Endorsed scope - Queensland Health

SCOPE DEFINITION
Translating evidence into best clinical practice
Guideline title: Venous thromboembolism prophylaxis in pregnancy and the puerperium – first review
Pico framework: Refer to Table 1
Clinical questions: Refer to Table 2
Clinical audit: Refer to Table 3
Change requests summary: There are no recorded change requests for this guideline.
Table 1: Pico framework
PICO Framework
Identify who is at risk of VTE and what measures can be taken to reduce the risk
Identify best practice for routine antenatal assessment
Identify best practice for antenatal education of women at risk of VTE
Identify best practice for thromboprohylaxis during pregnancy and the puerperium, giving
consideration to:
Risk category
Intervention
Specific patient groups
Mode of birth
Fetal safety in pregnancy
Identify best practice for postnatal care of women at risk of VTE including:
Self care education (e.g. self-administration of thromboprophylaxis)
Self referral and planned follow-up
Population Gravid women
Comparison N/a
Women receive best practice assessment for VTE risk
Women receive best practice non-pharmacological/pharmacological prophylaxis to minimise
harm to the fetus and VTE associated morbidity and/or mortality
Outcome
Women receive best practice care in pregnancy, labour and after birth to reduce the incidence
[Refer to Table 3]
of VTE
Women receive best practice discharge preparation and follow up to prevent postnatal
development of VTE
Table 2. Clinical questions to be addressed
Question
Introduction
1
2
3
4
Are some women at greater
risk of VTE?
What is best practice for
assessment of VTE risk?
What is best practice for
thromboprophylaxis for
women with low, medium and
high risk levels?
What is best practice
postnatal care and follow-up
for a woman at risk of VTE?
Likely Content/Headings/Document Flow
Definition of VTE
Incidence of VTE in Queensland
Clinical Standards
Counselling of women
Identify risk factors for VTE in pregnancy and the puerperium
Identify a best practice method for VTE risk scoring
Identify best practice methods of thromboprophylaxis
Identify best practice in prophylactic management of VTE across risk levels
and specific patient groups
Identify best practice principles for discharge planning
Identify teaching principles in relation to self-care in the puerperium
including:
Non-pharmacological VTE prevention methods
Principles of self-management of pharmacological VTE prophylaxis,
including :
Warfarin
Low molecular weight heparin
Unfractionated heparin
Identify best practice advice for follow-up e.g. self-referral to the GP, review
by specialist
Page 1 of 3

Translating evidence into best clinical practice
Exclusions:
Investigation and diagnosis of VTE in pregnancy and/or the puerperium
Acute management of VTE occurring in pregnancy and/or the puerperium
Table 3. Existing outcomes measures used in clinical audit for VTE
VTE outcome measures
Source
Clinical audit standards*
Australian
Council of
Healthcare
Standards:
Obstetric
indicators
Royal College of
Obstetricians
and
Gynaecologists:
Green-top
Guideline 37a
(2004)
Indicator Area 6: Pharmacological thromboprophylaxis and caesarean section:
CI. 6.1 Numerator: Total number of high risk women undergoing caesarean section who receive
appropriate pharmacological thromboprophlylaxis
Denominator: Total number of high risk women undergoing caesarean section
Thromboprophylaxis during pregnancy, labour and after vaginal delivery
Proportion of women with previous venous thromboembolism who undergo screening for
thrombophilia
Proportion of women with previous venous thromboembolism who receive six weeks postnatal
Low Molecular Weight Heparin
Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary
embolism) in patients admitted to hospital
National
Institute for
Health and
Clinical
Excellence:
Guideline CG92,
Audit support
Selected items for ‘All patients:
Criterion 1: Was the patient assessed for risk of VTE on admission?
Criterion 2: Was the patient assessed for risk of bleeding before being offered
pharmacological VTE prophylaxis?
Criterion 3: Was the risks of bleeding and VTE reassessed within 24 hours of admission?
Criterion 4: Was there evidence that the patient was encouraged to mobilise as soon as
possible?
Criterion 7: How long after the risk assessment was completed was pharmacological VTE
prophylaxis started?
Criterion 8: Was pharmacological VTE prophylaxis stopped when the patient was no longer at
increased risk of VTE?
Selected items for ‘Surgical patients’:
Criterion 9, 11, 13, 17, 18: Does the patient fall into any of the following categories, if so, was
the patient offered mechanical VTE prophylaxis?:
Has had a surgical procedure with a total anaesthetic and surgical time of more than 90
minutes, or 60 minutes if the surgery involves the pelvis or lower limb
Expected significant reduction in mobility
Acute surgical admission with inflammatory or intra-abdominal condition
One or more of the following risk factors:
Active cancer or cancer treatment
Critical care admission
Dehydration
Known thrombophilias
Obesity (BMI over 30 kg/m2)
One or more significant medical co-morbidities
Personal history or first-degree relative with a history of VTE
Use of hormone replacement therapy
Use of oestrogen-containing contraceptive therapy
Varicose veins with phlebitis
Page 2 of 3

Translating evidence into best clinical practice
Table 3. Existing outcomes measures used in clinical audit for VTE continued
VTE outcome measures
Source
Clinical audit standards*
National
Institute for
Health and
Clinical
Excellence:
Guideline CG92,
Audit support
Items for ‘All patients – provision of information
Criterion 19: Before starting VTE prophylaxis was the patient offered verbal and written
information about:
The treatment and care they should be offered, [including being made aware of availability
of written patient information available]?
The risks and possible consequences of VTE?
The importance of VTE prophylaxis and its possible side effects?
The correct use of VTE prophylaxis (for example, anti-embolism stockings, foot impulse or
intermittent pneumatic compression devices)?
How patients can reduce their risk of VTE (such as keeping well hydrated and, if possible,
exercising and becoming more mobile)?
Criterion 20: As part of the discharge plan, was the patient offered verbal and written
information on:
The signs and symptoms of deep vein thrombosis and pulmonary embolism?
The correct and recommended duration of use of VTE prophylaxis at home (if discharged
with prophylaxis)?
The importance of using VTE prophylaxis correctly and continuing treatment for the
recommended duration (if discharged with prophylaxis)?
The signs and symptoms of adverse events related to VTE prophylaxis (if discharged with
prophylaxis)?
The importance of seeking help and who to contact if they have any problems using the
prophylaxis?
The importance of seeking medical help if deep vein thrombosis, pulmonary embolism or
another adverse event is suspected?
*For source documents refer to:
ACHS Obstetric Manual: http://www.anzca.edu.au/resources/college-publications/books-andpublications/ClinicalIndicators.pdf
Royal College of Obstetricians and Gynaecologists Guideline No. 37a (2004) Thromboprophylaxis during
pregnancy, labour and after vaginal delivery: http:// www.rcog.org.uk/guidelines:
National Institute for Health and Clinical Excellence Guideline CG92, Audit support:
http://www.nice.org.uk/nicemedia/live/12695/47202/47202.doc
Page 3 of 3