What is the treatment for superficial venous thrombosis (SVT) in pregnancy?

From the Guidelines

Superficial venous thrombosis in pregnancy should be treated with low molecular weight heparin (LMWH) such as enoxaparin at prophylactic doses (40mg subcutaneously once daily) for at least 2 weeks and until symptoms resolve. This approach is supported by the guidelines for venous thromboembolism (VTE) prevention and management, which recommend LMWH over warfarin for both prevention and treatment of VTE in pregnant patients 1. The use of LMWH is preferred due to its safety profile, as it does not cross the placenta and has a lower risk of heparin-induced thrombocytopenia and osteoporosis compared to unfractionated heparin.

When considering the treatment of superficial venous thrombosis in pregnancy, several key points should be taken into account:

• The treatment should aim to prevent extension of the thrombus, reduce inflammation, and prevent progression to deep vein thrombosis (DVT), which carries significant risks during pregnancy.
• Conservative measures, including compression stockings (20-30 mmHg), leg elevation, and regular walking, are also important components of the treatment plan.
• Avoiding NSAIDs during pregnancy, especially in the third trimester, is recommended, and warm compresses can be used to help manage pain.
• Regular follow-up ultrasounds are necessary to monitor for progression to DVT, which occurs in approximately 10% of untreated SVT cases.

For extensive SVT (>5cm in length) or SVT close to deep veins, treatment with LMWH should continue throughout pregnancy and for 6 weeks postpartum, as recommended for pregnant women at increased risk of VTE 1. This approach ensures that the mother and fetus are protected from the risks associated with VTE, while also minimizing the risks associated with anticoagulant therapy.

From the Research

Treatment of Superficial Venous Thrombosis in Pregnancy

• The treatment of superficial venous thrombosis (SVT) in pregnancy is crucial to prevent complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE) 2.
• According to the Position Paper on the Management of Pregnancy-Associated Superficial Venous Thrombosis, the clinical severity of SVT largely depends on the localization of thrombosis, and if untreated or inadequately treated, SVT can potentially cause DVT or PE 2.
• A study published in the Archives of Internal Medicine found that treatment with a low-molecular-weight heparin (LMWH) or an oral nonsteroidal anti-inflammatory agent can reduce the incidence of deep and superficial venous thromboembolism in patients with SVT 3.

Anticoagulation Therapy

• Weight-adjusted therapeutic-dose LMWH is the anticoagulant treatment of choice in cases of acute venous thromboembolism (VTE) during pregnancy, as heparins do not cross the placenta 4.
• The ACOG Practice Bulletin No. 196 recommends that anticoagulation should be continued for at least 6 weeks postpartum or for a minimum period of 3 months 5.
• A randomized trial published in the Annals of Internal Medicine found that fondaparinux had efficacy and safety similar to those of enoxaparin in patients with deep venous thrombosis 6.

Management of Delivery

• The management of delivery in patients with SVT deserves attention and mainly depends on the time interval between the diagnosis of SVT and the expected delivery date 4.
• If SVT manifests at term, delivery should be attended by an experienced multidisciplinary team 4.
• In lactating women, an overlapping switch from LMWH to warfarin is possible 4.