1) Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant cause of maternal mortality in Malaysia, accounting for 101 deaths from 2008-2014. 2) Pregnancy increases the risk of VTE 4 to 6-fold, and the risk is even higher in the postpartum period. In Sarawak, 15 maternal deaths were attributed to VTE from 2008-2012. 3) To address this issue, Sarawak implemented an obstetric VTE screening and risk assessment program in 2013 to identify at-risk women and provide appropriate thromboprophylaxis like low molecular weight heparin. The goal is

1. Prevention and Treatment of VTE in
pregnancy & the puerperium
Dr. Harris N Suharjono FRCOG
Sarawak O&G Update, 6th May 2017

2. “There were 101 maternal deaths from pulmonary embolism in
Malaysia from 2008 - 2014”
Family Health Division, MOH
Impact in Malaysia?

3. Number of maternal deaths due VTE and specific MMR per 100,000 live births
in Malaysia, 2005 -2014
Year 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Number of maternal
deaths due to
pulmonary embolism
14 9 7 23 12 15 10 13 13 15
specific MMR per
100,000 live births
3.0 1.9 1.5 4.7 2.4 3.1 2.0 2.5 2.6 2.8
Family Health Division, MOH Malaysia
MBRRACE Report 2015
Year
No. of Maternal
Deaths from VTE
VTE Specific Deaths/
100,000 Maternities
2003 – 2005 41 1.9
2006 – 2008 18 0.76
2009 – 2011 30 1.2
2010 - 2012 26 1.08

4. What Does the Evidence Say?
 Pregnancy is an independent VTE risk factor
 Relative risk of VTE in pregnancy is increased 4 - 6 fold and
is even higher in the postnatal period1
 The RR in the postpartum period is 5x higher compared to
antepartum2
 50% of postnatal maternal deaths from VTE in the UK between
2009 - 2013 had caesarean sections3
1. Sultan AA, West J, Tata LJ, Fleming KM, Nelson-Piercy C, Grainge MJ. Risk of first venous thromboembolism in and around pregnancy: a population-
based cohort study. Br J Haematol 2012
2. Heit JA, Kobbervig CE. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Ann
Intern Med 2005
3. Knight M; UKOSS. Antenatal pulmonary embolism: risk factors, management and outcomes. BJOG 2008

5. Why Screen?
The large percentage of women at risk of VTE are identifiable, thus such events
should be largely preventable if these group of women are appropriately
managed with thromboprophylaxis
71% have at least 2 risk factors
MBRRACE 2015 report (2009 - 2013)
Risk Factors Percentage (%)
0 17
1 12
2 21
3 28
4 12
5 10

6. • LMWHs are more effective 1
• UFH is associated with the inconvenience of BD dosing,
regular monitoring, risk of HITT, osteoporosis and is not
recommended for women less than 50 kg or above 90Kg 1
• Fondaparinux is not recommended in pregnancy, it is reserved
for women intolerant to heparin. There is no antidote and it
has a longer half life 2
• Warfarin is not recommended for use in pregnancy 3
1. RCOG. Greentop Guideline No. 37B. The acute management of thrombosis and embolism during pregnancy and the
puerperium, 2007
2. Demfle CE. Minor transplacental passage of fondaprinux in vivo. N Engl J Med 2004; 50(18)
3. Gillis A, Shushan A, Eldor A. Use of low molecular weight heparin for prophylaxis and treatment of thromboembolism in
pregnancy. Int J Gynecol Obstet 1992;39:297301
Anticoagulant of choice?

7. Clinical guidelines on VTE in pregnancy
Several clinical guidelines are available

8.  Based on the 2012 Green Top
Guidelines 37a
 Printed in late 2015
Training Manual (2014)
Prevention & Treatment of Thromboembolism in Pregnancy & Puerperium
Being updated :
2017 edition should be published soon

9. Haematology Lead Initiative:
• The prevalence of VTE is approaching 100
per 100,000 hospitalized patients, figures
similar to the West.
• The cost of treating one patient with DVT
or PE is estimated between RM 5,000 –
10,000
• The cost of postnatal thromboprophylaxis
with LMWH for 10 days is estimated at
RM 165

10. Obstetric VTE program in Sarawak
 2.7 million population, 42,000 deliveries per annum
 15 maternal deaths attributed to VTE were recorded in the
2008-2012 period 1
 In 2012, there were 4 maternal deaths attributed to VTE,
making it the commonest direct cause! 1
1. Sarawak state CEMD data
Peninsula Malaysia: 50,810 square miles
Sarawak: 48,050 square miles

11. Sarawak Obstetric VTE Risk Assessment Program
March 2013:
• Documented VTE risk assessment of all antenatal & postnatal
women admitted to any wards in MOH hospitals in the state
March 2014
• VTE risk assessment @ antenatal booking for women
attending all MOH health clinics in the state
July 2015
• The program was revised to take into consideration the
recommendations made in the Green-top Guideline 37a, 2015
January 2017
• The program was updated – in line with the 2017 National
Training Manual for VTE in Pregnancy & the Puerperium

12. The Sarawak VTE in pregnancy Screening Program
Documented obstetric VTE risk assessment in ALL MOH health
facilities in the state:
1. @ Antenatal booking
2. During hospital admissions or when new risk factors emerge
3. @ Immediate postpartum

13. No. VTE risk factor Odds Ratio (OR)
1 Age > 35 1.3
2 Parity > 3 2.4
3 Smoking < 10/day 2.1
4 Preterm delivery < 37 weeks 1.7
5 Twins 2.6
6 Varicose veins 2.4
VTE risk factors with OR < 3 being excluded from the
2015 VTE risk assessment form

14. VTE Risk factors VTE
Score
Pre-
pregnancy/
Booking
Admission
1
Admission
2
Post
delivery
Date
Pre-existing Risk Factors
Previous VTE 4
High risk thrombophilia (anti thrombin,
protein C, protein S deficiency)
3
Medical comorbidities
(malignancies, cardiac failure, active
SLE, IVDU/ TB, nephrotic syndrome,
DM with nephropathy, thalassemia
major or intermedia post splenectomy)
3
Obesity
- BMI  40kg/m2
- BMI 30-39 kg/m2
2
1
Family history of VTE 1
Low risk thrombophilia (Factor V
Leiden, High FVIII)
1
Current smoker ( 10 /day) 1
Obstetric Risk Factors
All caesarean sections 2
Pre-eclampsia 1
IVF ( 1st trimester only) 1
Mid cavity/ Rotational instrumental
delivery
1
PPH (  1000mls) or require blood
transfusion
1
Stillbirth (current) 1
Prolonged labour (> 24 hours) 1
Transient Risk Factors
Surgical procedures (excluding
episiotomy, 1st & 2nd degree perineal
repair and ERPOC)
4*
Hyperemesis gravidarum/ OHSS 4*
Systemic infection/ infection requiring
IV antibiotics
1
Immobility/ dehydration 1
Admission beyond 3 days 1
Non-stop long distance travel (> 4Hrs) 1
Total score
Name & stamp
VTE Risk Assessment in Pregnancy and
Puerperium - 2017:
• All antenatal and postnatal mothers
have to be counseled on the risk of VTE
irrespective of her risks
• Only 70% of women who had VTE
episodes in pregnancy and the
puerperium period have identifiable risk
factors

15. Booking
VTE Risk Assessment
Very High Risk
(previous VTE)
High Risk
Score > 4
Intermediate Risk
Score 3
Low Risk
Score < 3
Refer
O&G spec/FMS
Refer
O&G spec/FMS
Refer
O&G spec/FMS
GENERAL ADVICE
ANTI EMBOLIC
STOCKINGS
AVOID
DEHYDRATION
BE PHYSICALLY
ACTIVE
Start VTE
prophylaxis as
soon as
possible
Start VTE
prophylaxis as
soon as
possible
Start VTE
prophylaxis from
28 weeks POA
ANTENATAL
POSTNATAL
Continue for
6/52
Continue for
3/52
Reassess by O&G spec to decide
giving another 3/52
Continue for
3/52 Postnatal
VTE Risk
Assessment
VTE Risk Assessment
Flowchart in clinics

16. Postnatal
VTE Risk
Assessment
Score > 2 Score 2 Score < 2
Consider
10 days VTE
prophylaxis but may
require longer
(O&G Spec to decide)
Consider
10 days VTE
prophylaxis
GENERAL ADVICE
ANTI EMBOLIC
STOCKINGS
AVOID DEHYDRATION
BE PHYSICALLY ACTIVE
Note: General counseling on VTE need to be given to all during the
pregnancy and the puerperium

17. The 2017 Sarawak Obstetric VTE program:
2 Main Focus
1. Ensuring universal screening or risk scoring
are carried out as recommended
2. Ensuring all antenatal and postnatal women
would be appropriately counselled on the
higher risk of VTE during pregnancy and in
the puerperium period irrespective of their
VTE risk

18. No. Year: S’wak State MMR (per
100, 000 live births)
National MMR (per
100,000 live births)
1 2007 29.6 29.0
2 2008 30.8 28.0
3 2009 26.0 27.0
4 2010 21.3 26.1
5 2011 17.7 26.2
6 2012 26.6 25.6
7 2013 9.3 25.2
8 2014 16.0 25.5
9 2015 16.2 25.0
10 2016 7.5 24.0 (est)

19. WHO’s Sustainable Development Goals
Goal 3:
Ending Preventable Maternal
Death by 2030
Maternal deaths from VTE is
preventable

20. Venous Thromboembolism (VTE)
 Deep Vein Thrombosis (DVT)
 Pulmonary Embolism (PE)

21. Pregnancy
Immobility &
stasis
LSCS /
Other
surgery

22. • 50% of all DVT cases are asymptomatic
• DVT signs & symptoms includes;
 Swelling in one or both legs
 Pain or tenderness in one or both legs
 Warmth in the skin of the affected leg
 Red or discoloured skin in the affected leg
 Leg fatigue
DEEP VEIN THROMBOSIS (DVT)

23. Diagnosis of DVT
 Clinical diagnosis of VTE – not sensitive enough
 Definitive diagnosis should be obtained urgently - USS
doppler of the ilio-femoral and popliteal vessels
 All clinically suspected VTE should have diagnostic
testing to confirm or refute the diagnosis.

24. DVT OF THE LOWER LIMB

25. Management of DVT
 All suspected cases of DVT should have treatment started
upon clinical suspicion ASAP
 Objective confirmation of DVT can await until modality and
its expertise becomes available
 Inform O&G specialist/ FMS
 Arrange venous doppler study urgently
 Start anti-coagulation based on suspicion
 Continue anti-coagulation once confirmed

26. Pulmonary Embolism (PE)
 PE is a potentially life-threatening condition
 PE usually happens due to an underlying blood
clot in the leg (DVT) in over 90% of cases
 A massive pulmonary embolism carries up to 80%
risk of death

27. Signs & Symptoms of PE
• PE symptoms vary greatly, depending on how much of the
lungs are involved, size of the clot and overall health of
the patient
• Signs and symptoms include:
 Shortness of breath
 Chest pain.
 Cough. (bloody or blood-streaked sputum)
 Wheezing
 Clammy or bluish-coloured skin
 Rapid or irregular heartbeat

28. Diagnosing PE: ECG
 Tachycardia
 Right axis deviation
 Right bundle branch block
 S1Q3T3 - uncommon
• Changes in the ECG may be
transient and may also
revert to normal as the
patient gets better.

29. Diagnosis of PE
 D-dimer: if negative not likely PE (not useful)
 Pulmonary angiogram (CTPA)
 Ventilation-perfusion scan (V/Q scan) – not widely available

30.  Inform specialist stat
 Trigger RED alert if patient has collapsed
 Start on anti-coagulation based on suspicion
 Urgent CTPA to confirm
 ICU/HDU management
Management of suspected PE IN
Specialist Hospitals

31. Suspected DVT / PE in HEALTH clinics
 A MEDICAL URGENCY /EMERGENCY!
 Consult an O&G specialist from nearest specialist hospital
 Start anticoagulation ASAP based on SUSPICION!
 Immediate referral to nearest specialist hospital
 Ensure ambulance is equipped with vital sign monitor &
resuscitation equipment
 Need Medical Officer escort if suspected PE
 Arrange appropriate confirmatory test urgently – the O&G
team in the specialist hospital should arrange it

32. Treatment: Drug of choice
The treatment of choice for VTE in pregnancy is Low Molecular
Weight Heparin (LMWH)
• The following LMWH are recommended in pregnancy:
1. Enoxaparin
2. Tinzaparin

33. LOW MOLECULAR WEIGHT HEPARIN
 Platelet count monitoring is not required
 Anti-Xa level monitoring is not indicated unless weight is
< 50kg or > 90kg or the patient has mechanical heart
valves)
 The target level is 0.5 - 1.2
 Anti-coagulation dose:
 Enoxaparin: 1 mg/kg BD
 Tinzaparin: 175 IU/kg OD

34. Unfractionated heparin (UFH)
 Subcutaneous: 10,000 IU twice daily
 IV Infusion:
5000 IU stat bolus followed by 1000 IU/hour infusion
80 IU/kg IV stat followed by 18 IU/kg/hour infusion
 aPTT target 1.5 to 2.5
 Monitor platelet counts daily during IV treatment & weekly
during SC treatment
 Heparin-induced thrombocytopenia is rare

35. Duration of treatment
 Varies depending on the risk factors
 In pregnancy need to continue throughout pregnancy plus 6
weeks postpartum
 If VTE episode occurs within the 6 weeks postpartum
period, therapy should be extended to a minimum duration
of 3 months

36. Postpartum care - precautions
 Active management of the 3rd stage
 PPH prophylaxis should be instituted
Blood should be grouped and saved
IV access
40 units oxytocin infusion over 4-6 hours after delivery
of the placenta
 Therapeutic dose can be recommenced 4 hours
postpartum (also for operative delivery)
 LSCS- abdominal drain should be inserted
 Heparins and warfarin are safe for breastfeeding

37. Other considerations
 Bed rest and elevation of the affected limb
 Anti-embolic stockings (compression stockings)
 IVC filter may be needed in some cases of DVT

38. Post DVT limb syndrome
 60% of women develop this condition characterized by
chronic swelling and pain
 Wearing anti-embolic stockings for 2 years on the affected
limb reduces this by more than half