Invasive gynaecological procedures with a moderate risk of bleeding are listed below:
- LLETZ
- Endometrial polypectomy/Myosure
- Endometrial curettage
- Elective manual vacuum aspiration (MVA) or medical/surgical management of miscarriage*
- Insertion of Word catheter for Bartholin’s cyst/abscess*
- Vulval excision biopsy/wide local excision
Discussion with Haematology and Cardiology may be required. The risk of thrombosis should be established (see Appendix B and NHS GG&C guidance).
Local anaesthetic using a vasoconstrictor should be considered if appropriate.
*These procedures may require discussion with Haematology in an acute emergency setting.
DOACs
The procedure should be delayed until ≥48 hours after the last dose of DOAC depending on the risk of bleeding. If the creatinine clearance is <30ml/min, then the DOAC should be withheld for ≥72 hours. If there are concerns about bleeding or renal impairment pre-operatively then obtaining an anti-xa level +/- coagulation screen (ensuring AP <13 seconds(s) and APTT <38s) may be indicated.
Pre-op bridging low molecular weight heparin (LMWH) is not usually required.
The post-operative dose of the DOAC should be deferred until >4-6 hours after the procedure however this may be longer if there is concern about haemostasis. This may be longer depending on the extent of the procedure or the use of regional anaesthesia however this is out with the scope of this guideline.
This is summarised in Figure 1.
Figure 1: Management of DOACs in patients undergoing an invasive outpatient gynaecological procedure at moderate/high risk of bleeding
Clopidogrel
Stop clopidogrel 7 days before any invasive gynaecological procedure at moderate/high risk of bleeding. Aspirin may be used in place of clopidogrel during these 7 days if indicated.
This may require discussion with Cardiology and risk of thrombosis assessed (see Appendix B and NHS GG&C guidance).
Post-operative LMWH (provided there is no contraindication) and anti-embolic stockings should be given post-operatively. The dose of LMWH should depend on the risk of VTE (see Appendix B and NHS GG&C guidance): if there is a low risk then prophylactic LMWH can be given; if there is a high risk then treatment dose LMWH should be considered.
Re-start clopidogrel 48 hours after the procedure.
Aspirin
Aspirin does not need to be withheld before any invasive outpatient gynaecological procedure at moderate/high risk of bleeding. Patients should be informed however of the greater risk of bleeding +/- haematoma formation.
Warfarin
Stop warfarin 5 days before any invasive gynaecological procedure at moderate risk of bleeding. The target INR should be ≤1.4 for the procedure. LMWH should be given on each day pre-operatively and the dose dependent on the thrombosis risk (see Appendix B and NHS GG&C guidance).
Postoperative LMWH and anti-embolic stockings should also be given. Again, the dose will depend on the risk of thrombosis (see Appendix B and NHS GG&C guidance). The original dose of warfarin therapy may be commenced from day 1 post-operatively as it would typically take 48-72 hours to have an effect.
The anticoagulant clinic should be informed of the date of the procedure and appropriate anticoagulant follow up should be in place 5-7 days following the discharge from hospital.
Vitamin K 5mg IV may be given to reverse anticoagulation effect of warfarin if INR is >1.5 on day before procedure.
