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Treatment of pregnant women with APS

  Antepartum Postpartum
APS with prior arterial or venous LMWH Warfarin
thrombosis

APS with prior arterial or venous LMWH and low­dose Warfarin


thrombosis and APS­defining pregnancy ASA
morbidity

APS based on laboratory criteria for aPL LMWH and low­dose LMWH and low­dose


and APS­defining pregnancy morbidity of ASA ASA
≥1 fetal losses ≥10 weeks of gestation or
≥3 unexplained consecutive spontaneous
pregnancy losses <10 weeks of
gestation, but no history of arterial or
venous thrombosis

APS based on laboratory criteria for aPL Low­dose ASA None


and APS­defining pregnancy morbidity of
LMWH with low­dose LMWH with low­dose
≥1 preterm deliveries of a
ASA in cases of ASA ASA
morphologically normal infant before 34
failure or when
weeks of gestation due to severe
placental examination
preeclampsia, eclampsia, or other
shows extensive
findings consistent with placental
decidual inflammation
insufficiency. No history of arterial or
and vasculopathy
venous thrombosis.
and/or thrombosis

Laboratory criteria for aPL but no clinical Low­dose ASA None


criteria for APS

APS: antiphospholipid syndrome; aPL: antiphospholipid antibodies; ASA: aspirin; LMWH: low molecular
weight heparin.

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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.

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* 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.

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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*

Condition COC/P/R POP DMPA Implants LNG­IUD Cu­IUD Clarific

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}

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after delivery of the
placenta}

10 min after delivery of         2 {3} 2 {3}  


the placenta to <4 wks
{WHO: ≥48 hrs to <4
wks}

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)

b. Acute DVT/PE   2 2 {3} 2 {3} 2 {3} 2 {1}  


{3}

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

Lower risk for recurrent 3 ¶ {4}         2 {1} Women 


DVT/PE (no risk factors) anticoag
therapy 
risk for
gynecolo
complica
of therap
such as
hemorrh
ovarian c
and seve
menorrh

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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

Complicated Δ         1 {2} 1 {2}  


(pulmonary
hypertension, risk for
atrial fibrillation, history
of subacute bacterial
endocarditis)

Ovarian cancer Δ         1 {Initiation = 1 {Initiation  


3, = 3,
Continuation Continuation
= 2} = 2}

Uterine fibroids         2 {1 if no 2 {1 if no  


uterine uterine
distortion and distortion and
4 if uterine 4 if uterine
distortion is distortion is
present} present}

Summary of recommendations for medical conditions added to the US Medical
Eligibility Criteria for Contraceptive Use*

Condition COC/P/R POP DMPA Implants LNG­IUD Cu­IUD Clarific

History of bariatric surgery Δ

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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

On immunosuppressive 2 1 2/3 ¶ 1 Initiation: 2 Initiation: 2 DMPA us


therapy among w
Continuation: Continuation:
on long­t
1 1
corticost
therapy 
history o
risk facto
nontraum
fractures
classified
Category
Otherwis
DMPA us

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women w
rheumat
arthritis 
classified
Category

Not on 2 1 2 1 1 1  
immunosuppressive
therapy

Endometrial hyperplasia 1 1 1 1 1 1  

Inflammatory bowel 2/3 Δ 2 2 1 1 1 For wom


disease (IBD) (ulcerative with mild
colitis, Crohn disease) with no o
risk facto
VTE, the
benefits 
COC/P/R
generally
outweigh
risks (Ca
2). Howe
for wome
with IBD
increased
for VTE (
those wi
active or
extensiv
disease,
surgery,
immobili
corticost
use, vita
deficienc
fluid
depletion
risks for
COC/P/R
generally
outweigh
benefits
(Categor

Solid organ transplantation Δ

Complicated: graft 4 2 2 2 Initiation: 3 Initiation: 3  


failure (acute or
Continuation: Continuation:
chronic), rejection, 2 2
cardiac allograft
vasculopathy

Uncomplicated 2¶ 2 2 2 2 2 Women 

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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.

Graphic 64282 Version 4.0

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