2. 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)
3. 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
4. Thrombophilia
Thrombophilia is a term used to describe a lab
abnormality that increases the tendency to Venous
Thromboembolism.
It can be congenital or acquired
5. Causes of inherited thrombophilia
Definitely inherited Multifactorial
Antithrombin deficiency Elevated factor VIII
Protein C Deficiency
Protein S Deficiency hyperhomocysteinnemia
Factor V Leiden
Prothrombin 20210A mutation
Congenital Thrombophilia
7. Recommendations for Screening
Venous Thromboembolism
History of Thrombosis in first degree relative
Adverse pregnancy outcome
Who should be tested for Thrombophilia..?
8. When to test for Thrombophilia..?
Factor V
Mutation
Factor II
Anytime
ATIII
Changes 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
Thrombo
sis
LA
ACL Antibodies
Can be done
9. 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 AT
Risk is high (1 –
3%)Thromboprophyl
axis for
4 – 6 weeks
Avoid or with
caution
10. Management
Thrombophilia Screen Positive
prior VTE
Without Pregnancy
With Pregnancy POST PARTUM
OCP|HRT
Prolonged post-op
prophylaxis
Give Antenatal
Thromboprophylaxis
Thromboprophylaxis
Contraindicate
11. 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
12. 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
13. Management of APAS
Without thrombosis or APO
Without SLE
With SLE
Without thrombosis with APO
With prior thrombosis
Avoid additional risk
Factors like OCP|HRT
Avoid additional risk
Factors like OCP|HRT
+
Thromboprophylaxis
for surgery/Pregnancy
Antenatal Thromboprophylaxis
Postpartunm Thromboprophylaxis
6 – 8 wks
Full anticoagulation during pregnancy
Life long warfarin
14. 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 ?
15. 4. Will you ask for Thrombophilia screen | APLA..?
5. Treatment options
6. Labour & Delivery
16. 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.
17. 2. D-DIMER NOT USEFUL
Routinely evlevated in 3rd
Trimerster
POSTPARTUM
PIH
Low Level – No DVT
3. INITIAL Rx
LMWH is accepted as safe alternative to UFH
– Reduced risk of bleeding
– Heparin induced thrombocytosis is less than UFH
– Osteroporosis is less
18. 4. Therapeutic Dose
LMWH recent weight of patient
ENOXAPARIN 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.
19. 6. Additional Therapy
– Leg Elevation
– Graduated Elastic Compression Stocking
– Mobilisation with stocking
6. 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.
21. 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..?
22. 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 PD
2. POSTNATAL prophylaxis
– Prev – VTE FULL THERAPEUTIC ANTI COAG
for 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.
23. 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.
24. 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
25. 3. IF SUSPICION IS HIGH
– Ventilation Perfusion Scan
– Computed Tomography Pulmonary ANGIOGRAPHY
3. CONT ANTI-COAGULANTS TILL PTE IS EXCLUDED
4. THROMBOPHILIA SCREEN PRIOR TO THERAPY IS
CONTROVERSIAL NOT RECOMMENDED
6. 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.
27. I. Young married software professional wants to
postpone pregnancy – 1st
degree relative has VTE.
28. GUIDELINES
– Relative risk of VTE with OCP
However the absolute risk is small
5 | 100,000 - 15 | 100,000
25 | 100,000 ( with 3rd
GEN
PROGESTERONE)
– Combined OCP’s LNG | NORETHISTERONE
Lower risk of VTE than Desogestrol or Gestodene
29. 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
30. Routine THROMBOPHILIA screen before OCP is not
recommended, Do it if 1 st
degree relative < 45 yrs had
VTE
31. II. 46 yr undergoes TAH with BSO
1. Do we require routine thromboprophylaxis..?
2. What are the risk factors which will prompt you for
routine peri-operative thromboprophylaxis..?
32. 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
33. 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 ..?
34. 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.
35. 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…?
36. 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.
37. 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.
38. 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 VTE
Old 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
