Sarawak VTE Risk Assessment - UPDATE - 2 nd July 2015 Introduction - - PowerPoint PPT Presentation

Sarawak VTE Risk Assessment

• UPDATE -

2nd July 2015

• PE is still the leading direct cause of maternal death in Malaysia
• PE specific MMR decreased from 1.56 (2003-2005) to 0.70 (2006-2008) per

100,000 maternities with the introduction of VTE guidelines – UK CEMD report

• Scandinavian study – 88% reduction in RR in obstetric pt with previous VTE given

LMWH

• 79-89% of women died of PE in UK has identifiable risk factors
• Maternal deaths from PE in the state has decreased since the introduction of the

VTE risk assessment in mid 2013

• Maternal deaths from VTE has dropped from an average 3 per year (preceding 5

years) to about 1 per year since 2013.

In Introduction - VTE in pregnancy

CPG on VTE

• Published in August 2013
• “All women should be assessed at

booking and after delivery or if they are admitted to the hospital for any reason or develops other problems”

• “All should be stratified into risk

groups according to risk factors and

• ffered prophylaxis with LMWH where

appropriate”

GREEN TOP GUIDELINE NO. 37a

• Reducing the risk of venous

thromboembolism during pregnancy and the puerperium - April 2015

• Generally, more aggressive with

longer duration of VTE prophylaxis and new risk factors

Do we need to foll llow the recommended changes?

• Clinical evidence that suggest longer duration of VTE prophylaxis is needed
• There are new VTE risk factors that needed to be included
• UK maternal deaths from VTE in subsequent years have not decreased as

much as initially seen in the 2006-2008 triennial report (MBRRACE – UK 2014)

• The updated guideline should not be too difficult to understand & follow
• Cost implications? Compliance? Inconvenience to patients?
• A compromise is needed if it’s to be implemented in Sarawak

WE SHOULD!

Year

• No. of maternal deaths

from VTE VTE deaths/ 100,000 maternities

2003-2005 41 1.9 2006-2008 18 0.76 2009-2011 30 1.2 2010-2012 26 1.08

MBRRACE-UK 2014

• VTE specific maternal mortality rate (MMR) for 2009-2011 & 2010-2012 are higher than

2006-2008 period

• No statistical difference between the MMR for 2006-2008 (0.76) and 2010-2012 (1.08)
• Highest VTE specific MMR was 2.18 (1994-1996)
• Full report on VTE is expected to be published end of 2015

• Many antenatal PE occur in 1st trimester
• Risk for VTE increases with gestational age, reaching a

maximum just after delivery

• RR in the postpartum is 5-fold higher compared to antepartum
• Absolute risk peaked in first 3/52 postpartum (22 fold

increase)

• Admission to hospital:

 18-fold increased risk, and risk remains after discharge  6-fold higher in the 28-days period after discharge  < 3 days – 4 fold increase  ≥ 3 days – 12 fold higher risk

Cli linical Evidence

• In the Green Top guideline: Emergency LSCS is a score of 2, while

elective LSCS is given a score of 1

• If heparin was used, the platelet count should be monitored every 2-3

days from day 4-14 or until heparin is stopped - Green Top Guideline 37a

• In the NEW Sarawak VTE assessment form: both elective & emergency

LSCS will be given a score of 2. This is to ensure that mothers who had undergone a surgical procedure receive at least 10 days of prophylaxis.

• In the NEW Sarawak VTE guideline: if heparin is used, platelet level

should be checked once between day 5-8 but if the mother is on long term heparin, platelet should be subsequently checked once every 2 weeks.

New Recommendations :

• LMWH is the preferred choice for VTE prophylaxis
• Admission for hyperemesis gravidarum, OHSS or surgery are given a score
• f 4 each in the NEW Sarawak VTE risk assessment form.
• In hyperemesis & OHSS: VTE prophylaxis should be given until the relief
• f symptoms
• The following new risk factors have a score of 1 each;

 IVF pregnancy (1st trimester)  Dehydration or immobility of > 3 days  Preterm labour in current pregnancy (< 37 weeks)  Blood transfusion

New Recommendations

• Documented VTE risk assessment in pregnancy for all women:

 @ PPC clinic (many antenatal PE occurs in the 1st trimester)  @ early pregnancy - booking  @ every hospital admissions to any department or when new risk factors emerge  @ immediate postpartum

When to screen for VTE TE?

If VTE assessment has been carried out less than 6 before she conceived, a repeat VTE assessment at antenatal booking would not be necessary

Sarawak VTE Risk Assessment Form (2013 version)

Sarawak VTE Risk Assessment Form – July 2015

Previous VTE (except a single event related to major surgery) 4

High Risk Factors for VTE

Other high risk VTE score Score Hyperemesis gravidarum / OHSS (1st trimester)

4 (transient) Surgery in pregnancy or puerperium (exclude ERPOC , T&S) 4 (transient)

Previous VTE provoked by major surgery

3

Known high risk thrombophilia

3

Current IVDU (previously score of 1)

3

Medical comorbidities, eg: cancer, heart failure, active SLE, inflammatory poly-arthropathy, inflammatory bowel disease, nephrotic syndrome, type 1 DM with nephropathy

3

Parity ≥ 3 (previously Para > 5) 1 IVF pregnancy (1st trimester only) 1 Gross varicose veins (above knee/symptomatic/phlebitis) 1 Elective & emergency caesarean section (still the same score in 2015) 2 Infection (e.g. active TB or any infection requiring IV antibiotics) 1 Long travel by road or air > 4 hours non stop (previously > 8 hours) 1 Chorioamnionitis or endometritis 1 Mid cavity / rotational instrumental delivery (previously – instrumental delivery) 1 Stillbirth in current pregnancy (new) 1 Preterm labour < 37 weeks POA in current pregnancy 1 Haemorrhage > 1.5L or requiring blood transfusion 1

Oth ther Changes fr from previous VTE Risk Assessment form:

Current systemic infection 1 Hyperemesis gravidarum 4 OHSS (1st Trimester only) 4 IVF pregnancy (1st Trimester only) 1 Admission or immobility (≥ 3 days) 1 Long-distance travel 1

Transient Risk Factors

• Duration of prophylaxis being planned should take into account if the risk factors are

transient

• A patient who has been admitted > 3 days and has at least another risk factor (total

score of 2), should receive at least 10 days prophylaxis upon discharge due to the 12x increase in risk

• ANTENATAL – score > 4 (other than for previous VTE or thrombophilia), may

consider VTE prophylaxis with LMWH from 1st trimester and up to 6/52 postnatal

• ANTENATAL – score 3 (other than for previous VTE or thrombophilia), consider VTE

prophylaxis with LMWH from 28 weeks and up to 6/52 postnatal

• POSTNATAL – score > 2 (other than for previous VTE or thrombophilia), consider

VTE prophylaxis for at least 10 days

Green Top Guid ideline 37a:

 The duration of VTE prophylaxis based on antenatal score is recommended to continue until up to 6/52 postnatal irrespective of the postnatal VTE score  In the 2015 Sarawak VTE Risk assessment Form: the duration of prophylaxis required in the postnatal period is based on the postnatal VTE score and not the antenatal score as recommended by the Green Top guideline 37a

2015 Sarawak VTE Guideline:

• ANTENATAL – score > 4 (other than for previous VTE or thrombophilia), may

consider VTE prophylaxis with LMWH from 1st trimester till onset of labour

• ANTENATAL – score 3 (other than for previous VTE or thrombophilia), consider

VTE prophylaxis with LMWH from 28 weeks till onset of labour

• POSTNATAL – score > 2 (other than for previous VTE or thrombophilia), consider

VTE prophylaxis for at least 10 days Postnatal VTE score will decide the duration of the postnatal prophylaxis required

Proposed duration of postnatal prophylaxis for 2015 Sarawak VTE Guideline:

Postnatal Score Duration of thromboprophylaxis 2 10 days 3 up to 14 days 4 or more up to 21 days

NOTE:

• Intra-partum events: e.g. PPH, blood transfusion, rotational instrumental

delivery, caesarean section are significant only for the first 10 days

• If the postnatal score is > 4: The specialist should decide the appropriate

duration of postnatal prophylaxis

How to remember? (Score – 1) = weeks

HIGH RISK FACTORS requiring longer postnatal prophylaxis:

• No. Antenatal High Risk Factors:

Duration of postnatal VTE prophylaxis

1 Previous VTE episode 6 weeks 2 Known history of thrombophilia 3 Medical Comorbidities 4 Current IVDU

Postnatal mothers with any of the above High Risk factors should be given 6 weeks

• f prophylaxis

Past history of IVDU – should be scored of 1, as in previous VTE assessment form

Unfractionated Heparin: monitoring

• Cheaper but higher manpower cost!
• BD dose – not convenient
• Need to monitor platelet level if heparin is used – suggest to check
• nce between day 5-8 if heparin is used for 10 -14 days only
• If longer heparin prophylaxis is needed – subsequent fortnightly FBC

test to check platelet levels would be reasonable

• If platelet level falls below 150K: consult a FMS or O&G specialist
• Consider stopping heparin and switching to an alternative drug
• If the decision is to continue on heparin then monitoring every 2-3

days would be required

• Patients who are low risk (score < 2) are advised for:

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 anti-embolism stocking

• Counseling should be given to all pregnant women….as

most do not know their thombophilia status

What about those at LOW RISK OF VTE??

• Counseling play an important role (consider further counseling by

FMS or O&G specialist)

• Doctors in health centers without specialists - consult an O&G

specialist or buddy specialist

• Upon failure to convince the patient;
• 1. Use appropriate compression stockings
• 2. Advise on ambulation, avoidance of dehydration & to seek

early treatment if feeling unwell

• 3. Teach patients to identify signs & symptoms of DVT & PE
• 4. Ensure ‘home visits’ by community midwife

?

VTE Risk k Assessment essment Flowchar hart t - 2013 13

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

Antenatal assessment

Score < 3 SCORE 3 Score > 4

< 28 WKS >28 WKS

Counselling on ambulation, avoid dehydration, +/- compression stocking Reassess risk if requires prolonged admission or develops new problems Non specialist hospital Specialist hospital Code yellow Counsel patient appropriately Initiate VTE prophylaxis (consult O&G specialist if unsure) Patient to learn how to self administer LMWH SC Heparin only to be given by healthcare personnel Shared care between MO/FMS/Specialist Trace patient if she defaulted follow-up Code yellow Counsel patient appropriately Initiate VTE prophylaxis – LMWH preferred Patient to learn how to self administer LMWH SC Heparin only to be given by healthcare personnel Document antenatal follow -up plan Shared care – Doctors at health clinics & specialist ANC

MANAGEMENT FLOWCHART - 2015

Post delivery VTE Risk Assessment - 2015

Provide general advice on DVT/PE prevention

Score < 2 Score > 2

Give patient information leaflet Advice on ambulation, adequate fluid intake Seek immediate treatment if symptomatic Refer to hospital if develops new problems/complications Home visit (look for symptoms’ of DVT/PE )

Non specialist hospital Specialist hospital

SCORE 2: VTE prophylaxis at least 10 days SCORE 3: VTE prophylaxis up to 2 weeks SCORE > 4: VTE prophylaxis up to 3 weeks (discuss with specialist) High Risk group: prophylaxis up to 6 weeks (discuss with specialist) E-Discharge Notifications (home visits compulsory) If on SC heparin – check platelet level once between day 5-8. If below 150K then consult O&G specialist. SCORE 2: VTE prophylaxis at least 10 days SCORE 3: VTE prophylaxis up to 2 weeks SCORE > 4: VTE prophylaxis up to 3 weeks (specialist decision) High Risk group: prophylaxis up to 6 weeks (specialist decision) E-Discharge Notifications (home visits compulsory) If on SC heparin – check platelet level once between day 5-8. If below 150K then get specialist opinion.

Antenatal Booking

Risk Factors >3

Health education on VTE in pregnancy Manage as per routine

To MO/FMS in the same clinic or refer to nearest clinic with MO/FMS

• Code: YELLOW. Counsel patient on VTE, her risk and treatment modalities
• If score is 3: start VTE prophylaxis from 28/52 POA
• If score is > 4: start from the first trimester
• VTE prophylaxis can be started in a hospital or selected health clinics
• Arrange for VTE drugs to be supplied from health clinics closest to where she lives
• If uncertain consult FMS or O&G specialist

NO YES

VTE Risk assessment @ Health Clinics

• By any nurse
• By any MO/FMS
• By any nurse

Refer

@ PPC Clinic

Risk Factors >3

NO YES

VTE Risk assessment @ Health Clinics

• By any MO/FMS
• By any MO/FMS

Counsel her about her VTE risk when she conceive Try to reduce modifiable risk factors e.g. smoking, obesity etc Advice early booking when she conceive Inform her about her VTE score and what it means in terms

• f timing of prophylaxis

Document & provide letter stating her VTE risk score Health education about VTE Inform her about her low VTE risk but it may change during pregnancy

No. Year: State MMR (per 100, 000 live births) National MMR (per 100,000 live births) 1 2008 30.8 27-30 2 2009 26.0 27-30 3 2010 21.3 27-29 4 2011 17.7 27-29 5 2012 26.6 26-29 6 2013 9.2 26-29 7 2014 16 26-29 8 2015 ?

Case scenario 1:

• 35 years old G4P3 @ 12 weeks + 4 days with a BMI of 25, presented with

hyperemesis gravidarum to a clinic. She was dehydrated and her urine ketone was 4+. An ultrasound showed a singleton pregnancy that corresponds to her

• date. This is an IVF pregnancy and she had booked 2 weeks ago at a KK.
• 1. What’s her VTE score @ booking?
• 2. Did she require VTE prophylaxis then?
• 3. What’s her VTE score when she presented to the clinic with hyperemesis?
• 4. What should the clinic staff do?
• 5. What treatment should be given at the KK?

Answer to case scenario 1:

• 1. Her score was 3 @ booking, for age, parity and IVF pregnancy
• 2. No. IVF pregnancy is a transient factor. After 13 weeks, her score would be 2

and she does not need prophylaxis

• 3. Score = 8 – hyperemesis (4), dehydration (1), others (3)
• 4. Transfer the patient to a hospital. Nurse should refer to MO/FMS in clinic b4

transferring to the hospital. If no MO in the clinic, nurse should transfer to the hospital.

• 5. The patient is dehydrated and is unable to tolerate fluids. Set IV line and give

fluids (saline) before transfer. If transfer is expected to take longer than 4 hours, consider giving first dose of VTE prophylaxis. Please check for signs & symptoms

• f DVT.

Case scenario 1- continuation

• The patient has been admitted to a district hospital. She improved after 4 days

and was able to tolerate moderate amount of fluids. She was given daily tinzaparin injections during her admission. Her urine ketone was negative and she was discharged with anti-emetics plus another 7 days of tinzaprin. She was given a 2 week appointment to be seen in the clinic.

• 1. What was her score on discharge?
• 2. Was the duration of prophylaxis adequate?
• 3. Does she need long term antenatal prophylaxis?
• 4. What else should the doctor managing her do?

Answer to case scenario 1:

1. Score 3: For age, parity and admission > 3days. IVF pregnancy is no longer a factor after 13 weeks. Dehydration has resolved and hyperemesis has improved enough to be discharged. 2. No! So she needs an additional 10 days of tinzaparin after discharge as she was already given 4 days in the ward. 3. No, her antenatal score is only 2 once her hyperemesis is resolved. Admission & IVF pregnancy are transient factors only. 4. High Risk E-Discharge – ensure home visits while she is on the prophylaxis is

• done. Counselling should be done. Clinic review should be in 1 week.

Case scenario 2:

• 25 year old G5P4 @ 28 weeks presented to MCHC for routine f/up. Booking was

done @ 14 weeks. She had a history heart disease but was well with NYHA class 1 but over the last month complained of SOB on mild exertions and needed to sleep with 2 pillows. She also gave a history of smoking but stopped when she got

• pregnant. The ultrasound showed a twin pregnancy which correspond to dates.
• 1. What was her VTE score at booking?
• 2. Should she be given VTE prophylaxis then?
• 3. What was her score at 28 weeks?
• 4. How long should she be given VTE prophylaxis?
• 5. What should the doctor do?

Answer case scenario 2:

1. Score 3, if twin pregnancy was diagnosed at booking. Parity, smoking & twin

• pregnancy. Only heart failure or severe heart disease is a risk factor.

2. No, as an antenatal score of 3 should only be given prophylaxis from 28 weeks POA 3. Score of 6, as her heart disease has worsened and now likely to have heart failure 4. She would need prophylaxis throughout her pregnancy and another 6 weeks

• postnatal. Medical comorbidities is considered High Risk.

Case scenario 3:

• A 33 year old G3P2 @ 35 weeks presented to a district hospital with uterine

contractions and gave a history of PPROM a day earlier. She had a fever of 38 degrees and os was already 6cm dilated. Her booking BMI was 32. She was given IV antibiotics & delivered 3 hours later. She developed PPH due to atony. Her EBL was 600mls but she was transfused with 1 pint of blood because her haemoglobin was 7mg/dl. She was discharged well with her baby 1 day later.

• 1. What was her VTE score on admission?
• 2. Does she need antenatal VTE prophylaxis on admission?
• 3. What was her postnatal VTE score?
• 4. Does she need VTE prophylaxis post delivery?
• 5. How long should she be given prophylaxis on discharge?
• 6. What else needed to be done on discharge?

Answer case scenario 3:

• 1. Score 3 for chrioamnionitis, BMI and preterm labour
• 2. She should not be given prophylaxis on admission as she was in labour
• 3. Postnatal score was 5 (Chorioamnionitis & IV antibiotics should be combined as

a score of 1, plus Parity, preterm labour, BMI and blood transfusion)

• 4. Yes, she should be given VTE prophylaxis post delivery in the ward
• 5. She need up to 3 weeks of postnatal VTE prophylaxis
• 6. Appropriate counselling on VTE and High Risk E-Discharge. Ensure postnatal

home visits are made.

Tha hank nk yo you! u!