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Treatment of pregnant women with APS
Antepartum Postpartum
APS with prior arterial or venous LMWH Warfarin
thrombosis
APS: antiphospholipid syndrome; aPL: antiphospholipid antibodies; ASA: aspirin; LMWH: low molecular
weight heparin.
Graphic 91501 Version 2.0
Anticoagulation regimen definitions
Management
Dosage
type
Prophylactic LMWH* Enoxaparin, 40 mg SC once daily
Dalteparin, 5000 units SC once daily
Tinzaparin, 4500 units SC once daily
Therapeutic LMWH ¶ Enoxaparin, 1 mg/kg every 12 hours
(Also referred to as Dalteparin, 200 units/kg once daily
weightadjusted, full
Tinzaparin, 175 units/kg once daily
treatment dose)
Dalteparin, 100 units/kg every 12 hours
Minidose prophylactic UFH, 5000 units SC every 12 hours
UFH
Prophylactic UFH UFH, 5000 to 10,000 units SC every 12 hours
UFH, 5000 to 7500 units SC every 12 hours in first trimester
UFH, 7500 to 10,000 units SC every 12 hours in the second
trimester
UFH, 10,000 units SC every 12 hours in the third trimester, unless
the aPTT is elevated
Therapeutic UFH UFH, 10,000 units or more SC every 12 hours in doses adjusted to
(Also referred to as target aPTT in the therapeutic range (1.5 to 2.5) six hours after
injection
weightadjusted, full
treatment dose)
Postpartum Prophylactic LMWH/UFH for four to six weeks
anticoagulation
OR
Vitamin K antagonists for four to six weeks with a target INR of 2.0
to 3.0, with initial UFH or LMWH therapy overlap until the INR is 2.0
or more for two days
Surveillance Δ
In addition, the American College of Chest Physicians (ACCP) provides the option of
intermediate dosing. Intermediatedose UFH refers to doses adjusted to target a specific
antiXa UFH level. Examples of intermediatedose LMWH include dalteparin 5000 units
subcutaneously every 12 hours or enoxaparin 40 mg subcutaneously every 12 hours.
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest
Physicians EvidenceBased Clinical Practice Guidelines. February 2012.
NOTE: Tinzaparin is not available in the United States.
The role and frequency of antiXa level testing for management of therapeutic dosing of
LMWH in pregnancy are reviewed in the UpToDate topic "Anticoagulation in pregnancy".
LMWH: low molecular weight heparin; SC: subcutaneously; UFH: unfractionated heparin; aPTT:
activated partial thromboplastin time; INR: international normalized ratio.
* Although at extremes of body weight, modification of dose may be required.
¶ May target an antiXa level in the therapeutic range of 0.6 to 1.0 units/mL for twice daily regimen;
slightly higher doses may be needed for a oncedaily regimen.
Δ Clinical vigilance and appropriate objective investigation of women with symptoms suspicious of deep
vein thrombosis or pulmonary embolism may be needed.
Reproduced with permission from: ACOG Practice Bulletin #138. Thromboembolism in pregnancy.
Obstet Gynecol 2013; 122:706. DOI: 10.1097/01.AOG.0000433981.36184.4e. Copyright © 2013
American College of Obstetricians and Gynecologists. Unauthorized reproduction of this material is
prohibited.
Graphic 56377 Version 12.0
Summary of changes to the World Health Organization Medical
Eligibility Criteria for Contraceptive Use, 4th Edition, to create the
US Medical Eligibility Criteria for Contraceptive Use, 2010
The classification additions, deletions, and modifications from the World Health Organization (WHO) Medical Eligibil
Criteria for Contraceptive Use, 4th Edition, are summarized below. For conditions for which classification changed f
methods or the condition description underwent a major modification, WHO conditions and recommendations appe
curly brackets.
Categories for classifying hormonal contraceptives and intrauterine devices:
1 = A condition for which there is no restriction for the use of the contraceptive method.
2 = A condition for which the advantages of using the method generally outweigh the theoretical or proven risk
3 = A condition for which the theoretical or proven risks usually outweigh the advantages of using the method.
4 = A condition that represents an unacceptable health risk if the contraceptive method is used.
Summary of changes in classifications from WHO Medical Eligibility Criteria for
Contraceptive Use, 4th edition*
Breastfeeding The US
Departm
Health a
Human
<1 mo postpartum 3 ¶ {4} 2¶ 2¶ 2 ¶ {3} Services
{WHO: <6 wks {3} {3} recomme
postpartum} that infa
exclusive
breastfed
during th
46 mon
life, prefe
for a full
months.
1 mo to <6 mos {WHO: 2 ¶ {3}
Ideally,
≥6 wks to >6 mos
breastfee
postpartum} should
continue
through
first year
life. {Not
included
WHO ME
Postpartum (in breastfeeding or nonbreastfeeding women), including post caesarean section
<10 min after delivery 2 {1 if not
of the placenta {WHO: breastfeeding
<48 hrs, including and 3 if
insertion immediately breastfeeding}
after delivery of the
placenta}
Deep venous thrombosis
DVT/pulmonary
embolism (PE)
a. History of DVT/PE,
not on anticoagulant
therapy
ii. Lower risk for 3 {4}
recurrent DVT/PE
(no risk factors)
c. DVT/PE and
established on
anticoagulant therapy
for at least 3 mos
Higher risk for recurrent 2 {1}
DVT/PE (≥1 risk factors)
Known thrombophilia,
including
antiphospholipid
syndrome
Active cancer
(metastatic, on
therapy, or within 6
mos after clinical
remission), excluding
nonmelanoma skin
cancer
History of recurrent
DVT/PE
Hormona
contrace
methods
be of ben
preventin
treating
complica
When a
contrace
method
used as a
therapy,
rather th
solely to
prevent
pregnanc
risk/bene
ratio ma
different
should b
considere
a caseby
basis. {N
included
WHO ME
Valvular heart disease
Summary of recommendations for medical conditions added to the US Medical
Eligibility Criteria for Contraceptive Use*
History of bariatric surgery Δ
Restrictive procedures: 1 1 1 1 1 1
decrease storage
capacity of the stomach
(vertical banded
gastroplasty,
laparoscopic adjustable
gastric band,
laparoscopic sleeve
gastrectomy)
Malabsorptive COCs: 3 3 1 1 1 1
procedures: decrease P/R: 1
absorption of nutrients
and calories by
shortening the
functional length of the
small intestine (Roux
enY gastric bypass,
biliopancreatic diversion)
Peripartum cardiomyopathy Δ
Normal or mildly impaired cardiac function (New York Heart Association Functional Class I or II: patients with n
limitation of activities or patients with slight, mild limitation of activity)
<6 mos 4 1 1 1 2 2
≥6 mos 3 1 1 1 2 2
Moderately or severely 4 2 2 2 2 2
impaired cardiac
function (New York
Heart Association
Functional Class III or
IV: patients with
marked limitation of
activity or patients who
should be at complete
rest)
Rheumatoid arthritis
women w
rheumat
arthritis
classified
Category
Not on 2 1 2 1 1 1
immunosuppressive
therapy
Endometrial hyperplasia 1 1 1 1 1 1
Solid organ transplantation Δ
Uncomplicated 2¶ 2 2 2 2 2 Women
BuddCh
syndrom
should n
COC/P/R
because
increased
for throm
Summary of additional changes to the US Medical Eligibility Criteria for Contracept
Use
Condition/contraceptive
Change
method
Emergency contraceptive History of bariatric surgery, rheumatoid arthritis, inflammatory bowel disease, and so
pills organ transplantation were added to Appendix D (Classifications for Emergency
Contraceptive Pills) and given a Category 1.
Barrier methods For 6 conditions history of bariatric surgery, peripartum cardiomyopathy, rheumato
arthritis, endometrial hyperplasia, inflammatory bowel disease, and solid organ
transplantation the barrier methods are classified as Category 1.
Sterilization In general, no medical conditions would absolutely restrict a person's eligibility for
sterilization. Recommendations from the World Health Organization (WHO) Medical
Eligibility Criteria for Contraceptive Use about specific settings and surgical procedure
sterilization are not included here. The guidance has been replaced with general text
sterilization.
Other deleted items Guidance for combined injectables, levonorgestrel implants, and norethisterone enan
has been removed because these methods are not currently available in the United
States.
Guidance for "blood pressure measurement unavailable" and "history of hypertensio
where blood pressure CANNOT be evaluated (including hypertension in pregnancy)"
been removed.
Unintended pregnancy and The following conditions have been added to the WHO list of conditions that expose a
increased health risk woman to increased risk as a result of unintended pregnancy: history of bariatric sur
within the past 2 years, peripartum cardiomyopathy, and receiving a solid organ
transplant within 2 years.
WHO: World Health Organization; COC: combined oral contraceptive; P: combined hormonal
contraceptive patch; R: combined hormonal vaginal ring; POP: progestinonly pill; DMPA: depot
medroxyprogesterone acetate; LNGIUD: levonorgestrelreleasing intrauterine device; CuIUD: copper
intrauterine device; DVT: deep venous thrombosis; PE: pulmonary embolism; VTE: venous
thromboembolism; IBD: inflammatory bowel disease.
* For conditions for which classification changed for ≥1 methods or the condition description
underwent a major modification, WHO conditions and recommendations appear in curly brackets.
¶ Consult the clarification column for this classification.
Δ Condition that exposes a women to increased risk as a result of unintended pregnancy.
Reproduced from: US Medical Eligibility Criteria for Contraceptive Use, 2010. Available at:
http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr59e0528a1.htm.
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