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