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MRCOG PART 2 SBAs and EMQs

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VTE in gynaecology

Posted by Kiran  J.
Women at high risk of VTE following Gynaecological surgery are the ones who have a previous history of VTE.Women with inhereted thrombophillias.Women who have a history of valvular heart disease or have replaced artificail heart valves or bio-prosthetic valves.Women known to have dysrythmias such as atrial fibrillation or SVT and are on life long anticoagulation. Her Currant status risks which may put her expose her to risk of VTE re intercurrant infection/sepsis,malignancy,dehydration, disability and immobilization.Raised BMI ad if the patient is pregnant.Her mediactions which may put her at risk are HRT or oral contraceptives (3rd generation).Iatrogenic risks to the patient are surgical procedure lasting more than 30 minutes and women who need extensive gynae oncology surgery (Lympadenectomy, lymph node dissection ,debulking surgery)

b. In order to minimize risk, it can be done by mechanical methods and pharmacological methods and more intensive methods involving the radiologist.She should have a formal risk assessment in pre-operative clinic where her risk is quantified by pre-formed written tables and charts by experienced staff.Pre-operatively written information on how to avoid dehydration and immobilization pre and post op.
If she is on HRT/ OCP then it should be adviced not to stop and as long as other prophylactic measures are bieng taken i.e mechanical and pharmacological.
Pharmacological agents include Unfractioned Heparine given subcutaneously in divided doses before operation and post op as well.It has proven efficacy in prevention of VTE .
UFH can also be given in the form of infusion in some cases such as atrial fibrillation or bi-prosthetic valves again according to the advice of Cardiologist,anaesthetist ,haematologist and local hospital protocols. The complications are thrombocytopenia( which is reversible after discontinuation of Heparine), haematoma in wound and cumbersome as 3 divided doses are given.
Low molecular wieght heparine (enoxaprine) is the other method.
Its given as a once daily dose as prophylaxis again quantified according to patients weight.Usual prophylaxis is by 40 mg on the evening before surgery and thereafter every evening.It has less risk of thrombocytopenia and given as single dose everyday.
Both UFH and clexane are given to patients for the duration of stay in hospital but in some studies there has been a comparisom to continue it for longer period post operation even after going home and the results may show less chances of VTE in the latter case and no significant increased risk of wound haematoma.Again local hospital protocols are to be followed.
Mechanical methods include compression stockings .During surgery intraoperative pneumatic compression stokings are used.
They are prophylaxic and have a role in prevention against DVT but thier role agianst prophylaxis against PE is not yet determined.
She should be adequately hydrated intraoperatively and post operative.Early mobilization is adviced.These methods have clear benefits in prevention and prophylaxis in mild and moderste risk patients against VTE.In high risk cases they are useful as adjuvants in the pharmacological methods used to minimize risk of VTE.
For women who are already on anticoagulation due to history of VTE/or cardiac dysfunction, close liason with anaesthetist and haematologist and cardiologist(in some cases needed) as she may need to be started on LMWH or heparine 2-3 days before operation with INR levels daily.There are parients who may need incorporation of IVC filter( patients with failure of anticoagulation or recurrant PE) hence an MDT involving radiologist,oncologist and haematologist for minimizing risk per-op.
Other methods include low dose Asprine , Dextran which are not used commonly.Asprin is accociated with haematoma formation and dextran with anphylaxis.
Patients who have intercurrant sepsis should be managed by MDT involving Anaethetist, microbiologist and Gynae oncologist aiming to treat with sepsis care bundles and appropriate antibiotics along with other prophylaxis to minimize risk as well.
Posted by Chitra.s M.
A. Women with a previous/family history of venous thromboembolism are at a high risk of VTE following surgery.Women with known thrombophilias are at increased risk of VTE. Surgery done for malignancy and surgery lasting> 30minutes under general anaesthesia puts the woman at increased risk.Women with BMI>30kg/m2 , age>40years ,gross varicose veins with phlebitis are at an increased risk of VTE.Immobility>3 days prior to surgery,major illness like heart disease,inflammatory disordes,endocrine & metabolic disorders increase the risk.Post operative dehydration, immobilisation and blood transfusion put the woman at increased risk.

B.Women who are scheduled for gynaecological surgery should have a documented risk assessment for VTE . Verbal and written information is offered regarding risks of VTE,methods of thromboprophylaxis- their benefits and risks. Women on estrogen containing contraceptives or hormone replacement therapy should be advised on stopping it 4 weeks prior to surgery. Antiplatelet drugs are stopped 1 week prior to surgery & women on these drugs are assessed by a mutidisciplinary team(gynaecologist, anaesthtist,hematologist).Any intercurrent infections are treated prior to surgery.Anesthesiologist referral is done to assess suitability for regional anesthesia as general anesthesia use is associated with increased risk of VTE.The timing of regional anesthesia is planned to minimise the risk of neuraxial hematoma.Placement of inferior venacaval filters are considered in women at high risk- like those with recurrent VTE/pulmonary embolism, malignancy.
Women assessed to be at high risk are offered graduated elastic compression stockings/foot impulse/intermittent pneumatic compression devices at admission and are continued till the woman is mobilised followng surgery.Women and her carers are taught about correct application and usage.Unfractionated heparin(UFH)/ low molecular weight heparin(LMWH) can be used for thromboprophylaxis.Thromboprophylaxis is started 2 hours before surgery ,dose dependent on the body weight and assessed risk and unit protocols.. UFH is given 12th hourly post operatively.LMWH has the convinience of once daily dosing and is less likely to cause thrombocytopenia compared to UFH.Dehydration is avoided .The woman is encouraged to mobilise as early as possible.Any infections are treated with appropriate antibiotics.Ongoing risk assessment is done during the hospital stay for identification of any additional risk factors .Mechanical methods(GECS.intermittent pneumatic compression) are advised when heparin prophylaxios is contraindicated.Thromboprophylaxis is continued for 5-7 days or until the woman is mobile.Women at high risk (malignancy, recurrent VTE) may require thromboprophylaxis for 4 weeksor more.warfarin is considered in those women requiring long term thromboprophylaxis. Other agents like aspirin are less effective as thromboprophylaxis and are not recommended.Dextran is not used as thromboprophylaxis.
As a part of discharge plan,women are given written advice about avoiding immobilisation and dehydration, signs & symptoms of VTE and when to seek medical help and whom to contact. Women discharged with thromboprophylaxis are advised about duration and method of use and follow up appointment.
Posted by nazia M.
a)High risk patients include those;undergoing major surgery for gynaecological cancer,personal history of vte,history of thrombophilia,pt on anticoagulants,and with 3 or more following factor;older pt,obesity,intercurrent medical illness(heart or lung disease,nephrotis syndrome,malignancy,heart failure or recent MI),infection,smoking,coc pills and hrt.b)preoperative;adequate assessment of the pt,heparin prophylaxis should be used,unfractionated heparin 5000iusubcutaneously 8hrly.LMW enoxaparin 40mg per day.given 12hr before surgery at site away from proposed wound continue for 5days or until fully mobilizedside effects;thrombocytopenia,increased risk of bleeding.intraoperative mechanical methods pneumatic calf compression postoperative;early mobilization,adequate hydration,graduated elastic stockings,proper monitoring of pt condition.other methods which can be considered include dextran 70 and aspirin these are less common used.
Posted by MR R.
MR

Which women are at high risk of venous thrombo-embolism following gynaecological surgery? [6 marks].

Women who are at high risk of venous thrombo-embolism (VTE)are when they undergo surgery for malignancy.Women who have a family (1 st degree relative) or personal history of VTE are considered high risk as well.If they have a BMI> 30 they fall into this category.Women aged >40 are and also if they have inherited (Factor 5 leiden, Protein C or S defeciency) or acquired (antiphospolipid syndrome) thrombophilia are at high risk.If they have 2 or more ofthe below mentioned moderate risk factors they are considered to be high risk category for VTE. The moderate risk factors include presence of varicose veins.If their surgery lasts longer( anaesthesia lasts > 30 minutes) or if there is excessive blood loss it increases their risk.Use of combined contraceptive pills ( risk is 15 - 25/100,000) or HRT( 20 3 fold increase) also increases their risk.Any intercurrent illness(cardiac diseases) or prolonged immobilsation before after surgery is also considered aa moderate risk for VTE.Presence of sepsis is also another risk factor for VTE development.



(b) Discuss how you will minimise the risk of venous thrombo-embolism in women undergoing gynaecological surgery [14 marks].

It is important to identify the moderate and high risk factors for VTE for adeqaute prophlaxis and also for discussion of high risk patients with haematologist if required.Combined contraceptive pills and HRT(estrogen) should be discontinued 4 weeks prior to major surgery. Use of mechanical devices like graduated compression stockings and pnuematic compression devices helps in reducing the risk of VTE.Early mobilisation and adequate hydration helps in reducing the risk of VTE.Unfractionated heparin in the dose of 5000 iu 8 - 12 hourly given in the properative and post operative period for the duration of stay in the hospital helps in reducing VTE and pulmonary embolism(PE) and mortality associated with these.The increased risk of wound haemotaoma can be reduced by giviing teh injection away from the wound.Alternatively Low molecular weight heparin(LMWH)can be given in the preoperative and once daily in the post operative period.It has longer half life and reduced risk of thrmbocytpenia compared to unfractionated heparin (UH).They are equally effective in reduciing VTE, PE and deaths associated with these.The risk of bleeding is the same as UH.In patients with moderate risk UH (5000 - 10,000 iu)is given 2 hours preoperatively and continued 8- 12 hourly .LMWH ( 40 mg sc)is given 2 hours preoperatively and continued once daily till discharge from hospital.If the patient is high risk LMWH is given 12 hours properatively and twice daily in the post operative period.If the patient is very high risk then the pre operative higher dose is given 12 hour prior and continued in the post operative period.The dose and duration for high risk patients are liased with the haemotologist.Antiplatelet drugs do not have any role in reducing VTE and they increase bleeding.
Posted by abalon  C.
A)The risk of venous thromboembolism following gynaecological surgery is high in women who have active cancer or who are undergoing cancer treatment. Obesity with BMI over 30 kg/m2 increases the risk of VTE. Women with acquired or inherited thrombophilia come under high risk group. The presence of one or more significant medical comorbidities for eg( heart disease, metabolic, endocrine or respiratory pathologies , inflammatory conditions) raises the risk of VTE following gynaecological surgery.
Personal history or a first-degree relative with a history of VTE are considered to be of high risk for VTE.Women who are using HRT or oestrogen containing contraceptives are under high risk for VTE. Other high risk factors include presence of varicose veins with phlebitis, immobilization, and dehydration. The risk of VTE is more if total time of surgery exceeds 60min
B)All women should undergo risk assessment for VTE at the time of admission and if clinical situation changes to ensure that the methods of VTE prophylaxis being used are suitable, to ensure that VTE prophylaxis is being used correctly and to identify adverse events resulting from VTE prophylaxis
Women undergoing gynaecological surgery are advised to consider stopping oestrogen-containing oral contraceptives or hormone replacement therapy 4 weeks before elective surgery.
Mechanical method of VTE prophylaxis is started at admission by in the form of anti-embolism stockings or foot impulse devices or intermittent pneumatic compression devices
Mechanical VTE prophylaxis should be continued until the patient no longer has significantly reduced mobility.
Pharmacological VTE prophylaxis in the form of low molecular weight heparin or Unfractionated heparin ( for patients with renal failure). is added to patients who have a low risk of major bleeding, taking into account of individual patient factors and according to clinical judgement Pharmacological VTE prophylaxis is continued until the patient is no longer has significant reduced mobility which is usually around 5 -7days. Pharmacological VTE prophylaxis should be extended to 28 days postoperatively for patients who have had major cancer surgery in the abdomen or pelvis.
Temporary inferior vena caval filters are offered to patients who are at very high risk of VTE such as patients with previous VTE event or an active malignancy and for whom mechanical and pharmacological VTE prophylaxis are contraindicated.
Women undergoing gynaecological surgery are encouraged to mobilize as soon as possible. Dehydration is avoided unless clinically indicated. Asprin or other platelet agents should not be regarded as adequate prophylaxis for VTE.
Posted by A A.
AA
a: Women at high risk of venous thromboembolism (VTE) are those having Inherited or Acquired Thrombophilia, personal history of VTE, family history of VTE, surgery for gynecological malignancies, obesity, age more than 40 years and having three or more moderate risk factors. Moderate risk factors are major operation requiring general anesthesia more than 30 minutes, varicose veins, on OCP or HRT, immobile before surgery, current infection, major current illness as cardiac failure, blood transfusion, post operation dehydration.
b: Risk of VTE should be taken into account when considering whether the overall benefits of surgery outweigh the risks, consideration of alternative treatment like mirena, TCRE for menorrhagia, Uterine Artery Embolisation for fibroid. All women should have risk assessment according to unit protocol. High risk women should be managed in liaise with hematologist and anesthetist. Preoperative management like weight reduction, stop smoking, discontinue OCP 4 weeks before major surgery, but HRT need not to stop before surgery. Unfractionated heparin (UFH) 5000 IU 2 hours before surgery than 5000 IU every 8-12 hours at site away from wound to avoid wound hematoma. Low molecular weight heparin (LMWH) have similar efficacy as UFH and less likely to cause heparin associated thrombocytopenia . however LMWH is more expensive than UFH. LMWH can be given once daily in moderate risk women, and every 12 hours in high risk. In very high risk women high prophylactic dose evening before surgery then high prophylactic dose once daily. Above knee graduated elastic compression stockings are as effective as UFH or LMWH and can be used in circumstances where heparin is contraindicated. Aspirin is less effective than UFH and increased risk of wound hematoma. Dextran is also less effective and is associated with risk of anaphylaxis. Postoperative early mobilization and avoid dehydration and continue thromboprophlaxis to 1 month after major surgery. Awareness of signs and symptoms of VTE and to start thromboprophylaxis on clinical suspicion while awaiting objective diagnosis. Use of Doppler studies venograms and lung perfusion scan for definitive diagnosis. On discharge women should advise to report early for medical advice on leg and chest symptoms. Follow up visit should arranged.
Posted by leelavathi C.
women who going for gynaecological surgery for malignancy are at high risk of VTE. if women having history of previous VTE or strong family history of VTE are considered high risk of thromboembolism. obesity(BMI>30), patient age(>40y) are independant risk factors for VTE.
if women having three or more moderate risk factors like varicose veins, usage of OCP\'S, immobility prior to or after surgery, major current illness like sickle cell disease, cardic failure, current infections are considered high risk of thromboembolism.

B) venous embolism is one of major cause of mortality. so all women who going for major gynaecological surgery need assessment of risk category for VTE according their risk factors. Thromboprophylaxis with either unfractionated heparin, or low molicular weight heparin reduces the risk of VTE(DVT, PE) as well as mortality.ther is no difference between UFH and LMWH in efficacy for thromboprophylaxis against DVT or PE. UFH should be given 5000iu 2 hours before surgery, then 5000u every 8-12 hourly. LMWH should be given 1-2 hours before surgery then once daily dose after surgery in moderate risk patients, in high risk patients twice daily dose after surgery. in very high risk patients LMWH should start day before surgery and high prophylactic dose once daily dose to minimise the risk of VTE.
Mechanical methods like graduated elastic compression stockings(GECS) are effective in reducing risk of DVT. the addition of GECS to UFH and LMWH increases the efficacy of prophylaxis againest asymptomatic DVT.
intermittent pneumotic compressions during surgery also minimises risk of DVT. post operative dehydation is one of risk factor for VTE. SO effective fluid mangement postoperatively reduses the risk of VTE. prophylactic antibiotics at the time of surgery reduces infection rate and VTE risk subsequently. encourage mobilisation before and after surgery reduces the risk of VTE. if women on COCP\'S advice to discontineu OCP 4weeks prior to surgery(only major gyaenecological surgery). optimise medial conditions like sicklecell disease, cardic failure prior to surgery also mimise the risk of VTE.
Posted by H H.
hhh
Women at high risk of venous thromboembolism VTE include those ,who had a prolonged surgery specially for malignant disease ,has been immobilized and dehydrated following surgery ,substandard care for risk assessment and prophylaxisis committed and local guidelines and protocols which comply with RCOG guidelines were omitted . High risk women include those who had history of previous VTE specially if recurrent, unprovoked, with family history of VTE or associated with thrombophilia.Women with 3 or more moderate risk factors are at high risk, these include, age 35 or more, BMI 30 or more, infections, immobility, varicose veins, those on COCP, HRT, tamoxifen or raloxifene.Also those who are smokers.

In patients who will undergo non urgent (elective) surgery I will need to balance the risk of VTE in a high risk patient against the benfit of surgery . I would postpone the surgery until the risk factor is over. In obese patient, would advise reducing weight. Would advise stop smoking. Multidisciplinary input with the help of hematologist to assess risk and plan management is vital.
Patients should be properly hydrated before and after surgery and should avoid immoblisation.
Patients who will undergo hysterectomy for large fibroids ,can have their fibroids reduced in size by the use of GNRH analogues to be removed via the vaginal route which would allow better post operative recovery and mobilization ,also if the abdominal route is chosen ,it can be removed via a transverse incision instead of a midline incision, this would allow better recovery.
TED stockings used preoperatively and flowtron boots will reduce risk of VTE .
In high risk patients use of unfractionated heparin or low molecular weight heparin LMWH reduce the risk of VTE. This should start 12hr before surgery and given according to local guidelines and protocols.
In patients with moderate heparin is started 2hrs before surgery.
Patients should be properly followed postoperatively for early detection of VTE (leg pain,tachypnea,cough,hemoptysis) so as immediate treatment given with therapeutic heparinisation.
Protocols for risk assessment are regularly audited and guidelines put and these are reaudited so as improve patient care and reduce risk of VTE.Incident reports for VTE are reviewed by risk assessment team and lessons learned circulated.
Patients are given written information about VTE and how to reduce it . Findings are documented in the notes for future review.
Posted by Aruna R.
High risk women for thromboembolism are those over 40 years,BMI over 30,previous history of venous thromboembolism and with congenital or acquired thrombophillia. varicose veins,prolonged immobilisation,medical conditions like heart failure,nephrotic syndrome,IBS and polycythemia are also some of the high risk factors.Malignancy, pregnancy,puerperium, acute infections and acute trauma can also precipitate venous thromboembolism.Surgery itself ,general anaesthesia and hospitalisation more than 3hours are also considered as high risk factors for VTE.Medications like combined oral contraceptives,HRT ,Tamoxiphen,rolaxiphen and high dose progesterone can cause VTE.

b. Risks can be minimised by proper patient selection and preoperative assessment. In case of emergency situation multidisciplinary team involvement to minimise sepsis, to deal with medical problems .First step is to do proper risk assessment and explainning it to the patient.

Following the unit policy and protocol for thromboprophylaxis and risik assessment.Women with high risk factors, undergoing minor gynaecological procedures need graduateed elastic stockingsGECS.
No need to stop the medications like oral ontraceptive pills and HRT.
Early mobilisation and maintanance of adequate hydration are enough.

Those who are undergoing major surgical procedures need GECs , Compression pneumatic stockings and Thromboprophylactic agents (low molecular weight heparin or Heparin) according to unit policy.Oral contraceptive pills should be stopped 2 weeks before the operation. HRT need not be stopped.Early mobilisation and management of other medical problems will reduce the risk.In selected cases IVC filters can also be used.
Posted by L S.
LS:
(a) Which women are at high risk of venous thrombo-embolism following gynaecological surgery? (6)
Women at high risk of venous thrombo-embolism (VTE) are those who are undergoing surgery for gynaecological malignancy; age more than 40; obese with body mass index more than 30. Other categories of women at high risk are those with a previous history of VTE; with a strong family history of VTE and those with inherited or acquired history of thrombophilia. Finally those women with 3 or more moderate risk factors are also at high risk of VTE following surgery.

(b) Discuss how you will minimise the risk of venous thrombo-embolism in women undergoing gynaecological surgery [14 marks].
The risk of VTE depends on type of gynaecological surgery or procedure which she will be undergoing and the period of immobility afterwards. I would evaluate each woman individually for risk factors for VTE and use the unit protocol for prophylaxis based on risk factors to decide on use of anti-thrombotic agents. The types of anti-thrombotic agents are unfractionated heparin (UFH), low molecular weight heparin (LMWH). Depending on unit protocol, if UFH is used, then the drug should be started with 5000U 2 hours before surgery and then 5000U every 8-12 hours. To prescribe LMWH depends on the category of risk of the women, in moderate risk the initial dose is 1-2 hours before surgery then once daily. In high risk group, LMWH is also started 1-2 hours before surgery with prophylactic dose given 12 hourly. In very high risk women especially those undergoing surgery for gynaecological malignancy a high prophylactic dose is given evening before surgery then followed by high prophylactic dose once daily. The duration of each therapy depends on the reason for prophylaxis and the ongoing risk for VTE. Together with anti-thrombotic agents, mechanical methods like graduated elastic compression stockings (GECS) or intermittent pneumatic compression (IPC) can be used. Above knee GECS are as effective as UFH or LMWH as prophylaxis and can be used if heparin is contraindicated. The addition of above knee GECS to UFH or LMWH will increase the efficacy of prophylaxis against asymptomatic DVT. In cases where heparin are contraindicated, IPC followed by above knee GECS can be used.
Posted by Bee N.
Which women are at high risk of venous thrombo-embolism following gynaecological surgery? [6 marks]. (b) Discuss how you will minimise the risk of venous thrombo-embolism in women undergoing gynaecological surgery [14 marks].

(BEE)
A) Women at high risk of Venous thrombo-embolism (VTE) following gynaecological surgery will include women with large BMI(greater than 30). The higher the BMI, the higher the risk. Older women are also at increased risk most especially post menopausal women. Women who have a personal history of VTE or family history especially first degree relatives of VTE are at increased risk. Women who have been diagnosed with a thrombophilis defect either inherited or acquired such as antithrombin III deficiency or antiphospholipid syndrome respectively are at increased risk. Women who are on oestrogen containing treatments either the combined pills or hormone replacement therapy are also considered to be at increased risk. A woman undergoing major surgery such as hysterectomy is considered at increased risk of VTE especially when compared with a woman undergoing minor surgery such as hysteroscopy. This can be attributed both to the stress caused by surgery and lenght of procedure. Women with major systemic illness such as cancer, systemic lupus erythematosus are at increased risk.

B)Minimising risk for VTE will take into consideration the factors which increases the risk and elements to which preventative strategies will be directed to avoid these risks. These elements will include the patient. Careful pre op assessment to identify at risk groups is important. Alternatives to surgery will be offered to those considered high risk.Weight loss will be adviced in the obese prior to surgery if appropriate as this contributes to increasing risk for VTE. Those with family history of VTE should be screened for thrombophilia since they are at higher risk of having defects when compared to the general populace. I will consider discontinuing hormone therapy for those undergoing major surgery as this has been shown to increase their risk for VTE. Multidisciplinary involvement in assessment will be considered when appropriate for instance in the management of patients found to have thrombophilic defect (hematologist involvement) or presence of previous VTE or heart valves (cardiologist and hematologist involvement). Where there are unit protocols or guidelines available, this will be used.
During surgery, use of appropriate elastic compression stockings will be adviced and undue waste of tim avioded during surgery. Patients who are having prolonged surgery will be well hydrated. Patients after surgery (major) will be treated with subcutaneous low molecular weight heparin and compression stockings. They will be kept well hydrated after surgery and early mobilisation encouraged.
In suspected cases of VTE, use of treatment dose low molecular weight heparin will be used until suspect diagnosis is ruled out. Staff should be trained in early recognition and management of VTE. Eraly liason with physicians and radiology for investgation of suspected cases. Patient will be educated as to the signs and symptoms of VTE and its implications. They will be adviced to contact or inform medical staff as soon as possible if any of the features are felt.Patients will be informed on the long term risk of heparin therapy which include osteoporosis and thrombocytopaenia. Clinical incident form should be filled for every case so that the unit can reflect on the management of the patient and evaluate how best it can be avoided.
Posted by zara A.
a]High risk patients for venous thromboembolism[vte] are,thosewho have previous vte,and who have family history of vte.Pts at risk of vte are those who have inherited and acquired thrombophilia.Patients who are undergoing surgery for gynaecology malignancy.The pts whose age more than40 and undergoing major surgery[more than 30 min].Patients who have more than 3 moderate risk factors [ which are current illness,immobility more than 4days,ocps ,hrt,gross varicose veins,major surgery more than 30 min. [b]Risk of vte in patients undergoing gynaecology surgery can be reduced by taking certian measures preoperatively,intraoperatively ,and post operatively.PREoperative measures include risk identification and then its modification.Smoking is associated with vte ,it should be stoppped atleast 24 hours before surgery.ocps should be stopped 4 weeks before surgery.Hrt should be considered a risk factor for vte but it should not stopped routinely .raloxifene should be stopped 3 days prior to surgery.Obesity inceases the risk of vte ,there fore weight reduction is recommended in collaboration with dietician ,but this option considered if surgery has tobe done for nonurgent indication,but in surgery for malignancy it is not suitable option.current infection s shouldbe treated as increases the risk of vte.Prophylactic antibiotics should be given according to unit protocol as post operative infection increases the risk of vte.High risk patient like pts with previous vte on anticoagulant should be managed in liasion with haematologist and anaesthetist.Patient selection is very important,high risk patient can be offered other treatment like in pt with dub mirena can be considered .Type of surgery can modify the risk of vte like vaginal surgery preferred over abdominal hysterectomy.Other measures like GnRhanalouges should be considered in pts with large fibroid as it reduces risk of intraoperative haemorrhage which isa risk factor for vte .immobilityprior to surgeryshould be avoided. Decision to remove or conserve ovaries should be considered carefully as hrt increases risk of vte.Risk assessment should be done in every pt who is undergoing gynaecology surgery according to thrift consensus and unit proocol.According to risk assessment mechanical and pharmacological thromboprophylaxsis offered to pts.Low risk pts should beoffered early mobilisation good hydration.Moderate risk pts should be offered LMWH or unfrationated heparin 1 to 2 hr prior tosurgery then once daily prophylactic dose.high risk offered heparin prophylaxis 1 to 2hr before surgery and then prophylactic dose 12 hourly and ted stocking.VERY high risk should be offered heparin prophylaxis 12 hours before surgery in high prophylactic dose and then once daily in high prophylactic doseand ted stocking.Unfractionised heparin should be given 5000iu ,then 8 hourly.Thromboprophylaxis should continued until pt hospitalised.INTRAoperative measures taken to prevent vte,measures should be taken to prevent haemorrhage as this is a risk factor for vte.Experienced surgeon,good surgical technique ,meticulous haemostasis are key factors to reduce haemorrhage and duration of surgery which are associated with vte.Post operative MEASURES taken to reduce vte are good hydration mantained.Early mobilisation encourged .Chest physiotherapy considered.Thromboprophylaxis continued until pt admitted.High risk patient should be told about sign and symptoms of vte,staff should be vigilant to diagnose vte.Timing of removal and insertion of epidural should be optimised according to heparin administration by anaesthetist.protocols for risk assessment and thromboprophylaxis should be available,and regularly updated according to guidelines.Staff should be familiar with protocols.Regular audit should be taken to look to ensure that protocols followed.
Posted by S V.
The risk of VTE in a healthy woman is 5 in 100,000. This risk increases if her BMI is more than 30 or if she has varicose veins.Age more than 40 and Coexisiting medical conditions like cardiac problems, diabetes, renal diseases increase potoperative VTE risk. Inherited and acquired thrombophilia ( FatorV leiden, antithrombin 3, antiphospholipd syndrome) also makes patients more susceptible to VTE.Prolonged immobility, infection, excessive blood loss at surgery are all factors that exacerbate risks of DVT and PE. Malignancies and major prolonged surgery under GA are known to increase risks of VTE.
HRT and COCP are also major risk factors as 2nd generation COCP have 15 in 100,000 and 3rd generation 25 in 100,000 risk of VTE. This is increased to 60/100,000 if the woman is pregnant.
Prevention of VTE should start with risk assessment at properative assessment. Patients at moderate risk would have one or more of the above risk factors and those at high risk would have 2 or more moderate risk factors.
All patients after major surgery lasting more than 30 minutes should have fitted graduated elastic compression stockings following pneumatic compression post surgery .Above knee stockings are as effective as Heparin and LMWH and can be used alone in patients contraindicated for anticoagulants.Avoiding dehydration and early mobilisation are imporatnt in preventing DVT.
Low molecular weight hepairin in the form of dalteparin, tinzaparin and clexane are as effective and safer than unfractionated heparin. They do not need anti X a monitoring unless renal problems or patients is in extremes of weight.They have lesser risks of heparin associated thrombocytopaenia and osteoporosis than UFH.
UFH heparin in doses of 5000iu 8- 12 hrly is effective against DVT and PE. Administration should be avoided near wounds as it can cause haematomas.
Aspirin is not effective in preventing VTE.Dextran are effective in reducing risk of PE but have adverse allergic and anaphylactic reactions.
Patients with moderate risk factors should have have a prophylactic dose 2 hrs pre surgery and then prohylactic dose daily postoperatively.If the patient is at major risk for VTE, after the 2 hr preop prophylactic dose , the next doses postoperatively should be at every 12 hrs.Patients at very high risk should have a high prophylactic dose the evening before surgery and then continue with a high prophylactic dose daily post surgery.
The effect of anticogulation postoperatively has been shown in randomised trials to be more effective if patients had prolonged treatment for 1 month outside hospital versus heparin for shorter periods as an inpatient. The risks of bleeding between both groups were not different.
Posted by Syamala H.
ans a:risk of vte in general gynecological surgery is16% risk of pul embolism 1% and risk of major blood loss 4% .factors that will determinethe risk of VTE in gynae surgical patient are. duration of surgery,duration of post surgery immobilisation, drugs like HRT or OCPS, associated nongynecological conditions that increase the risk of VTE like age >40(exponential increase in risk with increasing age) BMI->30 recent MI or stroke,heart failure,severe infection,inflmmatory bowel ds,nephrotic syndrome,polycythemia and proxysmal nocturnal hemoglobinuria and malignancy,peuperium.
ans b : patients to be assesed regarding the risk of vte at the time when decision is taken for surgery at the clinic or when the pt is admitted in ward. administration of thromboprophylaxis should be multideciplinary and a joint decision between gynecologist and anesthetist. in conditions where there are multiple risk factors or associated condition that increases the risk of bleeding opinion should be sought from hematologist. clear documentation should be there in pre and post operative managment plan. ocp to be stopped 4 wks before surgery, to be counselled regarding alterntive methods.hrt can be continued but should be assesed as a risk facter fot vte. measurement for GECS to be taken and pt should be wearing it before being shifted to OT. general measurs like early mobilisation (if feasble)and adequate hydration in all cases.
in cases of malignancy preop thromboprophylaxis to begin 12 hrs before surgery(dalteparin 2500) and post operatively(dalteparin5000) to be given 6 hrs after epidural or spinal anesthesia.consideration to be given to continue it for 28 -30 days. epidural catheter to be removed 12 hrs after last dose of lmwh.in all other surgical procedure lasting for more than 30 mins(from the time of induction of anesthesia)post op prophylaxis for 5-7 days should be given. in minor procedure of lesser duration and do not requiring immobilisation can be managed with adequate hydration and early mobilisation.choice of drug for prohylaxis are:
unfractionated heparin,LMWH both equally effective but differ in theirduration of action its reversibility in case of hemmorhage andside effect profile.increased risk of wound hematoma.
asprin less effective not routinely reccomended
dextran less effective and associated with anaphylaxis.
graduated elastic compression stocking can be combined with lmwh in high risk cases or with intermitent pneumatic compression in condition where heparin is contraindicated.
reasses for continuing risk factor before discharge.
education and information to pt if prophylaxis is to be continued after discharge.
Posted by VINITA N.
VN
Which women are at high risk of venous thrombo-embolism following gynaecological surgery? [6 marks]. (b) Discuss how you will minimise the risk of venous thrombo-embolism in women undergoing gynaecological surgery [14 marks].
A) Women having any operation lasting more than 30 minutes is increased risk for venous thromboembolism( vte), but those who have had thrombus developed in the past, history of thrombophilias, history of antiphospholipid antibody syndrome, anti s antibody, factor 5 leiden deficiency, as all these conditions increases risk of thrombosis. Women who are on HRT, OC pills are also at incresed risk. Other risk factors include high BMI, especially more than 40, chronic smoking, any disability leading to immobilization. A family history of developing clots and thrombophilias is also a risk factor for developing VTE.
B) The risk of having a DVT can be minimised by taking a history specifically looking for risk factors for vte in clinic and appropriately counselling women regarding the risk and where possible trying a medical management and resort to surgery only if medical management fails or unacceptable to patient.Maintaining BMI between 21- 25, stopping smoking are necessary lifestyle changes that can reduce risk of vte. Risk factors for vte should be assessed during preoperative assessment and classified into high, moderate and low groups in accordance with local hospital protocol. If high risk, it should be brought to the notice of the consultant and anaesthetist.She should be managed in anmultidisciplinary team involving gynecologist, anaesthetist and haematologist if has thrombophilia.If surgery necessary, she should be advised to continued her HRT and OCP as normal.A regional block is preferred to a general anaesthesia. During surgery inflation boots and pneumatic bags help maintain circulation. Post surgery, she should be given midthigh TEDS compression stocking of appropriate size and if high risk should be started on low molecular weight heparin prophylactic dose in accordance with weight. early mobilization should be encouraged and help of physiotherapist sought for this. Some patients who are high risk or who already have a clot may need surgical removal of clots with the use of filters, for which the the vascular team needs to be liased with.The nursing staff and doctors should be on the look out for signs symptoms of vte like calf swelling/ pain, shortness of breath. Such symptoms in the post operative period should be investigated for vte and treated as dvt untill prved otherwise by dopplers or vq scan.
Posted by Bobey B.
The high risk women include women with personal history of previous thromboembolism , family history of VTE , inherited or acquired thrombophilia. High risk women also,include those have gynaecological malignancy, obese with BMI more than 35 , their age are more than 40 years and those with three or more moderate risk factors.
Moderate risks are women who are undergoing major operations lasting more than 30 min., gross varicose veins ,taking COCP and HRT.
Moderate risks also include : immobility prior and after surgery, major current illness like cardiac failure, current infection , post-operative dehydration and blood transfusion.
b ) High risk of VTE should be taken into account when considering wheather the overall benefits of surgery outweigh the risk . Alternative treatment should be considered such as: Mirena , TCRE in treatment of menorrhagia.
Each unit should have a protocol for assessment of risk of VTE.
Multidisciplinary team including haematologist in liaison with gynaecologist should be involved in managing high risk women.
Preoperative measures should be discussed with the patient , such as weight reduction , stopping smoking , avoidance of sedentary life and avoidance of immobilization before surgery. COCP should be discontinued 4-6 weeks before major surgery.
HRT should not be discontinued but be considered in assessment of risk of VTE.
Any infection should be treated.
The patient should be offered thromboprophylaxis after appropriate counselling .
This can be in the form of graduated elastic compression stocking and s.c heparin 12 hours before surgery and 8 hourly after surgery.
The LMWH has the same efficacy as UFH but less risk of thrombocytopenia.
The side effect of heparin is haemorrhage in the form of haematoma . It could be avoided by s.c. injection away from the proposed site of surgery.
The value of intermittent pneumatic compression followed by above knee GECS is uncertain in reducing the mortality of VTE. The use of GECS and heparin increases the efficacy of thromboprophylaxis.
High prophylactic dose of LMWH can be given 1-2 hrs prior to surgery in high risk patients and once daily s.c. high prophylactic dose after surgery.
Early mobilization and adequate postoperative hydration are cost-effective measures to reduce risk of VTE.
The clinical symptoms suggestive VTE such as leg pain, chest pain and dyspnea
must be managed promptly .
Doppler lower limbs studies , venogram and lung perfusion scan should be considerd for definitive diagnosis of VTE.
Treatment should be started while awaiting for objective diagnosis , to prevent the mortality and morbidity from VTE.


Posted by SRABANI M.
The women at high risk of VTE are those having surgery for gynaecological malignancy, obesity ( BMI >30), family history of VTE, past history of VTE,age over 40 years and also inherited or acquired thrombophilia.She is also at increased risk of VTE if she has got three or more risk factors for developing VTE.
The women are at moderate risk of VTE are those who are having Genearl anaesthesia for > 30 minutes,past or present history of varicose vein,women who are taking OCP or are taking HRT.If the woman has got some medical condition like cardiac disease or she was immobile for prolonged period before or after surgery, she is at increased risk of VTE.Also blood transfusion, current infection or postoperative dehydration may increase her risk of VTE.

B. All women should undergo preoperative assessment of risk factors for VTE before any gynaecological surgery.Communication with haematologist and anaesthetist is necessary in high risk women. Preoperative advice should be given regarding smoking, weight loss in obese women, stopping oral contraceptive pills but not necessarily HRT , mobilisation. Graduated elastic compression stockings can be advised as they are as effective as unfractionated or low molecular weight Heparin in asymptomatic women. Intermittent pneumatic compression can be used as prophylaxis where heparin is contraindicated.Unfractionated heparin can be used 5000 iu , 2hrs preoperatively and 5000IU every 12 hourly.Low molecular weight heparin can be used as well in high risk or moderate risk women with initial dose 2 hours before surgery and continue once daily prophylactic dose. Prolonged thromboprophylaxis with LMWH significantly reduces the risk of VTE than using it only during hospital stay. Dehydration should be avoided after gynaecological surgery and also early mobilisation should be encouraged .Close monitoring of any symptoms of VTE is necessary in high risk women
Posted by Arun D.
a) The following group of women are very high risk for VTE..
1. Surgery for gynaecological malignancy
2. Previous VTE
3. Strong family hist of VTE
4. Inherited or acquired thrombophilia
5. Obesity
6. Age > 40 yrs
7. 3 or more moderate risk factors..
a. Major surgery : operations requiring > 30 min GA
b. Severe current illness
c. Post op dehydration
d. Current infection
e. Prolonged pre-op and post op immobilisation
f. HRT : 2-3 times risk
g. COCP
h. Varicose vein
i. Blood transfusion

b) the following steps may be taken to reduce incidence of VTE after gynae surgery:-
1. proper risk assessment for VTE during pre-op
2. counselling and provision of written information for need of thromboprophylaxis ans methods of that
3. advise to reduce weight. Stopping smoking
4. to stop OCP, HRT 1 month prior the date of surgery
5. to build up hemoglobin as far as possible if required before surgry to avoid post op blood transfusion
6. reducing total hospital stay, admission on day of surgery, preferably only few hours before surgery
7. prophylactic heparin injection 2 hours before surgery
8. to avoid GA if possible or to prefer regional anaesthesia as far as possible
9. graduated elastic calf stocking/intermittent pneumatic compression to start before surgery and to continue till the woman becomes fully mobilized
10. to achieve early mobilisation post op
11. to avoid dehydration
12. to treat any infection
13.thrombo-prophylaxis. Low molecular weight heparin is preferable to unfractionated heparin.
LMWH to be given in once daily dosage for 5-7 days post op
14. women should be discharged as soon as her clinical condition persists.
15. proper advice needs to be given regarding need for mobilisation and hydration.
16. if needs thromboprophylaxis at home, proper follow up plan should be given.



Posted by KWASI RICHARD A.
Women with privious history of venous thromboemnbulism.
Women with hertable thrombuphillia or acquired thrombophilli.
Medical co-morbidities lide heart or lung diseases systemic Lupus erythrematous, concer and infamatury conditions lide inflamatory bowel diseases. Diabeties are at risk of venous thromboembolism.
Women in any of the following categories are at risk of venous thromboembolism, shrf obrt 35 yrs. Body mass index greater than 30 kg/m2. Parity greater than five. Smokers immobility more than tree days. Elderly infirm for example walking with a stick if they fall into any of the above categories they will be indentefied and steps thaken to manage these risks.
- Women with raised body mass index will be adcised on weight reduction prior to surgery.
- Smokers will be advised to quit smoking or reduce the amount they smoke.
- Treat cormibid infections or diseases.
- Multidisciplinary team invoving the Anesthasist, physicians and haemotogist to assess and manage high risk patients to optimise conditions before surgery.
- Preoperatively give high risk patients Lower Mulecular weight Heparin as per local protocol and continue till fully mobilised .
Advise patients to consider stopping oestrogen-containing oral contraception or HRT 4 weeks before elective surgery and provide advice on alternative contraception methods. Early mobilisation after surgery should be encouraged and dehydration should be avoided.graguated elastic compression stockiing should be worn till full mobilisation. continue with lower molecular weight heparin postoperativelly till full mobilisation. consider using regional anaesthesai if appropriate as it reduces vte compared with general anaesthesia
Posted by Bgk H.
bgk

a. Women considered high risk of venous thromboembolismewhen she is a known case of thrombophilia such as antithrombin III deficiency,proteinc and s deficiency. Patient had proloned immobilization prior to surgery also cosidered high risk.

Apart from that patient who has 3 or more moderate risk factor is also considered high risk. Moderate risks are patient who smoke and drink alcohol. High BMI more than 30. Patients age more than 35 yaears. Long surgical procedure more than 60 minutes. patient who is consuming COCP and patient who has personal and family history of thrombophilia or previous history of thrombosis. patient who is dehydrated and having gross varicose vein also at risk.

b. To minimise the risk of VTE, multidisciplinary approach needed. VTE assssment should be done at preassessment before the op to identify high and moderte risks patients for VTE. Apprropriate surgical procedure should be considered such as laparoscopically minimally invasive procedure or open laparotomy.

Prior to operation weight reduction should be advice for high BMI patiets although difficult to achieve. Dietitian referral should be made. Advice on stop smoking and and reduction of alcohol intake should be given. Patient on oral contraceptive should be advice to stop taking it 3 months prior to the procedure.

Admission to ward should be made as near as possible to the surgery to avoid long hospitalisation and tendency to restrict mobilisation. Graduated compression stocking should be put on, and prophylactic low molecular weight heparin should be administered prior to op. Patient with intercurrent illness such as ongoing chest infection need to be postponed.

Intraoperatively, blood loss should be minimise, tromboembolic stocking should be applied continously till fully mobile. adequate hydration needed. early mobilisation should be encourage. Thromboprophylaxis such as heparin should be continued till fully mobile.
Posted by A- N.
Women with high BMI more than 30, on harmone replacement theraphy or oral contraception are at a high risk for VTE. history of congenital thrombophilic defects like antithrombin 3 deficiency, Protein s deficiency,protein c deficiency, factor V leiden mutation, prothrombin 20210A are at high risk.
Acquired thrombophilic defects like antiphospolipid antibodies, SLE are high risk for VTE.
If there is a personal history of thrombosis in the past or family history of thrombosis in first or second degree relatives is high risk for VTE.
Medical problems as nephrotic syndrome, sickle cell anaemia and problems as prolonged surgery, haemorrhage, malignancy Increase the risk. prolonged immobility also increases the risk.
How to minimise the risk of VTE:
Appropriate and systamatic risk assessment for VTE is important in taking adequate measures to prevent VTE.
Life style modifications like reducing weight if high BMI, Stopping smoking will reduce the risk.
If there is personal or family history of thrombosis, I shall offer thrombophilia screen prior to surgery if possible.
I shall also advise to stop HRT or combained harmonal contraception 3 months prior to elective surgery.
I would try to offer laparoscopic surgeries as opposed to laparotomy to reduce the risk of VTE, reduction in the operating time and blood loss will decrease the risk of VTE.
Post operatively, adevuate pain relief, correction of dehydration, early mobilisation, use of TED stockings or flowtron boots and thromboprophylaxis with low molecular weight heparin depending on the BMI of the patient will redice the risk of VTE.
Posted by NIRMALA M.
Women with personal history of VTE, family history of VTE in Ist degree relative, those requiring major gynaecological surgeries requiring prolonged hospitalisation, suspected immobilisation, surgeries for gynaecological malignancies, dehydration, those with co morbid conditions like high BMI>30, nephrotic syndrome, CCF, those who are on COC pills till surgery, smokers, women with gross varicose veins, inadvertent stopping or inappropriate low dose of anti coagulants before or following surgery for patients who were on thromboprophylaxis pre op, in appropriate/ no use of thrombo prophylaxis in others who had major gynae surgeries and hospitalised.
I will do proper risk assessment for VTE pre operatively. I will assess the patient\'s age, diagnosis and nature of surgery whether it is for benign or malignant condition, day case or not, as women undergoing major gynaecological surgeries especially for pelvic malignancies requiring hospitalisation are at more risk for developing VTE. In these high risk cases, they must be started on pre operative LMW clexane just before surgery according to their BMI and continued until they are mobile or according to the protocol. If there is personal or family history of VTE in first degree relative, and if she was on anti coagulation therapy, I will enquire about the duration of treatment to assess the severity of the condition and verify whether thrombophilia screen has been done. If not, I would do a thrombophilia screen and refer to haematologist for interpretation of results and advise for pre op and post op thrombo prophylaxis. If BMI is high, I would advise for weight reduction and refer to dietitian. If smoker, advise to stop smoking and refer to smoking cessation clinic if she is willing to stop smoking. Dehydration should be avoided post operatively. TEDs stockings and pneumatic compression stockings should be used intra and post operatively depending on the severity of the condition. I would encourage her to mobilise soon after the surgery. In cases of mechanical heart valves or atrial fibrillation on warfarin, Haematologist should be involved regarding starting of LMW heparin and stopping warfarin before surgery and switching back to warfarin after surgery as inappropriate low dose might lead on to VTE. Careful assessment for sepsis postoperatively like any increased temperature, raised pulse, increased inflamatory markers like CRP, WCC, should be investigated and treated promptly as sepsis can trigger VTE.
Posted by Mohamed D.
Mohamed
A) Women with previous history of thromboemolism are at high risk of recurrence. Women with thrombophilia (especially congenital thrombophilia) or family history of thrombophilia with VTE in first degree relative. Morbidly obese women especially with less mobility or bed ridden. Women taking OCP or HTR are at high risk. Women with risk factors for dehydration as chronic diarrhea.
Gynae malignancy surgery or major surgery put women at high risk. Massive haemorrhage with blood transfusion increases the risk of VTE. Prolonged operative time with venous stasis in lower limbs increase the risk.

B) Raising awareness of the problem among staff and clear guidelines should be in place for thromboprophylaxis.
Proper risk assessment for each woman before surgery is mandatory to reduce the risk of VTE, with a clear documentation of plan for thromboprophylaxis.
Preoperative optimization with stopping OCP or HRT 4 weeks before the operation and avoid dehydration with treatment of any cases. Avoid prolonged immoblization if possible.
Before the operation, TED stockings should be wearied according to the proper calf size and continued to wear them until discharge from hospital.
Intraoperatively, care to minimize operative time and blood loss with adequate hydration with IV fluids. Mechanical compression of calfs throughout the operation.
Postoperatively; LMWH should be given SC according to body weight until full mobilization occurred. Hydration with adequate IV fluids or oral intake.
Early diagnosis and management of any suspected cases of VTE and use of multidisciplinary team with haematologist and anaesthetist.
Posted by Ir A.
Women at high risk of venous thromoembolism (VTE) following gynaecological surgey are those who are above 35 years of age, smokers, have high BMI, have history of previous VTE, are known carriers of thrombophilias, are on oral contraceptives or HRT or have history of hypertension and coronary artery disease. Major surgery or long duration surgeries are especially at risk.
A careful assessment of risk factor should be undertaken prior to surgery and documented in the case notes. Women who have a history of previous VTE or a family history of VTE should be investigated for thrombophilias. OCPs should be stopped a month in advance of the surgery. HRT need not be stopped prior to surgery but is an independent risk factor to be considered in risk assessment. All medical conditions like hypertension and diabetes should be optimised prior to elective gynaecological surgeries.
Preoperative low molecular weight heparin at least 2 hours prior to surgery should be given to women at risk of VTE. Intraoperatively adequate hydration should be maintained and care should be taken to avoid hypothermia. Calf compressors should be used during the surgery. Antibiotic prophylaxis should be given. Care should be taken to minimise blood loss.
Postoperative management should include adequate hydration and pain relief. Early mobilization should be encouraged. Thromboembolic deterrent (TED) stockings may be used. LMWH should be given in once daily prophylactic doses for 3 to 5 days or till the patient is ambulating. Higher dose may be needed in women with high BMI.
Posted by Ir A.
Women with age more than 40 years, who are smokers, have personal or family history of venous thromboembolism (VTE) or are known carriers of thrombophilias are at high risk of VTE following gynaecological surgery. Surgical factors include surgery for malignancy, major surgery (requiring general anesthesia nad lasting for more than 30 minutes), current major illness or current infection. Patients with gross varicose veins or those who are on oral contraceptives, HRT or raloxifene are also at risk.
A thorough assessment of risk factors for VTE should be done preoperatively according to unit protocol and documented in the case notes. Alternative nonsurgical therapies should be considered and discussed with the patient. Where surgery is deemed necessary, vaginal route is safer than abdominal and should be considered wherever feasible. Care should be taken to optimise modifiable factors like smoking cessation, stopping raloxifene 3 days prior and COCs one month prior to elective surgery. Current infection should be treated. The patient should be managed in conjunction with anaesthetist and haematolgist. Medical problems like hypertension and diabtes should be optimised preoperatively. Low molecular weight heparin should be given in prophylactic dose 2 hours prior to surgery away from the site of incision. It may be given 12 hours earlier (on the night before surgery) to women at high risk for VTE.
Surgery should be done by an experienced surgeon or under his/her supervision taking care of meticulous surgical technique with minimum blood loss and secure haemostasis. Adequate hydration should be maintained during the surgery and care should be taken to avoid hypothermia. Prophylactic antibiotics should be given.
LMWH should be continued postoperatively in once daily dosing. Women with higher BMI and at high risk may require high prophylactic twice daily doses. Care should be taken to ensure adequate hydration. The patient should be encouraged to ambulate as early. TED stockings may be used in low risk women. The attending clinician must be aware of the signs and symptoms of VTE and the patient should be monitored carefully.