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Blood Adv. 2018 Nov 27;2(22):3317-3359. doi: 10.1182/bloodadvances.2018024802.

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

Author information

1
Division of Hematology and Thromboembolism, Department of Medicine, and.
2
Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada.
3
Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL.
4
Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
5
National Women's Health, Auckland City Hospital, Auckland, New Zealand.
6
Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
7
Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
8
Ottawa Blood Disease Centre, The Ottawa Hospital, Ottawa, ON, Canada.
9
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University, Durham, NC.
10
Department of Pharmacy Services, University of Utah Health Thrombosis Service, Salt Lake City, UT.
11
Queens University, Belfast, United Kingdom.
12
Department of Family Medicine and.
13
Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
14
Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada.
15
Wake Forest, NC.
16
Alexandria, VA; and.
17
Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada.

Abstract

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.

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