maternal newborn fellowship...•(ward, s. & hisley, s. (2016) maternal-child nursing care)....

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Maternal Newborn Fellowship

Recognition of Postpartum Complications

Postpartum Hemorrhage

• Outcome – Simulation Learning Outcomes: After

participation in the PPH simulation, the participants will have the knowledge to:

–Recognize the PPH bundle and components of the bundle within their organization

Outcomes

• Simulation Learning Outcomes: After participation in the PPH simulation, the participants will have the knowledge to:

–Recognize the PPH bundle and components of the bundle within their organization

Debriefing

• What went well?

• What didn’t go well?

• What could be better?

• How effective was communication between team members? What pieces of the maternal history would make you think about the patient being at higher risk for hemorrhage?

Postpartum Hemorrhage

• Hemorrhage is responsible for 25% of maternal deaths worldwide

» Guidelines for Oxytocin Administration after Birth: AWHONN Practice Brief #2 (2014)

• Women die from postpartum hemorrhage because they do not receive:

– Early

– Effective

–Aggressive lifesaving treatments • AWHONN PPH Implementation Community

Informational Call (2016)

Etiology of PPH • Primary PPH

–Uterine atony

–Retained placenta

• Especially an accreta

–Defects in coagulation

–Uterine inversion

• Secondary PPH

– Subinvolution of placental site

–Retain products of conception

– Infection

– Inherited coagulation defects

ACOG, (2006; reaffirmed 2013)

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Risk Factors for PPH • Prolonged labor

• Augmented labor

• Oxytocin during labor

• Rapid labor

• History of PPH

• Episiotomy, especially mediolateral

• Preeclampsia

• Overdistended uterus

• Lower genital tract lacerations

• Uterine rupture • Magnesium sulfate • Genital tract

lacerations • Operative delivery • Asian or Hispanic

ethnicity • Chorioamnionitis

Ogburn, P. (2005), Cunningham (2014) p 782

WARNING!!!!

Hemorrhage is a Symptom NOT a diagnosis!

Establish the Cause

• If the uterus is firm and contracted but bleeding is brisk

– Suspect lacerations of vagina, cervix, or perineum

–Deep lacerations may cause hematomas to develop

Establish the Cause

• Think hematoma if:

–patient reports excruciating pain

– restlessness

–hypotension, tachypnea, and tachycardia are developing

Establish the Cause

• If uterus is boggy or if uterus firms with massage, then quickly becomes boggy, suspect uterine atony

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Rapid versus Slow Hemorrhage

• Sometimes postpartum hemorrhage is not one large hemorrhage, but instead,

–Moderate losses over time

–Which add up to significant blood loss

• Any patient with heavy postpartum bleeding should be watched closely!!

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REMEMBER YOUR PATHOPHYSIOLOGY OF PREGNANCY

• Due to “normal” changes in the pregnancy such as:

– Increase in Blood volume – Blood Volume 40-60 % and RBCs by 20-30 %

– Multiple compensatory mechanisms – shunting of blood to the vital organs

– Rapid blood loss – perfusion to the uterus

Obstetrical patients tend to “fall off the cliff” rather than progressing through measureable stages of hypovolemic shock.

– Changes in vital signs are a latent sign of hemorrhage for the post-partum woman

Assessment: Blood Pressure

• Blood pressure – Narrowing of pulse pressure

• Pulse pressure represents the interrelationship between the systolic ( reflection of stroke volume) and the diastolic ( reflection of systemic vasoconstriction)

– Orthostatic blood pressure may occur when she has lost 20-25% of blood volume

– If she is overtly hypotensive she has most likely lost 30 to 35% of her total blood volume

Gabbe (2012) p. 416

Nursing Responsibilities

• Anticipate women at risk

• Prompt assessment and identification

• Respond quickly with effective interventions

• Alerting care provider and additional help

Nursing Interventions • GET HELP!!!

• Uterine massage

– Vigorous to dislodge clot?

– TWO hands

• Empty the bladder if it is distended

• Notify care provider and keep updated

– Do you need the care provider to be at the bedside?

• Be clear and concise regarding the situation and your expectations for them to come to the bedside

Treatment • Labs as ordered by physician

– CBC with platelets

– Coagulation panel

– Metabolic panel • Outcomes are improved with early and aggressive

treatment. Transfuse per clinical signs do not wait for lab values to transfuse

» CMQCC ( 2015)

• Type and crossmatch

– Administer blood products as ordered by MD

• Administer oxygen

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• Bair hugger, Level 1 infuser, warm irrigation • Maintain perfusion- Fluid and blood product

resuscitation! • Prevent/correct coagulopathy

Coagulopathy

Hypothermia Acidosis

Lethal Triad Reminder

• After acute blood loss

–Hematocrit will not change significantly for at least 4 hours

–Complete compensation requires 48 hours

– IV fluids can alter values

• Resulting in an earlier lowering of measured hematocrit

• Bendetti, 2002, p. 504

• Every obstetrical patient has the potential to hemorrhage due to the placental separation at delivery.

– Is designed to stop-mechanically but sometimes it does not

• Likely all or none clotting event-

– Once patients exceed 2500 ml EBL with ongoing bleeding many begin to show signs of coagulopathy (bloods ability to clot is impaired.)

Pearls Pearls

• Post-Partum blood loss is Cumulative

– Important to receive communication regarding the amounts of blood lost during delivery from the labor and delivery staff

– Communicate this with provider when reporting postpartum blood loss

http://ww2.nmh.org/oweb/MagnetDoc/dep-201003_lbp_5027-3.jpg

Resources Available

http://www.safehealthcareforeverywoman.org/secure/secure-download-home.php

Supported By







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References • American College of Obstetricians and

Gynecologists (2006; reaffirmed 2015). Postpartum hemorrhage. ACOG Practice Bulletin Number 76. October. Washington, DC: ACOG.

• American College of Obstetricians and Gynecologists (2014). Safe Prevention of the Primary Cesarean Section. VOL. 123, NO. 3, MARCH 2014 Washington, DC: ACOG.

• American College of Obstetricians and Gynecologists (2012; Reaffirmed 2015). Placenta Accreta. ACOG Committee Opinion Number 529. Washington, DC: ACOG.

• AWHONN (2014) Guidelines for Oxytocin Administration after Birth: AWHONN Practice Brief #2 . JOGNN, 00, 1-3; 2014.

• AWHONN (2016) PPH Implementation Community Informational Call. September 8th, 2016

References

• Abdel-Aleem, H. et al. (2012). WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organization . Geneva: Switzerland.

• Bendetti, T. J. (2002). Obstetric hemorrhage in Steven G. Gabbe, Jennifer R. Niebyl, and Joe Leigh Simpson (Eds.) Obstetrics Normal and Problem Pregnancies, 4th Edition (pp. 503-538). New York: Churchill Livingstone.

References

• Burke, C. (2010). Active versus expectant management of the third stage of labor and implementation of a protocol. Journal of Perinatal Neonatal Nursing, 24(3), 215-228.

• CMQCC: (2015) California Maternal Quality Care Collaborative. Improving Health Care Response to Obstetric Hemorrhage Version 2.0. A California Quality Improvement Toolkit http://www.cmqcc.org/ob_hemorrhage

References

• Cunningham, F. G., Leveno, K. J., Bloom, S. L., Hauth, J. C., Rouse, D. J., & Spong, C. Y. (2014). Obstetrical hemorrhage. Chapter 35 in William’s Obstetrics, 24th ed., pp. 780-828. New York: McGraw Hill Medical.

• Creanga, A. A., Berg, C. J., Syverson, C., Seed, K., Bruce, F. C., & Callaghan, W. M. (2015). Pregnancy-related mortality in the United States, 2006-2010. Obstetrics & Gynecology, 125(1), 5-12.

• Davies, G. A. L., Tessier, J. L., Woodman, M. C., Lipson, A., & Hahn, P. M. (2005). Maternal hemodynamics after oxytocin bolus compared with infusion in the third stage of labor: A randomized controlled trial. Obstetrics and Gynecology, 105(2), 294-299.

References

• Dildy, G. A., Paine, A. R., George, N. C., & Velasco, C. (2004). Estimating blood loss: Can teaching significantly improve visual estimation? Obstetrics and Gynecology, 104: 601-606.

• Dildy, G. A. (2002). Postpartum hemorrhage: New management options. Clinical Obstetrics and Gynecology, 45(2), 330-344.

http://www.cmqcc.org/ob_hemorrhage



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• Francois, K. E., & Foley, M. R. (2012). Antepartum and postpartum hemorrhage. Chapter 19 in Steven G. Gabbe, Jennifer R. Niebyl, & Joe Leigh Simpson’s Obstetrics: Normal and Problem Pregnancies, 6th ed. Philadelphia, PA: Churchill Livingstone.

• Francois, K. (2006). Managing uterine atony and hemorrhagic shock. Contemporary OB/GYN, February Issue, 52-59.

References References

• Gabbe, S.G., Niebyl, J.R., Simpson, J.L., Landon, M. B., Galan, H.L., Jauniaux, E.R. M. & Driscoll, D. A. (2012). Obstetrics Normal and Problem Pregnancies (6th ed). Philadelphia, PA: Elsevier/Saunders.

• Grotegut, C. A., Paglia, M. J., Johnson, L. N. C., Thames, B. & James, A. H. (2011). Oxytocin exposure during labor among women with postpartum hemorrhage secondary to uterine atony. American Journal of Obstetrics & Gynecology, 204, 56e1-6.

References • Gűlmezoglu, Forna, Villa, & Hoffmeyr (2007).

Prostaglandins for prevention of postpartum haemorrhage (Cochrane Review). In The Cochrane Library, Issue 3, 2007. Oxford: Update Software.

• Hofmeyr, G. J., Walraven, G., Gulmezoglu, A. M., Maholwana, B., Alfirevic, Z., & Villar, J. (2005). Misoprostol to treat postpartum haemorrhage: a systematic review. BJOG: an International Journal of Obstetrics and Gynaecology, 112, 547-553.

References

• Jackson, K. W., Albert, J. R., Schemmer, G. K., Elliot, M., Humphrey, A., & Taylor, J. (2001). A randomized controlled trial comparing oxytocin administration before and after placental delivery in the prevention of postpartum hemorrhage. American Journal of Obstetrics and Gynecology, 185, 873-877.

• Magann, E. F., Evans, S., Chauhan, S. P., Lanneau, G., Fisk, A. D., & Morrison, J. C. (2005). The length of the third stage of labor and the risk of postpartum hemorrhage. Obstetrics and Gynecology, 105(2), 290-293.

References • Pritchard, J. A., Baldwin, R. M., Dickey, J. C., et al (1962).

Blood volume changes in pregnancy and the puerieum II. Red blood cell loss and changes in apparent blood volume during and following vaginal delivery, cesarean section, and cesarean section plus total hysterectomy. American Journal of Obstetrics and Gynecology, 84, 1272-1282.

• Simpson, K.R, & Creehan, P.A. (2014). AWHONN Perinatal Nursing ( 4th ed). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins

• Skupski, D. W., Lowenwirt, I. P., Weinbaum, F. I., Brodsky, D., Danek, M., Eglinton, G. S. (2006). Improving hospital systems for the care of women with major obstetric hemorrhage. Obstetrics & Gynecology, 107(5), 977-983

References • Villar, J., Gulmezoglu, A. M., Hofmeyr, G. J., & Forna, F.

(2002). Systematic review of randomized controlled trials of misoprostol to prevent postpartum hemorrhage. Obstetrics and Gynecology, 100(6), 1301-1312.

• You, W. H., & Zahn, C. M. (2006). Postpartum hemorrhage: Abnormally adherent placenta, uterine inversion, and puerperal hematomas. Clinical Obstetrics and Gynecology, 49(1), 184-197.

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Hematomas

Hematomas

Definition – Localized collection of blood in connective or soft

tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue” p 613

• (Ward, S. & Hisley, S. (2016) Maternal-Child Nursing Care).

– Or from inadequate hemostasis at the site of repair of an incision or laceration

• (Olds’ Maternal-Newborn Nursing & Women’s Health Across the Lifespan, 10th edition, 2016).

•

Kinds of hematomas

• Vulvar- which involves branches of the pudendal artery

• Vaginal- is typically in the area of the ischial spines

• Vulvovaginal

• Subperitoneal- involve the uterine artery branches or vessels in the broad ligaments and need surgery to fix

• Retroperitoneal- usually occur after a vessel laceration from the internal iliac (hypogastric) arterial tree

Signs and Symptoms

• Pain and Pressure, most common sign

• May see bluish discoloration

• Bulging of the tissue

• Patient states tenderness if the area is touched

• If the hematoma is large patient may have inability to void, absence of vaginal bleeding, and signs of shock

Risk Factors Common Risk Factors:

– Episiotomy

– Forceps- or Vacuum assisted birth

–Genital Tract Laceration

Associated Risk Factors:

–Primiparity

–Macrosomia

–Prolonged Second Stage

–Preeclampsia

–Clotting Disorder

–History of vulvar Varicosities

Management

Hematomas less than 3-5 centimeters

• Palliative treatment

Hematomas larger than 5 centimeters

• May require incision and drainage

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Retroperitoneal Hematoma

• Rare but dangerous

• Due to the large amount of blood which can accumulate without clinical symptoms until the woman becomes hemodynamically unstable

• Require surgical repair

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjGjsqu4eLPAhUP84MKHXeUAbQQjRwIBw&url=http%3A%2F%2Fwww.glowm.com%2Fsection_view%2Fheading%2FSurgical%2520Management%2520of%2520Intractable%2520Pelvic%2520Hemorrhage%2Fitem%2F49&psig=AFQjCNGO3p8GJQG8xmq9ER7KSu2q7V_KXA&ust=1476825370774019

References

• Davidson,M., London, M., & Ladewig, P. (2016). Olds Maternal-Newborn Nursing & Women’s Health Across the Lifespan, 10th ed. Boston: Pearson Education, Inc.

• Ward, S. & Shelton, H. (2016). Maternal-Child Nursing Care Optimizing Outcomes for Mothers, Children, & Families, 2nd ed. Philadelphia: F.A. Davis Company

Thrombophlebitis

and Venous

Thrombosis

Thromboembolic Disease

• During pregnancy ↑ risk for thrombosis due to the following: – ↑ levels of coagulation factor – ↓ Fibrinolysis – what is this? – Venous dilation – Obstruction of the gravid uterus

• Rate of occurrence is 1 in 1500 pregnancies • Pulmonary embolism is a leading cause of

maternal mortality – Majority occur during the antenatal period

• Mattson & Smith (2016)

Virchow’s Triad

https://upload.wikimedia.org/wikipedia/commons/thumb/b/b7/Virchow%27s_Triad.svg/701px-Virchow%27s_Triad.svg.png

Thrombophelbitis

“When the thrombus is formed in response to inflammation in the vein wall”

– Olds’ Maternal-Newborn Nursing & Women’s Health Across the Lifespan, 10th edition, 2016, p 986

“The depth of the inflammation and the location of the involved veins determine the severity of this complication”

– Maternal-Child Nursing Care, 2nd edition, 2016, p 614

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Sites of Postpartum Thrombophlebitis

Venous Thrombosis

“Formation of a blood clot (thrombus formation) at an area of impeded blood flow in a superficial or deep vein”

• Olds’ Maternal-Newborn Nursing & Women’s Health Across the Lifespan, 10th edition, 2016 p 986

Superficial Vein Disease (SVD)

• More common in postpartum

• Typically involves the saphenous veins

• More common in women with pre-existing enlarged veins

• Typically anticoagulants are not necessary unless complications develop

– Olds’ Maternal-Newborn Nursing & Women’s Health Across the Lifespan, 10th edition, 2016

Deep Vein thrombosis (DVT)

• More commonly seen in women with history of thrombosis (DVT)

• Clinical manifestations:

– Edema of the ankle and leg

– Initial low-grade fever often followed by high temperature and chills

– Tenderness/pain

– Changes in limb color

– Difference in limb circumference of more than 2 cm – Olds’ Maternal-Newborn Nursing & Women’s Health Across the

Lifespan, 10th edition, 2016

– ACOG (2014)

Deep Vein thrombosis (DVT)

• Diagnosis

– Increase incidence is associated with Obstetric complications:

• Polyhydramnios

• Preeclampsia

• Operative births – Olds’ Maternal-Newborn Nursing & Women’s Health Across

the Lifespan, 10th edition, 2016

Risk Factors Associated with Increased Risk of Thromboembolic Disease

• Cesarean Birth

• Immobility (prolonged)

• Obesity

• Cigarette Smoking

• Previous Thromboembolic Disease or Strong Family History

• Varicose Veins

• Diabetes Mellitus

• Advanced Maternal Age

• Multiparity

• Anemia

• Malignancy

• Inherited coagulation Pathway Deficiency

• Proteins C and S Deficiency

Olds’ Maternal-Newborn Nursing & Women’s Health Across the Lifespan, 10th edition, 2016

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Treatment with Medications

http://images.wisegeek.com/person-in-white-receiving-insulin-injection.jpg

Warfarin

• Associated with potentially harmful fetal effects, especially within the first trimester exposure – Warfarin embryopathy has been linked with exposure at 6-

12 weeks gestation

• Most women who become pregnant who receive prolonged anticoagulation therapy will be switched to unfractionated heparin or LMWH in place of Warfarin

• However, Warfarin is still considered in pregnancy for women with mechanical heart valves due to the high risk of thombosis

• ACOG (2014).

LMWH

Prophylactic

• Enoxaprin (Lovenox) 40mg SC once daily

• Dalteparin (Fragmin) 5,000 units SC once daily

• Tinzaprin (Innohep) 4,500 units SC once daily

Therapeutic

• Enoxaprin, 1mg/kg every 12 hours

• Dalteparin 200units/kg daily

• Tinzaprin 175units/kg daily

• Dalteparin, 100units/kg daily

ACOG (2014)

Unfractionated Heparin – UFH

Prophylactic

• UFH, 5,000 to 10,000 units SC every 12 hours

• UFH, 5,000 to 7,000 units SC every 12 hours in 1st Trimester

• UFH, 7,500 to 10,000 units SC every 12 hours in 2nd Trimester

• UFH, 10,000 units or more SC every 12 hours in 3rd Trimester , unless the aPTT is elevated

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 injection)

Anticoagulation Therapy for Delivery

• Patient may be converted from LMWH during the last month of pregnancy to Unfractionated heparin – Purpose of the conversion is due to the risk of a hematoma during regional

anesthesia – Half life of LMWH is approximately two to four times longer than that of UFH,

and this is regardless of the injected dose of the different forms of LMWH. – It is excreted through the kidneys so caution if patient has renal involvement

• American Society of Regional Anesthesia and Pain Medicine Guidelines – Recommend withholding neuraxial blockade for 10-12 hours after the last

prophylactic dose of LMWH or 24 hours after last therapeutic dose of LMWH • Support the use of neuraxial anesthesia in patients receiving 5,000 units of

unfractionated heparin twice daily – Safety unknown for patients receiving 10,000 units (or more) twice daily

Postpartum Anticoagulation

• Prophylactic LMWH/UFH for 4-6 weeks

OR

• Vitamin K antagonists for 4-6 weeks with a target INR of 2.0-3.0, with initial UFH or LMWH therapy overlap until INR is 2.0 or more for 2 days

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Don’t Forget Mechanical Methods

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http://www.hopkinsmedicine.org/sebin/b/v/compression_socks.jpg

References

• American College of Obstetricians and Gynecologists (2011; reaffirmed 2014). Thromboembolism in Pregnancy. ACOG Practice Bulletin Number 123. October. Washington, DC: ACOG.


.

References

• Mattson, S. & Smith, JE. (2016). AWHONN Core Curriculum for Maternal-Newborn Nursing, 9th edition. Philadelphia: Lippincott Williams & Wilkins.

• Simpson KR, Creehan PA (2014). AWHONN Perinatal Nursing, 4th edition. Philadelphia: Lippincott Williams & Wilkins


Pulmonary Embolus

http://southof64.com/the-symptoms-of-blood-clots-in-lungs-treatment/

Pulmonary Embolism:

• when the clot (thrombi) formed in the deep leg vein migrates to the pulmonary artery, obstructing the pulmonary blood flow to one or both of the lungs

Pulmonary Embolism Most common signs:

• Tachpnea (>20 breaths/min)

• Tachycardia (>100 beats/min)

• Dyspnea-labored breathing, shortness of breath

• Chest pain

• Hemoptysis- coughing up of blood or bloody sputum

• Abdominal pain

Most serious signs

• Sudden collapse/Syncope

• Cyanosis

• Hypotention

• Presyncope

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Pulmonary Embolism Interventions: • Diagnostic testing: such as- Ventilation/Perfusion (VQ) scan, blood

gas studies, radiography, pulmonary angiography

• Elevate the head of the bed

• Administer oxygen 10L/Min nonrebreather face mask, pulse oximetry on

• Maintain the PaO2 >70 mm Hg

• Monitor arterial blood gases

• Frequently assess vital signs

• Provide for IV fluids (eg pulmonary artery catheter may be placed)

• Administer salt poor or hypertonic IV fluids as ordered

• Administer medications as ordered to counteract symptoms • Simpson, K.R. & Creehan, P.A. (2014). AWHONN Perinatal Nursing, 4th ed. Philadelphia:

Wolters Kluwer/Lippincott Williams & Wilkins page 564

Pulmonary Embolism

Diagnostic testing of DVT and PE during pregnancy brings on some challenges. ACOG states that exposure to less than 5 rads had not been connected with increases in pregnancy loss or fetal anomalies.

• Combination of chest xray, V/Q scan, and pulmonary angiography exposed the fetus to less than 0.5 rads. So diagnostic tests will be chosen carefully to monitor exposure.

Pulmonary Embolism

No role for D-dimer testing in the workup of pregnant patients with suspected PE

Just FYI

Treatment for acute DVT or PE

During pregnancy:

• Therapeutic anticoagulation, drugs of choice include Unfractionated Heparin (UFH) and Low-Molecular-Weight Heparin (LMWH)

• UFH does not cross the placenta and is not teratogenic, main side effects of this medication are: hemorrhage, osteoporosis, and thrombocytopenia.

• LMWH does not cross the placenta and does not enter the breast milk, and the risk of hemorrhage associated with this medication is lower. – Warfarin is a pregnancy category X medication due to fetal exposure is

of concern

Treatment for acute DVT or PE

During pregnancy:

• Per the American Society of Regional Anesthesia and Pain Medicine guidelines recommend:

– Withholding neuraxial blockade for 10-12 hours after the last prophylactic dose of LMWH or 24 hours after the last therapeutic dose of LMWH

– The guidelines are based on neuraxial anesthesia in patients receiving dosages of 5,000 units of unfractionated heparin twice daily, but the safety in patient getting 10,000 units twice daily or more in not known

Resuming anticoagulation therapy postpartum

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Resuming anticoagulation therapy postpartum

Mother’s may be bridged to Warfarin therapy post delivery. In that case she should be remain on therapeutic doses Heparin for about four to five days while the Warfarin is titrated to a goal INR of 2.0-3.0.

– If mom discontinues the heparin early while transition to warfarin there may be an increased short term risk of venous thromboembolism

Indication Description Anetpartum Postpartum

VTE in current pregnancy Therapeutic LMWH/UFH to complete 20 week course, then therapeutic or prophylactic LMWH/UFH regimen as appropriate based on thrombophilia or risk factors

Therapeutic LMWH/UFH regimen to complete 20 week course followed by prophylactic LMWH or postpartum warfarin

High risk thrombophilia

1. History of one prior VTE 2. No history of VTE

1. Therapeutic or prophylactic LMWH/UFH

2. Prophylactic LMWH/UFH

1. Therapeutic or prophylactic LMWH • Regimen or postpartum warfarin:

dosing/level to match antepartum regimen

2. Prophylactic LMWH Regimen or postpartum warfarin

Low risk thrombophilia

1. History of one prior VTE 2. No history of VTE

1. Prophylactic LMWH/UFH or surveillance without anticoagulation

2. Surveillance without anticoagulation or prophylactic LMWH/UFH

1. Prophylactic LMWH/UFH or postpartum warfarin 2. Surveillance without anticoagulation or prophylactic LMWH/UFH or postpartum warfarin if patient has additional risk factors

No thrombophilia

1. History of one prior VTE (pregnancy or estrogen related)

2. History of one prior VTE (idiopathic)

Prophylactic LMWH/UFH or surveillance without anticoagulation

Prophylactic LMWH or postpartum warfarin

Two or more prior VTE episodes (thrombophilia or no thrombophilia)

1. On long-term anticoagulation 2. Not on long-term

antiocoagulation

1. Therapeutic LMWH/UFH 2. Therapeutic or prophylactic

LMWH/UFH

1. Resumption of long-term anticoagulation therapy

2. Therapeutic or prophylactic LMWH/UFH

Gabbe, S., Niebyl, J., & Simpson J. (2017) Obstetrics: Normal and problem pregnancies, 7th ed. Philadelphia, PA: Elsevier page 976

References


• Gabbe, S., Niebyl, J., & Simpson J. (2017) Obstetrics: Normal and problem pregnancies, 7th ed. Philadelphia, PA: Elsevier

• Mattson, S. & Smith, J.E. (2014). Core Curriculum for Maternal-Newborn Nursing, 5th ed., AWHONN. St. Louis, MO: Elsevier

• Simpson, K.R. & Creehan, P.A. (2014). AWHONN Perinatal Nursing, 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins


maternal newborn fellowship...•(ward, s. & hisley, s. (2016) maternal-child nursing care)....

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