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OBSTETRIC EMBOLISM Dr. Rafaie Amin Consultant Obstetrician & Gynaecologist Sarawak General Hospital
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1. OBSTETRIC EMBOLISM Dr. Rafaie Amin Consultant Obstetrician & Gynaecologist Sarawak General Hospital 2. OBSTETRIC EMBOLISM AFE (Amniotic Fluid Embolism) VTE (Venous Thromboembolism) 3. Number of maternal deaths in Malaysia 2006 - 2008 Causes 2006 2007 2008 Amniotic Fluid Embolism 9 17 17 Pulmonary Embolism 9 7 23 Total 18 24 40 Report on confidential inquiries into maternal deaths in Malaysia, 2006-2008 4. Table: Causes of maternal deaths in Malaysia; 2008-2012p CAUSES OF MATERNAL DEATHS (MALAYSIA) 2008 2009 2010 2011 2012p n % n % n % n % n % Postpartum Haemorrhage 26 19.5 20 13.0 11 7.5 19 14.6 15 12.3 Hypertensive Disorders in Pregnancy 14 10.5 18 11.7 25 17.1 25 19.2 21 17.2 Associated Medical Conditions 24 18.0 51 33.1 46 31.5 37 28.5 36 29.5 Obstetric Embolism 40 30.0 23 14.9 30 20.5 16 12.3 20 16.4 Obstetric Trauma 5 3.8 4 2.6 10 6.8 12 9.2 3 2.5 Source of data : Bhg. Kesihatan Keluarga, KKM 5. VTE DVT PE 6. Pregnancy Immobility & stasis LSCS & Other surgeries 7. Increased risk of VTE in pregnancy 1. Pregnancy increases risk of VTE by 6 folds 2. Increase in factor VIII, IX, X, fibrinogen 3. Decreased in fibrinolytic activity, anti-thrombin and fall in protein S 4. Venous stasis in pregnancy 5. Caesarean sections further increases the risk approximately by 10-20 folds 8. Signs and Symptoms of DVT 50% of all DVT cases are asymptomatic DVT signs & symptoms includes; Swelling in one or both legs Pain or tenderness in one or both legs Warmth in the skin of the affected leg Red or discoloured skin in the affected leg Leg fatigue DVT 9. Pulmonary Embolism (PE) PE is a potentially life-threatening condition. PE usually happens due to an underlying blood clot in the leg (DVT) in over 90% of cases. A massive pulmonary embolism carries up to 80% risk of death 10. Signs & Symptoms of PE PE symptoms vary greatly, depending on how much of the lung is involved, the size of the clot and the overall health of the patient Signs and symptoms includes; Shortness of breath. Chest pain. Cough. (bloody or blood-streaked sputum) Wheezing Clammy or bluish-coloured skin Rapid or irregular heartbeat 11. Diagnosis of VTE Clinical diagnosis of VTE has a low sensitivity. Definitive diagnosis should be pursued in the first possible instance. All clinically suspected VTE should have diagnostic testing to confirm or refute the diagnosis. Unresolved diagnosis causes unnecessary anxiety to both the patients and clinicians. 12. Diagnosing a PE Chest X-ray. May be normal May show unequal density of the hemithorax Most frequent finding is a small pleural effusion . May show consolidation Wedge shaped opacities Elevated hemidiaphragm 13. Diagnosing PE: ECG Tachycardia Right axis deviation Right bundle branch block S1Q3T3 - uncommon Changes in the ECG may be transient and may also revert to normal as the patient gets better. 14. Diagnosis of PE D-dimer: if negative not likely PE Pulmonary angiogram (CTPA) Ventilation-perfusion scan (V/Q scan) not widely available 15. Patients suspected to have VTE / PE This is considered a MEDICAL EMERGENCY! Trigger RED alert Consult an O&G specialist from nearest hospital Immediate referral to nearest specialist hospital Escort by Medical Officer where possible for the transfer to the specialist hospital Ask for Obstetric Retrieval Team if available 16. During transfer Ambulance must be equipped with: o BP / PR monitoring o Pulse oxymeter o Oxygen and high flow mask o Equipment and drugs for maternal resuscitation 17. Management in Specialist Hospital Suspected PE in clinic/district hospital Urgent referral to Obstetrician /Physician and discuss on: oHeparinisation / anti-coagulation oIntubation (for suspected PE) oFurther investigations Jointly managed with Physician / Hematologist / Radiologist / Anaesthetist Nurse in High Dependency Unit or ICU (for suspected PE) 18. Management of VTE All suspected cases of DVT / PE should have treatment commenced upon clinical suspicion. Objective confirmation of DVT can await until modality and its expertise becomes available. Diagnosis should not delay commencement of treatment (where available, 1st dose of anticoagulation therapy should be given prior to transfer) 19. Treatment: Drug of choice The treatment of choice for VTE in pregnancy is low molecular weight heparin (LMWH) LMWH is superior to UFH in terms of efficacy. UFH is associated with more side effects. The following LMWH is recommended in pregnancy: 1. Enoxaparin 2. Tinzaparin 3. Dalteparin 20. LMWH Routine monitoring of platelet counts is not indicated. Anti-Xa level monitoring is not indicated unless when the weight is less than 50kg or more than 90kg. The target level is 0.5-1.2 Sampling should be done 4 hours post dose. 21. Anticoagulation: LMWH Enoxaparin: 1 mg/kg subcutaneously every 12 hours Tinzaparin: 175 IU/kg subcutaneously OD Dalteparin: 150-200 IU/kg subcutaneously OD (max dose 18,000 IU daily) For DVT, repeat doppler studies after 5 - 7 days of anticoagulation to check if clot has resolved! 22. Anticoagulation: UFH Subcutaneous: 10,000 IU twice daily IV Infusion: 5000 IU stat bolus followed by 1000 IU/hour by continuous IV infusion. Bolus dose of 80 IU/kg IV stat followed by 18 IU/kg/hour by continuous IV infusion The dosage adjusted to maintain the aPTT at 1.5 to 2.5 Platelet counts to be monitored daily during IV treatment & weekly for 4 weeks then monthly during SC treatment. Heparin-induced thrombocytopenia is rare 23. Duration of treatment Depends on the cause Outside pregnancy a total of 3 - 6 months treatment is recommended. In pregnancy therapeutic doses is to be continued through pregnancy till 6 weeks postpartum. Within the 6 weeks postpartum, therapy should be extended to complete a minimum total treatment duration of 3 months. 24. LMWH- Regional anaesthesia Wait at least 12 hours after a prophylactic dose before block Wait at least 24 hours after a therapeutic dose before block Wait at least 10 hours after dose before removing catheter After catheter removal wait 2 - 4 hours before next dose To stop injections 24 hours before a planned delivery (induction or caesarean) Advised to omit injection at onset of labour LMWH regional anaesthesia & labour 25. UFH: regional anaesthesia & labour Unfractionated heparin (subcutaneous) Wait at least 4 hours after a dose before block or catheter removal Wait at least 1 hour before dosing after procedure (catheter insertion or withdrawal) Unfractionated heparin (intravenous) Stop infusion 2-4 hours before block Start infusion > 1 hour after block Remove epidural catheter no sooner than 2 - 4 hours after discontinuation of infusion Labour stop at onset of labour 26. Treatment: Postpartum Active management of 3rd stage PPH prophylaxis should be instituted Blood grouped and saved large IV access 40 units oxytocin infused after delivery of placenta Therapeutic dose can be recommenced 4 hours postpartum (also for operative delivery) LSCS- recommended to insert drain 27. Treatment: Use of warfarin for maintenance therapy may be considered in the 2nd trimester up to 36 weeks or in the postnatal period. Women should be counseled that both heparins and warfarin are safe during breastfeeding. 28. Treatment: Unstable PE In severe cases of PE with cardiorespiratory compromise a) Consider thrombolytic therapy (e.g. alteplase, streptokinase) although no clear survival benefits have been established. b) Complications include 3-5% non-fatal maternal haemorrhage and 2% fetal demise. c) If all fails, get cardiothoracic input for thoracotomy (Pulmonary embolectomy) 29. Does guidelines work? There has been a significant decline in deaths from PE following the publication and implementation of guidelines that were recommended in previous confidential enquiry reports. (Confidential Enquiry into Maternal Deaths, UK) The number of deaths in the UK attributed to PE were 18 between 2006-2008 compared to 41 in 2003-2005. Evidence that clinical guidelines works.. 30. CPG on VTE Published in August 2013 All women should be assessed at booking and after delivery or if they are admitted to the hospital for any reason or develops other problems All should be stratified into risk groups according to risk factors and offered thromboprophylaxis with LMWH where appropriate 31. Strategy to reduce risk of VTE in pregnancy Modifying risk factors in women planning to embark on pregnancy PPC Clinic Improve awareness among health staff and public Guidelines Appropriate management of pregnant women based on VTE risk stratification 32. Patients with known Risk Factors PRE PREGNANCY High risk patients contemplating pregnancy e.g.: 1. Previous history of VTE /PE 2. Protein S and Protein C deficiencies 3. Collagen diseases especially SLE 4. Anti-phospholipid Antibody Syndrome 5. Other risk factors e.g. obesity, elderly, hypertensive, ART, smoker, varicose veins, paraplegia, IV drug users Refer to PPC clinic: Health clinics with FMS O&G Specialist clinics 33. PPC Clinic Counseling on individual risk of VTE To reduce BMI below 30kg/m2 Stop smoking Limit number of pregnancies Optimizing chronic medical illnesses Effective and appropriate contraception 34. VTE Risk factors Age above 35 years Weight > 80kg or pre pregnancy/ booking BMI> 30 Parity > 3 Past history of thromboembolism Thrombophilia Gross varicose veins Immobility e.g. long haul travel, hospital stay > 3 days Pre-eclampsia Caesarean section IV drug user Prolonged labour > 12 hours or instrumental deliveries Medical conditions: a) heart disease (especially prosthetic valves) b) nephrotic syndrome c) systemic inflammatory diseases. Massive postpartum haemorrhage Systemic infection Hyperemesis gravidarum Dehydration OHSS 35. Antenatal Assessment VERY HIGH RISK Recurrent VTE associated with either anti- thrombin deficiency or anti-phospholipid syndrome Require higher dose of LMWH (high prophylactic 12-hourly or 75% of treatment dose) Antenatal + 6 weeks postnatal or until conversion to warfarin 36. Antenatal Assessment HIGH RISK Single VTE with thrombophilia or unprovoked / estrogen-related Previous recurrent VTE (>1 episode) Require antenatal + 6 weeks postnatal thromboprophylaxis 37. Antenatal Assessment INTERMEDIATE RISK Single previous VTE with no family history or thrombophilia Thrombophilia but no VTE Has medical co-morbidities Intravenous drug user Surgical procedure Consider antenatal + 7 days up to 6 weeks postnatal thromboprophylaxis 38. Antenatal Assessment All women must undergo documented assessment for VTE risk at the following: a)Pre-pregnancy (@ PPC Clinic) b)Early pregnancy (@ booking) c)Every admission 39. Postnatal Assessment All postpartum women must undergo documented assessment for VTE risk Encourage ambulation Avoid dehydration Advised to seek treatment early in nearest health center if feeling unwell LMWH is the agent of choice LMWH & warfarin are safe during breastfeeding VTE Training Manual 2012 54 40. Postnatal Assessment Risk Factors All antenatal risk factors Anyone requiring antenatal thromboprophylaxis Caesarean section (Emergency & Elective) Mid-cavity rotational operative delivery Prolonged hospital admission ( > 3 days) Prolonged labour (>12hours) PPH >1.5L or blood transfusion 41. Postnatal Assessment Risk Categories HIGH RISK: require at least 6 weeks postnatal thromboprophylaxis INTERMEDIATE RISK (score > 2): consider at least 7 days of postnatal thromboprophylaxis LOW RISK (score of < 2): advise on mobilization and adequate hydration NEW GREEN TOP GUIDELINE: at least 10 days postnatal prophylaxis for score of 2 or more VTE Training Manual 2012 56 42. RISK FACTORS: Tick Tick Discharge (Tick) Score DATE: ANTENATAL: Previous VTE (estrogen related, unprovoked or recurrent) 3 Previous VTE (provoked, eg accident) 2 Thrombophilia 2 Medical illness (SLE, Cardiac, Connective tissue, Renal disease, Malignancy) 2 Family history of VTE 1 Age >35 years 1 Parity > 3 1 Obesity a) (BMI>40kg/m2) 2 b) (BMI>30kg/m2) 1 Gross varicose veins 1 Smoker/ IVDU 1 Multiple pregnancy 1 CURRENT EVENTS OR ADMISSION: Hyperemesis Gravidarum requiring admission 1 Pre-eclampsia 1 Dehydration/ OHSS** Hospital stay / immobilization > 3days 1 Systemic infection (eg active TB, pneumonia) 1 Chorioamnionitis 1 Surgery in pregnancy or puerperal period (includes BTL within 42 days of delivery. Exclude ERPOC & minor T&S*) 1 Long travel by road/air travel > 8 hours non stop 1 DELIVERY (CURRENT PREGNANCY): Caesarean section (emergency & elective) 2 Instrumental delivery 1 PPH > 1.5 L 1 Prolonged labour > 24 hours 1 Third/fourth degree perineal tear 1 Vulvo/vaginal haematoma 1 Septic miscarriage/ Molar pregnancy 1 TOTAL SCORE Name of 1st assessor Name of 2nd assessor Name of 3rd assessor Sarawak VTE Risk Assessment Form (Hospitals) Name: NRIC: Assessment should be performed: At antenatal booking During each hospital admission Reassessment whenever required Post delivery before discharge When to give thromboprophylaxis: 1) ANTENATALLY score > 3 (duration of thromboprophylaxis to be decided or discussed with an O&G specialist) 2) POSTNATALLY score > 2 (Rx duration for 7 days) Weight Enoxaparin (Clexane) S/C Heparin Tinzaparin (Innohep) 4 < 28 WKS >28 WKSCounselling on ambulation, avoid dehydration, +/- compression stocking Reassess risk if requires prolonged admission or develops new problems Non specialist hospital Specialist hospital Coded yellow Discuss with Buddy Specialist or O&G specialist on-call Initiate thromboprophylaxis (consult O&G specialist if unsure of duration) Shared care between MO/FMS/Specialist E-Discharge Notifications (specific instructions, home visits) Home visit by health staff (review compliance, symptoms- use check list) FMS/ Specialist follow up but shared care allowed Coded yellow Initiate thromboprophylaxis Documented follow up plans E-Discharge Notifications (specific instructions) Home visit by staff (review compliance, symptoms- use check list) Follow-up with specialist clinic or shared care MANAGEMENT FLOWCHART - MAY 2015 47. ANTENATALLY score > 4 (other than for previous VTE or thrombophilia), consider thromboprophylaxis from 1st trimester and may consider to continue up to 6/52 postnatally after risk reassessment (specialist decision) ANTENATALLY score 3 (other than for previous VTE or thrombophilia), consider thromboprophylaxis from 28 weeks onwards POSTNATALLY score > 2 (other than for previous VTE or thrombophilia), consider thromboprophylaxis for at least 10 days Who should be given thromboprophylaxis? 48. LMWH is the preferred thromboprophylaxis Antenatal women admitted for hyperemesis gravidarum, OHSS or surgery (score of 4 each): consider prophylaxis with LMWH unless there is a specific contraindication (e.g. risk of bleeding) In hyperemesis gravidarum & OHSS, VTE prophylaxis should be given until the relief of symptoms IVF pregnancy & dehydration are considered risk factors (score of 1 each) Other new recommendations 49. Women who had emergency caesarean section (score of 2) should be given VTE prophylaxis for 10 days after delivery. Women who had elective caesarean section (score of 1) plus 1 other risk factor should be given 10 days of VTE prophylaxis If heparin was used after caesarean section (or other surgery), the platelet count should be monitored every 2-3 days from day 4-14 or until heparin is stopped Women with recurrent VTE require higher doses of LMWH and co- managed with a Hematologist/Physician Other NEW recommendations : 50. VTE Checklist during home visits by nurses: If a patient develops any of these signs or symptoms, refer immediately to the nearest clinic or hospital for review by a doctor. Patients should be advised to ambulate, drink adequately and to seek medical treatment if feeling unwell during every visit Check if the patient is compliant to treatment THROMBOEMBOLISM CHECK LIST FOR ANTENATAL OR POST-NATAL HOME VISITS: 1) General well-being Y N a) Is the patient ambulating? b) Is the patient drinking well? c) Does the patient look dehydrated? d) Does the patient have fever? 2) Signs & symptoms of DVT Y N a) Leg swelling (usually unilateral) b) Calf pain (even at rest) c) Redness of calf d) Feeling unwell (unable to mobilize) e) Non pitting swelling f) Increased warmth of the limb g) Reduced capillary filling 3) Signs & symptoms of pulmonary embolism Y N a) Shortness of breath b) Chest pain (more during breathing) c) Cough (dry or blood stained) d) Pulse rate >100 e) Respiratory rate >24 f) Cyanosis g) Unconscious Please note: If a patient develops any of these signs or symptoms, refer immediately to the nearest clinic or hospital for review by a doctor. Please advise patients to ambulate, drink adequately and to seek medical treatment if feeling unwell during every visit Please ensure if the patient is compliant to the medication or injections being prescribed Assessed by: Name: .. Signature: .. Date: 51. MMR Sarawak 1998 2013 (direct & indirect causes) Excluding foreigners Source of data : maternal mortality report 2003, SHD, MOH Enquiry of maternal death 2005; SHD enquiry list 15 deaths due to PE from 2008-2012 4 deaths due to PE in 2012 1 PE death in 2013 52. VTE- contraception Progestogen only pills Implanon Mirena & Cu- IUCD Depo-provera Avoid combined OCP, transdermal patches & intravaginal rings 53. RECOMMENDATIONS Definitive diagnosis of DVT/PE in pregnancy should be obtained for all cases as it carries a long- term implication for future pregnancies. All at-risk patients in pregnancy and postpartum should be offered thromboprophylaxis. A standard checklist should be developed and used by the O&G services. The percentage of compliance to these checklists should be monitored at the hospital level. Awareness and the importance of thromboprophylaxis should be increased among the nursing personnel and junior medical officers 54. Case scenario 1 37 year-old woman at 28 weeks of gestation with PE. Her BMI is 35. She complained of leg swelling that makes it difficult to walk. 1. How is pedal oedema of pregnancy different from swelling of DVT? 2. What are the risk factors present for DVT in this woman? 3. Upon assessing, you find that the woman most likely has DVT of the right leg. What are your possible actions? 4. At the receiving hospital, you think it would be DVT. What are your actions? 5. How do you diagnose a lower limb DVT? 55. 1. Pedal oedema is usually bilateral. DVT of the lower limb is usually unilateral and it may be red, warm and tender 2. Risk factors: Gender, age, BMI, PE, immobility, pregnancy 3. Refer to MO/FMS/O&G specialist, arrange to be reviewed urgently in clinic or ETD 4. Confirm diagnosis then treat OR start treatment and confirm diagnosis. Anticoagulation with heparin/LMWH/warfarin. Give analgesia, TED stocking, elevate leg +/- antibiotics 5. Investigations: pulsed Doppler or venogram Case scenario 1: answer 56. Case scenario 2 35years old para 2 post SVD day 5, no antenatal complication or post natal complication till date. She complained of swollen left lower limb and mild chest discomfort upon review during the home visit on day 5. 1. What should be checked? 2. What is the next step? 3. While arrangement was being made for admission she suddenly complained of pleuritic chest pain and SOB? 4. What do you do? 57. Case scenario 2: Answer 1. CHECK LIST home visit postnatal check list 2. High suspicion of DVT, refer to be reviewed in clinic with MO/FMS stat. Advisable for admission for confirmation of diagnosis. 3. Suspicion of PE. 4. Urgent referral and arrange transfer to nearest specialist hospital. If heparin is available initiate anticoagulation after discussing with O&G specialist/Physician