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ThromboemboliThromboembolic diseases in c diseases in pregnancypregnancy

Venous Thromboembolism in Venous Thromboembolism in

PregnancyPregnancy::

Venous Thromboembolism (VTE) refers to the formation of a Venous Thromboembolism (VTE) refers to the formation of a thrombus within veinsthrombus within veins..This can occur anywhere in the venous system but the This can occur anywhere in the venous system but the clinically predominant sites are in the vessels of the leg clinically predominant sites are in the vessels of the leg (giving rise to (giving rise to deevein thrombosis, deevein thrombosis, DVTDVT) and in the lungs ) and in the lungs (resulting in a (resulting in a pulmonarypulmonary embolusembolus, PE), PE)..The major predisposing factors to VTE areThe major predisposing factors to VTE are : :

11..The activation of blood coagulationThe activation of blood coagulation . .22..Venous stasisVenous stasis . .

33..Endothelial injury (VirchowEndothelial injury (Virchow’’s triad)s triad)..Pregnancy is a major risk factor for VTE and it is greater in the Pregnancy is a major risk factor for VTE and it is greater in the

postpartum compared to the antepartum periodpostpartum compared to the antepartum period..

EpidemiologyEpidemiology

••It is about 5 times more common in pregnant than It is about 5 times more common in pregnant than in non-pregnant women of a similar agein non-pregnant women of a similar age..

•• Occurs in about 1/1000 pregnancies in women Occurs in about 1/1000 pregnancies in women under the age of 35under the age of 35 . .

•• Occurs in 2.4/1000 pregnancies in women over Occurs in 2.4/1000 pregnancies in women over the age of 35the age of 35 . .

•• 10-20%10-20% of VTEs are PEs which are the main of VTEs are PEs which are the main

contributors to VTE mortalitycontributors to VTE mortality..

Maternal haematological changes in Maternal haematological changes in pregnancypregnancy::

11..Increase White cell count (counts as high as 16 Increase White cell count (counts as high as 16 observed in the 3observed in the 3rdrd trimester.) the rise is mainly in trimester.) the rise is mainly in polymorph- nuclear cellspolymorph- nuclear cells..

22..Increase Factors Increase Factors V, VIIV, VII, , VIIIVIII, IX, , IX, X, XIIX, XII, , fibrinogenfibrinogen, , vWFvWF..

33..Decrease antithrombin III, protein CDecrease antithrombin III, protein C..

44..Decrease protein S by 40%Decrease protein S by 40% , ,

55..Fibrinolysis inhibitedFibrinolysis inhibited..

66..Slight decrease plateletsSlight decrease platelets..

risk factorsrisk factors

inherited factorsinherited factors::--Factor V Leiden mutationFactor V Leiden mutation

--Prothrombin 20210 mutationProthrombin 20210 mutation--Antithrombin III deficiencyAntithrombin III deficiency

--Protein C deficiencyProtein C deficiency --Protein S deficiencyProtein S deficiency

--HyperhomocysteinemiaHyperhomocysteinemia --DysfibrinogenemiaDysfibrinogenemia

--Disorders of plasminogen and plasminogen Disorders of plasminogen and plasminogen activationactivation

Acquired factorsAcquired factors:: --ObesityObesity

--Increased ageIncreased age--Immobilization (> 4 days bed rest)Immobilization (> 4 days bed rest)

--Previous thrombotic eventPrevious thrombotic event --Inflammatory disorders such as inflammatory bowel Inflammatory disorders such as inflammatory bowel

diseasedisease --CancerCancer

--Oestrogen therapy (including contraception and Oestrogen therapy (including contraception and hormone replacement therapy)hormone replacement therapy)

--Sepsis including urinary tract infectionsSepsis including urinary tract infections ) )--Gross varicose veinsGross varicose veins

--Antiphospholipid syndromeAntiphospholipid syndrome . .--Nephrotic syndromeNephrotic syndrome . .

--Paroxysmal nocturnal hemoglobinuriaParoxysmal nocturnal hemoglobinuria--StrokeStroke

--Polycythemia veraPolycythemia vera . .--Sickle cell diseaseSickle cell disease..

Factors specific to pregnancyFactors specific to pregnancy

--Venous stasisVenous stasis..

--Advanced maternal ageAdvanced maternal age . .

--MultiparityMultiparity . .

--Instrument-assisted or cesarean deliveryInstrument-assisted or cesarean delivery . .

--HemorrhageHemorrhage . .

--Pre-eclampsiaPre-eclampsia . .

--Prolonged labourProlonged labour..

Deep vein thrombosisDeep vein thrombosis::

PresentationPresentation: :

--leg pain and discomfort (the left is more commonly leg pain and discomfort (the left is more commonly affected)affected)-,-,swelling, tenderness, edemaswelling, tenderness, edema . .

--increased temperatureincreased temperature . .

--raised white cell countraised white cell count . .

There may also be abdominal painThere may also be abdominal pain . .

--The difficulty is that some of these symptoms may be The difficulty is that some of these symptoms may be found in normal pregnanciesfound in normal pregnancies . .

--The patient may also be asymptomatic with a The patient may also be asymptomatic with a retrospective diagnosis being made following a PEretrospective diagnosis being made following a PE . .

Investigations and diagnosisInvestigations and diagnosis

11..D-dimersD-dimers::

--VTE is associated with increased levels of VTE is associated with increased levels of blood D- dimers and this is often used as a blood D- dimers and this is often used as a screening test in non pregnant individualsscreening test in non pregnant individuals..

--However levels of D- dimers are increased in However levels of D- dimers are increased in uncomplicated pregnancy and levels uncomplicated pregnancy and levels increased with advancing pregnancyincreased with advancing pregnancy..

--A positive D- dimer screen is of no prognostic A positive D- dimer screen is of no prognostic significance in VTE but significance in VTE but a negative D- dimer a negative D- dimer in pregnancy means no VTEin pregnancy means no VTE..

22..Duplex ultrasoundDuplex ultrasound::

--This has a high sensitivity and specificity in This has a high sensitivity and specificity in proximal DVTs and is non-invasiveproximal DVTs and is non-invasive..

--It is unreliable for calf DVT as it has a much It is unreliable for calf DVT as it has a much lower sensitivitylower sensitivity..

--If the initial ultrasound scan is negative and If the initial ultrasound scan is negative and there is low level of clinical suspicion, there is low level of clinical suspicion, anticoagulant treatment can be stoppedanticoagulant treatment can be stopped..

--If the ultrasound is negative and there is high If the ultrasound is negative and there is high clinical suspicion, the patient should be clinical suspicion, the patient should be anticoagulated and the ultrasound repeated anticoagulated and the ultrasound repeated in one week, or venography performedin one week, or venography performed..

33..VenographyVenography::

--This adequately visualize calf and deep This adequately visualize calf and deep veinsveins..

--But there is risks of radiation, allergic But there is risks of radiation, allergic reaction and 5 percent risk of causing reaction and 5 percent risk of causing thrombosisthrombosis..

managementmanagement

--Medical anticoagulation is the treatment of Medical anticoagulation is the treatment of choice for acute VTEchoice for acute VTE . .

--Anticoagulation is by far the most common Anticoagulation is by far the most common treatment optiontreatment option . .

--Heparin is the most frequently used drug, Heparin is the most frequently used drug, being non-toxic to the fetus (it does not being non-toxic to the fetus (it does not cross the placental barrier)cross the placental barrier) . .

--However, its main disadvantages are that it However, its main disadvantages are that it has to be parentally administered and on has to be parentally administered and on the long-term, may give rise to heparin-the long-term, may give rise to heparin-induced osteoporosis and induced osteoporosis and thrombocytopeniathrombocytopenia..

--WarfarinWarfarin

is the other treatment option in the post-natal patient is the other treatment option in the post-natal patient but it must be avoided during pregnancy as it is but it must be avoided during pregnancy as it is teratogenic (causing chondrodysplasia punctata )teratogenic (causing chondrodysplasia punctata )

and can also cause placental abruption and fetal / and can also cause placental abruption and fetal / neonatal hemorrhage in the 2neonatal hemorrhage in the 2ndnd and 3 and 3rdrd trimesters trimesters . .

--It act by inhibiting the synthesis of four vitamin K-It act by inhibiting the synthesis of four vitamin K-dependent coagulant proteins ( factors II, VII, IX, X) dependent coagulant proteins ( factors II, VII, IX, X) and at least two vitamin K-dependent anticoagulant and at least two vitamin K-dependent anticoagulant factors, proteins C and Sfactors, proteins C and S..

--There is no agent available which can rapidly reverse There is no agent available which can rapidly reverse the effects of Warfarin, and reversal by stopping the effects of Warfarin, and reversal by stopping therapy and giving vitamin K up to 5 daystherapy and giving vitamin K up to 5 days..

--It can be used safely during breast feedingIt can be used safely during breast feeding..

--In clinically suspected DVT or PE, treatment In clinically suspected DVT or PE, treatment with unfractionated heparin or low with unfractionated heparin or low molecular weight heparin (LMWH) by molecular weight heparin (LMWH) by subcutaneous rout should be given until the subcutaneous rout should be given until the diagnosis is excluded by objective testing, diagnosis is excluded by objective testing, unless treatment is strongly unless treatment is strongly contraindicatedcontraindicated..

Initiating treatmentInitiating treatment

Baseline assessmentBaseline assessment::

--Carry out a full thrombophilia screen - this will not Carry out a full thrombophilia screen - this will not influence initial management but will provide influence initial management but will provide information guiding the duration and intensity of information guiding the duration and intensity of long-term managementlong-term management . .

--These results should be interpreted in the light of These results should be interpreted in the light of normal physiological changes during pregnancynormal physiological changes during pregnancy..

--Check full blood count, coagulation screen, urea and Check full blood count, coagulation screen, urea and electrolytes and liver function tests (renal and electrolytes and liver function tests (renal and hepatic dysfunction will influence intensity of hepatic dysfunction will influence intensity of treatment)treatment)..

Choosing the type of heparinChoosing the type of heparin::

Intravenous unfractionated heparinIntravenous unfractionated heparin:: this is an extensively used drug in the acute this is an extensively used drug in the acute

management of VTE, particularly massive management of VTE, particularly massive PEPE . .

It is initiated with a loading dose of 5000 iu It is initiated with a loading dose of 5000 iu followed by a continuous infusion of 1000-followed by a continuous infusion of 1000-2000 iu / hour depending on (daily) APTT 2000 iu / hour depending on (daily) APTT measurementsmeasurements , ,

--the first of which is taken 6 hours post the first of which is taken 6 hours post loading dose. Thus, there is the benefit of loading dose. Thus, there is the benefit of accurate drug administrationaccurate drug administration..

Subcutaneous unfractionated Subcutaneous unfractionated heparinheparin

- - This has been shown to be as effective as the This has been shown to be as effective as the intravenous formintravenous form . .

--It is administered as a 5000 iu bolus and It is administered as a 5000 iu bolus and subsequent 15,000 - 20,000 iu doses at 12 subsequent 15,000 - 20,000 iu doses at 12 hourly intervalshourly intervals . .

--The APTT needs to be checked and is best The APTT needs to be checked and is best done mid-way between the 12 hourly doses, done mid-way between the 12 hourly doses, once every 24 hoursonce every 24 hours . .

--A target of 1.5-2.5 times the control should A target of 1.5-2.5 times the control should be aimed forbe aimed for..

Low molecular weight heparinLow molecular weight heparin

--This has been shown to be more effective than This has been shown to be more effective than unfractionated heparin with lower mortality and unfractionated heparin with lower mortality and fewer hemorrhagic complications in the initialfewer hemorrhagic complications in the initial

treatment of DVT in non-pregnant subjectstreatment of DVT in non-pregnant subjects . .

--LMWHs are as effective as unfractionated LMWHs are as effective as unfractionated heparin for treatment of PEheparin for treatment of PE . .

-The exact dose will depend on the patient's early -The exact dose will depend on the patient's early pregnancy weight and tends to be administered pregnancy weight and tends to be administered twice daily.twice daily.

-Enoxaparin 1mg/kg twice daily-Enoxaparin 1mg/kg twice daily

-Dalteparin 100 units/kg twice daily.-Dalteparin 100 units/kg twice daily.

Maintenance therapyMaintenance therapy

During pregnancyDuring pregnancy --Heparins are the maintenance treatment of choiceHeparins are the maintenance treatment of choice. .. .

--Subcutaneous LMWH appears to have advantages over Subcutaneous LMWH appears to have advantages over unfractionated heparin in the maintenance treatment unfractionated heparin in the maintenance treatment of VTE in pregnancyof VTE in pregnancy . .

--The simplified therapeutic regimen for LMWH tends to be The simplified therapeutic regimen for LMWH tends to be more convenient for patients, minimizing blood tests more convenient for patients, minimizing blood tests (although platelet counts and levels of anti-Xa will (although platelet counts and levels of anti-Xa will need to be monitored on a monthly basis) and need to be monitored on a monthly basis) and allowing out-patient treatmentallowing out-patient treatment..

-Women should be taught to self-inject and can then be -Women should be taught to self-inject and can then be managed as out-patients until delivery.managed as out-patients until delivery.

-Unfractionated heparin (10,000 units twice daily)-Unfractionated heparin (10,000 units twice daily)

-LMWH: Enoxaparin 40 mg daily, -Dalteparin 5000 IU daily.-LMWH: Enoxaparin 40 mg daily, -Dalteparin 5000 IU daily.

LabourLabour

--When the patient thinks she is going into labour, she When the patient thinks she is going into labour, she should stop injecting and get in touch with the should stop injecting and get in touch with the delivery ward who will manage the anticoagulation delivery ward who will manage the anticoagulation throughout labour and immediately post deliverythroughout labour and immediately post delivery . .

--As these patients are at high risk of hemorrhage, they As these patients are at high risk of hemorrhage, they will be managed with intravenous unfractionated will be managed with intravenous unfractionated heparin throughout this timeheparin throughout this time..

--If the last dose was taken at least 12 hours previously, If the last dose was taken at least 12 hours previously, regional block is not contraindicatedregional block is not contraindicated..

--The risk of hemorrhage is low with prophylactic doseThe risk of hemorrhage is low with prophylactic dose..

--When full therapeutic doses are used, the dose should When full therapeutic doses are used, the dose should be reduced to a prophylactic level for the duration of be reduced to a prophylactic level for the duration of labourlabour..

--In such a case regional block is contraindicatedIn such a case regional block is contraindicated..

In emergency cases protamine sulphate can be usedIn emergency cases protamine sulphate can be used..

Postpartum periodPostpartum period::

--Depending on the patient's individual Depending on the patient's individual circumstances, she may be managed with circumstances, she may be managed with ongoing heparin treatment or Warfarin ongoing heparin treatment or Warfarin postpartumpostpartum . .

--If she opts for Warfarin, this can be initiated If she opts for Warfarin, this can be initiated day 2 or 3 post partum with an INR check at day 2 or 3 post partum with an INR check at day 2day 2 . .

--Continue heparin treatment until there have Continue heparin treatment until there have been two successive readings of an INR > 2been two successive readings of an INR > 2 . .

--It is not thought to pass into breast milkIt is not thought to pass into breast milk..

Stopping treatmentStopping treatment

--Therapy is continued for six months in the Therapy is continued for six months in the first instance, as would be the case for non-first instance, as would be the case for non-pregnant patientspregnant patients . .

--However, owing to the physiological However, owing to the physiological fluctuation of coagulation factors, current fluctuation of coagulation factors, current advice is to continue therapy for at least 6-advice is to continue therapy for at least 6-12 weeks post partum whichever the longer12 weeks post partum whichever the longer . .

--At that point, the patient should be assessed At that point, the patient should be assessed for the presence of ongoing risk factors for for the presence of ongoing risk factors for a VTE prior to making the decision to stop a VTE prior to making the decision to stop anticoagulation therapyanticoagulation therapy..

ComplicationsComplications

--Up to 60% of patients who have suffered from a DVT Up to 60% of patients who have suffered from a DVT go on to have post thrombotic syndrome up to 12 go on to have post thrombotic syndrome up to 12 months following the acute eventmonths following the acute event . .

--This arises from damage to the lumen of the vein This arises from damage to the lumen of the vein following the presence of a thrombusfollowing the presence of a thrombus . .

--Subsequently, patients manifest symptoms and signs Subsequently, patients manifest symptoms and signs akin to those of varicose veins: aching, swollen legs, akin to those of varicose veins: aching, swollen legs, pruritis, dermatitis and hyper pigmentation of the pruritis, dermatitis and hyper pigmentation of the affected areaaffected area . .

--Ulceration and cellulites may complicate the pictureUlceration and cellulites may complicate the picture . .

--There is emerging evidence to suggest that There is emerging evidence to suggest that compression stockings worn on the affected leg compression stockings worn on the affected leg reduces the risk of developing post thrombotic reduces the risk of developing post thrombotic syndromesyndrome . .

--PE is the other complication of DVTsPE is the other complication of DVTs..

Pulmonary embolism-PEPulmonary embolism-PE--

--This can occur with or without preceding DVTThis can occur with or without preceding DVT..

--Symptoms range from minimal disturbance to Symptoms range from minimal disturbance to sudden collapse and death, depending on sudden collapse and death, depending on the size, number and site of embolithe size, number and site of emboli..

Clinical featuresClinical features::

--It is crucial to recognize PE, as missing the It is crucial to recognize PE, as missing the diagnosis could have fatal implicationdiagnosis could have fatal implication..

The most common presentation isThe most common presentation is : :

--mild dyspneamild dyspnea , ,

--inspiratory chest paininspiratory chest pain , ,

--tachycardiatachycardia , ,

--tachypneatachypnea

--mild pyrexiamild pyrexia..

--Rarely massive PE may present with sudden Rarely massive PE may present with sudden cardio-respiratory collapse and even sudden cardio-respiratory collapse and even sudden deathdeath..

InvestigationInvestigation::

11--Arterial blood gas analysis-Arterial blood gas analysis- hypoxia and hypoxia and hypercapniahypercapnia..

22--ECG:ECG:inverted T-wave and Q wave in lead III inverted T-wave and Q wave in lead III and atrial arrhythmiasand atrial arrhythmias..

--In pregnancy T-inversion and Q-wave in lead III In pregnancy T-inversion and Q-wave in lead III are normal findingsare normal findings

33--Chest x-ray:Chest x-ray: an abnormal CXR is found in 60- an abnormal CXR is found in 60-80% of patients with PE80% of patients with PE..

..

44--Ventilation-perfusion scanVentilation-perfusion scan: in cases of : in cases of suspected PE, both V/Q scan and bilateral suspected PE, both V/Q scan and bilateral Doppler ultrasound of leg veins should be Doppler ultrasound of leg veins should be performedperformed..

--Interpretation of a V/Q is given as probability Interpretation of a V/Q is given as probability ratingrating. .

--Anticoagulation should be continued when the Anticoagulation should be continued when the V/Q scan reports a medium or high V/Q scan reports a medium or high probability of a PEprobability of a PE. .

--If the scan reports a low probability and If the scan reports a low probability and Doppler studies of the legs are positive Doppler studies of the legs are positive anticoagulation should be continuedanticoagulation should be continued . .

--If the Doppler is negative yet there is a high If the Doppler is negative yet there is a high degree of clinical suspicion treatment degree of clinical suspicion treatment continued with repeat testing after one weekcontinued with repeat testing after one week..

55..Spiral CTSpiral CT : it can visualize the blood : it can visualize the blood clot, also diagnose pother diseases clot, also diagnose pother diseases that mimic PEthat mimic PE..

The radiation dose to the fetus is The radiation dose to the fetus is minimalminimal..

66..Pulmonary angiogramPulmonary angiogram::

The gold standard for the diagnosis of The gold standard for the diagnosis of PEPE..

This is invasive, with mortality rate of This is invasive, with mortality rate of 0.5% and associated morbidity of 2-4%0.5% and associated morbidity of 2-4%..

TreatmentTreatment::--Intravenous unfractionated heparin is the treatment of Intravenous unfractionated heparin is the treatment of

choice in the acute situationchoice in the acute situation..

--For smaller, minimally symptomatic clots, LMWH may For smaller, minimally symptomatic clots, LMWH may be usedbe used..Warfarin is suitable for postpartum periodWarfarin is suitable for postpartum period..

--Inferior vena cava filters are reversed for those with Inferior vena cava filters are reversed for those with recurrent PE or those cannot receive anticoagulantrecurrent PE or those cannot receive anticoagulant..

--There is limited information on the use of thrombolysis There is limited information on the use of thrombolysis for PE in pregnancy. Streptokinase dose not cross for PE in pregnancy. Streptokinase dose not cross the placentathe placenta..

The major risks is sever hemorrhage and can be used in The major risks is sever hemorrhage and can be used in patient who is clinically unstablepatient who is clinically unstable..

--Surgical embolectomySurgical embolectomy . .

Prevention: prophylaxisPrevention: prophylaxis

--There are obvious risks associated with ante-There are obvious risks associated with ante-natal anticoagulation and the decision to go natal anticoagulation and the decision to go ahead with prophylactic thrombolysis is one ahead with prophylactic thrombolysis is one made jointly by the obstetricians and made jointly by the obstetricians and hematologistshematologists . .

--Guidance suggested by the Royal College of Guidance suggested by the Royal College of Obstetricians and Gynecologists suggestsObstetricians and Gynecologists suggests::

--Regardless of their VTE risk, dehydration and Regardless of their VTE risk, dehydration and immobilization of the patient ante-natally, during immobilization of the patient ante-natally, during labour and post-partum should be avoidedlabour and post-partum should be avoided

--If a decision is made to go ahead with prophylaxis, this If a decision is made to go ahead with prophylaxis, this should be initiated as early in the pregnancy as should be initiated as early in the pregnancy as possible (post-partum prophylaxis should commence possible (post-partum prophylaxis should commence as soon after the delivery as is practically possible)as soon after the delivery as is practically possible)

--Women with a history of a VTE but no thrombophilia Women with a history of a VTE but no thrombophilia should be offered LMWH for 6 weeks post partum should be offered LMWH for 6 weeks post partum (there is some debate about the ante-natal period (there is some debate about the ante-natal period owing to conflicting evidence) unless the VTE was owing to conflicting evidence) unless the VTE was clearly associated with a risk factorclearly associated with a risk factor . .

--If she has had multiple VTEs or if there is a strong If she has had multiple VTEs or if there is a strong family history of VTEs in a first degree relative, ante-family history of VTEs in a first degree relative, ante-

natal prophylaxis should also be offerednatal prophylaxis should also be offered . .

--Women with a history of VTE and known Women with a history of VTE and known thrombophilia should be offered LMWH thrombophilia should be offered LMWH prophylaxis ante-natally and for at least 6 prophylaxis ante-natally and for at least 6 weeks post partumweeks post partum . .

--Women with inherited thrombophilia but no Women with inherited thrombophilia but no previous VTE may or may not qualify for previous VTE may or may not qualify for ante / post natal prophylaxis depending on ante / post natal prophylaxis depending on the nature of the thrombophilia and the nature of the thrombophilia and whether there are associated risk factorswhether there are associated risk factors . .

--Patients with acquired thrombophilia Patients with acquired thrombophilia (Antiphospholipid syndrome) generally (Antiphospholipid syndrome) generally should receive prophylaxis throughout and should receive prophylaxis throughout and after pregnancy in most of casesafter pregnancy in most of cases..

--Women without previous VTE or Women without previous VTE or thrombophilia: if there are three or more thrombophilia: if there are three or more persisting risk factors, antenatal persisting risk factors, antenatal thromboprophylaxis should be considered thromboprophylaxis should be considered through to 3-5 days post-partumthrough to 3-5 days post-partum..

--Notably, if the patient is over 35, has a BMI Notably, if the patient is over 35, has a BMI of over 30 or a body weight of over 90kg, of over 30 or a body weight of over 90kg, prophylaxis is almost mandatory, especially prophylaxis is almost mandatory, especially in the immediate post partum periodin the immediate post partum period . .

deliverydelivery..

Prophylactic treatmentProphylactic treatment

ANTEPARTUM THROM-BOEMBOLIC ANTEPARTUM THROM-BOEMBOLIC PROPHYLAXISPROPHYLAXIS

-Unfractionated heparin 10,000 IU/ per 12 -Unfractionated heparin 10,000 IU/ per 12 hourshours

OROR-40 mg/day enoxaparin-40 mg/day enoxaparinOROR-Dalteparin 5000 IU/day S.C-Dalteparin 5000 IU/day S.C..

Antenatal and postnatal Antenatal and postnatal thromboprophylaxis risk assessment thromboprophylaxis risk assessment and managementand management

Single previous VTE + high riskSingle previous VTE + high risk

Thrombophilia or + ve family (antenatal prophylaxisThrombophilia or + ve family (antenatal prophylaxis

Unprovoked/ oestrogen-related and postpartum for sixUnprovoked/ oestrogen-related and postpartum for six

previous recurrent VTE (˃1) weeks with LMWHprevious recurrent VTE (˃1) weeks with LMWH))

Single previous VTE with no family intermediate riskSingle previous VTE with no family intermediate risk

history or thrombophilia (antenatal prophylaxis history or thrombophilia (antenatal prophylaxis Thrombophilia + no VTE and postpartum for Thrombophilia + no VTE and postpartum for Medical diseases e.g. heart or lung disease seven days postpartumMedical diseases e.g. heart or lung disease seven days postpartum

SLE, cancer, inflammatory conditions, with LMWHSLE, cancer, inflammatory conditions, with LMWH

Nephrotic syndrome, sickle cell diseaseNephrotic syndrome, sickle cell disease

Surgical procedureSurgical procedure

--Age ˃ 35 year if 3 or more Age ˃ 35 year if 3 or more considerconsider

--Obesity antenatal and orObesity antenatal and or

--parity≥ 3 postpartum parity≥ 3 postpartum prophylaxisprophylaxis

--Smoker with LMWHSmoker with LMWH

--Elective Caesarean sectionElective Caesarean section

--Gross varicose veinsGross varicose veins

--ImmobilityImmobility

--Pre-eclampsia less than 3 this is Pre-eclampsia less than 3 this is low risklow risk

--Prolonged labour consider Prolonged labour consider mobilization andmobilization and

--Instrumental delivery avoidance of Instrumental delivery avoidance of dehydrationdehydration

--Current systemic infectionCurrent systemic infection..

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