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Guideline Summary
Guideline Title
Reducing the risk of thrombosis and embolism during pregnancy and the puerperium.
Bibliographic Source(s)
Royal College of Obstetricians and Gynaecologists (RCOG). Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2009 Nov. 35 p. (Green-top guideline; no. 37).  [146 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Royal College of Obstetricians and Gynaecologists (RCOG). Thromboprophylaxis during pregnancy, labour and after vaginal delivery. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2004 Jan. 13 p. (Guideline; no. 37). [52 references]

Scope

Disease/Condition(s)

Thrombosis and embolism (venous thromboembolism) during pregnancy and the puerperium (postpartum period)

Note: This guideline excludes the management of pregnancy loss and other pregnancy complications, even in women with documented thrombophilia.

Guideline Category
Diagnosis
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Family Practice
Hematology
Internal Medicine
Obstetrics and Gynecology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)
  • To provide advice, based on clinical evidence where available, regarding the prevention of venous thromboembolism (VTE) during pregnancy, birth and following delivery
  • To review the risk factors for VTE in pregnancy and the puerperium and provide guidance as to which women require thromboprophylaxis in and after pregnancy
  • To review the safety and efficacy of different forms of thromboprophylaxis
Target Population

Women in the United Kingdom at risk of venous thromboembolism during pregnancy and the puerperium

Interventions and Practices Considered

Risk Assessment

  1. Assessment of risk factors for venous thromboembolism (VTE) in early pregnancy or before pregnancy and after delivery
  2. Patient history
  3. Screening for inherited and acquired thrombophilia (ideally before pregnancy)
  4. Repeat of risk assessment if admitted to hospital

Management/Prevention

  1. Prepregnancy counseling in women at high risk of VTE
  2. Antenatal and postnatal prophylaxis with low-molecular-weight heparin (LMWH) in high-risk and intermediate-risk women
  3. Thromboprophylaxis with LMWH following delivery
  4. Use of graduated compression stockings
  5. Use of warfarin during breastfeeding and for postpartum prophylaxis
  6. Timing and duration of VTE prophylaxis
Major Outcomes Considered
  • Incidence of thrombosis or venous thromboembolism (VTE) during pregnancy or the puerperium
  • Recurrence rate of VTE
  • Side effects of treatment
  • Maternal morbidity

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The Cochrane Library (including the Database of Systematic Reviews and the Control Register of Controlled Trials), the Database of Abstracts of Reviews and Effects (DARE), Embase, the American College of Physicians (ACP) Journal Club and Medline (including in-process and other non-indexed citations) were searched from 2002 to 2008 to identify all relevant randomised controlled trials (RCTs), systematic reviews and meta-analyses published since the previous edition of the guideline. The databases were searched using the relevant Medical Subject Headings (MeSH) terms including all sub-headings. The principal search terms used were: 'venous thromboembolism', 'thrombosis', 'pregnancy', 'postpartum', 'puerperium', 'antenatal', 'prenatal'. The search was limited to humans and English language. The National Library for Health and the National Guideline Clearinghouse were also searched for relevant guidelines and reviews.

Current guidelines for the prevention of venous thromboembolism (VTE) in pregnancy and the puerperium were reviewed. A recent Cochrane systematic review of randomised trials comparing one method of thromboprophylaxis with placebo or no treatment and randomised trials comparing two (or more) methods of thromboprophylaxis concluded that there was insufficient evidence on which to base recommendations for thromboprophylaxis during pregnancy and the early postnatal period. Large-scale randomised trials of currently-used interventions should be conducted.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Classification of Evidence Levels

1++ High-quality meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias

1- Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias

2++ High-quality systematic reviews of case–control or cohort studies or high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal

2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal

2- Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal

3 Non-analytical studies; e.g. case reports, case series

4 Expert opinion

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Once the evidence has been collated for each clinical question, it needs to be appraised and reviewed. For each question, the study type with least chance of bias should be used. If available, randomised controlled trials of suitable size and quality should be used in preference to observational data. This may vary depending on the outcome being examined.

The methods used to appraise individual study types are available from the Scottish Intercollegiate Guidelines Network (SIGN) (www.sign.ac.uk/methodology/checklists.html External Web Site Policy). An objective appraisal of study quality is essential but paired reviewing by guideline leads may be impractical because of resource constraints.

Once evidence has been collated and appraised, it can be graded. A judgement on the quality of the evidence will be necessary using the grading system (see the "Rating Scheme for the Strength of the Evidence" field). Where evidence is felt to warrant 'down-grading', for whatever reason, the rationale must be stated. Evidence judged to be of poor quality can be excluded. Any study with a high chance of bias (either 1– or 2–) will be excluded from the guideline and recommendations will not be based on this evidence. This prevents recommendations being based on poor-quality randomised controlled trials when higher-quality observational evidence is available.

Methods Used to Formulate the Recommendations
Expert Consensus
Informal Consensus
Description of Methods Used to Formulate the Recommendations

Guideline Development

The development of guidelines involves more than the collation and reviewing of evidence. Even with high-quality data from systematic reviews of randomised controlled trials, a value judgement is needed when comparing one therapy with another. This will therefore introduce the need for consensus.

Royal College of Obstetricians and Gynaecologists (RCOG) Green-top Guidelines are drafted by nominated developers, in contrast to other guideline groups such as the National Institute for Health and Clinical Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN), who use larger guideline development groups. Equally, in contrast to other guideline groups, the topics chosen for development as Green-top Guidelines are concise enough to allow development by a smaller group of individuals.

In agreeing the precise wording of evidence-based guideline recommendations and in developing consensus-based 'good practice points', the Guidelines and Audit Committee (GAC) will employ an informal consensus approach through group discussion. In line with current methodologies, the entire development process will follow strict guidance and be both transparent and robust. The RCOG acknowledges that formal consensus methods have been described but these require further evaluation in the context of clinical guideline development. It is envisaged that this will not detract from the rigor of the process but prevent undue delays in development.

Rating Scheme for the Strength of the Recommendations

Grades of Recommendations

The recommendations were graded according to the level of evidence upon which they were based.

A

At least one meta-analysis, systematic review or randomised controlled trial rated as 1++ and directly applicable to the target population; or

A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results

B

A body of evidence including studies rated as 2++ directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C

A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D

Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

Following discussion in the Guidelines and Audit Committee, each green-top guideline is formally peer reviewed. At the same time the draft guideline is published on the Royal College of Obstetricians and Gynaecologists (RCOG) website for further peer discussion before final publication.

The names of author(s) and nominated peer reviewers are included in the original guideline document.

Recommendations

Major Recommendations

In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.

Levels of evidence and grading of recommendations (A–D) are defined at the end of the "Major Recommendations" field.

Prepregnancy and Antenatal Risk Assessment

What Are the Risk Factors for Venous Thromboembolism (VTE) in Pregnancy and the Puerperium? What Is the Magnitude of Risk for These Factors?

The risk factors for VTE are listed in the table below. For most risk factors the level of evidence is 2+ but it varies from 2– to 2++ depending on the risk factor.

Table: Risk Factors for Venous Thromboembolism in Pregnancy

Timeframe Factors
Pre-existing Previous VTE

Thrombophilia

Heritable:

Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Factor V Leiden
Prothrombin gene G20210 A

Acquired (antiphospholipid syndrome)

Persistent lupus anticoagulant
Persistent moderate/high-titre anticardiolipin antibodies or beta2 glycoprotein 1 antibodies


Medical comorbidities (e.g., heart or lung disease, SLE, cancer, inflammatory conditions (inflammatory bowel disease or inflammatory polyarthropathy), nephrotic syndrome (proteinuria >3 g/day), sickle cell disease, intravenous drug user
Age >35 years
Obesity (BMI >30 kg/m2) either prepregnancy or in early pregnancy
Parity ≥3
Smoking
Gross varicose veins (symptomatic or above knee or with associated phlebitis, oedema/skin changes)
Paraplegia
Obstetric Multiple pregnancy, assisted reproductive therapy
Pre-eclampsia
Caesarean section
PPH (>1 litre) requiring transfusion
Prolonged labour, mid-cavity rotational operative delivery
New onset/transient Surgical procedure in pregnancy or puerperium (e.g., ERPC, appendicectomy, postpartum sterilisation)
Potentially reversiblea Hyperemesis, dehydration
Ovarian hyperstimulation syndrome
Admission or immobility (≥ 3 days' bed rest) (e.g., symphysis pubis dysfunction restricting mobility)
Systemic infection (requiring antibiotics or admission to hospital) (e.g., pneumonia, pyelonephritis, postpartum wound infection)
Long-distance travel (> 4 hours)

BMI = body mass index; ERPC = evacuation of retained products of conception; PPH = postpartum haemorrhage; SLE = systemic lupus erythematosus
aMay develop at later stages in gestation than the initial risk assessment or may resolve and therefore continuing individual risk assessment is important

Admission to Hospital

C - All women should undergo a documented assessment of risk factors for VTE in early pregnancy or before pregnancy. This assessment should be repeated if the woman is admitted to hospital for any reason or develops other intercurrent problems. The assessment should be repeated again intrapartum or immediately postpartum.

C - Any woman with three or more current or persisting risk factors shown in Figure 1 of the original guideline and the table above (other than previous VTE or thrombophilia) should be considered for prophylactic low-molecular-weight heparin (LMWH) antenatally and will usually require prophylactic LMWH for 6 weeks postnatally; a postnatal risk reassessment should be made.

C - Any woman with two or more current or persisting risk factors shown in Figure 1 of the original guideline and the table above (other than previous VTE or thrombophilia) should be considered for prophylactic LMWH for at least 7 days postpartum.

Previous VTE

Which Women with Prior VTE Require Thrombophilia Testing?

C - Women with a previous non-estrogen-related VTE provoked by a minor risk factor should undergo testing for thrombophilia, as this will influence management and decisions regarding thromboprophylaxis antenatally.

Recommendations for Women with a Previous VTE

C - Women with a previous single provoked (excluding estrogen-related) VTE (and no other risk factors) require close surveillance antenatally and thromboprophylaxis with LMWH for 6 weeks postpartum.

C - Women with previous recurrent VTE or a previous unprovoked or estrogen/pregnancy-related VTE or a previous VTE and a history of VTE in a first-degree relative (or a documented thrombophilia) or other risk factors should be offered thromboprophylaxis with LMWH antenatally and for 6 weeks postpartum.

Asymptomatic Heritable Thrombophilia How Should Women with Asymptomatic Thrombophilia Be Treated?

C - Women with asymptomatic inherited thrombophilia without other risk factors may be managed with close surveillance antenatally but should be considered for LMWH for at least 7 days postpartum.

Exceptions are in women with antithrombin deficiency or more than one thrombophilic defect (including homozygous factor V Leiden, homozygous prothrombin G20210A and compound heterozygotes) or those with additional risk factors where advice of a local expert should be sought and antenatal prophylaxis considered.

Recommendations on Thrombophilia

C - Women should be stratified according to level of risk associated with their thrombophilia and the presence or absence of a family history or other risk factors.

C - If thromboprophylaxis is given antenatally for a persisting risk factor, it should be continued postpartum for 6 weeks.

Acquired Thrombophilia (Antiphospholipid Syndrome) — How Should Women with Antiphospholipid Syndrome Be Treated?

C - Women with previous thromboses and antiphospholipid syndrome should be offered both antenatal and 6 weeks of postpartum thromboprophylaxis. Women with persistent antiphospholipid antibodies with no previous VTE and no other risk factors or fetal indications for LMWH may be managed with close surveillance antenatally but should be considered for LMWH for 7 days postpartum.

Timing of Initiation of Thromboprophylaxis

When Should Thromboprophylaxis Be Started?

B - Antenatal thromboprophylaxis should begin as early in pregnancy as practical.

Thromboprophylaxis after Delivery

For How Long Should Thromboprophylaxis Be Continued after Delivery?

C - Thromboprophylaxis should be continued for 6 weeks in women at high risk of postpartum VTE and for 1 week in women with intermediate risk.

Previous VTE

Which Women with Previous VTE Need Postpartum Thromboprophylaxis?

C - All women with a previous history of confirmed VTE should be offered thromboprophylaxis with LMWH or warfarin for 6 weeks postpartum, regardless of the mode of delivery.

Thrombophilia

Which Women with Thrombophilia without Previous VTE Need Postpartum Thromboprophylaxis?

C - All women with known heritable or acquired thrombophilia should be considered for LMWH for at least 7 days following delivery, even if they were not receiving antenatal thromboprophylaxis. This could be extended to 6 weeks if there is a family history or other risk factors present.

Caesarean Section

What Is the Magnitude of Risk of VTE after Caesarean Section?

C - All women who have had an emergency caesarean section (category 1–3) should be considered for thromboprophylaxis with LMWH for 7 days after delivery.

C - All women who have had an elective caesarean section (category 4) who have one or more additional risk factors (such as age over 35 years, BMI greater than 30) should be considered for thromboprophylaxis with LMWH for 7 days after delivery.

Which Agents Should Be Used for Thromboprophylaxis?

Low-molecular-weight Heparin

B - LMWHs are the agents of choice for antenatal thromboprophylaxis. They are at least as effective as and safer than unfractionated heparin.

Agents for Postpartum Thromboprophylaxis

Which Agents Are Appropriate for Postpartum Thromboprophylaxis?

C - LMWH is appropriate for postpartum thromboprophylaxis although, if women are receiving long term anticoagulation with warfarin, this can be started when the risk of haemorrhage is low, usually 5–7 days after delivery.

B - Both warfarin and LMWH are safe when breastfeeding.

Definitions:

Grades of Recommendation

A

At least one meta-analysis, systematic review or randomised controlled trial rated as 1++ and directly applicable to the target population; or

A systematic review of randomised controlled trials or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results

B

A body of evidence including studies rated as 2++ directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C

A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D

Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Classification of Evidence Levels

1++ High-quality meta-analyses, systematic review of randomised controlled trials or randomised controlled trials with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a low risk of bias

1- Meta-analyses, systematic reviews of randomised controlled trials or randomised controlled trials with a high risk of bias

2++ High-quality systematic reviews of case–control or cohort studies or high quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal

2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal

2- Case–control or cohort studies with a high risk of confounding, bias or chance and a significant risk that the relationship is not causal

3 Non-analytical studies; e.g. case reports, case series

4 Expert opinion

Clinical Algorithm(s)

The original guideline document contains clinical algorithms for:

  • Antenatal assessment and management of obstetric thromboprophylaxis risk
  • Postnatal assessment and management of obstetric thromboprophylaxis risk

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate thromboprophylaxis in pregnant women and the prevention of venous thromboembolism (VTE) during pregnancy and the puerperium

Potential Harms
  • There is a risk of bleeding and heparin-induced thrombocytopenia with low-molecular-weight heparin (LMWH), although the risk of thrombocytopenia is less with LMWH than with unfractionated heparin.
  • Warfarin crosses the placenta leading to an increased risk of congenital abnormalities including a characteristic warfarin embryopathy in approximately 5% of fetuses exposed between 6 and 12 weeks of gestation. Other reported complications associated with warfarin therapy during pregnancy include an increase in the risk of spontaneous miscarriage, stillbirth, neurological problems in the baby, and fetal and maternal haemorrhage.
  • Warfarin can be safely used following delivery and in breastfeeding mothers, although it requires close monitoring and visits to an anticoagulant clinic. It carries an increased risk of postpartum haemorrhage and perineal haematoma compared with LMWH. It is not appropriate for those women requiring 7 days of postpartum prophylaxis. However, it is appropriate for those on maintenance warfarin outside pregnancy. Conversion from LMWH back to warfarin should be delayed for at least 5 to 7 days after delivery to minimise the risk of haemorrhage during the period of overlap of LMWH and warfarin treatment.

Contraindications

Contraindications

Contraindications to Low-molecular-weight Heparin (LMWH)

LMWH should be avoided, discontinued or postponed in women who are at risk of bleeding after careful consideration of the balance of risks of bleeding and clotting. Risk factors for bleeding are:

  • Women with active antenatal or postpartum bleeding
  • Women considered at increased risk of major haemorrhage (such as placenta previa)
  • Women with a bleeding diathesis, such as von Willebrand's disease, haemophilia or acquired coagulopathy
  • Women with thrombocytopenia (platelet count less than 75 x 109)
  • Acute stroke in the last 4 weeks (ischaemic or haemorrhagic)
  • Severe renal disease (glomerular filtration rate less than 30 mL/minute/1.73 m2)
  • Severe liver disease (prothrombin time above normal range or known varices)
  • Uncontrolled hypertension (blood pressure greater than 200 mmHg systolic or greater than 120 mmHg diastolic)

Qualifying Statements

Qualifying Statements
  • These recommendations are not intended to dictate an exclusive course of management or treatment. They must be evaluated with reference to individual patient needs, resources and limitations unique to the institution and variations in local populations. It is hoped that this process of local ownership will help to incorporate these guidelines into routine practice. Attention is drawn to areas of clinical uncertainty where further research may be indicated.
  • The Royal College of Obstetricians and Gynaecologists (RCOG) produces guidelines as an educational aid to good clinical practice. They present recognised methods and techniques of clinical practice, based on published evidence, for consideration by obstetricians and gynaecologists and other relevant health professionals. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made by the doctor or other attendant in the light of clinical data presented by the patient and the diagnostic and treatment options available. This means that RCOG Guidelines are unlike protocols or guidelines issued by employers, as they are not intended to be prescriptive directions defining a single course of management. Departure from the local prescriptive protocols or guidelines should be fully documented in the patient's case notes at the time the relevant decision is taken.
  • As is apparent from the low grading of the evidence for many of the recommendations, they have been developed to provide a broad practical guide for obstetricians in clinical practice. However, it is recognised that, in individual women, alternative approaches may be reasonable, particularly following discussion with the woman concerned and, where available, input from a local expert in the field of thrombosis in pregnancy.
  • Further advice on the decision and the management of both VTE risk factors and bleeding risk factors may be sought from a haematologist with experience in the management of thrombosis and bleeding disorders in pregnancy.

Implementation of the Guideline

Description of Implementation Strategy

Auditable Standards

  • Correct risk assessment at booking, on admission to antenatal ward and after delivery
  • Correct dose of low-molecular-weight heparin (LMWH) (based on booking weight) prescribed antenatally and postpartum
  • LMWH prescribed and taken for 1 week postpartum in all women with class-3 obesity (BMI greater than 40)
  • LMWH prescribed and given for 6 weeks postpartum in all women with previous VTE
Implementation Tools
Audit Criteria/Indicators
Clinical Algorithm
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Royal College of Obstetricians and Gynaecologists (RCOG). Reducing the risk of thrombosis and embolism during pregnancy and the puerperium. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2009 Nov. 35 p. (Green-top guideline; no. 37).  [146 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2004 Jan (revised 2009 Nov)
Guideline Developer(s)
Royal College of Obstetricians and Gynaecologists - Medical Specialty Society
Source(s) of Funding

Royal College of Obstetricians and Gynaecologists

Guideline Committee

Guidelines Committee of the Royal College of Obstetricians and Gynaecologists

Composition of Group That Authored the Guideline

Committee Members: Dr C Nelson-Piercy MA, FRCP, FRCOG, Consultant Obstetric Physician, Guys & St Thomas' Hospital and Imperial College Healthcare Trust, London; Dr P MacCallum MD, FRCP, FRCPath, Senior Lecturer and Honorary Consultant Haematologist, Barts and the London School of Medicine and Dentistry and NHS Trust; Dr L Mackillop MA, MRCP, Consultant Obstetric Physician, Oxford Radcliffe Hospitals NHS Trust

Peer Reviewers: Association of Anaesthetists of Great Britain and Ireland; Dr R Arya, Head of Haemostasis and Thrombosis, King's College Hospitals NHS Trust, London; Dr TP Baglin, The British Committee for Standards in Haematology/BSH; Professor RM Bauersachs, Medical Department, Klinikum Darmstadt, Darmstadt, Germany; Mr RG Farquharson FRCOG, Liverpool; Professor M Greaves, Head of School of Medicine, University of Aberdeen, Aberdeen, Scotland; Professor IA Greer FRCOG, FRCP, York; Professor B Hunt FRCP, FRCPath, London; Professor MA Laffan FRCPath, Professor of Haemostasis and Thrombosis, Hammersmith Hospital, London; Dr A Mumford, MBChB, MRCPath, PhD, MRCP, Consultant Haematologist, St Michael's Hospital, Bristol; RCOG Consumers' Forum; Miss SM Sellers FRCOG, Bristol; Dr K Sheares, Chair of the Acute Pulmonary Embolism Group, British Thoracic Society; Dr A Shlebak, St. Mary's Hospital Haemophilia Centre, London; Dr J Voke, Consultant Haematologist, Luton; Professor I Walker, Director of UK NEQAS for Blood Coagulation, Sheffield

Financial Disclosures/Conflicts of Interest

Guideline authors are required to complete a "declaration of interests" form.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Royal College of Obstetricians and Gynaecologists (RCOG). Thromboprophylaxis during pregnancy, labour and after vaginal delivery. London (UK): Royal College of Obstetricians and Gynaecologists (RCOG); 2004 Jan. 13 p. (Guideline; no. 37). [52 references]

Guideline Availability
Availability of Companion Documents

The following are available:

  • Development of RCOG green-top guidelines: policies and processes. Clinical Governance Advice No 1a. 2006 Nov. Available from the Royal College of Obstetricians and Gynaecologists (RCOG) Web site External Web Site Policy.
  • Development of RCOG green-top guidelines: producing a scope. Clinical Governance Advice No 1b. 2006 Nov. Available from the RCOG Web site External Web Site Policy.
  • Development of RCOG green-top guidelines: producing a clinical practice guideline. Clinical Governance Advice No 1c. 2006 Nov. Available from the RCOG Web site External Web Site Policy.

In addition, auditable standards are available in section 12 of the original guideline document.

Patient Resources

The following is available:

Print copies: Available from the National Health Service (NHS) Response Line 0870 1555 455, ref: 23809. 11 Strand, London, WC2N 5HR.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on October 17, 2005. This summary was updated by ECRI on March 6, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin sodium). This summary was updated by ECRI Institute on June 22, 2007 following the U.S. Food and Drug Administration (FDA) advisory on heparin sodium injection. This summary was updated by ECRI Institute on September 7, 2007 following the revised U.S. Food and Drug Administration (FDA) advisory on Coumadin (warfarin). This summary was updated by ECRI Institute on March 14, 2008 following the updated FDA advisory on heparin sodium injection. This summary was updated by ECRI Institute on June 12, 2010. This summary was updated by ECRI Institute on March 7, 2014 following the U.S. Food and Drug Administration advisory on Low Molecular Weight Heparins.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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