RCOG Guidelines 2004 Summary

RCOG Guidelines, 2004
Prof Aboubakr Elnashar
Email: elnashar53@hotmail.com
ABOUBAKR ELNASHAR

 Pregnancy is a risk factor for VTE & is associated
with a10-fold increase
 Some women are at even higher risk [they have
one or more additional risk factors].
 All women should undergo an assessment of risk
factors in early pregnancy or before pregnancy {why?}
 Assessment should be repeated if the woman is
admitted to hospital or develops other intercurrent
problems.
C
ABOUBAKR ELNASHAR

Pre-existing
1. Previous VTE
2. Thrombophylia
3. Age above 35
4. Obesity (BMI >30 kg/m2)
5. Parity > 4
6. Gross VV
7. Paraplegia
8. Sickle cell disease
9. Inflammatory bowel disease
10.Nephrotic syndrome
New onset or transient
1. Surgery
2. Hyperemisis
3. Dehydration
4. OHSS
5. Severe infection e.g Pyelonephritis
6. Immobility (>4 d bed rest)
7. PET
8. Excessive Blood loss
9. Long-haul travel
10.Prolonged labor
11.Midcavity instrumental delivery
12.Immobility after delivery
Risk factors for VTE in pregnancy & puerperium
ABOUBAKR ELNASHAR

 Women with a previous VTE
should have:
1. Careful history
2. Screening for thrombophilia {?}
ideally before pregnancy.
B
ABOUBAKR ELNASHAR

 Regardless of their risk of VTE,
immobilization should be minimized and
 dehydration should be avoided.
Good Practice Point (GPP)
ABOUBAKR ELNASHAR

1. Women with a previous VTE
and no thrombophilia
 Antenatal prophylaxis with LMWH
1. Recurrent VTE or
2. Family history of VTE in a first-degree
relative
3. Unusual site (axillary)
• Postnatal prophylaxis with LMWH for 6 w
for all.
C
ABOUBAKR ELNASHAR

 Antenatal prophylaxis with LMWH and
postnatal for at least 6 w B
2. Women with a previous VTE
who have inherited thrombophilia
ABOUBAKR ELNASHAR

{risk of VTE is lower in women with no history of VTE}
 Antenatal thromboprophylaxis:
depend on:
type of thrombophilia
presence of other risk factors.
Indicated in:
1. combined defects,
2. homozygous defects
3. antithrombin deficiency.
• Post natal prophylaxis for 6 w in all
3. Women with no history of VTE but
with thrombophylia
C
ABOUBAKR ELNASHAR

4. Women with Antiphospholipid
syndrome {?}
Antenatal LMWH
Low-dose aspirin {improve pregnancy
outcome} for all women.
 History of thromboses
Postnatal prophylaxis for 6 w with LMWH.
 No history of thrombosis:
Postnatal for 3-5 d
ABOUBAKR ELNASHAR

• For diagnosis: 2
1 of 2 clinical criteria (thrombosis or
pregnancy morbidity) &
1 of 2 laboratory criteria (medium to high
titer of aCL or positive LA)
• For treatment: 2
low dose aspirin & heparin starting with
positive pregnancy test till 34 w.
ABOUBAKR ELNASHAR

 2 risk factors
Postnatal LMWH for 3-5 d after vaginal delivery.
 3 risk factors
Antenatal prophylaxis & postnatal for 3-5 d
 An extremely obese woman admitted to the
antenatal ward.
Antenatal prophylaxis with LMWH
 Age >35 yrs or BMI >30K/m2 or wt >90 kg with
any other risk factor
Postnatal prophylaxis for 3-5 d
5. Women without previous VTE
or thrombophilia
GPP
ABOUBAKR ELNASHAR

6. Air travelling
Risk factor Short haul flight <4
hours
Long haul flight
>4hours
No added risk Move around cabin
Avoid dehydration
Minimise coffee
The same+
Well fitted below knee elastic
stockings.
Added risk
factors
The same +
Well fitted below knee elastic
stockings.
LMWH pre-flight & the day
after . Or
75 mg Aspirin 3 days before & on
day of travel.
ABOUBAKR ELNASHAR

7. OHSS
Thromboprophylaxis for at least the period
of inpatient stay.
Women with multiple risk factors for VTE and at risk of
OHSS undergoing ovulation induction may also be
considered for thromboprophylaxis.
ABOUBAKR ELNASHAR

Antepartum
 Antenatal thromboprophylaxis should begin as early
in pregnancy as practical. {VTE during pregnancy has an equal
distribution throughout gestation}
 it should continue until delivery unless a specific
risk factor is removed or disappears.
B
ABOUBAKR ELNASHAR

Postpartum
 Postpartum thromboprophylaxis should be given as
soon as possible after delivery, provided that there is
no postpartum
hge.
 Those with postpartum hge should be fitted with
thromboembolic deterrent stockings.
 For 6 w in high-risk women.
 For 3-5 d in low risk.
B
ABOUBAKR ELNASHAR

 If the woman has been given regional
analgesia: LMWH should be withheld until 4 hrs
after insertion or removal of the epidural
catheter
(6 hrs if either insertion or removal were
traumatic).
 The first postpartum dose can be given after
insertion but before removal of the epidural
catheter.
ABOUBAKR ELNASHAR

 COC
should not be prescribed during the first 3 months
postpartum for women with other risk factors for
VTE.
ABOUBAKR ELNASHAR

LMWH
 Antenatal:
Agents of choice {as effective as & safer than
UFH in pregnancy: thrombocytopenia,
osteoporosis & fractures are less}
 Postpartum:
Agent of choice for
women who had LMWH antenatally or
those requiring only 3-5 d.
 Breast feeding:
Enoxaparin has no adverse effects
B
ABOUBAKR ELNASHAR

 Monitoring
1. Peak anti-Xa activity is not recommended
except in women
at extremes of B wt (<50 kg or >90 kg) or
with other complicating factors (e.g. renal
impairment or recurrent VTE) putting them at
high risk.
2. Platelet count should not be carried out (unless
UFH has been given).
ABOUBAKR ELNASHAR

Low-dose aspirin
 Safe in pregnancy, although its use for
thromboprophylaxis has never been assessed
by RCT.
 May be appropriate where the risk of VTE is
increased but is not high enough to warrant the
use of LMWH
e.g. previous VTE without thrombophilia.
ABOUBAKR ELNASHAR

Warfarin
 Should be avoided if possible during
pregnancy, especially between6 & 12 w of
gestation
{Teratogenesis (5%)
Miscarriage,
Fetal and maternal haemorrhage,
Neurological problems in the baby
Stillbirth}.
B
ABOUBAKR ELNASHAR

 Safe: after delivery & breastfeeding
 Requires :
1. Close monitoring,
2. Frequent visits to an anticoagulant clinic
 Increased risk of:
1. Postpartum hge
2. Perineal haematoma.
 Not appropriate for 3-5 d of postpartum
prophylaxis.
 Should be initiated on 2nd or 3rd postnatal day.
B
ABOUBAKR ELNASHAR

Dextran
 Should not be used
{risk of anaphylaxis, which has killed
fetuses by causing :
1. Massive histamine release &
2. Uterine hypertonus}.
ABOUBAKR ELNASHAR

Graduated elastic compression stockings
 Class-II below knee:
Previous VTE or thrombophilia:
throughout pregnancy & for 6–12 w after delivery.
 Class-I:
Hospital inpatients at increased risk of VTE
Pregnant women traveling by air.
ABOUBAKR ELNASHAR

Anticoagulant therapy during labour and delivery
 Once she is established in labour or thinks that she is
in labour: no further heparin.
 Planned delivery: LMWH should be discontinued 24
hrs before.
 Regional anaesthetic or analgesic techniques: should
not be undertaken until at least 24 hrs after the last
dose of therapeutic LMWH.
 A thromboprophylactic dose of LMWH: 3 hrs after CS
(>4 hrs after removal of the epidural catheter).
 The epidural catheter: should not be removed within
12 hrs of the most recent injection.
GPPABOUBAKR ELNASHAR

Women at high risk of hge with risk factors including:
1. Major antepartum hge,
2. Coagulopathy,
3. Progressive wound haematoma,
4. Suspected intraabdominal bleeding
5. Postpartum hge
managed UFH
{shorter half-life than LMWH,
more experience in the use of protamine sulphate to
reverse its activity}.
 Excess blood loss & blood transfusion are risk
factors for VTE, so thromboprophylaxis should be
commenced or reinstituted as soon as the immediate
risk of hge is reduced.
ABOUBAKR ELNASHAR

LMWHUFH
1000-100003000-30000Mol Wt range
4000-500012000-15000Mo Wt average
2:1-4:11:1AntiXa: antiIIa activity
NoYesaPTT monitoring required
NoYesInactivation by platelet factor 4
YesNoCapable of inactivation of platelet
bound factor Xa
++++++Inhibition of platelet function
NoYesIncrease vascular permeability
+++++Protein binding
-+++Endothelial cell binding
NoYesDose dependent clearance
2-5 times longer50-20 minElimination half life ABOUBAKR ELNASHAR

 All women should undergo an assessment of risk
factors for VTE in early pregnancy or before
pregnancy. This assessment should be repeated if the
woman is admitted to hospital or develops other
intercurrent problems.
 Women with previous VTE should be screened for
inherited and acquired thrombophilia, ideally before
pregnancy.
 Regardless of their risk of VTE, immobilization of
women during pregnancy, labour and the puerperium
should be minimized and dehydration should be
avoided.
C
B
GP
PABOUBAKR ELNASHAR

Women with previous VTE should be offered
postpartum thromboprophylaxis with LMWH. It may be
reasonable not to use antenatal thromboprophylaxis with
heparin in women with a single previous VTE
associated with a temporary risk factor that has now
resolved
Women with previous recurrent VTE or a previous VTE
and a family history of VTE in a first-degree relative
should be offered thromboprophylaxis with LMWH
antenatally, and for at least 6 w postpartum.
C
ABOUBAKR ELNASHAR

C
 Women with previous VTE and thrombophilia should be offered
thromboprophylaxis with LMWH antenatally and for at least 6 w
postpartum.
 Women with asymptomatic inherited or acquired thrombophilia
may qualify for antenatal or postnatal thromboprophylaxis,
depending on the specific thrombophilia and the presence of other
risk factors.
 Women with three or more persisting risk factors should be
considered for thromboprophylaxis with LMWH antenatally and for
3-5 d postpartum.
B
C
ABOUBAKR ELNASHAR

 Women should be reassessed before or during labour
for risk for VTE. Age over 35 yrs and BMI >30/body
weight greater than 90 kg are important independent
risk factors for postpartum VTE even after vaginal
delivery. The combination of either of risk factors
(Age over 35 years and BMI greater than30/body
weight greater than 90 kg) with any other risk factor for
VTE (PETor immobility) or the presence of 2 other
persisting risk factorsLMWH for 3-5 d postpartum.
 Antenatal thromboprophylaxis should begin as early in
pregnancy as practical. Postpartum prophylaxis
should begin as soon as possible after delivery.
B
GPP
ABOUBAKR ELNASHAR

 LMWHs are agents of choice for antenatal
thromboprophylaxis. They are as effective as and safer
than UFH in pregnancy.
 Warfarin should usually be avoided during pregnancy. It is
safe after delivery and during breastfeeding.
 Once the woman is in labour or thinks she is in labour,
she should be advised not to inject any further heparin.
She should be reassessed on admission to hospital and
further doses should be prescribed by medical staff.
GPP
B
B
ABOUBAKR ELNASHAR

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