Fahad Saadi

South West Acute Hospital

Western Health and Social Care Trust
Scope of the guidelines

• Prevention of venous thromboembolism (VTE) during

• 1- Pregnancy
• 2- Birth and
• 3- Following delivery
Importance

• Pulmonary embolism (PE) leading cause of maternal death in the UK

• Significant fall in the maternal mortality rate from PE after guidelines

Before Guidelines Following guidelines

1.56 per 100 000 0.70 per 100 000
in 2003–2005 in 2006–2008

[33 deaths] [16 deaths]

[95% CI 1.43–2.63] [95% CI 0.49–1.25]
Statistics

• 89% of the women who died from PE had identifable risk factors
(in UK, between 2006 and 2008)

• UK incidence of antenatal PE is 1.3 per 10000 maternities (UKOSS study)

• Relative risk of VTE in pregnancy is increased four- to six-fold

Risk Factors for VTE

• Pre-existing Risk

• Obstetric Risk

• Transient Risk

Numerical scoring system to identify at-risk women

for pharmacological thromboprophylaxis
a If low-risk thrombophilia + a family history of VTE in a first-degree relative postpartum prophylaxis for 6 weeks
- high-risk thrombophilia = antithrombin defciency, protein C or S defciency
b BMI ≥ 30 = 1; BMI ≥ 40 = 2
Summary

• Women with VTE due to antithrombin defciency or APS or with recurrent VTE should receive higher
dose LMWH (either 50%, 75% or full treatment dose) antenatally and for 6 weeks
postpartum or until returned to oral anticoagulant therapy after delivery. These women require
specialist management by experts in haemostasis and pregnancy
Suggested dosing (Antenatal and postnatal)
Heritable thrombophilia - Antithrombin
deficiency

• higher dose LMWH antenatally (either 50%, 75% or full

treatment dose)
• 6 weeks postpartum
• collaborate with a haematologist
• consider replacing antithrombin at initiation of labour or prior
to caesarean section
• consider monitoring antenatal anti-Xa
• anti-Xa levels: 4-hour peak levels of 0.5–1.0 iu/ml aimed for
Acquired thrombophilia –antiphospholipid
syndrome

• higher dose LMWH (either 50%, 75% or full treatment dose)

antenatally
• 6 weeks postpartum
• Collaborate with a haematologist and/or rheumatologist
Testing for thrombophilia in women with
prior VTE

Test for antithrombin deficiency, if

• FHx of VTE + antithrombin deficiency
• or
• FHx of VTE + specific thrombophilia not detected

Test for antiphospholipid antibodies, if

• unprovoked VTE
Asymptomatic heritable thrombophilia

Women with asymptomatic thrombophilia + no additional risk factors:

• refer to local expert
• consider antenatal prophylaxis
• recommended for six weeks’ postnatal prophylaxis

Women with heterozygosity for thrombophilia and 3+ additional risk factors:

• Consider antenatal thromboprophylaxis

Women with heterozygosity for thrombophilia and 2+ additional risk factors:

• considered thromboprophylaxis from 28 weeks

Women with heterozygosity for thrombophilia and 1+ additional risk factors:

• postnatal thromboprophylaxis for 10 days should be considered
When should thromboprophylaxis be
interrupted for delivery?

• After any vaginal bleeding or once labour begins

• Techniques should be avoided for atleast 12 hours (prophylactic

LMWH) or 24 hours (therapeutic LMWH)

• LMWH should not be given for 4 hours after use of spinal

anaesthesia or after the epidural catheter removal
Epidural catheter should not be removed within 12 hours
Anti-embolism stockings

Graduated compression with a calf pressure of 14–15 mmHg

• Hospitalised and have a contraindication to LMWH

• Hospitalised post-caesarean section (combined with LMWH) and are

high risk of VTE (e.g. previous VTE, 4+ risk factors antenatally or
2+ risk factors postnatally)

• Travelling long distance for more than 4 hours

Warfarin

• Warfarin is restricted to the few situations e.g. mechanical heart

valves

• Convert LMWH to warfarin postpartum when the risk of

haemorrhage is reduced, usually 5–7 days after delivery

• Warfarin is safe in breastfeeding

Thank you!

• Reference: Greentop guideline no. 37a April 2015