Benign Gynecology Postoperative Venous Thromboembolism Prophylaxis Guidelines

Contributors: Andrew Lane MD, Benjie Mills MD.
Updated: 1/28/15

Venous Thromboembolic Events (VTE), the collective term for Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE), are major postoperative concerns. There are 2 million cases of DVT annually in the U.S. One third of these patients will go on to develop a PE, leading to 60,000 deaths/year1. Seventy five percent of DVT’s will develop within in the first 72 hours postop2. Without appropriate prophylaxis, 15-40% of patients undergoing major benign gynecologic surgeries will develop a DVT. Appropriate prophylaxis decreases this risk to 0-2%3.

Mechanical Prophylaxis
Sequential Compression Devices (SCD’s) prevent venous stasis and are as effective as heparin preparations. They should be placed and activated, prior to anesthesia, used continuously until fully ambulatory, and (ideally) until time of discharge. A recent study showed only 58% of patients are compliant with SCD use4. Consider using pharmacologic prophylaxis if patient compliance is a concern. Do not place SCD’s on a limb where an acute DVT is suspected.

Pharmacologic Prophylaxis
Pharmacologic prophylaxis should be initiated within 12 hours of surgery for benign gynecology patients, unless otherwise specified by the attending surgeon. Patients with significant intraoperative or postoperative bleeding may have their anticoagulation held at the discretion of the attending surgeon. If an acute VTE develops, therapeutic dosing is required.

Unfractionated Heparin (UFH) is the most extensively studied method. UFH binds to antithrombin and enhances its activity. Use for more than 4 days requires monitoring of platelets as 6% will develop heparin induced thrombocytopenia (HIT). Other potential adverse events include osteoporosis and bleeding.

Low Molecular Weight Heparin (LMWH) has greater availability, more predictable pharmacokinetics, rare HIT, and less risk of osteoporosis with long-term use. LMWH inactivates factor Xa.