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
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.
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.
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
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
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
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
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
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
Jointly provided by
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