WSC 2026 | How should thrombotic risk be managed in pregnancy after cerebral venous thrombosis?

Yes, definitely this is a population that is often excluded from studies and especially trials. So, for example, we did a study some years ago on one question that is very common in clinical practice in CVT because CVT affects mostly women at fertile age. So actually more than half of the patients in the ISCVT cohort, which was a large prospective study on cerebral venous thrombosis, more than 600 patients, the evidence data on how to manage these patients. In the future, after having a CVT, if pregnancy was safe, what were the risks and what should be the prophylaxis, if any, during pregnancy in women that have already stopped anticoagulation was a very common question in clinical practice. And we know from several studies that some women were recommended not to be pregnant after CVT because of the risk of thrombotic events or were not managed with prophylactic anticoagulation because they stopped anticoagulation after a certain period and then they were not doing any antithrombotic prophylaxis during future pregnancies. So using this observational data from several studies and then also analysing the ISCVT pregnancy study, all the women that have been included in the study and followed with future pregnancies after follow-up, we could see overall with systematic review that the evidence, although it is observational, that it goes in the direction that women with history of CVT, they should receive antithrombotic prophylaxis with prophylactic heparin, at least during pregnancy, and puerperium as well, because the risk for patients that stopped anticoagulation and were not recommended to have any antithrombotic prophylaxis, so they were thought to be at low risk, the risk of thrombotic events was quite high. So in the puerperium for this group of patients was up to 5% could have recurrent venous thrombotic events, even peripheral, so deep vein thrombosis, pulmonary embolism, or recurrent CVT in about 1.5%. So these numbers are quite high for a short period of time. And this was not what was happening in women on antithrombotic prophylaxis with heparin. So although this is just associations and this is not a trial, we won’t have a trial on this setting, definitely. This highly suggests that this should be recommended for women with history of CVT. Then, of course, if CVT occurs during pregnancy and puerperium anticoagulation, you have to have different medications being used because DOACs cannot be used during pregnancy and warfarin as well is not recommended. So these patients receive parental anticoagulation with usually with enoxaparin or dalteparin, so low molecular weight heparin. And also during puerperium, there should be a period usually around 12 weeks where the risk is higher and these women should receive prophylaxis as well, and treatment if they had a CVT during pregnancy, anticoagulation. So these are the recommendations. Of course, then delivery has to be managed according to that, and there are, of course, multidisciplinary decisions that have to be taken in these patients. But again, more evidence is needed also on this topic and also on the prophylaxis in future pregnancies. It is good to have more evidence on the outcomes.

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