Approach to anticoagulation for pregnant individuals with inherited thrombophilia

Clinical setting		Antepartum management	Postpartum management
Lower-risk thrombophilia*	With personal history of previous VTE	Unprovoked VTE or VTE associated with a hormonal risk factor: Anticoagulation (low-dose heparin)	Anticoagulation (low-dose heparin)
	With personal history of previous VTE	VTE associated with a nonhormonal temporary provoking risk factor and no other risk factors for VTE: No antepartum anticoagulation	Anticoagulation (low-dose heparin)
	No personal history of VTE	Surveillance for VTE without anticoagulation. Anticoagulation may be warranted for individual patients with additional factors that place them at greater risk of thrombosis (eg, prolonged immobility, first-degree relative with unprovoked VTE under age 50 years).	Anticoagulation (low-dose heparin) for patients who have a cesarean birth
Higher-risk thrombophilia^¶	With previous VTE and on long-term anticoagulation	Anticoagulation (therapeutic-dose heparin)	Anticoagulation (therapeutic-dose heparin)
	With previous VTE not on long-term anticoagulation	Anticoagulation (intermediate- or therapeutic-dose heparin)	Anticoagulation (intermediate- or therapeutic-dose heparin)
	No personal history of previous VTE and not on chronic anticoagulation	Anticoagulation (low- or intermediate-dose heparin)	Anticoagulation (intermediate-dose heparin)

Low molecular weight heparin is generally preferred to use of unfractionated heparin. Refer to UpToDate content regarding use proximate to labor and birth. Postpartum anticoagulation can generally be started 4 to 6 hours after a vaginal birth or 6 to 12 hours after a cesarean birth, unless there is significant bleeding or risk for significant bleeding. It is generally continued for six weeks postpartum in patients who did not have a VTE during the pregnancy and who do not have indications for chronic anticoagulation.

VTE: venous thromboembolism; FVL: factor V Leiden; PGM: prothrombin G20210A gene mutation; AT: antithrombin.

* Lower-risk thrombophilias include heterozygosity for FVL or PGM and heritable deficiencies of protein C or protein S.

¶ Higher-risk thrombophilias include AT deficiency, homozygosity for FVL or PGM mutation, double heterozygosity for FVL and PGM, and protein C deficiency in combination with another hereditary defect. Some women with heterozygous deficiencies may be at higher risk based on their personal and family history.

Graphic 95707 Version 12.0

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Approach to anticoagulation for pregnant individuals with inherited thrombophilia