Perioperative management of women on oral anticoagulants and antiplatelet agents

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 3 – C O R E S U R G I C A L S K I L L S

Perioperative Management of Women on Oral Anticoagulants and Antiplatelet Agents Goh E et al. Perioperative management of women on oral anticoagulants and antiplatelet agents undergoing gynaecological procedures. TOG 2022;22:131–136. doi:10.1111/tog.12650

10–15% ≥7 days 5 days AF PATIENTS NEEDING TEMPORARY RECOMMENDED PREOP ASSESSMENT BEFORE WARFARIN STOPPED PREOP, ALL BLEEDING INTERRUPTION FOR ELECTIVE SURGERY SURGERY RISKS

DO N' T-M IS S FA C TS

1. Warfarin: stop 5 days preop (all risk levels); bridge with treatment-dose LMWH only if high thrombotic risk (Box 1)

2. Bridging LMWH restart delayed ≥48h after high bleeding-risk surgery; warfarin restart evening/next day if haemostasis adequate

3. Apixaban/rivaroxaban/edoxaban share one stop schedule by CrCl; dabigatran stratified separately (higher renal clearance, 80%)

4. Aspirin monotherapy – continue for gynae procedures; dual antiplatelet post-ACS/stent – postpone surgery ≥6 months if possible

5. Emergency warfarin reversal: 5 mg IV phytomenadione (6–8h available) or 25–50 u/kg 4-factor PCC (cannot wait)

6. Idarucizumab reverses dabigatran; no reversal agent for clopidogrel (effect lasts 7–9 days) — use tranexamic acid ± donor platelets

7. Neuraxial block: aspirin/NSAIDs need not stop; ADP antagonists stopped 7 days prior (treat as high bleeding risk)

8. Box 2 bleeding risk: no risk = smear/exam/swabs; minor = LLETZ, hysteroscopy, Pipelle, polypectomy, vulval/cervical biopsy; major = all day-case/inpatient surgery

QUICK AGENT SNAPSHOT

Aspirin: continue Warfarin: stop 5d Apixaban/rivaroxaban/edoxaban: stop 24–72h by CrCl

Dabigatran: stop 24–96h by CrCl Clopidogrel: 7d if high risk

ABBREVIATION KEY

DOAC — direct oral anticoagulant (previously novel oral ADP — adenosine diphosphate anticoagulant) NIC — net ingredient cost INR — international normalised ratio LLETZ — large loop excision of the transformation zone LMWH — low-molecular-weight heparin NSAID — nonsteroidal anti-inflammatory drug VTE — venous thromboembolism PCC — prothrombin complex concentrate TIA — transient ischaemic attack

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — procedures. TOG 2022;22:131–136. doi:10.1111/tog.12650

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