Thromboprophylaxis in gynaecology

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 4 – P O S T O P E R AT I V E C A R E

Thromboprophylaxis in Gynaecology Nambiar D et al. Thromboprophylaxis in gynaecology: a review of current evidence. TOG 2023;25:59–71. doi:10.1111/tog.12849

50–60% 17–40% £640m/yr VTE EVENTS THAT ARE HOSPITAL-ACQUIRED DVT AFTER MAJOR ABDOMINAL SURGERY, NO NHS ANNUAL COST OF VTE (HAT) PROPHYLAXIS

DO N' T-M IS S FA C TS

  1. HAT = 50–60% of all VTE; unprophylaxed major abdominal surgery DVT 17–40%

  2. RCOG score ≥4 or previous non-surgical VTE → pharmacological prophylaxis ASAP in first trimester; any surgery in pregnancy/puerperium scores 3 → minimum 10 days LMWH

  3. OHSS + IVF pregnancy = 100-fold VTE risk (vs 5-fold without OHSS); can present weeks after OHSS resolves, at unusual (upper limb/arterial) sites

  4. CHC: stop 4 weeks pre-op, restart ≥2 weeks after full mobility. HRT: do not stop before surgery

  5. GCS ankle pressure 18 mmHg; avoid pharmacological prophylaxis within 12h before/4h after spinal/epidural/lumbar puncture

  6. Bleeding contraindications: platelets <75×10⁵/L, BP ≥230/120, active bleeding, acute stroke

  7. LMWH is porcine-derived — offer fondaparinux/DOAC if this matters to the patient

  8. Caprini score bands: 0 = ambulation/IPC/GCS; 1–4 = IPC±GCS; 5–8 = IPC+LMWH 7–10 days; ≥9 = IPC+LMWH 30 days

PERIOPERATIVE HORMONES AT A GLANCE

HRT: continue, no need to stop CHC: stop 4wk pre-op, restart ≥2wk post-mobility

DOAC REVERSAL

Dabigatran → idarucizumab Apixaban/rivaroxaban → andexanet alfa Nonspecific: PCC / activated PCC

ABBREVIATION KEY

VTE — venous thromboembolism HRT — hormone replacement therapy

DVT — deep vein thrombosis BMI — body mass index

PE — pulmonary embolism BNF — British National Formulary

HAT — hospital-acquired/hospital-associated thrombosis SOGC — Society of Obstetricians and Gynaecologists of Canada

NHS — National Health Service COVID-19 — coronavirus disease 2019

NICE — National Institute for Health and Care Excellence GCS — graduated compression stockings

RCOG — Royal College of Obstetricians and Gynaecologists TED — thromboembolus deterrent (stockings)

CQUIN — Commissioning for Quality and Innovation IPC — intermittent pneumatic compression

MBRRACE-UK — Mothers and Babies: Reducing Risk through RCT — randomised controlled trial Audits and Confidential Enquiries across the UK LMWH — low-molecular-weight heparin OHSS — ovarian hyperstimulation syndrome UFH — unfractionated heparin IVF — in vitro fertilisation LDUH — low-dose unfractionated heparin MIS — minimally invasive surgery HIT — heparin-induced thrombocytopaenia CHC — combined hormonal contraception DOAC — direct oral anticoagulant PCC — prothrombin complex concentrate COPD — chronic obstructive pulmonary disease

ACOG — American College of Obstetricians and Gynecologists CI — confidence interval

ACCP — American College of Chest Physicians OR — odds ratio

WLCS — well leg compartment syndrome POP — pelvic organ prolapse

MI — myocardial infarction

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — doi:10.1111/tog.12849

Clinically reviewed by NHS obstetricians and gynaecologists

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