SMFM Consult Series

smfm.org

Society for Maternal-Fetal Medicine

Consult Series #51: Thromboembolism
prophylaxis for cesarean delivery
Society for Maternal-Fetal Medicine (SMFM); Luis D. Pacheco, MD; George Saade, MD; and Torri D. Metz, MD, MS

The American College of Obstetricians and Gynecologists (ACOG) endorses this document.

Venous thromboembolism is a major cause of maternal morbidity and mortality. The risk of venous
thromboembolism is particularly elevated during the postpartum period and especially after cesarean
delivery. There is considerable variation in the approach to prophylaxis of venous thromboembolism in
pregnancy, including after cesarean delivery. This Consult discusses the different guidelines on pro-
phylaxis of venous thromboembolism after cesarean delivery and provides recommendations based on
the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows:
(1) we recommend that all women who undergo cesarean delivery receive sequential compression
devices starting before surgery and that the compression devices be used continuously until the patient
is fully ambulatory (GRADE 1C); (2) we suggest that women with a previous personal history of deep
venous thrombosis or pulmonary embolism who undergo cesarean delivery receive both mechanical
(starting preoperatively and continuing until ambulatory) and pharmacologic (for 6 weeks post-
operatively) prophylaxis (GRADE 2C); (3) we suggest that women with a personal history of an inherited
thrombophilia (high-risk or low-risk) but no previous thrombosis who undergo cesarean delivery receive
both mechanical (starting preoperatively and continuing until ambulatory) and pharmacologic (for 6
weeks postoperatively) prophylaxis (GRADE 2C); (4) we recommend the use of low-molecular-weight
heparin as the preferred thromboprophylactic agent in pregnancy and the postpartum period (GRADE
1C); (5) when pharmacologic thromboprophylaxis is needed in pregnant women with class III obesity, we
suggest the use of intermediate doses of enoxaparin (GRADE 2C); and (6) we recommend that each
institution develop a patient safety bundle with an institutional protocol for venous thromboembolism
prophylaxis among women who undergo cesarean delivery (Best Practice).
Key words: cesarean delivery, maternal morbidity, maternal mortality, venous thromboembolism,
prophylaxis of venous thromboembolism

Introduction based on low-grade evidence, mainly from observational

Venous thromboembolism (VTE) is a major cause of
maternal morbidity and mortality. The estimated inci-
dence of VTE during pregnancy and the postpartum
period is 1e2 per 1000 deliveries.1 The risk of VTE is
particularly elevated during the postpartum period and
especially after cesarean delivery.2
There is considerable variation in the approach to
prophylaxis of VTE in pregnancy, including after cesar-
ean delivery. Current guidelines by various professional
organizations provide conflicting recommendations
Corresponding author: Society for Maternal-Fetal Medicine: Publications
Committee. pubs@smfm.org
data.3e5 This Consult discusses the different guidelines
on prophylaxis of VTE after cesarean delivery and
provides recommendations based on the available
evidence.
What are the current guidelines for venous
thromboembolism prophylaxis after
cesarean delivery?
The American College of Obstetricians and Gynecologists
(ACOG) currently recommends that all women undergoing a
cesarean delivery receive mechanical prophylaxis using
pneumatic sequential compression devices started preop-
eratively and continued until the woman is ambulatory.3 The

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guideline also recommends that all women be screened for
risk factors for VTE. For women with additional risk factors,
individual risk assessment may support the use of com-
bined pharmacologic and mechanical prophylaxis.
Furthermore, ACOG recommends that if such risk factors
persist during the postpartum period, pharmacologic pro-
phylaxis for up to 6 weeks should be considered. Several
guidelines are available that define risk factors for VTE,
including those from the American College of Chest Physi-
cians (ACCP), Royal College of Obstetricians and Gynae-
cologists (RCOG), and National Partnership for Maternal
Safety (NPMS). ACOG does not endorse any specific
guideline because of the lack of available evidence but
encourages hospitals to evaluate women for risk factors for
VTE and to implement a prophylaxis protocol weighing
benefits, harms, and cost-effectiveness.
The risk threshold at which pharmacologic prophylaxis of
VTE is warranted remains unknown. By extrapolating from
evidence in patients who have undergone general surgery,
the ACCP suggests that the benefits of thromboprophylaxis
outweigh potential harm when the absolute risk of VTE is 3%
or higher.4 The ACCP categorizes risk factors as major
(odds ratio [OR]>6) or minor (OR>6 when combined). The
presence of 1 major risk factor, 1 minor risk factor in the
setting of an emergent cesarean delivery, or 2 or more minor
risk factors suggests a VTE risk above 3%.4 For women
undergoing cesarean delivery with no risk factors for VTE,
the ACCP recommends no prophylaxis other than early
mobilization.4 For women at very high risk for VTE, com-
bined prophylaxis (pharmacologic and mechanical) is sug-
gested. If risk factors persist after delivery, prophylaxis is
suggested for up to 6 weeks postdelivery. The ACCP risk
stratification model is summarized in Table 1.
RCOG recommends that “all women who have had
caesarean [sic] sections should be considered for throm-
boprophylaxis with low-molecular-weight heparin (LMWH)
for 10 days after delivery apart from those having an elective
caesarean section who should be considered for thrombo-
prophylaxis with LMWH for 10 days after delivery if they
have any additional risk factors.”5 This guideline recom-
mends prophylaxis with LMWH for 10 days after delivery in
women at intermediate risk for VTE and for at least 6 weeks
after delivery in women at high risk for VTE. In these guide-
lines, an intrapartum or urgent cesarean delivery meets
the criteria for intermediate risk. Other risk factors must be
present for women to be considered at high risk for VTE. The
RCOG risk stratification model is summarized in Table 1.
The NPMS recommends a consensus bundle for the pre-
vention of VTE during pregnancy and the puerperium.6 For all
women undergoing cesarean deliveries, the NPMS recom-
mends the use of universal pneumatic compression devices.
The addition of pharmacologic prophylaxis may be consid-
ered for women at high risk for VTE based on the use of either
the RCOG guidelines or the modified Caprini scoring system.
Furthermore, the NPMS bundle states that “given the chal-
lenges in consistently identifying women with risk factors,”
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hospitals may consider providing pharmacologic VTE pro-
phylaxis to all women undergoing a cesarean delivery.
Is there sufficient evidence to recommend
one specific guideline over the other?
For certain subgroups of women, recommendations from
available guidelines are consistent. In general, all women
with a previous episode of VTE require prophylactic doses
of LMWH or unfractionated heparin (UFH) for at least 6
weeks after delivery.3e5 Similarly, women with no previous
personal history of VTE but who have tested positive for one
of the high-risk inherited thrombophilias (antithrombin III
deficiency, homozygous Factor V Leiden or G20210A, or
heterozygous for both Factor V Leiden and G20210A)
should also receive pharmacologic VTE prophylaxis after
cesarean delivery.3e5 For women with no previous VTE who
have a low-risk thrombophilia, postpartum pharmacologic
prophylaxis is warranted because a cesarean delivery is an
additional risk factor for VTE among this subgroup of
women.3e5 Women with a previous diagnosis of anti-
phospholipid antibody syndrome should receive prophy-
lactic or therapeutic doses of heparin (depending on
previous history of VTE) during the puerperium irrespective
of mode of delivery.
The main discrepancy among current guidelines concerns
pharmacologic prophylaxis for women with no history of
VTE and no inherited or acquired thrombophilia. A 2016
study of 293 patients who underwent cesarean delivery at a
single tertiary center in the United States found that if rec-
ommendations from RCOG were followed, 85.0% (95%
confidence interval [CI], 80.5%e88.6%) of women under-
going cesarean deliveries would be candidates for post-
partum pharmacologic VTE prophylaxis, compared with
1.0% (95% CI, 0.3%e3.0%) under ACOG guidelines and
34.8% (95% CI, 29.6%e40.4%) under ACCP guidelines.7
Recommendations from different organizations are
currently based on observational studies and expert opin-
ions because clinical trials are lacking.8 The risk-benefit ratio
of pharmacologic prophylaxis after cesarean delivery de-
pends on the accurate determination of the true incidence of
VTE. Administrative and retrospective data obtained from
analysis of large databases may overestimate the incidence
of VTE (up to 4% among women at high risk for VTE),
resulting in a similar overestimation of the benefit of any
intervention aimed at preventing it.9 The latter is particularly
important when considering the ACCP guidelines, in which
recommendations are based on a VTE risk of 3% or greater,
when in reality the incidence after cesarean delivery is
significantly lower.9 In prospective studies, although not
designed specifically to evaluate the incidence of VTE,
clinical VTE after cesarean delivery was noted in 0.6 per
1000 deliveries for elective cesarean delivery and 0.8 per
1000 deliveries after emergent cesarean delivery.10
Based on observational data, some authors have
attempted to calculate the number needed to treat (NNT) to
prevent 1 episode of VTE during the postpartum period.
smfm.org SMFM Consult Series

TABLE 1
Current guidelines on prophylaxis of thromboembolism after cesarean delivery
Organization Recommendation
American College of  Pneumatic compression devices for all women
Obstetricians and undergoing cesarean delivery
Gynecologists3  Women with additional risk factors for VTE may
benefit from pharmacologic prophylaxis.
American College of Chest  Other than early mobilization, no prophylaxis is
Physicians4 recommended in women without risk factors.
 Prophylaxis with LMWH is suggested when 1
major or 2 or more minor risk factors are present
or when 1 minor risk factor is present in the
setting of emergent cesarean delivery.
 In women at very high risk for VTE, combined
pharmacologic and mechanical prophylaxis is
suggested.
 If risk factors persist after delivery, prophylaxis
is suggested for up to 6 weeks postpartum.
Royal College of Women at high risk for VTE should receive LMWH for
Obstetricians and 6 weeks after delivery; women at intermediate risk for
Gynaecologists5 VTE should receive LMWH for at least 10 days after
delivery. For women at low risk for VTE, early
mobilization and avoidance of dehydration are
recommended.
BMI, body mass index; LMWH, low-molecular-weight heparin; VTE, venous thromboembolism.
Society for Maternal-Fetal Medicine. Society for Maternal-Fetal Medicine Consult Series #51: Thromboembolism prophylaxis for cesarean delivery. Am J Obstet Gynecol 2020.
Risk stratification
A preferred risk scoring system is not endorsed; recommends
each facility carefully consider the risk assessment protocols
available and implement one in a systematic way to reduce
the incidence of VTE in pregnancy and the postpartum period.
Major risk factors are as follows:
 Immobility for at least 1 week antepartum
 Postpartum hemorrhage with surgery
 Previous VTE
 Preeclampsia with fetal growth restriction
 Antithrombin deficiency
 Factor V Leiden or G20210A mutations
 Blood transfusion
 Postpartum infection
 Systemic lupus erythematosus
 Heart disease
 Sickle cell disease
Minor risk factors are as follows:
 Obesity
 Multiple pregnancy
 Postpartum hemorrhage
 Smoking
 Fetal growth restriction
 Preeclampsia
 Protein C or S deficiency
High-risk patients
Any previous VTE, any woman requiring antenatal LMWH,
high-risk thrombophilia, low-risk thrombophilia with
family history of thrombosis
Intermediate-risk patients
Any one of the following:
Cesarean delivery during labor, BMI >40 kg/m2, postdelivery
readmission, surgical procedures during the puerperium,
cancer, heart failure, active lupus, nephrotic syndrome,
sickle cell disease, type 1 diabetes with nephropathy, in-
flammatory bowel disease, intravenous drug use
or
Two or more of the following:
Age >35 years, parity 3, obesity, smoker, elective ce-
sarean delivery, family history of VTE, low-risk thrombo-
philia, varicose veins, current systemic infection,
preeclampsia, immobility, multiple pregnancy, preterm
delivery, stillbirth, operative vaginal delivery, prolonged
labor >24 hours, postpartum hemorrhage

Sultan et al11 reported that among women deemed at high
risk for VTE postpartum, 640 would require prophylaxis to
prevent 1 episode of VTE. Other authors have reported an
NNT as high as 4000 among women at high risk for VTE who
underwent cesarean delivery.9
The potential benefit of pharmacologic prophylaxis needs
to be weighed against the potential for adverse outcomes
associated with the intervention. The use of pharmacologic
VTE prophylaxis after cesarean delivery has been
associated with increased rates of wound separation and
wound hematomas.8,11e13 The number needed to harm
(NNH) with the use of pharmacologic VTE prophylaxis after
cesarean delivery has been reported to be as low as 200.9 In
the absence of adequately powered clinical trials, accurate
calculations of the NNT and NNH are limited. However, the
available evidence suggests that the NNH may be lower
than the NNT in most scenarios, particularly in the absence
of risk factors or the presence of a minor risk factor.

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Summary of recommendations
Number Recommendation Grade
1 We recommend that all women who undergo cesarean delivery receive sequential 1C
compression devices starting before surgery and that the compression devices be used Strong recommendation
continuously until the patient is fully ambulatory. Low-quality evidence
2 We suggest that women with a previous personal history of deep venous thrombosis or 2C
pulmonary embolism who undergo cesarean delivery receive both mechanical (starting Weak recommendation
preoperatively and continuing until ambulatory) and pharmacologic (for 6 weeks Low-quality evidence
postoperatively) prophylaxis.
3 We suggest that women with a personal history of an inherited thrombophilia (high-risk 2C
or low-risk) but no previous thrombosis who undergo cesarean delivery receive both Weak recommendation
mechanical (starting preoperatively and continuing until ambulatory) and pharmacologic Low-quality evidence
(for 6 weeks postoperatively) prophylaxis.
4 We recommend the use of low-molecular-weight heparin as the preferred 1C
thromboprophylactic agent in pregnancy and the postpartum period. Strong recommendation
Low-quality evidence
5 When pharmacologic thromboprophylaxis is needed in pregnant women with class III 2C
obesity, we suggest the use of intermediate doses of enoxaparin. Weak recommendation
Low-quality evidence
6 We recommend that each institution develop a patient safety bundle with an institutional Best Practice
protocol for venous thromboembolism prophylaxis among women who undergo
cesarean delivery.

Society for Maternal-Fetal Medicine. Society for Maternal-Fetal Medicine Consult Series #51: Thromboembolism prophylaxis for cesarean delivery. Am J Obstet Gynecol 2020.

Another consideration in making recommendations is that
the use of risk assessment models (eg, Caprini and Padua)
to predict VTE after cesarean delivery has not been
adequately studied. The authors of a 2018 study question-
ing the utility of risk assessment models during the peri-
partum period suggested the establishment of a maternal
clinical registry and more extensive research to identify
optimal models with which to predict VTE risk in the
obstetrical population.14
At present, the available evidence suggesting that uni-
versal (or near universal) pharmacologic VTE prophylaxis
effectively reduces maternal mortality is limited.8 After the
implementation of prophylactic guidelines in the United
Kingdom, a decrease in maternal mortality secondary to
VTE was noted between 2004 and 2008. However, more
recent analyses found that the reduction has not been
sustained, with an increase in VTE-related maternal mor-
tality after 2009 when compared with the initial reduction
noticed in previous years.15 In particular, the available data
do not allow us to attribute any reduction in mortality spe-
cifically to prophylaxis after cesarean delivery because the
RCOG recommendations would have increased the use of
thromboprophylaxis in a number of different clinical sce-
narios (eg, use of prophylaxis in the antepartum period or
after vaginal deliveries among women with risk factors for
VTE). Any attributable benefit of universal pharmacologic
VTE prophylaxis after cesarean delivery on maternal mor-
tality will likely be low because of the rarity of the event. A
recent study reported only 1 maternal death from VTE
among 465,880 women undergoing a cesarean delivery
who received mechanical prophylaxis (eg, sequential
compression devices).16 We recommend that all women who
undergo a cesarean delivery receive sequential compression de-
vices starting before surgery and that the compression devices be
used continuously until the patient is fully ambulatory (GRADE 1C).
We suggest that women with a previous personal history of deep
venous thrombosis or pulmonary embolism who undergo cesar-
ean delivery receive both mechanical (starting preoperatively and
continuing until ambulatory) and pharmacologic (for 6 weeks
postoperatively) prophylaxis (GRADE 2C). We suggest that women
with a personal history of an inherited thrombophilia (high-risk or
low-risk) but no previous thrombosis who undergo cesarean de-
livery receive both mechanical (starting preoperatively and
continuing until ambulatory) and pharmacologic (for 6 weeks
postoperatively) prophylaxis (GRADE 2C).
Which pharmacologic agents are
commonly used for prophylaxis of venous
thromboembolism?
The 2 most common agents used for prophylaxis of VTE are
LMWH and UFH. Current guidelines recommend LMWH
(eg, enoxaparin) as the first-line pharmacologic agent.3,4
Enoxaparin has a half-life of 4 to 6 hours and is eliminated by
the kidney. Therefore, it is not recommended in patients with
significant renal dysfunction, defined as creatinine clear-
ance of less than 30 mL/min.17 Compared with UFH,

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The Society for Maternal-Fetal Medicine grading system: grading of recommendations assessment,
development, and evaluation21
Grade of
recommendation Clarity of risk and benefit
1A. Strong Benefits clearly outweigh risks
recommendation, high- and burdens or vice versa.
quality evidence
1B. Strong Benefits clearly outweigh risks
recommendation, and burdens or vice versa.
moderate-quality evidence
1C. Strong Benefits seem to outweigh risks
recommendation, low- and burdens or vice versa.
quality evidence
2A. Weak Benefits closely balanced with
recommendation, high- risks and burdens.
quality evidence
2B. Weak Benefits closely balanced with
recommendation, risks and burdens; some
moderate-quality evidence uncertainty in the estimates of
benefits, risks, and burdens.
2C. Weak Uncertainty in the estimates of
recommendation, low- benefits, risks, and burdens;
quality evidence benefits may be closely balanced
with risks and burdens.
Best practice Recommendation in which either
(1) there is an enormous amount
of indirect evidence that clearly
justifies strong recommendation
(direct evidence would be
challenging, and inefficient use of
time and resources, to bring
together and carefully summarize)
or (2) recommendation to the
contrary would be unethical.
Adapted from Guyatt et al.22
Society for Maternal-Fetal Medicine. Society for Maternal-Fetal Medicine Consult Series #51: Thromboembolism prophylaxis for cesarean delivery. Am J Obstet Gynecol 2020.
SMFM Consult Series
Quality of supporting evidence
Consistent evidence from well-
performed, randomized controlled
trials or overwhelming evidence of
some other form. Further research is
unlikely to change confidence in the
estimate of benefit and risk.
Evidence from randomized controlled
trials with important limitations
(inconsistent results, methodologic
flaws, indirect or imprecise) or very
strong evidence of some other
research design. Further research (if
performed) is likely to have an impact
on confidence in the estimate of
benefit and risk and may change the
estimate.
Evidence from observational studies,
unsystematic clinical experience, or
randomized controlled trials with
serious flaws. Any estimate of effect is
uncertain.
Consistent evidence from well-
performed randomized controlled
trials or overwhelming evidence of
some other form. Further research is
unlikely to change confidence in the
estimate of benefit and risk.
Evidence from randomized controlled
trials with important limitations
(inconsistent results, methodologic
flaws, indirect or imprecise), or very
strong evidence of some other
research design. Further research (if
performed) is likely to have an effect
on confidence in the estimate of
benefit and risk and may change the
estimate.
Evidence from observational studies,
unsystematic clinical experience, or
randomized controlled trials with
serious flaws. Any estimate of effect is
uncertain.
— —
Implications
Strong recommendation that can
apply to most patients in most
circumstances without reservation.
Clinicians should follow a strong
recommendation unless a clear and
compelling rationale for an alternative
approach is present.
Strong recommendation that applies
to most patients. Clinicians should
follow a strong recommendation
unless a clear and compelling
rationale for an alternative approach is
present.
Strong recommendation that applies
to most patients. Some of the
evidence base supporting the
recommendation is, however, of low
quality.
Weak recommendation; best action
may differ depending on
circumstances or patients or societal
values.
Weak recommendation; alternative
approaches likely to be better for
some patients under some
circumstances.
Very weak recommendation; other
alternatives may be equally
reasonable.
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SMFM Consult Series
enoxaparin has the advantage of better bioavailability,
longer half-life, more predictable anticoagulation effect, less
bleeding risks, and less risk of heparin-induced thrombo-
cytopenia and osteopenia.17 We recommend the use of LMWH
as the preferred thromboprophylactic agent in pregnancy and the
postpartum period (GRADE 1C).
For purposes of prophylaxis, the recommended dose of
enoxaparin is typically 40 mg subcutaneously once a day.
Obese women may require higher doses; however, the
optimal dose is unknown. Some evidence supports the use
of intermediate doses of enoxaparin (40 mg subcutaneously
every 12 hours) for obese women.18 Other studies suggest
that compared with a fixed-dose regimen (eg, 40 mg sub-
cutaneously every 12 hours), a weight-based prophylactic
dose of 0.5 mg/kg subcutaneously every 12 hours of
enoxaparin in morbidly obese women after cesarean de-
livery results in anti-Xa levels that are more often within the
desired prophylactic target range.19 It is unknown if the
latter strategy results in fewer thrombotic events. When
pharmacologic thromboprophylaxis is needed in pregnant women
with class III obesity, we suggest the use of intermediate doses of
enoxaparin (GRADE 2C).
UFH has a shorter half-life than LMWH of 60 to 90 minutes
and is mostly cleared by the reticuloendothelial system,
rendering it a good choice in women with renal disease.17
Recommended prophylactic dosages range from 5000 to
10,000 units subcutaneously every 12 hours depending on
gestational age (5000 units subcutaneously every 12 hours
in the first trimester, 7500 units subcutaneously every 12
hours in the second trimester, and 10,000 units subcuta-
neously every 12 hours during the third trimester).3 In the
postpartum period, doses of 5000 units subcutaneously
every 8 to 12 hours are commonly used. There are insuffi-
cient data to recommend the use of new oral anticoagulants
(eg, apixaban, rivaroxaban, dabigatran) during the post-
partum period.
When is the optimal time to start
thromboembolism prophylaxis after a
cesarean delivery?
Current ACOG guidelines recommend starting mechanical
prophylaxis of VTE with sequential compression devices
preoperatively in all women undergoing cesarean delivery.3
Recent guidelines have addressed the optimal interval be-
tween neuraxial anesthesia and initiation of pharmacologic
VTE prophylaxis to prevent the development of spinal or
epidural hematomas.20 For LMWH, these recommenda-
tions consider both the time when the neuraxial block was
performed preoperatively and the time when the catheter
was removed postoperatively. Prophylactic doses of
enoxaparin (40 mg subcutaneously every day) may be
started postoperatively as early as 4 hours after catheter
removal but not earlier than 12 hours after the block was
performed. Intermediate doses of enoxaparin (40 mg sub-
cutaneously every 12 hours) and therapeutic doses may
also be started as early as 4 hours after catheter removal but
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not earlier than 24 hours after the block was performed.
Prophylactic doses of UFH may be started as early as 1 hour
after removal of the neuraxial catheter.20
In addition to concerns about spinal hematomas, the risk of
postoperative bleeding should also be considered in the
timing to start prophylaxis of VTE. With prophylactic doses of
anticoagulation, bleeding complications are usually mild, such
as wound hematomas, and rarely result in life-threatening
hemorrhage (unlike bleeding risks with the use of full-dose
anticoagulation in the postoperative period).12 In cases with
significant intraoperative bleeding complications, the decision
of when to start pharmacologic prophylaxis (if indicated) must
be individualized while recognizing that postpartum hemor-
rhage, blood transfusion, and prolonged surgery are risk
factors for VTE. In these cases, initiation of UFH, which is
reversible and has a shorter half-life, may be prudent.
Conclusions
VTE remains an important cause of maternal morbidity
and mortality during pregnancy and the postpartum
period. The use of mechanical prophylaxis sequential
compression devices is an inexpensive, safe intervention
and should be used in all women undergoing cesarean
delivery until the woman is fully ambulatory. The decision
to add pharmacologic prophylaxis depends on the
presence or absence of certain risk factors. Women with
a previous personal history of deep venous thrombosis
or pulmonary embolism and women with a personal
history of an inherited thrombophilia (either high-risk or
low-risk) should receive pharmacologic prophylaxis after
cesarean delivery. The use of universal or near-universal
pharmacological prophylaxis for women undergoing ce-
sarean delivery, other than those with a previous
thrombosis or an inherited thrombophilia, cannot be
recommended until further studies demonstrate that such
a strategy is beneficial. At present, the available VTE risk
stratification tools used to decide for or against phar-
macologic prophylaxis have not been validated in women
undergoing cesarean delivery. Individualization of care is
recommended for women at very high risk for VTE. We
recommend that each institution develop a patient safety
bundle with an institutional protocol for VTE prophylaxis among
women who undergo cesarean delivery (Best Practice). n
REFERENCES
1. Rodger M. Pregnancy and venous thromboembolism: ‘TIPPS’ for risk
stratification. Hematology Am Soc Hematol Educ Program 2014;2014:
387–92.
2. James AH, Jamison MG, Brancazio LR, Myers ER. Venous thrombo-
embolism during pregnancy and the postpartum period: incidence, risk
factors, and mortality. Am J Obstet Gynecol 2006;194:1311–5.
3. American College of Obstetricians and Gynecologists. ACOG practice
bulletin no. 196: thromboembolism in pregnancy. Obstet Gynecol
2018;132:e1–17.
4. Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM,
Vandvik PO. VTE, thrombophilia, antithrombotic therapy, and pregnancy:
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American
smfm.org
College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
Chest 2012;141(2 Suppl):e691S–736S.
5. Royal College of Obstetricians and Gynaecologists. Reducing the risk of
venous thromboembolism during pregnancy and the puerperium (Green-
top Guideline no. 37a). April 2015. Available at: https://www.rcog.org.uk/
globalassets/documents/guidelines/gtg-37a.pdf. Accessed February 4,
2019.
6. D’Alton ME, Friedman AM, Smiley RM, et al. National partnership for
maternal safety: consensus bundle on venous thromboembolism. Obstet
Gynecol 2016;128:688–98.
7. Palmerola KL, D’Alton ME, Brock CO, Friedman AM. A comparison
of recommendations for pharmacologic thromboembolism prophylaxis
after caesarean delivery from three major guidelines. BJOG 2016;123:
2157–62.
8. Bain E, Wilson A, Tooher R, Gates S, Davis LJ, Middleton P. Prophylaxis
for venous thromboembolic disease in pregnancy and the early postnatal
period. Cochrane Database Syst Rev 2014:CD001689.
9. Kotaska A. Postpartum venous thromboembolism prophylaxis may
cause more harm than benefit: a critical analysis of international guidelines
through an evidence-based lens. BJOG 2018;125:1109–16.
10. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal out-
comes associated with a trial of labor after prior cesarean delivery. N Engl J
Med 2004;351:2581–9.
11. Sultan AA, West J, Tata LJ, Fleming KM, Nelson-Piercy C, Grainge MJ.
Risk of first venous thromboembolism in and around pregnancy: a pop-
ulation-based cohort study. Br J Haematol 2012;156:366–73.
12. Ferres MA, Olivarez SA, Trinh V, Davidson C, Sangi-Haghpeykar H,
Aagaard-Tillery KM. Rate of wound complications with enoxaparin use
among women at high risk for postpartum thrombosis. Obstet Gynecol
2011;117:119–24.
13. Yang R, Zhao X, Yang Y, Huang X, Li H, Su L. The efficacy and safety of
pharmacologic thromboprophylaxis following caesarean section: a sys-
tematic review and meta-analysis. PLoS One 2018;13:e0208725.
14. Tran JP, Stribling SS, Ibezim UC, et al. Performance of risk assessment
models for peripartum thromboprophylaxis. Reprod Sci 2019;26:
1243–8.
15. Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J,
Kurinczuk JJ, eds. on behalf of MBRRACE-UK. Saving Lives, Improving
Mothers’ Care - Lessons learned to inform future maternity care from the
UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity
2009e12. Oxford: National Perinatal Epidemiology Unit, University of
Oxford; 2014.
16. Clark SL, Christmas JT, Frye DR, Meyers JA, Perlin JB. Maternal
mortality in the United States: predictability and the impact of protocols on
fatal postcesarean pulmonary embolism and hypertension-related intra-
cranial hemorrhage. Am J Obstet Gynecol 2014;211:32.e1–9.
17. Garcia DA, Baglin TP, Weitz JI, Samama MM. Parenteral anticoagu-
lants: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines. Chest 2012;141(2 Suppl):e24S–43S.
ª 2020 Published by Elsevier Inc. https://doi.org/10.1016/j.ajog.2020.04.032 AUGUST 2020
SMFM Consult Series
18. Shelkrot M, Miraka J, Perez ME. Appropriate enoxaparin dose for
venous thromboembolism prophylaxis in patients with extreme obesity.
Hosp Pharm 2014;49:740–7.
19. Overcash RT, Somers AT, LaCoursiere DY. Enoxaparin dosing after
cesarean delivery in morbidly obese women. Obstet Gynecol 2015;125:
1371–6.
20. Leffert L, Butwick A, Carvalho B, et al. The Society for Obstetric
Anesthesia and Perinatology consensus statement on the anesthetic
management of pregnant and postpartum women receiving thrombo-
prophylaxis or higher dose anticoagulants. Anesth Analg 2018;126:
928–44.
21. Society for Maternal-Fetal Medicine (SMFM), Chauhan SP,
Blackwell SC. SMFM adopts GRADE (Grading of Recommendations
Assessment, Development, and Evaluation) for clinical guidelines. Am J
Obstet Gynecol 2013;209:163–5.
22. Guyatt GH, Oxman AD, Kunz R, et al. Going from evidence to rec-
ommendations. BMJ 2008;336:1049–51.
All authors and committee members have filed a conflict of interest
disclosure delineating personal, professional, and/or business interests
that might be perceived as a real or potential conflict of interest in
relation to this publication. Any conflicts have been resolved through a
process approved by the executive board. The Society for Maternal-
Fetal Medicine (SMFM) has neither solicited nor accepted any com-
mercial involvement in the development of the content of this
publication.
This document has undergone an internal peer review through a
multilevel committee process within SMFM. This review involves
critique and feedback from the SMFM Publications and Document
Review Committees and final approval by the SMFM Executive Com-
mittee. SMFM accepts sole responsibility for document content.
SMFM publications do not undergo editorial and peer review by the
American Journal of Obstetrics & Gynecology. SMFM Publications
Committee reviews publications every 18e24 months and issues
updates as needed. Further details regarding SMFM publications
can be found at www.smfm.org/publications.
All questions or comments regarding the document should be referred
to the SMFM Publications Committee at pubs@smfm.org.
SMFM has adopted the use of the word “woman” (and the pronouns
“she” and “her”) to apply to individuals who are assigned female sex at
birth, including individuals who identify as men as well as nonbinary
individuals who identify as both genders or neither gender. As gender-
neutral language continues to evolve in the scientific and medical
communities, SMFM will reassess this usage and make appropriate
adjustments as necessary.
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