Should I stop prophylactic enoxaparin (Clexane) in a 38‑year‑old G6P4 woman, BMI 40, 6 weeks pregnant, who has no thrombotic indication and is anxious to discontinue?

Should Prophylactic Enoxaparin Be Discontinued?

Yes, discontinue the enoxaparin immediately—this patient has no evidence-based indication for thromboprophylaxis and continuing it exposes her to unnecessary bleeding risk without meaningful VTE reduction.

Why This Patient Does Not Require Prophylactic Anticoagulation

Risk Assessment in Early Pregnancy

• The American Society of Hematology guidelines recommend against antepartum antithrombotic prophylaxis for pregnant women with no prior VTE history and no documented thrombophilia, regardless of obesity or family history 1
• Obesity alone (BMI 40) is classified as a minor risk factor for VTE, and the American College of Chest Physicians requires at least two minor risk factors OR one major risk factor to justify pharmacologic prophylaxis 1, 2
• At 6 weeks gestation, this patient is in the first trimester when VTE risk is lowest—the highest risk period is the third trimester and immediate postpartum period 1

What Constitutes a Valid Indication

• Major risk factors that would justify prophylaxis include: prior personal VTE, high-risk inherited thrombophilia (antithrombin deficiency, homozygous Factor V Leiden), antiphospholipid antibody syndrome, or active thrombotic APS 1
• This patient has none of these conditions based on the clinical scenario provided 1

Safety Concerns With Unnecessary Anticoagulation

• Enoxaparin in low-risk pregnant patients increases bleeding complications (wound hematoma, postpartum hemorrhage) without reducing VTE events—the number needed to harm may exceed the number needed to treat 2
• The American College of Chest Physicians explicitly recommends against prophylactic anticoagulation in low-risk patients because it increases bleeding risk without meaningful VTE reduction 2

Appropriate Management Strategy

Immediate Action

• Discontinue enoxaparin immediately and reassure the patient that stopping is the evidence-based recommendation 1
• Counsel the patient that her anxiety about stopping is understandable but that continuing poses greater risk than benefit in her specific situation 2

Ongoing Surveillance

• Implement clinical vigilance throughout pregnancy—this means educating the patient about VTE symptoms (unilateral leg swelling, chest pain, dyspnea) and ensuring prompt evaluation if they occur 1
• Reassess VTE risk in the third trimester and postpartum period, when risk increases and additional factors (cesarean delivery, prolonged immobility, preeclampsia) may emerge 1, 2

When to Reconsider Prophylaxis

• If the patient develops two or more additional minor risk factors (e.g., cesarean delivery, preeclampsia, prolonged bed rest >1 week), then postpartum prophylaxis with enoxaparin 40 mg daily for 6 weeks would be appropriate 1, 2
• If she undergoes cesarean delivery, universal mechanical prophylaxis (sequential compression devices) is mandatory, and pharmacologic prophylaxis should be considered only if additional risk factors are present 2

Common Pitfalls to Avoid

• Do not continue enoxaparin "just to be safe"—this represents defensive medicine that increases harm without reducing VTE risk in this population 1, 2
• Do not confuse obesity-related VTE risk in the general population with pregnancy-specific risk stratification—pregnancy guidelines use different thresholds and require multiple risk factors 1, 2
• Do not assume that starting enoxaparin obligates continuation—stopping an inappropriate medication is always the correct clinical decision 1