Gynecologic Oncology Postoperative Venous Thromboembolism Prophylaxis Guidelines

Contributors: Andrew Lane MD, Jeffrey Elder 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, 34.6% of patients undergoing gynecologic oncology surgeries will develop a DVT. Appropriate prophylaxis decreases this risk to 1-6.5%3. Malignancy
increases VTE risk.

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 2 hours preoperatively for gyn onc 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.

Gyn Onc Inpatient Management
• All patients admitted with a cancer diagnosis, including chemotherapy patients and preoperative patients, should receive pharmacologic anticoagulation.
• All patients admitted with a cancer diagnosis who are at risk of bleeding should receive SCD prophylaxis.

Gyn Onc Preoperative Management
• All patients with a cancer diagnosis admitted on the day of surgery are candidates for preoperative pharmacologic DVT prophylaxis at home for 5 days prior to their surgery.
• All patients with a cancer diagnosis are candidates to receive Heparin 5000 IU SQ in preop holding 2 hours prior to surgery at the discretion of the attending surgeon.
• All patients with a known acute DVT should have a Greenfield filter placed preoperatively.

Gyn Onc Postoperative Management