The Use of a Scoring System to Guide Thromboprophylaxis in a High-Risk Pregnant Population

D Schoenbeck,J Hanley,K Newbegin,A D Loughney,A Nicolle

doi:10.1155/2011/652796

D Schoenbeck, J Hanley + Show 3 more

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https://doi.org/10.1155/2011/652796

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Journal: Thrombosis	Publication Date: Sep 8, 2011
Citations: 25	License type: CC BY 3.0

Affiliation: Royal Victoria Infirmary

Abstract

Guidelines for thromboprophylaxis in pregnancy are usually based upon clinical observations and expert opinion. For optimal impact, their use must be attended by consistency in the advice given to women. In this observational study, we evaluated the performance of a scoring system, used as a guide for clinicians administering dalteparin to pregnant women at increased risk of venous thromboembolism. The work included 47 women treated with dalteparin prior to adoption of the scoring system and 58 women treated with dalteparin after its adoption. The indication for thromboprophylaxis was recorded in each case together with details of the regimen employed, obstetric, and haematological outcomes. The main outcome measure was to determine whether consistency improved after adoption of the scoring system. We also recorded the occurrence of any new venous thromboembolism, haemorrhage, the use of regional anaesthesia during labour, evidence of allergy, and thrombocytopenia. We found that use of the scoring system improved the consistency of advice and increased the mean duration of thromboprophylaxis. None of the subjects suffered venous thromboembolism after assessment using the scoring system. There was no increase in obstetric or anaesthetic morbidity when dalteparin was given antenatally period and no evidence of heparin-induced thrombocytopenia.

Highlights

Venous thromboembolism (VTE) has been the commonest noniatrogenic, direct cause of maternal death in England and Wales for many years, reflecting a longstanding UK wide pattern of disease [1, 2]
Maternal allergy, osteoporosis, and thrombocytopenia are rare even after prolonged use [15,16,17], while epidural and spinal anaesthesia are thought to be safe for labour and delivery if at least 12 hours have elapsed since the last administration time of the drug [18]
With evidence of significant morbidity and mortality arising from VTE in pregnancy including case reports amassed through over 50 years of Confidential Enquiries reports, SIGN issued firm guidance for thromboprophylaxis in pregnancy in 2002 [19], necessarily basing their recommendations largely upon expert opinion

Summary

Introduction

Venous thromboembolism (VTE) has been the commonest noniatrogenic, direct cause of maternal death in England and Wales for many years, reflecting a longstanding UK wide pattern of disease [1, 2]. Maternal allergy, osteoporosis, and thrombocytopenia are rare even after prolonged use [15,16,17], while epidural and spinal anaesthesia are thought to be safe for labour and delivery if at least 12 hours have elapsed since the last administration time of the drug [18] Because of their efficacy and good safety profile, the use of low molecular weight heparins for thromboprophylaxis in pregnancy has increased greatly in recent years. A theoretical advantage of the scoring system over the SIGN and RCOG Guidelines is that it has achieved this consistency while retaining a highly individualised assessment of a woman’s VTE risk in the face of multiple risk factors for thromboembolism Whether or not this delivers a clinical advantage remains unproven. A score of 2.0 could trigger prophylaxis with a standard, once daily dose of LMWH throughout pregnancy while a score of 3.0 or more could for example trigger weight adjusted prophylaxis with concomitant anti-Xa monitoring

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