Thromboprophylaxis in Thromboprophylaxis in Pregnancy and the Pregnancy and the

PuerperiumPuerperium

Max Brinsmead PhD FRANZCOGMax Brinsmead PhD FRANZCOGJune 2015June 2015

BackgroundBackground Pulmonary embolism is the leading cause of Pulmonary embolism is the leading cause of

maternal deaths in developed countriesmaternal deaths in developed countries May be prevented by thromboprophylaxis May be prevented by thromboprophylaxis

measuresmeasures However, absolute risk is small (1-2 per 1000 However, absolute risk is small (1-2 per 1000

pregnancies)pregnancies) And only 1:100 patients with VTE will dieAnd only 1:100 patients with VTE will die Some risks associated with therapySome risks associated with therapy So screening for treatment is requiredSo screening for treatment is required And recommendations for some populations And recommendations for some populations

may not be universally applicablemay not be universally applicable

Who requires Who requires thromboprophylaxis?thromboprophylaxis?

Any patients with any previous VTE Any patients with any previous VTE Except those that had a previous VTE related to Except those that had a previous VTE related to

major surgery and have no other risk factorsmajor surgery and have no other risk factors AAny patient admitted to hospital with ny patient admitted to hospital with

dehydration dehydration e.g. associated with hyperemesis or OHSSe.g. associated with hyperemesis or OHSS

Any patient with 2 or more risk factors as Any patient with 2 or more risk factors as per following tablesper following tables

Who is at risk?Who is at risk? Known thrombophilia Known thrombophilia Age >35Age >35 Para >3Para >3 BMI >30BMI >30 BMI >40BMI >40 SmokesSmokes IV Drug userIV Drug user Severe varicose veins (above knee, phlebitis or skin changes)Severe varicose veins (above knee, phlebitis or skin changes) Medical condition e.g. active SLE, heart failure, cancer, Medical condition e.g. active SLE, heart failure, cancer,

nephropathynephropathy Sickle cell diseaseSickle cell disease ParaplegiaParaplegia Travel >4 hrsTravel >4 hrs Immobilisation >3dImmobilisation >3d IVF PregnancyIVF Pregnancy

Who is at risk (2)?Who is at risk (2)? Dehydration e.g. hyperemesis gravidarum or OHSSDehydration e.g. hyperemesis gravidarum or OHSS Pre eclampsiaPre eclampsia TwinsTwins Caesarean section (CS)Caesarean section (CS) Emergency CSEmergency CS Prolonged labourProlonged labour StillbirthStillbirth Midcavity assisted deliveryMidcavity assisted delivery PPH requiring transfusionPPH requiring transfusion Surgery or fracture in pregnancy or the puerperiumSurgery or fracture in pregnancy or the puerperium Any infection requiring admission to hospital or IV antibioticsAny infection requiring admission to hospital or IV antibiotics

FOR 2 OF THE ABOVE GIVE CLEXANE FOR 10 days FOR 2 OF THE ABOVE GIVE CLEXANE FOR 10 days POSTNATALPOSTNATAL

FOR 3 OF THE ABOVE CONSIDER ANTENATAL FOR 3 OF THE ABOVE CONSIDER ANTENATAL CLEXANE from 28 weeksCLEXANE from 28 weeks

FOR 4 OF THE ABOVE CONSIDER CLEXANE FOR 4 OF THE ABOVE CONSIDER CLEXANE NOWNOW

High Risk PatientsHigh Risk Patients

Any patient on long term anticoagualantsAny patient on long term anticoagualants Patients with antithrombin deficiencyPatients with antithrombin deficiency Patients with antiphospholipid syndromePatients with antiphospholipid syndrome Patients with prior arterial thrombosisPatients with prior arterial thrombosisThenThen Early consultation with haematologist is desirableEarly consultation with haematologist is desirable Usually require higher dose Clexane (75% or full-dose)Usually require higher dose Clexane (75% or full-dose) Planned delivery with anaesthetic consultation Planned delivery with anaesthetic consultation

desirabledesirable

Max Brinsmead PhD FRANZCOGMax Brinsmead PhD FRANZCOGJanuary 2010January 2010

When should treatment be When should treatment be started and stopped?started and stopped?

As soon as possible for high risk antenatal patientAs soon as possible for high risk antenatal patient Therefore risk score at 1Therefore risk score at 1stst opportunity opportunity And again with every admission, then at deliveryAnd again with every admission, then at delivery A role for pre pregnancy counsellingA role for pre pregnancy counselling Patients with personal or family history may benefit Patients with personal or family history may benefit

from testing for thrombophiliafrom testing for thrombophilia Must stop if there is PV bleeding or onset of labourMust stop if there is PV bleeding or onset of labour All patients requiring antenatal therapy require All patients requiring antenatal therapy require

postnatal therapy asap after deliverypostnatal therapy asap after delivery Not within 12 hours of spinal anaesthetic or insertion or Not within 12 hours of spinal anaesthetic or insertion or

removal of an epidural catheterremoval of an epidural catheter Continue for 10 days Continue for 10 days minimumminimum, and 6w if commenced , and 6w if commenced

in the antenatal periodin the antenatal period

What Drug and What Dose?What Drug and What Dose?

Clexane is the drug of choiceClexane is the drug of choice Has no risk of thrombocytopenia or osteoporosisHas no risk of thrombocytopenia or osteoporosis Dose by patient weightDose by patient weight Use BD for larger dosesUse BD for larger doses Prophylaxis postpartumProphylaxis postpartum

<50 Kg 20 mg once dily<50 Kg 20 mg once dily 51 – 69 Kg 30 mg once daily51 – 69 Kg 30 mg once daily 70 – 90 Kg 40 mg once daily70 – 90 Kg 40 mg once daily 91 – 130 Kg 30 mg 12 hourly91 – 130 Kg 30 mg 12 hourly 131 – 170 Kg 40 mg 12 hourly131 – 170 Kg 40 mg 12 hourly

Subtherapeutic doses do not need monitoringSubtherapeutic doses do not need monitoring Therapeutic dose is 1.0 mg/Kg per day antenatally and Therapeutic dose is 1.0 mg/Kg per day antenatally and

1.5 mg/Kg per day in the puerperium1.5 mg/Kg per day in the puerperium

Who should NOT have Clexane Who should NOT have Clexane or Heparin?or Heparin?

Those within 4 hours of spinal or epidural catheterThose within 4 hours of spinal or epidural catheter Allergy to LMWHAllergy to LMWH Patients with active bleedingPatients with active bleeding Patients at risk of bleeding e.g. Placenta previaPatients at risk of bleeding e.g. Placenta previa Thrombocytopenia (Platelet count <75)Thrombocytopenia (Platelet count <75) Known bleeding diathesis e.g. Von WillebrandsKnown bleeding diathesis e.g. Von Willebrands Severe renal disease (GFR < 30 ml/min)Severe renal disease (GFR < 30 ml/min) Severe liver diseaseSevere liver disease Uncontrolled Hypertension (>200/120)Uncontrolled Hypertension (>200/120) Haemorrhagic stroke within 4wHaemorrhagic stroke within 4wNB NB Postnatal Clexane increases the risk of PPH and Postnatal Clexane increases the risk of PPH and

wound haematomawound haematoma

Other MeasuresOther Measures

Early mobilisation and avoid dehydration for allEarly mobilisation and avoid dehydration for all Stockings not proven by RCT to be effectiveStockings not proven by RCT to be effective Thigh-length may be impractical and poorly toleratedThigh-length may be impractical and poorly tolerated Even knee-length stockings have a limited role for the Even knee-length stockings have a limited role for the

ambulant patientambulant patient Should be used in all patients with at least one risk Should be used in all patients with at least one risk

factor until mobilising normallyfactor until mobilising normally Make sure that they are fitted correctlyMake sure that they are fitted correctly Use intermittent calf compression for all pregnant Use intermittent calf compression for all pregnant

patients undergoing surgerypatients undergoing surgery

WarfarinWarfarin

Generally contraindicated in the antenatal patientGenerally contraindicated in the antenatal patient Except for some patients with mechanical heart valvesExcept for some patients with mechanical heart valves

Patients on Warfarin can be advised to switch to LMW Patients on Warfarin can be advised to switch to LMW Heparin as soon as they have a positive pregnancy Heparin as soon as they have a positive pregnancy testtest

Can be an alternative for a postnatal patient who Can be an alternative for a postnatal patient who requires long term therapyrequires long term therapy

Breast feeding is not contraindicatedBreast feeding is not contraindicated

For more detailed guidelines For more detailed guidelines and the treatment of venous and the treatment of venous

thromboembolism in prgnancy thromboembolism in prgnancy

See RCOG Greentop GuidelinesSee RCOG Greentop Guidelines

www.rcog.org.uk/en/guidelines-www.rcog.org.uk/en/guidelines-research-services/guidelines/research-services/guidelines/

gtg37a/gtg37a/

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