Download Contraception

Thromboprophylaxis in
Pregnancy and the
Puerperium
Max Brinsmead PhD FRANZCOG
June 2015
Background
 Pulmonary embolism is the leading cause of
maternal deaths in developed countries
 May be prevented by thromboprophylaxis
measures
 However, absolute risk is small (1-2 per 1000
pregnancies)
 And only 1:100 patients with VTE will die
 Some risks associated with therapy
 So screening for treatment is required
 And recommendations for some populations
may not be universally applicable
Who requires
thromboprophylaxis?
 Any patients with any previous VTE
 Except those that had a previous VTE related to
major surgery and have no other risk factors
 Any patient admitted to hospital with
dehydration
 e.g. associated with hyperemesis or OHSS
 Any patient with 2 or more risk factors as
per following tables
Who is at risk?
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Known thrombophilia
Age >35
Para >3
BMI >30
BMI >40
Smokes
IV Drug user
Severe varicose veins (above knee, phlebitis or skin changes)
Medical condition e.g. active SLE, heart failure, cancer,
nephropathy
Sickle cell disease
Paraplegia
Travel >4 hrs
Immobilisation >3d
IVF Pregnancy
Who is at risk (2)?
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Dehydration e.g. hyperemesis gravidarum or OHSS
Pre eclampsia
Twins
Caesarean section (CS)
Emergency CS
Prolonged labour
Stillbirth
Midcavity assisted delivery
PPH requiring transfusion
Surgery or fracture in pregnancy or the puerperium
Any infection requiring admission to hospital or IV antibiotics
 FOR 2 OF THE ABOVE GIVE CLEXANE FOR 10 days
POSTNATAL
 FOR 3 OF THE ABOVE CONSIDER ANTENATAL
CLEXANE from 28 weeks
 FOR 4 OF THE ABOVE CONSIDER CLEXANE NOW
High Risk Patients
 Any patient on long term anticoagualants
 Patients with antithrombin deficiency
 Patients with antiphospholipid syndrome
 Patients with prior arterial thrombosis
Then
 Early consultation with haematologist is desirable
 Usually require higher dose Clexane (75% or full-dose)
 Planned delivery with anaesthetic consultation
desirable
Max Brinsmead PhD FRANZCOG
January 2010
When should treatment be
started and stopped?
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As soon as possible for high risk antenatal patient
Therefore risk score at 1st opportunity
And again with every admission, then at delivery
A role for pre pregnancy counselling
Patients with personal or family history may benefit
from testing for thrombophilia
Must stop if there is PV bleeding or onset of labour
All patients requiring antenatal therapy require
postnatal therapy asap after delivery
Not within 12 hours of spinal anaesthetic or insertion or
removal of an epidural catheter
Continue for 10 days minimum, and 6w if commenced
in the antenatal period
What Drug and What Dose?
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Clexane is the drug of choice
Has no risk of thrombocytopenia or osteoporosis
Dose by patient weight
Use BD for larger doses
Prophylaxis postpartum
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<50 Kg
20 mg once dily
51 – 69 Kg 30 mg once daily
70 – 90 Kg 40 mg once daily
91 – 130 Kg 30 mg 12 hourly
131 – 170 Kg 40 mg 12 hourly
 Subtherapeutic doses do not need monitoring
 Therapeutic dose is 1.0 mg/Kg per day antenatally and
1.5 mg/Kg per day in the puerperium
Who should NOT have Clexane
or Heparin?
 Those within 4 hours of spinal or epidural catheter
 Allergy to LMWH
 Patients with active bleeding
 Patients at risk of bleeding e.g. Placenta previa
 Thrombocytopenia (Platelet count <75)
 Known bleeding diathesis e.g. Von Willebrands
 Severe renal disease (GFR < 30 ml/min)
 Severe liver disease
 Uncontrolled Hypertension (>200/120)
 Haemorrhagic stroke within 4w
NB
Postnatal Clexane increases the risk of PPH and
wound haematoma
Other Measures
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Early mobilisation and avoid dehydration for all
Stockings not proven by RCT to be effective
Thigh-length may be impractical and poorly tolerated
Even knee-length stockings have a limited role for the
ambulant patient
 Should be used in all patients with at least one risk
factor until mobilising normally
 Make sure that they are fitted correctly
 Use intermittent calf compression for all pregnant
patients undergoing surgery
Warfarin
 Generally contraindicated in the antenatal patient
 Except for some patients with mechanical heart valves
 Patients on Warfarin can be advised to switch to LMW
Heparin as soon as they have a positive pregnancy
test
 Can be an alternative for a postnatal patient who
requires long term therapy
 Breast feeding is not contraindicated
For more detailed guidelines and
the treatment of venous
thromboembolism in prgnancy
See RCOG Greentop Guidelines
www.rcog.org.uk/en/guidelinesresearchservices/guidelines/gtg37a/
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Comments?
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