Diagnosis and Management of Acute Venous Thromboembolism in Pregnancy and the Puerperium: A Comprehensive Review of Guidelines

Importance Venous thromboembolism (VTE) manifesting either as deep vein thrombosis or pulmonary embolism presents as the leading cause of maternal morbidity and mortality, worldwide. Objective The aim of this study was to review and compare the most recently published international guidelines on the diagnosis and management of acute VTE in pregnancy and the puerperium. Evidence Acquisition A comparative review of guidelines by the American College of Obstetricians and Gynecologists, the Royal College of Obstetricians and Gynecologists, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada, the American College of Chest Physicians, the European Society of Cardiology, and the American Society of Hematology on VTE was conducted. Results There is a consensus among the reviewed guidelines regarding the appropriate algorithm for diagnosis of VTE in the obstetric population, the appropriate anticoagulants suitable for the pregnancy and puerperium, even in cases of contraindications for heparin, and indications for extreme management measures, such as thrombolysis. On the other hand, few discrepancies were detected on the dosage of anticoagulants, indications of anticoagulation monitoring, appropriate management of anticoagulants related to neuraxial anesthesia, and indications for thrombophilia testing following a VTE event. Notably, only the European Society of Cardiology recommends the use of models assessing the clinical likelihood of pulmonary embolism, suggests a risk stratification algorithm to guide acute management, and proposes management strategies for the prevention of hemorrhagic events during labor. Conclusions VTE is a significant contributor of maternal morbidity and mortality, especially if managed in a suboptimal way. Hence, the development of consistent evidence-based protocols and algorithms is crucial to safely guide pregnant women and their physicians toward reducing improving fetal and maternal outcomes. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After participating in this activity, the learner should be better able to describe the diagnostic algorithms for deep vein thrombosis and pulmonary embolism; explain how to choose and monitor the appropriate antithrombotic regimens for pregnancy and puerperium; and discuss indications for extreme antithrombotic measures, such as thrombolysis.