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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 [UFH]) 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

Multiple tools exist to stratify the risk of thromboembolism, which can be used to guide perioperative prophylaxis. 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 UFH, 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 UFH 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 1-2 days before surgery; if not normalized (INR>1.5), 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 UFH. Subcutaneous UFH 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 bridging therapy with therapeutic dosing who have undergone a minor surgery, may resume LMWH or UFH 24 hours after surgery, if the patient underwent a major surgical procedure with a high risk of bleeding, restart 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.

Direct Oral Anticoagulants Bridging therapy is not generally recommended for gynecologic patents taking  direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, edoxaban, and dabigatran. DOACs may be continued or discontinued on the day of the procedure for patients undergoing minimal bleeding risk procedures. Patients undergoing a low-moderate bleeding risk procedure should typically discontinue DOACs 1 day before the procedure and restart DOACs 1 day after. DOACs should be stopped 2 days prior to a high bleeding risk procedure and restarted 2 days after, except for dabigatran with a longer half-life, which shall be held 2-4 days pre-procedure depending on patients baseline renal function. Routine preoperative evaluation of DOAC levels is not recommended. Consultation with a hematologist, cardiologist, or primary care provider may be beneficial for managing these patients.

Emergent Surgery

Patients 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. Patients on antiplatelet therapy may require transfusion of 1 pooled unit of platelets immediately before operation and redosing as needed for ongoing bleeding. Patients taking DOACs may require a DOAC reversal agent (eg, prothrombin complex concentrates, idarucizumab, or andexanet-α) prior to an emergent or urgent procedure.

Further Reading:

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.

Douketis JD, Spyropoulos AC. Perioperative Management of Patients Taking Direct Oral Anticoagulants: A Review. JAMA. 2024 Sep 10;332(10):825-834. doi: 10.1001/jama.2024.12708. Erratum in: JAMA. 2024 Oct 15;332(15):1306. doi: 10.1001/jama.2024.20028. PMID: 39133476.

Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest. 2022 Nov;162(5):e207-e243. doi: 10.1016/j.chest.2022.07.025. Epub 2022 Aug 11. Erratum in: Chest. 2023 Jul;164(1):267. doi: 10.1016/j.chest.2023.05.019. PMID: 35964704.

Initial Approval: December 2015. Reaffirmed May 2017, November 2018. Revised July 2021 and October 2024. Revised November 2024.

 

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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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