Recognition and Management of Pregnancy-Associated Venous Thromboembolism

Abstract

Pregnancy-associated venous thromboembolism is a leading cause of maternal mortality, particularly in the postpartum period. Thrombotic risk is heightened by physiological adaptations of pregnancy, including hypercoagulability, venous stasis, and vascular compression. Clinical signs and symptoms of pregnancy-associated venous thromboembolism such as edema and shortness of breath are frequently normal findings in pregnancy. Given the overlap of pathology and physiology, there is a low threshold for evaluation in the emergency department. Computed tomography is the gold standard for diagnosing pulmonary embolism. Noninvasive testing strategies use ultrasound and D-dimer testing to avoid chest imaging in patients with a low pretest probability for pregnancy-associated pulmonary embolism. Advanced emergency clinicians can influence maternal and fetal outcomes through evidence-based test selection and treatment.

Management of pregnancy-associated pulmonary embolism is guided by hemodynamic status. Patients with a low risk of short-term mortality are typically managed with anticoagulation for a minimum of 3 months and through 6 weeks postpartum. Hemorrhagic complications occur in less than one-third of patients treated with anticoagulation. The presence of hypotension, hypoxemia, and/or right ventricular dysfunction may necessitate urgent reperfusion. Reperfusion strategies include catheter-directed thrombolysis, mechanical or surgical thrombectomy, or, less frequently, systemic thrombolysis or extracorporeal membrane oxygenation. Early nonpharmacologic reperfusion should be considered for those who are at a higher risk of hemorrhagic complications.