Professional Documents
Culture Documents
Venous Thromboembolism (VTE) Prophylaxis in Pregnancy and The Puerperium
Venous Thromboembolism (VTE) Prophylaxis in Pregnancy and The Puerperium
Disclaimer
These guidelines have been prepared to promote and facilitate standardisation and consistency of
practice, using a multidisciplinary approach.
Queensland Health does not accept liability to any person for loss or damage incurred as a result of
reliance upon the material contained in this guideline.
Clinical material offered in this guideline does not replace or remove clinical judgement or the
professional care and duty necessary for each specific patient case.
Clinical care carried out in accordance with this guideline should be provided within the context of
locally available resources and expertise.
This Guideline does not address all elements of standard practice and assumes that individual
clinicians are responsible to:
• Discuss care with consumers in an environment that is culturally appropriate and which
enables respectful confidential discussion. This includes the use of interpreter services
where necessary
• Advise consumers of their choice and ensure informed consent is obtained
• Provide care within scope of practice, meet all legislative requirements and maintain
standards of professional conduct
• Apply standard precautions and additional precautions as necessary, when delivering care
• Document all care in accordance with mandatory and local requirements
This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to copy and
communicate the work in its current form for non-commercial purposes, as long as you attribute Queensland Clinical Guidelines, Queensland Health and abide
by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-
nd/3.0/au/deed.en
For further information contact Queensland Clinical Guidelines RBWH Post Office, Herston Qld 4029, email Guidelines@health.qld.gov.au,
phone (07) 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld
4001, email ip_officer@health.qld.gov.au, phone (07) 3234 1479.
Antenatal therapeutic
Pre-pregnancy therapeutic anticoagulation
anticoagulation
Queensland Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium. Guideline No: MN14.9-V5-R19
• Prior recurrent VTE (>1) • Consider IPC if hospitalised
• Family history VTE (but no personal history VTE)
+ antithrombin deficiency
Abbreviations: COCP: Combined oral contraceptive pill GCS: Graduated compression stockings HIT: Heparin induced thrombocytopenia
IPC: Intermittent pneumatic compression LMWH: Low molecular weight heparin ≥: Greater than or equal to >: Greater than
Postnatal therapeutic
Antenatal therapeutic anticoagulation
anticoagulation
High Risk
High Risk Factors • GCS
• Antenatal LMWH prophylaxis (refer to • #LMWH prophylaxis for
antenatal VTE prophylaxis flow chart) 6 weeks
• Any previous personal history of VTE (not • Consider IPC if
current pregnancy#) hospitalised
Abbreviations: CS: Caesarean section GCS: Graduated compression stockings HIT: Heparin induced thrombocytopenia
IPC: Intermittent pneumatic compression LMWH: Low molecular weight heparin ≥: Greater than or equal to >: Greater than
Queensland Clinical Guideline: Venous thromboembolism (VTE) prophylaxis in pregnancy and the puerperium. Guideline No: MN14.9-V5-R19
Abbreviations
AOR Adjusted odds ratio
APCR Activated protein C resistance
APPT Activated partial thromboplastin time
bd Twice daily
BMI Body mass index
CI Confidence interval
COCP Combined oral contraceptive pill
CS Caesarean section
DVT Deep vein thrombosis
GCS Graduated compression stockings
GI Gastrointestinal
HIT Heparin induced thrombocytopenia
INR International normalised ratio
IPC Intermittent pneumatic compression
IV Intravenous
LMWH Low molecular weight heparin
PE Pulmonary embolism
PPH Postpartum haemorrhage
stat Immediately
Subcut subcutaneous
UFH Unfractionated heparin
VTE Venous thromboembolism
> Greater than
≥ Greater than or equal to
Terminology
2B
Term Definition
Family history of Family history is considered positive if one or more first degree relatives are
1,2
VTE affected.
When a woman has the autonomy and control to make decisions about her care after
a process of information exchange that involves providing her with sufficient, evidence-
Informed choice
based information about all options for her care, in the absence of coercion by any
3
party and without withholding information about any options.
Table of Contents
1 Introduction ..................................................................................................................................... 7
1.1 Incidence................................................................................................................................ 7
1.2 Communication ...................................................................................................................... 7
1.3 Risk and benefit of VTE prophylaxis ...................................................................................... 7
1.4 Risks associated with VTE prophylaxis ................................................................................. 8
1.5 Signs and symptoms of VTE ................................................................................................. 9
1.6 Transfer of care ..................................................................................................................... 9
1.7 Clinical standards .................................................................................................................. 9
2 Risk assessment .......................................................................................................................... 10
2.1 High risk factors for VTE ...................................................................................................... 10
2.2 Known risk factors for VTE .................................................................................................. 11
2.3 Criteria for assessment of risk ............................................................................................. 12
2.4 Additional assessments ....................................................................................................... 12
3 Options for thromboprophylaxis ................................................................................................... 13
3.1 Other pharmaceutical agents............................................................................................... 14
4 Prophylactic management of VTE ................................................................................................ 15
4.1 Specific patient group management .................................................................................... 15
4.2 Antenatal prophylaxis .......................................................................................................... 15
4.3 Intrapartum prophylaxis ....................................................................................................... 15
4.4 Postnatal prophylaxis ........................................................................................................... 16
4.5 Neuraxial blockade .............................................................................................................. 17
5 Specific patient groups ................................................................................................................. 18
6 Discharge ..................................................................................................................................... 19
References .......................................................................................................................................... 20
Appendix A: Drug information .............................................................................................................. 22
Appendix B: Adjusted odds ratio (AOR) for risk of VTE ...................................................................... 23
Appendix C: Risk of VTE with Thrombophilia ...................................................................................... 24
Acknowledgements.............................................................................................................................. 25
List of Tables
Table 1. Risks associated with VTE prophylaxis ................................................................................... 8
Table 2. Signs and symptoms of VTE ................................................................................................... 9
Table 3. High risk factors for VTE ........................................................................................................ 10
Table 4. Known risk factors ................................................................................................................. 11
Table 5. Criteria for assessment of risk ............................................................................................... 12
Table 6. Additional risk assessment .................................................................................................... 12
Table 7. Options for thromboprophylaxis ............................................................................................. 13
Table 8. Other pharmaceutical agents ................................................................................................ 14
Table 9. Antenatal prophylaxis ............................................................................................................ 15
Table 10. Prophylaxis postpartum by assessment of risk ................................................................... 16
Table 11. Management of LMWH, UFH and neuraxial blockade ........................................................ 17
Table 12. Antenatal and postnatal management of specific patient groups ........................................ 18
Table 13. Preparation for discharge .................................................................................................... 19
1 Introduction
Pulmonary embolism (PE) and deep vein thrombosis (DVT) are the two components of a single
6,7
disease called venous thromboembolism (VTE). Pregnant women have an increased risk (4–5
1,7
fold ) of developing a VTE, in comparison to non-pregnant women due to hypercoagulability,
increased venous stasis, decreased venous outflow and compression of the inferior vena cava and
1
pelvic veins by the enlarging uterus.
1.1 Incidence
• Thromboembolism is a leading cause of maternal deaths in the developed world
8,9
1
o Second most common cause of direct maternal death in Australia
1
o Maternal mortality is reported to be 0.4–1.6 per 100,000 pregnancies
• The risk of VTE is greater postpartum than during the antenatal period
1,2,10
11
o 40–60% of antenatal VTE occur in the first trimester
• Rates of VTE are estimated at no more than 2 per 1000 pregnancies but vary
1,2
considerably
7 1
o 75–80% of events are caused by DVT and 20–25% by PE - of which 1 in 40 is fatal
2
o 43–60% of pregnancy related episodes of PE occur in the 4–6 weeks after birth
• DVT is more likely to occur in the left lower extremity
7
1.2 Communication
• Share and discuss information with the woman in a manner that enables informed choice
and consent and supports woman centred care [Refer to definition of terms]
• Discuss the woman’s preferences for management
2
• Provide the woman at increased risk of VTE, culturally appropriate information about
12
VTE , the risks of VTE prophylaxis and the symptoms suggestive of DVT and PE to
1
facilitate early recognition and management [Refer to Table 2. Signs and symptoms of
VTE]
Aspect Risk
• Active antenatal or postpartum bleeding (requiring at least two units of
blood/products to be transfused in 24 hours or PPH greater than 1 L)
• Chronic clinically significant and measurable bleeding over 48 hours
• Women at risk of major haemorrhage (e.g. placenta previa)
• Acquired or inherited bleeding disorders (e.g. acute liver failure,
haemophilia)
• Recent central nervous system bleeding
Patient-related • Intracranial or spinal lesion
risk factors for
15 • Abnormal blood coagulation
bleeding
• Thrombocytopenia
• Severe platelet dysfunction
• Active peptic ulcer or active ulcerative gastrointestinal disease
• Obstructive jaundice or cholestasis
• Recent major surgical procedure of high bleeding risk
• Concomitant use of medications that may affect the clotting process
• Regional axial or recent lumbar puncture
• *Contraindications to pharmacological therapy
o Known hypersensitivity
Cautions for o History of or current HIT
pharmacological o Creatinine clearance less than 30 mL/minute
15
prophylaxis • *Cautions to pharmacological therapy
o Renal impairment
o Hepatic impairment
• Recommend with caution where there is:
o Morbid obesity and correct fitting stocking cannot be achieved
o Inflammatory conditions of the lower legs
o Severe peripheral neuropathy
Mechanical
15 o Severe oedema of the legs
prophylaxis
o Diabetic neuropathy
o Severe lower limb deformity
• Intermittent pneumatic compression device (IPC) can exacerbate ischaemic
disease
*Consult an Australian pharmacopeia for complete drug information
• Document processes for referral and transfer appropriate to the local facility
2 Risk assessment
Failure to recognise and/or treat personal or pregnancy specific risk factors has been identified as a
1,10
significant contributing factor to maternal mortality and morbidity arising from thrombosis.
However, there is limited high level evidence from randomised trials or among evidence
23
based/consensus guidelines about which women require thromboprophylaxis during pregnancy and
1,9,15
postpartum.
• Assess all women for VTE risk factors in early pregnancy or before conception
1,10
• Repeat the assessment when there is a change in risk status and following birth
11
Risk factors
•
25-29
Age (greater than 35 years)
Socio-
• BMI ≥ 30 kg/m
2,26,27,30-33
demographic
•
26,28,30,31
Cigarette smoker (>10/day)
•
26,29,33
Single previous VTE with no family history VTE or thrombophilia
•
26
Thrombophilia and no previous VTE
•
1
Family history VTE
•
1
Antiphospholipid syndrome
•
10
Thrombophilia (inherited or acquired)
•
26
Systemic lupus erythematosus
•
26,31
Cardiac or lung disease
Medical history
•
26
Sickle cell disease
•
10
Ovarian hyperstimulation syndrome
•
31,32
Gross varicose veins
•
24,32
Inflammatory conditions
•
32
Nephrotic syndrome
•
24
Cancer
•
32
Pre-existing diabetes
•
30
Immobility (e.g. bed rest, long distance travel)
•
25,28-30,34
Preeclampsia/eclampsia
•
25,30,34
Artificial reproductive therapy (ART)
•
25,30
Gestational diabetes
•
27,28,31 29
Multiparity (greater than 2 or 3 )
Pregnancy
•
25,26,28,30,34
Multiple pregnancy
related
•
30
Intrauterine growth restriction
•
26
Hyperemesis/dehydration
•
32
Current systemic infection (requiring antibiotics or hospitalisation)
•
25,26
Antepartum haemorrhage
•
24
Surgical procedure in pregnancy
•
10
Prolonged labour (greater than 24 hours)
•
26,28,29,31-34 25,30 25
Caesarean section (emergency and elective )
•
10
Operative vaginal birth
•
32
Stillbirth
Birth/
•
31,32,35
Preterm birth
Postpartum
•
26,30,32,35
PPH (> 1L)
•
26
Transfusion
•
24
Any surgical procedure in the puerperium
•
26,30
Postpartum infection
Aspect Consideration
• A positive family history of VTE has been shown to increase the risk of VTE
1
two-fold
• Refer the woman with a positive personal or family history of VTE to an
obstetrician or physician experienced in VTE prophylaxis management
• All women with previous VTE require a full thrombophilia screen
10
including :
o *Activated protein C resistance (APCR)
o Factor V Leiden mutation will be done if APCR is detected
o Prothrombin gene mutation
o *Antithrombin III deficiency
Previous VTE o *Protein C deficiency
o *Protein S deficiency
o Antiphospholipid antibodies:
Lupus anticoagulant
*Anticardiolipin antibodies
Beta 2 Glycoprotein 1 (B2GP1)
Method Considerations
• Encourage and educate the pregnant woman about the importance of:
Non-
pharmacological o Mobilisation
o Avoidance of dehydration
• There is limited high quality evidence about the use of graduated elastic
compression stockings (GCS) during pregnancy and the puerperium
• GCS are effective in diminishing the risk of DVT in non-pregnant
hospitalised patients when used alone, with increased benefit when used in
36
conjunction with another method of prophylaxis
• There is limited high quality evidence about the effectiveness of knee
37
length versus thigh length GCS
• GCS
Mechanical o Patient compliance is essential – encourage to wear as much as
possible
o Contraindicated in critical limb ischemia
o Should be measured and fitted for each woman
o A health professional trained in garment sizing and application can
assist with GCS selection and fitting
o Check skin integrity regularly
• Intermittent pneumatic compression device (IPC) in combination with other
prophylactic modalities has been shown to reduce the incidence of DVT in
38
high-risk non-pregnant patients
• Low molecular weight heparin (LMWH)
2
o Agent of choice for antenatal thromboprophylaxis
2,9
o Does not cross placenta
2
o No evidence of teratogenicity or increased risk of fetal bleeding
o Associated with fewer bleeding episodes compared with
13
Unfractionated Heparin (UFH)
2
o Risk of HIT lower with LMWH than with UFH
2
o Risk of osteoporosis lower with LMWH than UFH
o Refer to Department of Health: Anticoagulation and prophylaxis using
Pharmacological LMWH in adult inpatients
39
• Unfractionated heparin
• Warfarin:
o Contraindicated antenatally for thromboprophylaxis
o Consider postnatal only for prolonged thromboprophylaxis or treatment
o If warfarin used pre-pregnancy recommence postpartum
o Refer to Appendix A for pharmacological information
• Note: LMWH, UFH and Warfarin are safe for breastfeeding mothers
2
Agents Considerations
• There is limited information about the use of newer pharmacological agents
(e.g. Rivaroxaban) during pregnancy and their safety while
16,40
breastfeeding
• The American College of Chest Physicians recommend :
2
6 Discharge
Table 13. Preparation for discharge
Aspect Considerations
• Offer women and their families verbal and written information on :
12
References
1. McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S, et al. Recommendations for the prevention of
pregnancy-associated venous thromboembolism. Aust N Z J Obstet Gynaecol. 2012; 52(1):3-13.
2. 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; 141(2 Suppl):e691S-736S.
3. National Health and Medical Research Council (NHMRC), Department of Health and Ageing, Australian Government.
National guidance on collaborative maternity care. Canberra: NHMRC; 2010.
4. NHS, Quality Improvement Scotland. Pathways for maternity care. Keeping Childbirth Natural and Dynamic Programme.
2009.
5. Homer C, Brodie P, Leap N. Midwifery continuity of care: a practical guide. Sydney: Elsevier; 2008.
6. Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. New England Journal of Medicine. 2008;
359(19):2025-33.
7. The American College of Obstetricians and Gynecologists. Practice Bulletin Number 123. Thromboembolism in pregnancy.
Obsetrics and Gynecology. 2011; 118(3):718-29.
8. Centre for Maternal and Child Enquiries (CMACE). Saving mothers' lives: reviewing maternal deaths to make motherhood
safer. 2006-2008. The eighth report on confidential enquiries into maternal deaths in the United Kingdom. BJOG. 2011; 118
(Suppl. 1):1-203.
9. Tooher R, Gates S, Dowswell T, Davis LJ. Prophylaxis for venous thromboembolic disease in pregnancy and the early
postnatal period. Cochrane Database Syst Rev. 2010; (5):CD001689.
10. Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy and
the puerperium. Green-top Guideline No.37a. 2009.
11. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of venous thromboembolism: a national
clinical guideline. 2010 [cited 2013 July 25]; SIGN publication no. 122. Available from: http://www.sign.ac.uk.
12. National Health and Medical Research Council (NHMRC). Blood Clots: Reducing your risk. 2010 [cited 2013 October 22].
Available from: http://www.nhmrc.gov.au/_files_nhmrc/file/nics/material_resources/stop_the_clot_patient_brochure_crop.pdf.
13. Wu P, Poole TC, Pickett JA, Bhat A, Lees CC. Current obstetric guidelines on thromboprophylaxis in the United Kingdom:
evidence based medicine? Eur J Obstet Gynecol Reprod Biol. 2013; 168(1):7-11.
14. James AH. Prevention and treatment of venous thromboembolism in pregnancy. Clinical Obstetrics and Gynecology.
2012; 55(3):774-787.
15. Australian Government. National Health and Medical Research Council. Clinical practice guideline for the prevention of
venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to Australian hospitals. 2009.
Available from: www.nhmrc.gov.au.
16. Lussana F, Coppens M, Cattaneo M, Middeldorp S. Pregnancy-related venous thromboembolism: risk and the effect of
thromboprophylaxis. Thromb Res. 2012; 129(6):673-80.
17. Queensland Government. Maternity services. In: Clinical services capability framework for public and licensed private
health facilities v3.1. Brisbane: Queensland Government Department of Health; 2012 [cited 2014 October 14]. Available from:
http://www.health.qld.gov.au/cscf/default.asp.
18. Australian College of Midwives. National midwifery guidelines for consultation and referral. 3rd edition. 2013.
19. Australian Commission on Safety and Quality in Healthcare. National consensus statement: essential elements to
recognising and responding to clinical deterioration. 2010 [cited 2013 August 12]. Available from:
http://www.safetyandquality.gov.au.
20. Queensland Health. Heparin intravenous infusion order and administration form (SW034). Health Services Support
Agency. 2013 [cited 2013 August 12]. Available from: http://qheps.health.qld.gov.au/hssa/home.htm.
21. Queensland Health. Guidelines for anticoagulation using warfarin. Health Services Support Agency. 2013 [cited 2013
August 12]. Available from: http://qheps.health.qld.gov.au/hssa/medicines/guidelines/home.htm.
22. Queensland Government. Patient Safety Communique No. 03/2013. Patient Safety Unit. [cited 2013, September 03].
Available from: http://qheps.health.qld.gov.au/psu/alerts/alerts.htm.
23. Okoroh E, Azonobi I, Grosse S, Grant A, Atrash H, James AH. Prevention of venous thromboembolism in pregnancy: a
revew of guidelines, 2000-2011. Journal of Women's Health. 2012; 21(6):611-5.
24. National Institute for Health and Clinical Excellence. Venous thromboembolism: reducing the risk. London: National
Institute of Clinical Excellence; 2010.
25. Jacobsen AF, Skjeldestad FE, Sandset PM. Incidence and risk patterns of venous thromboembolism in pregnancy and
puerperium--a register-based case-control study. Am J Obstet Gynecol. 2008; 198(2):233 e1-7.
26. James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum
period: incidence, risk factors, and mortality. Am J Obstet Gynecol. 2006; 194(5):1311-5.
27. Knight M. Antenatal pulmonary embolism: risk factors, management and outcomes. BJOG. 2008; 115(4):453-61.
28. Lindqvist P, Dahlback B, Marsal K. Thrombotic risk during pregnancy: a population study. Obstet Gynecol. 1999;
94(4):595-9.
29. Kane EV, Calderwood C, Dobbie R, Morris C, Roman E, Greer IA. A population-based study of venous thrombosis in
pregnancy in Scotland 1980-2005. Eur J Obstet Gynecol Reprod Biol. 2013; 169(2):223-9.
30. Jacobsen AF, Skjeldestad FE, Sandset PM. Ante- and postnatal risk factors of venous thrombosis: a hospital-based case-
control study. J Thromb Haemost. 2008; 6(6):905-12.
31. Simpson EL, Lawrenson RA, Nightingale AL, Farmer RD. Venous thromboembolism in pregnancy and the puerperium:
incidence and additional risk factors from a London perinatal database. BJOG. 2001; 108(1):56-60.
32. Sultan AA, Tata LJ, West J, Fiaschi L, Fleming KM, Nelson-Piercy C, et al. Risk factors for first venous thromboembolism
around pregnancy: a population-based cohort study from the United Kingdom. Blood. 2013; 121(19):3953-61.
33. Sharma S, Monga D. Venous thromboembolism during pregnancy and the post-partum period: incidence and risk factors
in a large Victorian health service. Aust N Z J Obstet Gynaecol. 2008; 48(1):44-9.
34. Won HS, Kim do Y, Yang MS, Lee SJ, Shin HH, Park JB. Pregnancy-induced hypertension, but not gestational diabetes
mellitus, is a risk factor for venous thromboembolism in pregnancy. Korean Circ J. 2011; 41(1):23-7.
35. Danilenko-Dixon DR, Heit JA, Silverstein MD, Yawn BP, Petterson TM, Lohse CM, et al. Risk factors for deep vein
thrombosis and pulmonary embolism during pregnancy or post partum: a population-based, case-control study. Am J Obstet
Gynecol. 2001; 184(2):104-10.
36. Sachdeva A, Dalton M, Amaragiri SV, Lees T. Elastic compression stockings for prevention of deep vein thrombosis.
Cochrane Database Syst Rev. 2010; (7):CD001484.
37. Sajid MS, Desai M, Morris RW, Hamilton G. Knee length versus thigh length graduated compression stockings for
prevention of deep vein thrombosis in postoperative surgical patients. Cochrane Database Syst Rev. 2012; 5:CD007162.
38. Kakkos SK, Caprini JA, Geroulakos G, Nicolaides AN, Stansby GP, Reddy DJ. Combined intermittent pneumatic leg
compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane
Database Syst Rev. 2008; (4):CD005258.
39. Department of Health. Anticoagulation and prophylaxis using LMWH in adult inpatients. Document Number # QH-GDL-
951:2014. 2014 [cited 2104 September 01]. Available from: http://www.health.qld.gov.au/qhpolicy/docs/gdl/qh-gdl-951.pdf.
40. Hale L. Medications and Mothers' Milk. 2013 [cited 2013, August 08]. Available from: https://www-medsmilk-
com.cknservices.dotsec.com/
41. Harrop-Griffiths W, Cook T, Gill H, Hill D, Ingram M, Makris M, et al. Regional anaesthesia and patients with abnormalities
of coagulation: The Association of Anaesthetists of Great Britain & Ireland The Obstetric Anaesthetists' Association Regional
Anaesthesia UK. Anaesthesia. 2013.
42. Department of Health. Guideline for managing patients on a factor Xa inhibitor - Apixaban (Eliquis®) or Rivaroxaban
(Xarelto®). Document Number # QH-GDL-950:2014. 2014 [cited 2014 September 01]. Available from:
http://www.health.qld.gov.au/qhpolicy/docs/gdl/qh-gdl-950.pdf.
43. Duley L, Henderson-Smart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications.
Cochrane Database Syst Rev. 2007; (2):CD004659.
Determine dose (standard, intermediate or therapeutic) based on assessment of an individual’s risk for VTE. Refer to Section 5: Specific patient groups
Source: Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy
and the puerperium. Green-top Guideline No.37a. 2009.
Adjusted odds ratio for risk of VTE in pregnancy and/or postpartum with different
thrombophilia
Risk of VTE
Thrombophilia
Odds Ratio Odds Ratio 95% CI
Antithrombin deficiency 10–unknown 4.7 1.3–17.0
Protein C deficiency 2–unknown 4.8 2.2–10.6
Protein S deficiency – 3.2 1.5–6.9
Factor V Leiden (heterozygous) 5–7 8.3 5.4–12.7
Prothrombin G20210A (heterozygous) 3–10 6.8 2.5–18.8
Factor V Leiden (homozygous) 10–41 34.4 9.9–120.1
Prothrombin G20210A (homozygous) – 26.4 1.2–559.2
Compound heterozygote (Factor V Leiden and prothrombin
9–107 – –
G20210A)
Source: Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy
and the puerperium. Green-top Guideline No.37a. 2009.
Estimated absolute risk of VTE with different thrombophilic defects in women with one or
more symptomatic first degree relatives
Thrombophilic defect Pregnancy Antenatal Postpartum
%/pregnancy 95% CI %/pregnancy 95% CI %/pregnancy 95% CI
Antithrombin, Protein C, Protein S
4.1 1.7–8.3 1.2 0.3–4.2 3.0 1.3–6.7
deficiency
15–50
Antithrombin deficiency type 1* – 0–40 – 11–28 –
(range)
Factor V Leiden (heterozygous) 2.1 0.7–4.9 0.4 0.1–2.4 1.7 0.7–4.3
Prothrombin G20210A
2.3 0.8–5.3 0.5 0.1–2.6 1.9 0.7–4.7
(heterozygous)
Factor V Leiden (homozygous) or
Compound heterozygote (Factor 1.8–15.8
– 0–5 – 1–10 –
V Leiden and prothrombin (range)
G20210A)
*Population-based not family study
Source: Royal College of Obstetricians and Gynaecologists. Reducing the risk of thrombosis and embolism during pregnancy
and the puerperium. Green-top Guideline No.37a. 2009.
Acknowledgements
Queensland Clinical Guidelines gratefully acknowledges the contribution of Queensland clinicians
and other stakeholders who participated throughout the guideline development process particularly:
Funding
This clinical guideline was funded by Queensland Health, Health Systems Innovation Branch.