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Venous Thromboembolism VTE Prophylaxis at Cesarean Section

Surgical Care Improvement Project (SCIP Measures). InfectionCardiacVenous ThromboembolismProcess Measures Prophylaxis orderedProphylaxis received 24 hrs before to 24 hrs after surgeryOutcome MeasuresPE (and DVT) diagnosed during hospitalization and within 30 days of surgery Respiratory. Obje

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Venous Thromboembolism VTE Prophylaxis at Cesarean Section

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    1. Venous Thromboembolism (VTE) Prophylaxis at Cesarean Section Phillip N. Rauk, MD

    2. 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

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

    4. “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 90’s 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

    5. VTE Risk Factors Prior VTE Thrombophilia Cancer Age >40 yrs Obesity (BMI>30) Tobbacco Estrogen Therapy Chronic Medical Disease Systemic Infection Vericose Veins Multiparity (>4) Immobilization Bedrest Preeclampsia Postpartum Hemorrhage Cesarean Section

    6. 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 DVT’s are asymptomatic) 50% in proximal veins will result in symptomatic pulmonary embolus 40-50% of proximal DVT have asymptomatic PE 10% of PE’s are fatal within one hour of symptoms

    7. Timing of DVT James – DVT only , multicenter registry Heit population , Blanco Molina multicenter registryJames – DVT only , multicenter registry Heit population , Blanco Molina multicenter registry

    8. Incidence of VTE

    9. Prophylaxis Based on Risk

    10. VTE Incidence

    11. 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%

    12. 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.”

    13. 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)

    14. Pneumatic Compression Device Prophylaxis for Cesarean Section Decision analysisDecision analysis

    15. Pneumatic Compression Device Prophylaxis for Cesarean Section Cost effective with following assumptions Incidence of DVT > 6.8/1000 75% are asymptomatic DVT reduced > 50% Cost of PCD < $180 Cost effective ,$50,000 per quality yearCost effective ,$50,000 per quality year

    16. Graded Compression Stockings nonpregnantnonpregnant

    17. Limitations of Mechanical Devices Compliance Both GCS and PCD removed due to discomfort Improper fit “Strangulation” with GCS

    18. Cost of Mechanical Devices

    20. 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

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