Thromboprophylaxis Post-Cesarean Delivery in a 128kg Woman
Recommended Regimen
For a woman weighing 128kg (BMI approximately 40-45, Class III obesity) after cesarean delivery, use intermediate-dose enoxaparin 40mg subcutaneously every 12 hours combined with sequential compression devices until fully ambulatory. 1
Mechanical Prophylaxis (Universal)
- Apply sequential compression devices before surgery and continue until the patient is fully ambulatory (GRADE 1C recommendation). 1, 2
- This mechanical prophylaxis is recommended for all women undergoing cesarean delivery regardless of weight or other risk factors. 2
Pharmacologic Prophylaxis Dosing
Standard vs. Intermediate Dosing in Obesity
Low-molecular-weight heparin (enoxaparin) is the preferred thromboprophylactic agent in the postpartum period (GRADE 1C). 1, 2
For Class III obesity (BMI ≥40), which applies to a 128kg woman, intermediate doses of enoxaparin are recommended rather than standard prophylactic dosing (GRADE 2C). 1
Intermediate-dose regimen: enoxaparin 40mg subcutaneously every 12 hours (rather than the standard 40mg once daily). 1
Evidence Supporting Higher Dosing
Weight-based dosing (0.5 mg/kg every 12 hours) achieves anti-Xa levels within the prophylactic target range significantly more often than fixed-dose regimens in morbidly obese women after cesarean delivery. 1, 3
In morbidly obese women (BMI ≥40), weight-based enoxaparin dosing resulted in 86% achieving adequate anti-Xa concentrations compared to only 26% with BMI-stratified fixed dosing. 3
The American Society of Hematology suggests either standard or intermediate-dose LMWH during the postpartum period, though evidence certainty is very low. 1
Timing of Initiation
Neuraxial Anesthesia Considerations
For intermediate-dose enoxaparin (40mg every 12 hours), initiate as early as 4 hours after epidural catheter removal but not earlier than 24 hours after the neuraxial block was performed. 1
For standard prophylactic doses (40mg once daily), the timing is less restrictive: may start 4 hours after catheter removal but not earlier than 12 hours after the block. 1
Bleeding Risk Considerations
If significant intraoperative bleeding occurred, consider delaying pharmacologic prophylaxis or using unfractionated heparin (which has a shorter half-life and is reversible). 1
Prophylactic-dose anticoagulation typically causes only mild bleeding complications such as wound hematomas, rarely resulting in life-threatening hemorrhage. 1
Duration of Prophylaxis
Continue mechanical prophylaxis until the patient is fully ambulatory. 2
Continue pharmacologic prophylaxis for at least 10 days postoperatively, extending up to 6 weeks if additional VTE risk factors persist (such as prolonged immobility, history of VTE, or thrombophilia). 2, 4
Additional Risk Assessment
When to Consider Extended Prophylaxis
The decision to extend prophylaxis beyond hospital discharge depends on the presence of additional risk factors beyond obesity and cesarean delivery: 2
Major risk factors: Previous VTE, known thrombophilia, active cancer
Additional minor risk factors: Advanced maternal age (≥35 years), smoking, prolonged labor, postpartum hemorrhage requiring transfusion, preeclampsia
If this patient has ≥2 minor risk factors total (obesity + cesarean delivery already = 2), pharmacologic prophylaxis is clearly indicated. 2
If multiple persistent risk factors exist, consider combining pharmacologic prophylaxis with continued elastic stockings after discharge. 2
Alternative Agent (If Contraindications Exist)
If creatinine clearance <30 mL/min, use unfractionated heparin instead of enoxaparin (5,000-10,000 units subcutaneously every 8-12 hours). 1
Unfractionated heparin has a shorter half-life (60-90 minutes) and is cleared by the reticuloendothelial system rather than kidneys. 1
Common Pitfalls to Avoid
Do not use standard-dose enoxaparin (40mg once daily) in Class III obesity—this dosing is inadequate for women with BMI ≥40 and results in subtherapeutic anti-Xa levels in the majority of patients. 1, 3
Do not delay mechanical prophylaxis—sequential compression devices should be applied preoperatively, not just postoperatively. 1, 2
Do not use direct oral anticoagulants (DOACs) in the postpartum period—there is insufficient safety data for apixaban, rivaroxaban, or dabigatran. 1
Do not stop prophylaxis at hospital discharge without assessing for persistent risk factors—obesity persists postpartum and may warrant extended prophylaxis. 2