D R . H A R R I S N S U H A R J O N O F R C O G S E N I O R C O N S U L T A N T & H E A D D E P A R T M E N T O F O & G S A R A W A K G E N E R A L H O S P I T A L
Sarawak VTE Risk Assessment Program:
Antenatal & Postnatal
Maternal Deaths:
Pulmonary embolism as a cause of maternal deaths is rising worldwide
In most developed countries it is one of the commonest cause of direct maternal deaths
In Malaysia, PPH and PE are the top 2 causes of direct maternal deaths
In Sarawak, there were 15 deaths from PE in a 5 year period (2008-2012). 10 of these deaths occurred in the postnatal period, 2 intra-partum and 3 in the antenatal period.
In 2012, there were 4 maternal deaths due to PE in Sarawak, making it the commonest direct cause….
Deaths from PE
Pulmonary embolism has been identified as the most important cause of direct maternal mortality in the UK today (Confidential Enquiry into Maternal Deaths, UK)
There has been a significant decline in deaths from PE following the publication and implementation of guidelines that were recommended in previous confidential enquiry reports.
The number of deaths attributed to pulmonary embolism and thromboembolism were 18 between 2006-2008 compared to 41 in 2003-2005.
Evidence that clinical guidelines works…..
Venous Thromboembolism (VTE)
A venous thrombosis is a blood clot (thrombus) that forms within a vein which can break off (embolize), and become a life-threatening pulmonary embolism (PE). The disease process is called venous thromboembolism
Venous thromboembolism (VTE) includes: Deep vein thrombosis (DVT)
Pulmonary embolism (PE)
Pulmonary Embolism (PE)
PE is a serious & potentially life-threatening condition.
PE usually happens due to an underlying blood clot in the leg – deep vein thrombosis (DVT).
PE can cause symptoms such as chest pain or breathlessness but may be asymptomatic and be hard to detect.
The embolus may cause blockage in a blood vessel in the lungs.
A massive pulmonary embolism can cause collapse and death.
Signs and Symptoms of DVT
Important to note that half of all DVT cases are asymptomatic
DVT signs & symptoms includes; Swelling in one or both legs
Pain or tenderness in one or both legs, which may occur only while standing or walking
Warmth in the skin of the affected leg
Red or discoloured skin in the affected leg
Leg fatigue
Especially when the above signs & symptoms occur suddenly
Sings & Symptoms of PE
Pulmonary embolism symptoms can vary greatly, depending on how much of your lung is involved, the size of the clot and your overall health
Signs and symptoms includes; Shortness of breath. This symptom typically appears suddenly
and occurs whether you're active or at rest. Chest pain. The pain will get worse with exertion but won't go away
when you rest. Cough. The cough may produce bloody or blood-streaked sputum. Wheezing Clammy or bluish-coloured skin Excessive sweating Rapid or irregular heartbeat Weak pulse
‘Thombophilia’
Thrombophilia is a condition where the blood clots more easily than normal.
Up to 50% of people who have an episode of thrombosis like DVT or PE may have this condition.
Check or ask for documented history of; 1. Protein C deficiency
2. Protein S deficiency
3. Antiphospholipid syndrome
4. Factor V Leiden
5. Dysfibrinogenaemia
6. Antithrombin deficiency
Increased risk of VTE in pregnancy
1. Pregnancy is a hypercoagulable state
2. Increase in factor VIII, IX, X, fibrinogen
3. Decreased in fibrinolytic activity, anti-thrombin and protein S fall
4. Venous stasis in pregnancy
5. Pregnancy increases risk of VTE 6 folds (from first trimester till 6 weeks post-partum)
6. Caesarean sections further increases the risk approximately by 10-20 folds
“Thromboembolism remains a significant but preventable
cause of maternal death”
Strategy to reduce risk of VTE in pregnancy
Identifying & modifying risk factors in women planning to embark on pregnancy – PPC Clinic
To reduce BMI below 30kg/m2
Stop smoking
History of VTE?
Limit number of pregnancies
Optimizing chronic medical illnesses
Effective and appropriate contraception
Improve awareness: e.g. Making patient information leaflets/brochures available
Strategy to reduce risk of VTE in pregnancy
Screening for VTE risk among antenatal and postnatal women;
Common VTE Risk Assessment form
Checklist for VTE for nurses to use during home visits
System put in place in to manage appropriately those at risk;
Simple guidelines for medical officers/nurses to follow
Practical management flowcharts
Making heparin & LMWH available in all hospitals
“Risk scoring of antenatal and postnatal women for VTE is
probably the most effective way of identifying who is at
significant risk and needed intervention or treatment with
thromboprophylaxis”
Sarawak Antenatal & Postnatal VTE Risk
Assessment Program:
RISK FACTORS: Tick Score
ANTENATAL:
Previous VTE (estrogen related, unprovoked or recurrent) 3
Previous VTE (provoked, eg accident) 2
Thrombophilia 2
Medical illness (SLE, Cardiac, Connective tissue, Renal disease,
Malignancy)
2
Family history of VTE 1
Age >35 years 1
Parity of 5 or more 1
Obesity a) (BMI>40kg/m2) 2
b) (BMI>30kg/m2) 1
Gross varicose veins 1
Smoker/ IVDU 1
Multiple pregnancy 1
CURRENT EVENTS OR ADMISSION:
Hyperemesis Gravidarum requiring admission 1
Pre-eclampsia 1
Dehydration/ OHSS**
Hospital stay / immobilization > 3days 1
Systemic infection (eg active TB, pneumonia) 1
Chorioamnionitis 1
Surgery in pregnancy or puerperal period (this includes BTL
within 42 days of delivery but excluding ERPOC & minor T&S*)
1
Long distance travel by road/air travel > 8 hours non stop 1
DELIVERY (CURRENT PREGNANCY):
Caesarean section (emergency & elective) 2
Instrumental delivery 1
PPH > 1.5 L 1
Prolonged labour > 24 hours 1
Third/fourth degree perineal tear 1
Vulvo/vaginal haematoma 1
Septic miscarriage/ Molar pregnancy 1
TOTAL SCORE
This assessment should be performed at: • Antenatal booking* • During each hospital admission** • Post delivery before discharge**
Patients who should be given thromboprophylaxis: • ANTENATALLY – score > 3 • POSTNATALLY – score > 2
* If VTE risk assessment is also implemented in health clinics in the state ** To be implemented in all hospitals by 1st July,2013
When to assess?
At this moment in time, the VTE risk assessment in the state will only be carried out in hospitals
When antenatal or postnatal patients are being admitted to the hospital for any indications (includes those admitted to other departments)
Reassessment required if other complications developed during the hospital stay or need to stay longer than 3 days
Those considered at risk upon discharge (e.g. surgery) in the antenatal period, may also need thromboprophylaxis
Post delivery before discharge to assess if she needs thromboprophylaxis
Who needs treatment?
Patients who should be given thromboprophylaxis: 1. ANTENATALLY – score > 3
2. POSTNATALLY – score > 2*
Low risk with score < 2 1. Early mobilization/encourage to ambulate
2. Avoidance of dehydration
3. To seek treatment early if feeling unwell
4. To seek treatment early if develops signs & symptoms of DVT/PE
5. +/- Compression or TED stocking
Counseling to be given to all pregnant women
* Risk of VTE postnatal is higher (thus a lower score needed to start thromboprophylaxis)
Types & dose of thromboprophylaxis
Weight Enoxaparin (Clexane)
S/C Heparin Tinzaparin
<50kg 20mg OD - -
50-90kg 40mg OD 5000 units BD 4500units OD 91-130kg 60mg OD Insufficient evidence of
efficacy 7000units OD
131-170kg 80mg OD 9000units OD Fondaparinux (50-90kg) – currently there is a lack of evidence of efficacy & safety in
pregnancy
Which thromboprophylaxis?
LMWH is preferred: once daily injection and safe enough to be self administered
Enoxaparine (Clexane) & tinzaparin (Innohep) clinically proven to be efficacious and safe in pregnancy but it is porcine based (Muslim patients have to be informed)
Fondaparinux is similar to ‘LMWH’ and is not porcine based but efficacy and safety in pregnancy and lactating mothers are not proven (patient needs to be counseled & the doctor can be held liable)
Heparin is effective and safe in pregnancy but requires BD dosing and need to be administered by a medical personnel as the risk is higher compared to LMWH
Ultimately, the patient needs to choose (fondaparinux not available in non specialist hospitals)
Unfractionated Heparin VS LMWH
LMWHs, interact relatively little with factor II and do not predictably prolong the aPTT. Thus monitoring their effect is more difficult and requires direct measurement of anti-factor-Xa activity. This test is not available in SGH & other hospitals in the state!
Unfractionated heparin: is a large molecule, so it does not cross the placenta. Its main limitations is the BD dosing and its potential maternal adverse effects mainly osteoporosis and heparin-induced thrombocytopenia when used long term.
Over the last decade, LMWH has been the preferred choice
LMWH however should be used with caution in patients with renal insufficiency
Role & Risks of warfarin in pregnancy:
Warfarin cross the placenta and thus pose a risk of teratogenicity.
Warfarin embryopathy: Nasal bone hypoplasia & chondrodysplasia punctata can occur when the drug is used between 6 and 12 weeks of gestation.
Later in pregnancy: Associated with potential fetal bleeding complications leading to central nervous system abnormalities, increased rates of intrauterine fetal death, and pregnancy loss.
Because of the many maternal and fetal concerns, warfarin use in pregnancy is largely restricted to women with mechanical prosthetic heart valves in whom the very high maternal thrombotic risk may outweigh the risk of maternal and fetal side effects.
How long to treat?
Depends on how high is the risk Depends if the risk is modifiable Those with previous VTE, thrombophilia or a combination
of antenatal non modifiable factors that adds up to a score of > 3, would require thromboprophylaxis throughout pregnancy & up to 42 days post delivery
Those who develops transient or temporary conditions that increases the risk temporarily (e.g. admission > 3 days, surgery, hyperemesis gravidarum) only needs short term treatment
Those that had LSCS or surgery during pregnancy requires 7 days of treatment or longer if indicated
When in doubt, consult an O&G specialist
How to start thromboprophylaxis?
Confirm VTE risk score Counsel patient appropriately:
Why she needs it & how long? Types: heparin or LMWH How to self administer (injection) How to keep the LMWH Possible side effects Follow-up plan
Thromboprophylaxis can be started by medical officers in non specialist hospitals
Heparin should only be administered by medical personnel as an inpatient or outpatient
When in doubt, consult an O&G specialist or your buddy specialist
Patients who refused thromboprophylaxis
Counseling play an important role (consider further counseling by FMS or O&G specialist)
Consult an O&G specialist or buddy specialist
Upon failure to convince patient;
Use appropriate compression stockings or ‘venaflow’ where available (inpatient)
Reinforce advise on ambulation, avoidance of dehydration & seeking early treatment if unwell
Teach patient to identify signs & symptoms of DVT & PE
Arrange regular clinic and home visits
When to stop & restart LMWH for labour/epidural/spinal/surgery ?
Stop LMWH about 24 hours before elective surgery
Stop LMWH when a patient goes into active labour or expected to go into active labour and restart the next day after delivery if she does not have PPH
Decision to restart LMWH after surgery depends on; If haemostasis safely secured
The risk of bleeding associated with the procedure
Restart 24 hours after surgery or the next day, in cases of massive PPH may delay by a day or two.
Stop 12 hours before spinal/epidural and restart about 12 -24 hours after catheter has been removed
VTE Risk Assessment Management flowchart (admission)
Assess risk for VTE
Score < 3 Score > 3
General advice (ambulate/avoid dehydration/seek
treatment if unwell, +/- Compression stocking)
Reassess risk if requires prolonged admission or
develops new problems
Non specialist
hospital
Specialist hospital
Counsel patient appropriately
Initiate thromboprophylaxis (duration discuss
with O&G specialist/buddy specialist)
E-Discharge Notifications (specific instructions,
incl. home visits)
Home visit by health staff (review compliance,
use check list)
Yellow coded: FMS/ Specialist f/up, shared care
with clinic with MO possible
Initiate thromboprophylaxis
Documented follow up plans
E-Discharge Notifications (specific
instructions, incl. home visits)
Home visit by staff (review
compliance, use check list)
Yellow coded: Specialist & FMS
antenatal f/up
VTE Risk Assessment Management flowchart on discharge
Provide general advice on DVT/PE prevention
< 2 post-natal risk 2 or more risk
Give patient information leaflet
Advice on ambulation,
importance of adequate fluid
intake
Seek immediate treatment if
symptomatic
Refer to hospital if develops
new problems/complications
Home visit (look for symptoms’
of DVT/PE – checklist)
Non specialist hospital Specialist hospital
Counselling & give patient
information leaflet
Initiate thromboprophylaxis (at
least 1 week, if longer Rx needed
consult O&G specialist)
E-Discharge Notifications (home
visits compulsory)
MO/ FMS review at 1week (re-
assess risk, may need longer Rx
if still high risk – consult
specialist)
VTE Risk assessment on discharge (antenatal or postnatal)
VTE Checklist during home visits by nurses:
1) General well-being Y N
a) Is the patient ambulating?
b) Is the patient drinking well?
c) Does the patient look dehydrated?
d) Does the patient have fever?
2) Signs & symptoms’ of DVT Y N
a) Leg swelling (usually unilateral)
b) Calf pain (even at rest)
c) Redness of calf
d) Feeling unwell (unable to mobilize)
e) Non pitting swelling
f) Increased warmth of the limb
g) Reduced capillary filling
3) Signs & symptoms’ of pulmonary embolism Y N
a) Shortness of breath
b) Chest pain (more during breathing)
c) Cough (dry or blood stained)
d) Pulse rate >100
e) Respiratory rate >24
f) Cyanosis
g) Unconscious
If a patient develops any of
these signs or symptoms,
refer immediately to the
nearest clinic or hospital for
review by a doctor.
Please advise patients to
ambulate, drink adequately
and to seek medical
treatment if feeling unwell
during every visit
Check if the patient is
compliant to treatment
Follow-up
Antenatal patients with a VTE risk score of > 3 and postnatal patients with a score of > 2, should be coded yellow
Antenatal f/up should be by FMS or in specialist ANC but shared care with normal clinics is acceptable
Frequency of antenatal clinic f/up should be at least biweekly Postnatal f/up at 1 week where possible should be arranged to see a
FMS/MO to review her risks. Longer thromboprophylaxis may be necessary if still considered at risk (i.e. not ambulating, feeling unwell, etc)
Very high risk postnatal patients who are planned to receive thromboprophylaxis for 42 days, should be reviewed by FMS or by specialist in clinics weekly/biweekly until 6 weeks
High Risk E-Discharge Notification with instructions for home visits Family planning advice for patients at high risk of VTE PPC Clinic appointment should be given to modify risks
This lecture along with the VTE Risk Assessment form and other relevant forms will be uploaded onto the O&G@SGH Resource
website