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| __NOTOC__
| | #Redirect [[Deep vein thrombosis special scenario pregnancy]] |
| {| class="infobox" style="float:right;"
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| | [[File:Siren.gif|30px|link=Deep vein thrombosis resident survival guide]]|| <br> || <br>
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| | [[Deep vein thrombosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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| |}
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| '''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}} ; [[User:Kashish Goel|Kashish Goel, M.D.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]
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| {{Deep vein thrombosis}}
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| ==Overview==
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| The approach to diagnosis of [[DVT]] may be modified in certain situations, where the suspicion is high or there is a recurrent episode. This chapter will discuss these modifications that have been recommended to the American College of Chest Physicians.<ref name="pmid22315267">{{cite journal |author=Bates SM, Jaeschke R, Stevens SM, ''et al.'' |title=Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e351S–418S |year=2012 |month=February |pmid=22315267 |doi=10.1378/chest.11-2299 |url=}}</ref>
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| == Specific Situations ==
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| === Recurrent DVT ===
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| * Patients suspected to have a recurrent episode of [[DVT]] may benefit from [[thrombophilia]] evaluation.
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| * Initial test in these patients should be a [[Deep vein thrombosis ultrasound|compression ultrasound]] if a previous ultrasound is available for comparison. A highly-sensitive [[Deep vein thrombosis D-dimer|D-dimer]] is also a possible test.
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| * If the [[Deep vein thrombosis ultrasound|compression ultrasound]] results are abnormal but nondiagnostic (increase in residual venous diameter of < 4 but ≥ 2 mm), further testing with [[Deep vein thrombosis venography|venography]] or [[Deep vein thrombosis CT venography|CT venography]] may be indicated.
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| | |
| === Pregnant Patients ===
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| * Initial test should be a proximal [[Deep vein thrombosis ultrasound|compression ultrasound]].
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| * If the initial proximal [[Deep vein thrombosis ultrasound|compression ultrasound]] is negative, serial testing with either proximal [[Deep vein thrombosis ultrasound|compression ultrasound]] at day 3 and day 7 or a D-dimer at presentation should be done.
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| * Doppler ultrasound of the [[iliac]] vein is recommended if there are signs of isolated iliac vein thrombosis like swelling of the entire leg, with or without flank, buttock, or back pain.
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| | |
| === Upper Extremity DVT ===
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| * Combined modality ultrasound ([[Deep vein thrombosis ultrasound|compression ultrasound]] with either Doppler to color Doppler) is the initial test of choice.
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| * If the initial ultrasound is negative, but clinical suspicion stays high, further testing with [[serial ultrasound]], [[D-dimer]], or [[venography]] should be performed.
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| | |
| === CUS as the First Initial Test ===
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| It is recommended that the [[Deep vein thrombosis pretest probabiltiy|pretest probability]] should be computed in each patient to assess the need for further testing. However, in certain clinical scenarios (like moderate probability), the clinician may decide to proceed with [[Deep vein thrombosis ultrasound|compression ultrasound]] as the first test.
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| * If positive, then treatment should be started.
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| * If negative, repeat the [[Deep vein thrombosis ultrasound|compression ultrasound]]. If not, D-dimer testing should be done in 1 week.
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| === Positive D-dimer only ===
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| * If the initial D-dimer is positive, but [[Deep vein thrombosis ultrasound|compression ultrasound]] is negative, a repeat [[Deep vein thrombosis ultrasound|compression ultrasound]] should be performed in 1 week.
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| | |
| === Isolated Distal DVT ===
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| * On identification of an isolated [[DVT]] in the distal calf veins, serial testing is recommended to rule out proximal extension.
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| ==2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)<ref name="pmid22315276">{{cite journal| author=Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO et al.| title=VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e691S-736S | pmid=22315276 | doi=10.1378/chest.11-2300 | pmc=PMC3278054 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315276 }} </ref>==
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| | |
| ===Maternal Complications of Anticoagulant Therapy===
| |
| {|class="wikitable"
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| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For pregnant patients, we recommend [[LMWH]] for the prevention and treatment of [[VTE]], instead of [[UFH]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| ===Fetal Complications of Antithrombotic Therapy During Pregnancy===
| |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| |-
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women receiving [[anticoagulation]] for the treatment of [[VTE]] who become pregnant, we recommend [[LMWH]] over vitamin K antagonists during the first trimester ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: A]]), in the second and third trimesters ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]]), and during late pregnancy when delivery is imminent ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]]). ''''<nowiki>"</nowiki>
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| |-
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For pregnant patients, we recommend [[LMWH]] for the prevention and treatment of [[VTE]], instead of [[UFH]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' For pregnant women, we recommend avoiding the use of oral direct thrombin (eg, [[dabigatran]]) and anti-Xa (eg, [[rivaroxaban]], [[apixaban]]) inhibitors. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| {|class="wikitable"
| |
| |-
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| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For women requiring long-term [[vitamin K antagonist]]s who are attempting [[pregnancy]] and are candidates for [[LMWH]] substitution, we suggest performing frequent pregnancy tests and substituting [[LMWH]] for [[vitamin K antagonist]]s when [[pregnancy]] is achieved rather than switching to LMWH while attempting [[pregnancy]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For pregnant women, we suggest limiting the use of [[fondaparinux]] and parenteral [[direct thrombin inhibitor]]s to those with severe allergic reactions to [[heparin]] (eg, [[HIT]]) who cannot receive [[danaparoid]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| ===Use of Anticoagulants in Breast-feeding Women===
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| {|class="wikitable"
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| |-
| |
| | |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For lactating women using [[warfarin]], [[acenocoumarol]], or UFH who wish to breast-feed, we recommend continuing the use of warfarin, acenocoumarol, or UFH. ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: A]]) ''''<nowiki>"</nowiki>
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| |-
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For lactating women using LMWH, danaparoid, or r-hirudin who wish to breast-feed, we recommend continuing the use of LMWH, danaparoid, or r-hirudin. ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]]) ''''<nowiki>"</nowiki>
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| |-
| |
| | |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' For breast-feeding women, we recommend alternative anticoagulants rather than oral direct thrombin (eg, dabigatran) and factor Xa inhibitors (eg, rivaroxaban, apixaban). ([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]]) ''''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For breast-feeding women, we suggest alternative anticoagulants rather than [[fondaparinux]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For lactating women using low-dose [[aspirin]] for vascular indications who wish to breast-feed, we suggest continuing this medication. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| ===VTE in Patients Using Assisted Reproductive Technology===
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| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women undergoing assisted reproduction, we recommend against the use of routine [[thrombosis]] prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
| |
| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For women undergoing assisted reproduction who develop severe ovarian hyperstimulation syndrome, we suggest [[thrombosis]] prophylaxis (prophylactic [[LMWH]]) for 3 months postresolution of clinical ovarian hyperstimulation syndrome rather than no prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| ===VTE Following Cesarean Section===
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| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women undergoing [[cesarean section]] without additional [[thrombosis]] risk factors, we recommend against the use of thrombosis prophylaxis other than early mobilization. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
| |
| |}
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| | |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
| |
| |-
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For women at increased risk of [[VTE]] after [[cesarean section]] because of the presence of one major or at least two minor risk factors, we suggest pharmacologic thromboprophylaxis (prophylactic [[LMWH]]) or mechanical prophylaxis ([[elastic stocking]]s or [[intermittent pneumatic compression]]) in those with contraindications to anticoagulants while in hospital following delivery rather than no prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For women undergoing cesarean section who are considered to be at very high risk for [[VTE]] and who have multiple additional risk factors for [[thromboembolism]] that persist in the [[puerperium]], we suggest that prophylactic [[LMWH]] be combined with [[elastic stocking]]s and/or [[intermittent pneumatic compression]] over [[LMWH]] alone. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
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| | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' For selected high-risk patients in whom significant risk factors persist following delivery, we suggest extended prophylaxis (up to 6 weeks after delivery) following discharge from the hospital. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
| |
| |}
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| | |
| ===Treatment of Proven Acute VTE During Pregnancy===
| |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For pregnant women with acute [[VTE]], we recommend therapy with adjusted-dose subcutaneous [[LMWH]] over adjusted-dose [[UFH]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| |-
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For pregnant women with acute [[VTE]], we recommend [[LMWH]] over [[vitamin K antagonist]] treatment antenatally. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' For pregnant women receiving adjusted-dose LMWH therapy and where delivery is planned, we recommend discontinuation of [[LMWH]] at least 24 h prior to induction of labor or [[cesarean section]] (or expected time of neuraxial [[anesthesia]]) rather than continuing [[LMWH]] up until the time of delivery. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| {|class="wikitable"
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| |-
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| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
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| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For pregnant women with acute [[VTE]], we suggest that anticoagulants should be continued for at least 6 weeks postpartum (for a minimum total duration of therapy of 3 months) in comparison with shorter durations of treatment. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| ===Prevention of VTE in Pregnant Women With Prior DVT or PE===
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| {|class="wikitable"
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| |-
| |
| | |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For all pregnant women with prior [[VTE]], we suggest postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose [[LMWH]] or [[vitamin K antagonist]]s targeted at [[INR]] 2.0 to 3.0 rather than no prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For pregnant women at low risk of recurrent VTE (single episode of VTE associated with a transient risk factor not related to pregnancy or use of estrogen), we suggest clinical vigilance antepartum rather than antepartum prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' For pregnant women at moderate to high risk of recurrent [[VTE]] (single unprovoked VTE, [[pregnancy]]- or estrogen-related VTE, or multiple prior unprovoked VTE not receiving long-term [[anticoagulation]]), we suggest antepartum prophylaxis with prophylactic- or intermediate-dose [[LMWH]] rather than clinical vigilance or routine care. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' For pregnant women receiving long-term [[vitamin K antagonist]]s, we suggest adjusted-dose [[LMWH]] or 75% of a therapeutic dose of LMWH throughout [[pregnancy]] followed by resumption of long-term anticoagulants postpartum, rather than prophylactic-dose [[LMWH]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| ===Prevention of VTE in Pregnant Women With Thrombophilia and No Prior VTE===
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| {|class="wikitable"
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| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For pregnant women with no prior history of VTE who are known to be homozygous for [[factor V Leiden]] or the [[prothrombin 20210A]] mutation and have a positive family history for [[VTE]], we suggest antepartum prophylaxis with prophylactic- or intermediate-dose [[LMWH]] and postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose [[LMWH]] or [[vitamin K antagonist]]s targeted at [[INR]] 2.0 to 3.0 rather than no prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| | |
| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For pregnant women with all other [[thrombophilia]]s and no prior VTE who have a positive family history for VTE, we suggest antepartum clinical vigilance and postpartum prophylaxis with prophylactic- or intermediate-dose [[LMWH]] or, in women who are not [[protein C]] or protein S|S]] deficient, [[vitamin K antagonist]]s targeted at [[INR]] 2.0 to 3.0 rather than routine care. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| | |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' For pregnant women with no prior history of [[VTE]] who are known to be homozygous for [[factor V Leiden]] or the prothrombin 20210A mutation and who do not have a positive family history for VTE, we suggest antepartum clinical vigilance and postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose [[LMWH]] or [[vitamin K antagonist]]s targeted at [[INR]] 2.0 to 3.0 rather than routine care. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| | |
| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' For pregnant women with all other [[thrombophilia]]s and no prior VTE who do not have a positive family history for VTE, we suggest antepartum and postpartum clinical vigilance rather than pharmacologic prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| |
| |-
| |
| |}
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| | |
| ===Thrombophilia and Pregnancy Complications===
| |
| {|class="wikitable"
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| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women with recurrent early pregnancy loss (three or more [[miscarriage]]s before 10 weeks of [[gestation]]), we recommend screening for APLAs. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| | |
| |-
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| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For women who fulfill the laboratory criteria for APLA syndrome and meet the clinical APLA criteria based on a history of three or more pregnancy losses, we recommend antepartum administration of prophylactic- or intermediate-dose [[UFH]] or prophylactic [[LMWH]] combined with low-dose [[aspirin]], 75 to 100 mg/d, over no treatment. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]]
| |
| |-
| |
| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For women with a history of pregnancy complications, we suggest not to screen for inherited [[thrombophilia]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
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| |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' For women with inherited thrombophilia and a history of pregnancy complications, we suggest not to use antithrombotic prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| ===Management of Women With a History of Preeclampsia or Recurrent Fetal Loss and No Thrombophilia===
| |
| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| | |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For women considered at risk for [[preeclampsia]], we recommend low-dose [[aspirin]] throughout [[pregnancy]], starting from the second trimester, over no treatment. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| |
| | |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For women with two or more miscarriages but without APLA or [[thrombophilia]], we recommend against antithrombotic prophylaxis. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
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| |-
| |
| |}
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| | |
| ===Maternal and Fetal Risks Related to Anticoagulation During Pregnancy for Mechanical Prosthetic Valves===
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| {|class="wikitable"
| |
| |-
| |
| | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| |
| |-
| |
| | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For pregnant women with [[mechanical heart valve]]s, we recommend one of the following anticoagulant regimens in preference to no [[anticoagulation]] ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: A]])'':
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| | |
| (a) Adjusted-dose bid [[LMWH]] throughout pregnancy. We suggest that doses be adjusted to achieve the manufacturer’s peak anti-Xa [[LMWH]] 4 h postsubcutaneous-injection or
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| | |
| (b) Adjusted-dose [[UFH]] throughout pregnancy administered subcutaneously every 12 h in doses adjusted to keep the mid-interval aPTT at least twice control or attain an anti-Xa heparin level of 0.35 to 0.70 units/mL or
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| (c) [[UFH]] or [[LMWH]] (as above) until the 13th week, with substitution by [[vitamin K antagonist]]s until close to delivery when [[UFH]] or [[LMWH]] is resumed.<nowiki>"</nowiki>
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| |-
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| |}
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| ==References==
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| {{reflist|2}}
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| [[Category:Disease]]
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| [[Category:Cardiology]]
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| [[Category:Hematology]]
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| [[Category:Angiology]]
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| [[Category:Emergency medicine]]
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| [[Category:Vascular surgery]]
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| [[Category:Up-To-Date]]
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| [[Category:Cardiovascular diseases]]
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| {{WH}}
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| {{WS}}
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