Use of antithrombotic agents during pregnancy.

Anticoagulant therapy is indicated during pregnancy for the prevention and treatment of VTE, for the prevention and treatment of systemic embolism in patients with mechanical heart valves, and, in combination with aspirin, for the prevention of pregnancy loss in women with APLA and previous pregnancy losses. Several questions concerning anticoagulant therapy remain unanswered. Oral anticoagulants are fetopathic, but the true risks of the warfarin embryopathy and CNS abnormalities are unknown. There is some evidence that warfarin embryopathy occurs only when oral anticoagulants are administered between the 6th and the 12th weeks of gestation and that oral anticoagulants may not be fetopathic when administered in the first 6 weeks of gestation. Oral anticoagulant therapy should be avoided in the weeks before delivery because of the risk of serious perinatal bleeding caused by the trauma of delivery to the anticoagulated fetus. The safety of aspirin during the first trimester of pregnancy is still a subject of debate. There is a concern about the efficacy of unfractionated heparin in the prevention of arterial embolism in pregnant women with mechanical heart valves. Finally, the role of LMWH and heparinoids and appropriate dosing have still to be determined. Because it is safe for the fetus, heparin is the anticoagulant of choice during pregnancy for situations in which its efficacy is established. The evidence for the efficacy of heparin for the prevention and treatment of VTE disorders during pregnancy is based on level IV studies. There is some doubt that heparin is effective for the prevention of systemic embolism in patients with mechanical heart valves. Low doses of heparin or poorly controlled heparin therapy are not effective in preventing systemic embolism in patients with mechanical heart valves.