Thromboembolism & Thromboprophylaxis
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
Risk factors for thromboembolism
Deep vein thrombosis (DVT)
This is usually recognized by a painful swollen hot calf or lower limb a few days after surgery.
Immediate management of DVT
- Do FBC +/- INR, APTT depending on the post-op condition of the patient
- Give Clexane 80mg bd sc
- Arrange Doppler and ultrasound scan of the ilio-femoral or popliteal veins
- Start Warfarin if the diagnosis is confirmed
Pulmonary embolism
This may present as chest pain, shortness of breath, haemoptysis or acute collapse with cyanosis & cardiac arrest. Treatment is as for acute collapse, with Clexane/iv Heparin (1,000 units per hour) as for DVT. Treatment should not be delayed while waiting for V/Q scan or CT PA scan. Call for physician help if the patient is unstable.
Risk factors for thromboembolism
- Previous history of deep venous thrombosis
- Prolonged pre-operative bed-rest
- Dehydration
- Obesity
- Smoking
- Hypertension
- Malignancy
- Sepsis
- Age >35years
- Known thrombophilia
- Discuss with consultant &/or anaesthetist when considering thromboprophylaxis
Giving thromboprophylaxis
All gynaecological surgical patients are potentially at risk.
- Keep patients well hydrated postoperatively, & avoid taking down intravenous lines unless the patient is drinking adequately
- Mobilise patients early postoperatively, within reason
- Pneumatic compression stockings may be used
- Give Clexane 40 mg daily, starting 4-6 hours after surgery
- Continue thromboprophylaxis until the patient is fully mobile, although in certain high risk patient (previous thromboembolism with other factors) 6 weeks anticoagulation is required
- Current oncology guidelines recommend prophylaxis in indicated patients for 4-6 weeks post-op. This may not be chosen. Discuss with consultant