This document discusses strategies to reduce maternal mortality from venous thromboembolism (VTE) in Sarawak, Malaysia. Pulmonary embolism is a leading cause of maternal death in Malaysia and Sarawak. The document outlines a VTE risk assessment and management program for antenatal and postnatal patients. It provides a risk scoring system and recommends thromboprophylaxis for high-risk patients. LMWHs like enoxaparin and tinzaparin are preferred treatments but are porcine-derived, requiring discussion with Muslim patients. Unfractionated heparin and fondaparinux are alternatives but have limitations. The program aims to standardize VTE screening and protocols across health clinics and hospitals in Sar

1. Reducing Maternal Mortality
from Venous Thromboembolism
“ SARAWAK VTE RISK
MANAGEMENT”

2.  Introduction/Background
 Sarawak VTE prophylaxis strategies
 Options of drugs available
 Administrations problems
 Common error
 Early VTE detection.

4.  VTE (venous thromboembolism) includes
1. 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

5. Pulmonary embolism is
the main cause of
maternal mortality in
Malaysia and
Sarawak

8. “Thromboembolism remains a
significant but preventable cause of
maternal death”

10. “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”

11.  Prevention of DVT or PE
1. 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

12.  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.

13. 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

14.  This assessment should be performed :
-During antenatal period
-During each hospital admission
-Post delivery
 Using Standard form (Sarawak
thromboprophylaxis risk assessment form)

15.  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

16. 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
1
delivery but excluding ERPOC & minor T&S*)
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

18.  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
 Counselling to be given to all pregnant women
 * Risk of VTE postnatal is higher (thus a lower score
needed to start thromboprophylaxis)

19. 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

20. VTE Risk assessment on discharge ( postnatal)
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)

22. 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

23.  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

24.  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)

25.  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

27. Self injection after
discharge
Porcine Based drugs
(Clexane and Tinzaparin)

28.  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)

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

32.  Muzakarah Jawatankuasa Fatwa Majlis Kebangsaan
Bagi Hal Ehwal Ugama Islam Malaysia Kali Ke-87
yang bersidang pada 23 – 25 Jun 2009 telah
membincangkan HukumPenggunaan Ubat Clexane
Dan Fraxiparine. Muzakarah telah memutuskan
bahawa:
 Islam menegah penggunaan ubat dari sumber yang
haram bagi mengubati sesuatu penyakit, kecuali
dalam keadaan di mana tiada ubat dari sumber yang
halal ditemui dan bagi menghindari kemudharatan
mengikut kadar yang diperlukan sahaja sehingga ubat
dari sumber yang halal ditemui.

33.  Oleh itu, berhubung dengan penggunaan ubat
Clexane dan Fraxiparine yang dianggap darurat
kepada para pesakit bagi mencegah formulasi
pembekuan darah secara serta merta ketika
pesakit berada pada tahap kronik, Muzakarah
memutuskan bahawa penggunaan kedua-dua
jenis ubat ini adalah ditegah kerana ia dihasilkan
dari sumber yang diharamkan oleh Islam,
memandangkan pada masa ini telah terdapat
alternatif ubat iaitu Arixtra (Fondaparinux) yang
dihasilkan daripada sumber halal dan
mempunyai fungsi serta keberkesanan yang
sama dengan Clexane dan Fraxiparine.

34.  But……Fondaparinux in Pregnancy
 Not enough data on efficacy and safety
 No antidote
………………??? Alternative to
clexane/tinzaparine/fraxiparine in obstetrics
patients.

35.  Options
1. 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)

36. 1. Patient on LMWH (Clexane/Tinzaparine) who
are not keen for self injection.
2. Patient on Unfractionated
heparin ( refused porcine
based LMWH)

37. Kuching Sibu Miri Bintulu
KK Jalan Masjid
Klinik 1M Bintawa
Klinik 1M Pantai
Damai
Klinik 1M Tabuan
Klinik 1M Malihah
KK Lanang
Klinik 1M Teku
Klinik 1M Sungai Bidut
Klinik 1M Taman
Rejang
Klinik 1M Soon-Hup
Permai
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)

38.  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.

39.  The correct dose of unfractionated heparin is
……..
5000 unit B.D
Subcutaneously

40.  Heparin are given intra-mascularly instead of
subcutaneously.
Overdose !!!!!...........few patient are
wrongly given up to 25,000 unit b.d

42.  Did not read the heparin
concentration properly
 1 vial = 5 ml
5000 unit = 1 ml
Only 1 ml is
needed

44. 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 VTE
5. Patient information leaflet on heparin

45.  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

47. 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

48.  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)

50. Bahasa Malaysia version is available and can be
downloaded from SGH O&G website
Sgh-og.tumblr.com

51. Bahasa Malaysia version is available and can be
downloaded from SGH O&G website
Sgh-og.tumblr.com