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Preventing Thromboembolism in Ob and Gyn.pptx

  1. 1. Venous Thromboembolism Prevention in Pregnancy and Puerperium Dr (Mrs.) V BAGRI BUCKTOWAR, Obstetrician and Gynaecologist MBBS, MD, DGO, DPM, Dip USG.
  2. 2. Learning outcomes When you have completed this course you will be able to: • describe the normal mechanism of coagulation and how this alters in pregnancy. • describe the epidemiology, pathophysiology and risk factors in venothromboembolism in pregnancy. • conduct prenatal counselling and the subsequent management of those women with thromboembolic disorders. • recognise who needs to be given thromboprophylaxis to prevent venothromboembolism.
  3. 3. VTE Disease Embolus lodged in left pulmonary artery-chest pain,SOB,if large- FATAL
  4. 4. Incidence • Pregnancy is a prothrombotic state. • The relative risk of VTE in pregnancy is increased four to six fold and this is increased further postpartum. • Although the risk of VTE is higher in the puerperium ,the antenatal period is longer and antepartum deaths from VTE occur as commonly as postpartum deaths. • VTE remains the leading cause of direct maternal death. • Women giving birth are now older, have preexisting health problems and rates of obesity in the pregnant population is on the rise
  5. 5. Incidence of VTE in pregnancy (DVT, PE, CVT) • The incidence of non-fatal PE and DVT in pregnancy is 0.1% • DVT accounts for 75% of pregnancy associated VTE and PE about 25% • The risk of DVT after caesarean section is around 1-2% • The incidence of CVT during pregnancy and puerperium in developed countries is 11.6 per 100,000 deliveries per year. • In pregnancy, DVT is more likely to be more proximal (involving the iliac and iliofemoral veins)and in the left leg as the left iliac vein is compressed by the right iliac artery and 5th lumbar veretebra Reference-Handbook of Obstetric Medicine :Catherine Nelson-Piercy 2015 DVT Pregnant % Non-pregnant % Left sided 85 55 Ilio-femoral 72 9
  6. 6. Morbidity following DVT • Post thrombotic syndrome (PTS) is characterised by chronic persistent leg swelling, pain, a feeling of heaviness, dependant cyanosis, telangiectasis, chronic pigmentation, eczema, associated varicose veins and in the most severe cases, venous ulceration. There is no role of compression stockings in the prevention of post- thrombotic syndrome. • Venous insufficiency resulting in pigmentation and venous leg ulcers. • Pulmonary hypertension in 3–4% following pulmonary embolism. • Recurrent DVT – the incidence of a recurrent DVT outside pregnancy is 3.7% but in pregnancy this increases to 10.9%.
  7. 7. There needs to be a balance between thrombosis and fibrinolysis • In pregnancy, there are changes in both the clotting and fibrinolysis system. The purpose of these changes is to safeguard against bleeding after delivery, but the associated consequence is that there is an increased risk of thrombosis.
  8. 8. Blood concentrations of clotting factors in pregnancy Constituent Change Fibrinogen Factor V Factor VII Factor VIII Factor X Factor XII von Willebrand factor Increases Factor IX Factor XI Protein C Stays the same Antithrombin Protein S Plasminogen activation inhibitor Platelets Decreases Trend changes in the constituents of blood in a normal pregnancy Pregnancy predisposes to thrombosis as explained below: • pregnancy is a physiologically hypercoagulable state - this risk is present from the first trimester up to 6 weeks postpartum. • Although the risk persists until 12 weeks the absolute risk beyond 6 weeks is low. • Fibrinogen levels rise by up to 50% while fibrinolytic activity is decreased • Antithrombin and protein S levels decrease thus altering the balance towards thrombosis.
  9. 9. Pregnancy fulfills all the 3 criteria of Virchow’s Triad!
  10. 10. Prepregnancy and antenatal risk assessment Q: What are the risk factors for venous thromboembolism (VTE) in pregnancy and puerperium?what is the magnitude of risk for these factors?  All women should undergo a documented assessment of risk factors for VTE in early pregnancy or prepregnancy.  Risk assessment should be repeated if the woman is admitted to hospital for any reason or develops other intercurrent problems.  Risk assessment should be repeated again intrapartum or immediately postpartum.  Any woman with four or more current risk factors (other than previous VTE or thrombophilia)-prophylactic (LMWH) throughout the antenatal period and prophylactic LMWH for 6 weeks postnatally.  Any woman with three current risk factors (other than previous VTE or thrombophilia) prophylactic LMWH from 28 weeks and require prophylactic LMWH for 6 weeks postnatally .  Any woman with two current risk factors (other than previous VTE or thrombophilia) - prophylactic LMWH for at least 10 days postpartum. [New 2015]  OHSS/HYPEREMESIS
  11. 11. Risk factors for venous thromboembolism in pregnancy and the puerperium
  12. 12. Risk factors for venous thromboembolism in pregnancy and the puerperium-contd.
  13. 13. Obstetric thromboprophylaxis -Risk assessment and management
  14. 14. Obstetric thromboprophylaxis - risk assessment and management- contd.
  15. 15. NUMERICAL SCORING SYSTEM Risk factors for VTE-pre-existing risk factors
  16. 16. NUMERICAL SCORING SYSTEM Risk factors for VTE-Obstetric risk factors
  17. 17. NUMERICAL SCORING SYSTEM Risk factors for VTE-transient risk factors
  18. 18. Risk assessment for venous thromboembolism (VTE)
  19. 19. Thrombophilias • A thrombophilia is defined as a predisposition to thrombosis, secondary to any persistent or identifiable hypercoagulable state. This can be inherited or acquired. • Present in about 5% of the population • Not all thrombophilias carry the same risk and risk assessment should therefore be stratified. Thromboprophylaxis should be offered depending on the score after considering other risk factors. Heritable thrombophilia • Antithrombin deficicency • Protien C deficiency • Protien S deficiency • Factor V Leiden • Prothrombin gene mutation The most common acquired thrombophillia is Antiphospholipid syndrome.
  20. 20. Summary of revised classification criteria for APS
  21. 21. Risks of APS The risks to pregnancy include: • pregnancy loss • pre-eclampsia • fetal growth restriction • preterm delivery • thrombosis – deep vein thrombosis/pulmonary embolism/cerebral infarction.
  22. 22. Management of women with APS and a previous thrombotic event • a change from warfarin should be made once a positive pregnancy test is obtained. • It is important to emphasise the necessity of an early pregnancy test, to ensure a change to heparin before 6 weeks of gestation to minimise the risk of warfarin embryopathy. • The dose of heparin should be at intermediate or therapeutic levels, depending on assessment of overall risk • In those women not on anticoagulation, a high prophylactic or intermediate dosage should be commenced early in the first trimester on confirmation of a viable pregnancy and continued untill 6 weeks postpartum • Low dose Aspirin (75-150mg) should be started from 12 weeks, preferably at bedtime. • Women need to be managed in a multidisciplinary team comprising of an obstetrician, rheumatologist, haematologist and anaesthetist. Management of women with APS and no previous thrombotic event • Persistent Antiphospholipid antibodies in women without previous VTE should be considered for antenatal or postnatal thromboprophylaxis.
  23. 23. Testing for thrombophilia in women with prior VTE Q:Which women with prior VTE require thrombophilia testing? Women with a family history of VTE . Women with an unprovoked VTE should be tested for the presence of antiphospholipid antibodies. [New 2015]
  24. 24. • Women with previous VTE associated with antithrombin deficiency (who will often be on long-term oral anticoagulation) should be offered thromboprophylaxis with higher dose LMWH (either 50%, 75% or full treatment dose) antenatally and • for 6 weeks postpartum or until returned to oral anticoagulant therapy after delivery. • Women with previous VTE associated with other heritable thrombophilia should be offered standard doses of thromboprophylaxis. • Management should be undertaken in collaboration with a haematologist with expertise in thrombosis in pregnancy. • Antenatal anti-Xa monitoring and the antithrombin replacement at initiation of labour or prior to caesarean section. [New 2015]
  25. 25. Asymptomatic heritable thrombophilia Q: How should women with asymptomatic thrombophilia be treated? Women should be stratified according to level of risk associated with their thrombophilia and the family history or other risk factors. [New 2015]: 1.Women with asymptomatic antithrombin, protein C or S deficiency or 2.those with more than one thrombophilic defect (including homozygous factor V Leiden, homozygous prothrombin genemutation and compound heterozygotes) should be referred to a local expert and antenatalprophylaxis considered. and 6 wks postnatal prophylaxis even in the absence of additional risk factors. [New 2015] In the presence of:  three other risk factors- antenatal thromboprophylaxis  two other risk factors: thromboprophylaxis from 28 weeks  one other risk factor: postnatal thromboprophylaxis for 10 days should be considered. [New 2015]
  26. 26. Antiphospholipid antibodies Q:How should women with antiphospholipid antibodies be treated? • Persistent antiphospholipid antibodies (lupus anticoagulant and/or anticardiolipin and/or β2-glycoprotein 1 antibodies) in women without previous VTE should be considered for antenatal or postnatal thromboprophylaxis. [New 2015]
  27. 27. Thrombophilias –key points • Thrombophilias may be acquired or congenital and vary in their degree of thrombogenicity. • Thrombophilias increase the risk of VTE but most carriers never experience a deep vein thrombosis or pulmonary embolism. • Initiation and intensity of anticoagulant therapy following a diagnosis of acute venous thrombosis should be the same in woman with and without heritable thrombophilia. • Antithrombin III, compound thrombophilias and homozygosity for FVL and G20210A prothrombin gene mutation are the most thrombogenic. • Thrombophilias are also associated with fetal loss, placental abruption and pre-eclampsia.
  28. 28. Previous VTE/recurrent VTEs Q: How should women with previous VTE be managed in pregnancy? Single previous VTE • prepregnancy counselling and a prospective management plan for thromboprophylaxis in pregnancy made. • Referral at the earliest opportunity in pregnancy to a clinician with expertise in thrombosis in pregnancy. • Thromboprophylaxis with LMWH throughout the antenatal period. [New 2015] Q: What extra advice is needed for women with previous recurrent VTE? • Clinician with expertise in haemostasis and pregnancy should be involved. [New 2015] these women require higher doses of LMWH. [New 2015] • Women on long-term warfarin or other oral anticoagulants should be counselled about the risks of these agents to the fetus and advised to stop their oral anticoagulant therapy and change to LMWH as soon as pregnancy is confirmed, ideally within 2 weeks of the missed period and before the sixth week of pregnancy. [New 2015] • Women not on warfarin or other oral anticoagulants should be advised to start LMWH as soon as they have a positive pregnancy test. [New 2015]
  29. 29. Stratification of women with previous VTE Q: How should women with previous VTE be stratified to determine management in pregnancy? Q: When should thromboprophylaxis be started?  Women with VTE associated with either antithrombin deficiency or APS or with recurrent VTE (who will often be on long-term oral anticoagulation) should be offered thromboprophylaxis with higher dose LMWH (either 50%, 75% or full treatment dose) antenatally and for 6 weekspostpartum or until returned to oral anticoagulant therapy after delivery.  Women in whom the original VTE was unprovoked/idiopathic or related to estrogen (estrogen-containing contraception/pregnancy) or related to a transient risk factor should be offered thromboprophylaxis with LMWH throughout the antenatal period.  In women in whom the original VTE was provoked by major surgery from which they have recovered and who have no other risk factors, thromboprophylaxis with LMWH can be withheld antenatally until 28 weeks provided no additional risk factors are present (in which case they should be offered LMWH). They require close surveillance for the development of other risk factors.
  30. 30. First trimester risk factors Q:What are the first trimester risk factors for VTE and how should they be managed?  Women admitted with hyperemesis should be considered for thromboprophylaxis with LMWH and can discontinue thromboprophylaxis when the hyperemesis resolves. [New 2015]  Women with ovarian hyperstimulation syndrome should be considered for thromboprophylaxis with LMWH in the first trimester. [New 2015]  Women with an IVF pregnancy and three other risk factors should be considered for thromboprophylaxis with LMWH starting in the first trimester.
  31. 31. Thromboprophylaxis during labour and delivery
  32. 32. Q:When should thromboprophylaxis be interrupted for delivery? • LMWH should be stopped by the pt. if they have any vaginal bleeding or once labour begins. She should continue to wear support stockings in labour and remain hydrated. • If a patient anticoagulated with LMWH has required a caesarean section, consideration should be given to insertion of wound drains. • However, bleeding complications are very uncommon with LMWH. • There is a 2% chance of wound haematoma with both LMWH and UH, so staples or interrupted skin sutures should be used. • Women at high risk of haemorrhage including major antepartum haemorrhage, coagulopathy, progressive wound haematoma, suspected intra-abdominal bleeding and postpartum haemorrhage may be managed with anti-embolism stockings (AES), foot impulse devices or intermittent pneumatic compression devices. • Unfractionated heparin (UFT) may also be considered. • If a woman develops a haemorrhagic problem while on LMWH the treatment should be stopped and expert haematological advice sought. • Thromboprophylaxis should be started or reinstituted as soon as the immediate risk of haemorrhage is reduced.
  33. 33. Thromboprophylaxis and the use of regional analgesia
  34. 34. • Regional techniques should be avoided if possible until at least 12 hours after the previous prophylactic dose of LMWH. • LMWH should not be given for 4 hours after use of spinal anaesthesia or after the epidural catheter has been removed and the catheter should not be removed within 12 hours of the most recent injection. • When a woman presents while on a therapeutic regimen of LMWH, regional techniques should be avoided if possible for at least 24 hours after the last dose of LMWH. • Elective caesarean -thromboprophylactic dose of LMWH on the day prior to delivery and, on the day of delivery, any morning dose should be omitted and the operation performed that morning. • The first thromboprophylactic dose of LMWH should be given as soon as possible after delivery provided there is no PPH and regional analgesia has not been used. [New 2015] NICE GUIDELINE
  35. 35. Cautionary use of regional analgesia techniques in pregnant women on LMWH Regional analgesia in pregnant women on LMWH Timing to avoid epidural haematoma Regional analgesia can be given On prophylactic LMWH ≥12 hours after last dose On therapeutic LMWH ≥24 hours after last dose Epidural catheter removal On LMWH 12 hours after last dose Next dose LMWH ≥4 hours after removal
  36. 36. Thromboprophylaxis after delivery-Assessment of risk Q:What are the risk factors for VTE after delivery? 1. Class 3 obesity (BMI greater than or equal to 40 kg/m2) - prophylactic LMWH in doses appropriate for their weight for 10 days after delivery. [New 2015] 2. Women with two or more persisting risk factors -LMWH in prophylactic doses appropriate for their weight for 10 days after delivery. [New 2015] 3. Previous VTE-All women with a previous history of confirmed VTE should be offered thromboprophylaxis with LMWH or warfarin for at least 6 weeks postpartum regardless of the mode of delivery. 4. Asymptomatic thrombophilia- Women with thrombophilia without previous VTE should be stratified according to both the level of risk associated with their thrombophilia and the presence or absence of a family history or other risk factors. [New 2015] 5. Women with a family history of VTE and an identified thrombophilia should be considered for 6 weeks’ postnatal thromboprophylaxis. 6. Caesarean section- All women who have had caesarean sections should be considered for thromboprophylaxis with LMWH for 10 days after delivery .
  37. 37. Q: For how long should thromboprophylaxis be continued after delivery? • Risk assessment should be performed in each woman at least once following delivery and before discharge. • Thromboprophylaxis should be continued for 6 weeks in high-risk women and for 10 days in intermediate-risk women [New 2015] • In women with additional persistent (lasting more than 10 days postpartum) risk factors, such as prolonged admission, wound infection or surgery in the puerperium, thromboprophylaxis should be extended for up to 6 weeks or until the additional risk factor/s is/are resloved.
  38. 38. Q:Which agents should be used for thromboprophylaxis?
  39. 39. Heparin • Heparin does not cross the placenta, hence there are no fetal adverse effects. • It prevents clot formation and propagation. LMWH use is preferred in pregnancy for thromboprophylaxis and treatment of VTE. • It is an effective anticoagulant, is easy to administer, has less side effects and less maternal bleeding risk than unfractionated heparin, and levels do not need to be routinely monitored. • LMWHs are the agents of choice for antenatal and postnatal thromboprophylaxis. • It is only necessary to monitor the platelet count if the woman has had prior exposure to unfractionated heparin (UFH). • Monitoring of anti-Xa levels is not required when LMWH is used for thromboprophylaxis. • Doses of LMWH should be reduced in women with renal impairment. LMWH is safe in breastfeeding. Side effects of LMWH • osteoporosis 1/500 fracture rate – can be severe (e.g. vertebral collapse) • allergy • injection site bruising • thrombocytopenia – very rare idiosyncratic reaction. Platelet count does not need to be checked unless patient received UFH before LMWH.
  40. 40. Unfractionated heparin (UFH) and Warfarin UFH needs to be administered as an infusion for treatment and has more side effects than LMWH: • symptomatic vertebral fractures 2% • allergic reactions • heparin-induced thrombocytopenia. Warfarin is an excellent anticoagulant but is not used for the treatment of antenatal VTE due to its placental passage, which can result in: • miscarriage • warfarin embryopathy • stillbirths • fetal bleeding especially intracerebral • microcephaly • neonatal haemorrhage following delivery. • There is an increased risk of maternal bleeding, particularly retroplacental with warfarin use.
  41. 41. More about warfarin embryopathy • Warfarin is teratogenic and should be avoided in the first trimester. • The period of risk is 6–12 weeks so must be replaced within 2 weeks of missed period. • Risk is dose dependent and is greater if dose is >5 mg per day. • It can cause chondrodysplasia punctate, nasal hypoplasia, chondral calcification, short proximal limbs and phalanges. • Women should be offered a choice of LMWH or oral anticoagulant for postnatal therapy • Postpartum warfarin should be avoided until at least the fifth day and for longer in women at increased risk of postpartum haemorrhage.
  42. 42. Characteristics of anticoagulants used to treat VTE Assay Dose adjusted according to Crosses placenta Teratogen Maternal osteoporosis risk LMWH Anti-Xa* BMI No No 0.04% Unfractionated heparin APTT Keep APTT 1.5–2.0x normal No No 2% Warfarin INR Keep INR 2.0–3.0 Yes Yes 0 •level only performed if extremes of bodyweight (less than 50 kg or more than 90 kg) or other complicating risk factors e.g. recurrent VTE or renal impairment. Aim for peak level 3 hour post injection of 0.5–1.2 u/ml. •Nelson-Piercy C. Handbook of Obstetric Medicine. 5th ed. Taylor & Francis Group; 2015.
  43. 43. Role of newer agents • Consideration should be given to the use of newer anticoagulants (fondaparinux, argatroban or r-hirudin) in pregnant women who are unable to tolerate heparin (LMWH or unfractionated heparin) or danaparoid and who require continuing anticoagulant therapy. • Non-vitamin K antagonist oral anticoagulants (NOACs e.g. rivaroxaban, apixaban, betrixaban and dabigatran) are likely to cross the placenta and should therefore be avoided in pregnancy and puerperium.
  44. 44. Low-dose aspirin • Aspirin inhibits platelet function. • Platelets play a small role in venous thrombosis. • Any benefit of aspirin in VTE prevention appears uncertain and significantly less than that of LMWH. • Aspirin is not recommended for thromboprophylaxis in pregnant woman.
  45. 45. Q:Which agents should be used for thromboprophylaxis?contd. Unfractionated heparin • In women at very high risk of thrombosis, UFH may be used peripartum inpreference to LMWH where there is an increased risk of haemorrhage or where regional anaesthetic techniques may be required. • If UFH is used after caesarean section (or other surgery), the platelet count should be monitored every 2–3 days from days 4–14 or until heparin is stopped. [New 2015] Danaparoid Potential use of danaparoid should be in conjunction with a consultant haematologist with expertise in haemostasis and pregnancy
  46. 46. Q:Which agents should be used for thromboprophylaxis?-contd. • Fondaparinux  Reserved for women intolerant of heparin compounds. [New 2015]  Fondaparinux use in pregnancy should be in conjunction with a consultant haematologist with expertise in haemostasis and pregnancy. • Low-dose aspirin × Aspirin is not recommended for thromboprophylaxis in obstetric patients. [New 2015]
  47. 47. Q:Which agents should be used for thromboprophylaxis?-contd. • Warfarin use in pregnancy is restricted to the few situations where heparin is considered unsuitable, e.g. some women with mechanical heart valves. • Women receiving long-term anticoagulation with warfarin can be converted from LMWH to warfarin postpartum when the risk of haemorrhage is reduced, usually 5–7 days after delivery. • Warfarin is safe in breastfeeding. • Dextran should be avoided antenatally and intrapartum because of the risk of anaphylactoid reaction. • Oral thrombin and Xa inhibitors • Non-vitamin K antagonist oral anticoagulants (NOACs) should be avoided in pregnant women.[New 2015] and is not currently recommended in women who are breastfeeding. [New 2015]
  48. 48. Thromboprophylactic doses for antenatal and postnatal LMWH
  49. 49. Contraindications/cautions to LMWH use Q: Which women should not be given thromboprophylaxis with LMWH?
  50. 50. Q: If LMWH is contraindicated? What should be done?  LMWH should be avoided, discontinued or postponed in women at risk of bleeding after careful consideration of the balance of risks of bleeding and thrombosis.  Women with previous or current allergic reactions to LMWH should be offered an alternative preparation or alternative form of prophylaxis. [New 2015]  Further advice may be sought from a haematologist with expertise in the management of thrombosis and bleeding disorders in pregnancy.
  51. 51. Anti-embolism stockings/Graduated Elastic compression stockings(GECS) In addition to starting anticoagulation, the leg should be elevated and GECS should be applied to reduce oedema. Mobilisation with GECS should be encouraged. Appropriate size, properly applied, anti-embolism stockings (AES) providing graduated compression with a calf pressure of 14–15 mmHg is recommended in pregnancy and the puerperium for women who are hospitalised and have a C/I to LMWH. These include women who are hospitalised post- caesarean section (combined with LMWH) and considered to be at particularly high risk of VTE,eg:  previous VTE  more than four risk factors antenatally, or  more than two risk factors postnatally) and  women travelling long distance for more than 4 hours. [New 2015]
  52. 52. Graduated elastic compression stockings-contd. • The mechanism of action of GECS is uncertain, but studies have shown that they improve venous emptying, and increase the blood flow while decreasing the lumen diameter of the superficial femoral and common femoral vein. • As most DVT in pregnant women are ileofemoral, properly applied full length GECS are ideal but if they are ill-fitted or compliance is poor knee length should be considered. Contraindications to use: • suspected or proven peripheral arterial disease • fragile tissue paper skin, dermatitis, gangrene or recent skin graft • known allergy to material • peripheral neuropathy • peripheral arterial bypass grafting • major limb deformity or unusual leg size or shape • severe leg oedema Use with caution in cases of: • venous ulcers or wounds
  53. 53. Flying in pregnancy • Although the absolute risk of DVT is small, this risk is likely to be increased by air travel owing to immobility by approximately three-fold, with an 18% higher risk of VTE for each 2-hour increase in flight duration. • It is now recognised that the risk of VTE is associated with all long-distance travel. • With regard to minimising the risk of DVT, appropriate general advice would be:  have an aisle seat to facilitate movement  take regular walks around the cabin  carry out in-seat exercises every 30 minutes on a medium or long haul flight  maintain good fluid intake and minimise caffeine and alcohol intake  for medium- to long-haul flights(lasting > 4hrs) wear appropriate-sized GEC stockings  LMWH prophylaxix is advised starting from the day of travel in those with other risk factors of VTE if not already on it.
  54. 54. Contraception and VTE • Concerns about the role of hormonal contraceptives in mediating thrombosis risk have been ongoing since the introduction of hormonal contraceptives in the 1960s. Venous thromboembolism CHC POP IMP DMPA LNG-IUS Cu-IUD History of VTE 4 2 2 2 2 1 Current VTE (on anticoagulation) 4 2 2 2 2 1 • Emergency contraception (CU -IUD, Ulipristal acetate, Levonorgestrel) is UKMEC 2 in woman with history of VTE or current VTE. UK Medical eligibility criteria for contraceptive use
  55. 55. WHAT NICE GUIDELINE RECOMMENDS: • Interventions for pregnant women and women who gave birth or had a miscarriage or termination of pregnancy in the past 6 weeks • Consider LMWH for all women who are admitted to hospital if they are pregnant or gave birth, had a miscarriage or had a termination of pregnancy in the past 6 weeks, and whose risk of VTE outweighs their risk of bleeding. [2018] • Do not offer VTE prophylaxis to women admitted to hospital or a midwife-led unit who are in active labour. [2018] • Stop pharmacological VTE prophylaxis when women are in labour. [2018] • If using LMWH in pregnant women, start it as soon as possible and within 14 hours of the risk assessment being completed and continue until the woman is no longer at increased risk of VTE or until discharge from hospital. [2018]
  56. 56. NICE GUIDELINE RECOMMENDS: Contd. • If using LMWH in women who gave birth or had a miscarriage or termination of pregnancy, start 4 to 8 hours after the event unless contraindicated and continue for a minimum of 7 days. [2018] • Consider combined prophylaxis with LMWH plus mechanical prophylaxis for pregnant women or women who gave birth or had a miscarriage or termination of pregnancy in the past 6 weeks and who are likely to be immobilised, or have significantly reduced mobility for 3 or more days after surgery, including caesarean section:  Use intermittent pneumatic compression as first-line treatment.  If contraindicated, use anti-embolism stockings. Continue until the woman no longer has significantly reduced mobility or until discharge from hospital. [2018]
  57. 57. ACOG guidelines recommends • women with antithrombin deficiency alone do not need antenatal prophylaxis whilst most clinicians in the UK would advise it. • That having been said, hereditary thrombophilia screens should not be routinely undertaken in pregnancy given the high risk of thrombosis in antithrombin deficiency. • However if there is a strong suspicion or family history this may be undertaken. • should be interpreted by an experienced haematologist. • NOTE: Protein C, Protein S and antithrombin III are all altered by pregnancy.
  58. 58. Key points • Pregnancy is a risk factor for venous thromboembolism (VTE), an important cause of maternal morbidity and mortality. Although there is a 4–5-fold increased risk compared to that of nonpregnant women of the same age, the absolute risk is low at no more than two episodes of VTE per 1000 pregnancies. • There is uncertainty about which women require thromboprophylaxis during pregnancy or postpartum because of a lack of data from appropriate clinical trials. • For this reason, recommendations for prophylaxis should be made only after explaining the available evidence to the patient and taking into account her perception of the balance of risk and benefit in thromboprophylaxis. • The aim of these recommendations is to provide clinicians with practical advice to assist in decisions regarding thromboprophylaxis in women considered to be at risk of VTE during pregnancy and the postpartum.VTE is a common cause of maternal mortality. • All women must be risk assessed for VTE at booking, on admission, in labour and postpartum. • The first line choice for pharmacological thromboprophylaxis and/or therapy is LMWH. • Unfractionated heparin (UFH) is used in cases of massive PE, or in cases where rapid reversibility is required. • Warfarin is not recommended antenatally other than in specific circumstances. It can be used for postnatal anticoagulation.
  59. 59. Thank you !
  60. 60. REFERENCES • Royal College of Obstetricians and Gynaecologists. Reducing the Risk of Thrombosis and Embolism During Pregnancy and the Puerperium. Green-top Guideline No. 37a.London: RCOG; 2015. • Royal College of Obstetrics and Gynaecology. The Acute Management of Thrombosis and Embolism during Pregnancy and the Puerperium. Green-top Guideline No. 37b.London: RCOG; 2015. • National Institute for Health and Care Excellence. Venous Thromboembolism in Over 16s: Reducing the Risk of Hospital-acquired Deep Vein Thrombosis or Pulmonary Embolism. NG89 NICE; London: 2018. • Tuffnell D, Knight M, Mackillop L on behalf of the MBRRACE-UK VTE Chapter-writing Group. Lessons for prevention and treatment of thrombosis and thromboembolism. In: Knight M, Bunch K, Tuffnell D, Jayakody H, Shakespeare J, Kotnis R, et al, on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-16. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2018:34-41. •
  61. 61. REFERENCES-Contd. • Greer IA, Nelson-Piercy C. Low molecular weight heparins fot thromboprophylaxis and treatment of venothrombo-embolism in pregnancy: a systematic review of safety and efficacy. Blood 2005;106:401–7. • 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;156:366–73. • Kamel H, Navi BB, Sriram N, Hovsepian DA, Devereux RB, Elkind MS. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med 2014;370:1307–15. • MacCallum P, Bowles L, Keeling D. Diagnosis and management of heritable thrombophilias. BMJ 2014;349:g4387 [Abstract]. • McLintock C, Brighton T, Chunilal S, Dekker G, McDonnell N, McRae S et al. Recommendations for the prevention of pregnancy-associated venous thromboembolism. Aust N Z J Obstet Gynaecol 2012;52:3-13 [Abstract].
  62. 62. REFERENCES-Contd. • 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy: The Task Force for the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC) • Scottish Intercollegiate Guidelines Network (SIGN).Prevention and management of venous thromboembol-ism. SIGN publication no. 122. Edinburgh: SIGN; 2010 • Duhl AJ, Paidas MJ, Ural SH, Branch W, Casele H, Cox-Gill J, et al.; Pregnancy and Thrombosis Working Group.Antithrombotic therapy and pregnancy: consensus report and recommendations for prevention and treatment of venous thromboembolism and adverse pregnancy outcomes. Am J Obstet Gynecol 2007;197:457.e1–21. • Wilson WA, Gharavi AE, Koike T, Lockshin MD, Branch DW, Piette JC, et al.International consensus statement on preliminary classification criteria for definite antiphospholipid syndrome: report of an international workshop. Arthritis Rheum 1999;42:1309–11. doi:10.1002/1529 0131(199907)42:71309::AID-ANR13.0.CO;2-F • Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, et al.International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost2006;4:295–306. doi:10.1111/j.1538-7836.2006.01753.x • Royal College of Obstericians and Gynaecologists. Air Travel and Pregnancy. Scientific Impact Paper Number No. 1. London; RCOG: 2013. • Faculty of Sexual and REproductive Healthcare. The UK Medical Eligibility Criteria for Contraceptive Use. UKMEC; 2016.

Notas del editor

  • Venous thromboembolic disease (VTE) is caused by a blood clot developing in the venous system, usually in the deep veins (deep vein thrombosis [DVT]).

    This will cause local symptoms of pain and swelling. If a portion or all of this blood clot detaches, it will travel through the venous system, through the heart and into the pulmonary arterial system where it will lodge.
    Pulmonary embolus (PE), generally presents with symptoms of chest pain, shortness of breath, and, if sufficiently large, can be fatal.
  • 17.8% of Mauritians are obese, among 6.5% are men and 11.3% are women
  • If the known low-risk thrombophilia is in a woman with a family history of VTE in a first-degree relative postpartum thromboprophylaxis should be continued for 6 weeks.

    BMI ≥ 30 = 1; BMI ≥ 40 = 2
  • All women should undergo a documented assessment of risk factors for venous thromboembolism in early pregnancy or pre-pregnancy. Risk assessment should be repeated if the woman is admitted to hospital for any reason or develops other intercurrent problems. Risk assessment should be repeated again intrapartum or immediately postpartum. ACTION: Service managers, health professionals

    Reassessment of VTE risk after miscarriage or ectopic pregnancy to consider whether thromboprophylaxis is required is as important as reassessment of risk after giving birth. ACTION: Service managers, health professionals.
  • Summary of guideline for thromboprophylaxis in women with previous VTE and/or thrombophilia
  • THESE PATIENTS will often be on long- term oral anticoagulation)
  • It is likely that these women will be on long-term anticoagulation, although this depends on the circumstances of the thrombotic event. If there was clearly a temporary provoking factor, they may have had a limited duration of anticoagulation.
  • Prior to testing for thrombophilia, women should be counselled regarding the implications for themselves and family members of a positive or negative result.
    The results should be interpreted by clinicians with specific expertise in the area.
  • Heterozygosity for factor V Leiden or prothrombin gene mutation or antiphospholipid antibodies are considered as risk factors for thrombosis in asymptomatic women (see Appendix I).
  • Antenatal thromboprophylaxis for those with previous VTE should begin as early in pregnancy as practical. [New 2015]
    Women without previous VTE and without particular first trimester risk factors or admission to hospital, but with four other risk factors, should be considered for antenatal prophylaxis throughout pregnancy. [New 2015]
    Women without previous VTE and without particular first trimester risk factors or admission to hospital, but with three other risk factors, can start antenatal prophylaxis at 28 weeks of gestation. [New 20
  • 02 Copyright ©Faculty of Sexual and Reproductive Healthcare 2006 to 2016. USING THE UKMEC The UKMEC considers the following groups of contraceptive methods: intrauterine contraception (IUC), progestogen-only contraception (POC), combined hormonal contraception (CHC) and emergency contraception (EC). The UKMEC categories for each of these groups can be found in Section B, together with evidence summaries and clarifications. Additional comments can be found at the end of each method section. References and additional resources are located in Section C. Commonly used abbreviations are listed in Appendix 3. The UKMEC Categories For each of the personal characteristics or medical conditions considered by the UKMEC a Category 1, 2, 3 or 4 is given. The definitions of the categories are given in Table 1. Table 1: Definition of UKMEC categories Category 1 A condition for which there is no restriction for the use of the method Category 2 A condition where the advantages of using the method generally outweigh the theoretical or proven risks Category 3 A condition where the theoretical or proven risks usually outweigh the advantages of using the method. The provision of a method requires expert clinical judgement and/or referral to a specialist contraceptive provider, since use of the method is not usually recommended unless other more appropriate methods are not available or not acceptable Category 4 A condition which represents an unacceptable health risk if the method is used
  • All VTE risk assessment should be individualised.
    The knowledge of thrombophilia is only a single risk factor and must be viewed in context with the rest of the patient's risk factors. For example, a small, thin primigravida who has factor V Leiden (heterozygote) does not need antenatal prophylaxis although this could be considered postnatally, particularly if there are additional VTE risk factors. Conversely, a woman (para 5) with a BMI of 40 with factor V Leiden (heterozygote) would be advised to have LMWH both antenatally and for 6 weeks postnatally.