Assessment of Risk Factors and Risk Stratification for Venous Thromboembolism (VTE) in Pregnancy: A Study Conducted in A Tertiary Level Hospital

Asma Habib (1) , Akhtar -Uz - Zaman (2) , Sultana Jebunnahar (3) , Alamgir Kabir (4) , Mohammad Shahbaz Hossain (5)
(1) Bangladesh Medical College & Hospital , Bangladesh
(2) Bangladesh Medical College & Hospital , Bangladesh
(3) , Bangladesh
(4) Bangladesh Medical College & Hospital , Bangladesh
(5) , Bangladesh

Abstract

Background: Pregnancy itself is one of the most provoking factors for the development of venous thromboembolism (VTE) with an incidence of 5-12 per 10 000 pregnancies (from conception to delivery, i.e., 40 weeks) and 3-7 per 10 000 deliveries postpartum (6 weeks).1 Moreover, certain clinical conditions and individual patient profile make each pregnant women more susceptible to develop symptomatic VTE comprising deep vein thrombosis (DVT) and pulmonary embolism (PE). There is no denial of the fact that risk stratification based upon individual risk factors (both clinical and biochemical) during antenatal period will rationalize the implementation of precise antenatal care/ personalized prophylaxis tailored to each pregnant women, ultimately leading to safe and healthy maternal and perinatal outcome. Objective: The objective of this study is to apply the documented assessment scoring system according to the RCOG Guideline 37a mainly based on clinical risk factors to detect and stratify antenatal patient risk of VTE and institute appropriate preventive treatment/advice. Method: This is a prospective cross-sectional study involving 50 antenatal/pregnant women randomly selected over a period of 6 months undergoing antenatal care in Bangladesh Medical College. For the assessment of risk of VTE in these patients, RCOG guideline 37a risk assessment tool was used. (Appendix 1) A score ranging from 0 to 4 or more was objectively found among these patients. Based upon the score, each patient was categorized as high risk, intermediate risk, and lower risk. Then thromboprophylaxis with LMWH (Enoxaparin)/mobilization was advised for variable durations depending upon the timing of presentation and scores. The patients were reassessed after admission and post-delivery using the same tool for change in transient factors and advised according to the score. Implementation of this risk stratification tool resulted in improved patient care and counselling; the pregnancy outcome of each case was followed up. Results: Among the fifty antenatal patients, RCOG guideline 37a risk assessment tool revealed the following scores: one patient scored zero. Eighteen patients scored one. Sixteen patients scored two. Nine patients scored three. Six patients scored four. Those who scored 0 and 1 (19 patients) required no thromboprophylaxis. The sixteen patients with a score of two were advised for post-natal thromboprophylaxis with low molecular weight heparin/ Enoxaparin (LMWH) for 10 days. They were reassessed/ re-scored in the postnatal period for VTE risk and 5 of these patients down scored to one. Thereby they were judged as not to require post-natal thromboprophylaxis and were advised early mobilization and avoidance of dehydration. The remaining 11 patients with a score of two on postnatal review were put on LMWH (Enoxaparin) at a dose of 20 mg daily subcutaneous (s.c.) (<50 kg), 40 mg daily (50-90 kg), 60 mg daily in 2 divided dose (91-130 kg) for 10 days. Conclusion: Pulmonary embolism is a dreaded consequence of VTE in pregnancy and post-partum, resulting in sudden severe maternal morbidity and mortality. Individualized scoring of the risk of VTE or early detection of DVT (deep venous thrombosis) with subsequent treatment /prophylaxis can reduce /eliminate the risk of maternal death related to VTE. Implementation of risk stratification for VTE of antenatal patients has resulted in a change of practice emphasising preventive measures such as mobilisation and anticoagulation according to the objective scoring system. It is clear that the antepartum and postpartum periods have different magnitudes of risk and distinct risk factors for VTE and therefore must be considered separately. As a continuum of care, carefully reviewed post-partum risk factors has also been proposed by the RCOG in the GTG 37a guideline. Low-molecular-weight heparin is safe in pregnancy and post-partum in prophylactic and therapeutic doses and does not require coagulation monitoring by haematological studies. LMW heparin provides advantages over heparin in that it has better bioavailability and longer half-life, simplified dosing, predictable anticoagulant response, lower risk of Heparin induced thrombocytopenia (HIT), and lower risk of osteoporosis. However, if monitoring is necessary particularly in case of ?Class II Obesity, renal insufficiency and presence of mechanical heart valves, anti–factor Xa levels must be measured because LMWH preparations have little effect on activated partial Thromboplastin Time (aPTT). 

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References

Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium Green-top Guideline No. 37a April 2015, RCOG.

Simpson EL, Lawrenson RA, Nightingale AL, Farmer RD. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. BJOG. 2001;108(1):56-60.

https://www.macrotrends.net/countries/BGD/bangladesh/maternal-mortality-rate

Solange da Cruz Chaves, José Guilherme Cecatti, Guillermo Carroli Pisake Lumbiganon, Carol J Hogue , Rintaro Mori , Jun Zhang et al. Obstetric transition in the World Health Organization Multicountry Survey on Maternal and Newborn Health: exploring pathways for maternal mortality reduction.. Rev Panam Salud Publica. 2015 May;37(4-5):203-10.

https://www.who.int/news-room/fact-sheets/detail/maternal-mortality

Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133(6 suppl):381S–453S.

Jobin S, et al. Health care guideline: venous thromboembolism prophylaxis. 8th ed. Bloomington, Minn.: Institute for Clinical Systems Improvement; 2010.

http://www.icsi.org/guidelines_and_more/gl_os_prot/cardiovascular/. Accessed October 21, 2011

Zhang, Wei et al. “Risk scores, prevention, and treatment of maternal venous thromboembolism.” World journal of clinical cases vol. 8,11 (2020): 2210-2218. doi:10.12998/wjcc. v8.i11.2210

Yang, Genyan et al. “The effects of obesity on venous thromboembolism: A review.” Open journal of preventive medicine vol. 2,4 (2012): 499-509. doi:10.4236/ojpm.2012.24069

Kabrhel C, Varraso R, Goldhaber SZ, Rimm EB, Camargo CA. Prospective study of BMI and the risk of pulmonary embolism in women. Obesity. 2009; 17:2040–2046. doi: 10.1038/oby.2009.92.

Torben Bjerregaard Larsen, Henrik Toft Sørensen, Mette Gislum, Søren Paaske Johnsen . Maternal smoking, obesity, and risk of venous thromboembolism during pregnancy and the puerperium: A population-based nested case-control study. VOLUME 120, ISSUE 4, P505-509, JANUARY 01, 2007 DOI: .https://doi.org/10.1016/j.thromres.2006.12.003

Wattanakit K, Lutsey PL, Bell EJ, et al. Association between cardiovascular disease risk factors and occurrence of venous thromboembolism. A time-dependent analysis. Thrombosis and Haemostasis. 2012 Sep;108(3):508-515. DOI: 10.1160/th11-10-0726. PMID: 22782466; PMCID: PMC3482827.

Cheng Y-J, Liu Z-H, Yao F-J, Zeng W-T, Zheng D-D, et al. (2013) Current and Former Smoking and Risk for Venous Thromboembolism: A Systematic Review and Meta-Analysis. PLoS Med 10(9): e1001515. doi: 10.1371/journal.pmed.1001515

Li R, Chen Z, Gui L, Wu Z, Miao Y, Gao Q, Diao Y and Li Y (2022) Varicose Veins and Risk of Venous Thromboembolic Diseases: A Two-Sample-Based Mendelian Randomization Study. Front. Cardiovasc. Med. 9:849027

H. E. Fuentes, L. H. Paz, A. Al-Ogaili, X. A. Andrade, D. M. Oramas, J. P. Salazar-Adum, L. Diaz-Quintero, C. Acob, A. Tafur, J. Caprini. Validation of a Patient-Completed Caprini Risk Score for Venous Thromboembolism Risk Assessment. TH Open Vol. 1 No. 2/2017, e 106-112. DOI https://doi.org/ 10.1055/s-0037-1607339. ISSN 2512-9465.

Piazza, Gregory et al. “Venous thromboembolism in patients with diabetes mellitus.” The American journal of medicine vol. 125,7 (2012): 709-16. doi: 10.1016/j.amjmed.2011.12.004

Tsai AW, Cushman M, Rosamond WD, et al. Cardiovascular risk factors and venous thromboembolism incidence: the longitudinal investigation of thromboembolism etiology. Arch Intern Med. 2002; 162:1182–1189.

Ageno W, Becattini C, Brighton T, et al. Cardiovascular risk factors and venous thromboembolism: a meta-analysis. Circulation. 2008; 117:93–102.

Tripodi A, Branchi A, Chantarangkul V, et al. Hypercoagulability in patients with type 2 diabetes mellitus detected by a thrombin generation assay. J Thromb Thrombolysis. 2011; 31:165–172.

Ayub Akbari, Elizabeth Kunkel, Sarah E Bota, Ziv Harel, Gregoire Le Gal, Conor Cox, Gregory L Hundemer et al. Proteinuria and venous thromboembolism in pregnancy: a population-based cohort study, Clinical Kidney Journal, Volume 14, Issue 9, September 2021, Pages 2101–2107.

Al-Homood IA. Thrombosis in systemic lupus erythematosus: a review article. ISRN Rheumatol. 2012; 2012:428269. doi:10.5402/2012/428269.

Roman MJ, Shanker BA, Davis A, et al. Prevalence and correlates of accelerated atherosclerosis in systemic lupus erythematosus. New England Journal of Medicine. 2003;349(25):2399–2406.

Ruiz-Irastorza G, Hunt BJ, Khamashta MA. A systematic review of secondary thromboprophylaxis in patients with antiphospholipid antibodies. Arthritis Care and Research. 2007;57(8):1487–1495.

Yechiel S. Mor,Joseph G. Schenker. Ovarian Hyperstimulation Syndrome and Thrombotic Events. American Journal of Reproductive Immunology, Volume 72, Issue 6,December 2014, Pages 541-548. https://doi.org/10.1111/aji.12310.

Strina et al. Venous Thromboembolism (VTE) and Assisted Reproductive Technologies (ART): A Complex Relationship. J Blood Lymph 2018, 8:1 DOI: 10.4172/2165-7831.1000199

A.T. Hansen, U.S. Kesmodel, S. Juul, A.M. Hvas, Increased venous thrombosis incidence in pregnancies after in vitro fertilization, Human Reproduction, Volume 29, Issue 3, March 2014, Pages 611–617.

Authors

Asma Habib
asma.imam2003@yahoo.com (Primary Contact)
Akhtar -Uz - Zaman
Sultana Jebunnahar
Alamgir Kabir
Mohammad Shahbaz Hossain
Author Biographies

Asma Habib , Bangladesh Medical College & Hospital

Associate Professor of Obstetrics & Gynaecology, Bangladesh Medical College & Hospital, Dhaka

Akhtar -Uz - Zaman, Bangladesh Medical College & Hospital

Associate Professor of Cardiology, Bangladesh Medical College & Hospital

Sultana Jebunnahar

Associate Professor of Obs. and Gynae., Bangladesh Medical College & Hospital

Alamgir Kabir, Bangladesh Medical College & Hospital

Professor of Haematology, Bangladesh Medical College & Hospital

Mohammad Shahbaz Hossain

Intern Doctor, Bangladesh Medical College & Hospital

1.
Habib A, Zaman A-U-, Jebunnahar S, Kabir A, Hossain MS. Assessment of Risk Factors and Risk Stratification for Venous Thromboembolism (VTE) in Pregnancy: A Study Conducted in A Tertiary Level Hospital . Haematol J Bangladesh [Internet]. 2024 Feb. 14 [cited 2024 Mar. 4];7(1):32-44. Available from: https://journal.hematologybd.org/index.php/haematoljbd/article/view/102

Article Details

How to Cite

1.
Habib A, Zaman A-U-, Jebunnahar S, Kabir A, Hossain MS. Assessment of Risk Factors and Risk Stratification for Venous Thromboembolism (VTE) in Pregnancy: A Study Conducted in A Tertiary Level Hospital . Haematol J Bangladesh [Internet]. 2024 Feb. 14 [cited 2024 Mar. 4];7(1):32-44. Available from: https://journal.hematologybd.org/index.php/haematoljbd/article/view/102