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Reducing Maternal Mortality from Venous Thromboembolism
“ SARAWAK VTE RISK MANAGEMENT”
Introduction/Background Sarawak VTE prophylaxis strategies
Options of drugs available Administrations problems
Common error Early VTE detection.
VTE (venous thromboembolism) includes1. 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
Pulmonary embolism is the main cause of
maternal mortality in Malaysia and
Sarawak
“Thromboembolism remains a significant but preventable cause of
maternal death”
“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”
Prevention of DVT or PE1. 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
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.
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
This assessment should be performed :-During antenatal period
-During each hospital admission
-Post delivery
Using Standard form (Sarawak thromboprophylaxis risk assessment form)
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
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
delivery but excluding ERPOC & minor T&S*)
1
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
Patients who should be given thromboprophylaxis:1.ANTENATALLY – score > 3
2.POSTNATALLY – score > 2*
Low risk with score < 21.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)
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
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)
VTE Risk assessment on discharge ( postnatal)
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
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
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)
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
Self injection after discharge
Porcine Based drugs (Clexane and Tinzaparin)
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)
Heparin should only be administered by medical personnel as an inpatient or outpatient
Muzakarah Jawatankuasa Fatwa Majlis KebangsaanBagi Hal Ehwal Ugama Islam Malaysia Kali Ke-87 yang bersidang pada 23 – 25 Jun 2009 telahmembincangkan Hukum Penggunaan Ubat ClexaneDan Fraxiparine. Muzakarah telah memutuskan bahawa:
Islam menegah penggunaan ubat dari sumber yang haram bagi mengubati sesuatu penyakit, kecualidalam keadaan di mana tiada ubat dari sumber yang halal ditemui dan bagi menghindari kemudharatanmengikut kadar yang diperlukan sahaja sehingga ubatdari sumber yang halal ditemui.
Oleh itu, berhubung dengan penggunaan ubatClexane dan Fraxiparine yang dianggap daruratkepada para pesakit bagi mencegah formulasipembekuan darah secara serta merta ketikapesakit berada pada tahap kronik, Muzakarahmemutuskan bahawa penggunaan kedua-duajenis ubat ini adalah ditegah kerana ia dihasilkandari sumber yang diharamkan oleh Islam, memandangkan pada masa ini telah terdapatalternatif ubat iaitu Arixtra (Fondaparinux) yang dihasilkan daripada sumber halal danmempunyai fungsi serta keberkesanan yang sama dengan Clexane dan Fraxiparine.
But……Fondaparinux in Pregnancy
Not enough data on efficacy and safety
No antidote
………………??? Alternative to clexane/tinzaparine/fraxiparine in obstetrics patients.
Options1. 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)
1. Patient on LMWH (Clexane/Tinzaparine) who are not keen for self injection.
2. Patient on Unfractionatedheparin ( refused porcine based LMWH)
Kuching Sibu Miri Bintulu
KK Jalan Masjid
Klinik 1M Bintawa
Klinik 1M PantaiDamai
Klinik 1M Tabuan
Klinik 1M Malihah
KK Lanang
Klinik 1M Teku
Klinik 1M Sungai Bidut
Klinik 1M Taman Rejang
Klinik 1M Soon-HupPermai
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)
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.
The correct dose of unfractionated heparin is ……..
5000 unit B.DSubcutaneously
Heparin are given intra-mascularly instead of subcutaneously.
Overdose !!!!!...........few patient are
wrongly given up to 25,000 unit b.d
Did not read the heparin concentration properly
1 vial = 5 ml
5000 unit = 1 ml
Only 1 ml is needed
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 VTE5. Patient information leaflet on heparin
Important to note that half of all DVT cases are asymptomatic
DVT signs & symptoms includes; Swelling in one or both legsPain or tenderness in one or both legs, which may
occur only while standing or walkingWarmth in the skin of the affected legRed or discoloured skin in the affected legLeg fatigue
Especially when the above signs & symptoms occur suddenly
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
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)
Bahasa Malaysia version is available and can be downloaded from SGH O&G website
Sgh-og.tumblr.com
Bahasa Malaysia version is available and can be downloaded from SGH O&G website
Sgh-og.tumblr.com