ACOG Recommendations for Prevention of Venous Thromboembolism in Gynecologic Surgery

SUMMARY:

All patients should undergo venous thromboembolism (VTE) risk assessment prior to gynecologic surgery via Caprini Score (see ‘Learn More – Primary Sources’ below). Consider a weight-adjusted dosage regimen for obese patients undergoing gynecologic surgery.

Risk Factors for Major Bleeding Complications (CHEST guidelines)

  • Hematologic
    • Active bleeding
    • Previous major bleeding
    • Known, untreated bleeding disorder
    • Thrombocytopenia
    • Concomitant use of anticoagulants, antiplatelet therapy, or thrombolytic drugs
  • Medical issues
    • Acute stroke
    • Malignancy
    • Severe renal or hepatic failure
    • Uncontrolled systemic hypertension
  • Surgical / Procedures
    • Complex surgery: ≥2 procedures | Difficult dissection | ≥1 anastomosis
    • Lumbar puncture, epidural, or spinal anesthesia within previous 4 hours or next 12 hours

Low Risk Patients (1.5% risk for VTE)

  • Includes minimally invasive patients with benign conditions
  • Mechanic thromboprophylaxis via intermittent pneumatic compression devices (SCDs)
  • Graduated compression stockings reasonable alternative if SCDs not available

Moderate Risk Patients (3.0% risk for VTE)

  • If patient is not at increased risk of bleeding complications
    • Mechanical prophylaxis via SCDs or pharmacologic prophylaxis via low-dose unfractionated heparin (LDUH) or low molecular weight heparin (LMWH)
  • If patient has high risk of major bleeding complications
    • Mechanical prophylaxis via SCDs is recommended

High Risk Patients (6.0% risk for VTE) 

  • If patients have average risk of bleeding complications
    • Dual thromboprophylaxis: SCDs and pharmacologic prophylaxis recommended (via LDUH or LMWH)
  • Patients undergoing cancer related surgery who are at high risk of VTE
    • Should get dual thromboprophylaxis in the hospital
    • Discharge home with extended pharmacologic prophylaxis with LMWH (28 days)
  • If patient at high risk of bleeding complications
    • Use mechanic prophylaxis until pharmacologic prophylaxis can be added
  • If LMWH or LDUH contraindicated or not available
    • Not at high risk of bleeding complications: Use fondaparinux and/or mechanical prophylaxis
    • If patient is at high risk of bleeding complications: Mechanical prophylaxis only

Hormonal Use in Perioperative Period

  • Combined OCPs contraindicated if patient is undergoing major surgery with prolonged immobilization
  • Menopausal hormonal therapy use should be individualized with shared decision making

Additional Considerations

  • If patient has experienced a VTE in perioperative period, routine thrombophilia testing not warranted
  • Neuraxial anesthesia
    • LDUH prophylaxis
      • Should be administered 4 to 6 hours before catheter placement/removal,
      • Can be administered immediately after removal postoperatively
    • LMWH prophylaxis
      • Should be administered at least 12 hours before catheter placement/removal
      • Should be delayed 4 hours after catheter removal
      • Should not be used twice-daily in patients with catheter in place

CAPRINI SCORE FOR DVT RISK

Scoring 

  • 0: Lowest Risk
  • 1-2: Low Risk
  • 3-4: Moderate Risk
  • 5-6: High Risk
  • ≥9: Highest Risk

Reference 

Prevention of VTE in Nonorthopedic Surgical Patients – PMC (nih.gov)

Learn More – Primary Sources:

ACOG Practice Bulletin: Prevention of Venous Thromboembolism in Gynecologic Surgery

Caprini Score: Prevention of VTE in Nonorthopedic Surgical Patients Table 7

Completion of the Updated Caprini Risk Assessment Model (2013 Version)

Caprini Score for Venous Thromboembolism – MDCalc