Poster Presentation Society of Obstetric Medicine of Australia and New Zealand ASM 2015

Acute venous thromboemboli in pregnancy and the postpartum period: A retrospective case control study of 14 years at National Women’s Health, Auckland, New Zealand. (#113)

Shannon Emmett 1 , Claire McLintock 2
  1. John Flynn Private Hospital, Gold Coast, QLD, Australia
  2. National Women's Health, Auckland City Hospital, Auckland, New Zealand

A retrospective study of acute venous thromboemboli (VTE) that occurred from 1998 to 2011 was performed. The study group contained 78 events and 123 women formed the control group.

 The two groups were compared for these VTE risk factors: age>35, parity>=3, multiple pregnancies, smoking, BMI>30, comorbidities, preeclampsia and delivery related factors including caesarian deliveries.  Modes of delivery, anaesthetic types and ethnicities were compared. The study group was further assessed for personal and family histories of VTE, acquired and inherited thrombophilias and the use of postpartum thromboprophylaxis. Management of inherited thrombophilias in current guidelines will be discussed.

The incidences and types of VTE were compared between the trimesters and postpartum. Lower limb DVTs were compared between the trimesters and postpartum for incidences, sides (left vs right) and sites (proximal vs distal) and leg diameters were assessed.

 CTPA vs VQ scan for the diagnosis of pulmonary emboli (PE), and the usefulness of the D Dimer assay were reviewed.

Treatment with enoxaparin, warfarin, unfractionated heparin, thrombolysis and IVC filter use was evaluated and monitoring of enoxaparin with anti-Xa levels reviewed.

 Therapeutic enoxaparin was reduced to prophylactic dose in 32 of the 56 women with antenatal VTEs. The efficacy of this management was assessed. Alternatively, planned delivery with unfractionated heparin (UFH) infusion was required.  The anaesthetic types and modes of delivery were compared between the control group, women with and without UFH and those with postpartum VTEs. The efficacy of anticoagulation was determined by the rates of new or progressive thrombosis.

Maternal safety parameters were the incidence of heparin-induced thrombocytopenia (HIT), osteopenia and blood loss including antepartum haemorrhage, estimated blood loss at delivery, primary PPH and secondary PPH rates compared with those of the control group.

 Fetal parameters were birth weight centiles, preterm delivery rates, admissions to NICU and fetal anomaly rates. These were compared between the control group, the group who received anticoagulation antenatally and those who received anticoagulation postpartum (no fetal exposure). 

  1. Bates SM and Ginsberg JS. How we manage venous thromboembolism during pregnancy. Blood. 2002;100(10):3470.
  2. Chan W-S, Lee A, Spencer FA, Chunilal S, Crowther M, Wu W, Johnston M, Rodger M, Ginsberg JS. D-dimer testing in pregnant patients: towards determining the next _level’ in the diagnosis of deep vein thrombosis. J Thromb Haemost 2010; 8: 1004–11.
  3. Chan WS, Spencer FA, Ginsberg JS. Anatomic distribution of deep vein thrombosis in pregnancy. Canadian Medical Association Journal. 2010. Apr 20;182(7):657-60.
  4. Wallace A, Goergen S. Inside Radiology The RCR. 2011
  5. McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S, Muller P, Tran H, Walters B, Young L. Recommendations for the diagnosis and treatment of deep venous thrombosis and pulmonary embolism in pregnancy and the postpartum period. Aust N Z J Obstetetrics and Gynaecology. 2012; 52: 14–22.
  6. McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S, Muller P, Tran H, Walters B, Young L. Recommendations for the prevention of pregnancy-associated venous thromboembolism. Aust N Z J Obstetetrics and Gynaecology. 2012 Feb;52(1):3-13.
  7. Ridge C, McDermott S, Freyne B, Brennan DJ, Collins CD, Stephen J. Pulmonary Embolism in Pregnancy: Comparison of Pulmonary CT Angiography and Lung Scintigraphy. American Journal of Roentgenology. 2009;193: 1223-1227.
  8. Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e691S-736S
  9. Updated recommendations to decrease risk of spinal column bleeding and paralysis in patients on low molecular weight heparins. FDA Safety Announcement 11/6/2013.
  10. Kamel H, Navi BB. Sriram N, Hovsepian DA, Devereux RB, Elkind MSV. Risk of a Thrombotic Event after the 6-Week Postpartum Period. New England Journal fo Medicine. 2014; 370:1307-1315.
  11. Kahn SR et al. Compression stockings to prevent post-thrombotic syndrome: A randomised placebo-controlled trial. Lancet 2014 Mar 8;383(9920):880-8.
  12. Prevalence and predictors for post-thrombotic syndrome 3 to 16 years after pregnancy-related venous thrombosis: a population-based, cross-sectional, case-control study. Wik HS, Jacobsen AF, Sandvik L, Sanset PM. JTH. 2012; 10: 840–7.
  13. Catheter Directed Thrombolysis for Thromboembolic Disease During Pregnancy: A Viable Option. Krishnamurthy P. J. Matern.-Fetal Med. 1999;8:24-27.
  14. The use of thrombolytic therapy in pregnancy. Gartman E. Obstetric Medicine. 2013; 6(3) 105–111.
  15. Radiology 2011; Revel MP, et al. Pulmonary embolism during pregnancy: diagnosis with lung scintigraphy or CT angiography? 258: 590-598
  16. AJR 2011; Ridge CA, et al. Pulmonary CT angiography protocol adapted to the hemodynamic effects of pregnancy. 197: 1058-1063