Obstetric embolism

OBSTETRIC EMBOLISM
Dr. Rafaie Amin
Consultant Obstetrician & Gynaecologist
Sarawak General Hospital

OBSTETRIC EMBOLISM
• AFE (Amniotic Fluid Embolism)
• VTE (Venous Thromboembolism)

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

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

Pregnancy
Immobility
& stasis
LSCS &
Other
surgeries

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

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

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

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

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.

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

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.

Diagnosis of PE
• D-dimer: if negative not likely PE
• Pulmonary angiogram (CTPA)
• Ventilation-perfusion scan (V/Q scan) – not widely
available

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

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

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)

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)

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

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.

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!

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

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.

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

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

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

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.

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)

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…..

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”

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

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

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

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

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

HIGH RISK
• Single VTE with thrombophilia or unprovoked
/ estrogen-related
• Previous recurrent VTE (>1 episode)
 Require antenatal + 6 weeks postnatal
thromboprophylaxis

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

• All women must undergo documented
assessment for VTE risk at the following:
a)Pre-pregnancy (@ PPC Clinic)
b)Early pregnancy (@ booking)
c)Every admission

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

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

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

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)
<50kg 20mg OD - -
50-90kg 40mg OD 5000 units BD 4500units OD
91-130kg 60mg OD Insufficient
evidence of
efficacy
7000units OD
131-170kg 80mg OD 9000units OD
Dosage for thromboprophylaxis:

SARAWAK VTE RISK ASSESSMENT FORM:

NEW RECOMMENDATIONS FROM
THE JUST RELEASED GREEN TOP
GUIDELINES, APRIL 2015 ON VTE IN
PREGNANCY
SOME OF THESE RECOMMENDATIONS
WOULD BE IMPLEMENTED IN THE STATE…..

Sarawak VTE Risk assessment Form (May, 2015)

Antenatal assessment
Score < 3 SCORE 3 Score > 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

• 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?

• 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

• 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 :

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: ………………………

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

VTE- contraception
• Progestogen only pills
• Implanon
• Mirena & Cu- IUCD
• Depo-provera
• Avoid combined OCP, transdermal patches &
intravaginal rings

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

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?

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

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?

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

Obstetric embolism

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