بسم الله الرحمن الرحيم
12th Annual  Congress  “RAS EL BAR ”  5- 2009 Thromboprophylaxis During Pregnancy, Birth and Puerperium  Dr. Mahdy El-Mazz...
problem solving
Case 1 <ul><li>A 29-year-old gravida 3, para 1 </li></ul><ul><li>At 7 weeks' gestational age </li></ul><ul><li>History of ...
Which of the following  should be done? <ul><li>A. Factor V Leiden mutation, Protein C and protein S deficiency </li></ul>...
What is the evidence? <ul><li>Women with previous VTE   </li></ul><ul><li>should receive thromboprophylaxis with LMWH ante...
<ul><li>Which women with prior VTE require a thrombophilia screen?   </li></ul>
<ul><li>Women with previous provoked and non estrogen related VTE.  </li></ul><ul><li>Grade C   </li></ul><ul><li>Women wi...
Antenatal Assessment & Management     (To be assessed at booking and repeated if admitted) <ul><li>Single previous VTE +  ...
Antenatal Assessment & Management     (To be assessed at booking and repeated if admitted) 1.Age > 35 yrs 2.Obesity (BMI>3...
Timing of initiation of thromboprophylaxis
Timing of initiation of thromboprophylaxis  <ul><li>first trimester is associated with the greatest risk of VTE, many ante...
Which agents should be used for thromboprophylaxis?
Which agents should be used for thromboprophylaxis?   <ul><li>LMWHs are the agents of choice for antenatal thromboprophyla...
<ul><li>FDA warns docs to stop using Baxter's heparin </li></ul><ul><li>Hundreds of allergic reactions to the blood thinne...
RCOG Guideline April 2009 Thromboprophylaxis During Pregnancy Tinzaparin 20,000U/ml Enoxaparin  (100 U/mg) weight 3500 U/d...
Thromboprophylaxis after delivery
Postnatal Assessment & Management   (to be assessed on Delivery Suite) <ul><li>Any previous VTE </li></ul><ul><li>Asymptom...
Postnatal Assessment & Management   (to be assessed on Delivery Suite) 1.Age > 35 yrs  2.Obesity (BMI>30kg/m2)  3.Parity 3...
Thromboprophylaxis after delivery  <ul><li>The first thromboprophylactic dose of LMWH should be given as soon as possible ...
7 D Thromboprophylaxis with CS  <ul><li>1-Eemergency CS </li></ul><ul><li>2-Elective CS + one or more additional risk </li...
When should thromboprophylaxis be interrupted for delivery?
Delivery  by elective caesarean section in women receiving antenatal LMWH <ul><li>On the day prior to delivery ,the woman ...
<ul><li>Regional techniques should not be used until:- </li></ul><ul><ul><li>12 hours after the previous prophylactic dose...
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Thromboprophylaxis

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Thromboprophylaxis

  1. 1. بسم الله الرحمن الرحيم
  2. 2. 12th Annual Congress “RAS EL BAR ” 5- 2009 Thromboprophylaxis During Pregnancy, Birth and Puerperium Dr. Mahdy El-Mazzahy Damietta General Hospital
  3. 3. problem solving
  4. 4. Case 1 <ul><li>A 29-year-old gravida 3, para 1 </li></ul><ul><li>At 7 weeks' gestational age </li></ul><ul><li>History of L.DVT while taking COC pills </li></ul><ul><li>History of 2 miscarriages at 7&9 weeks </li></ul><ul><li>Tall 162cm weight 71 kg : BMI < 27 kg/m2) </li></ul>
  5. 5. Which of the following should be done? <ul><li>A. Factor V Leiden mutation, Protein C and protein S deficiency </li></ul><ul><li>B. Antithrombin deficiency </li></ul><ul><li>C. Lupus anticoagulant /anticardiolipin </li></ul><ul><li>D. All of the above </li></ul><ul><li>E. None of the above </li></ul>E
  6. 6. What is the evidence? <ul><li>Women with previous VTE </li></ul><ul><li>should receive thromboprophylaxis with LMWH antenatally and for 6 weeks post partum if : </li></ul><ul><li>Recurrent VTE </li></ul><ul><li>Unprovoked </li></ul><ul><li>Estrogen/pregnancy related </li></ul><ul><li>With history of VTE in a first degree relative </li></ul><ul><li>With other risk factors </li></ul>RCOG Guideline April 2009 Grade C
  7. 7. <ul><li>Which women with prior VTE require a thrombophilia screen? </li></ul>
  8. 8. <ul><li>Women with previous provoked and non estrogen related VTE. </li></ul><ul><li>Grade C </li></ul><ul><li>Women with a previous single provoked VTE (and no other risk factors) require close surveillance antenatally and prophylaxis with LMWH for 6 weeks post partum. </li></ul><ul><li>Grade C </li></ul>Green-top Guideline April 2009
  9. 9. Antenatal Assessment & Management (To be assessed at booking and repeated if admitted) <ul><li>Single previous VTE + </li></ul><ul><li>*Thrombophilia, or FH </li></ul><ul><li>*Unprovoked/estrogen related </li></ul><ul><li>2. Previous recurrent VTE (>1) </li></ul>HIGH RISK REQUIRES ANTENATAL prophylaxis with LMWH <ul><li>Single previous </li></ul><ul><li>provoked VTE without </li></ul><ul><li>FH or thrombophilia </li></ul><ul><li>Thrombophilia + no VTE </li></ul>Intermediate Risk require close surveillance antenatally and prophylaxis with LMWH for 6 W post partum Green-top Guideline April 2009
  10. 10. Antenatal Assessment & Management (To be assessed at booking and repeated if admitted) 1.Age > 35 yrs 2.Obesity (BMI>30kg/m2) 3.Parity > 3 4 Smoker 5.MEDICAL CO-MORBIDITIES e.g. heart or lung disease; SLE; cancer; inflammatory conditions; Proteinuria >3g/24 hrs; Sickle Cell Disease . 6.Gross varicose veins 7.Current systemic infection 8.Immobility, e.g. paraplegia, SPD, long-haul travel 9.Pre-eclampsia 10. Dehydration/hyperemesis/OHSS 11.Multiple pregnancy or ART 12.Surgical procedure e.g. ERPC 3 or more risk factors 2 or more if admitted <3 risk factors Intermediate Risk Consider antenatal prophylaxis with LMWH Low Risk Mobilisation & avoidance of dehydration. Green-top Guideline April 2009
  11. 11. Timing of initiation of thromboprophylaxis
  12. 12. Timing of initiation of thromboprophylaxis <ul><li>first trimester is associated with the greatest risk of VTE, many antenatal VTE events (including fatal events) occur in the first trimester </li></ul><ul><li>So women should be advised to start LMWH as soon as they have a positive pregnancy test. </li></ul>Green-top Guideline April 2009
  13. 13. Which agents should be used for thromboprophylaxis?
  14. 14. Which agents should be used for thromboprophylaxis? <ul><li>LMWHs are the agents of choice for antenatal thromboprophylaxis. They are as effective and safer than unfractionated heparin. </li></ul><ul><li>Grade A </li></ul>Green-top Guideline April 2009
  15. 15. <ul><li>FDA warns docs to stop using Baxter's heparin </li></ul><ul><li>Hundreds of allergic reactions to the blood thinner have been reported </li></ul>
  16. 16. RCOG Guideline April 2009 Thromboprophylaxis During Pregnancy Tinzaparin 20,000U/ml Enoxaparin (100 U/mg) weight 3500 U/d 4500 U/d 7000 U/d* 9000 u/d* 75u/kg/d* 4500U/12 h 175U/kg/12h (antenatal &postnatal) 20 mg/d 40 mg/d 60 mg/d* 80mg/d* 0.5mg/kg/d* 40 mg/12h 1mg/kg/12h (antenatal) 1.5 mg post Body weight < 50 kg Normal weight : 50–90 kg Body weight 91-130 kg Body weight 131-170 kg >170 kg Higher prophylactic dose(50-90kg) Treatment dose
  17. 17. Thromboprophylaxis after delivery
  18. 18. Postnatal Assessment & Management (to be assessed on Delivery Suite) <ul><li>Any previous VTE </li></ul><ul><li>Asymptomatic Thrombophilia </li></ul>High Risk At least 6 weeks postnatal prophylactic LMWH Caesarean Section in Labour BMI > 40 kg/m2 Prolonged Hospital Admission Intermediate Risk At least 7days postnatal prophylactic LMWH Green-top Guideline April 2009
  19. 19. Postnatal Assessment & Management (to be assessed on Delivery Suite) 1.Age > 35 yrs 2.Obesity (BMI>30kg/m2) 3.Parity 3 4.Smoker 5. Elective Caesarean Section 6.MEDICAL CO-MORBIDITIES e.g. heart or lung disease; SLE; cancer; inflammatory conditions; Proteinuria >3g/24 hrs; Sickle Cell Disease; IVDU 7.Gross varicose veins 8. Current systemic infection 9. Immobility, e.g. paraplegia, SPD, long-haul travel 10 Pre-eclampsia 11.mid-cavity or rotational forceps 12.Prolonged labour (>24 hrs) 13.PPH > 1litre or Blood Transfusion 2 or more risk factors <2 risk factors Intermediate Risk At least 7 days postnatal prophylactic LMWH Low Risk EARLY Mobilisation and avoidance of dehydration. NB If persisting or > 3 risk factors consider extending prophylaxis with LMWH Green-top Guideline April 2009
  20. 20. Thromboprophylaxis after delivery <ul><li>The first thromboprophylactic dose of LMWH should be given as soon as possible after delivery provided there is no post partum haemorrhage . </li></ul>
  21. 21. 7 D Thromboprophylaxis with CS <ul><li>1-Eemergency CS </li></ul><ul><li>2-Elective CS + one or more additional risk </li></ul>Green-top Guideline April 2009
  22. 22. When should thromboprophylaxis be interrupted for delivery?
  23. 23. Delivery by elective caesarean section in women receiving antenatal LMWH <ul><li>On the day prior to delivery ,the woman should receive a thromboprophylactic dose of LMWH </li></ul><ul><li>On the day of delivery, any morning dose should be omitted. </li></ul><ul><li>The thromboprophylactic dose of LMWH heparin should be given by four hours post-operatively or four hours after removal of the epidural catheter. </li></ul>Green-top Guideline April 2009
  24. 24. <ul><li>Regional techniques should not be used until:- </li></ul><ul><ul><li>12 hours after the previous prophylactic dose of LMWH and </li></ul></ul><ul><ul><li>24 hours after the last therapeutic dose.. </li></ul></ul><ul><li>cannula should not be removed within 10-12 hours of the most recent injection. </li></ul><ul><li>LMWH should not be given for four hours after the epidural catheter has been removed </li></ul>Green-top Guideline April 2009
  25. 25. Thank you

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