VTE Prophylaxis for Cesarean Section in a 45-Year-Old Woman with BMI 31
This patient requires combination prophylaxis with enoxaparin 40 mg subcutaneously once daily plus sequential compression devices (Answer A). 1
Risk Stratification
This patient has at least two minor risk factors that elevate her VTE risk above 3%, warranting pharmacologic thromboprophylaxis:
- Advanced maternal age (45 years) qualifies as a minor risk factor 1
- Class I obesity (BMI 31) represents another minor risk factor 1
- Cesarean delivery itself inherently increases VTE risk compared to vaginal delivery 1
The American College of Chest Physicians (ACCP) specifically states that the presence of at least two minor risk factors indicates VTE risk exceeding 3%, which mandates pharmacologic prophylaxis 1
Recommended Prophylaxis Strategy
Mechanical Prophylaxis (Universal)
All women undergoing cesarean delivery must receive sequential compression devices starting before surgery and continuing until fully ambulatory, regardless of other risk factors (GRADE 1C recommendation) 2, 1
Pharmacologic Prophylaxis (Required for This Patient)
Low-molecular-weight heparin (enoxaparin) is the preferred thromboprophylactic agent in pregnancy and the postpartum period (GRADE 1C) 2, 1
- Standard prophylactic dose: enoxaparin 40 mg subcutaneously once daily 1
- Initiate postoperatively 1
- Continue while hospitalized at minimum 1
Duration Considerations
- Mechanical prophylaxis continues until full ambulation 2, 1
- Pharmacologic prophylaxis may extend up to 6 weeks postpartum if risk factors persist (Grade 2C) 1
Why Other Options Are Inadequate
Option B (vitamins only) is inappropriate because this patient has multiple VTE risk factors requiring active prophylaxis beyond routine prenatal care 1
Option C (early ambulation alone) fails to address the elevated thrombotic risk; while ambulation is beneficial, it does not replace indicated pharmacologic prophylaxis in moderate-to-high risk patients 2, 1
Option D (aspirin) is not recommended for VTE prophylaxis in the obstetric population; antiplatelet agents do not provide adequate protection against venous thromboembolism 1
Important Clinical Caveats
- Class III obesity (BMI ≥40) requires intermediate-dose enoxaparin, but this patient's BMI of 31 qualifies for standard prophylactic dosing 2, 1
- Each institution should implement a standardized VTE prophylaxis protocol as part of a patient safety bundle (Best Practice recommendation) 2, 1
- The combination of mechanical plus pharmacologic prophylaxis is specifically endorsed by ACOG for patients with elevated risk profiles 1