The management of thromboembolic disease in pregnancy and puerperium

Abstract

Pregnancy and particularly postpartum period associate a high risk of thromboembolic disease, especially when ano­ther procoagulant condition is present. Besides the hypercoagulable state characteristic to pregnancy, the factors that in­crease this risk are venous stasis of the lower extremities, endothelial injury, and the presence of an inherited thrombo­philia. The thromboembolic risk grows exponentially during pregnancy and persists 12 weeks postpartum. Regarding the localization, there is a predisposition for developing deep vein thrombosis in left inferior limb, characteristic for 70% to 90% of cases, this predisposition being augmented by the hospitalization status. A history of venous thromboembolism associates a recurrence risk in pregnancy 20-30 times higher than the incidence of this pathology in pregnant and postpartum population. About 50% of venous thromboembolism in pregnancy associates hereditary or acquired thrombophilias; in this context, the screening for thrombophilic disorders should be recommended to all pregnant women who associate a history of venous thromboembolism or manifested venous thrombosis during the current pregnancy. For all cases of pregnancies and postpartum women, avoidance of dehydration, active live and, respectively, early mobilization are recommended. For the cases of pregnancies with confirmed antiphospholipid syndrome (APS), low doses of aspirin are recommended to be added to the prophylactic therapy with LMWH/UFH, as early as possible in pregnancy, up to 36 weeks of gestation, this treatment schedule having the highest efficiency in early pregnancy loss prevention and favorable pregnancy outcome. The cases of thromboembolism during pregnancy and puerperium are complex, with high mortality and morbidity risk, and require team collaboration between cardiologist, gynecologist, hematologist and intensive care specialists. The key to success for a good prognosis is the compliance with a clear, standardized, adapted protocol.