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Use of Antithrombotic Agents During Pregnancy

Jeffrey S. Ginsberg, MD, FCCP, Chair; Ian Greer, MD; Jack Hirsh, MD, FCCP
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Correspondence to: Jeffrey S. Ginsberg, MD, FCCP, McMaster University Medical Center, Room 3W12, 1200 Main St. West, Hamilton, Ontario, L8N 3Z5, Canada



Chest. 2001;119(1_suppl):122S-131S. doi:10.1378/chest.119.1_suppl.122S
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Fatal pulmonary embolism (PE) remains a common cause of maternal mortality. Maternal mortality from PE can be reduced in two ways: (1) by aggressively investigating symptomatic women when they present with a clinical suspicion of deep vein thrombosis (DVT) or PE; and (2) by treatment and/or prophylaxis in women who have an increased risk for DVT and/or PE. Both approaches are problematic for several reasons. The first approach is problematic because nonthrombotic symptoms that mimic DVT and PE are common during pregnancy, the tests used to diagnose DVT can be altered by the compressive effects of the gravid uterus on the iliac veins, and there is a concern about performing procedures (such as lung scanning) that expose the fetus to radiation. The second approach is problematic because prophylaxis or treatment of DVT and PE involves long-term parenteral unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH); both are inconvenient, painful, expensive, and associated with a risk of bleeding, osteoporosis, and heparin-induced thrombocytopenia (HIT), although these complications are probably less frequent with LMWH than UFH. Appropriate management of pregnant women with prior venous thromboembolism (VTE) is problematic because, until recently, reliable information on the true incidence of recurrence in such women was not available. Furthermore, many women with prior VTE have an identifiable abnormality associated with thrombophilia, and the management of such individuals is controversial.

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