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Prevention of Venous Thrombo-Embolism

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Prevention of Venous Thrombo-Embolism

Published in: Health & Medicine

Prevention of Venous Thrombo-Embolism

  1. 1. PREVENTION OF VTE IN OBSTETRIC POPULATION BY Dr Kanddy Loo O&G Updates 1/11/14 O&G department Miri hospital
  2. 2. CASE SCENARIO • 40 year-old P6, post emergency caesarean section for acute fetal distress D 6 • Had BMI of 40 • Presented with acute onset of SOB and chest pain • Denied calf swelling • Otherwise, no known medical illness; normotensive antenatally and intrapartumly • Examination showed tachycardia and tachypnoea; with saturation under room air of 80%; normotensive • Lungs examination was unremarkable
  3. 3. PROBABLE DIAGNOSIS…..
  4. 4. INTRODUCTION • Pulmonary embolism remains the leading direct cause of maternal death • Most of the patients who died from PE have identifiable risks • 70% of women who died from PE in UK between 2003-2005 had identifiable risk • Thromboprophylaxis antenatally and postnatally – estimated to reduce risk of VTE in obstetric patients by up to 2/3 • Objective of this lecture • Introduction of state VTE prevention programme • Risk stratification of patient according to VTE score to identify patients for thromboprophylaxis • Antenatal VTE occur in the first trimester • Therefore assessment and prophylaxis, if indicated should be given as early as possible in pregnancy
  5. 5. MATERNAL MORTALITY - UK CEMACH 2003-2005 CEMACH 2006-2008
  6. 6. MATERNAL MORTALITY - MALAYSIA
  7. 7. PATHOPHYSIOLOGY • Incidence of VTE in pregnancy – 60/100000 woman-years • 12 fold increase compared to non pregnant population • Virchow’s Triad
  8. 8. SARAWAK VTE PREVENTION PROGRAMME • Introduced on 1 July 2013 • To be implemented over Sarawak state • Initially hospital based • Expanded to primary health care centre on Mac 2014 • Obstetric patients are assessed based on modified VTE scoring system • Done as early in pregnancy as possible • Repeat assessment if there’s emergence of new risk factors/during hospitalisation • Start thromboprophylaxis if • VTE score 3 or more antenatally and continue postnatally for 6 weeks • VTE score 2 or more postnatally – for at least 1 week • Patient with additional persistent risk factor (lasting more then 1/52 postnatal) should thromboprophylaxis should be extended for up to 6 weeks or longer
  9. 9. VERY HIGH VTE RISK • Needs antenatal high-dose thromboprophylaxis (high prophylactic – 12 hourly or 75% of treatment dose) antenatally and postnatally 6 weeks • Very high risk factors • Recurrent VTE associated with APS • Patient on long term anticoagulation • Antithrombin deficiency
  10. 10. HIGH RISK • Thromboprophylaxis antenatally and 6 weeks postnatally • Risk factors • Previous unprovoked, estrogen related (pregnancy/pills induced), recurrent VTE • Previous VTE with risk factors (family history of VTE, thrombophyilia or other risk factors • Asymptomatic thrombophilia (combine defects, homozygous Factor V Leiden) • Combination of 3 or more risk factors
  11. 11. INTERMEDIATE RISK • Postnatal 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 factors • Presence of 2 or more risk factors
  12. 12. THROMBOPHILIA SCREENING • Only done for those VTE provoked by minor risk factors • Antenatal thromboprophylaxis till postnatal 6/52 • Previous VTE with thromphilia • Asymptomatic thrombophilia with other risk factors • Asymptomatic thrombophilia • Combine defects • Homozygous Factor V Leiden • Postnatal thrombophylaxis • Other asymptomatic thrombophilia without other risk factors
  13. 13. ANTI COAGULANT AGENTS • Low molecular weight heparin • Agents of choice • As effective as and safer then the unfractionated heparin • Lower risk of Heparin induced thrombocytopaenia and osteoporosis • Risk of bleeding - <2% with prophylactic dose • Monitoring of anti-Xa levers is not required if women have normal renal function • Unfractionated Heparin • Shorter half life • More complete reversal of its activity • May be used around the time of delivery in women with very high risk of thrombosis
  14. 14. • Fondaparinox • Licenced for prevention and treatment of VTE outside pregnancy • Similar efficacy to LMWH • Limited experience in pregnancy • Although no adverse effects were observed in newborns, it is premature to conclude its safety in pregnancy • Reserved for women intolerance to heparin • Local setting – used in postnatal thrombophylaxis • Warfarin • Associated with warfarin embriopathy • 5% risk when exposed between 6 – 12 weeks • For patient with mechanical heart valve • Can be used postnatally – 5 – 7 days post delivery • Safe in breastfeeding • Other anti coagulant – avoided in pregnancy • Graduated elastic compression stocking
  15. 15. CONTRAINDICATION TO THROMBOPROPHYLAXIS • Antenatal or postpartum bleeding • Massive PPH – risk factor for VTE; therefore risk and benefits of thromboprophylaxis should be weighted • Increased risk of major haemorrhage • Bleeding diathesis, including thrombocytopaenia • Platelet less than 75 x 109 • Acute stroke in last 4 weeks • Severe renal disease • Severe liver disease • Uncontrolled hypertension (SBP>200mmHg; DBP>120mmHg)
  16. 16. ANAESTHESIA • Regional techniques should not be used at least 12 hours after previous prophylactic dose of LMWH • 24 hours after last dose of therapeutic dose • 4 hours after last dose of unfractionated heparin • LMWH should not be given for 4 hours after regional anaesthesia or after removal of epidural catheter • Epidural catheter should not be removed within 10 – 12 hours of the last dose
  17. 17. QUIZ – SCENARIO 1 • 40 year-old; primigravida; subfertility for 20 years • BMI 32 • Currently at 10 weeks…..
  18. 18. • At 12 weeks, she was admitted with hyperemesis gravidarum…. • At 30 weeks, she was again admitted and treated as acute appendicitis; appendicectomy was done
  19. 19. • At 38 weeks, she has EMLSCS for fetal compromise; complicated with massive PPH and had massive transfusion….
  20. 20. QUIZ – SCENARIO 2 • 30 year-old G2P1 at 8 weeks; came for booking • Previous history of postpartum DVT; completed warfarin treatment for 6 months • Currently well, no leg swelling • BM1 25
  21. 21. • At 36 weeks, she presented with SROM with TMSL and os was only 1 cm…. • Postnatally….
  22. 22. THANK YOU

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