Thromboprophylaxis During Pregnancy, Labour And

THROMBOPROPHYLAXIS DURING PREGNANCY, LABOUR ANDAFTER VAGINAL DELIVERY
Dr.V.Ravimohan

Sources
1.Royal College Of Obstetrician & Gynaecologist guidelines
2.Medical disorders in Obstetrics & Gynaecology Edited by Michael de Swiet

Pre conceptual antenatal risk assessment
Pre pregnancy counselling -women at high risk of VTE, including those with previous confirmed VTE, should be offered with a prospective management plan.
Pre pregnancy & early pregnancy -an individual assessment of thrombotic risk should be undertaken.
Assessment should be repeated if the woman is admitted to hospital or develops other intercurrent problems.

Risk factors
2 types-Pre-existing/ New onset or transient

Pre-existing
Previous DVT
Thrombophilia
Congenital
antithrombin deficiency
protein C deficiency
protein S deficiency
Factor V Leiden
prothrombin gene variant
Acquired
Antiphospolipid

Pre-existing
Age over 35 years
Obesity (BMI > 30 kg/m2) either pre-pregnancy or in early pregnancy
Parity > 4
Gross varicose veins
Paraplegia
Sickle cell disease
Inflammatory disorders e.g. inflammatory bowel disease
Some medical disorders, e.g. nephrotic syndrome, certain cardiac diseases
Myeloproliferative disorders, e.g. essential thrombocythaemia, polycythaemiavera

New onset or transient
Surgical procedure in pregnancy or puerperium, e.g. evacuation of retained products of conception, postpartum sterilisation
Midcavity instrumental delivery
Immobility after delivery
Pre-eclampsia
Hyperemesis
Dehydration
Excessive blood loss
Ovarian hyperstimulation syndrome
Severe infection, e.g. Pyelonephritis
Immobility (> 4 days bed rest)
Long-haul travel
Prolonged labour

Investigation of women with previous VTE
Recognition:
good history and received prolonged (6–12 weeks) therapeutic anticoagulation.
Investigation:
for congenital/acquired
ideally pre pregnancy

5 groups of women
a previous VTE and no thrombophilia
a previous VTE who have inherited thrombophilia
inherited thrombophilia without previous VTE
acquired thrombophilia (antiphospholipid syndrome)
Women without previous VTE or thrombophilia

a previous VTE and no thrombophilia
antenatal thromboprophylaxis-controversial
Indicated if
more than one previous episode of VTE
a family history of VTE in a first degree relative
Consider if
Unprovoked DVT
Oestrogen related
Associated risks ex: high BMI
an unusual site (such as the axillary vein)
reasonable not to use antenatal thromboprophylaxis
If DVT was associated with temporary risk factor
Post natal-low molecular weight heparin (LMWH) for six weeks after

Women with a previous VTE who have inherited thrombophilia
Thromboprophylaxis with LMWH antenatally and for at least six weeks postpartum.
higher doses of LMWH may be needed
women with symptomatic thrombophilia
specific thrombophilias,particularly AT deficiency
Seek expert haematological advice

Antenatal prophylactic and therapeutic doses of low-molecular-weight heparin

Women with inherited thrombophilia without previous VTE
Antenatal prophylaxis is not always necessary.
Consider if
Antithrombin deficiency
combined defects
homozygosity for defects
Other risk factors
Postnatal-LMWH or warfarin for six weeks

Women with acquired thrombophilia (antiphospholipid syndrome)
Antiphospholipid syndrome (APS)
Definition:
presence of lupus anticoagulant or anticardiolipin antibodies of medium–high titre
on two occasions eight weeks apart
found in association with a history of
thrombosis (arterial or venous) or
adverse pregnancy outcome
three or more unexplained miscarriages before ten weeks of gestation
a fetal death after ten weeks of gestation
a premature {less than 35 weeks} birth due to
severe pre-eclampsia or
intrauterine growth restriction)

women with three or more
current or persisting risk factors should be considered for
prophylactic LMWH antenatally
at least three to five days postpartum.
two current or persisting risk factors
should be considered for prophylactic LMWH for three to five days after vaginal delivery.
Clinical judgement is required with regard to the weighting of the above risk factors.
an extremely obese woman admitted to the antenatal ward may be sufficient to justify antenatal thromboprophylaxis

important independent risk factors for postpartum VTE even after vaginal delivery
Age over 35 years and
BMI greater than 30/body weight greater than 90 kg
The combination of either of these risk factors with any other risk factor for VTE (such as pre-eclampsia or immobility) or the presence of two other persisting risk factors should lead the clinician to consider the use of LMWH for three to five days postpartum.

Thrombophilia
Activated protein C inhibits Factors V & VIII
Levels of functional and immunological protein C doesn’t change in pregnancy
Protein S is a cofactor for protein C
Free protein S drop by 20% at the end of third trimester
Thrombosis in Antithrombin deficiency should be treated with heparin & Antithrombin concentrate.

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Thromboprophylaxis During Pregnancy, Labour And

by Ravimohan Ravimohan on Nov 16, 2009

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