Prevention of vte

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PREVENTION OF vtE in obstetric populationBY Dr Kanddy LooO&G Updates1/11/14O&G departmentMiri hospitalCASE SCENARIO40 year-old P6, post emergency caesarean section for acute fetal distress D 6Had BMI of 40Presented with acute onset of SOB and chest painDenied calf swellingOtherwise, no known medical illness; normotensive antenatally and intrapartumlyExamination showed tachycardia and tachypnoea; with saturation under room air of 80%; normotensiveLungs examination was unremarkable

ProBable diagnosis..introductionPulmonary embolism remains the leading direct cause of maternal deathMost of the patients who died from PE have identifiable risks70% of women who died from PE in UK between 2003-2005 had identifiable riskThromboprophylaxis antenatally and postnatally estimated to reduce risk of VTE in obstetric patients by up to 2/3Objective of this lectureIntroduction of state VTE prevention programmeRisk stratification of patient according to VTE score to identify patients for thromboprophylaxisAntenatal VTE occur in the first trimester Therefore assessment and prophylaxis, if indicated should be given as early as possible in pregnancy

Maternal mortality - uk

CEMACH 2003-2005CEMACH 2006-2008Maternal mortality - malaysia

pathophysiologyIncidence of VTE in pregnancy 60/100000 woman-years12 fold increase compared to non pregnant populationVirchows Triad

Sarawak vte prevention programmeIntroduced on 1 July 2013To be implemented over Sarawak stateInitially hospital basedExpanded to primary health care centre on Mac 2014Obstetric patients are assessed based on modified VTE scoring systemDone as early in pregnancy as possibleRepeat assessment if theres emergence of new risk factors/during hospitalisationStart thromboprophylaxis ifVTE score 3 or more antenatally and continue postnatally for 6 weeksVTE score 2 or more postnatally for at least 1 weekPatient with additional persistent risk factor (lasting more then 1/52 postnatal) should thromboprophylaxis should be extended for up to 6 weeks or longer

Very high vte riskNeeds antenatal high-dose thromboprophylaxis (high prophylactic 12 hourly or 75% of treatment dose) antenatally and postnatally 6 weeksVery high risk factorsRecurrent VTE associated with APSPatient on long term anticoagulationAntithrombin deficiencyHigh riskThromboprophylaxis antenatally and 6 weeks postnatallyRisk factorsPrevious unprovoked, estrogen related (pregnancy/pills induced), recurrent VTEPrevious VTE with risk factors (family history of VTE, thrombophyilia or other risk factorsAsymptomatic thrombophilia (combine defects, homozygous Factor V Leiden)Combination of 3 or more risk factorsIntermediate riskPostnatal thromboprophylaxis (duration ranges from 1 6 weeks)Single previous VTE associated with temporary risk factor with no other risk factors (thromboprophylaxis upto 6 weeks postnatal)Asymptomatic thrombophilia (except antithrombin deficiency, combined defects, homozygous FVL) 1 week prophylaxis or 6 weeks if presence of other risk factorsPresence of 2 or more risk factors

Thrombophilia screeningOnly done for those VTE provoked by minor risk factors Antenatal thromboprophylaxis till postnatal 6/52Previous VTE with thromphiliaAsymptomatic thrombophilia with other risk factorsAsymptomatic thrombophiliaCombine defectsHomozygous Factor V LeidenPostnatal thrombophylaxisOther asymptomatic thrombophilia without other risk factorsAnti coagulant agentsLow molecular weight heparinAgents of choiceAs effective as and safer then the unfractionated heparinLower risk of Heparin induced thrombocytopaenia and osteoporosisRisk of bleeding - 200mmHg; DBP>120mmHg)anaesthesiaRegional techniques should not be used at least 12 hours after previous prophylactic dose of LMWH24 hours after last dose of therapeutic dose4 hours after last dose of unfractionated heparinLMWH should not be given for 4 hours after regional anaesthesia or after removal of epidural catheterEpidural catheter should not be removed within 10 12 hours of the last doseQuiz scenario 140 year-old; primigravida; subfertility for 20 yearsBMI 32Currently at 10 weeks..At 12 weeks, she was admitted with hyperemesis gravidarum.

At 30 weeks, she was again admitted and treated as acute appendicitis; appendicectomy was doneAt 38 weeks, she has EMLSCS for fetal compromise; complicated with massive PPH and had massive transfusion.Quiz scenario 230 year-old G2P1 at 8 weeks; came for bookingPrevious history of postpartum DVT; completed warfarin treatment for 6 monthsCurrently well, no leg swellingBM1 25At 36 weeks, she presented with SROM with TMSL and os was only 1 cm.


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