Obstetric
Venous thromboembolism (VTE) is a leading cause for maternal morbidity and
mortality. Venous thromboembolism encompasses deep vein thrombosis(DVT) and pulmonary
embolism (PE) complicates 0.5 to 3.0 per 1,000 pregnancies.[1]
PE is the seventh leading cause of maternal mortality and contributes to 9% of maternal
deaths.[2]
Maternal
deaths due to VTE are preventable by forming and implementing comprehensive guidelines
for prophylaxis of thromboembolism. But, presently sufficient clinical trial data
remains unavailable to formulate VTE prophylaxis guidelines in pregnancy.
In US only women
who are at high risk for VTE receive pharmacologic prophylaxis, thereby
increasing the rate of obstetric VTE in the last decade.
On the
contrary, RCOG guidelines in U.K recommend screening and assessment of antepartum
and postpartum women for at risk for VTE. Due to regular assessment many women receive
pharmacologic thromboprophylaxis, bringing down the rates of VTE since the
release of the guidelines.
Observational
data support risk-factor-based prophylaxis in bringing down the incidence of
VTE, hence the National Partnership for Maternal Safety under the guidance of
the Council on Patient Safety in Women's Health Care developed safety bundle.
Safety bundle supports routine risk evaluation for obstetric patients with
pharmacological and mechanical thromboprophylaxis when needed. [3]
It outlines simple practices that can be implemented in every maternal units, adapting
according to the healthcare resources available in each community.
The article
was published in October issue of Obstetrics and Gynecology journal.[4]
The bundle is grouped into 4 domains: Readiness, Recognition, Response, and
Reporting and Systems Learning.
Readiness:
Every Unit should use standard VTE risk assessment tool during prenatal
outpatient visits, antepartum admissions to hospital, post labor and post
cesarean stay in hospitals and 6 weeks postpartum.
Recognition
and Response: Once the risk assessment is done, physicians should use patients Caprini[5]
or Padua score[6] to
identify those patients who will need thromboprophylaxis according to clinical situation
and risk score. The thromboprophylaxis guidelines are as advocated by ACOG,
American College of Chest Physicians and RCOG.
- Antepartum outpatient prophylaxis: women with a history of multiple VTE or thrombophilia episodes low-molecular-weight (LMW) heparin or unfractionated heparin (UFH) is recommended.
- Antepartum Inpatients for more than 3 days: Women who are not at risk for bleeding or imminent childbirth, prophylaxis with daily LMW heparin or twice-daily UFH is advocated.
- Women with a history of VTE who are undergoing a trial of vaginal birth are given intrapartum mechanical thromboprophylaxis using pneumatic compression devices while in bed. After the delivery, LMW heparin or UFH can be for those at high risk for VTE based on RCOG criteria or a Padua score of 4 or greater.
- Those women undergoing an operative delivery are prescribed mechanical thromboprophylaxis using pneumatic compression. Once the surgery is over, they can also be given LMW heparin or UFH, based on RCOG criteria or modified Caprini scores.
- RCOG criteria also advocates that all women who are undergoing operative delivery may be routinely prescribed LMW heparin or UFH due to complications with mechanical prophylaxis.
- Women with repeated history of VTE, high-risk thrombophilia, or VTE with acquired thrombophilia can be put on extended 6-week treatment-dose of LMW heparin or UFH postpartum.
Reporting and Systems Learning: All centers should meticulously keep
records of patients receiving prophylaxis for VTE, adverse reactions and complications.
Routine audits should be performed to
check whether physicians are evaluating, assessing the risk factors for VTE and
planning the treatment accordingly.
However, in an accompanying editorial Baha M. Sibai, MD, from the
University of Texas Medical School at Houston, and Dwight J. Rouse, MD, MSPH,
associate editor for Obstetrics & Gynecology, have expressed concern
that the widespread use pharmacological prophylaxis may do more harm than good.
The authors are specially concerned with 3 days’ prophylaxis for antepartum
hospitalized patients and women at high risk for VTE and have undergone vaginal
birth.
They were especially worried about following the RCOG criteria of
pharmacological prophylaxis after cesarean delivery, which would apply to more
than half of the C.S. patients in the US.
According to the editorial analysis” approximately 1 million women
would require pharmacologic prophylaxis to prevent even one maternal death from
cesarean delivery–associated pulmonary embolism."
Nevertheless, they advocate the use of mechanical prophylaxis in all
obstetrics units’ post-cesarean and building a database of huge obstetric
patients in whom the mechanical method was used. In the future, this large data
base created can be used to assess the pros and cons of using pharmacological prophylaxis
in obstetrics patients.
[1] Snow
V, Qaseem A, Barry P, et al., for the American College of Physicians, American
Academy of Family Physicians Panel on Deep Venous Thrombosis/Pulmonary
Embolism. Management of venous thrombo-embolism: a clinical practice guideline
from the American College of Physicians and the American Academy of Family
Physicians. Ann Intern Med. 2007;146(3):204–210....
[2] The
Confidential Enquiry into Maternal and Child Health (CEMACH). Saving mothers’
lives: reviewing maternal deaths to make motherhood safer — 2003–2005: the
seventh report on confidential enquiries into maternal deaths in the United
Kingdom. London: CEMACH, 2007
[3] http://www.safehealthcareforeverywoman.org/secure/vte-prevention-patient-safety-bundle.php
[4] http://journals.lww.com/greenjournal/Citation/2016/10000/National_Partnership_for_Maternal_Safety_.3.aspx
[5] http://www.wikidoc.org/index.php/Caprini_risk_assessment_model
[6] http://www.mdcalc.com/padua-prediction-score-for-risk-of-vte/
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