1. بسم الله الرحمن الرحيم

2. 12th Annual Congress “RAS EL BAR ” 5- 2009 Thromboprophylaxis During Pregnancy, Birth and Puerperium Dr. Mahdy El-Mazzahy Damietta General Hospital

3. problem solving

10. Antenatal Assessment & Management (To be assessed at booking and repeated if admitted) 1.Age > 35 yrs 2.Obesity (BMI>30kg/m2) 3.Parity > 3 4 Smoker 5.MEDICAL CO-MORBIDITIES e.g. heart or lung disease; SLE; cancer; inflammatory conditions; Proteinuria >3g/24 hrs; Sickle Cell Disease . 6.Gross varicose veins 7.Current systemic infection 8.Immobility, e.g. paraplegia, SPD, long-haul travel 9.Pre-eclampsia 10. Dehydration/hyperemesis/OHSS 11.Multiple pregnancy or ART 12.Surgical procedure e.g. ERPC 3 or more risk factors 2 or more if admitted <3 risk factors Intermediate Risk Consider antenatal prophylaxis with LMWH Low Risk Mobilisation & avoidance of dehydration. Green-top Guideline April 2009

11. Timing of initiation of thromboprophylaxis

13. Which agents should be used for thromboprophylaxis?

16. RCOG Guideline April 2009 Thromboprophylaxis During Pregnancy Tinzaparin 20,000U/ml Enoxaparin (100 U/mg) weight 3500 U/d 4500 U/d 7000 U/d* 9000 u/d* 75u/kg/d* 4500U/12 h 175U/kg/12h (antenatal &postnatal) 20 mg/d 40 mg/d 60 mg/d* 80mg/d* 0.5mg/kg/d* 40 mg/12h 1mg/kg/12h (antenatal) 1.5 mg post Body weight < 50 kg Normal weight : 50–90 kg Body weight 91-130 kg Body weight 131-170 kg >170 kg Higher prophylactic dose(50-90kg) Treatment dose

17. Thromboprophylaxis after delivery

19. Postnatal Assessment & Management (to be assessed on Delivery Suite) 1.Age > 35 yrs 2.Obesity (BMI>30kg/m2) 3.Parity 3 4.Smoker 5. Elective Caesarean Section 6.MEDICAL CO-MORBIDITIES e.g. heart or lung disease; SLE; cancer; inflammatory conditions; Proteinuria >3g/24 hrs; Sickle Cell Disease; IVDU 7.Gross varicose veins 8. Current systemic infection 9. Immobility, e.g. paraplegia, SPD, long-haul travel 10 Pre-eclampsia 11.mid-cavity or rotational forceps 12.Prolonged labour (>24 hrs) 13.PPH > 1litre or Blood Transfusion 2 or more risk factors <2 risk factors Intermediate Risk At least 7 days postnatal prophylactic LMWH Low Risk EARLY Mobilisation and avoidance of dehydration. NB If persisting or > 3 risk factors consider extending prophylaxis with LMWH Green-top Guideline April 2009

22. When should thromboprophylaxis be interrupted for delivery?

25. Thank you