Treatment of Cerebral Venous Thrombosis in Pregnancy
Low-molecular-weight heparin (LMWH) is the recommended first-line treatment for cerebral venous thrombosis (CVT) during pregnancy. 1
First-Line Management
Anticoagulation Therapy
- LMWH is strongly preferred over unfractionated heparin (UFH) for treatment of CVT during pregnancy (strong recommendation, moderate certainty in evidence) 1
- Either once-daily or twice-daily LMWH dosing regimens may be used (conditional recommendation) 1
- Routine monitoring of anti-FXa levels to guide LMWH dosing is not recommended 1
Duration of Treatment
- Anticoagulation should be continued throughout pregnancy and for at least 6 weeks postpartum, with a minimum total duration of 3 months 1
Special Considerations
Delivery Planning
- For pregnant women receiving therapeutic-dose LMWH for CVT, scheduled delivery with prior discontinuation of anticoagulant therapy is suggested 1
- Typically, LMWH should be discontinued 24 hours before planned delivery or induction of labor to minimize bleeding risk
Severe or Refractory Cases
- For most pregnant women with CVT, additional interventions beyond anticoagulation are not recommended:
Postpartum Management
- For breastfeeding women who require continued anticoagulation, several options are considered safe:
- LMWH
- UFH
- Warfarin
- Acenocoumarol
- Fondaparinux (in cases of severe heparin allergy)
- Danaparoid 1
Monitoring and Follow-up
- Regular neurological assessment throughout pregnancy
- Follow-up imaging to assess recanalization may be considered, though treatment duration is not typically altered based on imaging findings
Outcomes and Prognosis
- With appropriate anticoagulation, recurrent venous thrombotic events during subsequent pregnancies are infrequent (approximately 3.7%) 3
- Women with prior CVT on LMWH prophylaxis during subsequent pregnancies have a low risk of recurrent thrombosis 4
Common Pitfalls
- Delayed diagnosis: Headache in pregnancy may be attributed to other causes, delaying CVT diagnosis
- Inadequate anticoagulation: Underdosing LMWH due to concerns about bleeding risk
- Inappropriate imaging: CT without contrast has low sensitivity for CVT; MRI with venography is preferred when available 5
- Premature discontinuation: Stopping anticoagulation too early increases recurrence risk
- Oral direct thrombin inhibitors: Dabigatran and factor Xa inhibitors (rivaroxaban, apixaban) should be avoided during pregnancy 1
In cases where the patient has severe allergic reactions to heparin (e.g., heparin-induced thrombocytopenia), fondaparinux or parenteral direct thrombin inhibitors may be considered, though experience with these agents in pregnancy is limited 1.