Does a pregnant woman at 37 weeks gestation with acute Deep Vein Thrombosis (DVT) require hospital admission?

Hospital Admission for Pregnant Women with Acute DVT at 37 Weeks Gestation

For a pregnant woman at 37 weeks gestation with acute Deep Vein Thrombosis (DVT), hospital admission is recommended due to the advanced gestational age and proximity to delivery. 1

Rationale for Hospital Admission

The American Society of Hematology (ASH) guidelines specifically identify advanced gestational age as an indicator for initial hospitalization in pregnant women with venous thromboembolism (VTE) 1. At 37 weeks gestation, the patient is:

• At term pregnancy with imminent delivery
• Requiring careful anticoagulation management for the peripartum period
• Needing coordination between obstetrics, hematology, and anesthesiology teams

Risk Factors Supporting Admission

Several factors make outpatient management inappropriate at this gestational age:

• Advanced gestational age (37 weeks): Specifically identified as a high-risk feature requiring hospitalization 1
• Proximity to delivery: Requires careful planning for anticoagulation interruption
• Need for scheduled delivery planning: ASH guidelines suggest scheduled delivery with prior discontinuation of anticoagulant therapy 1

Management During Admission

During hospitalization, the following should be implemented:

1. Initiate therapeutic anticoagulation:

   • LMWH is the treatment of choice (e.g., Enoxaparin 1 mg/kg twice daily or 1.5 mg/kg once daily) 2
   • Unfractionated heparin may be preferred if delivery is imminent due to shorter half-life

2. Delivery planning:

   • Schedule delivery with planned anticoagulation interruption
   • Discontinue LMWH 24 hours before planned delivery 2
   • Consider transition to unfractionated heparin if delivery is anticipated within days

3. Multidisciplinary coordination:

   • Obstetrics for delivery planning
   • Anesthesiology for epidural/spinal considerations
   • Hematology for anticoagulation management

Outpatient Management Considerations

While ASH guidelines do suggest outpatient therapy for low-risk pregnant women with VTE 1, this recommendation specifically excludes patients with:

• Advanced gestational age (as in this case)
• Extensive VTE
• Severe pain requiring analgesia
• Maternal comorbidities affecting VTE tolerance
• Contraindications to LMWH
• Inadequate home support

Postpartum Management

After delivery, anticoagulation should be:

• Resumed 12-24 hours after delivery if no bleeding complications 2
• Continued for at least 6 weeks postpartum with a minimum total duration of 3 months 2
• Options include continuing LMWH or transitioning to warfarin (safe during breastfeeding) 2

Common Pitfalls to Avoid

1. Delaying anticoagulation: Treatment should begin immediately upon diagnosis
2. Using direct oral anticoagulants: DOACs (dabigatran, rivaroxaban, apixaban) are contraindicated during pregnancy 2
3. Failing to plan for delivery: Anticoagulation must be appropriately managed around delivery to minimize bleeding risk
4. Inadequate postpartum anticoagulation: Thrombotic risk remains elevated for 6 weeks postpartum

In conclusion, while outpatient management may be appropriate for some pregnant women with DVT, the advanced gestational age of 37 weeks makes hospital admission the appropriate choice to safely manage anticoagulation and coordinate delivery planning.