Maternal Safety Bundle for Venous Thromboembolism

January 6, 2014

Venous Thromboembolism Bundle: Key Elements

• Risk assessment tools • Standardized approach

– Protocols for postnatal prophylaxis – Anesthesia checklist

• Suggested dosing schedule • Diagnostic algorithm for PE/DVT

Risk Assessment Tools

PREGNANCY INITIAL ASSESSMENT

History of VTE VTE Prophylaxis

Multiple VTE episodes Yes -> T*

1st VTE idiopathic Yes -> P*

1st VTE pregnancy/OC Related Yes -> P*

1st VTE provoked No

Inherited Thrombophilia carrier High Risk Low Risk

Yes -> T* Yes -> P*

Acquired Thrombophilia carrier Yes -> T*

Inherited Thrombophilia

High Risk Yes -> P*

Low Risk No

Acquired Thrombophilia No

Family History of VTE +High Risk (I+A) Yes -> P*/I

Fam Hx + low risk No

Risk Assessment

• High risk thrombophilia –FVL or PT gene homozygous, –Antithrombin deficiency, or –Combined disorders

• Low risk thrombophilia –FVL or PT gene heterozygous –Protein C or S deficiency

• Acquired thrombophilia –LA, ACA, APLS

• MTHFR or PAI-1 do not require prophylaxis

Risk Assessment: Pregnancy Re-Assessment

• B-1. Hospital admission for antepartum complications

(for conservative management not in labor, not scheduled for delivery.)

• B-2. Postpartum • B-3. On discharge

Risk Assessment: Antepartum Hospitalized B-1

• All receive SCD (sequential compression device) during hospitalization

• Add chemotherapy (LMWH/UFH) – Already receiving

prophylaxis/full anticoagulation

– Morbid obesity (BMI >40) – History of VTE – not

already on prophylaxis – All those with score 3 or

more risks

B-1 Antepartum Risk Factors

Thrombophilia – not already on prophylaxis

Age >40 years or <15 years

Medical complications

Pregnancy complication s (multiple, preeclampsia, IUGR)

Bed rest

Contraindications to LMWH Therapy

• Hemophilia or other known bleeding disorder (e.g. von Willibrand or acquired coagulopathy)

• Active or threatened antenatal bleeding (e.g. placenta previa, placental abruption)

• Thrombocytopenia (platelet count <75 x109)

• Stroke in previous 4/52 (hemorrhagic/ischemic) • Severe renal disease (GFR <30ml/min) • Severe liver disease (prolonged PT) • Uncontrolled hypertension (BP >200mmHg systolic or

>120mmHg diastolic)

Risk Assessment: Postpartum

• For cesarean delivery – SCDs prior to delivery

• For all vaginal and cesarean deliveries – Early mobilization, avoid dehydration – Add chemoprophylaxis if:

• Already receiving prophylaxis/full anticoagulation • History of VTE not already on chemoprophylaxis • Family history of VTE with any thrombophilia • Morbid obesity (BMI>40) • With score 2 or more (see B-1 + B-2 Risks)

Risk Assessment: Risk Factors

B-1 Antepartum Risk Factors B-2 Postpartum Risk Factors

Thrombophilia – not already on prophylaxis Any factors from B-1

Age >40 years or <15 years Cesarean section

Obesity (BMI >30) Peripartum Hemorrhage

Medical complications Hysterectomy

Pregnancy complication s (multiple, preeclampsia, IUGR) General Anesthesia

Bed rest Postpartum infection

Risk Assessment: Postpartum on Discharge

History of VTE VTE Prophylaxis

Multiple VTE episodes Yes -> T*

1st VTE idiopathic Yes -> P*

1st VTE pregnancy/OC Related Yes -> P*

1st VTE provoked Yes -> P*

Inherited Thrombophilia carrier High Risk Low Risk

Yes -> T* Yes -> P*

Acquired Thrombophilia carrier Yes -> T*

Inherited Thrombophilia

High Risk Yes -> P*

Low Risk No

Acquired Thrombophilia Yes ->P*

Family History of VTE +High Risk (I+A) Yes -> P*

Fam Hx + low risk No

VTE Prophylaxis at Discharge (at leas 6 weeks postpartum)

THERAPEUTIC HEPARIN/WARFARIN (one of the following)

Multiple VTE episodes

Single VTE + high risk thrombophilia

Single VTE + acquired thrombophilia

PROPHYLACTIC HEPARIN/WARFARIN (one of the following)

Single VTE unprovoked

Single VTE pregnancy or OC related

Single VTE provoked + Low Risk Thrombophilia

High risk Thrombophilia + No history of VTE

Acquired Thrombophilia + No history of VTE

Family History of VTE+ High risk or Acquired Thrombophilia

Low Risk Thombophilia; Family History of VTE+ Low Risk Thrombophilia DO NOT require DVT prophylaxis post discharge

VTE Prophylaxis at Discharge

Therapeutic Heparin/Warfarin

Prophylactic Heparin/Warfarin

One of the following:

• Multiple VTE • VTE with high risk

thrombophilia

One of the following:

• Any VTE episode • Low risk thrombophilia • Family history of VTE

with high risk thrombophilia

VTE Prophylaxis at Discharge

• Multiple VTE • Single VTE + High Risk

Thrombophilia • Single VTE + Acquired

Thrombophilia

• Single VTE Idiopathic • Single VTE Pregnancy/OC

Related • Single VTE Provoked • Single VTE+ Low Risk

Thrombophilia • High Risk Thrombophilia • Acquired Thrombophilia • Family history VTE + High Risk

Acquired Thrombophilia

THERAPEUTIC LMWH/UFH

for 6 weeks postpartum

PROPHYLACTIC LMWH/UFH

for 6 weeks postpartum

Post-Cesarean Thromboprophylaxis

• National data: – 1,263,205 women underwent cesarean

delivery between 2003-2010 – Perioperative and postpartum

thromboprophylaxis evaluated – Mechanical prophylaxis underused – Pharmacologic prophylaxis very rare

Post-Cesarean Thromboprophylaxis

0

10

20

30

40

50

60

70

80

90

100

2003 2004 2005 2006 2007 2008 2009 2010

None

Mechanical

Pharmacologic

Combination

Year of hospitalization

Perc

enta

ge o

f pat

ient

s

Prophylaxis:

Conclusion

Quality Data Measures

Measuring Care Quality

• Appropriate prophylaxis represents a major opportunity to reduce VTE

• How can improvements in care quality be best

measured?

VENOUS THROMBOEMBOLISM PROCESS MEASURES

1. % of obstetric patients who undergo a risk assessment for thromboembolism for any hospital admission:

a. Antepartum

b. Delivery

c. Postpartum

2. % of hospitals that offer educational resources and teaching tools for providers to assess thromboembolism risk during prenatal care:

VENOUS THROMBOEMBOLISM TREATMENT MEASURES

1. % of patients undergoing cesarean delivery who receive:

a. Mechanical prophylaxis

b. Heparin prophylaxis (+/- mechanical prophylaxis) universally or because of risk factors

2. % of patients who receive mechanical thromboembolism prophylaxis during:

a. Antepartum hospitalizations

b. Postpartum hospitalizations

c. Vaginal delivery hospitalizations

3. % of patients who receive heparin thromboembolism prophylaxis during:

a. Antepartum hospitalizations

b. Postpartum hospitalizations

c. Vaginal delivery hospitalizations

VENOUS THROMBOEMBOLISM OUTCOME MEASURES

1. Incidence of thromboembolism

a. Adjustment for comorbidities and risk factors

2. Type of thromboembolism

a. DVT

b. Pulmonary embolism

ACOG DISTRICT II VENOUS THROMBOEMBOLISM WORKGROUP

Mary D’Alton, MD (Co-Lead) Adiel Fleischer, MD (Co-Lead)

Richard Berkowitz, MD Robin D’Oria Robert Silverman, MD

Barry Brown, MD Alexander Friedman, MD Richard Smiley, MD

Steven Clark, MD (HCA) Deborah Karsnitz Georges Sylvestre, MD

Adriann Combs, MD Howard Minkoff, MD Anthony Vintzileos, MD

Ted Denious, MD Michael Paidas, MD (Yale) Richard Waldman, MD

Keith Eddleman, MD Alexander Shilkrut, MD Wendy Wilcox, MD

Jennifer Donnelly, MD