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Society for Maternal-Fetal Medicine Special Statement: Checklist for thromboembolism prophylaxis after cesarean delivery

      Venous thromboembolism (VTE) is a leading cause of potentially preventable maternal death.
      • Petersen E.E.
      • Davis N.L.
      • Goodman D.
      • et al.
      Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017.
      Cesarean delivery is associated with a 3- to 4-fold increased risk of developing VTE compared with vaginal delivery.
      • Blondon M.
      • Casini A.
      • Hoppe K.K.
      • Boehlen F.
      • Righini M.
      • Smith N.L.
      Risks of venous thromboembolism after cesarean sections: a meta-analysis.
      Routine postcesarean thromboprophylaxis can reduce the risk of maternal death from VTE.
      • Clark S.L.
      • Christmas J.T.
      • Frye D.R.
      • Meyers J.A.
      • Perlin J.B.
      Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage.
      The Society for Maternal-Fetal Medicine (SMFM) recently published guidelines for postcesarean thromboprophylaxis.
      • Pacheco L.D.
      • Saade G.
      • Metz T.D.
      Society for Maternal-Fetal Medicine (SMFM)
      Society for Maternal-Fetal Medicine Consult Series #51: Thromboembolism prophylaxis for cesarean delivery.
      Here we summarize the SMFM guidelines in a convenient 1-page checklist (Box) to help providers select the appropriate method for postcesarean thromboprophylaxis.
      Thromboembolism prophylaxis after cesarean delivery checklist
      Thromboembolism Prophylaxis After Cesarean Delivery
      Checklist following the Guidelines of SMFM Consult Series #51
      This checklist is a SAMPLE only and does not dictate an exclusive course of action for individual patients.
      For all cesarean deliveries:
      • □ Pneumatic sequential compression devices (SCDs) placed prior to surgery start
      • □ SCDs continued until patient is fully ambulatory
      For women with personal history of deep venous thrombosis or pulmonary embolism:
      • □ SCDs as above
      • □ Prophylactic low-molecular-weight heparin (eg, enoxaparin 40 mg SC daily); see section below for starting time; continue for 6 weeks postoperatively
      For women with inherited or acquired thrombophiliaa and no previous thrombosis:
      • □ SCDs as above
      • □ Prophylactic low-molecular-weight heparin (eg, enoxaparin 40 mg SC daily); see section below for starting time; continue for 6 weeks postoperatively
      For women with body mass index (BMI) 40 kg/m2 or greater (class 3 obesity) who have thrombophiliaa or history of deep venous thrombosis or pulmonary embolism:
      • □ SCDs as above
      • □ Intermediate-dose low-molecular-weight heparin (eg, enoxaparin 40 mg SC every 12 hours); see section below for starting time; continue for 6 weeks postoperatively
      For women with combinations of the above risk factors:
      • □ SCDs as above
      • □ Individualized management, such as intermediate-dose low-molecular-weight heparin (eg, enoxaparin 40 mg SC every 12 hours) or adjusted-dose (therapeutic) low-molecular-weight heparin (eg, enoxaparin 1 mg/kg SC every 12 hours); see section below for starting time; continue for 6 weeks post-operatively
      Timing of initial dose of postoperative low-molecular-weight heparin:
      • □ General anesthesia: at least 1 hour postoperatively.
      • □ Neuraxial anesthesia (spinal or epidural):
      • ○ Prophylactic low-molecular-weight heparin dose: at least 12 hours after placement of spinal needle or epidural catheter and at least 4 hours after removal of epidural catheter.
      • ○ Intermediate or therapeutic low-molecular-weight heparin dose: at least 24 hours after placement of spinal needle or epidural catheter and at least 4 hours after removal of epidural catheter.
      • □ In patients at very high risk for thromboembolism (eg, mechanical heart valve or recent extensive thrombosis), IV heparin starting 1 hour after removal of spinal needle or epidural catheter to avoid long periods without anticoagulation. Alternatively, consider general anesthesia.
      • □ Significant intraoperative bleeding: Individualize, balancing increased risk of thromboembolism after hemorrhage or transfusion versus risk of further bleeding. Consider unfractionated heparin.
      Version August 6, 2020.
      FVL, Factor V Leiden; IV, intravenous; MTHFR, methylenetetrahydrofolate reductase; PGM, prothrombin gene G20210A mutation; SC, subcutaneous, SMFM, Society for Maternal-Fetal Medicine.
      aThrombophilias include acquired (antiphospholipid syndrome), high-risk inherited (antithrombin deficiency, FVL homozygosity, PGM homozygosity, or heterozygosity for both FVL and PGM), and low-risk inherited (protein C deficiency, protein S deficiency, FVL heterozygosity, or PGM) disorders. MTHFR mutations are not considered thrombophilias.
      Society for Maternal-Fetal Medicine. SMFM Special Statement: Checklist for thromboembolism prophylaxis after cesarean delivery. Am J Obstet Gynecol 2020.
      Facilities may choose to implement this checklist by referencing it in the “sign out” portion of the cesarean delivery checklist, which typically includes a review of key concerns for recovery.
      • Haynes A.B.
      • Weiser T.G.
      • Berry W.R.
      • et al.
      A surgical safety checklist to reduce morbidity and mortality in a global population.
      Alternative methods of implementation can be considered, such as incorporating the checklist into the routine postcesarean order set or including it in a VTE prevention bundle.
      • Pacheco L.D.
      • Saade G.
      • Metz T.D.
      Society for Maternal-Fetal Medicine (SMFM)
      Society for Maternal-Fetal Medicine Consult Series #51: Thromboembolism prophylaxis for cesarean delivery.
      Reliance on memory alone to guide prophylaxis is likely to result in errors because the guidelines are somewhat complex.

      References

        • Petersen E.E.
        • Davis N.L.
        • Goodman D.
        • et al.
        Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 423-429
        • Blondon M.
        • Casini A.
        • Hoppe K.K.
        • Boehlen F.
        • Righini M.
        • Smith N.L.
        Risks of venous thromboembolism after cesarean sections: a meta-analysis.
        Chest. 2016; 150: 572-596
        • Clark S.L.
        • Christmas J.T.
        • Frye D.R.
        • Meyers J.A.
        • Perlin J.B.
        Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage.
        Am J Obstet Gynecol. 2014; 211: 32.e1-32.e9
        • Pacheco L.D.
        • Saade G.
        • Metz T.D.
        • Society for Maternal-Fetal Medicine (SMFM)
        Society for Maternal-Fetal Medicine Consult Series #51: Thromboembolism prophylaxis for cesarean delivery.
        Am J Obstet Gynecol. 2020; 222: B11-B17
        • Haynes A.B.
        • Weiser T.G.
        • Berry W.R.
        • et al.
        A surgical safety checklist to reduce morbidity and mortality in a global population.
        N Engl J Med. 2009; 360: 491-499