Management of Pulmonary Embolism in Pregnancy: Aspirin Use with Apixaban
Aspirin should not be used in pregnant patients with pulmonary embolism who are on apixaban, as apixaban is contraindicated during pregnancy and low molecular weight heparin (LMWH) should be used instead. 1
Anticoagulation in Pregnancy with PE
Contraindication of NOACs in Pregnancy
- NOACs (including apixaban) are explicitly contraindicated during pregnancy and lactation according to current guidelines 1
- The FDA label for apixaban does not include specific guidance for pregnancy, but European guidelines clearly state not to use NOACs during pregnancy 2
Recommended Anticoagulation in Pregnancy
- Therapeutic, fixed doses of LMWH based on early pregnancy weight are the recommended treatment for PE in pregnant women without hemodynamic instability 1
- LMWH should be administered throughout the entire pregnancy 1
- Unfractionated heparin (UFH) may be considered as an alternative, particularly in situations requiring rapid reversal 1
Management Algorithm for PE in Pregnancy
Initial Assessment and Treatment
- Perform formal diagnostic assessment with validated methods if PE is suspected during pregnancy 1
- For confirmed PE in pregnancy, immediately discontinue apixaban 1
- Switch to therapeutic fixed-dose LMWH based on early pregnancy weight 1
Duration of Treatment
- Continue anticoagulant therapy with LMWH throughout pregnancy 1
- After delivery, heparin treatment may be replaced by anticoagulation with vitamin K antagonists (VKAs) 1
- Anticoagulant treatment should be administered for at least 3 months after delivery 1
Special Considerations for Peripartum Management
Labor and Delivery Planning
- Discontinue LMWH at the onset of regular uterine contractions 1
- Do not insert a spinal or epidural needle within 24 hours since the last LMWH dose 1
- Do not administer LMWH within 4 hours of removal of an epidural catheter 1
- Close collaboration between obstetrician, anesthetist, and attending physician is recommended 1
Post-Delivery Management
- VKAs can be given to breastfeeding mothers after delivery 1
- Assess the need for extended anticoagulation based on risk factors for recurrence 1
Common Pitfalls and Caveats
- Mistakenly continuing apixaban during pregnancy instead of switching to LMWH 1
- Adding aspirin to anticoagulation therapy in pregnancy without specific indication increases bleeding risk without clear benefit 3, 4
- Failure to adjust LMWH dosing based on weight changes during pregnancy 1
- Inadequate planning for labor and delivery anticoagulation management 1
- Insufficient communication between specialists (hematology, obstetrics, anesthesiology) regarding anticoagulation management 1
High-Risk PE Management in Pregnancy
- For high-risk PE with hemodynamic instability in pregnancy, thrombolysis may be considered in life-threatening situations 3
- A multidisciplinary approach involving PE response teams and obstetricians is essential for high-risk PE in pregnancy 3
- For women in peripartum and early post-partum period with high-risk PE, non-fibrinolytic treatments may be preferred as first-line due to high bleeding risk 3