Venous Thromboembolism in Pregnancy - Prevention.pdf
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1、 If printed, this document is only valid for the day of printing. Venous Thromboembolism in Pregnancy Dec11.doc Page 1 of 12 Venous Thromboembolism in Pregnancy - Prevention Document Type Guideline Function(s) Clinical Service Delivery Health Service Group (HSG) Womens Health Departments affected Ma
2、ternity Staff affected All clinicians in Maternity Key words Pregnancy, thromboprophylaxis, venous thromboembolism Author role only Lead Clinician, Obstetric Physicians, Womens Health and Haematologist, ACH Owner (see ownership structure) Clinical Director of Obstetrics, Womens Health Edited by Clin
3、ical Policy Advisor Date first published December 2011 Date this version published December 2011 Date of next scheduled review December 2014 Unique Identifier NMP200/SSM/084 Contents 1. Purpose of guideline 2. Guideline management principles 3. Risk factors 4. Risk factors tables 5. Risk assessment
4、6. Thromboprophylaxis: general 7. Thromboprophylaxis: antenatal and flowchart 8. Thromboprophylaxis: postnatal and flowchart 9. Dosage for low molecular weight heparin (LMWH) 10. Epidural/spinal anaesthesia/analgesia 11. Supporting evidence 12. Associated ADHB documents 13. Disclaimer 14. Correction
5、s and amendments If printed, this document is only valid for the day of printing. Venous Thromboembolism in Pregnancy Dec11.doc Page 2 of 12 1. Purpose of guideline This guideline establishes the expected measures to prevent venous thromboembolism (VTE) during pregnancy within Auckland District Heal
6、th Board (ADHB). Venous thromboembolism in pregnancy and the postpartum remains one of the most common causes of maternal mortality in the developed world. The majority of women who develop VTE in association with pregnancy have personal or pregnancy-specific risk factors for thrombosis that were ei
7、ther untreated or unrecognised. Risk assessment of women and recommendations regarding thromboprophylaxis are still supported only by weak clinical evidence and the majority of recommendations are based on expert opinion rather than from information for randomised clinical trials. Also Recommendatio
8、ns from a group of Australian and New Zealand Specialists and Green- Top Guidelines from The Royal College of Obstetricians and Gynaecologists (RCOG) in the UK both advocate risk assessment of all pregnant women to determine their risk of pregnancy-associated VTE. The evidence correlating risk facto
9、rs and the occurrence of PA-VTE is imprecise, with wide estimates of risk, and is likely to be subject to various sources of bias. The assessment of risk in an individual woman not been validated by relevant studies. The Royal College of Obstetricians and Gynaecologists (RCOG) empirically recommend
10、three or more risk factors as a threshold for prophylaxis even though this has not been formally tested in clinical trials. An assessment of risk of thromboembolism should be carried out in all pregnant women. Some women have risk factors (Table 1 and Table 2) that place them at an increased risk of
11、 VTE throughout pregnancy and the postpartum period that are identified before or during pregnancy and warrant extended thromboprophylaxis. Others will develop complications during pregnancy with thromboprophylaxis only recommended while they are hospitalised, especially if additional risk factors f
12、or VTE as present. Back to Contents 2. Guideline management principles The management principles of this guideline are to: (a) Assess risk of VTE for all pregnant women at the earliest opportunity (Section 4) (b) Consider whether antenatal prophylaxis is required (Section 7) (c) Consider postnatal t
13、hromboprophylaxis (Section 8) (d) Reassess risk throughout the pregnancy and puerperium (e) Make an individualised plan with the patient (f) Ensure all women mobilise early postpartum and avoid dehydration Back to Contents If printed, this document is only valid for the day of printing. Venous Throm
14、boembolism in Pregnancy Dec11.doc Page 3 of 12 3. Risk factors Pregnancy is associated with a 5-10-fold increase in the risk of VTE due to factors specific to pregnancy and additional maternal risk factors. Pregnancy factors include venous stasis, an increase procoagulant factors and a reduction in
15、natural anticoagulants, and vessel wall injury occurs during labour and following caesarean section (CS). Increased BMI is an important and consistent risk factor for PA-VTE especially in combination with immobilisation. Long haul air travel has not been specifically studied in pregnant women but is
16、 associated with a two-fold increased risk in the general population. Risk factors are summarised in Table 1. Prior history of VTE Previous VTE is one of the most important risk factors for PA-VTE. The risk of recurrence is higher following previous unprovoked (no identified risk factors) than provo
17、ked (associated with a risk factor) events. Women with previous hormonally provoked VTE (pregnancy or oral contraceptive associated) have an increased risk of developing a recurrent VTE in a subsequent pregnancy. The role of hereditary thrombophilia in PA-VTE has been extensively reviewed. Table 2 s
18、ummarises the absolute risks of PA-VTE in women with thrombophilia, with data derived from studies of either unselected women or family cohort studies. While the most common thrombophilia, factor V Leiden (fVL) and the prothrombin gene mutation, increase the relative risk of PA-VTE, the absolute ris
19、k of VTE during pregnancy with these conditions is small. For example, fVL was associated with an eight-fold increased risk of PA-VTE in a cohort of 2480 women but this represented only three cases (1.1%) among 270 fVL positive women. There is no case for screening asymptomatic women for thrombophil
20、ia whether pregnant or not or undergoing fertility therapy. Notwithstanding this, many women have already been tested and for this reason it was necessary to include recommendations to deal with such cases. The methylenetetrahydrofolate reductase (MTHFR) polymorphism has not been shown to be more pr
21、evalent in women with PA-VTE and testing for this and homocysteine is not recommended. Family history of VTE Hereditary thrombophilias are only identified in around 50% of family cohorts with VTE so that in many women who have a positive family history of VTE there will be no laboratory marker that
22、helps identify if they are at increased risk. VTE is increasingly being recognised as a multigenic disease and the relevance of a positive family history i.e. one or more first-degree relative (parent, sibling or child) with VTE is being increasingly recognised and has been shown to increase the ris
23、k of VTE 2-fold. The strength of the association increases if younger relatives (age) are affected Odds ratio 2.7 (95%CI 2.2-3.4) and if more than one relative is affected Odds ratio 3.9 (95%CI 2.7-5.7). In the absence of a documented thrombophilia it will not be possible to identify which members o
24、f a family cohort are at increased risk, so all women from these families must be assumed to be at higher risk. Back to Contents If printed, this document is only valid for the day of printing. Venous Thromboembolism in Pregnancy Dec11.doc Page 4 of 12 4. Risk factors tables Table 1 Clinical risk fa
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