VTE Prophylaxis in Pregnancy (Green Top 2015)

Intro

-       Maternal deaths from VTE down from 1.56/100,000 to 0.70/100,000 due to prophylaxis

 

Which women with prior VTE require thrombophilia testing?

 

-       Prior to testing, counsel regarding implications for themselves and family

-       Test for AT deficiency if: FHx of VTE and either AT def known in family or a specific thrombophilia has not been detected in the family.

-       Test for APL Antibodies if: the prior VTE was unprovoked

 

Which women without prior VTE require thrombophilia testing?

 

-       Consider testing if: the woman has no personal history or RF’s for VTE but has a FHx of an unprovoked or estrogen-provoked VTE in a 1st degree relative when aged <50.

-       i.e. if it will change the risk score from 0 to 2.

 

prophylaxis

 

Previous VTE Alone (Remember to score any additional factors)

vte 1.png

 

Thrombophilia Alone (Remember to score any additional factors)

vte 2.png

 

Risk Scoring

vte 3.png
vte 4.png

 

A few notes on VTE Treatment in Pregnancy

(see full GTG 2015 guideline for details)

 

Diagnosis

-       Do not check D-dimer

-       No role for pre-test probability scores as not validated (ie Wells)

 

-       If DVT USS normal but clinical suspicion high, re-scan on days 3 and 7

-       No need to scan for PE if DVT already proven by USS

 

-       VQ higher risk of childhood cancer > CTPA.

-       CTPA higher risk of maternal breast cancer > VQ.

-       Absolute risks of both are very small

 

Treatment

-       LMWH dose should be calculated on booking weight

-       Consider monitor Anti-Xa if weight <50kg or >90kg

-       Continue through pregnancy and for 6 weeks postpartum, or for three months – whichever is the longer duration

 

Delivery

-       If VTE occurs at term, consider UFH infusion

-       Stop LMWH at start of labour, or 24 hours prior to a planned delivery,

-       Neuroaxial anaesthetic should not be performed until 24 hours after last dose of LMWH, and next dose should not be given until 4 hours after the procedure. The catheter should not be removed within 12 hours after the last dose.