What is the recommended VTE prophylaxis for a 45-year-old pregnant female at 35 weeks gestational age, scheduled for a cesarean section, with a BMI of 31 and no history of DVT or coagulopathy?

VTE Prophylaxis for Cesarean Section in a 45-Year-Old Woman with Obesity

This patient requires both enoxaparin and sequential compression devices (Answer A). 1, 2

Risk Factor Assessment

This patient has two minor risk factors that together mandate pharmacologic prophylaxis:

• Advanced maternal age (45 years) - classified as a minor risk factor for VTE 2
• Obesity (BMI 31, Class I obesity) - represents a minor risk factor for VTE 1, 2
• Cesarean delivery - inherently increases VTE risk compared to vaginal delivery 2

The American College of Chest Physicians establishes that at least two minor risk factors indicate a VTE risk above 3%, warranting pharmacologic thromboprophylaxis in addition to mechanical prophylaxis. 2

Recommended Prophylaxis Strategy

Mechanical Prophylaxis (Universal for All Cesarean Deliveries)

All women undergoing cesarean delivery must receive sequential compression devices starting before surgery and continuing until fully ambulatory (GRADE 1C). 3, 1, 2 This is non-negotiable regardless of other risk factors. 3

Pharmacologic Prophylaxis (Required for This Patient)

Enoxaparin 40 mg subcutaneously once daily is the preferred agent for pharmacologic prophylaxis (GRADE 1C). 1, 2 Low-molecular-weight heparin is specifically recommended as the preferred thromboprophylactic agent in pregnancy and the postpartum period. 3, 2

For this patient with Class I obesity (BMI 31), standard prophylactic dosing of enoxaparin 40 mg daily is appropriate. 2 Intermediate doses are only suggested for Class III obesity (BMI ≥40). 3, 2

Duration of Prophylaxis

• Mechanical prophylaxis: Continue until the patient is fully ambulatory 1, 2
• Pharmacologic prophylaxis: Initiate postoperatively and continue for at least 10 days, with consideration for extension to 6 weeks if additional risk factors persist 1, 2

Why Other Options Are Inadequate

Option B (vitamins only) is completely inappropriate - pregnancy vitamins provide no VTE prophylaxis, and this patient's risk profile mandates active intervention. 1, 2

Option C (early ambulation alone) is insufficient. While early ambulation is appropriate for vaginal delivery with obesity as the only risk factor, cesarean delivery combined with obesity and advanced age requires both mechanical and pharmacologic prophylaxis. 1

Option D (aspirin) has no role in VTE prophylaxis after cesarean delivery. Antiplatelet agents do not prevent venous thromboembolism. 3, 2

Clinical Implementation

Apply sequential compression devices preoperatively, initiate enoxaparin 40 mg subcutaneously once daily postoperatively (typically 6-12 hours after surgery if no bleeding concerns), and continue compression devices until fully ambulatory. 1, 2 Continue enoxaparin for at least 10 days, extending to 6 weeks given the persistent risk factors of age and obesity. 1, 2

Common Pitfalls to Avoid

Do not withhold pharmacologic prophylaxis based on obesity alone being considered "minor" - the combination of two or more minor risk factors (age 45 + obesity + cesarean delivery) elevates this patient to requiring full prophylaxis. 2 The Society for Maternal-Fetal Medicine recommends that each institution develop a standardized protocol for VTE prophylaxis to prevent such omissions. 3, 2

Do not delay enoxaparin initiation excessively - studies demonstrate safety of administration within 24 hours of cesarean section, even with epidural anesthesia, with no increased risk of spinal epidural hematoma. 4

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