Thromboprophylaxis Recommendations for Term Pregnancy Undergoing LSCS
For women undergoing cesarean section without additional thrombosis risk factors, mechanical prophylaxis with sequential compression devices starting preoperatively and continuing until fully ambulatory is recommended, without the need for pharmacologic prophylaxis. 1
Risk Assessment and Prophylaxis Algorithm
Low Risk (No Additional Risk Factors)
- Use sequential compression devices starting preoperatively and continuing until fully ambulatory
- Early mobilization
- No pharmacologic prophylaxis needed
Increased Risk (One Major or ≥2 Minor Risk Factors)
- Use sequential compression devices starting preoperatively and continuing until fully ambulatory
- PLUS pharmacologic prophylaxis with LMWH while in hospital
- OR mechanical prophylaxis (elastic stockings or intermittent pneumatic compression) if contraindications to anticoagulants exist
High Risk (Previous VTE or Thrombophilia)
- Use sequential compression devices starting preoperatively and continuing until fully ambulatory
- PLUS pharmacologic prophylaxis with LMWH for 6 weeks postoperatively
Very High Risk (Multiple Risk Factors Persisting in Puerperium)
- Combine prophylactic LMWH with elastic stockings and/or intermittent pneumatic compression
- Continue prophylaxis for up to 6 weeks after delivery
Pharmacologic Agent Selection
LMWH is the preferred thromboprophylactic agent due to:
- Better bioavailability
- Longer half-life
- More predictable anticoagulation effect
- Lower bleeding risks
- Reduced risk of heparin-induced thrombocytopenia and osteopenia 1
Standard Dosing
- Enoxaparin 40 mg subcutaneously once daily
Special Populations
- Class III obesity: Consider intermediate doses of enoxaparin (40 mg subcutaneously every 12 hours) or weight-based dosing (0.5 mg/kg subcutaneously every 12 hours) 1
- Renal disease: Consider unfractionated heparin (UFH) at 5000 units subcutaneously every 8-12 hours postpartum 1
Timing of Prophylaxis
Mechanical Prophylaxis
- Start sequential compression devices preoperatively for all women undergoing cesarean delivery 1
Pharmacologic Prophylaxis (When Indicated)
- For prophylactic doses of enoxaparin (40 mg daily): Start postoperatively at least 4 hours after catheter removal and not earlier than 12 hours after neuraxial block 1
- For intermediate doses of enoxaparin: Start at least 4 hours after catheter removal and not earlier than 24 hours after neuraxial block 1
- For prophylactic doses of UFH: May start as early as 1 hour after removal of neuraxial catheter 1
Duration of Prophylaxis
- Standard risk with indications: Continue while in hospital
- High risk: Continue for 6 weeks postpartum 1
Important Considerations and Pitfalls
Avoid oral direct thrombin inhibitors and anti-Xa inhibitors (dabigatran, rivaroxaban, apixaban) during pregnancy and postpartum due to insufficient safety data 1
Timing relative to neuraxial anesthesia is critical to prevent spinal/epidural hematomas. Follow specific timing guidelines based on the agent used 1
Postoperative bleeding risk must be considered, especially with significant intraoperative bleeding complications. In these cases, UFH may be preferred due to its shorter half-life and reversibility 1
Risk assessment models (e.g., Caprini and Padua) have not been adequately studied for cesarean delivery, requiring clinicians to focus on established risk factors 1
Institutional protocols are recommended to standardize VTE prophylaxis for women undergoing cesarean delivery 1
By following these evidence-based recommendations, the risk of VTE-related morbidity and mortality can be significantly reduced while minimizing the risks associated with unnecessary anticoagulation.