LMWH prophylaxis recommendations across major clinical practice guidelines after cesarean delivery
| Characteristic . | ASH 201813 . | RCOG 201516 . | SOGC 201418 . | ACCP 201215 . | ANZJOG 201217 . |
|---|---|---|---|---|---|
| Elective CD alone | For women with no or 1 clinical RF (excluding a known thrombophilia or history of VTE), the ASH guideline panel suggests against antepartum postpartum prophylaxis (conditional recommendation, low certainty in evidence about effects). | No | No | For women undergoing cesarean section without additional thrombosis RFs, we recommend against the use of thrombosis prophylaxis other than early mobilization (grade 1B). | No; early mobilization and avoidance of dehydration |
| Emergent CD alone | All women who have had cesarean sections should be considered for thromboprophylaxis with LMWH for 10 days after delivery apart from those having an elective cesarean section who should be considered for thromboprophylaxis with LMWH for 10 days after delivery if they have any additional RFs (grade C). | No | Following emergency cesarean section thromboprophylaxis with LMWH or UFH is recommended for at least 5 days or longer until recovery of full mobility (group consensus level 1). | ||
| Elective CD + RF | Not stated | See above; considered for thromboprophylaxis with LMWH for 10 days after delivery (grade C). | Postpartum thromboprophylaxis should be considered in the presence of multiple clinical or pregnancy-related RFs when the overall absolute risk is estimated to be greater than 1% drawn from the following groupings: Any 2 of the following RFs (emergency cesarean section counts as 1 RF) (II-2B) LMWH until discharge up to 2 weeks if 2 RFs | For women at increased risk of VTE after cesarean section because of the presence of 1 major or at least 2 minor RFs, we suggest pharmacologic thromboprophylaxis (prophylactic LMWH) or mechanical prophylaxis (elastic stockings or intermittent pneumatic compression) in those with contraindications to anticoagulants while in the hospital following delivery rather than no prophylaxis (grade 2B). | ≥1 major and ≥2 minor RFs: Postpartum thromboprophylaxis for ≥5 days or until fully mobile; 1 major or 2 minor RFs: Consider graduated compression stockings. |
| Emergent CD + RF | Not stated | All women who have had cesarean sections should be considered for thromboprophylaxis with LMWH for 10 days after delivery apart from those having an elective cesarean section who should be considered for thromboprophylaxis with LMWH for 10 days after delivery if they have any additional RFs (grade C). | Postpartum thromboprophylaxis should be considered in the presence of multiple clinical or pregnancy-related RFs when the overall absolute risk is estimated to be >1% drawn from the following groupings: Any 3 or more of the following RFs (elective cesarean section counts as 1 RF) (II-2B) LMWH until discharge up to 2 weeks if 1 RF | Further details in Table 3: Requires presence of at least 1 major RF OR presence of at least 2 minor RFs (planned cesarean section) OR 1 minor RF in the setting of an emergency cesarean section | Following emergency cesarean section, thromboprophylaxis with LMWH or UFH is recommended for at least 5 days or longer until recovery of full mobility (group consensus level 1). |
| Characteristic . | ASH 201813 . | RCOG 201516 . | SOGC 201418 . | ACCP 201215 . | ANZJOG 201217 . |
|---|---|---|---|---|---|
| Elective CD alone | For women with no or 1 clinical RF (excluding a known thrombophilia or history of VTE), the ASH guideline panel suggests against antepartum postpartum prophylaxis (conditional recommendation, low certainty in evidence about effects). | No | No | For women undergoing cesarean section without additional thrombosis RFs, we recommend against the use of thrombosis prophylaxis other than early mobilization (grade 1B). | No; early mobilization and avoidance of dehydration |
| Emergent CD alone | All women who have had cesarean sections should be considered for thromboprophylaxis with LMWH for 10 days after delivery apart from those having an elective cesarean section who should be considered for thromboprophylaxis with LMWH for 10 days after delivery if they have any additional RFs (grade C). | No | Following emergency cesarean section thromboprophylaxis with LMWH or UFH is recommended for at least 5 days or longer until recovery of full mobility (group consensus level 1). | ||
| Elective CD + RF | Not stated | See above; considered for thromboprophylaxis with LMWH for 10 days after delivery (grade C). | Postpartum thromboprophylaxis should be considered in the presence of multiple clinical or pregnancy-related RFs when the overall absolute risk is estimated to be greater than 1% drawn from the following groupings: Any 2 of the following RFs (emergency cesarean section counts as 1 RF) (II-2B) LMWH until discharge up to 2 weeks if 2 RFs | For women at increased risk of VTE after cesarean section because of the presence of 1 major or at least 2 minor RFs, we suggest pharmacologic thromboprophylaxis (prophylactic LMWH) or mechanical prophylaxis (elastic stockings or intermittent pneumatic compression) in those with contraindications to anticoagulants while in the hospital following delivery rather than no prophylaxis (grade 2B). | ≥1 major and ≥2 minor RFs: Postpartum thromboprophylaxis for ≥5 days or until fully mobile; 1 major or 2 minor RFs: Consider graduated compression stockings. |
| Emergent CD + RF | Not stated | All women who have had cesarean sections should be considered for thromboprophylaxis with LMWH for 10 days after delivery apart from those having an elective cesarean section who should be considered for thromboprophylaxis with LMWH for 10 days after delivery if they have any additional RFs (grade C). | Postpartum thromboprophylaxis should be considered in the presence of multiple clinical or pregnancy-related RFs when the overall absolute risk is estimated to be >1% drawn from the following groupings: Any 3 or more of the following RFs (elective cesarean section counts as 1 RF) (II-2B) LMWH until discharge up to 2 weeks if 1 RF | Further details in Table 3: Requires presence of at least 1 major RF OR presence of at least 2 minor RFs (planned cesarean section) OR 1 minor RF in the setting of an emergency cesarean section | Following emergency cesarean section, thromboprophylaxis with LMWH or UFH is recommended for at least 5 days or longer until recovery of full mobility (group consensus level 1). |
Note: These mostly include pregnancy-related RFs and do not review inherited thrombophilia guidance unless stated below.
ACCP15 : Major RFs: Immobility, postpartum hemorrhage ≥1000 mL with surgery, previous VTE, preeclampsia with fetal growth restriction, thrombophilia (AT deficiency, factor V Leiden, prothrombin gene mutation), medical conditions (SLE, heart disease, sickle cell disease), blood transfusion, postpartum infection. Minor RFs: BMI >30 kg/m2, multiple pregnancy, PPH >1 L, smoking >10 cigarettes/d, fetal growth restriction, thrombophilia (protein C and S deficiency), preeclampsia.
RCOG16 : See Table 1 of the 2015 RCOG guidelines.
SOGC18 : Any 2 of the following RFs: BMI ≥30 kg/m2, smoking >10 cigarettes/d, preeclampsia, intrauterine growth restriction, placenta previa, emergency cesarean section, peripartum or postpartum blood loss of >1 L or blood product replacement, any low-risk thrombophilia (protein C or protein S deficiency), heterozygous factor V Leiden, or prothrombin gene mutation 20210A, maternal cardiac disease, SLE, sickle cell disease, inflammatory bowel disease, varicose veins, gestational diabetes, preterm delivery, stillbirth. Any 3 or more of the following RFs: age >35 years, parity ≥2, any assisted reproductive technology, multiple pregnancy, placental abruption, premature rupture of membranes, elective cesarean section, maternal cancer.
ANZJOG17 : Major RFs: Elective cesarean section, BMI ≥30 kg/m2, immobilization, medical comorbidity (eg, inflammatory bowel disease, SLE, pneumonia), preeclampsia, systemic infection. Minor RFs: Age >35 years, prolonged labor (>24 hours), smoker, PPH >1000 mL, extensive perineal trauma and prolonged repair, gross varicose veins.
Descriptions used for evidence grading and consensus:
ASH 2018: The panel used the GRADE approach to assess the certainty in the evidence and formulate recommendations.
RCOG 2015: Described in a separate methodology article: “using the SIGN methodology, the quality of the evidence used and the directness of its application should be incorporated into the formulation and grading of the recommendation.”
SOGC 2014: “The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care.”
ACCP 2012: “We followed the approach articulated by Grades of Recommendations, Assessment, Development, and Evaluation for formulation of recommendations.”
ANZJOG 2012: “To assess the level of consensus with the recommendations, all authors were sent a spreadsheet listing all the recommendations and were asked to indicate whether they agreed or disagreed with each statement. Recommendations were then graded with the following levels of consensus: Group Consensus Level 1—complete consensus: all ten authors in agreement; Group Consensus Level 2—partial consensus: eight of ten authors in agreement; Group Consensus Level 3—no consensus—two or more authors disagreed with recommendation.”
AT, antithrombin; BMI, body mass index; GRADE, Grading of Recommendations Assessment, Development and Evaluation; PPH, postpartum hemorrhage; SLE, systemic lupus erythematosus; SOGC, Society of Obstetricians and Gynaecology of Canada.