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ESSAY 203 - VTE

Posted by Zaharuddin R.
Patient at high risk of venous thrombo-embolism(VTE) after gynaecology surgery should be identified pre-operatively. Obese patient especially BMI > 30 is at high risk to develop VTE, weight reduction pre operatively especially for benign gynae-surgery is advisable. Smoker should be advised to stop smoking not only to reduce VTE risk but to reduce anaesthetic complication especially general anaesthesia during operation. Drugs should be reviewed especially combined oral contraceptive pills or hormone replacement therapy should be off at least a month and raloxifene should be off at least a week pre operatively. Non-ambulating patient like post hip fracture is at high risk for VTE. Medical illness such as diabetes mellitus should be controlled preoperatively to reduce complication post operatively such as keto-acidosis which put the patient at higher risk to develop VTE.

Type of surgery is a main factor for VTE. Gynae-oncology surgery such as whertheim\'s hysterectomy and long surgery such as hysterectomy for severe endometriosis put the patient at high risk for VTE due to long hours of operation. Positioning of patient such as lithotomy for vaginal hysterectomy with anterior and posterior repair also higher risk for VTE compared to supine position with abdominal hysterectomy.

Pre operative patients for gynae-surgery should be referred to physiotherapist for not only deep breathing exercise but leg exercise post operatively. Subcutanous heparin especially low molecular weight heparin should be given 12hours pre-operatively to patient at high risk and it should be continued post operatively if no bleeding tendency. Thrombo-embolic deterrent stocking should be applied starting pre operation till post operation. Adequate hydration should be maintained either by intavenous fluid or oral intake. This could be monitored by input/output chart and urine ketone test.

Good analgesia post operatively is important for patient to do exercise post operatively and to encourage early ambulation. Support from nursing staff and physiotherapist is important for patient post operatively for exercise and early ambulation.

Written information especially regarding operation and physiotherapy should be given to the patient to be take part actively in minimizing risk of VTE for gynaecology operation.
Posted by Balakrishnan V.
Venous thromboembolism (VTE) is associated with high morbidity and mortality and most of the time its underdiagnosed. According to Royal College of Obstetricians and Gynaecologist guideline every patient undergoing gynae surgery should be assessed for her risk of thromboembolism and grouped into low,moderate or high risk so appropriate thromboprophylaxis can be given.
High risk patient\'s are those having three or more of the risk factors which are age more than 35, parity more than four, BMI more than thirty, medical problem like cardiac or renal problem, sickle cell, inflammatory bowel disease, paraplegia, immobility prior to surgery or having emergency surgery which last more than 30 minutes. Patients with personal or family history of VTE or thrombophilia are also high risk.

To minimise the risk of VTE in high risk patients every unit should have a protocol to assess the patient\'s risk of VTE and give thromboprophylaxis accordingly. This should be done preoperative, intraoperative and post operative period.
The high risk patients should be identified and adviced to healthy life style in gynae OPD when a decision of operation is made.
There are some risk factors which cannot be changed like age or parity but emphasis should be to reduce the modifiable risk factors like high BMI, sedantary life style, smoking and alcohol intake. They should be referred to appropriate specialities if they have diabetes, hypertension or other medical problem. Patients on COCP should be advised to stop it three months prior to operation as it increases the VTE risk but they should be given alternative contraception for the time being. HRT not needed to be stopped. Patients who are already on oral thromboprophylaxis should be switched to therapeutic dose of LMWH as it has short half life and can be injected during fasting phase. Patients should be given written informations and a followup appointment in preassessment clinic.
Preassessment clinics play an important role in diagnosing risk factors of thromboembolism and initiating steps to reduce them.
All this is possible in planned gynae surgery but not in emergency operations.
Risks during surgery can be reduced by selection of anaesthesia and procedure, if there are options, to minimise the time of surgery and hence immobility.
Postop good hydration, analgesia, TEDS and early mobility are cost effective measures to reduce thromboembolism. Signs and symptoms of VTE should be specifically looked for in post op followup like pain or swelling in legs. There should be low threshold of suspicion of VTE and investigations should be started early to prevent unnecessary treatment but if there is delay in test results treatment should be started and modified later on according to the results.
There should be regular audits to see effectiveness of protocols and amendmends, if needed, to make the protocol more effective
Posted by neera  B.
Thrombophilias, especially antithrombin III deficiency & factor V Leiden mutation; family history of VTE in first or second degree relative; previous history of VTE; surgery for gynae malignancy ; presence of three or more moderate risk factors are considered high risk factors for VTE after gynae surgery.
Moderate risk factors include age over 40 yrs, BMI over 35, gross vericose veins, infection, immobilisation , concommitant intake of COC pill or HRT.
To minimise risk of VTE, preoperatively weight reduction should be advised before elective cases, if her BMI is over 35. Referral to dietician and physiotherapist should be made. Infections should be treated and smoking cessation advise rendered. Mutidisciplinary team involving hematologist,senior gynaecologist, senior anaesthetist, physiotherapist, suppotive nurses should be invoved in her care. LMWH should be started 12 hrs before surgery and continued into the postop period as per the unit protocol. The patient should be involved in making the management plan which should be attatched to her handheld notes. Informed consent should be taken and the discussion should be documented. Preop immobilisation should be avoided. It is not recommended to stop HRT before surgery. COC should be stopped 4 weeks before major surgery when immobilisation is expected. It does not need to bestopped before minor gynae surgery.
During operation, correctly fitted thromboembolic deterrent stockings or pneumatic calf compression stockings shoulld be worn if operation is expected to continue for more than half an hour. The operation should be done by a senior gynaecologist so that operation time is reduced.
Post operatively, early mobilisation, chest physiotherapy, leg exercises are encouraged and correctly fitted TED stockings are adviced. Heparin prophylaxis is continued post operatively in consultation with hematologist. Symptoms of DVT (unilateral leg swelling, pain or pelvic pain) and pulmonary embolism (chest pain, breathlessness) are explained to the patient.
Before discharge, 24 hr helpline numbers, pamphlets are provided and patient is asked to report immediately to the hospital in case of such symptoms. Follow up visit is arrranged. If VTE occurs incident performa is filled.
Posted by Srivas  P.
The risk of venous thromboembolism is increased in all patients undergoing major surgeries lasting more than 30 mins even when she has no high risk contributory factors. Similarly the risks of VTE exist even after minor gynecologic procedures if the woman has 3-4 high risk factors that can contribute to it.

So, before any gynecologic procedure it is necessary to identify woman at high risk of VTE so that preventive measures can be given and thrombo prophylaxis can be given as appropriate.

Woman at high risk include obese individuals, H/O family and personal history of VTE, known thrombophilias detected on screening due to suspicions, woman taking COCs, excessive smokers, woman being operated for malignancies, prolonged immobilization prior to and with possibility of post operative immobilization due either to systemic diseases, arthritis, morbid obesity, woman with gross varicose veins, Inflammatory bowel disease, sickle cell disease. Severely anaemic woman being operated for some gynecologic emergency, massive intra operative bleeding and any cardiac conditions etc.

Woman should be assessed pre operatively prior to surgery and categorized as high risk/low risk. Woman with prior VTE, family history of VTE, morbid obesity, hereditary thrombophilias like homozygous Leiden mutation, antithrombin deficiency and patients with malignancy should be categorized as high risk.

In low risk cases she may have 1 or two risk factors and she should be counseled about possible weight reduction, stopping smoking and stopping COCP atleast 6 weeks prior to planned major surgery. HRT need not be stopped but she may need thromboprophylaxis. She should be given TED stockings post surgery and early ambulation. Hydration should be adequate.

High risk patients should have LMWH gives 12 hrs before surgery and post op should use TED stockings along with early ambulation and calf exercises. Preferably surgery should be done by senior to decrease time of operation. If she is very high risk for VTE it maybe worthwhile finding a conservative option for her condition and avoid surgery if possible.

If she has any signs and symptoms of VTE she should be put on empirical thrombo prophylactic treatment pending objective confirmation. COCP should not be restarted at least for 3 months post major surgery. Regular audits should be taken to review measures taken and if any improvements done based on audit results and reviewed again.

Posted by Ebeinheizer S.
Patients who are at high risk for venous-thromboembolism (VTE) after gynaecological surgery are those with pre-existing conditions such as obesity (especially BMI>30), thrombophilias (Protein S and Protein C deficient, Factor V Leiden Mutation, antiphospholipid syndrome), systemic illness (nephritic syndrome, liver disease, chronic renal failure) and history of or current VTE. Patients who smoke or immobilized for prolonged period prior to surgery are also at high risk. Coexisting malignancy such as gynaecological malignancy for which surgery is undertaken also increases the risk.

Surgery for gynaecological malignancy and those which involves extensive pelvic tissue manipulation such as severe endometriosis also puts patient at high risk for VTE. Long (especially >4 hours) and major surgery such as Radical Hysterectomy, Pelvic eccentration and Debulking Surgery also put patients at high risk for VTE.

Precautionary measures will begin by identifying high risk patients prior to surgery. If necessary, some surgery can be postponed to optimize patients such as referring obese patients to weight loss clinic, smokers to smoke cessation clinic and other medical illness well controlled before surgery. Written communication with the treating physician emphasizing the risk of VTE if surgery undertaken is important.

For patients with thrombophilia and past or current VTE, a multidisplinary approach with haematologist, anaesthetist and senior gynaecologist should be taken. Prophylatic heparin (unfractionated heparin infusion which is stopped 6 hours prior to surgery) and or venous filter (?umbrella?) should be considered. Elastic TED Stockings should be used before, during and after surgery.

Surgery need to be performed by skilled/senior gynaecologist for high risk patients. This will reduce the duration of surgery/anaesthesia, blood loss and tissue manipulation which can increase the risk of VTE. During surgery, electrical/pneumatic calf compressor should be used. Adequate hydration should also be maintained.

Post-operatively, low molecular weight heparin (LMWH) as VTE prophylaxis should be used. Each unit should have written protocols for each type of surgery with risk factor scoring pertaining LMWH prophylactic anti-coagulation. Dose adjustment need to be made for the very obese. In the event of massive haemorrhage during surgery, haematologist input should be sought regarding anticoagulation with LMWH. Adequate hydration with CVP monitoring (if any) or simple fluid input/output chart is important to prevent haemoconcentration which predisposes to VTE. Usage of TED Stockings and early ambulation (even while in bed) prevents venous stasis and reduces the risk of VTE.

Clear documentation and communication with medical and nursing team is vital. High index of suspicion for VTE should be maintained. If VTE suspected, anticoagulation should be started immediately and objective tests such as Spiral CT-Scan should be performed. Haematologist need to be involved in the management. Long term LMWH or warfarin might be necessary. Patient should be counselled with diagrams. Risk management forms should be filled and internal audits performed in the occurance of VTE in such patients.

Upon discharge, patient should be explained about risk of VTE while at home. Signs and symptoms should be explained with diagrams. She should be advised to seek early medical attention if any signs or symptoms. GP should be informed about the type of surgery and patient?s high risk of VTE.
Posted by Remi A.
Patients at high risk of venous thrombo-embolism[VTE] after gynaecological surgery are women undergoing major surgery[lasting more than 30 minutes]and High risk patients even when undergoing minor procedures[<30 minutes].

Personal history VTE,Thrombophilia,strong family history of VTE,woman with malignant disease,and presence of three or more moderate risk factors would make a woman high-risk patient for VTE.

Age over 40yrs,obesity[BMI>35],Immobility prior to surgery,intercurrent infections,combined contraceptive[COCP] use,and HRT are moderate risk factors.

With repect to measures to minimise risk in High-risk patients,risk assessment should be done pre-operatively.High-risk patients[as mentioned above]undergoing major and minor surgery should have multidisciplinary input[Haematologist and Anaesthestists].
Risk of VTE should be considered in whether overall benefits of surgery outweighs risk,and alternative treatments considered where appropriate.
Malignant cases should be managed in Cancer centres to optimise outcome.
Intercurrents conditions like Diabetes should be controlled before surgery.
Pre-operative measures like stopping smoking,weigh loss,and discontinuation of COCP[4-6 Weeks before surgery] should be recommended.RCOG guidelines does not recommend discontinuation of HRT pre-operatively,but it should be consider as a risk factor.
High risk patients should be offered thromboprophylaxis,after appropriate counselling.This can be in form of Tromboembolic detterents stockings,with heparin 12 hours pre-op,and then 8hourly.
LMW heparin has better bioavailability and reduced side effect profile compared to unfractionated heparin.
Duration of surgery should not be unduely long,and senior personnel should be involved as appropriate.
Good hydration and early mobilisation are important postoperatively.It important to observe patient for clinical symptoms of VTE[calf pain,chest pain,dyspnoea],and treatment should be prompt on clinical suscipion,while awaiting objective confirmation[Doppler studies,ventilation/perfusion scan,venogram].
As VTE can still occur well after discharge information abouts symptoms should be provided,and patient encourage to report same.
Follow appointment should be provided.
Posted by Kishor S.
Patients with high risk for VTE carries a risk of 20 to 40% of VTE following a gynaecological surgery. Such patients are either age >60 years, or age 40 to 60 with additional risk factors. The risk factors for thrombosis are immobility/paresis, obesity, smoking, varicose veins, previous VTE, malignancy, pregnancy/postpartum, estrogen containing pills/HRT, SERMs and medical disorders e.g. heart failure, nephrotic syndrome, inflammatory bowel disease, SLE, thrombophilia and acute medical illness.

The measures adopted to minimize the risk will be directed towards the correction of factors which are amenable, and proper thromboprophylaxis. Patients with benign condition where surgery can be deferred, measures to reduce the risk factors can be implemented. She should be advised to reduce weight by at least 10% and give up smoking. No smoking for six months would reduce the risk. Use of pills containing estrogen should be stopped 3 months before surgery, HRT/SERMs before one month. Use of local vaginal estrogen cream need not be stopped. Medical disorders should be managed in consultation with the Medical team.

Thromboprophylaxis should be given in situations where surgery cannot be deferred or the risk factors could not be corrected. The recommended therapy is LMWH 30 mg twice daily (or Unfractionated heparin 5000 units SC thrice daily) to be started 12 hours before the surgery and to be continued post operative till she becomes completely ambulatory, which will be 4 to 5 days post op. This should be supplemented with use of TED stockings during surgery, early mobilization and avoidance of dehydration.

It has been shown that use of epidural anaesthesia reduces DVT by virtue of vasodilation following medical sympathectomy. Patients who are on therapeutic heparin for an active disease should have the regime changed to prophylaxis regime 12 hours before surgery to avoid intraoperative and post op bleeding. It can be resumed once the phase of bleeding is over (12 hours Post op).

Proper documentation is necessary, and information about the risk and treatment involved should be given to the patient in detail.
Posted by adnan S.
Risk of venous thromboembolism should be assessed in all woman under going major gynaecological surgery lasting >30mints and in women at high risk undergoing minor procedure.Patient who are at high of VTE are women with previous h/o VTE,strong family h/o of VTE or thrombophilia,women undergoing major surgery for gynaecological cancer,and 3or more moderate risk factors.Moderate risk factors are age >40yrs,obesity BMI>35,immobility prior to surgery more than 4days ,gross varicose veins, intercurrent infections, and combined oral contraceptive pill.

To minimize the risk of VTE in high risk patient, pre-operative measures are risk of VTE should be taken into account when considering whether the overall benefits of surgery outweighs the risks consideration of alternative treatments like mirena/TCRE for monorrhagia should be considerd.Patients who are on anticoagulants and high risk factors should cared in liaison with heamatologist and aneasthetist.Patient is advice for weight reduction,to stop smoking ,if she is taking combined oral contraceptive pill should be stoped 4-6 wks before surgery ,this sould be balanced against the risk of un wanted pregnancy and alternative contraception should be considerd like progesterone only pillwhich does not increase the risk of VTE and no need to discontinue preoperatively.Prophylactic heparin should be given 12hrs preoperative and then 8hrly along with TEDS.LMWH has the advantage of equal or improved antithrombotic activity,reduced incidence of bleeding ,no need for coagulation monitoring.Intra venous UFH is needed in some circumstances like patients with renal failure ,with prosthetic heart valves and those taking therapeutic doses of LMWH.
Intra-operatively avoid pressure on calf by using pneumatic or electric calf compression devices along with TEDS .In the post operative period early mobilization ,adequate hydration sould be considerd along with heparin and TEDS till patient is fully mobilized.
Posted by Vinayak B.
High risk patients are those who have three or more moderate risk factor (sickle cell disease, varicose veins ,family h/o ,thrombophilia,smoking,,agemore than 35, obesity immobilization prior to surgery more than 4 days ), single high risk factors are major surgery more than 30 min with family or personal h/o thrombophilia. , surgery for malignancy,.

Preoperative risk assessment done. If time permits reduction of weight stopping smoking advocated .If high risk factor is present prophylactic heparin therapy 12 hours prior to surgery started. And continued till 5 days or patient is ambulatory. Drug of choice is LMWH in higher prophylactic doses ( enoxaparin 40 mg od) . no need to stop HRT prior to operation.

Intra operative period avoid excessive blood loss, appropriate fluid replacement, pneumatic compression boots during operation followed by graduated elastic stockings in post operative period. Surgery done by senior personal to cut short time period

Postoperative period early mobilization, continuation of heparin prophylaxis and graduated elastic stockings avoid smoking. ,dehydration, ealrly identification of thrombosis ( leg swelling calf muscle tenderness) or breathless ness cough mild fever to detect early PET , High index of suspicion to diagnose dvt/ / pulmonary embolisation and switch over to therapeutic doses of Lmwh ,

In few cases ( recurrent dvt/ preexisted dvt) and cant avoid surgery even prophylactic inferior vena caval filter can be considered preoperative period after consultation with hematologist. .


Posted by Ismatara B.
It is important to the identify preoperatively the risk of thromboembolism, as it has a high mortality and morbidity, especially when undiagnosed and timely preventive measures are not undertaken. Patients at high risk of venous thrombo-embolism (VTE) after gynaecological surgery are women undergoing major surgery (lasting over 30 minutes) and high risk patients undergoing minor procedures (<30 minutes).
Personal history VTE, Thrombophilia (especially antithrombin, protein C and S deficiency and factor V Leiden mutation), strong family history of VTE in first and second degree relatives, woman with malignant disease, and presence of three or more moderate risk factors would make a woman high-risk patient for VTE.
Moderate risk factors are age over 40yrs, obesity (BMI>35), blood group other than O, immobility prior to surgery for more than 4 days, intercurrent infections, excessive smokers, systemic diseases, arthritis, woman with gross varicose veins, inflammatory bowel disease, sickle cell disease, nephrotic syndrome, heart or lung disease, heart failure or recent myocardial infarction, combined contraceptive (COCP) and HRT use.
According to RCOG guideline every patient undergoing for gynaecological surgery should be assessed for risk factors for venous thromboembolism, grouped accordingly and proper thromboprophylaxis should be given timely to reduce the risk. To minimize the risk of VTE in high-risk patient, first consideration should take into account that the benefit of surgery outweighs the risk of VTE. Alternative treatment: conservative both medical and surgical (e.g. mirena/ TCRE for menorrhagia) should be discussed. If necessary some surgery may be postponed to optimize the risk such as weight reduction of obese women (BMI >35) with the help of dietician, refer smokers to smoke cessation clinic and control of medical illness in consultation with medical team. Infections should be treated. Preoperative immobilization should be avoided. COC should be stopped 4 weeks before major surgery. It is not recommended to stop HRT before surgery. Mutidisciplinary team involving hematologist, senior gynaecologist, senior anaesthetist and supportive nurses should be involved in her care. LMWH should be started 12 hrs before surgery given at a site away from the proposed wound and continued during postoperative period as per the unit protocol. Heparin prophylaxis is associated with thrombocytopaenia and an increased risk of bleeding. The patient should be involved in making the management plan. Informed consent should be taken and the discussion should be documented. During operation, correctly fitted thromboembolic deterrent stockings or pneumatic calf compression stockings should be worn if operation is expected to continue for more than half an hour. A senior gynaecologist should do the operation so that operation time is reduced. Patient with malignancy should be treated in cancer center.
Post operatively adequate hydration, early mobilization, chest physiotherapy, leg exercises are encouraged and correctly fitted TED stockings are advised. Heparin prophylaxis is continued post operatively in consultation with haematologist. Symptoms of DVT (unilateral leg swelling, pain or pelvic pain) and pulmonary embolism (chest pain, breathlessness) are explained to the patient. If any sign/symptom of VTE, Doppler studies /venograms and lung perfusion scan should be arranged for definitive diagnosis and appropriate treatment should be started while waiting for objective diagnosis to reduce the mortality and morbidity.
Before discharge, patient is informed about sign symptom of VTE and asked to report immediately to the hospital in case of such symptoms. Follow up visit is arranged. GP should be informed about type of surgery and high risk of VTE.
Posted by Aroosha B.
The patients at the risk of venous thromboembulism, following surgery can be categorized into those who have moderate risk factors and high risk patients. Moderate risk factors includes the patients having minor surgery lasting less than 30 minutes, who have personal or family history of thromboembolic desiese or thrombophilia. Other risks include patients having operations expected to last over 30 min., extended leproscopic surgery, age over 40 years, obesity that is more than 80 kg, gross varicose veins, current infection, immobility before surgery for more than 4 days, major concurrent disease i.e. heart and lung disease, inflammatory bowel disease, nephrotic syndrome, non gynecological malignancy and heart failure. The patients on combined oral contraceptive pills are also at risk of VTE and the pills should be stopped 3 months before the major surgery.
The patients who have high risk of VTE are those who have 3 or more moderate risk factors as mentioned above and those who are undergoing major surgery for gynecological cancer. Persons who have a family history of VTE are suffering from paralysis or immobilization undergoing surgery lasting for 30 minutes.
The other measures which can be taken to reduce, are by taking proper history and identifying risk factors like obesity is a major risk factor and patient should be advised on weight reduction before surgery. Cessation of smoking should be advised those who have chest infection or any disease, which limit their mobility should be treated before surgery. Adequate preoperative assessment of the patient including plan to switch to heparin preoperatively in patients already on warfarin if appropriate should be done. Heprine prophylaxix should be used with un fractionated heparin 5000 IU subcutaneously 8 hourly, the other alternative is LMWH e.g. enoxaparin 40 mg daily can be given which has the advantage of once daily dosage because it is effective and probably safer than UH. Haprane should be given 12 hours before surgery and it should be given at a site away from the proposed wound for 5 days. Heparin prophylaxis is associated with thrombocytopoenia and increase risk of bleeding (wound haematoma) but there are no significant changes in postoperative haemoglobin or blood transfusion requirement. Intraoperatively thromboembolic deterrent stocking or calf compression is recommended to decrease the risk of VTE. Post operatively early mobilization and adequate hydration should be done. thromboembolic deterrent stockings should also be used. Apart from all the risk mentioned above each patient should also be assessed on individual basis and those who are at very high risk should be managed by multi disciplinary approach involving a heamatologist.
Posted by afroz S.
VTE is a major cause of morbidity and mortality.
High risk factors include
- 3 or more moderate risk factors
- radical gynaecological oncology surgery
- previous h/o DVT or family h/o DVT or pulmonary embolism
- h/o paralysis leading to immobilization
- thrombophilia screening positive
Modetare risk factors include
- age of pt > 40 years
- obesity,BMI > 30kg/mt2
- surgery lasting for > 30 mnts
- immobility for > 4days before surgery
- varicose veins
- current infection
- diseases for e.g cardiac ,inflammatory bowel disease, nephrotic syndrome
- use of COCP
Measures to reduce the risk of VTE include
1] pre operative assessment & evaluation.If pt is on warfarin,should be changed to heparin before surgery.High risk pts should be started on heparin prophylaxis with unfractionated heparin 5000 IU 12th hourly s/c started at least 12 hours before surgery.
The alternative is LMWH,Clexane 40mg ,once daily s/c .It is associated with less side effects,e.g thrombocytopenia. It should be continued into the post op period till the pt is mobilized. Special precaution is taken regarding the regional anaesthesia in consultation with the anaesthetist.Heparin injection is given away from the site of proposed incision.Complications include thrombocytopenia & wound hematoma.

2]Intra op- Thrombo embolic deterrent stocking & pneumatic calf compressions is helpful.

3] early mobilization, adequate hydration and TED stockings


Posted by Samir A.
Venous thrombo-embolism is a leading cause of
Posted by Samir A.
Venous thrombo-embolism (VTE) is a leading cause of post op morbiditity and mortality in the UK.
Patients who at high risk after Gyn Surgery are the patients with 3 or more of: age >40, Obese>35 BMI, Gross varicose veins, Immobilisation>4days, Current infectioc,Major current illness(Cancer, IBD, cardiac or pulmonary disease or polyythaemia), on COCP, have surgery >30 minutes.OR one of the following: surgery for cancer, personal or family history of VTE/PE. or LL paralysis or thrombophilia.

Minmisation of the risk of post op VTE could be achieved by identification of this high risk group, stop COCP 4weeks before surgery,prophylactic LMW heparine 12 h before surgery then 12 hourly, adequqte hydration during and after syrgery, pneumatic calf bags or elastic stocking preoperaively untill full mobilisation, early mobilisation.as well as try to have the incision site away from the injection site.
Unfractionated heparine could be also used 12 hourly.However wuond haematoma,thrombocytopenia, paradoical thrombosis and bone demineralisation are much less with LMW heparine.LMWH is monitored by anti Xa, unfractionated heparine monitored by Aptt, the aim is to have it 1.5-2.5 normal.

Low index of suspecion toward diagnosis of VTE post op is important to minimise the risk in thise group of patints.Observation for fever,tachcardia, LL pain, swelling, redness and tenderness, lower abdominal pain, acute chest pain, breathlesness, cyanosis should arouse the suspecion of VTE.
Multidiscipliary care is required: pre op; the anaesthetist, Haematologist eg in cases with thrombophilia, as well as the Gynaecologist. In case of diagnosis of post op VTE the senior Anaesthetist, Intensovest, Cardiologist as well as Haematologist help is manadatory.

The treatment of post op VTE rwquires the same multidisciplinary team with theraputic dose of heparin, thromblytic therapy and keeping the patient in the ITU unit.

I\'ll dicuss all the possibilities. with the patient pre op as well as giving information leaflet . I\'ll discuss any pot op evevt(if any0 with the patient and document that in the notes.