1. Purpose
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Patients undergoing major (e.g. duration over 45 minutes) gynaecological surgery, who are aged 40 years and over or who have other risk factors, have a significant risk of both asymptomatic and symptomatic venous thromboembolism (VTE). The risk of VTE increases with the number of risk factors.
There is substantial high level evidence supporting the use of thromboprophylaxis in patients with risk factors undergoing major gynaecological surgery.
There is less evidence guiding the exact choice of therapeutic agent, dose and timing of administration hence these guidelines constitute a local practice recommendation.
Substitution with unfractionated heparin could be considered as an alternative.
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2. Responsibility
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The decision to administer thromboprophylaxis is a team decision i.e. both surgeons and anaesthetists have an equal responsibility to consider thromboprophylaxis. Discussion should take place between the surgical and anaesthetic teams with regards to the optimal timing for administration, taking into account the following considerations:
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- the gynaecology surgery registrar has overall responsibility for:
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 | - ensuring the VTE risk assessment is performed and documented:
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| | - at pre-admission clinic (PAC) for elective patients (attending PAC)
- at time of admission for all other patients
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| - ensuring VTE prophylaxis is prescribed.
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- the registrar may choose to delegate the tasks to another medical officer involved in the woman’s care.
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3. Assessment of risk
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Risk assessment is made on the nature of surgery, and the VTE risk factors associated with each patient (refer to the list below and the form: Venous thromboembolism (VTE) Risk Assessment for women undergoing gynaecological surgery [MR/59]).
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Patients with particularly high risk factors and/or complex issues should have an individualised VTE prophylaxis plan developed and documented. This can occur in consultation with the haematologist if required.
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Patient related risk factors
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- Active cardiac or respiratory failure
- Age over 40 years
- Antiphospholipid syndrome
- Cancer (current) / chemotherapy
- Central venous catheter in situ
- Continuous travel: > 3 hrs, 4 weeks before or after surgery
- Immobility e.g. paralysis
- Inflammatory bowel disease
- Inherited thrombophilias
- Medical illness
- Multiple myelomas
- Myeloproliferative diseases
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| - Nephrotic syndrome
- Obesity (BMI > 30)
- Oral contraceptive or HRT use
- Paroxysmal nocturnal haemoglobinuria
- Personal or family history of DVT/PE
- Pregnancy or puerperium (first 6 weeks post birth)
- Recent myocardial infarction or stroke
- Severe infection
- Systemic inflammatory diseases
- Varicose veins with associated phlebitis
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Adapted from NICE clinical guideline 46: Venous thromboembolism 2007
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4. Timing of administration of LMWH
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General anaesthesia
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Pre-operative
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All women undergoing major surgery for suspected malignancy are admitted the day prior to surgery and are administered 2,500units Dalteparin (12 hours prior to surgery).
(NB: Prescribe on 1st page of national inpatient Medicine chart: Once only section).
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Post-operative
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All women undergoing major gynaecological surgery should be administered 5,000units Dalteparin at the completion of the procedure in theatre.
Surgery complicated by increased bleeding requires surgical consultation regarding the timing of the recommencement of LMWH.
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Note: specific instructions (below) relate to regional anaesthesia.
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Regional anaesthesia
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Pre-operative
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Women admitted the evening prior to surgery, should be administered the pre-operative dose of LMWH at least 12 hours prior to regional anaesthesia.
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Post-operative
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The post-operative dose of LMWH should be administered at least 6 hours post regional anaesthesia (post initial spinal block/post insertion of epidural catheter).
Indwelling epidural catheters should be removed 12 hrs after the last dose of LMWH.
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Note: the subsequent dose of LMWH should be 2 hours after catheter removal.
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5. Management
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| Venous thromboembolism (VTE) prophylaxis: Management table (for women undergoing gynaecological surgery)
| Click thumbnail to view full size image of management table (pdf 28kb)
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6. Appendices
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Appendix 1
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Venous thromboembolism (VTE) Risk Assessment form (for women undergoing gynaecological surgery) (printed form [MR/59] that is filed in the health record)
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Appendix 2
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| Anticoagulants/Antiplatelets List
| Click thumbnail to view full size image of anticoagulant/antiplatelet list (pdf 40kb) - contains generic and trade names.
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Appendix 3
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Consumer Information
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Blood Clots: Reducing the risk of blood clots in your lungs or legs
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7. References
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Evidence table: VTE Prophylaxis: Gynaecological Surgery Patients
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Revised and published: 1 February 2009
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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