulmonary embolism
  • Major bleeding

Pregnant women with proven acute VTE

  • Venal caval filter  
  • No vena caval filter    
  • Symptomatic recurrent DVT or pulmonary embolism
  • Fatal pulmonary embolism
  • Major bleeding
  • Postthrombotic syndrome

Pregnant women with proven acute VTE    

 

 

 

  • Elective delivery with discontinuation of antithrombotic therapy 24 to 48 h prior to delivery
  • No elective delivery, transition to unfractionated heparin
  • No elective delivery, transition to prophylactic dose of antithrombotic agent
  • No elective delivery with discontinuation of antithrombotic therapy as soon as labor commences  
  • Other intervention    
  • Symptomatic recurrent DVT or pulmonary embolism
  • Major bleeding: total
  • Epidural hematoma
  • Postthrombotic syndrome

 

Page last reviewed March 2018
Page originally created January 2018

Internet Citation: Prevention and Treatment of VTE and Pregnancy. Content last reviewed March 2018. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/get-involved/nominated-topics/31643

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