
MAT/GUI/0510/THRVTE
MATERNITY SERVICE GUIDELINE
TITLE:
Thromboprophylaxis and management of
venous thromboembolism (VTE) in
pregnancy and the puerperium
Shohreh Beski – Consultant O&G,
Peter MacCallum – Consultant Haematologist,
Louise Bowles - Haematologist, Sarah Mills VTE Nurse Specialist, Emily Hill – Audit &
Quality Midwife
Shohreh Beski
GUIDELINE LEAD:
Guideline group
RATIFIED BY:
June 2010
ACTIVE DATE:
May 2010
RATIFICATION DATE:
May 2013
REVIEW DATE:
Thromboprophylaxis and VTE management in
APPLIES TO:
pregnancy and the puerperium.
None
EXCLUSIONS:
The severely ill parturient (2010)
RELATED POLICIES
Obesity in Pregnancy (2010)
Maternity Training Needs Analysis (2010)
Barts and The London VTE Guideline
THIS
DOCUMENT Thromboprophylaxis and treatment of
venous thromboembolism (VTE) in pregnancy
REPLACES
(2007).
Prophylaxis for Thromboembolism in Caesarean
section (2006).
AUTHORS:
1.
INTRODUCTION/PURPOSE OF THE GUIDELINE
1.1.
Venous thromboembolism (VTE) remains the major cause of direct maternal deaths
(1.94 per 100,000 maternities) in the Confidential Enquiry into Maternal and Child
Health Report 2003-5 (CEMACH, 2007). VTE can occur at any stage of pregnancy,
during delivery and afterwards.
This guideline is written with regard to relevant national guidelines:
 Reducing the risk of thrombosis and embolism during pregnancy and the
puerperium (Royal College of Obstetricians and Gynaecologists (RCOG)
2009)
 RCOG guidelines on treatment of VTE in pregnancy (2007)
 National Institute of Clinical Excellence (NICE) guideline of prevention of
venous thromboembolism in patients admitted to hospital (2010)
This guideline states the risk factors for VTE in pregnancy and the puerperium and
so provides guidance as to which women require thromboprophylaxis in and after
pregnancy. The guideline also outlines the management of VTE during pregnancy
and in the postnatal period.
1.2.
1.3.
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2.
IMPLEMENTATION
2.1
2.4
The updated paper copy will be attached to guideline notice board, in each clinical
area for four weeks.
Electronic copies will be distributed to the lead Midwives in each clinical area.
The guideline will be available via the trust intranet and circulated to guidelines
folders.
See Training Needs Analysis for training requirements.
3.
ROLES AND RESPONSIBILITIES
3.1.
It is the responsibility of the whole multi-professional team to actively risk assess
women for risk of VTE
Midwives should risk assess women at booking, when admitted into hospital and
early in the postnatal period.
Midwives should refer to the joint Antenatal High Risk clinic if deemed high risk,
when the woman is in the antenatal period.
Midwives should refer to obstetrician if women are in-patients or postnatal for
appropriate management plan to be initiated.
Medical professionals should ensure that when women are at risk of VTE, a
management plan initiated
Medical professionals have the responsibility to promptly refer woman appropriately
if they suspect VTE.
2.2
2.3
3.2.
3.3.
3.4.
3.5.
3.6.
4.
GUIDELINE
4.1.
THE APPROPRIATE AND TIMELY RISK ASSESSMENT TO IDENTIFY THOSE AT
RISK OF VENOUS THROMBOEMBOLISM (VTE)
Algorithm available Appendix 1
4.2.
4.3.
Assess all women regarding risk factors for VTE (Appendix 2)
 At booking
 On admission into hospital
 Early in the postnatal period
DOCUMENTATION OF RISK ASSESSMENT AND INDIVIDUAL ACTION/
MANAGEMENT PLAN FOR THROMBOPROPHYLAXIS.
Complete risk assessment stickers (for every risk assessment carried out) and place
in hand held notes (ideally on management page). This should include an individual
action plan (if required).
GENERAL MEASURES
All women should be encouraged to:
 keep mobile
 stop smoking
 The use of graduated compression stockings should be limited to women who
are high risk and have contraindications to low molecular weight heparin
(LMWH) or have had an operative delivery. As RCOG (2009) identified that
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the evidence was limited in supporting the use of graduated compression
stockings.
4.4.
THROMBOPROPHYLAXIS IN PREGNANCY
 All antenatal women at high risk of VTE will need considering for prophylaxis.
Therefore refer to high risk multi disciplinary antenatal clinic that comprises
consultants in obstetrics, haematology, anaesthetics and rheumatology
(please request next available appointment on 1 st or 3rd Tuesday of the
month)
 The consultants will discuss the options for prophylaxis based on the RCOG
guidelines (2009), taking account of the wishes of the individual woman.
 All antenatal admissions should be thromboprophylaxis risk assessed, if
required as an in-patient. The Obstetrician should assess the women prior to
discharge to see if thromboprophylaxis should be continued after discharge
these women should be referred to high risk high-risk multidisciplinary clinic.
 If in doubt, discuss the case with a consultant Obstetrician and consultant
Haematologist.
 Women deemed high risk should be considered to receive
thromboprophylaxis for the whole pregnancy and postnatal period.
 The standard prophylaxis is clexane 40mg sc OD for women weight 50-90kg.
Refer to RCOG (2009) guideline for dosing for weights <50kg and >90kg.
 See Appendix 3 for risks of low molecular weight heparin
 Measure FBC and anti Xa if advised by consultant Haematologist.
4.5.
CARE DURING LABOUR AND DELIVERY OF WOMEN ON
THROMBOPROHYLAXIS
 Thromboprophylaxis should be stopped, if women have any vaginal bleeding
or once labour begins or 12 hours prior to region anaesthetic
 Graduated compression stockings are appropriate for high risk women in
labour and/or when women have an operative delivery (RCOG, 2009)
4.6.
POSTNATAL THROMBOPROPHYALIS
 A further risk assessment is required to identify risk factors
 If thromboprophylaxis was received antenatally, it should be continued for 6
weeks post-partum (unless individual plan states otherwise)
4.7. Common Signs and Symptoms of VTE
Deep Vein Thrombosis (DVT)
Pulmonary Embolism (PE)
 Pain/ tenderness in one leg
 Dyspnoea (73%)
 Unilateral oedema
 Pleuritic pain (66%)
 Superficial venous dilation
 Cough (37%)
 Skin discolouration
 Tachypnoea (70%)
 Crepitations (51%)
 Tachycardia (30%)
 Collapse
(Blann and Lip 2006)
4.2.
VTE can be asymptomatic
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4.8
DOCUMENTATION
All women, requiring thromboprophylaxis or treatment for a diagnosed VTE should
have a documented individual management plan in their maternity notes (preferably
on the management page).
Documentation should include the risks of VTE investigations and management
where appropriate
4.9
THE SIGNIFICANCE OF SIGNS AND SYMPTOMS OF VTE
Management of pregnant or postnatal women with suspected VTE
All pregnant or postnatal women presenting with shortness of breath or chest pain
must be suspected of having a pulmonary embolism.
Women suspected of having VTE should be commenced on therapeutic doses of
clexane, 1mg/kg bd, until diagnosis is confirmed or excluded (unless bleeding is a
concern).
For differential diagnosis see Appendix 3.
Specific measures
 Consider risk factors for VTE (see appendix 2)
 Respiratory and cardiovascular system examination
 Temperature, pulse, blood pressure, O2 saturations
 ECG:
Sinus tachycardia is the commonest finding, atrial fibrillation, right
bundle branch block, S1Q3T3 pattern
 CXR
 Blood gases
The presence of normal oxygen saturation, arterial blood gases, ECG and CXR does
not exclude pulmonary embolism.
Investigation during pregnancy



Every effort should be made to confirm the diagnosis objectively.
For suspected DVT, the initial investigation is Doppler ultrasonography (x7104),
which detects DVT at the popliteal vein or more proximally - calf veins are not
scanned. Sensitivity is 97% and specificity 94% for proximal leg DVT (Kearon et
al., 1998).
For suspected PE, if CXR is normal, a 50% dose perfusion lung scan (x3284) is
requested +/- ventilation scan in discussion with nuclear medicine consultant. If
CXR abnormal a CTPA should be requested. CTPA is also available out of hours
and at weekends. In patient with suspected massive PE too ill to transfer to
radiology department, a portable echocardiogram should be requested.
Investigation post-partum
Investigate as above.
 V/Q scan or CTPA for PE diagnosis.
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Breast feeding should be discontinued for 24 hours following a V/Q scan – discuss
with consultant in nuclear medicine (where possible, milk expressed prior to scan
could be used).
4.10
TREATMENT OF VTE
Antenatally
 Women with confirmed diagnosis of DVT or PE should be referred immediately to
the on-call haematologist and/or medical registrar. Refer woman on discharge to
anticoagulation clinic and high risk antenatal clinic.
 Treatment should continue for remainder of pregnancy and for 6 weeks postpartum or for 6 months, whichever is longer.
 Omit Enoxaparin from the onset of labour and resume as soon as possible postpartum if no excessive bleeding.
 Management of VTE close to term is particularly challenging. If delivery is
anticipated within 2 weeks of start of anticoagulant treatment, and particularly if
diagnosis is PE or the iliac veins are involved, insertion of an IVC filter should be
considered. Delivery by caesarean section is usually preferable because it limits
manipulation of the pelvic veins and the time off anticoagulants.
 Refer to Appendix 4 for management in delivery with regard to regional
anaesthesia.
 Refer to Appendix 5 for management postnatally.
Postnatal follow-up for women who develop VTE antenatally or postnatally
 An appointment should be made in the Thrombosis Clinic with the
haematology team where the duration of anticoagulation should be reviewed
and thrombophilia testing should be considered.
 Advice should be offered about thromboprophylaxis in further pregnancies
4.11
MANAGEMENT OF MASSIVE LIFE THREATENING PE IN PREGNANCY AND
POSTNATAL
 See Appendix 7 for actions if suspected massive life threatening PE
 Admit to Accident and Emergency Department if in the community
 If stable enough perform CT pulmonary angiogram (CTPA) if unstable perform
echocardiogram to diagnose pulmonary embolism
 If PE diagnosed and is associated with shock or systemic hypotension
(systolic BP < 90 mmHg), urgent discussion should occur between consultant
obstetrician, anaesthetist, haematologist, respiratory physician and
interventional radiologist.
 IV heparin (loading dose 80 u/kg followed by continuous IV heparin infusion of
18 u/kg/hr with APTT checked at 6 hours and dose-adjusted to keep APTT
ratio between 1.5-2.5).
 Thrombolysis (e.g. alteplase either 100 mg IV over 90 minutes if woman
relatively stable or 50 mg iv bolus if deteriorating)
 Catheter–directed thrombolysis.
For continuation of treatment post-partum liaise with anticoagulation team and
consultant haematologist for dosing regime and duration.
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MAT/GUI/0510/THRVTE
5.
BREACH OF GUIDELINES/POLICIES
The incident will be reviewed within the Risk Management framework. The impact of this incident will be reviewed by the appropriate lead
clinician and feedback/training given to staff as required.
6.
MONITORING COMPLIANCE
Element to be
monitored
Lead
Monitoring Tool
Frequency
Reporting arrangements
Documented and
appropriate risk
assessment at
booking, on
admission to hospital
and postnatal
Audit and
Quality
Midwife
Proforma
10 sets of maternity records
per month
Labour Ward Forum
Supervisors of midwives
meeting
Management of
signs and symptoms
of VTE
Proforma
Lead
Midwife
Lead
Midwife
10 sets of maternity records
per month
Proforma
Change in practice and
lessons to be shared
Quarterly report will be
circulated it all relevant
clinical areas
Emailed to all relevant
staff groups
Labour Ward Forum
Quarterly report produced
Results of report shared
quarterly
Labour Ward Forum,
(multidisciplinary team)
review results and
recommendations
This process with be
documented in the
meetings minutes
10 sets of maternity records
per month
Labour Ward Forum,
(multidisciplinary team)
review results and
recommendations
This process with be
documented in the
meetings minutes
Quarterly report produced
Results of report shared
quarterly
Acting on
recommendations
and Lead (s)
Labour ward forum will
undertake
recommendations
Required changes to
practice will be identified
and actioned within a
specific time frame, at
the Labour ward forum.
A lead member will be
identified to take each
change forward.
Lessons will be shared
with the relevant staff
groups
Labour ward forum will
undertake
recommendations
Quarterly report will be
circulated it all relevant
clinical areas
Emailed to all relevant
staff groups
Required changes to
practice will be identified
and actioned within a
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MAT/GUI/0510/THRVTE
specific time frame, at
the Labour ward forum.
A lead member will be
identified to take each
change forward.
Lessons will be shared
with the relevant staff
groups
Appropriate
prophylaxis/
care/treatment for
high risk women
(antenatal,
intrapartum &
postnatal)
Lead
Midwife
Documentation of an
appropriate
individualised
management plan,
incl. postnatal
management plan
Lead
Midwife
Proforma
10 sets of maternity records
per month
Quarterly report produced
Results of report shared
quarterly
Proforma
10 sets of maternity records
per month
Quarterly report produced
Results of report shared
quarterly
Labour Ward Forum,
(multidisciplinary team)
review results and
recommendations
This process with be
documented in the
meetings minutes
Labour ward forum will
undertake
recommendations
Labour Ward Forum,
(multidisciplinary team)
review results and
recommendations
This process with be
documented in the
meetings minutes
Labour ward forum will
undertake
recommendations
Quarterly report will be
circulated it all relevant
clinical areas
Emailed to all relevant
staff groups
Required changes to
practice will be identified
and actioned within a
specific time frame, at
the Labour ward forum.
A lead member will be
identified to take each
change forward.
Lessons will be shared
with the relevant staff
groups
Quarterly report will be
circulated it all relevant
clinical areas
Emailed to all relevant
staff groups
Required changes to
practice will be identified
and actioned within a
specific time frame, at
the Labour ward forum.
A lead member will be
identified to take each
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MAT/GUI/0510/THRVTE
change forward.
Lessons will be shared
with the relevant staff
groups
Postnatal follow-up
for women
diagnosed with VTE
during pregnancy or
postnatal period,
with appropriate
thrombophilia testing
Lead
Obstetrician
Proforma
Annual audit
Results presented at
Maternity and
Gynaecology Audit
Meeting
Maternity and
Gynaecology audit
Committee
Mini-report to be emailed
to relevant staff groups
Min-report to be
displayed on the Audit
Board in relevant clinical
areas.
Maternity and
Gynaecology audit
Committee will monitor
action plan, which will
address the required
changes to practice will
be identified and
actioned within a specific
time frame. A lead
member will be identified
to take each change
forward.
Management of
massive life
threatening
Pulmonary
thromboembolism in
pregnancy
Maternity
Risk and
Governance
Manager
Serious Incident
(SI) investigation
process
Weekly or within 3 days if SI
Trust Serious Incident
framework
Risk Management
Committee,
reporting to Maternity
and Gynaecology
Governance Board
Required changes to
practice will be identified
and actioned within a
specific time frame. A
lead member will be
identified to take each
change forward.
Action plan monitored by
Risk Management
Committee
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REFERENCES
Blann, A. & Lip, G. (2006) Venous thromboembolism. British Medical Journal; 332:
215-9.
Confidential Enquiry into Maternity and Child Health (CEMACH) (2007). Saving
Mother’s Lives. Reviewing maternal deaths to make motherhood safer 2003 – 2005.
London: CEMACH.
Kearon, C. Julian, JA. Newman, TE. & Ginsberg, JS. (1998) Noninvasive diagnosis
of deep vein venous thrombosis. American College of Physicians. 128:633-77.
National Institute for Health and Clinical Excellence (2010) Venous
Thromboembolism – Reducing the risk. London: NICE.
Royal College of Obstetrics and Gynaecologists (2007) Thromboembolic disease in
pregnancy and the puerperium acute management (Green-top 28). London: RCOG.
Royal College of Obstetrics and Gynaecologists (2009) Thrombosis and embolism
during pregnancy and puerperium, reducing the risk (Green-top 37). London: RCOG.
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APPENDIX 1
Thromboprophylaxis during pregnancy and postnatally
6.1.
Use Risk assessment tool for all
women
 At booking
 On admission into hospital
 Early in the postnatal period
6.2.
6.3.
(Place sticker in maternity notes
e.g. on management page)
6.4.
6.5.
6.6.
Calculation total score
Antenatal
Total Score ≥ 3
Postnatal (remember to
recalculate score)
If woman having
thromboprophylaxis during
pregnancy to continue for 6
weeks.
All women with BMI ≥ 40
Unless Contraindicated
Refer to
High Risk Antenatal clinic
(please request next
available appointment on
1st or 3rd Tuesday of the
month)
Total score 2
For thromboprohylaxis for at
least 7 days
Consider
Thromboprophylaxis
If thromboprohylaxis
commenced while inpatient. Obstetrician to
review if
thromboprohylaxis is
required following
discharge.
6.8.
Total Score ≥ 3
For thromboprohylaxis for 6
weeks
6.7.
Standard Thromboprophylaxis is Clexane 40mg sc OD
for women weight 50-90kg.
See RCOG for dosing for weights <50kg and >90kg.
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APPENDIX 2
SCORE 1 FOR EACH RISK FACTOR TICKED IN THIS GREEN BOX;  Hospitalisation
 BMI > 30  Family history VTE  Pre-eclampsia
 Dehydration/ hyperemesis/OHSS  Current systemic
infection
 Parity ≥ 3  Gross varicose veins  Reduced Mobility
 Prolonged labour > 24 hours
 Mid-cavity or rotational
forceps
 Age > 35  Smoker
 Multiple pregnancy/ ART  PPH (> 1 litre or transfusion)
 Elective caesarean section
SCORE 2 FOR EACH RISK FACTOR TICKED IN THIS AMBER BOX;
 BMI >40  Medical comorbidities  Known thrombophilia
 Caesarean section in labour
 Surgical procedure in
pregnancy or ≤ 6 weeks post
partum
SCORE 3 FOR EACH RISK FACTOR TICKED IN THIS RED BOX;
 Recurrent or previous venous thromboembolism
PROPHYLAXIS PLAN;
(Exclude Bleeding Risks)
ANTENATAL :
POSTNATAL :
≥ 3 risk factor score CONSIDER ENOXAPARIN
2 risk factor score CONSIDER ENOXAPARIN for 7 days
and referral to high risk antenatal clinic
≥3 risk factor score consider ENOXAPARIN FOR 6 WEEKS
TOTAL SCORE …………………ACTION PLAN…………………………………………………………………
SIGNATURE……………………………...….…..PRINT NAME………………………..DATE…………............
APPENDIX 3
Risks of heparin





Active bleeding or potential for bleeding
Heparin-induced thrombocytopenia – very uncommon with low-molecular-weight heparin. If
suspected, stop heparin and discuss urgently with a consultant haematologist.
Osteoporosis – low risk with low-molecular-weight heparin.
Low-molecular-weight heparins do not have a full product licence for use in pregnancy but there
is experience of their use internationally, and they have significant advantages over
unfractionated heparin.
Cautions and contraindications; antiplatelet agents, procedure with related bleeding risks, acute
stroke (haemorrhagic or large infarct, inherited bleeding disorder, severe/acute liver disease
(CrCl <30), Platelets <75, BP >230 systolic or >120 diastolic, Lumbar puncture/ epidural/spinal in
previous 4 hours or within next 12 hours (for anticoagulants other than LMWH contact
haematology SpR)
APPENDIX 4
Differential Diagnosis for Shortness of Breath in Pregnancy
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



Physiological dyspnoea
Chest infection
Acute asthma
Amniotic fluid embolism




Anaemia
Pulmonary oedema and preeclampsia
Peripartum cardiomyopathy
Haemorrhage
APPENDIX 5
Delivery and Regional Anaesthesia
Women on Enoxaparin at time of labour
Prophylactic dose
Therapeutic dose
Do
not
proceed
to
regional Do not proceed to regional anaesthesia if the last
anaesthesia if the last Enoxaparin Enoxaparin injection was within 24 hours
injection was within 12 hours
If required regional anaesthesia needed prior to time frame, discuss with consultant
anaesthetist






Omit any Enoxaparin due during labour
Check for Normal Clotting Screening, Platelet count > 80 x 10 9/l and no sudden
reduction in platelet count
Epidural catheter should not be removed within 12 hours of an Enoxaparin
injection
Allow 4 hours minimum to elapse between removal of epidural catheter and next
Enoxaparin injection (prophylactic dose)
Avoid aspirin and non-steroidal anti-inflammatory drugs (NSAIDs)
It is not usually necessary to check antiXa level urgently pre-regional anaesthesia
but this may occasionally be indicated in discussion with consultant haematologist.
APPENDIX 6
Postnatal management of VTE
Women diagnosed antenatally - Enoxaparin treatment can be switched to warfarin,
which should be started when bleeding risk has reduced and should be overlapped with
Enoxaparin for 5 days minimum and until INR  2.0 for 2 consecutive days. Alternatively,
Enoxaparin can be continued if duration of postpartum anticoagulation is ≤ 6 weeks.
Postpartum the treatment dose of Enoxaparin is 1.5 mg/kg/once daily.
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Women diagnosed postnatally - Tinzaparin is the Trust’s LMWH of choice at a dose of
175 u/kg daily for minimum of 5 days, overlapping with warfarin, and continuing
Tinzaparin until INR  2.0 for 2 consecutive days
APPENDIX 7
Actions if suspect life-threatening Massive PE in Pregnancy
Immediate management of Sudden Maternal Collapse should be the same regardless of
cause
A= Airway, B=Breathing C=Circulation
Woman Unresponsive
Open Airway
Look for signs of life
No pulse or
respiration
Call for Help
use emergency buzzer where possible
(ask for Midwife Co-ordinator)
Call 2222 – State Cardiac Arrest &
exact location
Call 2222- State Obstetric Emergency
& exact location
Pulse and respiration
present
Call for Help
use emergency buzzer where possible
(ask for Midwife Co-ordinator)
Call 2222- State
Obstetric Emergency
& exact location
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Follow Adult Advance Life Support
(2007)
The following modification are required
in Pregnancy;
 Uterine displacement
(left lateral tilt)
 Increased chest wall
compression force
 Use cricoid pressure if
assistance available
 Early tracheal intubation
 Perimortem caesarean delivery
if mother fails to respond within
4 minutes
 Consider other aetiologies e.g.
MgSO4 Toxicity
 If resuscitation successful –
Start PE investigations








Recovery position
Administer 100% oxygen by facial
mask
 Insert 2 large venous cannula –
take blood for FBC, Clotting, U&E’s
LFTS X-Match
 Request 2 units X-Matched blood
 If GCS <8 or airway reflexes
compromised, anaesthetist should
intubate and ventilate
 If systolic pressure <90mmHg
Ensure uterine displacement
Infuse 1 litre colloid/crystalloid
Consider ephedrine 6mg bolus
 Regular evaluate, A, B, C
 Assess fetal condition & consider
urgent delivery of fetus
Do CTPA (Echocardiogram if unstable)
If PE diagnosed and is associated with shock or systemic hypotension (systolic BP <
90 mmHg), urgent discussion should be had between consultant obstetrician,
anaesthetist, haematologist, respiratory physician and intervention radiologist.
IV heparin (loading dose 80 u/kg followed by continuous IV heparin infusion of 18
u/kg/hr with APTT checked at 6 hours and dose-adjusted to keep APTT ratio 1.5-2.5).
Thrombolysis (e.g. alteplase either 100 mg IV over 90 minutes if patient relatively
stable or 50 mg iv bolus if deteriorating)
Catheter–directed thrombolysis.
Consider Urgent Embolectomy – Discuss with interventional radiologist
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