Thursday, December 3, 2015 11:00 a.m....
Transcript of Thursday, December 3, 2015 11:00 a.m....
Slide 1
Thursday December 3 2015
1100 am EasternDial In 8888630985
Conference ID 62201128
Thursday December 3 2015
1100 am EasternDial In 8888630985
Conference ID 62201128
Slide 2Slide 2
Speakers
Alexander Friedman MD MPH FACOG Columbia University Medical Center New York NY
Douglas Montgomery MD FACOGSouthern California Permanente Medical GroupRiverside Medical Center Riverside CaliforniaDirector Maternal Fetal Medicine Chair Southern California Kaiser Obstetric VTE committeeCo- Chair California Maternal Quality Care Collaborative VTE Task Force
Slide 3
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 4
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 5
National Partnership for Maternal SafetyFocus on decreasing Maternal Mortality amp 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
DAlton ME et al The national partnership for maternal safety Obstet Gynecol 2014123973
Institute for Healthcare Improvement Evidence-Based Care Bundles Ihiorg
Slide 6
VTE WORKING GROUPComprised of the following individuals with representation from obstetrics nursing midwifery and anesthesia
bull STEVEN CLARK MD
bull MARY DrsquoALTON MD
bull ROBYN DrsquoORIA MA RNC APC
bull ALEXANDER FRIEDMAN MD
bull JENNIFER FROST MD MPH
bull AFSHAN HAMEED MD
bull DEBORAH KARSNITZ DNP CNM
bull DOUGLAS MONTGOMERY MD
bull MICHAEL PAIDAS MD
bull RICHARD SMILEY MD
Slide 7
Pregnancy Related MortalityUnited States (1987-2010)
Creanga AA et al Pregnancy-related mortality in the United States 2006-2010 Obstet Gynecol (2015 Jan)125(1)5-12 doi 101097AOG0000000000000564
Slide 8
New York City 2006-2010Pregnancy-Associated Mortality
NYC Department of Health and Hygiene Bureau of Maternal Infant and Reproductive Health (2015) Report of the Pregnancy-Associated Mortality Review Project
Slide 9
Morbidity
Long-term sequelae include
bull Recurrent VTEbull Post-thrombotic syndrome May develop in up to 50 of patients
who experience DVT Chronic leg pain edema erythema
and ulcerationsbull Lung damagebull Cardiovascular
Vasquez SR et al Cardiology Patient Page Postthrombotic Syndrome Circulation (2010) 121217-219
Slide 10
Venous Thromboembolism (VTE) Prophylaxisldquosingle cause of death most amenable to reduction by systematic change in practicerdquo ndash Steven Clark MD SeminPerinatol 201236(1)42-7
Saving Mothersrsquo Lives 2006-2008 National Launch March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG
Direct Deaths per Million
Maternities by Cause UK 1994-2008
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
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A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 2Slide 2
Speakers
Alexander Friedman MD MPH FACOG Columbia University Medical Center New York NY
Douglas Montgomery MD FACOGSouthern California Permanente Medical GroupRiverside Medical Center Riverside CaliforniaDirector Maternal Fetal Medicine Chair Southern California Kaiser Obstetric VTE committeeCo- Chair California Maternal Quality Care Collaborative VTE Task Force
Slide 3
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 4
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 5
National Partnership for Maternal SafetyFocus on decreasing Maternal Mortality amp 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
DAlton ME et al The national partnership for maternal safety Obstet Gynecol 2014123973
Institute for Healthcare Improvement Evidence-Based Care Bundles Ihiorg
Slide 6
VTE WORKING GROUPComprised of the following individuals with representation from obstetrics nursing midwifery and anesthesia
bull STEVEN CLARK MD
bull MARY DrsquoALTON MD
bull ROBYN DrsquoORIA MA RNC APC
bull ALEXANDER FRIEDMAN MD
bull JENNIFER FROST MD MPH
bull AFSHAN HAMEED MD
bull DEBORAH KARSNITZ DNP CNM
bull DOUGLAS MONTGOMERY MD
bull MICHAEL PAIDAS MD
bull RICHARD SMILEY MD
Slide 7
Pregnancy Related MortalityUnited States (1987-2010)
Creanga AA et al Pregnancy-related mortality in the United States 2006-2010 Obstet Gynecol (2015 Jan)125(1)5-12 doi 101097AOG0000000000000564
Slide 8
New York City 2006-2010Pregnancy-Associated Mortality
NYC Department of Health and Hygiene Bureau of Maternal Infant and Reproductive Health (2015) Report of the Pregnancy-Associated Mortality Review Project
Slide 9
Morbidity
Long-term sequelae include
bull Recurrent VTEbull Post-thrombotic syndrome May develop in up to 50 of patients
who experience DVT Chronic leg pain edema erythema
and ulcerationsbull Lung damagebull Cardiovascular
Vasquez SR et al Cardiology Patient Page Postthrombotic Syndrome Circulation (2010) 121217-219
Slide 10
Venous Thromboembolism (VTE) Prophylaxisldquosingle cause of death most amenable to reduction by systematic change in practicerdquo ndash Steven Clark MD SeminPerinatol 201236(1)42-7
Saving Mothersrsquo Lives 2006-2008 National Launch March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG
Direct Deaths per Million
Maternities by Cause UK 1994-2008
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 3
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 4
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 5
National Partnership for Maternal SafetyFocus on decreasing Maternal Mortality amp 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
DAlton ME et al The national partnership for maternal safety Obstet Gynecol 2014123973
Institute for Healthcare Improvement Evidence-Based Care Bundles Ihiorg
Slide 6
VTE WORKING GROUPComprised of the following individuals with representation from obstetrics nursing midwifery and anesthesia
bull STEVEN CLARK MD
bull MARY DrsquoALTON MD
bull ROBYN DrsquoORIA MA RNC APC
bull ALEXANDER FRIEDMAN MD
bull JENNIFER FROST MD MPH
bull AFSHAN HAMEED MD
bull DEBORAH KARSNITZ DNP CNM
bull DOUGLAS MONTGOMERY MD
bull MICHAEL PAIDAS MD
bull RICHARD SMILEY MD
Slide 7
Pregnancy Related MortalityUnited States (1987-2010)
Creanga AA et al Pregnancy-related mortality in the United States 2006-2010 Obstet Gynecol (2015 Jan)125(1)5-12 doi 101097AOG0000000000000564
Slide 8
New York City 2006-2010Pregnancy-Associated Mortality
NYC Department of Health and Hygiene Bureau of Maternal Infant and Reproductive Health (2015) Report of the Pregnancy-Associated Mortality Review Project
Slide 9
Morbidity
Long-term sequelae include
bull Recurrent VTEbull Post-thrombotic syndrome May develop in up to 50 of patients
who experience DVT Chronic leg pain edema erythema
and ulcerationsbull Lung damagebull Cardiovascular
Vasquez SR et al Cardiology Patient Page Postthrombotic Syndrome Circulation (2010) 121217-219
Slide 10
Venous Thromboembolism (VTE) Prophylaxisldquosingle cause of death most amenable to reduction by systematic change in practicerdquo ndash Steven Clark MD SeminPerinatol 201236(1)42-7
Saving Mothersrsquo Lives 2006-2008 National Launch March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG
Direct Deaths per Million
Maternities by Cause UK 1994-2008
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 4
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 5
National Partnership for Maternal SafetyFocus on decreasing Maternal Mortality amp 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
DAlton ME et al The national partnership for maternal safety Obstet Gynecol 2014123973
Institute for Healthcare Improvement Evidence-Based Care Bundles Ihiorg
Slide 6
VTE WORKING GROUPComprised of the following individuals with representation from obstetrics nursing midwifery and anesthesia
bull STEVEN CLARK MD
bull MARY DrsquoALTON MD
bull ROBYN DrsquoORIA MA RNC APC
bull ALEXANDER FRIEDMAN MD
bull JENNIFER FROST MD MPH
bull AFSHAN HAMEED MD
bull DEBORAH KARSNITZ DNP CNM
bull DOUGLAS MONTGOMERY MD
bull MICHAEL PAIDAS MD
bull RICHARD SMILEY MD
Slide 7
Pregnancy Related MortalityUnited States (1987-2010)
Creanga AA et al Pregnancy-related mortality in the United States 2006-2010 Obstet Gynecol (2015 Jan)125(1)5-12 doi 101097AOG0000000000000564
Slide 8
New York City 2006-2010Pregnancy-Associated Mortality
NYC Department of Health and Hygiene Bureau of Maternal Infant and Reproductive Health (2015) Report of the Pregnancy-Associated Mortality Review Project
Slide 9
Morbidity
Long-term sequelae include
bull Recurrent VTEbull Post-thrombotic syndrome May develop in up to 50 of patients
who experience DVT Chronic leg pain edema erythema
and ulcerationsbull Lung damagebull Cardiovascular
Vasquez SR et al Cardiology Patient Page Postthrombotic Syndrome Circulation (2010) 121217-219
Slide 10
Venous Thromboembolism (VTE) Prophylaxisldquosingle cause of death most amenable to reduction by systematic change in practicerdquo ndash Steven Clark MD SeminPerinatol 201236(1)42-7
Saving Mothersrsquo Lives 2006-2008 National Launch March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG
Direct Deaths per Million
Maternities by Cause UK 1994-2008
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 5
National Partnership for Maternal SafetyFocus on decreasing Maternal Mortality amp 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
DAlton ME et al The national partnership for maternal safety Obstet Gynecol 2014123973
Institute for Healthcare Improvement Evidence-Based Care Bundles Ihiorg
Slide 6
VTE WORKING GROUPComprised of the following individuals with representation from obstetrics nursing midwifery and anesthesia
bull STEVEN CLARK MD
bull MARY DrsquoALTON MD
bull ROBYN DrsquoORIA MA RNC APC
bull ALEXANDER FRIEDMAN MD
bull JENNIFER FROST MD MPH
bull AFSHAN HAMEED MD
bull DEBORAH KARSNITZ DNP CNM
bull DOUGLAS MONTGOMERY MD
bull MICHAEL PAIDAS MD
bull RICHARD SMILEY MD
Slide 7
Pregnancy Related MortalityUnited States (1987-2010)
Creanga AA et al Pregnancy-related mortality in the United States 2006-2010 Obstet Gynecol (2015 Jan)125(1)5-12 doi 101097AOG0000000000000564
Slide 8
New York City 2006-2010Pregnancy-Associated Mortality
NYC Department of Health and Hygiene Bureau of Maternal Infant and Reproductive Health (2015) Report of the Pregnancy-Associated Mortality Review Project
Slide 9
Morbidity
Long-term sequelae include
bull Recurrent VTEbull Post-thrombotic syndrome May develop in up to 50 of patients
who experience DVT Chronic leg pain edema erythema
and ulcerationsbull Lung damagebull Cardiovascular
Vasquez SR et al Cardiology Patient Page Postthrombotic Syndrome Circulation (2010) 121217-219
Slide 10
Venous Thromboembolism (VTE) Prophylaxisldquosingle cause of death most amenable to reduction by systematic change in practicerdquo ndash Steven Clark MD SeminPerinatol 201236(1)42-7
Saving Mothersrsquo Lives 2006-2008 National Launch March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG
Direct Deaths per Million
Maternities by Cause UK 1994-2008
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 6
VTE WORKING GROUPComprised of the following individuals with representation from obstetrics nursing midwifery and anesthesia
bull STEVEN CLARK MD
bull MARY DrsquoALTON MD
bull ROBYN DrsquoORIA MA RNC APC
bull ALEXANDER FRIEDMAN MD
bull JENNIFER FROST MD MPH
bull AFSHAN HAMEED MD
bull DEBORAH KARSNITZ DNP CNM
bull DOUGLAS MONTGOMERY MD
bull MICHAEL PAIDAS MD
bull RICHARD SMILEY MD
Slide 7
Pregnancy Related MortalityUnited States (1987-2010)
Creanga AA et al Pregnancy-related mortality in the United States 2006-2010 Obstet Gynecol (2015 Jan)125(1)5-12 doi 101097AOG0000000000000564
Slide 8
New York City 2006-2010Pregnancy-Associated Mortality
NYC Department of Health and Hygiene Bureau of Maternal Infant and Reproductive Health (2015) Report of the Pregnancy-Associated Mortality Review Project
Slide 9
Morbidity
Long-term sequelae include
bull Recurrent VTEbull Post-thrombotic syndrome May develop in up to 50 of patients
who experience DVT Chronic leg pain edema erythema
and ulcerationsbull Lung damagebull Cardiovascular
Vasquez SR et al Cardiology Patient Page Postthrombotic Syndrome Circulation (2010) 121217-219
Slide 10
Venous Thromboembolism (VTE) Prophylaxisldquosingle cause of death most amenable to reduction by systematic change in practicerdquo ndash Steven Clark MD SeminPerinatol 201236(1)42-7
Saving Mothersrsquo Lives 2006-2008 National Launch March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG
Direct Deaths per Million
Maternities by Cause UK 1994-2008
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 7
Pregnancy Related MortalityUnited States (1987-2010)
Creanga AA et al Pregnancy-related mortality in the United States 2006-2010 Obstet Gynecol (2015 Jan)125(1)5-12 doi 101097AOG0000000000000564
Slide 8
New York City 2006-2010Pregnancy-Associated Mortality
NYC Department of Health and Hygiene Bureau of Maternal Infant and Reproductive Health (2015) Report of the Pregnancy-Associated Mortality Review Project
Slide 9
Morbidity
Long-term sequelae include
bull Recurrent VTEbull Post-thrombotic syndrome May develop in up to 50 of patients
who experience DVT Chronic leg pain edema erythema
and ulcerationsbull Lung damagebull Cardiovascular
Vasquez SR et al Cardiology Patient Page Postthrombotic Syndrome Circulation (2010) 121217-219
Slide 10
Venous Thromboembolism (VTE) Prophylaxisldquosingle cause of death most amenable to reduction by systematic change in practicerdquo ndash Steven Clark MD SeminPerinatol 201236(1)42-7
Saving Mothersrsquo Lives 2006-2008 National Launch March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG
Direct Deaths per Million
Maternities by Cause UK 1994-2008
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 8
New York City 2006-2010Pregnancy-Associated Mortality
NYC Department of Health and Hygiene Bureau of Maternal Infant and Reproductive Health (2015) Report of the Pregnancy-Associated Mortality Review Project
Slide 9
Morbidity
Long-term sequelae include
bull Recurrent VTEbull Post-thrombotic syndrome May develop in up to 50 of patients
who experience DVT Chronic leg pain edema erythema
and ulcerationsbull Lung damagebull Cardiovascular
Vasquez SR et al Cardiology Patient Page Postthrombotic Syndrome Circulation (2010) 121217-219
Slide 10
Venous Thromboembolism (VTE) Prophylaxisldquosingle cause of death most amenable to reduction by systematic change in practicerdquo ndash Steven Clark MD SeminPerinatol 201236(1)42-7
Saving Mothersrsquo Lives 2006-2008 National Launch March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG
Direct Deaths per Million
Maternities by Cause UK 1994-2008
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 9
Morbidity
Long-term sequelae include
bull Recurrent VTEbull Post-thrombotic syndrome May develop in up to 50 of patients
who experience DVT Chronic leg pain edema erythema
and ulcerationsbull Lung damagebull Cardiovascular
Vasquez SR et al Cardiology Patient Page Postthrombotic Syndrome Circulation (2010) 121217-219
Slide 10
Venous Thromboembolism (VTE) Prophylaxisldquosingle cause of death most amenable to reduction by systematic change in practicerdquo ndash Steven Clark MD SeminPerinatol 201236(1)42-7
Saving Mothersrsquo Lives 2006-2008 National Launch March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG
Direct Deaths per Million
Maternities by Cause UK 1994-2008
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 10
Venous Thromboembolism (VTE) Prophylaxisldquosingle cause of death most amenable to reduction by systematic change in practicerdquo ndash Steven Clark MD SeminPerinatol 201236(1)42-7
Saving Mothersrsquo Lives 2006-2008 National Launch March 2011 Professor Gwyneth Lewis OBE FRCOG FACOG
Direct Deaths per Million
Maternities by Cause UK 1994-2008
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 11
VTE ProphylaxisThe Agency for Healthcare Research and Quality defined VTE as the ldquonumber one patient safety practicerdquo for hospitalized
patients
Safe practices published by the National Quality Forum (NQF) recommend
bull Routine evaluation of hospitalized patients for risk of VTEbull Use of appropriate prophylaxis
ENDORSE Survey
bull Evaluated prophylaxis rates in 17084 major surgery patients
bull More than one third of patients at risk for VTE (38) did not receive prophylaxis
bull 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 ReportTechnology 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 NO01-E058) Rockville MD Agency for Healthcare Research and Quality
National Quality Forum National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism (2006)
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
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 12
Prophylaxis in Vaginal Delivery Hospitalizations
No Prophylaxis Any Prophylaxis
Characteristic n n
All Patients 2605151 974 68835 26
Year of Delivery
2006 366317 984 5950 16
2007 374851 983 6662 18
2008 352438 978 7825 22
2009 354460 973 9884 27
2010 367470 969 11675 31
2011 402359 971 11911 29
2012 390881 972 11303 28
Friedman A et al Thromboembolism incidence and prophylaxis during vaginal delivery hospitalizations Am J Obstet Gynecol 2015 Feb 212(2) 221e1-12
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 13
Underuse of Post-cesarean Thromboembolic Prophylaxis
Characteristic None Mechanical Pharmacologic Combination
955787 (757) 278669 (221) 16639 (13) 12110 (10)
Year of Surgery
2003 115663 (916) 8717 (69) 1274 (10) 664 (05)
2004 124230 (874) 15674 (110) 1319 (09) 923 (07)
2005 131220 (846) 21013 (135) 1889 (12) 1051 (07)
2006 154876 (810) 32302 (169) 2413 (13) 1608 (08)
2007 145589 (747) 44842 (230) 2451 (13) 2053 (11)
2008 131250 (660) 62545 (314) 2852 (14) 2294 (12)
2009 125096 (605) 75315 (364) 3609 (18) 2753 (13)
2010 27863 (584) 18261 (383) 832 (17) 764 (16)
Friedman AM Ananth CV et al (2013) Underuse of post cesarean thromboembolic prphylaxis Am J Obstet and Gynecol 122(6)1197-204
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 14
Underuse of Post-cesarean Thromboembolic Prophylaxis
Lack of Protocol Adherence
bull Systematic review of over 2500 surgical patients demonstrated up to one fourth are noncompliant with post operative mechanical thromboprophylaxis
bull Observational study demonstrated noncompliance with post-cesarean mechanical thromboprophylaxis in 21 of 293 patients
bull Lack of adherence persist despite education amp audits
Craigie Samantha et al Adherence to mechanical thromboprophylaxis after surgery A systematic review and meta-analysis Thrombosis Research (2015) 136 (4) 723 ndash 72
Palmerola KL et al A comparison of recommendations for pharmacologic thromboembolism prophylaxis after caesarean delivery from three major guidelines BJOG (2015 Oct) DOI 1011111471-052813706
Brady et al Sequential Compression Device Compliance in Postoperative Obstetrics and Gynecology Patients Obstet amp Gynecol (2015 Jan) 125 (1) 19
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 15
Maternal Venous Thromboembolism Prevention Safety Bundle
bull Use a standardized thromboembolism risk assessment tool for VTE during
bull Outpatient prenatal care
bull Antepartum hospitalization
bull Hospitalization after cesarean or vaginal deliveries
bull Postpartum period (up to 6 weeks after delivery)
RECOGNITION (Every Patient)bull Apply standardized tool to all patient to asses VTE risk at time point designated under
ldquoReadinessrdquo
bull Apply standardized tool to identify patients for thromboprophylaxis
bull Provide patient education
bull Provide all healthcare providers education regarding risk assessment tools and recommended thromboprophylaxis
RESPONSE (Every Unit)bull Use standardized recommendations for mechanical thromboprophylaxis
bull Use standardized recommendations for dosing of prophylactic and therapeutic pharmacologic anticoagulation
bull Use standardized recommendations for appropriate timing of pharmacologic prophylaxis with neuraxial anesthesia
REPORTINGSYSTEMS LEARNING (Every Unit)bull Review all thromboembolism events for systems issues and compliance with protocols
bull Monitor process metrics and outcomes in a standardized fashion
bull Assess for complications of pharmacologic thromboprophylaxis
READINESS (Every Unit)
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 16
bull Thromboembolism prophylaxis is a Joint Commission quality measure
bull 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 admissionrdquo
VTE Prevention Readiness
Specifications Manual for National Hospital Inpatient Safety The Joint Commission (2015) 5
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 17
VTE Prevention ReadinessExcluded populations Joint Commission measure
Patients with ICD-9-CM Principal or Other Diagnosis Codes of Obstetrics
Sample Codes
Full list available in the 2015 Joint Commission Specifications Manual for National Hospital Inpatient Safety (Appendix A Table 702)
826
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 18
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
bull Presentation for prenatal care bull Hospitalization for an antepartum indicationbull Delivery hospitalization (in-house postpartum)bull Discharge from a delivery hospitalization
VTE Prevention Readiness
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 19
VTE Prevention ReadinessVTE RISK ASSESSMENT MULTIPLE TIMES IN PREGNANCY
Initial Risk Assessment
Delivery amp Postpartum Discharge
5
30
60
Antepartum
frac12 of all VTE
Marik PE Venous thromboembolism in pregnancy Clin Chest Med (2010 Dec) 31(4)731-40 DOI 101016jccm201006004
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 20
VTE Prevention Recognitionbull VTE risk assessment tools should be applied to every
patient to determine risk for VTE
bull 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)
bull 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 Feb141(2 Suppl)e691S-736S
American College of Obstetricians and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 21
VTE Prevention Recognition
ANTEPARTUM MANAGEMENT
ndash ACOGbull 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
ndash ACCPbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
ndash RCOGbull Thromboprophylaxis recommended for reduced mobility history of VTE or
high risk thrombophilia
Guidelines agree on recommendations for high-risk patients
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 22
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia
1st VTE provokedFamily history of VTE with LR thrombophiliaLR thrombophilia (no prior event)
Treatment doseLMWH or UFH
ProphylacticLMWH or
UFH
No treatment
Anticoagulation
Recognition and Response at First Prenatal Visit
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 23
All patientsIn-Patient Antepartum Hospitalization for at least 72 hours
bull All patients should be considered for pharmacologic prophylaxis
bull For women at high risk of delivery or bleeding mechanical thromboprophylaxis should be utilized
bull Consider prophylaxis with unfractionated heparin near time of expected delivery rather than low molecular weight heparin (LMWH) to facilitate intrapartum conduction anesthesia
In-Patient Antepartum HospitalizationRecognition amp Response
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 24
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION Length of Stay
TWO LARGE COHORTS SIMILAR RESULTS
HOSPITALIZED gt= 3 days ~ 12 times increased risk of VTE
ldquoThe association between admission and venous thromboembolism remained when we restricted our analysis to women without medical comorbidities including obesity cardiac disease and varicose veinsrdquo
HOSPITALIZED lt 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
Virkus et al Risk Factors for Venous Thromboembolism in 13 Million Pregnancies A Nationwide Prospective Cohort PLoS One (2014 May) e96495
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 25
In-Patient Antepartum HospitalizationRecognition
ANTEPARTUM ADMISSION BMI amp Immobility
Bates SM 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 GuidelinesCHEST (2012 Feb) 141(2)(Suppl)e691Sndashe736S
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 26
LEFT
VIRCHOWrsquoS TRIAD
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 27
OB MODIFIED PADUA RISK
ASSESSMENT MODEL
Risk factors Points
Previous VTE 3
Reduced mobility (bed rest with
bathroom privileges for at least 3 days)
3
Thrombophilia 3
Acute infection andor rheumatologic
disorder
1
Obesity (BMI gt25kgm2) 1
Pregnancy 1 Antithrombin deficiency Protein C or S deficiency factor V Leiden G20210A prothrombin gene mutation
antiphospholipid antibody syndrome
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 101111j1538-7836201004044x Kahn SR 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 101378chest11-2296
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 28
RCOG Clinical Recommendations
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 29
Antepartum Hospitalization RR Warrants VTE Prophylaxis
ADMIT
1 Biologic Plausibility2 Epidemiologic Data3 RCOG amp PADUA RAM
Major Risk Factor
RR 12 - 60
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 30
bull How should patients be prophylaxed
bull After a vaginal delivery
bull After a cesarean delivery
bull Scoring systems
bull RCOG
bull ACCP
bull Caprini
Recognition and ResponsePostpartum patients in the hospital
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 31
bull All patients
Early mobilization
Avoid dehydration
bull 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
bull For women with multiple lesser risk factors for VTE by RCOG criteria
Pharmacologic prophylaxis with LMWH or UFH may be considered
Vaginal Delivery
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 32
Women undergoing cesarean delivery should
bull Receive mechanical prophylaxis devices perioperatively and postpartum
bull Receive pharmacologic prophylaxis (LMWH or UFH) based on risk factors
An ldquoopt-outrdquo strategy where all women undergoing cesarean delivery receive prophylaxis with LMWH or UFH unless there is a specific contraindication is also an acceptable approach
Cesarean Delivery
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 33
Chest Post Cesarean Section 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
Immobility (strict bed rest ge1 week in the antepartum period)Postpartum haemorrhage ge1000 mL with surgeryPrevious VTEPre-eclampsia with fetal growth restrictionThrombophilia
Antithrombin deficiencyFactor V Leiden (homozygous or heterozygous)Prothrombin G20210A (homozygous or heterozygous)
Medical conditionsSystemic Lupus erythematosusHeart diseaseSickle cell disease
Blood transfusionPostpartum infection
BMI gt30 kgm2Multiple pregnancyEmergency caesareanSmoking gt10 cigarettesdayFetal growth restrictionThrombophilia
Protein C deficiencyProtein S deficiency
Pre-eclampsia
ACCP Recommendations
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 Feb141(2 Suppl)e691S-736S
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 34
RCOG Recommendations
bull If total score gt 4 antenatally consider thromboprophylaxis from the first trimester
bull If total score 3 antenatally consider thromboprophylaxis from 28 weeks
bull If total score gt 2 postnatally consider thrombroprophylaxis for at least 10 days
bull If admitted to hospital antenatally consider thromboprophylaxis
bull If prolonged admission (gt 3 days) or readmission to hospital during the pueperium consider thromboprophylaxis
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 35
1 Point
bull Family history of unprovoked or estrogen-related VTE in first-degree relative
bull Known low-risk thrombophilia (no VTEbull Age (gt35 years)bull Obesity (BMI gt30kgm2)bull Parity gt 3bull Smokerbull Gross varicose veinsbull Preeclampsia in current pregnancy
bull Assisted reproductive technologyin vitro fertilization (antenatal only)
bull Multiple pregnancybull Elective cesareanbull Mid-cavity rotational operative deliverybull Prolonged labor (gt24 hours)bull Postpartum hemorrhage (gt1 liter or blood
transfusion)bull Preterm birth lt37 weeks in current pregnancybull Stillbirth in current pregnancy
4 Points
bull Previous VTE (except for a single event related to major surgery
bull Ovarian hyperstimulation syndrome (1st trimester only)
3 Points
bull Previous VTE provoked by major surgerybull Known high-risk thrombophiliabull Any surgical procedure in pregnancy or puerperium except immediate repair of the perineum eg
appendectomy postpartum sterilizationbull Hyperemesisbull Medical comorbidities eg 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
2 Points
bull Cesarean in laborbull Obesity (BMI gt40kgm2)
RCOG Recommendations
Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 36
CHEST APPLICATION CAPRINI MODEL
General Abdominal or Pelvic Surgery
SCORE RISK estimated VTE risk no prophylaxis
PROPHYLAXIS
1-2 Pregnancy = 1 point
Surgery lt 45 minutes = 1
point
LOW ~ 15 risk VTE MECHANICAL- intermittent pneumatic compression
3-4 MEDIUM ~ 3 risk VTE MECHANICAL OR CHEMICAL- LMWH OR LD UFH
gt= 5 Previous VTE= 3 points
Thrombophilia = 3 pointsConsider additional
RisksMany pregnant patients will have multiple additional risks (slide )
HIGH ~ 6 risk VTE MECHANICAL PLUS CHEMICAL
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)e227Sndashe277S
Caprini JA Caprini DVT Risk Assessment Venous Resource Center Web httpvenousdiseasecomcaprini-dvt-risk-assessment
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 37
Table 1 Modified Caprini risk assessment model
Risk factors 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 25kgm2) 1
Currently on bed rest 1
Serious lung disease including pneumonia (lt1 month) 1
Pregnancy or postpartum (lt1 month) 1
History of unexplained stillborn infant recurrent spontaneous abortion
(gt 3) premature birth with toxemia or growth-restricted infant
1
Other risk factors (smoking diabetes BMI gt40kgm2 blood transfusions) 1
Central venous access 2
Major surgery (gt45 minutes) 2
Patient confined to bed (gt72 hours) 2
Family history of thrombosis 3
History of DVTPE 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
Original Caprini scoring system condensed to include conditions commonly encountered in obstetric patients
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 38
Caesarean ThromboprophylaxisComparison of 3 Leading Guidelines
bull 293 patients included in analysis
All based on having a prior event
Emergency caesarean Pre-eclampsiaObesity Multiple gestationPostpartum haemorrhage
1
35
85
ACOG
Chest
RCOG Caesarean during labor Maternal Age ge35Obesity 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 1011111471-052813706
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 39
Multiple VTE episodesVTE with high-risk (HR) thrombophiliaVTE with acquired thrombophilia
Clinical history
Idiopathic VTEVTE with pregnancy or oral contraceptiveVTE with low risk (LR) thrombophiliaFamily history of VTE with HR thrombophiliaHR thrombophilia (including acquired)
VTE provoked LR thrombophilia and family history of VTE
LR thrombophilia
6 Weeks Treatment LMWHUFH
No treatment
Anticoagulation
6 WeeksProphylacticLMWHUFH
(two changes from initial assessment)
Recognition and ResponsePostpartum after delivery hospitalization
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 Feb141(2 Suppl)e691S-736S
American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 40
Agent LMWH
Enoxaparin Dalteparin Tinzaparin
UFH
Unfractionated heparin
Weight based Gestational age-based
lt50kg 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
Third
trimester
10000 units
Twice daily
131-170kg 80mg daily 10000 units
daily
9000 units daily
gt170kg 06mgkgday 75 unitskgday 75 unitskgday
Protocols for Prophylaxis
=may be given in two divided doses
Hospitalized antepartum patients may receive 5000 units UFH twice daily for
prophylaxis to facilitate regional anesthesia
Protocols for Prophylaxis
Adapted from American College of Obstetricans and Gynecologists Thromboembolism in Pregnancy Practice Bulletin No 123 Obstet Gynecol (2011) 118 718ndash29 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 Feb141(2 Suppl)e691S-736S
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 41
AntepartumIntrapartum
UFH le10000IUdayNo contraindications to timing of heparin dose and performance of neuraxial blockadeyen
UFH gt10000IUdayWait 12 hours after last dose prior to neuraxial blockade or check
aPPT
IV HeparinWait 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 le10000IUdayHeparin may be administered at any time interval after epidural catheter removal or spinal needle placement
UFH gt10000IUday or IV Heparin
Wait ge1 hour after epidural catheter removal or spinal needle placement
LMWH prophylaxisWait ge4 hours after epidural catheter removal or spinal needle placement
LMWH therapeuticAvoid therapeutic dosing with epidural catheter in situ Wait at least 24 hours after catheter removal or spinal needle
Timing of Neuroaxial Anesthesia
yen No specific society guidelines for management of
patients also receiving aspirin No specific society guidelines for management
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 TT 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
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 42
bull 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
NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 43
bull 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
Sources FDA Drug Safety Communication Nov 2013 NYP protocol
Post-Cesarean VTE Prophylaxis
New York Presbyterian Hospital Surgical Prophylaxis Antibiotic Recommendations for Adult Patients
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 44
Heparin Induced Thrombocytopenia (HIT)
bull Extremely rare complication in the obstetric population receiving UFHLMWH for VTE prevention
bull For patients expected to be on either UFH or LMWH for greater than gt7 days a reasonable clinical strategy is to check a complete blood count 7-10 days after initiation of therapy
bull Some guidelines such as those from ASRA recommend that patients receiving prophylaxis have a CBC checked 4 days after prophylaxis is initiated
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 45
ReportingSystems LearningRecommendation
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 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 46
bull All patients require VTE risk assessment at multiple time points in pregnancy and postpartum
bull All patients undergoing cesarean delivery require mechanical prophylaxis early ambulation and adequate hydration
bull Women with additional risk factors for VTE after delivery will benefit from pharmacologic prophylaxis
bull Empiric pharmacologic prophylaxis is a reasonable option for
all women undergoing cesarean delivery
all antepartum hospital admissions gt72 hours
Conclusion
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 47
Bundle ResourcesREADINESS
ndash Bahl V et al A validation study of a retrospective venous thromboembolism risk scoring method Ann Surg 2010 Feb251(2)344-50 Note Abstract only must be subscriber to access full-text
ndash 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 Nov8(11)2450-7
ndash 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 Feb141(2 Suppl)e691S-736S
ndash Royal College of Obstetricians and Gynaecologists Thrombosis and Embolism during Pregnancy and the Puerperium Reducing the Risk Green-top Guideline No 37a April 2015
ndash Thromboembolism in Pregnancy ACOG practice bulletin No 123 American College of Obstetricians and Gynecologists Obstet Gynecol 2011 Sep118(3)718-29 Available until 102816
RECOGNITIONndash National Blood Clot Alliance Available at httpwwwstoptheclotorg Retrieved October 29 2015 ndash Partnership for Patients Venous Thromboembolism (VTE) Resource List ndash Available at httppartnershipforpatientscmsgovp4p_resourcestsp-
venusthromboembolismtoolvenousthromboembolismvtehtml Retrieved October 29 2015
RESPONSE ndash American College of Obstetricians and Gynecologists Safe motherhood initiative Availablendash at httpwwwacogorgAbout-ACOGACOG-DistrictsDistrict-IISMI-Registration Retrieved September
22 2014ndash Dresang L et al Venous Thromboembolism During Pregnancy Am Fam Physician 2008 Jun
1577(12)1709-1716ndash Venous Thromboembolism Prevention in the Hospital Presentation (AHRQ) May 2010 Available at
httparchiveahrqgovnewseventsconference2009maynard2indexhtml Retrieved October 29 2015
REPORTINGSYSTEMS LEARNINGNo resources selected
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress
Slide 48
QampA Session Press 1 to ask a question
You will enter the question queue
Your line will be unmuted by the operator for your turn
A recording of this presentation will be made available on our website
wwwsafehealthcareforeverywomanorg
Slide 49
Next Safety Action Series
Click Here to Register
Empowering Patients Improving Outcomes
Maternal Mental Health Presentation
Monday December 14th 2015 | 1200 pm Eastern
Lisa Kay
2020 Mom
Lynne McIntyre
Postpartum Support International
Katherine Stone
Postpartum Progress