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 regimens

 

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 for prophylaxis

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.