1. Thromboprophylaxis in Pregnancy and the Puerperium
Max Brinsmead PhD FRANZCOG
June 2015

2. Background
Pulmonary embolism is the leading cause of maternal deaths in developed countries
May be prevented by thromboprophylaxis measures
However, absolute risk is small (1-2 per 1000 pregnancies)
And only 1:100 patients with VTE will die
Some risks associated with therapy
So screening for treatment is required
And recommendations for some populations may not be universally applicable

3. Who requires thromboprophylaxis?
Any patients with any previous VTE
Except those that had a previous VTE related to major surgery and have no other risk factors
Any patient admitted to hospital with dehydration
e.g. associated with hyperemesis or OHSS
Any patient with 2 or more risk factors as per following tables

4. Who is at risk? Known thrombophilia Age >35 Para >3 BMI >30
Smokes
IV Drug user
Severe varicose veins (above knee, phlebitis or skin changes)
Medical condition e.g. active SLE, heart failure, cancer, nephropathy
Sickle cell disease
Paraplegia
Travel >4 hrs
Immobilisation >3d
IVF Pregnancy

5. Who is at risk (2)?
Dehydration e.g. hyperemesis gravidarum or OHSS
Pre eclampsia
Twins
Caesarean section (CS)
Emergency CS
Prolonged labour
Stillbirth
Midcavity assisted delivery
PPH requiring transfusion
Surgery or fracture in pregnancy or the puerperium
Any infection requiring admission to hospital or IV antibiotics
FOR 2 OF THE ABOVE GIVE CLEXANE FOR 10 days POSTNATAL
FOR 3 OF THE ABOVE CONSIDER ANTENATAL CLEXANE from 28 weeks
FOR 4 OF THE ABOVE CONSIDER CLEXANE NOW

6. High Risk Patients Any patient on long term anticoagualants
Patients with antithrombin deficiency
Patients with antiphospholipid syndrome
Patients with prior arterial thrombosis
Then
Early consultation with haematologist is desirable
Usually require higher dose Clexane (75% or full-dose)
Planned delivery with anaesthetic consultation desirable

7. Max Brinsmead PhD FRANZCOG January 2010

8. When should treatment be started and stopped?
As soon as possible for high risk antenatal patient
Therefore risk score at 1st opportunity
And again with every admission, then at delivery
A role for pre pregnancy counselling
Patients with personal or family history may benefit from testing for thrombophilia
Must stop if there is PV bleeding or onset of labour
All patients requiring antenatal therapy require postnatal therapy asap after delivery
Not within 12 hours of spinal anaesthetic or insertion or removal of an epidural catheter
Continue for 10 days minimum, and 6w if commenced in the antenatal period

9. What Drug and What Dose? Clexane is the drug of choice
Has no risk of thrombocytopenia or osteoporosis
Dose by patient weight
Use BD for larger doses
Prophylaxis postpartum
<50 Kg mg once dily
51 – 69 Kg 30 mg once daily
70 – 90 Kg mg once daily
91 – 130 Kg 30 mg 12 hourly
131 – 170 Kg 40 mg 12 hourly
Subtherapeutic doses do not need monitoring
Therapeutic dose is 1.0 mg/Kg per day antenatally and 1.5 mg/Kg per day in the puerperium

10. Who should NOT have Clexane or Heparin?
Those within 4 hours of spinal or epidural catheter
Allergy to LMWH
Patients with active bleeding
Patients at risk of bleeding e.g. Placenta previa
Thrombocytopenia (Platelet count <75)
Known bleeding diathesis e.g. Von Willebrands
Severe renal disease (GFR < 30 ml/min)
Severe liver disease
Uncontrolled Hypertension (>200/120)
Haemorrhagic stroke within 4w
NB Postnatal Clexane increases the risk of PPH and wound haematoma

11. Other Measures Early mobilisation and avoid dehydration for all
Stockings not proven by RCT to be effective
Thigh-length may be impractical and poorly tolerated
Even knee-length stockings have a limited role for the ambulant patient
Should be used in all patients with at least one risk factor until mobilising normally
Make sure that they are fitted correctly
Use intermittent calf compression for all pregnant patients undergoing surgery

12. Warfarin Generally contraindicated in the antenatal patient
Except for some patients with mechanical heart valves
Patients on Warfarin can be advised to switch to LMW Heparin as soon as they have a positive pregnancy test
Can be an alternative for a postnatal patient who requires long term therapy
Breast feeding is not contraindicated

13. See RCOG Greentop Guidelines
For more detailed guidelines and the treatment of venous thromboembolism in prgnancy
See RCOG Greentop Guidelines

14. Any Questions or Comments?
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