Perioperative management of women on oral anticoagulants and antiplatelet agents undergoing gynaecological procedures TOG 2020

Question 1

Most common DOAC used?

Answer 1

Rivaroxaban, then apixaban

Question 2

What proportion of patients with AF will require temporary interruption of anticoagulation therapy for elective surgery?

Answer 2

15%

Question 3

When should warfarin be stopped before surgery? Is this respective of their risk of bleeding?

Answer 3

At least 5 days before, irrespective of their risk of bleeding

Question 4

For which patients should bridging be considered who are taking warfarin?

Answer 4

VTE within 3 months
Very high risk who’s target INR of 3.5

AF
- patients who have had TIA within last 3 months
- previous TIA/stroke with 3+ - congestive cardiac failure, HTN >140/90, >75, DM

Mechanical heart valve

Question 5

If having bridging treatment dose LMWH - when should the last dose be given?

Answer 5

24 hours pre-op

Question 6

When should bridging tinz be started post-op?

Answer 6

At least 48 hours after procedure if high risk of bleeding (consider prophylactic dose)

If haemostasis achieved - can restart warfarin on day of morning after surgery. Takes at least 24 hours for desired INR. Bridging during this time dependant on VTE risk

Question 7

Which gynae procedures are considered no bleeding risk

Answer 7

Pelvic examination
Smear test
Genital swabs

Question 8

Which gynae procedures are considered minor bleeding risk

Answer 8

Cervical biopsy
Diagnostic hysteroscopy
Hysteroscopy and resection of polyp
Labial/Bartholin’s abscess
Large loop excision of transformation zone
MyoSure polypectomy
NovaSure ablation
Pipelle biopsy
Transcervical resection of endometrium
Vulval biopsy

Question 9

Which gynae procedures are considered major bleeding risk

Answer 9

All day case and inpatient surgery

Question 10

How to manage patients taking antiplatelts medication before gynaecological procedures

Answer 10

Aspirin alone can be continues

If dual therapy - aspirin and clopidogrel due to ACS/stenting - advise where possible to delay surgery

Question 11

What local haeomstatic agents can be used to control bleeding at minor procedures

Answer 11

Monsel’s olution
Cauterisation with silver nitrate

If ensure - vaginal packing

Batholins - electrocautery or oxidised cellulose

Question 12

What is mechanism of action warfarin

Answer 12

Inhibits vit K reductase prevention activation of Vit K clotting factors

Question 13

Warfarin + low risk of bleeding, when should it be stopped & restarted

Answer 13

Pre-op
5 days prior to elective surgery with INR check ideally the day before surgery (if INR >1.5 phytomenadione should be given) and on the day of surgery.

Post-op
Start warfarin when adequate haemostasis is achieved approximately 12–24 hours after completion of surgery.10 LMWH can be restarted 24 hours after surgery until INR in therapeutic range.

Question 14

Warfarin + high risk of bleeding - when stop/restart

Answer 14

5 days prior to elective surgery with INR check ideally the day before surgery (if INR >1.5 phytomenadione should be given) and on the day of surgery.

Bridging with treatment dose LMWH should be considered in those with high VTE risk.

LMWH should not be given until 48 hours after surgery. Restart warfarin when bleeding risk minimised. LMWH should be continued until INR is in therapeutic range.

Mechanical thromboprophylaxis should be considered in all cases until INR in therapeutic range.

Question 15

For apixiban, rivaroxaban, edoxaban + low risk of bleeding when to stop and restart

Answer 15

Low bleeding risk:
Stop:
Creatinine clearance ≥30 ml/min: stop 24 hours prior.
Creatinine clearance <30 ml/min: stop 48 hours prior.

Restart
Recommence 6–12 hours postprocedure.

Question 16

For apixiban, rivaroxaban, edoxaban + high risk of bleeding when to stop and restart

Answer 16

High risk bleeding
Stop
Creatinine clearance ≥30 ml/min: stop 48 hours prior.
Creatinine clearance <30 ml/min: stop 72 hours prior.

Restart
Wait 48 hours before re-introducing at the full dose. If high VTE risk, consider prophylactic dose of anticoagulation before restarting at full therapeutic dose.

Question 17

In emergency surgery how can reverse warfarin?

Answer 17

If can wait 6-8hrs - 5mg IV phytomenadione

Cannot delay 25-50u/kg prothrombin complex concentrate

Question 18

If patient on DOAC and requires emergency gynae surgert

Answer 18

Delay if possible to allow drug to fall
Can give TXA to reduce bleeding
Aviods NSAIDs

If dabigatran - can given idarucizumab

Question 19

Any reversal agents for antiplatelet medication? How long is the platelet inhibition following clopidogrel

Answer 19

No reversible agent
7-9 days
Can offer TXA, if excessive bleeding - 2 pools donor platelets

Question 20

How long before neuraxial anaesthesia should clopidogrel be stopped?

Answer 20

7 Days