Hereford Hospitals NHS Trust

Policy Reference 25
Maternity
Thromboprophylaxis in pregnancy, following vaginal delivery
and caesarean section

Thromboprophylaxis in
pregnancy, following vaginal
delivery and caesarean section
Policy Details:
Author job title:
Dept/Working Group(s):

Mr D Mowbray, Consultant Obstetrician

Dr S Willoughby, Consultant Haematologist
Maternity

Current review changes:

Options
Substantially reviewed and re-written/revised

Ratifying Body:
Date ratified:
Date operational:
Date to be reviewed:
PFI involvement: project
liaison completed
accordingly (Yes/No)
Refers to the following Trust
policies:
Review History:
First Operational:
Previously
Reviewed:
Updated yes/no:

Labour Ward Forum

16/05/07
11/07/07
April 2010
No

October 2003
January
April
2007
2007
Yes
Yes

Operational Date: 11/07/07

Review Date: April 2010

Date Approved by LWF: 16/05/07

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Hereford Hospitals NHS Trust

Policy Reference 25
Maternity
Thromboprophylaxis in pregnancy, following vaginal delivery
and caesarean section
Pulmonary thromboembolism (PTE) remains a major cause of maternal death in the
UK.
The incidence of DVT is shown in the table below:
Maternal Age Antenatal
< 35
0.615 per 1000
> 35
1.216 per 1000

Postnatal
0.304 per 1000
0.720 per 1000

Thrombophilic abnormalities affect 15% of the population. Risk factors may act
synergistically. 1

Low molecular weight heparin (LMWH) is the anticoagulant of choice in

pregnancy as it does not cross the placenta.

Monitoring is required for therapeutic doses and a twice daily dosing regime
should be considered in view of the altered pharmacokinetics in pregnancy.

Skin rashes are occasionally seen with LMWHs and are seen more commonly
in pregnancy.

The LMWH used in Hereford County Hospital is tinzaparin:

Therapeutic dose = Tinzaparin 175u/Kg/day (or 90u/kg 12hourly)

Prophylactic dose = Tinzaparin 3500u/day if<50kg

4500u/day if 50-90kg
4500u 12hourly if>90kg

Note all weights are booking/early pregnancy weights

Monitoring of LMWH

It is only necessary to monitor levels for women on therapeutic doses of

LMWH

It can only be done by using an anti-X assay as the APTT is not affected by
LMWH

It is arranged by liaison with the Haematology laboratory - ext 5710

Anti-Xa levels should be checked every 4 weeks during the 1st and 2nd
trimesters and every 2 weeks in the 3rd trimester and LMWH doses altered
accordingly.
Operational Date: 11/07/07
Review Date: April 2010

Date Approved by LWF: 16/05/07

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Hereford Hospitals NHS Trust

Policy Reference 25
Maternity
Thromboprophylaxis in pregnancy, following vaginal delivery
and caesarean section
Levels should be taken exactly 4 hours post sc injection to get an accurate peak
level.
It is important to monitor platelet counts of ALL patients on heparin therapy
a) before starting
b)

after seven days on heparin.

Target range for Anti-Xa level:

Therapeutic heparin

0.3 - 0.7 iu/ml

Prophylaxis for patients with thrombophilia or previous history of

venous thromboembolism (VTE)
1. Single VTE associated with a clear precipitating cause which is now
resolved OR
Asymptomatic thrombophilia (without an episode of VTE) of types
a) heterozygous factor V Leiden (FVL)
b) heterozygous protein C/S deficiency
c) heterozygous prothrombin (PT) mutation

Treatment
6 weeks postnatal prophylactic dose LMWH or warfarin (INR target 2.5)
Consider antenatal LMWH if strong +ve family history of VTE

2. Single VTE with no precipitating cause, at unusual site, associated with

a) a positive family history (1st degree relative) of VTE
b) homozygous FVL/ PT mutation
c) recurrent VTE (not on long term warfarin)
Treatment
Prophylactic dose antenatal LMWH (as soon as practical) + 6 weeks postnatal
prophylactic LMWH or Warfarin (INR target 2.5)
3. If Antithrombin III (AT III) deficient
Treatment
Operational Date: 11/07/07
Review Date: April 2010

Date Approved by LWF: 16/05/07

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Hereford Hospitals NHS Trust

Policy Reference 25
Maternity
Thromboprophylaxis in pregnancy, following vaginal delivery
and caesarean section
Therapeutic dose LMWH throughout pregnancy, AT III concentrate at delivery
and therapeutic dose LMWH or warfarin 6/52 postpartum (INR target 2.5)
4. If on long term warfarin:
Treatment
Convert to LMWH prior to conception if possible to avoid teratogenic effects
of warfarin.
Therapeutic does of LMWH throughout pregnancy and convert back to
warfarin postpartum.
For combined thrombophilic defects, antiphospholipid syndrome or for any
women who do not fit within these guidelines, please discuss on an individual
basis with a consultant haematologist

Recommendation for delivery

For patients on prophylactic doses of LMWH, delivery can proceed as per normal.
For patients on therapeutic doses of LMWH, it is advisable to reduce to a prophylactic
dose on the day of delivery, if this can be planned.
For patients on therapeautic LMWH who present unplanned in labour
If last dosage > 6hrs ago site venflon, x-match 4 units blood and manage
normally (low risk of haemorrhage)
If last therapeutic dose <6hrs ago as above, avoid instrumental delivery, inform
on call haematologist. Consider protamine sulphate if haemorrhage occurs (see
appendix for guideline)

Recommendations for regional anaesthesia in patients on LMWH

Information is contained in a separate guideline available on the obstetrics intranet site
produced by the anaesthetic department.

Treatment of established VTE in pregnancy

Therapeutic doses should be used (tinzaparin 175 u/Kg/day sc) and treatment
continued for 3 or 6 months depending on site of VTE. Warfarin may be substituted
postpartum. Labour should be managed as in recommendations for delivery above.

Operational Date: 11/07/07

Review Date: April 2010

Date Approved by LWF: 16/05/07

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Hereford Hospitals NHS Trust

Policy Reference 25
Maternity
Thromboprophylaxis in pregnancy, following vaginal delivery
and caesarean section

Thromboprophylaxis for caesarean section

Caesarean section increases the risk of thrombosis 2-6 fold. Emergency caesarean
section is associated with a higher risk than elective caesarean section

All women undergoing emergency caesarean section MUST have s/c

tinzaparin

All women undergoing caesarean section MUST be given TED stockings

All women should have early mobilisation and attention to hydration

Risk classification- caesarean section

Low Risk
Elective lower segment caesarean section or
None labouring emergency lower segment caesarean section
With NO additional risk factors
Moderate Risk
Any caesarean section with 1-2
of the additional factors below:
Age > 35
Obesity, BMI > 30 (or weight >80Kg)
Parity >4
Labour >12hrs
Gross varicose veins
Current Infection
Pre-eclampsia
Immobility prior to surgery >4 days
Major current illness
Emergency caesarean in labour
High Risk
Patient with 3 or more moderate risk factors
Extended pelvic or abdominal surgery, e.g. Caesarean
hysterectomy
Patient with a personal or family history of:
DVT
PE
Thrombophilia
Antiphospholipid antibody*
Operational Date: 11/07/07
Review Date: April 2010

Date Approved by LWF: 16/05/07

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Hereford Hospitals NHS Trust

Policy Reference 25
Maternity
Thromboprophylaxis in pregnancy, following vaginal delivery
and caesarean section
Lupus anticoagulant*
Paralysis of lower limbs
*these patients should have an individualised prophylaxis programme agreed with a
consultant haematologist in the antenatal period

Length of treatment:

Low risk - continued until discharge

Moderate and high risk - continue until day 5 or fully mobile whichever is
later (i.e. the minimum length of treatment is 5 days)

Women in the high risk group only should be discharged with TED
stockings, unless otherwise instructed by medical staff

Heparin dosage after caesarean section (booking or early pregnancy weight)

Low risk
Moderate risk

early mobilisation/hydration only

Tinzaparin 3500iu o.d. <50kg
4500iu o.d. 50-90kg
High risk or>90kg
Tinzaparin 4500iu 12 hourly
The first dose should be prescribed for four hours after surgery

Subsequent doses should be prescribed at 22.00hrs

If the first dose is given before 10am give a second dose of 3500iu at 22.00hrs
If the first dose is to be given after 10am miss out that day's evening dose and continue
with subsequent doses the following day at 22.00hrs

Operational Date: 11/07/07

Review Date: April 2010

Date Approved by LWF: 16/05/07

Page 6 of 9

Hereford Hospitals NHS Trust

Policy Reference 25
Maternity
Thromboprophylaxis in pregnancy, following vaginal delivery
and caesarean section

Thromboprophylaxis after Vaginal Delivery

Risk factors for venous thromboembolism in pregnancy and the puerperium
Pre existing
Thrombophilia*
Age >35yrs
BMI>30 pre-pregnancy/early pregnancy
Parity>4
Gross varicose veins
Paraplegia
Sickle cell disease
Inflammatory disorders
Nephrotic syndrome
Myeloproliferative disorders
*these patients should have an individualised
prophylaxis programme agreed with a
consultant haematologist in the antenatal period

New onset or transient

Surgical procedure in pregnancy or puerperium
Hyperemesis
Dehydration
OHSS
Severe infection
Immobility (>4 days bed rest)
Pre-eclampsia
Excessive blood loss
Long-haul travel
Prolonged labour
Mid-cavity instrumental delivery
Immobility after delivery

Those women who are at low risk (non or one of the above risk factors)
require early mobilisation and avoidance of dehydration only

Women with three or more pre-existing risk factors should be considered

for and offered antenatal heparin prophylaxis and for five days post
partum

Women with two current risk factors (to include pre-existing and new
onset/transient factors) should be considered for and offered heparin
prophylaxis for five days post-partum

Heparin dosage after vaginal delivery (booking or early pregnancy

weight)

Tinzaparin 3500iu o.d body weight <50kg

Tinzaparin 4500iu o.d body weight 50-90kg
Tinzaparin 4500iu 12 hourly body weight >90kg

Operational Date: 11/07/07

Review Date: April 2010

Date Approved by LWF: 16/05/07

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Hereford Hospitals NHS Trust

Policy Reference 25
Maternity
Thromboprophylaxis in pregnancy, following vaginal delivery
and caesarean section
Discharge
Self administration
1. The women should ideally be taught to self administer the heparin and should
continue to give the heparin at 22.00hrs
2. It must be ensured that the woman is sent home with sufficient heparin to complete
the treatment course
Non-self administration
1. If it is not possible for the woman to self-administer the heparin then a community
midwife will need to administer the heparin
2. On the day of discharge administer the heparin after 10.00hrs and BEFORE the
woman leaves the ward
3. Subsequent doses should be given between 10.00 and 14.00hrs or at another
convenient time (ideally it should be the same time each day)
4. It must be ensured that the woman is sent home with sufficient heparin to complete
the treatment course
References
1. Greer I. Treatment of Venous thromboembolism in pregnancy, Reprod Vasc Med
2001; 1(4):114-19
2. Royal College of Obstetricians and Gynaecologists. Report of a Working Party on
Prophylaxis against Thromboembolism in Gynaecology and Obstetrics. London:
RCOG; 1995
3. Thromboprophylaxis during pregnancy, labour and after vaginal delivery RCOG
Guideline No. 37 January 2004
4. BCSH guideline: Investigation and management of Heritable thrombophilia, I
Walker et al, ,BJ Haem 2001,114,512-528
5. BCSH guideline: Guidelines on the use and monitoring of heparin, T Baglin et al,
2006 BSH, 133, 19-34
6. Confidential Enquiry into Maternal and Child Health. Why Mothers Die. 20002002. CEMACH

Operational Date: 11/07/07

Review Date: April 2010

Date Approved by LWF: 16/05/07

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Hereford Hospitals NHS Trust

Policy Reference 25
Maternity
Thromboprophylaxis in pregnancy, following vaginal delivery
and caesarean section
Appendix 1

Operational Date: 11/07/07

Review Date: April 2010

Date Approved by LWF: 16/05/07

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