Managing VTE risk in CD
Recognizing that VTE is a major cause of maternal morbidity and mortality, as well as the variety of the published guidelines for VTE prophylaxis after CD, the SMFM Consult Series provides recommendations to assist clinicians caring for postpartum women after CD. As reviewed in the ACOG Practice Bulletin, there are good data to support pharmacologic prophylaxis during pregnancy and the postpartum period for women with a history of VTE or a thrombophilia. Solid evidence is lacking, however, for what to do for women who have a CD without this history but may have other potential risk factors for VTE, such as obesity, preeclampsia, and transfusion requirement. Universal pharmacologic prophylaxis also is not yet supported by evidence. SMFM supports LMWH as the preferred medication in pregnancy and postpartum and provides these additional recommendations:
- All women who have a CD should have sequential compression devices (SCDs) placed prior to surgery and continued until they are ambulatory.
- Women with a history of VTE or thrombophilia without history of VTE should have SCDs and pharmacologic VTE prophylaxis for 6 weeks postpartum.
- Intermediate dosing of LMWH is recommended for patients with class III obesity.
- Institutions should develop patient safety bundles for VTE prophylaxis to identify additional risk factors that may warrant pharmacologic prophylaxis after CD in select patients.
Our approach to patients with COVID-19 infection
At our institution, we recently incorporated a VTE prophylaxis protocol into our electronic medical record that provides risk stratification for each patient. In addition to the above recommendations, our patients may qualify for short-term in-house or longer postpartum prophylaxis depending on risk factors.
A new risk factor in recent months is COVID-19 infection, which appears to increase the risk of coagulopathy, especially in patients with disease severe enough to warrant hospitalization. Given the potential for additive risk in pregnancy, in consult with our medicine colleagues, we have placed some of our more ill hospitalized pregnant patients on a course of prophylactic LMWH both in the hospital and after discharge independent of delivery status or mode of delivery. ●
WHAT THIS EVIDENCE MEANS FOR PRACTICE
- Pregnant patients with a history of VTE or a thrombophilia may be candidates for pharmacologic anticoagulation during pregnancy and/or postpartum.
- LMWH is the preferred method of pharmacologic VTE prophylaxis during pregnancy and postpartum.
- For most patients, CD and neuraxial anesthesia safely can be performed 12 to 24 hours after the last dose of prophylactic or intermediate LMWH, respectively.
- All patients undergoing CD should have at least mechanical VTE prophylaxis with SCDs.
- All women who have a CD should be evaluated via institutional patient safety bundles for VTE prophylaxis for additional risk factors that potentially warrant postpartum pharmacologic VTE prophylaxis.
- More data are needed to determine recommendations for universal/ near universal pharmacologic VTE prophylaxis in the postpartum period.
- Pregnant or postpartum patients with moderate to severe COVID-19 infection may be at increased risk for VTE, warranting consideration of additional pharmacologic prophylaxis.