This application is designed to help you assess the risk of developing VTE in pregnancy and puerperium in a simple and quick way, as well as presenting brief and detailed recommendations based on rating and / or risk factors for developing VTE based on RCOG Guidelines.
Executive summary of recommendations
All women should undergo a documented assessment of risk factors for VTE in early pregnancy or pre-pregnancy.
Risk assessment should be repeated if the woman is admitted to hospital for any reason or develops other intercurrent problems.
Risk assessment should be repeated again intrapartum or immediately postpartum. Risk assessment should be performed in each woman at least once following delivery and before discharge and arrangements made for LMWH prescription and administration (usually by the woman herself) in the community where necessary.
A formal VTE risk assessment with numerical scoring for all pregnant and postpartum women is recommended (see Appendix III). Women admitted to hospital when pregnant (including to the gynaecology ward with hyperemesis gravidarum or ovarian hyperstimulation syndrome) should usually be offered thromboprophylaxis with LMWH unless there is a specific contraindication such as risk of labour or active bleeding.
The risk of VTE should be discussed with women at risk and the reasons for individual recommendations explained.
Women receiving antenatal LMWH should be advised that if they have any vaginal bleeding or once labour begins they should not inject any further LMWH. They should be reassessed on admission to hospital and further doses should be prescribed by medical staff.
Women at high risk of haemorrhage with risk factors including major antepartum haemorrhage, coagulopathy, progressive wound haematoma, suspected intra-abdominal bleeding and postpartum haemorrhage may be managed with anti-embolism stockings (AES), foot impulse devices or intermittent pneumatic compression devices. Unfractionated heparin (UFT) may also be considered.
If a woman develops a haemorrhagic problem while on LMWH the treatment should be stopped and expert haematological advice sought. Thromboprophylaxis should be started or reinstituted as soon as the immediate risk of haemorrhage is reduced.
Clinical guidelines are: ‘systematically developed statements which assist clinicians and patients in making decisions about appropriate treatment for specific conditions’. Each guideline is systematically developed using a standardised methodology. Exact details of this process can be found in Clinical Governance Advice No. 1 Development of RCOG Green-top Guidelines (available on the RCOG website at http://www.rcog.org.uk/green-top-development). These recommendations are not intended to dictate an exclusive course of management or treatment. They must be evaluated with reference to individual patient needs, resources and limitations unique to the institution and variations in local populations. It is hoped that this process of local ownership will help to incorporate these guidelines into routine practice. Attention is drawn to areas of clinical uncertainty where further research may be indicated.
The Royal College of Obstetricians and Gynaecologists produces guidelines as an educational aid to good clinical practice. They present recognised methods and techniques of clinical practice, based on published evidence, for consideration by obstetricians and gynaecologists and other relevant health professionals. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made by the doctor or other attendant in the light of clinical data presented by the patient and the diagnostic and treatment options available.
This means that RCOG Guidelines are unlike protocols or guidelines issued by employers, as they are not intended to be prescriptive directions defining a single course of management. Departure from the local prescriptive protocols or guidelines should be fully documented in the patient’s case notes at the time the relevant decision is taken.