Download PDF
Hamostaseologie 2020; 40(01): 054-063
DOI: 10.1055/s-0039-1700501
Review Article
Georg Thieme Verlag KG Stuttgart · New York

How Do We Treat Pregnancy-Related Venous Thromboembolism?

Birgit Linnemann
1   Division of Angiology, University Center of Vascular Medicine, University Hospital Regensburg, Regensburg, Germany
,
Birgit Seelbach-Goebel
2   Department of Obstetrics and Gynaecology of the University Hospital Regensburg, St. Hedwig Clinic, Regensburg, Germany
,
Susanne Heimerl
3   Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Germany
,
Christina Hart
4   Department of Haematology and Oncology, Internal Medicine III, University Hospital Regensburg, Regensburg, Germany
› Author Affiliations
Further Information

Publication History

25 July 2019

10 September 2019

Publication Date:
04 November 2019 (online)

Also available at
   Permissions and Reprints

Abstract

Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality during pregnancy and the postpartum period. Due to a lack of adequate study data, therapeutic strategies for pregnancy-related VTE are deduced from observational studies and extrapolated from recommendations for nonpregnant patients. Because heparins do not cross the placenta, weight-adjusted therapeutic-dose low-molecular-weight heparins (LMWHs) are the anticoagulant treatment of choice in cases of VTE during pregnancy. Once- and twice-daily dosing regimens are suitable. There is no evidence that measurement of factor Xa activities and consecutive LMWH dose adjustments improve clinical outcomes. There is no support for the routine use of vitamin K antagonists, direct oral thrombin or factor Xa inhibitors, fondaparinux, or danaparoid in uncomplicated pregnancy-related VTE. Management of delivery deserves special attention, and treatment strategies depend on the time interval between the diagnosis of acute VTE and the expected delivery date. In lactating women, an overlapping switch from LMWH to warfarin is possible. Anticoagulation should be continued for at least 6 weeks postpartum or for a minimum period of 3 months.

Zusammenfassung

Venöse Thromboembolien (VTE) sind eine der Hauptursachen für mütterliche Morbidität und Mortalität während der Schwangerschaft und postpartal. Aufgrund fehlender randomisierter kontrollierter Studien sind therpeutische Strategien vorzugsweise aus Beobachtungsstudien und aus Therapieempfehlungen für Nicht-Schwangere abgeleitet. Heparine sind nicht plazentagängig und gelten in der Schwangerschaft als sicher. Niedermolekulare Heparine (NMH) in gewichts-adaptierter volltherapeutischer Dosierung sind daher Mittel der Wahl für die VTE-Therapie in der Schwangerschaft. Dosisregime mit Einmal- oder Zweimalgabe sind möglich. In Abhängigkeit des Präparates wird das NMH ein- oder zweimal täglich subkutan appliziert. Da es keine Evidenz für einen Nutzen einer Dosisanpassung an anti-Faktor-Xa-Spiegel gibt, werden routinemäßige Spiegelkontrollen nicht empfohlen. Andere Antikoagulanzien wie Vitamin-K-Antagonisten, die direkten oralen Thrombin- und Faktor-Xa-Inhibitoren (DOAKs), Fondaparinux und Danaparoid haben in der VTE-Behandlung bei unkompliziertem Schwangerschaftsverlauf keinen Stellenwert. Das peripartale Vorgehen hängt wesentlich vom Zeitabstand zwischen VTE-Manifestation und dem Geburtszeitpunkt ab. In der Stillzeit kann die NMH-Therapie fortgeführt oder überlappend auf Warfarin umgestellt werden. Bei schwangerschafts-assoziierter VTE sollte eine Antikoagulation für die Mindestdauer von 3 Monaten und bis mindestens 6 Wochen postpartum fortgeführt werden.

Keywords

venous thromboembolism - deep vein thrombosis - pulmonary embolism - heparin - pregnancy - postpartum

Schlüsselwörter

venöse Thromboembolie - tiefe Venenthrombose - Lungenembolie - Heparin - Schwangerschaft - Stillzeit
 

  • References

  • 1 Nelson-Piercy CMP, Mackillop L. , et al, for the Royal College of Obstetricians and Gynaecologists. Reducing the risk of venous thromboembolism during pregnancy and the puerperium. Green-top Guideline No 37a London : RCOG 2015 https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf . Accessed September 26, 2019
    PubMed
  • 2 Linnemann B, Bauersachs R, Rott H. , et al; Working Group in Women's Health of the Society of Thrombosis and Haemostasis. Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH). Vasa 2016; 45 (02) 87-101
    CrossrefPubMedGoogle Scholar
  • 3 Kamel H, Navi BB, Sriram N, Hovsepian DA, Devereux RB, Elkind MS. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med 2014; 370 (14) 1307-1315
    CrossrefPubMedGoogle Scholar
  • 4 Favresse J, Lippi G, Roy PM. , et al. D-dimer: preanalytical, analytical, postanalytical variables, and clinical applications. Crit Rev Clin Lab Sci 2018; 55 (08) 548-577
    CrossrefPubMedGoogle Scholar
  • 5 Konstantinides SV, Torbicki A, Agnelli G. , et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35 (43) 3033-3069 , 3069a–3069k
    CrossrefPubMedGoogle Scholar
  • 6 Bates SM, Rajasekhar A, Middeldorp S. , et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood Adv 2018; 2 (22) 3317-3359
    CrossrefPubMedGoogle Scholar
  • 7 van der Pol LM, Tromeur C, Bistervels IM. , et al; Artemis Study Investigators. Pregnancy-adapted YEARS algorithm for diagnosis of suspected pulmonary embolism. N Engl J Med 2019; 380 (12) 1139-1149
    CrossrefPubMedGoogle Scholar
  • 8 Linkins LA, Dans AL, Moores LK. , et al. Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2 Suppl): e495S-e530S
    CrossrefPubMedGoogle Scholar
  • 9 Cuker A, Arepally GM, Chong BH. , et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia. Blood Adv 2018; 2 (22) 3360-3392
    CrossrefPubMedGoogle Scholar
  • 10 Mol GC, van de Ree MA, Klok FA. , et al. One versus two years of elastic compression stockings for prevention of post-thrombotic syndrome (OCTAVIA study): randomised controlled trial. BMJ 2016; 353: i2691
    PubMedGoogle Scholar
  • 11 Ten Cate-Hoek AJ, Amin EE, Bouman AC. , et al; IDEAL DVT investigators. Individualised versus standard duration of elastic compression therapy for prevention of post-thrombotic syndrome (IDEAL DVT): a multicentre, randomised, single-blind, allocation-concealed, non-inferiority trial. Lancet Haematol 2018; 5 (01) e25-e33
    CrossrefPubMedGoogle Scholar
  • 12 Voke J, Keidan J, Pavord S, Spencer NH, Hunt BJ. ; British Society for Haematology Obstetric Haematology Group. The management of antenatal venous thromboembolism in the UK and Ireland: a prospective multicentre observational survey. Br J Haematol 2007; 139 (04) 545-558
    CrossrefPubMedGoogle Scholar
  • 13 Zondag W, Kooiman J, Klok FA, Dekkers OM, Huisman MV. Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis. Eur Respir J 2013; 42 (01) 134-144
    CrossrefPubMedGoogle Scholar
  • 14 Linnemann B, Scholz U, Rott H. , et al; Working Group in Women's Health of the Society of Thrombosis and Hemostasis. Treatment of pregnancy-associated venous thromboembolism - position paper from the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH). Vasa 2016; 45 (02) 103-118
    CrossrefPubMedGoogle Scholar
  • 15 Romualdi E, Dentali F, Rancan E. , et al. Anticoagulant therapy for venous thromboembolism during pregnancy: a systematic review and a meta-analysis of the literature. J Thromb Haemost 2013; 11 (02) 270-281
    CrossrefPubMedGoogle Scholar
  • 16 Hellgren M, Mistafa O. Obstetric venous thromboembolism: a systematic review of dalteparin and pregnancy. J Obstet Gynaecol 2019; 39 (04) 439-450
    CrossrefPubMedGoogle Scholar
  • 17 Middeldorp S. How I treat pregnancy-related venous thromboembolism. Blood 2011; 118 (20) 5394-5400
    CrossrefPubMedGoogle Scholar
  • 18 Knol HM, Schultinge L, Veeger NJ, Kluin-Nelemans HC, Erwich JJ, Meijer K. The risk of postpartum hemorrhage in women using high dose of low-molecular-weight heparins during pregnancy. Thromb Res 2012; 130 (03) 334-338
    CrossrefPubMedGoogle Scholar
  • 19 Carroli G, Cuesta C, Abalos E, Gulmezoglu AM. Epidemiology of postpartum haemorrhage: a systematic review. Best Pract Res Clin Obstet Gynaecol 2008; 22 (06) 999-1012
    CrossrefPubMedGoogle Scholar
  • 20 Nelson-Piercy C, Powrie R, Borg JY. , et al. Tinzaparin use in pregnancy: an international, retrospective study of the safety and efficacy profile. Eur J Obstet Gynecol Reprod Biol 2011; 159 (02) 293-299
    CrossrefPubMedGoogle Scholar
  • 21 Sephton V, Farquharson RG, Topping J. , et al. A longitudinal study of maternal dose response to low molecular weight heparin in pregnancy. Obstet Gynecol 2003; 101 (06) 1307-1311
    PubMedGoogle Scholar
  • 22 Greer IA. Thrombosis in pregnancy: updates in diagnosis and management. Hematology (Am Soc Hematol Educ Program) 2012; 2012: 203-207
    CrossrefPubMedGoogle Scholar
  • 23 Bauersachs RM. Treatment of venous thromboembolism during pregnancy. Thromb Res 2009; 123 (Suppl. 02) S45-S50
    CrossrefPubMedGoogle Scholar
  • 24 Knight M. ; UKOSS. Antenatal pulmonary embolism: risk factors, management and outcomes. BJOG 2008; 115 (04) 453-461
    CrossrefPubMedGoogle Scholar
  • 25 Bhutia S, Wong PF. Once versus twice daily low molecular weight heparin for the initial treatment of venous thromboembolism. Cochrane Database Syst Rev 2013; 7 (07) CD003074
    PubMedGoogle Scholar
  • 26 Patel JP, Green B, Patel RK, Marsh MS, Davies JG, Arya R. Population pharmacokinetics of enoxaparin during the antenatal period. Circulation 2013; 128 (13) 1462-1469
    CrossrefPubMedGoogle Scholar
  • 27 Lebaudy C, Hulot JS, Amoura Z. , et al. Changes in enoxaparin pharmacokinetics during pregnancy and implications for antithrombotic therapeutic strategy. Clin Pharmacol Ther 2008; 84 (03) 370-377
    CrossrefPubMedGoogle Scholar
  • 28 Kitchen S, Iampietro R, Woolley AM, Preston FE. Anti Xa monitoring during treatment with low molecular weight heparin or danaparoid: inter-assay variability. Thromb Haemost 1999; 82 (04) 1289-1293
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Kovacs MJ, Keeney M, MacKinnon K, Boyle E. Three different chromogenic methods do not give equivalent anti-Xa levels for patients on therapeutic low molecular weight heparin (dalteparin) or unfractionated heparin. Clin Lab Haematol 1999; 21 (01) 55-60
    CrossrefPubMedGoogle Scholar
  • 30 Patel JP, Hunt BJ. Where do we go now with low molecular weight heparin use in obstetric care?. J Thromb Haemost 2008; 6 (09) 1461-1467
    CrossrefPubMedGoogle Scholar
  • 31 McDonnell BP, Glennon K, McTiernan A. , et al. Adjustment of therapeutic LMWH to achieve specific target anti-FXa activity does not affect outcomes in pregnant patients with venous thromboembolism. J Thromb Thrombolysis 2017; 43 (01) 105-111
    CrossrefPubMedGoogle Scholar
  • 32 Bates SM, Greer IA, Middeldorp S. , et al. 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; 141 (2 Suppl): e691S-e736S
    CrossrefPubMedGoogle Scholar
  • 33 Thomsen AJ, Greer IA. Thromboembolic disease in pregnancy and the puerperium: acute management (Green-top guideline no. 37b). Royal College of Obstetricians and Gynaecologists; 2015: 1-32
    Google Scholar
  • 34 Garcia DA, Baglin TP, Weitz JI. , et al. Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2 Suppl): e24S-e43S
    CrossrefPubMedGoogle Scholar
  • 35 Lee AY, Levine MN, Baker RI. , et al; Randomized Comparison of Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer (CLOT) Investigators. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003; 349 (02) 146-153
    CrossrefPubMedGoogle Scholar
  • 36 Bauersachs RM, Dudenhausen J, Faridi A. , et al; EThIG Investigators. Risk stratification and heparin prophylaxis to prevent venous thromboembolism in pregnant women. Thromb Haemost 2007; 98 (06) 1237-1245
    Article in Thieme ConnectPubMedGoogle Scholar
  • 37 Gándara E, Carrier M, Rodger MA. Intermediate doses of low-molecular-weight heparin for the long-term treatment of pregnancy thromboembolism. A systematic review. Thromb Haemost 2014; 111 (03) 559-561
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Schindewolf M, Lindhoff-Last E, Ludwig RJ, Boehncke WH. Heparin-induced skin lesions. Lancet 2012; 380 (9856): 1867-1879
    CrossrefPubMedGoogle Scholar
  • 39 Schindewolf M, Gobst C, Kroll H. , et al. High incidence of heparin-induced allergic delayed-type hypersensitivity reactions in pregnancy. J Allergy Clin Immunol 2013; 132 (01) 131-139
    CrossrefPubMedGoogle Scholar
  • 40 Greinacher A. CLINICAL PRACTICE. Heparin-induced thrombocytopenia. N Engl J Med 2015; 373 (03) 252-261
    CrossrefPubMedGoogle Scholar
  • 41 Cines DB, Levine LD. Thrombocytopenia in pregnancy. Blood 2017; 130 (21) 2271-2277
    CrossrefPubMedGoogle Scholar
  • 42 Monreal M, Lafoz E, Olive A, del Rio L, Vedia C. Comparison of subcutaneous unfractionated heparin with a low molecular weight heparin (Fragmin) in patients with venous thromboembolism and contraindications to coumarin. Thromb Haemost 1994; 71 (01) 7-11
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Dahlman TC. Osteoporotic fractures and the recurrence of thromboembolism during pregnancy and the puerperium in 184 women undergoing thromboprophylaxis with heparin. Am J Obstet Gynecol 1993; 168 (04) 1265-1270
    CrossrefPubMedGoogle Scholar
  • 44 Le Templier G, Rodger MA. Heparin-induced osteoporosis and pregnancy. Curr Opin Pulm Med 2008; 14 (05) 403-407
    CrossrefPubMedGoogle Scholar
  • 45 Galambosi P, Hiilesmaa V, Ulander VM, Laitinen L, Tiitinen A, Kaaja R. Prolonged low-molecular-weight heparin use during pregnancy and subsequent bone mineral density. Thromb Res 2016; 143: 122-126
    CrossrefPubMedGoogle Scholar
  • 46 Leentjens J, Peters M, Esselink AC, Smulders Y, Kramers C. Initial anticoagulation in patients with pulmonary embolism: thrombolysis, unfractionated heparin, LMWH, fondaparinux, or DOACs?. Br J Clin Pharmacol 2017; 83 (11) 2356-2366
    CrossrefPubMedGoogle Scholar
  • 47 Chunilal SD, Young E, Johnston MA. , et al. The APTT response of pregnant plasma to unfractionated heparin. Thromb Haemost 2002; 87 (01) 92-97
    Article in Thieme ConnectPubMedGoogle Scholar
  • 48 Raschke RA, Guidry JR, Foley MR. Apparent heparin resistance from elevated factor VIII during pregnancy. Obstet Gynecol 2000; 96 (5, Pt 2): 804-806
    PubMedGoogle Scholar
  • 49 Gould MK, Dembitzer AD, Doyle RL, Hastie TJ, Garber AM. Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. A meta-analysis of randomized, controlled trials. Ann Intern Med 1999; 130 (10) 800-809
    CrossrefPubMedGoogle Scholar
  • 50 Quinlan DJ, McQuillan A, Eikelboom JW. Low-molecular-weight heparin compared with intravenous unfractionated heparin for treatment of pulmonary embolism: a meta-analysis of randomized, controlled trials. Ann Intern Med 2004; 140 (03) 175-183
    CrossrefPubMedGoogle Scholar
  • 51 Gerhardt A, Zotz RB, Stockschlaeder M, Scharf RE. Fondaparinux is an effective alternative anticoagulant in pregnant women with high risk of venous thromboembolism and intolerance to low-molecular-weight heparins and heparinoids. Thromb Haemost 2007; 97 (03) 496-497
    Article in Thieme ConnectPubMedGoogle Scholar
  • 52 Knol HM, Schultinge L, Erwich JJHM, Meijer K. Fondaparinux as an alternative anticoagulant therapy during pregnancy. J Thromb Haemost 2010; 8 (08) 1876-1879
    CrossrefPubMedGoogle Scholar
  • 53 Lindhoff-Last E, Kreutzenbeck HJ, Magnani HN. Treatment of 51 pregnancies with danaparoid because of heparin intolerance. Thromb Haemost 2005; 93 (01) 63-69
    Article in Thieme ConnectPubMedGoogle Scholar
  • 54 Dempfle CE. Minor transplacental passage of fondaparinux in vivo. N Engl J Med 2004; 350 (18) 1914-1915
    CrossrefPubMedGoogle Scholar
  • 55 D'Souza R, Ostro J, Shah PS. , et al. Anticoagulation for pregnant women with mechanical heart valves: a systematic review and meta-analysis. Eur Heart J 2017; 38 (19) 1509-1516
    CrossrefPubMedGoogle Scholar
  • 56 Hassouna A, Allam H. Anticoagulation of pregnant women with mechanical heart valve prosthesis: a systematic review of the literature (2000–2009). J Coagul Disord 2010; 2: 81-88
    PubMedGoogle Scholar
  • 57 Bapat P, Pinto LS, Lubetsky A. , et al. Examining the transplacental passage of apixaban using the dually perfused human placenta. J Thromb Haemost 2016; 14 (07) 1436-1441
    CrossrefPubMedGoogle Scholar
  • 58 Bapat P, Pinto LS, Lubetsky A, Berger H, Koren G. Rivaroxaban transfer across the dually perfused isolated human placental cotyledon. Am J Obstet Gynecol 2015; 213 (05) 710.e1-710.e6
    CrossrefPubMedGoogle Scholar
  • 59 Bapat P, Kedar R, Lubetsky A. , et al. Transfer of dabigatran and dabigatran etexilate mesylate across the dually perfused human placenta. Obstet Gynecol 2014; 123 (06) 1256-1261
    CrossrefPubMedGoogle Scholar
  • 60 Beyer-Westendorf J, Michalski F, Tittl L. , et al. Pregnancy outcome in patients exposed to direct oral anticoagulants - and the challenge of event reporting. Thromb Haemost 2016; 116 (04) 651-658
    Article in Thieme ConnectPubMedGoogle Scholar
  • 61 Wiesen MH, Blaich C, Müller C, Streichert T, Pfister R, Michels G. The direct factor Xa inhibitor rivaroxaban passes into breast milk. Chest 2016; 150 (01) e1-e4
    CrossrefPubMedGoogle Scholar
  • 62 European Medicines Agency Product Information Leaflet. Xarelto - EMEA/H/C/000944-IB/0040/G (06/09/2018). Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000944/WC500057108.pdf . Accessed July 21, 2019
    PubMed
  • 63 European Medicines Agency Product Information Leaflet. Eliquis - EMEA/H/C/002148-N/0026 (01/08/2018). Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/002148/WC500107728.pdf . Accessed July 21, 2019
    PubMed
  • 64 European Medicines Agency Product Information Leaflet. Lixiana - EMEA/H /C/PSUSA/00010387/201710 (31/08/2018). Available at: https://www.ema.europa.eu/en/documents/product-information/lixiana-epar-product-information_en.pdf . Accessed July 21, 2019
    PubMed
  • 65 European Medicines Agency Product Information Leaflet. Pradaxa - EMEA/H/C/000829-II/0073 (16/07/2019). Available at: http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/000829/WC500041059.pdf . Accessed July 21, 2019
    PubMed
  • 66 Leduc D, Senikas V, Lalonde AB. ; CLINICAL PRACTICE OBSTETRICS COMMITTEE. Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage. J Obstet Gynaecol Can 2009; 31 (10) 980-993
    CrossrefPubMedGoogle Scholar
  • 67 Gogarten W, Vandermeulen E, Van Aken H, Kozek S, Llau JV, Samama CM. ; European Scoeity of Anaesthesiology. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 2010; 27 (12) 999-1015
    CrossrefPubMedGoogle Scholar
  • 68 Milford W, Chadha Y, Lust K. Use of a retrievable inferior vena cava filter in term pregnancy: case report and review of literature. Aust N Z J Obstet Gynaecol 2009; 49 (03) 331-333
    CrossrefPubMedGoogle Scholar
  • 69 Mismetti P, Laporte S, Pellerin O. , et al; PREPIC2 Study Group. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone on risk of recurrent pulmonary embolism: a randomized clinical trial. JAMA 2015; 313 (16) 1627-1635
    CrossrefPubMedGoogle Scholar
  • 70 Patel JP, Auyeung V, Patel RK. , et al. Women's views on and adherence to low-molecular-weight heparin therapy during pregnancy and the puerperium. J Thromb Haemost 2012; 10 (12) 2526-2534
    CrossrefPubMedGoogle Scholar
  • 71 Richter C, Sitzmann J, Lang P, Weitzel H, Huch A, Huch R. Excretion of low molecular weight heparin in human milk. Br J Clin Pharmacol 2001; 52 (06) 708-710
    CrossrefPubMedGoogle Scholar
  • 72 te Raa GD, Ribbert LSM, Snijder RJ, Biesma DH. Treatment options in massive pulmonary embolism during pregnancy; a case-report and review of literature. Thromb Res 2009; 124 (01) 1-5
    CrossrefPubMedGoogle Scholar
  • 73 Martillotti G, Boehlen F, Robert-Ebadi H, Jastrow N, Righini M, Blondon M. Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review. J Thromb Haemost 2017; 15 (10) 1942-1950
    CrossrefPubMedGoogle Scholar
  • 74 Wik HS, Jacobsen AF, Sandvik L, Sandset PM. Prevalence and predictors for post-thrombotic syndrome 3 to 16 years after pregnancy-related venous thrombosis: a population-based, cross-sectional, case-control study. J Thromb Haemost 2012; 10 (05) 840-847
    CrossrefPubMedGoogle Scholar
  • 75 White RH, Chan WS, Zhou H, Ginsberg JS. Recurrent venous thromboembolism after pregnancy-associated versus unprovoked thromboembolism. Thromb Haemost 2008; 100 (02) 246-252
    Article in Thieme ConnectPubMedGoogle Scholar
  • 76 Bleker SM, Buchmüller A, Chauleur C. , et al. Low-molecular-weight heparin to prevent recurrent venous thromboembolism in pregnancy: rationale and design of the Highlow study, a randomised trial of two doses. Thromb Res 2016; 144: 62-68
    CrossrefPubMedGoogle Scholar
  • 77 Hart C, Bauersachs R, Scholz U. , et al. Prevention of venous thromboembolism during pregnancy and the puerperium with a special focus on women with hereditary thrombophilia or prior VTE – Position Paper of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH). Hamostaseologie 2019 ; Submitted
    PubMedGoogle Scholar