Final-VTE-Slide-Deck.. - Council on Patient Safety in Women`s

Thursday,
Thursday, December
December 3,
3, 2015
2015
11:00
11:00 a.m.
a.m. Eastern
Eastern
Dial
Dial In:
In: 888.863.0985
888.863.0985
Conference
Conference ID:
ID: 62201128
62201128
Slide 1
Speakers
Alexander Friedman, MD, MPH, FACOG
Columbia University Medical Center
New York, NY
Douglas Montgomery, MD, FACOG
Southern California Permanente Medical Group
Riverside Medical Center, Riverside California
Director Maternal Fetal Medicine
Chair Southern California Kaiser Obstetric VTE committee
Co- Chair California Maternal Quality Care Collaborative VTE Task Force
Slide 2
Disclosures
Alexander Friedman, MD, MPH FACOG has
no real or perceived conflicts of interest to
disclose.
Douglas Montgomery, MD, FACOG has no
real or perceived conflicts of interest to
disclose.
Slide 3
Objectives
 Provide an in-depth overview of the Maternal
Venous Thromboembolism Prevention Patient
Safety Bundle.
 Take a look at the processes, methods, and
tools that were used to develop the bundle.
 Give suggestions for how to effectively
implement and utilize the bundle within your
organization.
 Identify resources to customize the bundle for
use within your organization.
Slide 4
National Partnership for Maternal Safety
Focus on decreasing Maternal Mortality & Morbidity
Three core bundles focus on leading causes of maternal mortality
and morbidity that are amenable to prevention. Bundles are sets of
critical clinical practices when performed systematically, have been
validated to improve outcomes. Safety Bundles are not meant to
introduce new guidelines but rather organize existing materials in
ways that facilitate systematic implementation in every maternity
unit in the United States
Venous Thromboembolism
Severe Hypertension in pregnancy
Obstetric Hemorrhage
Slide 5
D'Alton M.E. et al. The national partnership for maternal safety. Obstet Gynecol 2014;123:973.
Institute for Healthcare Improvement. Evidence-Based Care Bundles. Ihi.org.
VTE WORKING GROUP
Comprised of the following individuals with representation
from obstetrics, nursing, midwifery, and anesthesia:
•
•
•
•
•
•
•
•
•
•
STEVEN CLARK, MD
MARY D’ALTON, MD
ROBYN D’ORIA, MA, RNC, APC
ALEXANDER FRIEDMAN, MD
JENNIFER FROST, MD, MPH
AFSHAN HAMEED, MD
DEBORAH KARSNITZ, DNP, CNM
DOUGLAS MONTGOMERY, MD
MICHAEL PAIDAS, MD
RICHARD SMILEY, MD
Slide 6
Pregnancy Related Mortality
United States (1987-2010)
Slide 7
Creanga, A.A., et al. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol. (2015
Jan);125(1):5-12. doi: 10.1097/AOG.0000000000000564.
New York City 2006-2010
Pregnancy-Associated Mortality
Slide 8
NYC Department of Health and Hygiene, Bureau of Maternal, Infant and Reproductive Health. (2015). Report
of the Pregnancy-Associated Mortality Review Project.
Morbidity
Long-term sequelae include:
• Recurrent VTE
• Post-thrombotic syndrome
 May develop in up to 50% of patients
who experience DVT
 Chronic leg pain, edema, erythema
and ulcerations
• Lung damage
• Cardiovascular
Slide 9
Vasquez, SR et al. Cardiology Patient Page: Postthrombotic Syndrome. Circulation. (2010);
121:217-219
Venous Thromboembolism (VTE) Prophylaxis
“single cause of death most amenable to reduction by
systematic change in practice” – Steven Clark, M.D., Semin
Perinatol 2012;36(1):42-7
Direct Deaths per
Million
Maternities by Cause
UK 1994-2008
Slide 10
Saving Mothers’ Lives 2006-2008, National Launch, March 2011 Professor Gwyneth Lewis OBE
FRCOG FACOG
VTE Prophylaxis
The Agency for Healthcare Research and Quality defined VTE as
the “number one patient safety practice” for hospitalized
patients.
Safe practices published by the National Quality Forum (NQF)
recommend:
• Routine evaluation of hospitalized patients for risk of VTE
• Use of appropriate prophylaxis
ENDORSE Survey
• Evaluated prophylaxis rates in 17,084 major surgery
patients
• More than one third of patients at risk for VTE (38%) did
not receive prophylaxis
• Rates varied by surgery type
Shojania KG, Duncan BW, McDonald DM, et al. (Eds.). (2001). "Making healthcare safer; A critical analysis of patient safety practices
(Evidence Report/Technology Assessment No. 43)." Prepared by the University of California at San Francisco-Stanford Evidenced-based
Practice Center under Contract no. 290-97-0013 (AHRQ Publication NO.01-E058). Rockville, MD: Agency for Healthcare Research and
Quality.
National Quality Forum. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism. (2006).
Slide 11
Cohen AT, Tapson VF, Bergmann JF, et al. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE
study): a multinational cross-sectional study. The Lancet. 2008; 371: 387-394.
Prophylaxis in Vaginal Delivery
Hospitalizations
No Prophylaxis
Characteristic
Any Prophylaxis
n
%
n
%
2,605,151
97.4
68,835
2.6
2006
366,317
98.4
5950
1.6
2007
374,851
98.3
6662
1.8
2008
352,438
97.8
7825
2.2
2009
354,460
97.3
9884
2.7
2010
367,470
96.9
11,675
3.1
2011
402,359
97.1
11,911
2.9
2012
390,881
97.2
11,303
2.8
All Patients
Year of Delivery
Slide 12
Friedman A, et al. Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations. Am J Obstet
Gynecol. 2015 Feb; 212(2): 221.e1-12.
Underuse of Post-cesarean
Thromboembolic Prophylaxis
Characteristic
None
Mechanical
Pharmacologic
Combination
955,787 (75.7)
278,669 (22.1)
16,639 (1.3)
12,110 (1.0)
2003
115,663 (91.6)
8,717 (6.9)
1,274 (1.0)
664 (0.5)
2004
124,230 (87.4)
15,674 (11.0)
1,319 (0.9)
923 (0.7)
2005
131,220 (84.6)
21,013 (13.5)
1,889 (1.2)
1,051 (0.7)
2006
154,876 (81.0)
32,302 (16.9)
2,413 (1.3)
1,608 (0.8)
2007
145,589 (74.7)
44,842 (23.0)
2,451 (1.3)
2,053 (1.1)
2008
131,250 (66.0)
62,545 (31.4)
2,852 (1.4)
2,294 (1.2)
2009
125,096 (60.5)
75,315 (36.4)
3,609 (1.8)
2,753 (1.3)
2010
27,863 (58.4)
18,261 (38.3)
832 (1.7)
764 (1.6)
Year of
Surgery
Slide 13
Friedman A.M., Ananth C.V., et al. (2013). Underuse of post cesarean thromboembolic prphylaxis. Am J Obstet
and Gynecol, 122(6):1197-204.
Underuse of Post-cesarean
Thromboembolic Prophylaxis
Lack of Protocol Adherence
• Systematic review of over 2,500 surgical patients
demonstrated up to one fourth are noncompliant
with post operative mechanical
thromboprophylaxis.
• Observational study demonstrated noncompliance
with post-cesarean mechanical thromboprophylaxis
in 21% of 293 patients.
• Lack of adherence persist despite education &
audits.
Craigie, Samantha et al. Adherence to mechanical thromboprophylaxis after surgery: A systematic review and metaanalysis. Thrombosis Research. (2015). 136 (4): 723 – 72.
Palmerola KL, et al. A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean
delivery from three major guidelines. BJOG. (2015 Oct). DOI: 10.1111/1471-0528.13706.
Slide 14
Brady, et al. Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet &
Gynecol. (2015 Jan); 125 (1): 19.
Maternal Venous Thromboembolism Prevention Safety Bundle
READINESS (Every Unit)
• Use a standardized thromboembolism risk assessment tool for VTE during:
• Outpatient prenatal care
• Antepartum hospitalization
• Hospitalization after cesarean or vaginal deliveries
• Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)
• Apply standardized tool to all patient to asses VTE risk at time point designated under
“Readiness”
• Apply standardized tool to identify patients for thromboprophylaxis
• Provide patient education
• Provide all healthcare providers education regarding risk assessment tools and recommended
thromboprophylaxis
RESPONSE (Every Unit)
• Use standardized recommendations for mechanical thromboprophylaxis
• Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic
anticoagulation
• Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with
neuraxial anesthesia
REPORTING/SYSTEMS LEARNING (Every Unit)
• Review all thromboembolism events for systems issues and compliance with protocols
• Monitor process metrics and outcomes in a standardized fashion
• Assess
for complications of pharmacologic thromboprophylaxis
Slide
15
VTE Prevention: Readiness
• Thromboembolism prophylaxis is a Joint
Commission quality measure
• The Joint Commission states that all patients
should receive VTE prophylaxis or have
documentation why no VTE prophylaxis was given
 "the day of or the day after hospital admission"
 "the day of or the day after surgery end date for surgeries
that start the day of or the day after hospital admission”
Slide 16
Specifications Manual for National Hospital Inpatient Safety. The Joint Commission. (2015); 5.
VTE Prevention: Readiness
Excluded populations Joint Commission
measure:
Patients with ICD-9-CM Principal or Other
Diagnosis Codes of Obstetrics
Sample Codes:
826
Slide 17
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety
(Appendix A, Table 7.02)
VTE Prevention: Readiness
Recommendation: The National Partnership
recommends that this Joint Commission measure be
extended to the obstetric population
All patients should be assessed for VTE risk multiple
times in pregnancy including during:
• Presentation for prenatal care
• Hospitalization for an antepartum indication
• Delivery hospitalization (in-house postpartum)
• Discharge from a delivery hospitalization
Slide 18
VTE Prevention: Readiness
VTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
60
30
Antepartum
½ of all VTE
5
Initial Risk
Assessment
Slide 19
Marik, P.E. Venous thromboembolism in pregnancy. Clin Chest Med. (2010 Dec); 31(4):731-40.
DOI: 10.1016/j.ccm.2010.06.004.
Delivery & Postpartum
Discharge
VTE Prevention: Recognition
• VTE risk assessment tools should be applied to every
patient to determine risk for VTE
• Risk assessment tools based on recommendations from
major society guidelines
 American College of Obstetricians and Gynecology
(ACOG)
 American College of Chest Physicians (ACCP)
 Royal College of Obstetricians and Gynaecologists
(RCOG)
• Pharmacologic prophylaxis may be with unfractionated
heparin (UFH) or low-molecular weight heparin (LMWH)
Bates S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2
Suppl):e691S-736S.
American College of Obstetricians and Gynecologists. Thromboembolism in Pregnancy. Practice Bulletin No. 123. Obstet
Gynecol (2011); 118: 718–29
Slide 20
Royal College of Obstetricians and Gynaecologists. Thrombosis and Embolism during Pregnancy and the Puerperium,
Reducing the Risk. Green-top Guideline No. 37a; April 2015.
VTE Prevention: Recognition
ANTEPARTUM MANAGEMENT
– ACOG
• Anticoagulation during pregnancy and postpartum for women with
a history of thrombosis or those those with high-risk acquired or
inherited thrombophilias. Immobility considered as a modifying
risk factor
– ACCP
• Thromboprophylaxis recommended for: reduced mobility, history of VTE or
high risk thrombophilia
– RCOG
• Thromboprophylaxis recommended for: reduced mobility, history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 21
Recognition and Response at
First Prenatal Visit
Clinical history
Multiple VTE episodes
VTE with high-risk (HR) thrombophilia
VTE with acquired thrombophilia
Anticoagulation
Treatment dose
LMWH or UFH
Idiopathic VTE
VTE with pregnancy or oral contraceptive
VTE with low risk (LR) thrombophilia
Family history of VTE with HR thrombophilia
HR thrombophilia
1st VTE provoked
Family history of VTE with LR thrombophilia
LR thrombophilia (no prior event)
Bates S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012
Feb;141(2 Suppl):e691S-736S.
Slide 22
American College of Obstetricans and Gynecologists. Thromboembolism in Pregnancy. Practice Bulletin No. 123. Obstet
Gynecol (2011); 118: 718–29
Prophylactic
LMWH or
UFH
No treatment
In-Patient Antepartum Hospitalization
Recognition & Response
In-Patient Antepartum
Hospitalization for at least
All patients:
72 hours:
• All patients should be considered for
pharmacologic prophylaxis.
• For women at high risk of delivery or bleeding,
mechanical thromboprophylaxis should be utilized.
• Consider prophylaxis with unfractionated heparin
near time of expected delivery rather than low
molecular weight heparin (LMWH) to facilitate
intrapartum conduction anesthesia.
Slide 23
In-Patient Antepartum Hospitalization
Recognition
ANTEPARTUM ADMISSION: Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS :
HOSPITALIZED >/= 3 days ~ 12 times increased risk of VTE
* “The association between admission and venous
thromboembolism remained when we restricted our analysis to
women without medical comorbidities including obesity, cardiac
disease, and varicose veins”.
*HOSPITALIZED < 3 days ~ 4 times increased VTE risk
*Sultan, et al. Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study
from England. BMJ. (2013 Nov); 7: 347
Slide 24
Virkus, et al. Risk Factors for Venous Thromboembolism in 1.3 Million Pregnancies: A Nationwide Prospective
Cohort. PLoS One. (2014 May); e96495
In-Patient Antepartum Hospitalization
Recognition
ANTEPARTUM ADMISSION: BMI & Immobility
Slide 25
Bates, S.M. et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
CHEST. (2012 Feb); 141(2)(Suppl):e691S–e736S
VIRCHOW’S TRIAD
LEFT
Slide 26
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors
Previous VTE
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
Thrombophilia*
Acute infection and/or rheumatologic
disorder
Obesity (BMI >25kg/m2)
Pregnancy
* Antithrombin deficiency, Protein C or S deficiency, factor V Leiden, G20210A prothrombin gene mutation,
antiphospholipid antibody syndrome.
Slide 27
Barbar, S. et al, A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism:
the Padua Prediction Score. J Thromb Haemost. (2010 Nov); 8 (11):2450-7. doi: 10.1111/j.1538-7836.2010.04044.x.
Kahn, S.R. et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed:
American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. (2012 Feb); 141(2 Suppl):e195S-226S. doi:
10.1378/chest.11-2296.
Points
3
3
3
1
1
1
RCOG Clinical Recommendations
• If admitted to hospital antenatally consider
thromboprophylaxis
• If prolonged admission (> 3 days) or
readmission to hospital during the
pueperium consider thromboprophylaxis
Slide 28
Royal College of Obstetricians and Gynaecologists. Thrombosis and Embolism during Pregnancy and the
Puerperium, Reducing the Risk. Green-top Guideline No. 37a; April 2015.
Antepartum Hospitalization RR
Warrants VTE Prophylaxis
1. Biologic Plausibility
RR 12 - 60
2. Epidemiologic Data
3. RCOG & PADUA RAM
A
Major Risk Factor
Slide 29
D
M
I
T
Recognition and Response:
Postpartum patients in the hospital
• How should patients be prophylaxed?
• After a vaginal delivery
• After a cesarean delivery
• Scoring systems
• RCOG
• ACCP
• Caprini
Slide 30
Vaginal Delivery
• All patients
 Early mobilization
 Avoid dehydration
• Very high-risk patients should receive
postpartum pharmacologic prophylaxis with
LMWH or UFH
 History of VTE or thrombophilia
 Already receiving LMWH or UFH as outpatients
• For women with multiple, lesser risk factors for
VTE by RCOG criteria
 Pharmacologic prophylaxis with LMWH or UFH may
be considered
Slide 31
Cesarean Delivery
Women undergoing cesarean delivery should:
• Receive mechanical prophylaxis devices
perioperatively and postpartum
• Receive pharmacologic prophylaxis (LMWH or
UFH) based on risk factors
An “opt-out” strategy where all women undergoing
cesarean delivery receive prophylaxis with LMWH or
UFH unless there is a specific contraindication is also
an acceptable approach
Slide 32
ACCP Recommendations
Pharmacologic prophylaxis (LMWH) recommended for one major or
two or more minor risk factors
Mechanical prophylaxis recommended for those with contraindications
to pharmacologic prophylaxis
Major risk factors - VTE risk ~ 3%
Minor risk factors - VTE
risk ~ 3%
BMI >30 kg/m2
Chest Post Cesarean Section
Immobility (strict bed rest ≥1 week in the antepartum
period)
Postpartum haemorrhage ≥1000 mL with surgery
Previous VTE
Pre-eclampsia with fetal growth restriction
Thrombophilia
Antithrombin deficiency
Factor V Leiden (homozygous or heterozygous)
Prothrombin G20210A (homozygous or heterozygous)
Medical conditions
Systemic Lupus erythematosus
Heart disease
Sickle cell disease
Blood transfusion
Postpartum infection
Recommendations
Slide 33
Bates S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines. Chest. 2012 Feb;141(2 Suppl):e691S-736S.
Multiple pregnancy
Emergency caesarean
Smoking >10 cigarettes/day
Fetal growth restriction
Thrombophilia
Protein C deficiency
Protein S deficiency
Pre-eclampsia
RCOG Recommendations
• If total score > 4 antenatally, consider thromboprophylaxis from
the first trimester
• If total score 3 antenatally, consider thromboprophylaxis from 28
weeks
• If total score > 2 postnatally, consider thrombroprophylaxis for
at least 10 days
• If admitted to hospital antenatally consider thromboprophylaxis
• If prolonged admission (> 3 days) or readmission to hospital
during the pueperium consider thromboprophylaxis
Slide 34
Royal College of Obstetricians and Gynaecologists. Thrombosis and Embolism during Pregnancy and the
Puerperium, Reducing the Risk. Green-top Guideline No. 37a; April 2015.
RCOG Recommendations
4 Points
•
•
2 Points
Previous VTE (except for a single event related to
major surgery
Ovarian hyperstimulation syndrome (1st trimester
only)
•
•
Cesarean in labor
Obesity (BMI >40kg/m2)
3 Points
•
•
•
•
•
Previous VTE provoked by major surgery
Known high-risk thrombophilia
Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum, e.g.
appendectomy, postpartum sterilization
Hyperemesis
Medical comorbidities e.g. cancer, heart failure, active systemic lupus erythematosus, inflammatory
polyarthropathy or inflammatory bowel disease, nephrotic syndrome, type I diabetes mellitus with
nephropathy, sickle cell disease, current intravenous drug user
1 Point
•
•
•
•
•
•
•
•
Family history of unprovoked or estrogenrelated VTE in first-degree relative
Known low-risk thrombophilia (no VTE
Age (>35 years)
Obesity (BMI >30kg/m2)
Parity > 3
Smoker
Gross varicose veins
Preeclampsia in current pregnancy
Slide 35
•
•
•
•
•
•
•
•
Assisted reproductive technology/in vitro
fertilization (antenatal only)
Multiple pregnancy
Elective cesarean
Mid-cavity rotational operative delivery
Prolonged labor (>24 hours)
Postpartum hemorrhage (>1 liter or blood
transfusion)
Preterm birth <37 weeks in current pregnancy
Stillbirth in current pregnancy
Royal College of Obstetricians and Gynaecologists. Thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the Risk. Green-top Guideline No. 37a; April 2015.
CHEST APPLICATION CAPRINI
MODEL
General Abdominal or Pelvic Surgery
SCORE
RISK
PROPHYLAXIS
estimated VTE risk no
prophylaxis
1-2 Pregnancy = 1 point
LOW
~ 1.5% risk VTE
- intermittent pneumatic compression
Surgery < 45 minutes = 1
point
3-4
MECHANICAL
MEDIUM
~ 3% risk VTE
MECHANICAL OR CHEMICAL
- LMWH OR LD UFH
>/= 5 Previous VTE= 3 points
Thrombophilia = 3 points
Consider additional
HIGH
~ 6% risk VTE
MECHANICAL PLUS
CHEMICAL
Risks
Many pregnant patients will
have multiple additional risks
(slide ***)
Gould, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST
(2012 Feb); 141(2)(Suppl):e227S–e277S
Slide 36
Caprini, J.A. Caprini DVT Risk Assessment. Venous Resource Center. Web: http://venousdisease.com/caprini-dvtrisk-assessment/
* Original Caprini scoring system condensed to include conditions commonly encountered in
obstetric patients
Table 1. Modified Caprini risk assessment model *
Risk factors
Slide 37
Points
Age 41-60
1
Minor surgery (less than 45 minutes)
1
Visible varicose veins
1
Swollen legs (current)
1
Overweight or obese (body mass index above 25kg/m2)
1
Currently on bed rest
1
Serious lung disease including pneumonia (<1 month)
1
Pregnancy or postpartum (<1 month)
1
History of unexplained stillborn infant, recurrent spontaneous abortion
(> 3), premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking, diabetes, BMI >40kg/m2, blood transfusions)
1
Central venous access
2
Major surgery (>45 minutes)
2
Patient confined to bed (>72 hours)
2
Family history of thrombosis
3
History of DVT/PE
3
Prothrombin 20210A or factor V Leiden
3
Lupus anticoagulant or elevated anticardiolipin antibodies
3
Elevated serum homocysteine
3
Other congenital or acquired thrombophilia
3
Caesarean Thromboprophylaxis
Comparison of 3 Leading Guidelines
• 293 patients included in analysis
1%
ACOG
35%
85%
Slide 38
All based on having a prior event
Chest
RCOG
Emergency caesarean, Pre-eclampsia
Obesity, Multiple gestation
Postpartum haemorrhage
Caesarean during labor, Maternal Age ≥35
Obesity, Pre-eclampsia, Infection, High Parity
In Press: Palmerola KL, et al. A comparison of recommendations for pharmacologic thromboembolism
prophylaxis after caesarean delivery from three major guidelines. BJOG. (2015 Oct). DOI:
10.1111/1471-0528.13706.
Recognition and Response
Postpartum after delivery hospitalization
Clinical history
Multiple VTE episodes
VTE with high-risk (HR) thrombophilia
VTE with acquired thrombophilia
Anticoagulation
6 Weeks Treatment
LMWH/UFH
Idiopathic VTE
VTE with pregnancy or oral contraceptive
VTE with low risk (LR) thrombophilia
Family history of VTE with HR thrombophilia
HR thrombophilia (including acquired)
6 Weeks
Prophylactic
LMWH/UFH
VTE provoked*
LR thrombophilia and family history of VTE*
* (two changes from initial assessment)
LR thrombophilia
Bates S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012
Feb;141(2 Suppl):e691S-736S.
Slide 39American College of Obstetricans and Gynecologists. Thromboembolism in Pregnancy. Practice Bulletin No. 123.
Obstet Gynecol (2011); 118: 718–29
No treatment
Protocols
Protocolsfor
forProphylaxis
Prophylaxis
Agent
LMWH
Enoxaparin
Dalteparin
Tinzaparin
Weight based
UFH
Unfractionated heparin
Gestational age-based
<50kg
20mg daily
2500 units daily
3500 units daily First
trimester
5000-7500 units
Twice daily
50-90kg
40mg daily
5000 units daily
4500 units daily Second
trimester
7500-10000 units
Twice daily
91-130kg
60mg daily*
7500 units daily* 7000 units
daily*
131-170kg
80mg daily*
>170kg
0.6mg/kg/day*
10000 units
daily*
75 units/kg/day
Third
trimester
10000 units
Twice daily
9000 units daily
75 units/kg/day
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
*=may be given in two divided doses
Slide 40
Adapted from American College of Obstetricans and Gynecologists. Thromboembolism in Pregnancy. Practice
Bulletin No. 123. Obstet Gynecol (2011); 118: 718–29; Royal College of Obstetricians and Gynaecologists.
Thrombosis and Embolism during Pregnancy and the Puerperium, Reducing the Risk. Green-top Guideline No.
37a; April 2015.; Bates S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic
Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical
Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e691S-736S.
Timing of Neuroaxial Anesthesia
Antepartum/Intrapartum
UFH ≤10,000IU/day
No contraindications to timing of heparin dose and performance of
neuraxial blockade¥
UFH >10,000IU/day
Wait 12 hours after last dose prior to neuraxial blockade or check
aPPT *
IV Heparin
Wait 4-6 hours after discontinuation of IV heparin; consider checking
aPPT
LMWH prophylaxis
Wait 12 hours post last dose prior to neuraxial blockade
LMWH therapeutic
Wait 24 hours post last dose prior to neuraxial blockade
Postpartum
UFH ≤10,000IU/day
Heparin may be administered at any time interval after epidural
catheter removal or spinal needle placement
UFH >10,000IU/day or IV
Heparin
Wait ≥1 hour after epidural catheter removal or spinal needle
placement
LMWH prophylaxis
Wait ≥4 hours after epidural catheter removal or spinal needle
placement
LMWH therapeutic
Avoid therapeutic dosing with epidural catheter in situ. Wait
at least 24 hours after catheter removal or spinal needle
¥ No
specific society guidelines for management of
patients also receiving aspirin
* No specific society guidelines for management
Slide 41
FDA. FDA Drug Safety Communication: Updated recommendations to decrease risk of spinal column
bleeding and paralysis in patients on low molecular weight heparins. (2013 Nov).
New York Presbyterian Hospital. Surgical Prophylaxis: Antibiotic Recommendations for Adult Patients.
Horlocker, T.T., et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic
Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third
Edition). Regional Anesthesia and Pain Medicine. (2010); 35 (1): 64-101
Post-Cesarean VTE
Prophylaxis
• Unfractionated heparin (UFH)
 The patient may receive standard order of 5000 units SC
every 12 hours starting at any time before or after spinal
anesthesia placement or epidural catheter placement or
removal
 A reasonable clinical strategy is to administer the first
dose of 5000 units SC when the patient meets PACU
discharge criteria
Slide 42
New York Presbyterian Hospital. Surgical Prophylaxis: Antibiotic Recommendations for Adult Patients.
NYP protocol
Post-Cesarean VTE
Prophylaxis
• Low-molecular-weight heparin (LMWH)
 The patient should receive the first dose of LMWH no
sooner than 6 hours postoperatively regardless of
anesthesia technique
 If an epidural catheter remains in situ for pain control,
it should not be removed until 12 hours after last dose
of LMWH
 If the epidural catheter is to be removed prior to
a dose of LMWH, the LMWH may not be given until 4
hours after removal
Slide 43
Sources: FDA Drug Safety Communication Nov, 2013; NYP protocol
New York Presbyterian Hospital. Surgical Prophylaxis: Antibiotic Recommendations for Adult Patients.
Heparin Induced
Thrombocytopenia (HIT)
•
Extremely rare complication in the obstetric population
receiving UFH/LMWH for VTE prevention
•
For patients expected to be on either UFH or LMWH for
greater than >7 days a reasonable clinical strategy is to
check a complete blood count 7-10 days after initiation
of therapy
•
Some guidelines, such as those from ASRA, recommend
that patients receiving prophylaxis have a CBC checked
4 days after prophylaxis is initiated
Slide 44
Reporting/Systems Learning
Recommendation
Review all thromboembolism events for
systems issues and compliance with protocols
Monitor process metrics and outcomes in a
standardized fashion
Assess for complications of pharmacologic
thromboprophylaxis
Slide 45
Conclusion
• All patients require VTE risk assessment at multiple time
points in pregnancy and postpartum
• All patients undergoing cesarean delivery require
mechanical prophylaxis, early ambulation, and adequate
hydration
• Women with additional risk factors for VTE after delivery
will benefit from pharmacologic prophylaxis
• Empiric pharmacologic prophylaxis is a reasonable option
for
 all women undergoing cesarean delivery
 all antepartum hospital admissions >72 hours
Slide 46
Bundle Resources
READINESS
– Bahl V, et al. A validation study of a retrospective venous thromboembolism risk scoring method. Ann
Surg. 2010 Feb;251(2):344-50. Note: Abstract only; must be subscriber to access full-text.
– Barbar S, et al. A risk assessment model for the identification of hospitalized medical patients at risk for
venous thromboembolism: the Padua Prediction Score. J Thromb Haemost. 2010 Nov;8(11):2450-7.
– Bates S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice
Guidelines. Chest. 2012 Feb;141(2 Suppl):e691S-736S.
– Royal College of Obstetricians and Gynaecologists. Thrombosis and Embolism during Pregnancy and the
Puerperium, Reducing the Risk. Green-top Guideline No. 37a; April 2015.
– Thromboembolism in Pregnancy. ACOG practice bulletin No. 123. American College of Obstetricians and
Gynecologists. Obstet Gynecol. 2011 Sep;118(3):718-29. Available until 10/28/16
RECOGNITION
– National Blood Clot Alliance. Available at: http://www.stoptheclot.org/. Retrieved October 29, 2015.
– Partnership for Patients Venous Thromboembolism (VTE) Resource List.
– Available at: http://partnershipforpatients.cms.gov/p4p_resources/tspvenusthromboembolism/toolvenousthromboembolismvte.html. Retrieved October 29, 2015.
RESPONSE
– American College of Obstetricians and Gynecologists. Safe motherhood initiative. Available
– at: http://www.acog.org/About-ACOG/ACOG-Districts/District-II/SMI-Registration. Retrieved September
22, 2014.
– Dresang L, et al. Venous Thromboembolism During Pregnancy. Am Fam Physician. 2008 Jun
15;77(12):1709-1716.
– Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ); May 2010. Available at:
http://archive.ahrq.gov/news/events/conference/2009/maynard2/index.html. Retrieved October 29, 2015.
REPORTING/SYSTEMS LEARNING
No resources selected.
Slide 47
Q&A Session
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Slide 48
Next Safety Action Series
Empowering Patients, Improving Outcomes
Maternal Mental Health Presentation
Monday, December 14th, 2015 | 12:00 p.m. Eastern
Lisa Kay
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2020 Mom
Postpartum Support International
Postpartum Progress
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Slide 49