What is the recommended DVT (Deep Vein Thrombosis) prophylaxis for a pregnant patient with a history of DVT and using a Sequential Compression Device (SCD)?

DVT Prophylaxis for Pregnant Patient with Prior DVT and Sickle Cell Disease

This patient requires both mechanical and pharmacologic prophylaxis throughout pregnancy and for 6 weeks postpartum, given her dual high-risk factors of prior DVT and sickle cell disease. 1

Risk Stratification

This patient has two major independent risk factors that place her at very high risk for VTE:

• Prior DVT history (2 years ago): Classifies her as moderate-to-high risk for recurrent VTE 1
• Sickle cell disease: Listed as a major risk factor (OR >6) for VTE in pregnancy 1

The combination of these factors mandates aggressive prophylaxis throughout pregnancy and the postpartum period.

Recommended Prophylaxis Strategy

Antepartum (During Pregnancy)

Pharmacologic prophylaxis with prophylactic- or intermediate-dose LMWH is recommended throughout pregnancy rather than clinical vigilance alone (Grade 2C). 1

• Low-molecular-weight heparin (LMWH) is the preferred agent in pregnancy and postpartum (Grade 1C) 1
• Standard prophylactic dosing: Enoxaparin 40 mg subcutaneously once daily 2
• Alternative: Dalteparin 5000 units once daily 1

Postpartum Period

All pregnant women with prior VTE require postpartum prophylaxis for 6 weeks with prophylactic- or intermediate-dose LMWH or warfarin (INR 2.0-3.0) (Grade 2B). 1

• This applies regardless of delivery mode 1
• If cesarean delivery occurs, combine mechanical and pharmacologic prophylaxis (Grade 2C) 1

Mechanical Prophylaxis

Sequential compression devices (SCDs) should be used if cesarean delivery is performed:

• Start before surgery and continue until fully ambulatory (Grade 1C) 1
• SCDs complement but do not replace pharmacologic prophylaxis in high-risk patients 1

Important Clinical Considerations

Timing Around Delivery

Discontinue LMWH at least 24 hours prior to planned delivery or neuraxial anesthesia (Grade 1B) to minimize bleeding risk and allow for epidural placement. 1

• Resume LMWH postpartum once hemostasis is assured (typically 6-12 hours after vaginal delivery, 12-24 hours after cesarean) 3
• Continue for minimum 6 weeks postpartum 1

Duration Considerations

Total anticoagulation duration should be at least 3 months if acute VTE occurs during pregnancy (Grade 2C), but the 6-week postpartum prophylaxis is standard for prior VTE history. 1

Breastfeeding Compatibility

Both LMWH and warfarin are safe during breastfeeding as neither is secreted in breast milk. 1

Common Pitfalls to Avoid

• Do not rely on mechanical prophylaxis alone in patients with prior VTE—this patient needs pharmacologic prophylaxis 1
• Do not use warfarin during pregnancy due to teratogenicity; LMWH is the only appropriate anticoagulant antepartum (Grade 1A) 1
• Do not continue LMWH up to delivery time if neuraxial anesthesia is planned—allow 24-hour window 1
• Do not stop prophylaxis at hospital discharge—extend for full 6 weeks postpartum (Grade 2C) 1

Clinical Algorithm Summary

1. Initiate prophylactic-dose LMWH (enoxaparin 40 mg SC daily) as soon as pregnancy confirmed 1, 2
2. Continue throughout pregnancy until 24 hours before planned delivery 1
3. If cesarean delivery: Apply SCDs preoperatively, continue until ambulatory 1
4. Resume LMWH postpartum once hemostasis established 3
5. Continue for 6 weeks postpartum (may switch to warfarin postpartum if preferred) 1