Thromboprophylaxis

الله بسمالرحمن الرحيم

12th Annual Congress “RAS EL BAR ” 5- 2009

12th Annual Congress “RAS EL BAR ” 5- 2009

Thromboprophylaxis During Pregnancy, Birth and Puerperium

Dr. Mahdy El-MazzahyDamietta General Hospital

problem solving

Case 1 A 29-year-old gravida 3, para 1 At 7 weeks' gestational age History of L.DVT while taking COC

pills History of 2 miscarriages at 7&9

weeks Tall 162cm weight 71 kg : BMI < 27

kg/m2)

Which of the following should be done?

A. Factor V Leiden mutation, Protein C and

protein S deficiency

B. Antithrombin deficiency

C. Lupus anticoagulant /anticardiolipin

D. All of the above

E. None of the above

E

What is the evidence?

Women with previous VTE

should receive thromboprophylaxis with LMWH

antenatally and for 6 weeks post partum if :

Recurrent VTE

Unprovoked

Estrogen/pregnancy related

With history of VTE in a first degree relative

With other risk factors

RCOG Guideline April 2009Grade C

• Which women with prior VTE require a

thrombophilia screen?

Women with previous provoked and non estrogen related VTE.

Grade C

Women with a previous single provoked VTE (and no other risk factors) require close surveillance antenatally and prophylaxis with LMWH for 6 weeks post partum.

Grade C

Green-top Guideline April 2009

Antenatal Assessment & Management (To be assessed at booking and repeated if admitted)

1. Single previous VTE +

*Thrombophilia, or FH

*Unprovoked/estrogen related

2. Previous recurrent VTE (>1)

HIGH RISK

REQUIRES ANTENATAL

prophylaxis with LMWH

•Single previous provoked VTE without FH or thrombophilia •Thrombophilia + no VTE

Intermediate Risk require close surveillance antenatally andprophylaxis with LMWH for 6 W post partum


Antenatal Assessment & Management (To be assessed at booking and repeated if admitted)

1.Age > 35 yrs2.Obesity (BMI>30kg/m2) 3.Parity > 34 Smoker5.MEDICAL CO-MORBIDITIESe.g. heart or lung disease; SLE; cancer; inflammatory conditions; Proteinuria >3g/24 hrs; Sickle Cell Disease.6.Gross varicose veins 7.Current systemic infection 8.Immobility, e.g. paraplegia, SPD, long-haul travel 9.Pre-eclampsia10.Dehydration/hyperemesis/OHSS 11.Multiple pregnancy or ART12.Surgical procedure e.g. ERPC

3 or more risk factors2 or more if admitted

<3 risk factors

Intermediate RiskConsider antenatal prophylaxis with LMWH

Low RiskMobilisation &avoidance of dehydration.


Timing of initiation of thromboprophylaxis

Timing of initiation of thromboprophylaxis

first trimester is associated with the greatest risk of VTE, many antenatal VTE events (including fatal events) occur in the first trimester

So women should be advised to start LMWH as soon as they have a positive pregnancy test.


Which agents should be used for thromboprophylaxis?

Which agents should be used for thromboprophylaxis?

LMWHs are the agents of choice for antenatal thromboprophylaxis. They are as effective and safer than unfractionated heparin.

Grade A


•FDA warns docs to stop using Baxter's heparin•Hundreds of allergic reactions to the blood thinner have been reported

weightEnoxaparin (100 U/mg)

Tinzaparin20,000U/ml

Body weight < 50 kg

Normal weight : 50–90 kg

Body weight 91-130 kg

Body weight 131-170 kg

>170 kg

Higher prophylactic dose(50-90kg)

Treatment dose

20 mg/d

40 mg/d

60 mg/d*

80mg/d*

0.5mg/kg/d*

40 mg/12h

1mg/kg/12h

(antenatal)

1.5 mg post

3500 U/d

4500 U/d

7000 U/d*

9000 u/d*

75u/kg/d*

4500U/12h

175U/kg/12h

(antenatal

&postnatal)

RCOG Guideline April 2009

Thromboprophylaxis During Pregnancy

ThromboprophylaThromboprophylaxis after deliveryxis after delivery

Postnatal Assessment & Management

(to be assessed on Delivery Suite)

•Any previous VTE•Asymptomatic Thrombophilia

High RiskAt least 6 weekspostnatal prophylactic LMWH

Caesarean Section in Labour BMI > 40 kg/m2 Prolonged Hospital Admission

Intermediate RiskAt least 7days postnatal prophylactic LMWH


Postnatal Assessment & Management (to be assessed on Delivery Suite)

1.Age > 35 yrs 2.Obesity (BMI>30kg/m2) 3.Parity 3 4.Smoker5. Elective Caesarean Section 6.MEDICAL CO-MORBIDITIES e.g. heart or lung disease; SLE; cancer; inflammatory conditions; Proteinuria >3g/24 hrs; Sickle Cell Disease; IVDU 7.Gross varicose veins8. Current systemic infection9. Immobility, e.g. paraplegia, SPD, long-haul travel10 Pre-eclampsia 11.mid-cavity or rotational forceps 12.Prolonged labour (>24 hrs)13.PPH > 1litre or Blood Transfusion

2 or more risk factors

<2 risk factors

Intermediate RiskAt least 7 days postnatal prophylactic LMWH

Low RiskEARLY Mobilisation and avoidance of dehydration.

NB If persisting or > 3 risk factors consider extending prophylaxis with LMWH


Thromboprophylaxis after delivery

The first thromboprophylactic dose of LMWH should be given as soon as possible after delivery provided there is no post partum haemorrhage .

7 D Thromboprophylaxis with CS

1-Eemergency CS2-Elective CS + one or more additional risk


When should thromboprophylaxis be interrupted for delivery?

Delivery by elective caesarean section in women receiving

antenatal LMWH On the day prior to delivery ,the

woman should receive a thromboprophylactic dose of LMWH

On the day of delivery, any morning dose should be omitted.

The thromboprophylactic dose of LMWH heparin should be given by four hours post-operatively or four hours after removal of the epidural catheter.


Regional techniques should not be used until:- 12 hours after the previous

prophylactic dose of LMWH and 24 hours after the last therapeutic

dose.. cannula should not be removed

within 10-12 hours of the most recent injection.

LMWH should not be given for four hours after the epidural catheter has been removed


Health & Medicine

Thromboprophylaxis