Thromboprophylaxis in obstetrics: a quality-improvement project investigating prescription and administration of thromboprophylaxis during the immediate post-delivery period
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Authors
Mitchell , F
Divinney , E
Kamath , P
Issue Date
2021
Type
Scientific Paper
Language
Keywords
Research Subject Categories::MEDICINE::Surgery::Anaesthetics and intensive care::Anaesthetics
Alternative Title
Abstract
Venous thromboembolism (VTE) remains one of the main direct causes of maternal death in the UK, with 11% of maternal morbidity due to VTE [1]. VTE can occur at any stage during pregnancy, but the puerperium is the time of highest risk [1]. On this basis, in 2015 the Royal College of Obstetricians (RCOG) Green top Guidelines: ‘Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium’ added a recommendation that the ‘first thromboprophylactic dose of low molecular weight heparin (LMWH) should be given as soon as possible after delivery provided there is no post-partum haemorrhage and regional analgesia has not been used’ [1]. The Association of Anaesthetists/Obstetric Anaesthetists' Association/Regional Anaesthesia UK guidelines, state that an acceptable time post-neuraxial block/removal of catheter is 4 h [2].
Methods
A departmental audit was carried out over a 2-week period. A pro forma was created to collect data from the notes of 166 women who delivered during this time. This looked at delivery method, VTE score and the prescribing of LMWH in relation to the timing of neuraxial analgesia and anaesthesia. The data of women who had clinical reasons for receiving delayed LMWH (for example a major haemorrhage) were excluded.
Results
From the audit, 60.3% of women received a spinal/epidural. The average VTE score for all women was 1.7, but for women who received a spinal/epidural the average VTE was 2.5, if the total score is > 2 postnatally then thromboprophylaxis should be prescribed and given for at least 10 days. The average time from spinal/epidural catheter removal to first prescription of LMWH was 7 h 30 min. The average time difference from spinal/epidural catheter removal to the first administration of LMWH was 8 h 55 min.
Discussion
The results demonstrate that as a department, we are not following the RCOG guidelines with regards to giving the LMWH as soon as possible after delivery. This is due to delays in both prescribing and administration of LMWH. It may be that the RCOG guidelines are not well known amongst anaesthetists or junior members of the obstetric teams who are the main prescribers, and the midwives who are administrating the LMWH. Steps need to taken to investigate this further and address this as needed, for example, by surveying these members of staff about the reasoning behind their prescribing or administrating practices and implementing changes to these practices to reduce the time delay in patients receiving LMWH.
References
1. Royal College of Obstetricians and Gynaecologists. Reducing the risk of venous thromboembolism during pregnancy and puerperium. Green-top guideline no.37a. April 2015. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-37a.pdf (accessed 21/04/2021).
2. Harrop-Griffiths W, Cook T, Gill H et al. Regional anaesthesia and patients with abnormalities of coagulation. Anaesthesia 2013; 68: 966–72.
Approvals
REC Advice not sought
R&D department Advice not sought
Audit department Approval obtained
Caldicott Guardian Advice not sought
Consent None
Description
Citation
Mitchell, F., Divinney, E., Kamath, P. (2021) Thromboprophylaxis in obstetrics: A quality-improvement project investigating prescription and administration of thromboprophylaxis during the immediate post-delivery period. Anaesthesia. 76(Suppl 6): 55. DOI: http://dx.doi.org/10.1111/anae.15578