Overview

Venous thromboembolism (VTE) such as deep vein thrombosis (DVT) and pulmonary embolism (PE) can lead to significant morbidity and mortality. NICE has produced guidelines to help assess the risk of VTE and manage it in patients who are in hospital.

Risk Factors

The same general VTE risk factors apply, see Deep Vein Thrombosis. Patients are assessed individually accounting for existing risk factors and the risk of bleeding. Risk factors in hospital can be:

  • Expected to have or have had reduced mobility for ≥3 days
  • Expected to have a significant reduction in mobility, especially if the general risk factors for VTE are present
  • Surgery involving total anaesthetic, particularly if it includes the pelvis or lower limb
  • Acute surgery for inflammatory or intra-abdominal conditions
  • Surgery that may lead to a significant reduction in mobility

Management

All patients

  • Avoid dehydration
  • Encourage early mobilisation after surgery or treatment
  • Give patients verbal and written information on the signs and symptoms of VTEs, the correct use of prophylaxis, and the implications of not using prophylaxis correctly.

Mechanical prophylaxis

  • Graduated compression anti-embolism stockings
  • Intermittent pneumatic compression devices

Pharmacological prophylaxis

This depends on the patient’s comorbidities, their wishes, and local policies. Options are:

Specific Scenarios

  • Patients taking oestrogen-containing oral contraceptives or hormone replacement therapy should stop four weeks before surgery
  • Prophylaxis is not necessary for those taking warfarin who are in the therapeutic range
  • Patients already on full anticoagulant therapy do not need additional prophylaxis – both mechanical or pharmacological

VTE Prophylaxis in Pregnancy

Risk factors

The Royal College of Obstetricians and Gynaecologists (RCOG) has identified the following risk factors which should be taken into account in people who are pregnant:

  • Age >35 years
  • BMI > 30
  • Parity >3
  • Smoker
  • Significant varicose veins
  • Pre-eclampsia
  • Immobility
  • Family history of unprovoked VTE
  • Low-risk thrombophilia
  • Multiple pregnancy
  • Pregnancy induced by in-vitro fertilisation (IVF)

Management

  • If 4 or more risk factors: LMWH antenatally until 6 weeks postnatally
  • If 3 risk factors: LMWH from 28 weeks until 6 weeks postnatally
  • If DVT is diagnosed after delivery: treat as provoked VTE:
    • Warfarin is safe for breastfeeding, but not pregnancy
    • DOACs are not used in either pregnancy or breastfeeding due to limited information surrounding their use

Author