SMFM Guidance: VTE Prophylaxis and Cesarean Delivery

SUMMARY:

SMFM has released guidance on VTE prophylaxis in the setting of cesarean delivery. The following recommendations are based on best available evidence, while recognizing that there are still many areas that warrant further research. SMFM has also released a checklist for thromboembolism prophylaxis after cesarean delivery (see link in ‘References’)

Cesarean Delivery VTE Prophylaxis

• All women should receive (“recommend”)
  • Mechanical sequential compression devices (preop until ambulatory)
• Previous history of DVT or PE (“suggest”)
  • Mechanical (preop until ambulatory) and
  • Pharmacological (continue for 6 weeks postop)
• Personal history of an inherited thrombophilia (high risk and low risk) but no previous thrombosis (for thrombophilia definitions and ACOG recommended prophylaxis, see ‘Related ObG Topics’ below)
  • Mechanical (preop until ambulatory) and
  • Pharmacological (continue for 6 weeks postop)

Pharmacological Agents

First Line in Pregnancy And Postpartum: LMWH (Recommend)

• Enoxaparin (provided as an example)
  • Dose: 40 mg subcutaneous daily | Class III Obesity use 40 mg subcutaneous q12 hours
  • Benefit of LMWH vs UFH
    • Better bioavailability
    • Longer half-life
    • Anticoagulation effect more predictable
    • Reduced risk for bleeding and heparin-induced thrombocytopenia and osteopenia
  • Caution in patients with renal impairment: Do not use enoxaparin in patients with creatine clearance <30 mL/min

UFH

• Prophylaxis dosing
  • First trimester: 5000 units subcutaneously q12 hours
  • Second trimester: 7500 units subcutaneously q12 hours
  • Third trimester: 10,000 units subcutaneously q12 hours
  • Postpartum: 5000 units subcutaneously q8 to 12 hours

New Oral Anticoagulants (apixaban, rivaroxaban, dabigatran)

• Insufficient data to make a recommendation during the postpartum period

KEY POINTS:

When to Start Pharmacological Agents

To Minimize Risk for Spinal Hematoma

• Enoxaparin
  • 40 mg subcutaneous daily: Start 4 hours after catheter removal but not <12 hours after block was performed
  • 40 mg subcutaneously q12 hours and therapeutic doses: Start ≥4 hours after catheter removal but not <24 hours after block was performed
• UFH (prophylactic doses): ≥1 hour after removal of the neuraxial catheter

To Minimize Risk for Postop Bleeding

• Prophylactic dosing, vs therapeutic dosing usually does not result in serious postop bleeding | Complications if they occur are usually mild (e.g., wound hematoma)
• However, in the setting of intraoperative bleeding
  • Individualize when to start VTE prophylaxis
  • SMFM states “in these cases, initiation of UFH, which is reversible and has a shorter half-life, may be prudent”  

Learn More – Primary Sources:

SMFM  Consult Series 51: Thromboembolism Prophylaxis for Cesarean Delivery

SMFM Special Statement: Checklist for thromboembolism prophylaxis after cesarean delivery