Avoiding Maternal DVT with a Fractured Leg

Last week there was an unfortunate woman who had fractured her patella a week before her scheduled repeat caesarean section. She was hospitalised in a splint 4 days before delivery. I saw her on the day of surgery, unaware she was already an inpatient with trauma. She had her caesarean with spinal anaesthesia, and I arranged for her to commence on 40 mg enoxaparin bd ( she was about 90 kg pregnant), and to have a leg ultrasound for DVT four days later.She was to have ORIF of the patella the following week. I felt she was in a high risk category for DVT: pregnant, overweght, leg trauma, immobilisation, and surgery (twice). Therefore she warranted the generous LMWH dose (as supported by the RCOG and the Scottish (www.sign.ac.uk/guidelines/fulltext/62/index.html). I was surprised that the prophylaxis was not given sooner: she had presented at an emergency department after the fracture, and was admitted two days later and was quite bed bound for four days pre-caesarean. Thromboembolism remains the leading cause of maternal mortality and sick or injured pregnant patients should be considered for some form of prophylaxis. As it was the leg ultrasound was clear, but she went home after the ORIF to take enoxaparin for another 6 weeks (although only as a daily dose).