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Thromboprophylaxis in OBS & GYN
By Dr Pushpalatha
SRMC
Rationale for Thromboprophylaxis
High prevalence of venous thromboembolism (VTE) in hospitalised patients
Clinically silent nature of disease
Unprevented thrombi result in- morbidity- costs- potential mortality (fatal PE)
PE: Facts & Figures
Annually: 20-30 cases / 100 000 population
30% mortality if untreated
40-80% fatal PE occur in Medical Patients
Commonest cause of in-patient mortality
Leading cause of maternal death
Thrombophilia
Thrombophilia is a term used to describe a lab abnormality that increases the tendency to Venous Thromboembolism.
It can be congenital or acquired
Causes of inherited thrombophilia
Definitely inherited Multifactorial
Antithrombin deficiency Elevated factor VIII Protein C DeficiencyProtein S Deficiency hyperhomocysteinnemia
Factor V LeidenProthrombin 20210A mutation
Congenital Thrombophilia
Acquired
• Antiphospholipid antibody syndrome
• Hyperhomocystinemia
• Pregnancy
• Cancer
• Oral Contraceptives
• Hormone replacement therapy
• Heparin-induced thrombocytopenia
• Behcet’s disease
• Active inflammatory bowel disease
Recommendations for Screening
Venous Thromboembolism History of Thrombosis in first degree relative Adverse pregnancy outcome
Who should be tested for Thrombophilia..?
When to test for Thrombophilia..?
Factor VMutation
Factor II
Anytime
ATIIIChanges after Thrombosis
Changes after anti-coagulation
Protein C
Protein S
Factor VIII
Altered by pregnancy
OCP, warfarin
Acute Thrombosis
Delay Testing
It has to be done after acute Thrombosis
LA ACL Antibodies
Can be done
Management
Thrombophilia Screen Positive
No prior VTE
Without Pregnancy
With Pregnancy POST PARTUM
OCP|HRT
No anticoagulation after surgery – 4 weeks Prophylaxis (AT) No antenatal anticoagulation
(0.3 to 1.2 %) except for ATRisk is high (1 – 3%)Thromboprophylaxis for 4 – 6 weeks
Avoid or with caution
Management
Thrombophilia Screen Positive
prior VTE
Without Pregnancy
With Pregnancy POST PARTUM
OCP|HRT
Prolonged post-op prophylaxis
Give Antenatal Thromboprophylaxis
Thromboprophylaxis
Contraindicate
Criteria for APS
Vascular Thrombosis Pregnancy Morbidity
– One or more unexplained loss of a morphologically normal fetus at or > 10wks gestation
– One or more premature births of a morphologically normal neonate at or <34 wks due to severe PE or IUGR
– Three or more unexplained consecutive spontaneous abortions < 10wks gestation
APS cont
Lab Criteria
ACL Antibodies
IgG
IgM
Anti Beta 2 glycoprotein Antibodies
IgG
IgM
LA Antibodies
Prolonged aPTT
Dilute Russels Viper venom time
KCT
Faliure to correct after mixing with normal plasma
Management of APAS
Without thrombosis or APO
Without SLE
With SLE
Without thrombosis with APO
With prior thrombosis
Avoid additional riskFactors like OCP|HRT
Avoid additional riskFactors like OCP|HRT+Thromboprophylaxis for surgery/Pregnancy
Antenatal Thromboprophylaxis Postpartunm Thromboprophylaxis 6 – 8 wks
Full anticoagulation during pregnancy Life long warfarin
Case Scenarios
I. 26 yr old PRIMIGRAVIDA AT 33wks pregnancy c/o
• LEG PAIN 4 Days• SWELLING 1. What are the clinical signs . How reliable are
they ? 2. What are investigations for objective
evidence ?3. Is D –dimer useful ?
4. Will you ask for Thrombophilia screen | APLA..?5. Treatment options 6. Labour & Delivery
GUIDELINES
1. SIGNS SYMP of DVT START LMWH OBJECTIVE TEST COMPRESSION DUPLEX USG. If still there is suspicion continue on LMWH RPT scan after 1 week ILIAC VEIN THROMBOSIS – MRI or CONTRAST
VENOGRAPHY for diagnosis.
2. D-DIMER NOT USEFUL Routinely evlevated in 3rd Trimerster
POSTPARTUM PIH
Low Level – No DVT3. INITIAL Rx
LMWH is accepted as safe alternative to UFH– Reduced risk of bleeding– Heparin induced thrombocytosis is less than UFH– Osteroporosis is less
4. Therapeutic DoseLMWH recent weight of patientENOXAPARIN 1mg/Kg twice daily (subcutenaously)DALTEPARIN 100 units / Kg (subcutenaously)No Oral anti-coagulants
5. Monitoring– Only in extremes of body weight < 50 Kg or >
90kg– Renal Impairment– Recurrenct Thrombosis– Anti Xa level 3hrs post injection 0.5 – 1.2 units /
ml CONT same dosage throughout pregnancy.
6. Additional Therapy– Leg Elevation– Graduated Elastic Compression Stocking– Mobilisation with stocking
7. Labour And Delivery– Est Labour or Thinks is in labour to stop INJ– Stop LMWH 24hrs prior to delivery– REG ANAEST | ANALGESIA 24 hrs after last dose – Thromboprophylactic dose can be given 3 hrs
after LSCS 4 hrs after removal of epidural catheter
– Epidural catheter not to be removed within 12 hrs after last dose.
– Subcut – UFH should be stopped 12 hrs prior delivery
– IV - UFH 6 hrs prior to induction of labour.
8. Special Surgical Measures– Therapeutic LMWH– Wounddrain Intra-Abdominal & Rectus Sheath– Skin Interrupted Sutures
II. 25 yr P2+0 underwent LSCS with ST 5 days back admitted
Episode of convlusion (generalized) B.P Normal H/O DVT in prev pregnancy Rx Thrombophilia screen negative No antenatal DVT prophylaxis
1. What are the issues in the patient ..? 2. Is it advisable to withhold antenatal DUT
porphylaxis ..? 3. Would you recommend post natal prophylaxis..?
GUIDELINES
1. Antenatal Prophylaxis– If DVT was not related to estrogen (surgery or Trauma)
close observation during pregnancy.– If prev DVT is during pregnancy or ESTROGEN related
THROMBOPROPHYLAXSIS to be given in ANTENATAL PD2. POSTNATAL prophylaxis
– Prev – VTE FULL THERAPEUTIC ANTI COAGfor 6 wks | 3 mths for prox DVT LPE
– LMWH | WARFARIN dosage same as ANTENATAL PD – LMWH dosage same as in antinatal period– No CONTRAIND to breast feeding – WARFARIN only after 3rd day of delivery– Check INR 48hrs after starting WARFARIN maintain INR
2-3 & CONT LMWH till INR is more than 2 for two successive days.
III. 33 yr G3 P 1 + 1 24 wks early onset PIH in last pregnancy LSCS at 34 wks
Missed abortion at 12 wks Lupus anticoagulant LA +ve PIH in this pregnancy on antihypertensives.
1. What are your recommendations ..? 2. Undergoes Rpt LSCS at 37 wks for severe PIH.3. Develops BREATHLESSNESS on 2nd Post Op day.
GUIDELINES
1. LUPUS ANTI-COAGULANT POSITIVE– With APO she is a candidate for Antenatal
thromboprophylaxsis with LMWH– Stop LMWH 24hrs prior to LSCS start 3hr post
op
2. Start LMWH– Clinical suspicion of acute PTE– Chest X-Ray (ATELECTASIS LOBAR COLLAPSE)
NORMAL in > 50% of women PTE– Compression Duplex Scan– Both are normal
3. IF SUSPICION IS HIGH– Ventilation Perfusion Scan– Computed Tomography Pulmonary ANGIOGRAPHY
4. CONT ANTI-COAGULANTS TILL PTE IS EXCLUDED5. THROMBOPHILIA SCREEN PRIOR TO THERAPY IS
CONTROVERSIAL NOT RECOMMENDED6. MASSIVE LIFE THREATHENING PE
– INTRAVENOUS UFH is drug of choice.– Loading Dose 80 units / Kg followed by cont
INFUSION 18 units / Kg / hour– Check APTT 4 – 6 hrs after loading dose , 6hrs
after any dose change. Keep APTT 1.5 - 2.5 times control value.
GYNECOLOGY
I. Young married software professional wants to postpone pregnancy – 1st degree relative has VTE.
GUIDELINES
– Relative risk of VTE with OCPHowever the absolute risk is small
5 | 100,000 - 15 | 100,00025 | 100,000 ( with 3rd GEN
PROGESTERONE)– Combined OCP’s LNG | NORETHISTERONE
Lower risk of VTE than Desogestrol or Gestodene
Risk first four months after starting OCP with duration of use , But still high compared to non users
VTE risk returned to normal within 3 mths of discontinuation
Progestogen only PILL / INJ / LNG
Do Not risk of VTE
CERAZETTE does not risk.
No in risk with emergency contraception
Routine THROMBOPHILIA screen before OCP is not recommended, Do it if 1 st degree relative < 45 yrs had VTE
II. 46 yr undergoes TAH with BSO1. Do we require routine thromboprophylaxis..?2. What are the risk factors which will prompt you
for routine peri-operative thromboprophylaxis..?
GUIDELINES
In gynaecological procedures less than thirty minutes and for benign disease, the authors recommend against the use of routine thromboprophylaxis.
In laparoscopic gynecologic procedures, in whom additional risk factors are present, we recommend the use of thromboprophylaxis with any of the following; LMWH, LDUH, IPC
III. 40 Year patient with weight 35Kg with stage 3 ovarian carcinoma undergoes laparotomy with ovarian debulking with sampling of paraaortic nodes
Justify why she needs thromboprophylaxis and for how long ..?
GUIDELINES
Thromboprophylaxis should be given for all major gynaecological surgery.
For major surgery in benign disease,LMWH less than 3400IU or LDUH 5000IU bid , or IPC till patient is ambulant, are the recommendations.
In extensive surgery or for surgery for malignancy, routine prophylaxis with once daily high dose LMWH or LDUH 5000IU tid are recommended.
IV. Underwent TAH with BSO 3 mths back wants HRT thrombophilia screen +ve
1. Does the risk of VTE with age ..?
2. Is there a risk of VTE with oral HRT ..?
3. Universal screen for thrombophilia or a good personal & family history..?
4. Would you prescribe HRT for a woman with H/O prev DVT if she is thrombophilia negative…?
5. Should we stop HRT before surgery…?
GUIDELINES
Incidence of VTE in post menopausal women is double that of pre menopausal women
Incidence of VTE was 10.7% in HRT group 2.3 % placebo group.
Presence of VTE in 1 st or 2 nd degree relative or personal history of VTE should be obtained , No universal screen for thrombophilia.
No HRT for prior DVT even if thrombophilia –ve Best to avoid HRT especially in AT deficiency.
SERM carry same risk of thrombosis as conventional HRT .
Need not routinely stop HRT before any surgery provided LMWH prophylactic with or without stocking is used.
Current Guidelines for Prosthetic Heart Valve with Pregnancy
European & American college of cardiology / American Heart Association.
WARFARIN upto 35 wks FIRST TRIMESTER – No Warfarin
– High Risk Prev VTEOld generation Medivalve
– UFH IV APTT 2-3 times control– Low risk adjusted dose S/C UFH APTT 2-3 times
control UFH to replace WARFARIN after 36 wks After delivery resume heparin 4-6 hrs later along with
WARFARIN
THANK YOU
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