VTE THROMBOPROPHYLAXIS Rationale Whom to give Risk assessment When to initiate Agents used When to interrupt How long to continue Gynae in patient thromboprophylaxis risk assessment and management

1. …Caring hearts, healing hands
DR. SHARDA JAIN
DR. JYOTI AGARWAL
VTE PROPHYLAXIS
IN GYNAE PATIENTS
BREAKTHROUGH
Life.. altering secret from Today, scutting - edge Doctors

2. VTE THROMBOPROPHYLAXIS
• Rationale
• Whom to give
Risk assessment
• When to initiate
• Agents used
• When to interrupt
• How long to continue
• Gynae in patient thromboprophylaxis risk
assessment and management
…Caring hearts,healing hands

3. WHEN BAD THING HAPPEN
AFTER GOOD & SUCCESSFUL SURGERY ...
YOU FEEL BAD.
IT IS HIGH time Gynaecologists become
obsessed about Venous Thrombo
Embolism & start using Throboprophylaxis
&
NOT LOOSE THEIR DEAR PATIENTS
RATIONALE
…Caring hearts,healing hands

4. CASE - I
• 76 Yrs. old ,85 kg lady ,with known
DM,HYPERTENTION.. had hysterectomy.
• Died suddenly on 10 th day at home.. she did
not complain anything. Went to the garden &
collapsed
• ..suggesting pulmonary thromboembolism
…Caring hearts,healing hands

5. CASE - II
• Mrs Meena 56 yrs old.. had postmenopausal
bleeding.
• Endometrial cancer was diagnosed.
• Had TAH WITH BSO WITH LYMPHADENECTOMY…
• She was recovering well.. had dypsnoea & chest
pain .. diagnosed as PULMONARY EMBOLISM.. But
saved by timely treatment
…Caring hearts,healing hands

6. These Two cases in Tertiary Hospital
within one year prompted us in 2010
to use VTE THROMBO PROPHYLAXIS
PLEASE
Assess risk of VTE and bleeding
in all Gynae patients
undergoing hospitalization
…Caring hearts,healing hands

7. WHEN IS THE RISK OF VTE
&
WHEN THROMBOPROPHYLAXIS
NEEDED?
…Caring hearts,healing hands

8. IN MEDICAL PATIENTS
1. If mobility is reduced significantly for >-3 days
or
2. If expected to have ongoing reduced mobility
relative to normal state plus any VTE risk factor
IN SURGICAL PATIENTS
1. If surgery involving pelvis with total
anesthesia and surgery time >1 hour
2. Any acute surgical admission with
inflammatory and intra-abdominal condition

9. VTE RISK FACTORS: WHERE
THROMBOPROPHYLAXIS IS NEEDED
1. Active cancers or cancer treatment
2. Critical care admission
3. Age>50 years
4. Dehydration
5. History of thrombophilia
6. Obesity (BMI >30 Kg/m2)
7. Use of HRT
…Caring hearts,healing hands

10. 8. Use of oestrogen-progesterone contraceptive pills
9. One or more medical co-morbidities like
cardiac disease, metabolic, endocrine or
respiratory pathologies, Acute infectious
diseases, inflammatory conditions
10. Varicose veins with Phlebitis
11. Pregnancy and puerperium
VTE RISK FACTORS: WHERE
THROMBOPROPHYLAXIS IS NEEDED
…Caring hearts,healing hands

11. General VTE RISK
STRATIFICATION
irrespective to speciality the
patient belongs
…Caring hearts,healing hands

12. LOW RISK
• Ambulatory patient without additional VTE
risk factors
• Expected length of stay <2 days
• Minor surgery in patients without additional
VTE risk factors (same day surgery or
operating room time <30 minutes )
• Early Ambulation
…Caring hearts,healing hands

13. MODERATE RISK
• Patients who aren’t in either the low or high risk
groups
• Choose one option
• Inj. Enoxaparin 40 mg SC q24hrs,
OR
• Sequential compression Device (SCD)
Both lower extremities
Right leg only
Left leg only
Patient intolerant or has skin lesions on both legs
(do not use SCD)(Ref Contraindications)

14. HIGH RISK
• Elective hip/knee Arthroplasty
• Acute Spinal cord injury with paresis
• Multiple major trauma
• Abdominal or Pelvic surgery for cancer
• Intensive Care Unit Patient
Choose both the treatment Options (Unless contraindicated for heparin)
Inj. Enoxaparin 40 mg SC q24hrs,
AND
Sequential compression Device (SCD)
• Both lower extremities
• Right leg lonely
• Let leg only
• Patient intolerant or has skin lesions on both legs ( do not use SCD)
(Ref Contraindications)
…Caring hearts,healing hands

15. 5. Acute stroke
6. Thrombocytopenia (Platelets <75000)
7. Uncontrolled systemic hypertension
(BP >- 230/120 mmHg)
8. Uncontrolled inherited bleeding disorders like
haemophilia or Von Willibrand’s disease.
Avoid thromboprophylaxis
Whenever Risk of bleeding is more
…Caring hearts,healing hands

16. Contraindications for thromboprophylaxis
Absolute
• Active haemorrage
• Severe trauma to head or spinal cord with haemorrhage in the last 4 weeks
Relative
• Intracranial haemorrhage within last year
• Craniotomy within 2 weeks
• Intraocular surgery within 2 weeks
• GI, Gu haemorrhage within last month
• Thrombocytopenia(<50K) or coagulopathy (PT > 18 seconds)
• End stage liver disease
• Active intracranial lesions/neoplasms
• Hypertensive urgency/emergency
• Post operative bleeding concerns
• Concurrent use of anticoagulant known to increase the risk of bleeding
Other conditions
• Immune mediated heparin induced thrombocytopenia
• Epidural analgesia with spinal catheter (current or planned )

17. OVERVIEW OF CARE
Type of
patients
When to
assess for VTE
risk
Management
Patients
having
elective
surgery
Before
admission
1. Stop OCs and HRT 4 weeks before
surgery
2. Assess risk and benefit of stopping
antiplatelet one week before surgery
3. Prefer regional anesthesia and plan
prophylaxis timing accordingly
Stop mini dose Aspirin 5 days before surgery

18. Type of
patients
When to assess
for VTE risk
Management
All Patients At Admission and
during ward-
based care
1. Assess risk of VTE and bleeding
2. Offer patients verbal and written information
3. Start any one of mechanical VTE prophylaxis
and monitor (thigh or knee length
stockings/Pneumatic compression devices)
4. Start pharmacological VTE prophylaxis if
appropriate and review
5. Keep patients hydrated and encourage them
to mobillise as soon as possible
6. Continue until mobility no longer significantly
reduced. It is 5-7 days in patients undergoing
routine surgery in cancer surgeries continue
for 28 days.
OVERVIEW OF CARE

19. Type of
patients
When to
assess for VTE
risk
Management
All Patients Before
discharge
Offer information on sign and symptoms
of VTE and PE
Patients
discharged
with VTE
prophylaxis
Before
discharge
Offer correct use and duration of use
VTE prophylaxis and whom to contact in
case of help
OVERVIEW OF CARE
…Caring hearts,healing hands

20. HEPARINS: UFH VS LMWH
 UFH is cheaper, shorter half life, S/C or I/V and can be
reversed rapidly
 UFH causes HIT, bone loss, needs monitoring baseline
platelet count, after 2-3 days, weekly x 2 weeks then
monthly.
 UFH preferred in patients with severe renal
insufficiency.
 LMWH is effective, easy to administer S/C, has more
predictable response and do not require routine
monitoring….so used by all
…Caring hearts,healing hands

21. Suggested doses of LMWH for Thrombo
prophylaxis in Gynae patients

22. Contraindications/cautions to LMWH

23. ANTI EMBOLISM STOCKINGS

24. TO SUMMARIZE
• All women should undergo risk assessment for venous
thromoembolism before surgery Reassessment on any
surgical admission, during surgery
• Both LMWH or UFH can be used for
thromboprophylaxis
• LMWH is effective and easy to administer in
dose of 40 ..60 mg S/C once a day 12 hours after
surgery and does not require any monitoring.It
is given for 4 to 10 days following Surgery
depending on risk of patients.
…Caring hearts,healing hands

25. • Any woman with Moderate VTE risk factors should
be offered prophylactic LMWH for 4 days following
surgery in postoperative period
• Any woman with HIGH risk factors should be
offered prophylactic LMWH for 10 days period in
post operative period.
…Caring hearts,healing hands

26. ADDRESS
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Karkari Morh Flyover,
Delhi - 51
CONTACT US
9650588339
9599044257
011-22414049
WEBSITE :
www.lifecareivf.in
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