UNIVERSAL C/SUNIVERSAL C/STHROMBOPROPHYLAXISTHROMBOPROPHYLAXIS

DECEMBER2011DECEMBER2011

RIVERSIDERIVERSIDE

Recommendations for Recommendations for thromboprophylaxis following thromboprophylaxis following C-SECTIONC-SECTION

• The need for thromboprophylaxis for preventing venous thromboembolism The need for thromboprophylaxis for preventing venous thromboembolism

in asymptomatic, pregnant women with identifiable risk factors in both the in asymptomatic, pregnant women with identifiable risk factors in both the

antepartum and postpartum period has antepartum and postpartum period has not been defined in clinical trialsnot been defined in clinical trials. .

• Currently, thromboprophylaxis is prescribed based on Currently, thromboprophylaxis is prescribed based on EXPERT EXPERT

OPINIONOPINION guideline recommendations guideline recommendations and assessment of risks and benefits and assessment of risks and benefits

of anticoagulant therapy. of anticoagulant therapy. The decision to use thromboprophylaxis The decision to use thromboprophylaxis

should be made on the basis of each patient’s risk assessment,should be made on the basis of each patient’s risk assessment,

with continuation of low-molecular- weight heparin and the use of with continuation of low-molecular- weight heparin and the use of

compression stockings for up to 6 weeks in selected high-risk patients in compression stockings for up to 6 weeks in selected high-risk patients in

whom important risk factors persist after deliverywhom important risk factors persist after delivery

• Broad practical guidelines (ACCP/ NICE / RCOG /ACOG ) Broad practical guidelines (ACCP/ NICE / RCOG /ACOG ) for for LMWHLMWH

THROMBOPROPHYLAXISTHROMBOPROPHYLAXIS AFTER CESAREAN SECTION ARE IN AFTER CESAREAN SECTION ARE IN

AGREEMENT WITH AGREEMENT WITH GENERAL CONSENSUS GENERAL CONSENSUS for clinical practice. for clinical practice.

However, it is recognized that, in individual women, alternative However, it is recognized that, in individual women, alternative

approaches may be reasonable, particularly following discussion approaches may be reasonable, particularly following discussion

with the woman concernedwith the woman concerned

ACOG / RCOG / ACCP / NICEACOG / RCOG / ACCP / NICERecommendationsRecommendations;; Thromboprophylaxis Following Cesarean SectionThromboprophylaxis Following Cesarean Section

1) For women considered at HIGH risk of VTE after cesarean section because of the 1) For women considered at HIGH risk of VTE after cesarean section because of the

presence presence

At least one HIGH RISK FACTOR in addition to a C-sectionAt least one HIGH RISK FACTOR in addition to a C-section ( SCORE OF 3 OR MORE) ( SCORE OF 3 OR MORE) FOR @ FOR @

LEAST 7 DAYSLEAST 7 DAYS

BMIBMI > > 40 40

LOW RISK THROMBOPHILIA LOW RISK THROMBOPHILIA

MEDICAL CO-MORBIDITIESMEDICAL CO-MORBIDITIES

> > 3 DAYS IMMOBILAZATION PRIOR TO SURGERY3 DAYS IMMOBILAZATION PRIOR TO SURGERY

SURGERY DURING PREGNANCY OR POSTPARTUMSURGERY DURING PREGNANCY OR POSTPARTUM

EMERGENCY C-SECTION OR HYSTERECTOMYEMERGENCY C-SECTION OR HYSTERECTOMY

2) Pharmacologic Thromboprophylaxis (PROPHYLACTIC LMWH AND MECHANICAL 2) Pharmacologic Thromboprophylaxis (PROPHYLACTIC LMWH AND MECHANICAL

PROPHYLAXIS ) PROPHYLAXIS ) FOR @ LEAST 7 DAYS FOR @ LEAST 7 DAYS

• For women with For women with TWO OR MORE additional risk factors TWO OR MORE additional risk factors for thromboembolism who are for thromboembolism who are

undergoing cesarean section are considered to be at very high risk of VTE, we suggest undergoing cesarean section are considered to be at very high risk of VTE, we suggest

that pharmacologic prophylaxis be combined WITH intermittent pneumatic compressionthat pharmacologic prophylaxis be combined WITH intermittent pneumatic compression

(Grade 2C).(Grade 2C).

•For selected high-risk patients in whom important For selected high-risk patients in whom important risk factors persist following risk factors persist following

delivery, ( HIGH RISK THROMBOPHILIA OR REQUIREMENT FOR ANTENATAL delivery, ( HIGH RISK THROMBOPHILIA OR REQUIREMENT FOR ANTENATAL

THOMBOPROPHYLAXIS) we suggest extended prophylaxis (up to 4 to 6 weeks after THOMBOPROPHYLAXIS) we suggest extended prophylaxis (up to 4 to 6 weeks after

deliverydelivery) following discharge from hospital) following discharge from hospital (Grade 2C) (Grade 2C)

7 DAY

SCD

MULTIPLE GESTATIONMULTIPLE GESTATION

Emergency cs HysterectomyEmergency cs Hysterectomy

MULTIPLE GESTATIONMULTIPLE GESTATION

Anticoagultion LMWH

yy

y

y

lmwh

RISK

FACTORS

Y

SCORE OF 3 OR HIGHER CONSIDER @ LEAST 7 DAYS OF LMWH LOVENOX +SCD

11

Weight < 50 kg = 20 mg Lovenox/ Q 24Weight 50–90 kg = 40 mg Lovenox/ Q 24Weight 91–130 kg = 60 mg Lovenox/ Q 24Weight 131–170 kg = 80 mg Lovenox/ Q 24Weight > 170 kg = 0.6 mg/kg/day

heparin prophylactic dose 5000 -8,000 no sooner than 1 hour prior to spinal or epidural / SCD PRIOR TO SPINALlovenox administration 8-12 hours after c/s and no sooner than 2 hours after removal of epidural catheter

POSTPARTUM TREATMENT SHOULD BE >/=TO ANTEPARTUM TREATMENT

IF PATIENT GAINS IF PATIENT GAINS 20% OR MORE FROM 1 20% OR MORE FROM 1 STST TRIMESTER TRIMESTER WEIGHT WEIGHT CHECK LEVELS 4 HRS AFTER 3 RD DOSECHECK LEVELS 4 HRS AFTER 3 RD DOSE

1.1. Tailor treatment to individual WEIGHT IF NECESSARYTailor treatment to individual WEIGHT IF NECESSARY

2.2. ProphylaxisProphylaxis LMWH LMWH 40mg SQ/24 hrs40mg SQ/24 hrs Lovenox AntiXa Lovenox AntiXa

0.2-0.4 0.2-0.4

3.3. IntermediateIntermediate LMWHLMWH 40mg SQ/12 hrs40mg SQ/12 hrsLovenox Lovenox AntiXa 0.4-0.6AntiXa 0.4-0.6

4.4. Adjusted doseAdjusted dose LMWHLMWH 1mg/Kg/12hrs1mg/Kg/12hrsLovenox AntiXa 0.5-1.0Lovenox AntiXa 0.5-1.0

VTE Risk factors DefinedVTE Risk factors Defined• BMI >/=40 (based on 1BMI >/=40 (based on 1stst trimester weight or prepregnancy weight) trimester weight or prepregnancy weight)

• Gross varicose veins = symptomatic, above the knee or Gross varicose veins = symptomatic, above the knee or

associated with phlebitis/edema/skin changes associated with phlebitis/edema/skin changes

• MEDICAL COMORBIDITIES :heart failure or severe lung disease, MEDICAL COMORBIDITIES :heart failure or severe lung disease,

SLE, cancer, inflammatory conditions (inflammatory bowel disease SLE, cancer, inflammatory conditions (inflammatory bowel disease

or inflammatory polyarthropathy), nephrotic syndrome or inflammatory polyarthropathy), nephrotic syndrome

(proteinuria >3 g/day), sickle cell disease, intravenous drug user(proteinuria >3 g/day), sickle cell disease, intravenous drug user

• Immobility or clinically significant reduced mobility = ≥ 3 daysImmobility or clinically significant reduced mobility = ≥ 3 days

• long-distance travel = > 4 hourslong-distance travel = > 4 hours

• Systemic infection (requiring antibiotics or admission to hospital) Systemic infection (requiring antibiotics or admission to hospital)

(e.g., pneumonia, pyelonephritis, postpartum wound infection)(e.g., pneumonia, pyelonephritis, postpartum wound infection)

• surgery during pregnancy OR after delivery e.g. appendectomy surgery during pregnancy OR after delivery e.g. appendectomy

ORORPPostpartum tubal ligationostpartum tubal ligation

• OHSS = ovarian hyperstimulation syndrome,OHSS = ovarian hyperstimulation syndrome,

• PPH = postpartum hemorrhage, (>1 liter ) or requiring transfusion PPH = postpartum hemorrhage, (>1 liter ) or requiring transfusion

Recommendations for Recommendations for thromboprophylaxis following deliverythromboprophylaxis following delivery

• High risk At least 6 weeks High risk At least 6 weeks postnatal ANTICOAGULATION LMWHpostnatal ANTICOAGULATION LMWH

• Intermediate risk At least 7 days Intermediate risk At least 7 days postnatal prophylatic LMWHpostnatal prophylatic LMWH

• Note: if persisting or > 3 risk factors, consider extending Note: if persisting or > 3 risk factors, consider extending

thromboprophylaxis with LMWH FOR DURATION OF RISK FACTOR OR 6 thromboprophylaxis with LMWH FOR DURATION OF RISK FACTOR OR 6

WEEKSWEEKS

• SUGGESTED THROMBOPROPHYLAXIS DOSINGSUGGESTED THROMBOPROPHYLAXIS DOSING

• Weight < 50 kg = 20 mg enoxaparin/ Q 24Weight < 50 kg = 20 mg enoxaparin/ Q 24

• Weight 50–90 kg = 40 mg enoxaparin/ Q 24Weight 50–90 kg = 40 mg enoxaparin/ Q 24

• Weight 91–130 kg = 60 mg enoxaparin/ Q 24Weight 91–130 kg = 60 mg enoxaparin/ Q 24

• Weight 131–170 kg = 80 mg enoxaparin/ Q 24Weight 131–170 kg = 80 mg enoxaparin/ Q 24

• Weight > 170 kg = 0.6 mg/kg/day enoxaparin/Q Weight > 170 kg = 0.6 mg/kg/day enoxaparin/Q

2424

ARSA GUIDELINESARSA GUIDELINESEPIDURAL & EPIDURAL & LMWHLMWH• 1212 hours after last hours after last prophylactic lmwhprophylactic lmwh dose dose

epidural can be placedepidural can be placed

• 2424 hours after hours after last full anticoaglast full anticoag dose epidural can dose epidural can be placedbe placed

• PP start prophylaxis PP start prophylaxis 2 hrs2 hrs after removal of after removal of cathetercatheter

• PP PP full anticoagfull anticoag (Lovenox/Coumadin) (Lovenox/Coumadin) 24 hrs24 hrs after after removal of catheterremoval of catheter

Reg Anesth Pain Med 2003;28:172Reg Anesth Pain Med 2003;28:172

Reg Anesth Pain Med 2010;35:64Reg Anesth Pain Med 2010;35:64

HITHIT

• Acute systemic “allergic reaction” Acute systemic “allergic reaction” fever, fever, chills, hypertension, tachycardia, chest chills, hypertension, tachycardia, chest pain, dyspneapain, dyspnea

• Check platelet count @ initiation of Check platelet count @ initiation of therapy and weekly for 3 weekstherapy and weekly for 3 weeks

• Day 5 – 7 platelets begin decline Day 5 – 7 platelets begin decline < 150K< 150K• Day 10 – 14 decrease >50% from baseline Day 10 – 14 decrease >50% from baseline

• Suspect HIT if platelet Suspect HIT if platelet <150k or 50%<150k or 50% decrease from baseline platelet countdecrease from baseline platelet count