Is Lovenox (enoxaparin) routinely administered after a cesarean section (C-section)?

Lovenox After Cesarean Section: Recommendations for Thromboprophylaxis

Lovenox (enoxaparin) is not routinely administered after all cesarean sections but should be given to women with specific risk factors for venous thromboembolism (VTE). 1

Risk-Based Approach to Thromboprophylaxis

The decision to administer Lovenox after cesarean section follows a risk-stratified approach:

For Women Without Risk Factors:

• Mechanical prophylaxis only - Sequential compression devices should be used in all women undergoing cesarean delivery until fully ambulatory 1
• Early mobilization is recommended 1
• No pharmacologic prophylaxis is recommended 1

For Women With Risk Factors:

Pharmacologic thromboprophylaxis with Lovenox should be administered to:

1. High-risk patients:

   • Women with prior history of VTE
   • Women with inherited thrombophilia (either high-risk or low-risk)
   • Women with multiple risk factors that persist postpartum 1

2. Moderate-risk patients (presence of one major or at least two minor risk factors):

   • Prophylactic LMWH (Lovenox) is suggested while in hospital following delivery 1

Dosing and Administration

When Lovenox is indicated after cesarean section:

• Standard prophylactic dose: 40 mg subcutaneously once daily 1
• For obese women: Consider intermediate doses (40 mg subcutaneously every 12 hours) or weight-based dosing (0.5 mg/kg subcutaneously every 12 hours) for class III obesity 1

Timing of Administration

The timing of Lovenox administration after cesarean section is critical, especially with neuraxial anesthesia:

• Prophylactic doses may be started as early as 4 hours after epidural catheter removal
• Must not be started earlier than 12 hours after the neuraxial block was performed 1
• In cases of significant intraoperative bleeding, timing should be adjusted with consideration of bleeding risk 1

Duration of Prophylaxis

• For most patients requiring pharmacologic prophylaxis: Continue while in hospital
• For selected high-risk patients with persistent risk factors: Extended prophylaxis for up to 6 weeks after delivery 1

Safety Considerations

Research shows that early administration of Lovenox after cesarean section appears to be reasonably safe:

• No cases of spinal epidural hematoma were reported in a study of 578 women who received enoxaparin within 24 hours of cesarean section 2
• Wound complications may be slightly increased with enoxaparin use (wound separation 6.8% vs 3.6% in controls) 3
• The benefit of preventing potentially fatal VTE outweighs the risk of minor bleeding complications in high-risk patients 1

Common Pitfalls to Avoid

1. Failure to risk-stratify patients - Not all women need pharmacologic prophylaxis after cesarean section
2. Inappropriate timing with neuraxial anesthesia - Starting Lovenox too soon after epidural placement/removal increases risk of spinal hematoma
3. Overlooking persistent risk factors - Some patients require extended prophylaxis beyond hospital discharge
4. One-size-fits-all dosing - Obese patients may require adjusted dosing regimens

Lovenox remains the preferred thromboprophylactic agent in pregnancy and postpartum periods due to its better bioavailability, longer half-life, more predictable anticoagulation effect, and lower risk of heparin-induced thrombocytopenia compared to unfractionated heparin 1.