Venous Thromboembolism VTE Prophylaxis at Cesarean Section

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Venous Thromboembolism (VTE) Prophylaxis at
Cesarean Section

• Phillip N. Rauk, MD

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Surgical Care Improvement Project (SCIP Measures)

• Infection
• Cardiac
• Venous Thromboembolism
• Process Measures
• Prophylaxis ordered
• Prophylaxis received 24 hrs before to 24 hrs
  after surgery
• Outcome Measures
• PE (and DVT) diagnosed during hospitalization and
  within 30 days of surgery
• Respiratory

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Objectives

• Review the epidemiology of venous thromboembolism
  (VTE) in pregnancy
• Relate the pregnancy specific risks to
  nonpregnant patient population
• Discuss prophylaxis options

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Scope of the Problem

• VTE risk is increased in pregnancy and postpartum
  3-5 fold
• VTE is 3-10 fold higher after CS than vaginal
  delivery
• Pulmonary embolism (PE) - leading cause of
  maternal mortality in the 90s accounting for 20
  of deaths
• VTE Mortality rate 1.1/100,000 deliveries in
  2000-2001
• No pregnancy specific data related to prophylaxis
  in most situations
• Recommendations are extrapolated from
  non-pregnant populations

CDC 2003, James 2005
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VTE Risk Factors

• Prior VTE
• Thrombophilia
• Cancer
• Age gt40 yrs
• Obesity (BMIgt30)
• Tobbacco
• Estrogen Therapy
• Chronic Medical Disease
• Systemic Infection
• Vericose Veins

• Multiparity (gt4)
• Immobilization
• Bedrest
• Preeclampsia
• Postpartum Hemorrhage
• Cesarean Section

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Natural History of DVT Related to Surgery

• Majority develop in the calf during surgery
• 50 will resolve spontaneously within 72 hours
• 15 with extend into proximal veins
• 80 of symptomatic DVT involve proximal veins
  (majority of calf vein DVTs are asymptomatic)
• 50 in proximal veins will result in symptomatic
  pulmonary embolus
• 40-50 of proximal DVT have asymptomatic PE
• 10 of PEs are fatal within one hour of symptoms

Kearon, 2003
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Timing of DVT
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Incidence of VTE
Samama, 2006 ACCP, 2008
without prophylaxis
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Prophylaxis Based on Risk
ACCP, 2008
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VTE Incidence
Greer, 1999
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Risks of Heparin Prophylaxis

• Severe bleeding
• Incidence - 1/1000
• Heparin-induced thrombocytopenia (HIT)
• Incidence 1 probably lower in pregnancy
• Thrombosis develops (arterial or venous) in 30-50

Collins, 1988
Arepally, 2006
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VTE Associated with Cesarean Section

• the risk of VTE is higher after CS than after
  vaginal delivery. The presence of additional
  risk factors may exacerbate this risk. It has
  been recommended that GCS be used during and
  after cesarean section in patients at moderate
  risk and heparin prophylaxis be added in those
  at high risk. However there is insufficient
  data to provide information as to the benefits
  with these interventions.

ACCP 2004
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ACCP Cesarean Section Prophylaxis Recommendation

• without additional risk factors we recommend
  against the use of specific thromboprophylaxis
  other than early mobilization (Grade 1B)
• in the presence of at least one additional risk
  factor pharmacologic thromboprophylaxis or
  mechanical prophylaxis while in hospital
  recommended. (Grade 2C)

ACCP 2008
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Pneumatic Compression Device Prophylaxis for
Cesarean Section
Incidence per 10,000 Cesarean Sections
Quinones, 2005
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Pneumatic Compression Device Prophylaxis for
Cesarean Section

• Cost effective with following assumptions
• Incidence of DVT gt 6.8/1000
• 75 are asymptomatic
• DVT reduced gt 50
• Cost of PCD lt 180

Casele, 2006
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Graded Compression Stockings
Amaragiri, Cochrane Collaboration, 1999
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Limitations of Mechanical Devices

• Compliance
• Both GCS and PCD removed due to discomfort
• Improper fit
• Strangulation with GCS

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Cost of Mechanical Devices
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Summary

• Objective data to guide VTE prophylaxis for CS is
  very limited
• In the absence of data First do no Harm
• Individualize heparin therapy and reserve it for
  the highest risk patients previous VTE,
  thrombophilia, multiple risk factors (elderly
  gravida, obese, severe preeclampsia, at bed rest)
• Early ambulation alone is acceptable and
  recommended for many CS patients
• GCS or PCD are acceptable and may be cost
  effective