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Approach to VTE prophylaxis in pregnant women with inherited thrombophilia

Clinical setting	Antepartum management	Postpartum management
Lower-risk thrombophilia* with personal history of previous VTE or Higher-risk thrombophilia^¶without personal history of previous VTE	Anticoagulation (intermediate dose)	Anticoagulation (intermediate dose)
Lower-risk thrombophilia* without personal history of VTE	Surveillance for VTE without anticoagulation. Anticoagulation may be warranted for individual patients with additional factors that place them at greater risk of thrombosis (eg, prolonged immobility, first-degree relative with unprovoked VTE under age 50 years).	Anticoagulation (prophylactic dose) for women who deliver by cesarean
Higher-risk thrombophilia^¶ with previous VTE on chronic anticoagulation	Anticoagulation (therapeutic dose)	Anticoagulation (therapeutic dose)

Postpartum anticoagulation can generally be started 4 to 6 hours after vaginal delivery or 6 to 12 hours after cesarean delivery, unless there is significant bleeding or risk for significant bleeding.

VTE: venous thromboembolism; FVL: factor V Leiden; PGM: prothrombin G20210A gene mutation; AT: antithrombin.
* Lower-risk thrombophilias include heterozygosity for FVL or PGM and heritable deficiencies of protein C or protein S.
¶ Higher-risk thrombophilias include AT deficiency, homozygosity for FVL or PGM mutation, double heterozygosity for FVL and PGM, and protein C or protein S deficiency in combination with another defect. Some women with heterozygous deficiencies of only protein C or protein S (or FVL and PGM for that matter) may be at higher risk based on their personal and family history.

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