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12/1/2015

Perioperative Management of Anticoagulation in Gynecologic Patients

For patients using chronic antithrombotic therapy undergoing gynecologic surgery, interruption of therapy to reduce bleeding risk must be balanced against risk of thromboembolism. Patients may benefit from “bridging” therapy, in which a short-acting anticoagulant (low-molecular weight heparin [LMWH] or unfractionated heparin) is used in the perioperative period. The decision to use bridging therapy depends on individualized risk assessment, including patient preferences and multidisciplinary input.

 

Risk Stratification

Risk assessment may include use of an instrument such as the CHADS2 (Congestive Heart Failure-Hypertension-Age-Diabetes-Stroke) score to predict risk of stroke. Risk of bleeding and of thromboembolism may also be predicted; Tables 2-4 in ACOG Committee Opinion # 610 define risk and the associated recommended management protocols for perioperative anticoagulation. Other considerations include the type of thromboembolism (arterial or venous) and individual patient characteristics (such as age, BMI, mobility) which may upgrade or downgrade recommendations. Patients with a personal history of venous thromboembolism (VTE) more than 12 months before their planned surgery do not need to be anticoagulated as the chance of repeat VTE is rare.  The exception to this is if the patient has an active malignancy. Patients with a mechanical heart valve may be at high risk; consultation with a cardiologist to define risk and management is generally advised.

 

Bridging Protocols

Bridging protocols may incorporate LMWH or unfractionated heparin, and are generally divided into low- and high-dose regimens. Low-dose is considered “prophylactic”, involving once- (e.g. 40 mg enoxaparin) or twice-daily (e.g. 30 mg enoxaparin) LMWH or subcutaneous heparin (5,000 – 7,500 IU twice daily). High dose (“therapeutic”) regimens include LMWH (1 mg/kg twice daily or 1.5 mg/kg once daily) or intravenous unfractionated heparin to achieve an APTT 1.5 – 2 times control. Therapeutic dosing regimens have been the most widely studied for bridging therapy.

 

Preoperative Timing

Vitamin K antagonist (warfarin) therapy is typically stopped five days before surgery, and bridging therapy (if used) is started. Patients with higher INR on vitamin K antagonist therapy may need to stop earlier. INR should be checked the day before surgery; if not normalized, oral Vitamin K (1 -2 mg) is recommended. When using bridging therapy, therapeutic dosing is stopped 24 hours before surgery when using LMWH, and six hours for intravenous unfractionated heparin. Subcutaneous unfractionated heparin should be stopped the night before the procedure. Thromboprophylaxis should be administered with pneumatic compression devices and possibly prophylactic heparin dosing depending on the risks of thromboembolism and bleeding.

 

Postoperative Timing

If adequate hemostasis is present, vitamin K antagonist therapy may begin 12 – 24 hours postoperatively. Patients receiving bridge therapy with therapeutic dosing and/or those who have undergone surgery with a high risk of bleeding, may re-start therapy 48 – 72 hours postoperatively. Bridging therapy is continued until the INR reaches a therapeutic range.

 

Antiplatelet Therapy (aspirin, clopidogrel)

Bridging therapy is typically not recommended for patients on antiplatelet agents. For patients using aspirin at high risk of a cardiovascular event, aspirin should be continued because the benefit outweighs the risk of bleeding. Patients at low risk should stop aspirin seven to ten days before surgery and re-start it with a similar schedule to the vitamin K antagonist recommendations. Clopidogrel should be stopped five to seven days before surgery and therapeutic dosing should be re-started 12 – 24 hours postoperatively.

 

Newer Agents

Less is known about perioperative management for patents using target-specific anticoagulants such as rivaroxaban, apixaban, and dabigatran. Possible schemes include stopping therapy five days before surgery with bridging therapy, or stopping one to five days before without bridging therapy. Consultation with a hematologist, cardiologist, or primary care provider may be beneficial for managing these patients.

 

Emergent Surgery

Women receiving vitamin K antagonists may require vitamin K (1 – 2 mg) to reverse the anticoagulation effects and decrease the delay for surgery. IV heparin may be used as bridging therapy if the nature and urgency of the procedure allow.

 

Further Reading:

 

Hornor MA, Duane TM, Ehlers AP, et al. American College of Surgeons' Guidelines for the Perioperative Management of Antithrombotic Medication. J Am Coll Surg. 2018 Nov;227(5):521-536.e1. doi: 10.1016/j.jamcollsurg.2018.08.183. Epub 2018 Aug 24. PMID: 30145286.

Committee opinion no 610: chronic antithrombotic therapy and gynecologic surgery. Obstet Gynecol. 2014 Oct;124(4):856-862. doi: 10.1097/01.AOG.0000454931.07554.0a. PMID: 25244459.

Committee Opinion No. 750: Perioperative Pathways: Enhanced Recovery After Surgery: Correction. Obstet Gynecol. 2019 Nov;134(5):1121. doi: 10.1097/AOG.0000000000003569. Erratum for: Obstet Gynecol. 2018 Sep;132(3):e120-e130. doi: 10.1097/AOG.0000000000002818. PMID: 31651825.

Initial Approval: December 2015. Reaffirmed May 2017, November 2018. Revised July 2021.

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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