SMFM Consult Series #51: Thromboembolism prophylaxis for cesarean delivery

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 prophylaxis
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 postoperatively)
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).