| ACCP[1] | SMFM[2] | ACOG[3] |
| Recommendations |
- Patients at low VTE risk (ie, no risk factors for VTE other than cesarean birth): Early ambulation.
- Patients at increased VTE risk:
- Pharmacologic thromboprophylaxis (prophylactic LMWH) while in the hospital following delivery.
- If anticoagulation is contraindicated, use mechanical prophylaxis (elastic stockings or intermittent pneumatic compression) while in the hospital following delivery.
- Patients at very high VTE risk:
- Prophylactic LMWH plus elastic stockings and/or intermittent pneumatic compression while in the hospital following delivery.
- If significant risk factors persist postpartum, prophylaxis is continued for up to 6 weeks following hospital discharge.
| - All patients: sequential compression devices starting before surgery and used continuously until the patient is fully ambulatory.
- Patients with a previous personal history of deep venous thrombosis or pulmonary embolism: both mechanical prophylaxis (starting preoperatively and continuing until ambulatory) and pharmacologic prophylaxis (for 6 weeks postoperatively).
- Patients with a personal history of an inherited thrombophilia (high-risk or low-risk) but no previous thrombosis: both mechanical prophylaxis (starting preoperatively and continuing until ambulatory) and pharmacologic prophylaxis (for 6 weeks postoperatively).
- Class 3 obesity (BMI ≥40 kg/m2): When pharmacologic thromboprophylaxis is needed, use intermediate doses of enoxaparin.
- Each institution should develop a patient safety bundle and institutional protocol for VTE prophylaxis for patients undergoing cesarean delivery.
| - All patients: Placement of pneumatic compression devices before cesarean delivery and early mobilization after cesarean delivery. Pneumatic compression devices are left in place until the patient is ambulatory.
- Patients with additional risk factors for thromboembolism require individual risk assessment, which may support thromboprophylaxis with pneumatic compression devices and low-molecular-weight heparin. In those with contraindications to anticoagulants, postpartum mechanical prophylaxis is advised.
|
| Definitions of risk |
| Increased VTE risk: one major or at least two minor risk factors, except in patients undergoing emergency cesarean birth in whom one minor risk factor is sufficient. Very high VTE risk: increased risk plus multiple additional risk factors for thromboembolism that persist in the puerperium. | | |
| Risk stratification |
Major risk factors: - Immobility (strict bed rest for 1 week in the antepartum period)
- Postpartum hemorrhage ≥1000 mL with surgery
- Previous VTE
- Preeclampsia with fetal growth restriction
- Thrombophilia (antithrombin deficiency, Factor V Leiden [homozygous or heterozygous], prothrombin G20210A [homozygous or heterozygous])
- Systemic lupus erythematosus
- Heart disease
- Sickle cell disease
- Blood transfusion
- Postpartum infection
| As described above (Recommendations) and clinicians should refer to standard sources for descriptions of additional risk factors for VTE. | As described above (Recommendations) and clinicians should refer to standard sources for descriptions of additional risk factors for VTE. |
Minor risk factors: - BMI >30 kg/m2
- Multiple pregnancy
- Postpartum hemorrhage >1000 mL
- Smoking >10 cigarettes/day
- Fetal growth restriction (<25th percentile)
- Thrombophilia (Protein C deficiency or Protein S deficiency)
- Preeclampsia
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