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The CMQCC Toolkit: Pregnancy Related Risk Factors & Thrombophilia Defined

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Apply the CMQCC First Prenatal Visit Risk Assessment to your practice
2. Discuss the ACOG definitions for anticoagulation regimens for the prevention and treatment of maternal VTE

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from July 19 2018 through July 19 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Pharmacy Education

Postgraduate Institute for Medicine designates this continuing education activity for 0.25 contact hour(s) (0.25 CEUs) of the Accreditation Council for Pharmacy Education. (Universal Activity Number – JA4008162-9999-18-324-H01-P)

Type of Activity: Knowledge

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.2 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

The CMQCC Task Force has released guidance on the prevention of PE and DVT in pregnancy. The document also helps clarify terminology to provide clarity when performing risk assessment at various time points in pregnancy (see ‘Related ObG Topics’ below). In addition, the CMQCC Task Force provides the anti-coagulation regimens recommended by ACOG.

Risk Factors

FAMILY HISTORY of VTE

VTE occurring in a first-degree relative prior to age 50

HIGH RISK THROMBOPHILIA

Antithrombin III deficiency
Antiphospholipid syndrome (APS)
- Requires at least one clinical and one laboratory criteria be met
Factor V Leiden or Prothrombin pathogenic variant
- Homozygosity or compound heterozygosity

LOW RISK THROMBOPHILIA

Factor V Leiden or Prothrombin pathogenic variant
- Heterozygote state
Protein C or S deficiency

Anticoagulation Regimens (ACOG)

LMWH – PROPHYLACTIC DOSE

Enoxaparin, 40 mg SC once daily
Dalteparin, 5,000 units SC once daily
Tinzaparin, 4,5000 units SC once daily
Nadroparin, 2,850 units SC once daily

LMWH – INTERMEDIATE DOSE

Enoxaparin, 40 mg SC every 12 hours
Dateparin, 5,000 units SC every 12 hours

LMWH – ADJUSTED DOSE (THERAPEUTIC)

Enoxaparin, 1mg/kg SC every 12 hours
Dalteparin, 200 units/kg SC once daily
Tinzaparin, 175 units/kg SC once daily
Dalteparin, 100 units/kg every 12 hours

UFH – PROPHYLACTIC

UFH, 5,000-7,500 units SC every 12 hours in first trimester
UFH, 7,500-10,000 units SC every 12 hours in the second trimester
UFH, 10,000 units SC every 12 hours in the third trimester, unless the aPTT is elevated

UFH – ADJUSTED DOSE (THERAPEUTIC)

UFH, 10,000 units or more SC every 12 hours in doses adjusted to target aPTT in the therapeutic range (1.5-2.5) 6 hours after the injection

POSTPARTUM ANTICOAGULATION

Prophylactic, intermediate or adjusted dose LMWH for 6-8 weeks as indicated
Oral anticoagulants may be considered postpartum based upon planned duration of therapy, lactation and patient preference

SURVEILLANCE

Clinical vigilance and appropriate objective investigation of women with symptoms suspicious of deep vein thrombosis or pulmonary embolism
VTE risk assessment should be performed prepregnancy or early in pregnancy and repeated if complications develop, particularly those necessitating hospitalization or prolonged immobility

Notes:

Anti-Xa level testing is available to monitor activity of LMWH agents
CMQCC defines ‘LMWH therapeutic dose’ as enoxaparin, 1mg/kg SC every 12 hours, adjusted to target Xa 0.6-1.0 units/mL 4-6 hours after injection with acute VTE
aPTT testing is used to determine UFH dosing, not LMWH activity
Anti-Xa level testing is not currently mandated due to cost, inconvenience and lack of high quality data
Dose adjustment may be considered with extremes of body weight (< 50 kg or > 90 kg)
Consultation and ongoing collaboration with Anesthesia is strongly recommended

CMQCC Maternal VTE Patient Education Handout

Learn More – Primary Sources:

CMQCC Venous Thromboembolism Toolkit

ACOG Practice Bulletin 196: Thromboembolism in Pregnancy

ACOG District II/Safe Motherhood Initiative: Maternal Safety Bundle for Venous Thromboembolism

International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS)

Locate a genetic counselor or genetics services:

Genetic Services Locator-ACMG

Genetic Services Locator-NSGC

Genetic Services Locator-CAGC

Locate a Maternal Fetal Medicine Specialist

Maternal Fetal Medicine Specialist Locator-SMFM

Take a post-test and get CME credits

TAKE THE POST TEST

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