Medikamentöse Thromboseprophylaxe in der Schwangerschaft

Venöse Thromboembolien (VTE) sind eine der Hauptursachen für Morbidität und Mortalität in der Schwangerschaft und im Wochenbett. Zu den Hauptrisikofaktoren gehören vorausgegangene VTE, das Vorliegen einer Thrombophilie sowie eine positive Familienanamnese für VTE. Dieser Beitrag zeigt, in welchen Situationen eine VTE-Prophylaxe indiziert ist, welche Antikoagulanzien eingesetzt werden und wie das peri- und postpartale Management von antikoagulierten Schwangeren erfolgt.

Abstract

Venous thromboembolism (VTE) is a major cause of maternal morbidity during pregnancy and the postpartum period. The main VTE risk factors are previous VTE, known thrombophilia and a family history for VTE. This manuscript includes information on VTE risk assessment, anticoagulants that can safely be used in pregnancy, and the puerperium and the peripartal management of anticoagulated women.

Kernaussagen

• Eine Evaluation des individuellen VTE-Risikos sollte bei Frauen bereits vor bzw. zu Beginn einer Schwangerschaft, in Risikosituationen während einer Schwangerschaft sowie zum Geburtstermin und postpartal erfolgen.

• Zu den Hauptrisikofaktoren für eine VTE zählen vorausgegangene VTE, bekannte Thrombophilie sowie eine positive Familienanamnese.

• Eine postpartale VTE-Prophylaxe mit NMH ist bei allen Frauen mit vorausgegangener VTE indiziert. Eine antepartale Prophylaxe wird bei Z.n. hormonassoziierter VTE oder VTE spontaner Genese empfohlen sowie in Risikosituationen bei Z.n. VTE, die im Rahmen eines starken transienten, nicht hormonellen Risikofaktors (z.B. OP, Trauma) aufgetreten ist.

• Frauen mit milder Thrombophilie und unauffälliger VTE-Anamnese benötigen in der Regel keine antepartale VTE-Prophylaxe.

• Wie die HighLow-Studie kürzlich zeigte, ist eine intermediäre Dosierung von NMH der Prophylaxedosis in der Verhinderung eines VTE-Rezidivs nicht überlegen.

Schlüsselwörter

Thromboseprophylaxe - Schwangerschaft - Wochenbett

Keywords

venous thromboembolism prophylaxis - pregnancy - postpartum period

Publication History

Article published online:
02 June 2023

• Literatur

• 1 Arnesen CAL, Veres K, Horvath-Puho E. et al. Estimated lifetime risk of venous thromboembolism in men and women in a Danish nationwide cohort: impact of competing risk of death. Eur J Epidemiol 2022; 37: 195-203
• 2 Kourlaba G, Relakis J, Kontodimas S. et al. A systematic review and meta-analysis of the epidemiology and burden of venous thromboembolism among pregnant women. Int J Gynaecol Obstet 2016; 132: 4-10
• 3 Virkus RA, Lokkegaard EC, Bergholt T. et al. Venous thromboembolism in pregnant and puerperal women in Denmark 1995–2005. A national cohort study. Thromb Haemost 2011; 106: 304-309
• 4 Szecsi PB, Jorgensen M, Klajnbard A. et al. Haemostatic reference intervals in pregnancy. Thromb Haemost 2010; 103: 718-727
• 5 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 2020; 40: 572-590
• 6 de Moreuil C, Tromeur C, Daoudal A. et al. Risk factors for recurrence during a pregnancy following a first venous thromboembolism: A French observational study. J Thromb Haemost 2022; 20: 909-918
• 7 Hart C, Bauersachs R, Scholz U. et al. Thromboseprophylaxe in der Schwangerschaft, deutsche Kurzversion In. https://gth-online.org/wp-content/uploads/2020/12/GTH-Working-Group-VTE-Prophylaxe-Schwangerschaft-Linnemann_2020_12_08-final.pdf
• 8 De Stefano V, Martinelli I, Rossi E. et al. The risk of recurrent venous thromboembolism in pregnancy and puerperium without antithrombotic prophylaxis. Br J Haematol 2006; 135: 386-391
• 9 Gerhardt A, Scharf RE, Greer IA. et al. Hereditary risk factors for thrombophilia and probability of venous thromboembolism during pregnancy and the puerperium. Blood 2016; 128: 2343-2349
• 10 Linnemann B, Hart C. Laboratory Diagnostics in Thrombophilia. Hamostaseologie 2019; 39: 49-61
• 11 Jacobsen AF, Dahm A, Bergrem A. et al. Risk of venous thrombosis in pregnancy among carriers of the factor V Leiden and the prothrombin gene G20210A polymorphisms. J Thromb Haemost 2010; 8: 2443-2449
• 12 Hart C, Rott H, Heimerl S. et al. Management of Antithrombin Deficiency in Pregnancy. Hamostaseologie 2022; 42: 320-329
• 13 Middeldorp S. Thrombosis in women: what are the knowledge gaps in 2013?. J Thromb Haemost 2013; 11: 180-191
• 14 Miyakis S, Lockshin MD, Atsumi T. et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006; 4: 295-306
• 15 Devreese KMJ, Ortel TL, Pengo V. et al. Laboratory criteria for antiphospholipid syndrome: communication from the SSC of the ISTH. J Thromb Haemost 2018; 16: 809-813
• 16 Platton S, Hunt C. Influence of DOAC Stop on coagulation assays in samples from patients on rivaroxaban or apixaban. Int J Lab Hematol 2019; 41: 227-233
• 17 Branch DW, Silver RM, Blackwell JL. et al. Outcome of treated pregnancies in women with antiphospholipid syndrome: an update of the Utah experience. Obstet Gynecol 1992; 80: 614-620
• 18 Lima F, Khamashta MA, Buchanan NM. et al. A study of sixty pregnancies in patients with the antiphospholipid syndrome. Clin Exp Rheumatol 1996; 14: 131-136
• 19 Tektonidou MG, Andreoli L, Limper M. et al. EULAR recommendations for the management of antiphospholipid syndrome in adults. Ann Rheum Dis 2019; 78: 1296-1304
• 20 Alijotas-Reig J, Esteve-Valverde E, Anunciacion-Llunell A. et al. Pathogenesis, Diagnosis and Management of Obstetric Antiphospholipid Syndrome: A Comprehensive Review. J Clin Med 2022; 11
• 21 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: e691S-e736S
• 22 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: 3317-3359
• 23 Nelson-Piercy C, MacCallum P, Mackillop L. et al. Reducing the risk of venous thromboembolism in pregnancy and the puerperium. Green-top Guideline No 37a London: RCOG 2015.
• 24 Bulletins—Obstetrics ACoOaGCoP. ACOG Practice Bulletin No. 196: Thromboembolism in Pregnancy. Obstet Gynecol. Obstet Gynecol 2018;
• 25 Beyer-Westendorf J, Tittl L, Bistervels I. et al. Safety of direct oral anticoagulant exposure during pregnancy: a retrospective cohort study. Lancet Haematol 2020; 7: e884-e891
• 26 Huttel E, Padberg S, Meister R. et al. Pregnancy outcome of first trimester exposure to the vitamin K antagonist phenprocoumon depends on duration of treatment. Thromb Haemost 2017; 117: 870-879
• 27 Sammaritano LR, Bermas BL, Chakravarty EE. et al. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol 2020; 72: 529-556
• 28 Dempfle CE, Koscielny J, Lindhoff-Last E. et al. Fondaparinux Pre-, Peri-, and/or Postpartum for the Prophylaxis/Treatment of Venous Thromboembolism (FondaPPP). Clin Appl Thromb Hemost 2021; 27
• 29 Magnani HN. An analysis of clinical outcomes of 91 pregnancies in 83 women treated with danaparoid (Orgaran). Thromb Res 2010; 125: 297-302
• 30 Ito S. Drug therapy for breast-feeding women. N Engl J Med 2000; 343: 118-126
• 31 Bistervels IM, Buchmuller A, Wiegers HMG. et al. Intermediate-dose versus low-dose low-molecular-weight heparin in pregnant and post-partum women with a history of venous thromboembolism (Highlow study): an open-label, multicentre, randomised, controlled trial. Lancet 2022; 400: 1777-1787
• 32 Kietaibl S, Ferrandis R, Godier A. et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39: 100-132