wednesday, april 20 11:30 a.m. eastern€¦ · slide 1 wednesday, april 20 11:30 a.m. eastern dial...
TRANSCRIPT
Slide 1
Wednesday, April 20
11:30 a.m. EasternDial In: 888.863.0985
Conference ID: 88305603
Slide 2Slide 2
Speakers
Michael Paidas, MD, FACOG
Professor & Vice Chair, Obstetrics
Director, MFM Fellowship
Director, Yale Women and Children’s Center for Blood Disorders and
Preeclampsia Advancement
Department of Obstetrics, Gynecology & Reproductive Sciences, Yale Medical
School
Liyana Winchell, RN, BSN
Labor and Birth and Maternal Special Care Units, Yale-New Haven
Hospital
Slide 3
Disclosures
Michael Paidas, MD has no real or perceived conflicts of interest to disclose.
Liyana Winchell, RN, BSN has no real or perceived conflicts of interest to disclose.
Slide 4
Objectives
Describe the need for antenatal VTE prevention in hospitalized women.
Discuss the importance of conducting effective antenatal VTE risk assessment.
Review patient factors associated with increased risk of VTE during antenatal hospitalization.
Provide a summary of VTE prevention measures that can be modified for use within your institution.
Identify issues that may arise from use of antenatal chemoprophylaxis.
Slide 5
Slide 6
Epidemiology of VTE & Pregnancy
Slide 7
Risk of VTE is correlated with age
Annual incidence of all venous thromboembolism, deep vein thrombosis (DVT) alone, and pulmonary embolism (PE) with or without deep vein thrombosis (PE ± DVT) by age.
Slide 8
Rate of VTE in pregnancy
1. The incidence of VTE increases exponentially with age, from 5/100,000/year among children to 6/1000/year among 80 year olds.
2. Among reproductive age women (< 40 years) the risk of VTE is 1/10,000.
3. A retrospective cohort study of 268,525 patients over a 19 year period reported a prevalence of VTE of 1 per 1627 births.
4. Thus the risk of VTE is increased 6-fold during pregnancy.
Cushman. Semin Hematol. 2007; 44:62-9. Gherman et al. ObstetGynecol. 1999; 94:730-4.
Slide 9
Slide 10
VTE & GA: Danish National Cohort
Adjusted incidence rate ratios (IRR) of thromboembolism in pregnant & puerperal women vs
non pregnant women not using oral contraceptives, adjusted for age, calendar yr &
education.
Venous thromboembolism in pregnant and puerperal women in Denmark 1995-2005. A national cohort study. Virkus RA, Løkkegaard EC, Bergholt T, Mogensen U, Langhoff-Roos J, Lidegaard Ø. Thromb Haemost. 2011 Aug;106(2):304-9.
Slide 11
Risk of VTE Postpartum:Systematic Review
1. VTE risk is 21.5 to 84-fold higher in postpartum women compared to non-pregnant women
2. VTE risk postpartum is highest immediately after delivery (standardized incidence ratio for DVT 115.1 [95% CI 96.4-137.0] and for PE 80.7 [95% CI 53.9-117.9].
3. Between four and six weeks postpartum, VTE risk declined but is still five times to seven times that of nonpregnant, nonpostpartum women.
Jackson E et al Obstet Gynecol 2011;117:691-703.
Slide 12Friedman. Vaginal delivery and thromboprophylaxis AM Am J Obstet Gynecol 2015
Thromboembolism EventsA
A, Rate of thromboembolism events per 100,000 hospitalizations. B, Change in the rate of thromboembolic events since 2006.DVT, deep vein thrombosis; PE, pulmonary embolism; VTE, venous thromboembolism
Ra
te o
f th
rom
bo
emb
oli
c ev
ents
(p
er 1
00
,00
0 h
osp
ita
liza
tio
ns)
Ch
an
ge
in t
he
rate
of
thro
mb
oem
bo
lic
even
ts s
ince
20
06
(%
)
BA
Slide 13
Risk Factors of VTE & Pregnancy
Slide 14
Anatomic Changes During Pregnancy
• ↑venous
capacitance
• ↑mechanical
obstruction by
the uterus
• ↓ venous
outflow
• ↓mobility
• ↑vascular injury
Courtesy of Andra James, MD
Slide 15
Clotting Factor Changes in Pregnancy
Coagulation Factors: • Marked Increase in Pregnancy:
– Fibrinogen, FVII, von Willebrand factor & ristocetincofactor, FX, FXII, F XIII
• Slight Increase or No Change:– F II, FV & IX
• Decrease: – FXI
Decrease in Anticoagulant & Fibrinolytic Activity:• Protein S levels (free and total) decrease by 40%
– PAI-1 levels increase two to three-fold in pregnancy– PAI-2 present due to placental production
Practice bulletin no. 123: thromboembolism in pregnancy.Obstet Gynecol. 2011 Sep;118(3):718-29.
Slide 16
The Risk of Venous Thromboembolism in Pregnant
Patient with Selected ThrombophiliasCondition Prevelance in
European populations
Prevelance in Patients with VTE
in Pregnancy
Risk of VTEwithout prior
history
Risk of VTE with prior history
Factor V Leiden (FVL)HeterozygousHomozygous
5.3%0.07%
44<1
0.26%1.50%
>10%>10%
Prothrombin mutation (PGM)
HeterozygousHomozygous
2.90%0.02%
17<1
0.37-0.5%2.8
>10%>10%
Compound FVL/PGM 0.17% <1 4.70%
Protein C deficiency 0.2-0.3% <14 0.8-1.7%
Protein S deficiency 0.03%-0.13% 12 <1-6.6%
Antithrombin deficiency 0.02-1.1% 1 11.6%* 11-40%
Hendrix PW and Paidas MJ, Ch Thrombophilia in Pregnancy, Textbook: Management and Therapy of Early Pregnancy Complications, In Press 2016
*Rheaume M. Pregnancy- related Venous Thromboembolism in Asymptomatic Women with Antithrombin Deficiency Obstet Gynecol 2016; 127 (4): 649.
Slide 17Modified from: Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger
M.Lancet. 2010 Feb 6;375(9713):500-12.
Virchow’s triad
Slide 18
Risk Factors for VTE Associated with Pregnancy
Antepartum & Postpartum VTE
Odds ratio (95% CI)
Thrombophilia 51.8 (38.7-69.2)
Previous VTE 24.8 (17.1-36.0)
Family history of VTE 3.9
Superficial venous thrombosis
10.0 (1.3-78.1)
BMI >25 kg/m2 1.8 (1.3-2.4)
Antepartumimmobilization
7.7 (3.2-19.0)
BMI > 25 kg/m2 ^ & antepartum immobilization
62.3 (11.5-337.6)
Postpartum VTE Odds ratio(95% CI)
Infection (vaginal) 20.2 (6.4-63.5)
Infection (Cesarean) 6.2 (2.4-26.3)
Pre-eclampsia &IUGR 5.8 (2.1-16.0)
Emergency Cesarean 2.7 (1.8-4.1)
Hemorrhage (w/o surg.) 4.1 (2.3-7.3
Hemorrhage (w/ surg.) 12.1 (3.9-36.9)
Modified from Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger M.Lancet. 2010 Feb 6;375(9713):500-12.
Antepartum VTE Odds ratio(95% CI)
Assisted Reproduction 4.3 (1.3-3.4)
Smoking 2.1 (17.1-36.0)
Other possible Risk factors
Odds ratio(95% CI)
Cesarean 2.1 (1.8-2.4),1.3 (0.7-2.2)
Age 2.1 (2.0-2.3),0.8 (0.6-1.1)
Parity 1.1 (0.9-1.4)1.7 (1.2-2.4)
^ BMI at first prenatal visit
Slide 19
Prevention of VTE associated with Pregnancy:
The Controversies
before we address antepartum prophylaxis in the hospital….
Slide 20
ACOG Practice Bulletin Thromboembolism in Pregnancy Number 123, September 2011
• Pneumatic compression devices recommended prior to Cesarean delivery for all women not already receiving thromboprophylaxis
• Studies of routine thromboprophylaxis for Cesarean delivery are too small & underpowered.
• For patients with undergoing Cesarean delivery with additional risk factors for thromboembolism, individual risk assessment may require thromboprophylaxis with both pneumatic compression devices & UFH or LMWH.
Slide 21
Table 1. Summary of major society guideline recommendations for obstetric thromboprophylaxis for patients who have undergone caesarean delivery
ACOG
Perioperative mechanical thromboprophylaxis recommended for all patients undergoing caesarean delivery
Pharmacologic prophylaxis (LMWH or UFH) recommended for
High-risk thrombophilias
Any prior VTE event
A family history of VTE and a thrombophilia
Chest
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 (one needed for prophylaxis)
Immobility (strict bed rest ≥1 week in the antepartum period)
Postpartum haemorrhage ≥1000 mL with surgery
Previous VTE
Pre-eclampsia with fetal growth restriction
Thrombophilia
Antithrombin deficiency
Factor V Leiden (homozygous or heterozygous)
Prothrombin G20210A (homozygous or heterozygous)
Medical conditions
Systemic Lupus erythematosus
Heart disease
Sickle cell disease
Blood transfusion
Postpartum infection
Minor risk factors (two needed for prophylaxis)
BMI >30 kg/m2
Multiple pregnancy
Emergency caesarean
Smoking >10 cigarettes/day
Fetal growth restriction
Thrombophilia
Protein C deficiency
Protein S deficiency
Pre-eclampsia
RCOG
Risk factors (LMWH recommended for any of the following risk factors)
Previous VTE
Antenatal anticoagulation
Caesarean in labour
Asymptomatic thrombophilia
Prolonged admission
Major medical co-morbidities (e.g. heart or lung disease, systemic Lupus erythematosus, cancer, inflammatory conditions, nephrotic syndrome, sickle cell disease, intravenous drug user
Age >35
BMI >30 kg/m2
Parity ≥3
Smoker
Any surgical procedure
Gross varicose veins
Current systemic infection
Immobility
Pre-eclampsia
Mid-cavity rotational operative delivery
Labour >24 hours
PPH >1 litre or transfusion
BMI, body mass index; PPH, postpartum haemorrhage; VTE, venous thromboembolism.
Palmerola KL, D’Alton ME, Brock CO, Friedman AM BJOG 2015
VTE prevention after Cesarean Delivery
Slide 22
Calculated Rates of Pharmacologic Prophylaxis Post Cesarean Delivery for using Major Societal Guidelines in a tertiary care center
Society Percent (95% CI)
ACOG 1 (0.3-3.0)
CHEST 34.8 (29.6-40.4)
RCOG 85.0 (80.5-88.6)
Palmerola KL, D’Alton ME, Brock CO, Friedman AM BJOG 2015
BMI ≥ 30kg/m2
38.6%
BMI ≥ 40kg/m2
9.0%
Slide 23
VTE Prevention: Initial Assessment
Friedman AM and D’Alton ME Sem Perinatology 2016
Slide 24
Antepartum Hospitalization (not for delivery) & VTE Risk in Pregnancy
• Associated with an increased risk of VTE incidence rate ratio 17.5, 95% CI 7.69 to 40.0) compared with time outside hospital.
• Greatest risk factors for VTE:
• BMI >30 kg/m2
• maternal age >35 years
• Admission during third trimester
• Hospital stay >3 days.
Sultan AA et al. BMJ 2013;347:f6099
Slide 25 Friedman AM and D’Alton ME Sem Perinatology 2016
VTE Prevention: Antepartum Hospitalization
Slide 26
Yale Approach to Postpartum VTE Prophylaxis
Pre Pregnancy
BMI (kg/m2)
Enoxaparin UFH
<40 40mg daily(CrCl < 30 ml/min)
5,000 U q8 hr
≥40 40mg q 12 hr(CrCl < 30 ml/min)
7,500 U q8 hr
Slide 27
VTE Prevention: Postpartum (in hospital)
Friedman AM and D’Alton ME Sem Perinatology 2016
Slide 28
VTE Prevention: After Discharge
Friedman AM and D’Alton ME Sem Perinatology 2016
Slide 29
Contraindications to low-molecular weight heparin administration
• Hemophilia or other known bleeding disorder
• Active or threatened antenatal bleeding (e.g., previa, abruption). Balance risks/benefits
• Thrombocytopenia (platelet count <75 x 109)
• Recent stroke (hemorrhagic/ischemic)
• Severe renal disease (GFR < 30 ml/min)
• Severe liver disease (prolonged PT)
• Uncontrolled hypertension (BP > 200 mmHg systolic or >120 mmHg diastolic)
Friedman AM and D’Alton ME Sem Perinatology 2016
Slide 30Hendrix PW and Paidas MJ, Ch Thrombophilia in Pregnancy, Textbook:
Management and Therapy of Early Pregnancy Complications, In Press 2016
Suggested Anticoagulation Doses
Slide 31
Neuraxial Anesthesia & Anticoagulation
Friedman AM and D’Alton ME Sem Perinatology 2016
Slide 32
Nursing Perspective
• Nursing Handoff: Discussion of antepartum or postpartum VTE risk factors & prophylactic interventions.
• Nursing Interventions: – Pharmacologic prophylaxis – Sequential Compression Devices and/or compression stockings– Encourage ambulation – Passive and active ROM– Physical therapy – Intravenous hydration – Encourage smoking cessation (i.e. Nicotine patch), etc.
• Documentation: Electronic Health Records “Peripheral Neurovascular” flowsheet to document any assessed VTE issues & prophylactic interventions.
Slide 33
Take Home Points
• Venous thromboembolism (DVT & PE) rates associated with pregnancy are rising in the USA.
• Reducing the rate of VTE will lower maternal mortality and morbidity.
• Pregnant patients and women considering pregnancy should have a VTE risk assessment and a plan established for each time period.
• Every hospital should evaluate and adopt workable guidelines, by consensus involving all stakeholders, for VTE prevention in the antepartum and postpartum periods.
• Reevaluate protocols as new data is gathered.
• Clinical studies are required to identify optimal strategies for VTE prevention in the hospital setting.
Slide 34
Q&A 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:
www.safehealthcareforeverywoman.org
Slide 35
Next Safety Action SeriesMaternal Mental Health: Enhancing Screening
and Better PracticesThursday, May 5, 2016 | 11:00 a.m. Eastern
Tiffany Moore Simas, MD, MPH, MEd,
FACOG
Director, Research Division & Associate Director,
Residency Program, Dept Ob/Gyn
University of Massachusetts Medical School/UMass
Memorial Health Care
Christena Raines, RN, MSN, APRN-BC
Perinatal Psychiatric Nurse Practitioner
University of North Carolina Perinatal Mood Disorder
Clinic, UNC Hospitals
Click Here to Register