Project team members: Profs Alex Sia, Tan Kok Hian, Tan Thiam Chye, Drs Ng Zheng Yuan, Michelle Lim, DD Teo Chor Cher, AD Ding Na, SNM Jane Tay, Teo Hua Zhen, Elizabeth Chan, Marionette A. Catahan.
Venous thromboembolism is an important cause of maternal morbidity and mortality. The puerperium is a particular time of heightened risk, especially post-Caesarean section. With rising Caesarean section rates, increasing maternal age and obesity, the incidence of postpartum thromboembolism is likely to increase. Although there are international guidelines and thromboprophylaxis is being prescribed, there is no standardized assessment of its risk and management in our institution.
The team introduced a standardized care pathway in women undergoing elective Caesarean section, to include risk assessment and initiation of thromboprophylaxis with intermittent pneumatic compression (IPC) devices and low molecular weight heparin (LMWH) with the aim of reducing the rate of venous thromboembolic events and associate morbidity.
Women were risk assessed 3-4 weeks before planned Caesarean section. As the majority of women had at least a moderate risk of thromboembolism, the team implemented an opt-out system for combined thromboprophylaxis. Therefore, a woman would always receive postoperative anti-embolism stockings, intra-and postoperative IPC and postoperative LMWH unless there are contraindications or assessed to be in lower risk category.
The introduction of pathway was well-received, with large increase in IPC device use from 2% to 97.8%. Use of AES and LMWH remained high at 94.5% and 96.2% respectively. There was a significant reduction in the incidence of pulmonary embolism from the pre to the post-implementation period.
The team was successful in implementing a universal care pathway for thromboprophylaxis in patients undergoing Caesarean section. Preliminary results appear promising but a greater duration of follow-up would be required to demonstrate a sustained reduction in rates. The team hope to extend universal prophylaxis to other patient subgroups, including elective and emergency gynaecological major surgeries.