From the Guidelines
Superficial thrombophlebitis in pregnancy should be managed with low molecular weight heparin (LMWH) over no anticoagulant, as recommended by the American Society of Hematology 2018 guidelines 1.
Management Overview
The management of superficial thrombophlebitis during pregnancy involves a combination of conservative measures and, when necessary, anticoagulation therapy. Initial management includes:
- Leg elevation to reduce swelling
- Compression stockings to prevent progression
- Regular ambulation to reduce symptoms
- Acetaminophen for pain relief, with a typical dose of 650-1000 mg every 6 hours, not exceeding 4000 mg daily
Anticoagulation Therapy
For more severe cases or those with risk factors for deep vein thrombosis, LMWH such as enoxaparin 40 mg subcutaneously once daily is recommended 1, as it does not cross the placenta and is safe during pregnancy. The benefits of treating with LMWH were thought to outweigh the potential harms, which in this situation consist mostly of bleeding and the burden of injections, especially for very symptomatic superficial vein thrombosis and superficial vein thrombosis at risk of extension into the deep venous system 1.
Treatment Duration and Monitoring
Treatment duration typically ranges from 2-4 weeks, depending on symptom resolution 1. Patients should be monitored for progression to deep vein thrombosis, which presents with increased pain, swelling, and warmth. Superficial thrombophlebitis in pregnancy warrants attention because the hypercoagulable state of pregnancy increases thrombotic risk, and untreated cases may progress to more serious venous thromboembolism.
Special Considerations
Prompt evaluation by an obstetrician is essential, especially for thrombophlebitis involving the saphenofemoral junction or extending over large segments of the vein, as these cases have higher risk of complications and may require more aggressive management. The diagnosis of superficial vein thrombosis should be confirmed by compression ultrasound whenever possible 1.
From the Research
Superficial Thrombophlebitis in Pregnancy
- Superficial venous thrombophlebitis (SVT) is characterized as a localized inflammatory condition of the venous vessels underlying the skin, which can be associated with pregnancy 2.
- SVT is typically associated with venous valvular insufficiency, pregnancy, infection, and prothrombotic conditions, including malignancy 2.
- Medical therapies comprising bedrest, elastic stockings, compression bandages, nonsteroidal anti-inflammatory drugs, and low molecular weight heparins are used to reduce the extension of inflammation and recurrence of thrombotic events in patients experiencing SVT 2.
Risk Factors and Treatment
- Pregnancy is a risk factor for SVT, and treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of SVT 3, 4.
- Low molecular weight heparin prophylaxis may reduce the incidence of superficial vein thrombosis/superficial thrombophlebitis in patients with vein catheters 5.
- Fondaparinux, rivaroxaban, and low molecular weight heparin (LMWH) have been studied as treatment options for ST, with fondaparinux showing a significant reduction in symptomatic VTE, ST extension, and ST recurrence compared to placebo 4.
Management and Prevention
- Exercise reduces pain and the possibility of deep vein thrombosis, and only in cases where pain is very severe is bed rest necessary 5.
- Deep vein thrombosis prophylaxis should be established in patients with reduced mobility, and antibiotics usually do not have a place in superficial vein thrombosis/superficial thrombophlebitis unless there are documented infections 5.
- Prevention of superficial vein thrombosis should be considered on the basis of patient's history and clinical evaluation, and further research is needed to assess the role of rivaroxaban and other direct oral factor-X or thrombin inhibitors, LMWH, and NSAIDs 4.