Ultrasound-accelerated catheter-directed thrombolysis for the management of postpartum deep venous thrombosis

Catheter-Directed Thrombolysis for Postpartum Deep Venous Thrombosis

Venous thromboembolism is a major concern during pregnancy as well as in the postpartum period. In acute proximal deep venous thrombosis, endovascular recanalization with locally administered thrombolytic agents has evolved as therapeutic alternative to anticoagulation alone. However, data on the bleeding risk of thrombolysis in the postpartum period is limited. We addressed the key clinical question of safety outcomes of catheter-directed thrombolysis (CDT) in the peri- and postpartum period. Therefore, we performed a non-exhaustive literature review and illustrated the delicate management of a patient with postpartum acute iliofemoral thrombosis treated with CDT and endovascular revascularization with thrombectomy, balloon angioplasty and stenting.

American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy

BACKGROUND

Venous thromboembolism (VTE) complicates ∼1.2 of every 1000 deliveries. Despite these low absolute risks, pregnancy-associated VTE is a leading cause of maternal morbidity and mortality.

OBJECTIVE

These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians and others in decisions about the prevention and management of pregnancy-associated VTE.

METHODS

ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

RESULTS

The panel agreed on 31 recommendations related to the treatment of VTE and superficial vein thrombosis, diagnosis of VTE, and thrombosis prophylaxis.

CONCLUSIONS

There was a strong recommendation for low-molecular-weight heparin (LWMH) over unfractionated heparin for acute VTE. Most recommendations were conditional, including those for either twice-per-day or once-per-day LMWH dosing for the treatment of acute VTE and initial outpatient therapy over hospital admission with low-risk acute VTE, as well as against routine anti-factor Xa (FXa) monitoring to guide dosing with LMWH for VTE treatment. There was a strong recommendation (low certainty in evidence) for antepartum anticoagulant prophylaxis with a history of unprovoked or hormonally associated VTE and a conditional recommendation against antepartum anticoagulant prophylaxis with prior VTE associated with a resolved nonhormonal provoking risk factor.