Reducing Maternal Mortality from Venous Thromboembolism

“ SARAWAK VTE RISK MANAGEMENT”

Introduction/Background Sarawak VTE prophylaxis strategies

Options of drugs available Administrations problems

Common error Early VTE detection.

VTE (venous thromboembolism) includes1. Deep vein thrombosis (DVT)2. Pulmonary embolism (PE)

In Malaysia, PE is the common cause of direct maternal death and it is rising nowadays

It is preventable cause of maternal death

Pulmonary embolism is the main cause of

maternal mortality in Malaysia and

Sarawak

“Thromboembolism remains a significant but preventable cause of

maternal death”

“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”

Prevention of DVT or PE1. Health clinics: Should identify very high risk patients during

antenatal period and manage or refer them appropriately. Screen using VTE Risk Assessment forms

2. Hospital: VTE risk assessment should be undertaken during every admission and prior to discharge from the hospital.

3. High Risk E-Discharge Notification plays an important role in communicating between hospitals and health side. Patients who are high risk of VTE or are on treatment should be included in the E-discharge for both antenatal and postnatal cases!

Early detection of DVT or PE Improving AWARENESS among staff and patients

Clinic health staff are expected to be able to identify patients who are VERY HIGH RISK for VTE and manage them or refer accordingly

Nurses performing home visits should be assessing postnatal patients for VTE using the Postnatal VTE Risk assessment form.

This simplified form was initially prepared for use

in health clinics across the state.

JKNS has made the decision to include

health clinics in the VTE Risk Management

Program

This assessment should be performed :-During antenatal period

-During each hospital admission

-Post delivery

Using Standard form (Sarawak thromboprophylaxis risk assessment form)

Antenatal patient who come to clinic follow up 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

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 follow up• During each hospital admission• Post delivery before discharge

Patients who should be given thromboprophylaxis:• ANTENATALLY – score > 3(duration to be discussed with specialist)

• POSTNATALLY – score > 2(duration of at least 1 week)

** To be implemented in all hospitals by 1st July,2013

Patients who should be given thromboprophylaxis:1.ANTENATALLY – score > 3

2.POSTNATALLY – score > 2*

Low risk with score < 21.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

Counselling to be given to all pregnant women * Risk of VTE postnatal is higher (thus a lower score

needed to start thromboprophylaxis)

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

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 ( postnatal)

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

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)

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

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)

Ultimately, the patient needs to choose (fondaparinux not available in non specialist hospitals)

Depends on how high is the risk

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

Self injection after discharge

Porcine Based drugs (Clexane and Tinzaparin)

Clexane and Tizaparin can be easily and safely injected by patient. (After been properly taught)

Prefilled syringe

Fixed dose

Heparin otherwise should only be administered by medical personnel as an inpatient or outpatient

Risk of overdose ( need to withdraw a correct dose from the vial- technically difficult for patient to do so)

Heparin should only be administered by medical personnel as an inpatient or outpatient

Muzakarah Jawatankuasa Fatwa Majlis KebangsaanBagi Hal Ehwal Ugama Islam Malaysia Kali Ke-87 yang bersidang pada 23 – 25 Jun 2009 telahmembincangkan Hukum Penggunaan Ubat ClexaneDan Fraxiparine. Muzakarah telah memutuskan bahawa:

Islam menegah penggunaan ubat dari sumber yang haram bagi mengubati sesuatu penyakit, kecualidalam keadaan di mana tiada ubat dari sumber yang halal ditemui dan bagi menghindari kemudharatanmengikut kadar yang diperlukan sahaja sehingga ubatdari sumber yang halal ditemui.

Oleh itu, berhubung dengan penggunaan ubatClexane dan Fraxiparine yang dianggap daruratkepada para pesakit bagi mencegah formulasipembekuan darah secara serta merta ketikapesakit berada pada tahap kronik, Muzakarahmemutuskan bahawa penggunaan kedua-duajenis ubat ini adalah ditegah kerana ia dihasilkandari sumber yang diharamkan oleh Islam, memandangkan pada masa ini telah terdapatalternatif ubat iaitu Arixtra (Fondaparinux) yang dihasilkan daripada sumber halal danmempunyai fungsi serta keberkesanan yang sama dengan Clexane dan Fraxiparine.

But……Fondaparinux in Pregnancy

Not enough data on efficacy and safety

No antidote

………………??? Alternative to clexane/tinzaparine/fraxiparine in obstetrics patients.

Options1. Unfractionated heparin

Currently we do not allow patient to administer the injections themselves (because of safety issue)

Have to go to hospital/nearest clinic to get injected. BD dose…..night dose ( limited number of clinic are

open at night)2. Fondaparinux

National O&G services do not endorse use of fondaparinux in pregnancy and puerperium (the doctor can held liable if complication developed/Patient has VTE)

1. Patient on LMWH (Clexane/Tinzaparine) who are not keen for self injection.

2. Patient on Unfractionatedheparin ( refused porcine based LMWH)

Kuching Sibu Miri Bintulu

KK Jalan Masjid

Klinik 1M Bintawa

Klinik 1M PantaiDamai

Klinik 1M Tabuan

Klinik 1M Malihah

KK Lanang

Klinik 1M Teku

Klinik 1M Sungai Bidut

Klinik 1M Taman Rejang

Klinik 1M Soon-HupPermai

Klinik 1M Farly Sentosa

Klinik 1M Bandong

KK Bandar Miri KK Bintulu

1. In other district , unfractionated heparin only can be given in the hospital

2. Patient on clexane/tinzaparine can go to any MCH /clinic as its only need 1 dose/day

These clinic are open at night up to 9/10 pm (for

evening dose of heparin)

Not many patient Most Muslim patient are keen for

clexane/tinzaparine after counselling. Proportion of patient on unfractionated

heparin will receive the injection in the hospital.

The correct dose of unfractionated heparin is ……..

5000 unit B.DSubcutaneously

Heparin are given intra-mascularly instead of subcutaneously.

Overdose !!!!!...........few patient are

wrongly given up to 25,000 unit b.d

Did not read the heparin concentration properly

1 vial = 5 ml

5000 unit = 1 ml

Only 1 ml is needed

1. E-Discharge informing health side on high risk patient.

2. Home visit within 7 days of discharge 3. VTE checklist during home visit by nurses.4. Patient information leaflet on VTE5. Patient information leaflet on heparin

Important to note that half of all DVT cases are asymptomatic

DVT signs & symptoms includes; Swelling in one or both legsPain or tenderness in one or both legs, which may

occur only while standing or walkingWarmth in the skin of the affected legRed or discoloured skin in the affected legLeg fatigue

Especially when the above signs & symptoms occur suddenly

THROMBOEMBOLISM CHECK LIST FOR ANTENATAL OR POST-NATAL HOME VISITS:

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

Please note:

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

Please ensure if the patient is compliant to the medication or injections being

prescribed

Assessed by:

Name: ………………………………………………….. Signature: …………………………………………….. Date: ………………………

Health Nurses should use this form to assess patients during home visits: after Antenatal or Postnatal Discharge

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

(Clexane/Tinzaparine/Hepa

rin)

Bahasa Malaysia version is available and can be downloaded from SGH O&G website

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Bahasa Malaysia version is available and can be downloaded from SGH O&G website

Sgh-og.tumblr.com