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