VENOUS

THROMBOEMBOSLIM
(VTE)
Presenter: Dayang Nurul Alwani
Supervised by: Dr Wong WH
Introduction

• A venous thrombosis is a blood clot (thrombus) that forms within a vein which can break off
(embolize), and become a life-threatening pulmonary embolism (PE).
• PE is still the leading direct cause of maternal death in Malaysia
• Pregnancy is a hypercoagulable state and risk of VTE increases by 4-6 fold.
• Maternal deaths from PE in the state has decreased since the introduction of the VTE risk
assessment in mid 2013
• Maternal deaths from VTE has dropped from an average 3 per year (preceding 5 years) to about 1
per year since 2013.
EPIDEMIOLOGY OF VTE
• More than 2/3 of VTEs are hospital acquired
• About 10% die within the first month of VTE diagnosis
• In Asia, VTE is increasing due to several factors:
• Aging population
• Higher rates of major complex surgeries
• Higher rates of caesarean deliveries
• Rise in Obesity
• Rise in Cancer
• Low rates for thromboprophylaxis
PATHOGENESIS & NATURAL HISTORY
OF VTE
• Most DVT begin in the calf. In pregnancy it begins in the proximal and pelvic veins
• The risk factors for VTE influence at least one of Virchow’s triad: blood coagulability, vessel
integrity and blood flow
• The risk of VTE is highest following major orthopedic surgery where vessel damage and
immobility play a major role
• The risk of symptomatic VTE is highest within 2 weeks of surgery and remains elevated for a
further 2 to 3 months
• The risk of fatal PE is highest within 1 week of surgery
• Following treatment, the resolution of DVT is slower than for PE with complete resolution being
more common with PE than in DVT, where recanalisation is commoner
• The risk of VTE recurrence is higher in unprovoked than in provoked (recent surgery)
VTE
• The risk of recurrence remains elevated after a first episode of VTE
• Active cancer and the antiphospholipid syndrome are risk factors for VTE recurrence
• The risk of mortality is higher with recurrent PE than recurrent DVT
• Postthrombotic syndrome and chronic thromboembolic pulmonary hypertension are
complications of VTE
• Postthrombotic syndrome occurs more frequently following pregnancy associated VTE
because the proximal iliofemoral veins are usually involved
WHEN DO WE DO ASSESSMENT FOR
VTE SCORING?
• Pre or early pregnancy
• Antenatal booking
• During each hospital admission or whenever a new risk factor occurs
• Postnatal
PROPOSED DURATION OF POSTNATAL PROPHYLAXIS
FOR 2015 SARAWAK VTE GUIDELINE:
Postnatal score Duration
2 10 days
3 Up top 14 days
4 or more Up to 21 days

Note:

•Intra-partum events: e.g. PPH, blood transfusion, rotational instrumental delivery, caesarean section
are significant only for the first 10 days
•If the postnatal score is > 4: The specialist should decide the appropriate duration of postnatal
prophylaxis
Type of
anticoagulant
WHICH ANTICOAGULANT AGENTS SHOULD BE USED
FOR THROMBOPROPHYLAXIS?
• Low molecular weight heparins (LMWH) such as Tinzaparin (Innohep) &
Enoxaparin (Clexane) are preferred
• Monitoring of platelet levels levels is not necessary if LMWH is used as
thromboprophylaxis unless her weight is less than 50Kg or more than 90Kg.
• LMWH is safe in breastfeeding
• Tinzaparin has a better renal safety profile compared to clexane
• Unfractionated heparin should ideally be administered by trained health personnel
twice daily
• Long term unfractionated heparin use is associated with a very small increase risk
of osteoporosis. It is also associated with heparin induced thrombocytopaenia and
thrombosis.
WHICH ANTICOAGULANT AGENTS
SHOULD BE USED FOR
THROMBOPROPHYLAXIS? - cont
• Patients on unfractionated heparin should have their platelet level
checked at least once between day 5-8, if they are on a 10 -14 day
prophylaxis.
• Fondaparinux - reserved for women intolerant of heparin compounds.
• It has a longer half-life and no known antidote, so usage in the antenatal
period carries risks.
• Warfarin use in pregnancy is restricted to a few situations where
heparin is considered unsuitable, e.g. women with mechanical valve.
While it is safe in breastfeeding, it is associated with several
significant complications. The use must be under the supervision of an
O&G specialist / Cardiologist / Haematologist.
PATIENT WITH LOW RISK VTE
Patients who are low risk (score < 2) are advised for:
• Early mobilization/encourage to ambulate
• Avoidance of dehydration
• To seek treatment early if feeling unwell
• To seek treatment early if develops signs & symptoms of DVT/PE
• +/- Compression or anti-embolism stocking
PATIENTS WHO REFUSED VTE
PROPHYLAXIS
• Counselling (consider further counselling by FMS or O&G specialist)

• Upon failure to convince the patient;

1. Use appropriate compression stockings
2. Advise on ambulation, avoidance of dehydration & to seek early
treatment if feeling unwell
3. Teach patients to identify signs & symptoms of DVT & PE
4. Ensure ‘home visits’ by community midwife
 SARAWAK ‘VTE RISK
ASSESSMENT IN PREGNANCY’
MANAGEMENT FLOW CHARTS:
ANTENATAL ASSESSMENT
POST DELIVERY VTE ASSESSMENT
VTE RISK ASSESSMENET IN HEALTH
CLINIC
THANK YOU

References:
• http://www.sgh-og.com/downloads/venous-thromboembolism-updat
e-july-2015/
• Sarawak obstetric VTE risk assessment programme