1. Venous Thromboembolism O&G spectrum Tan Lay Kok Department of O&G Singapore General Hospital

3. VTE is important In Obstetrics Its not just a “western” problem Incidence low (0.5-2 per 1000 pregnancies) But important cause of morbidity and mortality – PE the commonest DIRECT cause of death in pregnancy and puerperium

6. Thrombosis Research Volume 130, Issue 3 2012 291 - 301

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8. VTE risk is increased in Caesarean section Sepsis Hyperemesis gravidarum

9. We are seeing more mothers who are Older Overweight and obese IVF pregnancies Having twins (or more)

11. VTE Is not confined to late pregnancy Occurs in all trimesters Puerperium highest risk

12. Left sided VTE more common

13. Cerebral vein thrombosis 1 in 10,000 HIGH MORTALITY RATE Pregnancy accounts up to 20% of cases (60% India) Most pregnancy cases occurs in PUERPERIUM Similar risk factors to DVT, PE Association with thrombophilia Sepsis, dehydration CT venogram, MR venogram Headache Seizures Imparied consciousness Raised ICP Vomiting, photophobia Focal signs eg hemiparesis ± fever,  WBC Venous infarction, ICB

14. VTE and Infertility PCOS – obesity Ovulation induction Superovulation OHSS – upper extremities, cerebrovascular, arterial

15. IVF in Singapore

21. VTE & contraception COCP – 2 nd versus 3 rd generation

22. VTE & contraception COCP: the progestin is the primary determinant for the risk of VTE Low risk products with norethisterone, levonorgestrel or norgestimate confer about half the risk of VTE as combined high risk pills with desogestrel, gestodene, drospirenone or cyproterone acetate COCP with 30-40 mcg estrogen confer about 20% higher risk than 20 mcg estrogen, with the same dose and type of progestin Progestin-only pills, levonorgestrel IUS, and implants do not confer any increased risk of venous or arterial thrombosis Transdermal patches and vaginal ring belong to high-risk products

23. VTE & contraception COCP: the progestin is the primary determinant for the risk of VTE Low risk products with norethisterone, levonorgestrel or norgestimate confer about half the risk of VTE as combined high risk pills with desogestrel, gestodene, drospirenone or cyproterone acetate COCP with 30-40 mcg estrogen confger about 20% higher risk than 20 mcg estrogen, with the same dose and type of progestin Progestin-only pills, levonorgestrel IUS, and implants do not confer any increased risk of venous or arteral trambosis Transdermal patches and vaginal ring belong to high-risk products But getting pregnant through no or inadequate contraception carries a much higher risk of VTE!

24. VTE & HRT

25. VTE & Gynae Oncology Ovarian cancer

26. VTE & Gynae Oncology

28. VTE & Gynae surgery Laparoscopy Laparotomy Vaginal surgery

29. VTE in O&G Its not that uncommon! Under-diagnosed Unsuspected Why will it become even more relevant? – Older mothers – More obesity – Rising caesarean section rates – More IVF

30. Conclusions Obstetricians in Asia need to be aware of VTE as an important risk complicating pregnancies. May be a rising incidence in VTE – Increased urbanisation and lifestyle changes – Increased age of maternity, obesity, rising caesarean section rates and wider incidence of assisted reproductive technology are contributing factors Importance of having protocols for risk assessment, stratification and policies for thromboprophylaxis