Heparin dosing during pregnancy and in the immediate postpartum period

Indication	Type of heparin	Pregnancy dosing	Postpartum dosing
VTE prevention	LMW heparin	Low dose (also called prophylactic dose)
		Enoxaparin: Weight <100 kg: 40 mg SUBQ once daily Weight ≥100 kg: 60 mg SUBQ once daily or Dalteparin: Weight <100 kg: 5000 units SUBQ once daily Weight ≥100 kg: 7500 units SUBQ once daily
		Intermediate dose^* (prophylactic dosing for patients at higher risk of thrombosis)
		Enoxaparin (adjust dose as weight increases during pregnancy): Weight <50 kg: 60 mg SUBQ once daily Weight 50 to <70 kg: 80 mg SUBQ once daily Weight 70 to <100 kg: 100 mg SUBQ once daily Weight ≥100 kg: 120 mg SUBQ once daily or Dalteparin (adjust dose as weight increases during pregnancy): Weight <50 kg: 7500 units SUBQ once daily Weight 50 to <70 kg: 10,000 units SUBQ once daily Weight 70 to <100 kg: 12,500 units SUBQ once daily Weight ≥100 kg: 15,000 units SUBQ once daily	Enoxaparin 30 mg SUBQ every 12 hours or 40 mg SUBQ once daily for 24 to 48 hours postpartum, then dose using postpartum weight: Weight <50 kg: 60 mg SUBQ once daily Weight 50 to <70 kg: 80 mg SUBQ once daily Weight 70 to <100 kg: 100 mg SUBQ once daily Weight ≥100 kg: 120 mg SUBQ once daily or Dalteparin 5000 units SUBQ once daily for 24 to 48 hours postpartum, then dose using postpartum weight: Weight <50 kg: 7500 units SUBQ once daily Weight 50 to <70 kg: 10,000 units SUBQ once daily Weight 70 to <100 kg: 12,500 units SUBQ once daily Weight ≥100 kg: 15,000 units SUBQ once daily
	UFH	Dose according to trimester: First trimester: 5000 to 7500 units SUBQ every 12 hours Second trimester: 7500 to 10,000 units SUBQ every 12 hours Third trimester: 10,000 units SUBQ every 12 hours Some clinicians use 5000 units SUBQ every 12 hours throughout the pregnancy; however, this dose may be insufficient in some patients	5000 to 10,000 units SUBQ every 12 hours (doses at the upper end of this range are chosen for patients with obesity or higher thrombotic risk; use postpartum weight)
VTE treatment (therapeutic dose)	LMW heparin	Enoxaparin 1 mg/kg SUBQ every 12 hours or Dalteparin 100 units/kg SUBQ every 12 hours
	UFH	Can be given as a continuous IV infusion or SUBQ dose every 12 hours. The dose is titrated to keep the aPTT or anti-factor Xa level (calibrated for UFH) in the therapeutic range.

This table applies to VTE in pregnant and postpartum individuals, with the exception of individuals with a prosthetic heart valve, which is discussed separately in UpToDate.

Choice of agent – LMW heparin is recommended for most patients. UFH is used when there may be a need for rapid discontinuation, such as for delivery or perioperatively or in individuals with severely reduced kidney function (eg, CrCl <30 mL/min). Only one heparin product is given at any point in time. Confirm the absence of preservatives (eg, benzyl alcohol) in the heparin product chosen.
Dose level – Prevention typically uses low or intermediate dose, but therapeutic dose may be used for prevention in selected cases (eg, individuals with recurrent unprovoked thrombotic events [with or without hereditary thrombophilia or antiphospholipid antibody syndrome] who are receiving long-term anticoagulation with warfarin or a direct oral anticoagulant such as rivaroxaban 20 mg daily or apixaban 5 mg twice daily).
Timing – The ideal time to start anticoagulation after giving birth is based on clinical judgment. LMW heparin or UFH are usually resumed 4 to 6 hours after vaginal birth or 6 to 12 hours after cesarean birth, unless there was significant postpartum bleeding or traumatic neuraxial catheter placement. The urgency is less for VTE prophylaxis than for VTE treatment.

Refer to UpToDate for anticoagulation indications, choice of dose level, duration of pharmacologic therapy, timing of switches between LMW heparin and UFH, and timing issues in patients who receive neuraxial anesthesia.

ACCP: American College of Chest Physicians; ACOG: American College of Obstetricians and Gynecologists; aPTT: activated partial thromboplastin time; CrCl: creatinine clearance; IV: intravenous; LMW: low molecular weight; SUBQ: subcutaneously; UFH: unfractionated heparin; VTE: venous thromboembolism.

* Our intermediate dosing is taken from the Highlow trial^[1] and differs from that used in society guidelines (eg, ACCP, ACOG). Some clinicians prefer to use a different intermediate dose level such as enoxaparin 40 mg SUBQ every 12 hours; however, this entails a significant increase in the number of injections over the course of the pregnancy.

Courtesy of Kenneth A Bauer, MD.

Reference:

Bistervels IM, Buchmüller 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.

Additional data from: UpToDate Lexidrug. More information available at https://online.lexi.com/.

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Heparin dosing during pregnancy and in the immediate postpartum period