Sarawak VTE Risk Assessment - UPDATE - 2 nd July 2015
Introduction - VTE in pregnancy In • 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.
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 offered 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!
MBRRACE-UK 2014 Year No. of maternal deaths VTE deaths/ 100,000 from VTE maternities 2003-2005 41 1.9 2006-2008 18 0.76 2009-2011 30 1.2 2010-2012 26 1.08 • 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
Cli linical Evidence • Many antenatal PE occur in 1 st 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
New Recommendations : • 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 of 4 each in the NEW Sarawak VTE risk assessment form . • In hyperemesis & OHSS: VTE prophylaxis should be given until the relief of symptoms • The following new risk factors have a score of 1 each; IVF pregnancy (1 st trimester) Dehydration or immobility of > 3 days Preterm labour in current pregnancy (< 37 weeks) Blood transfusion
When to screen for VTE TE? • Documented VTE risk assessment in pregnancy for all women: @ PPC clinic (many antenatal PE occurs in the 1 st trimester) If VTE assessment has been carried out less than 6 before she conceived, a repeat VTE assessment at antenatal booking would not be necessary @ early pregnancy - booking @ every hospital admissions to any department or when new risk factors emerge @ immediate postpartum
Sarawak VTE Risk Assessment Form (2013 version)
Sarawak VTE Risk Assessment Form – July 2015
High Risk Factors for VTE Previous VTE (except a single event related to major surgery) 4 Other high risk VTE score Score Hyperemesis gravidarum / OHSS (1 st trimester) 4 (transient) Surgery in pregnancy or puerperium (exclude ERPOC , T&S) 4 (transient) 3 Previous VTE provoked by major surgery Known high risk thrombophilia 3 3 Current IVDU (previously score of 1) Medical comorbidities, eg: cancer, heart failure, active SLE, 3 inflammatory poly-arthropathy, inflammatory bowel disease, nephrotic syndrome, type 1 DM with nephropathy
Oth ther Changes fr from previous VTE Risk Assessment form: Parity ≥ 3 (previously Para > 5) 1 IVF pregnancy (1 st 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
Transient Risk Factors Current systemic infection 1 Hyperemesis gravidarum 4 OHSS (1 st Trimester only) 4 IVF pregnancy (1 st Trimester only) 1 Admission or immobility (≥ 3 days) 1 Long-distance travel 1 • 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
Green Top Guid ideline 37a: • ANTENATAL – score > 4 (other than for previous VTE or thrombophilia), may consider VTE prophylaxis with LMWH from 1 st 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 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 1 st 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 How to remember? 2 10 days (Score – 1) = weeks 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
HIGH RISK FACTORS requiring longer postnatal prophylaxis: Duration of postnatal VTE prophylaxis No. Antenatal High Risk Factors: 1 Previous VTE episode 2 Known history of thrombophilia 6 weeks 3 Medical Comorbidities 4 Current IVDU Postnatal mothers with any of the above High Risk factors should be given 6 weeks of 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 once 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
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