Strategies to prevent mortality from obstetric venous thromboembolism begin with identification, risk stratification and subsequently, implementation of prophylactic measures. We sought to identify the burden of pharmacologic thromboprophylaxis in postpartum women, including the main clinical indications and its uptake in a multireligious population, with Islam as the official religion. A total of 2514 deliveries between 1st January to 31st December 2016, across three centres in Malaysia were reviewed retrospectively from hospital-based registries. 770 (30.62%) patients fulfilled the criteria for thromboprophylaxis based on the revised 2015 criteria proposed by the Royal College of Obstetricians and Gynaecologists. A combination of age, parity, BMI, caesarean section and preterm births were the main indications. One out of the five patients who delivered vaginally required thromboprophylaxis. In our setting with a sizable Muslim population, low molecular weight heparin was the thromboprophylaxis of choice in more than two-third of the patients. The information obtained from this study allows better local resource planning. Impact statement What is already known on this subject: Risk factors for venous thromboembolism in pregnancy and puerperium are largely drawn from registries due to the rarity of the index event. Up to 7% of women require antenatal thromboprophylaxis based on the criteria proposed by the Royal College of Obstetrician and Gynaecologists in 2009. What do the results of this study add: Using the RCOG guideline revised in 2015, a significant proportion of women delivering vaginally would require postnatal thromboprophylaxis based on age, parity and BMI. When either age or parity, both with relatively low odds ratio for thrombosis were omitted, a substantial proportion of women would not achieve the threshold for prophylaxis. Despite a sizable Muslim population in the country, the uptake of low molecular weight heparin was relatively high. What are the implications of these findings for clinical practice and/or future research: Cost-benefit studies should consider the adjusted odds ratio of individual indications on a VTE event. While uptake and acceptability is high, prospective studies on medication adherence is equally pertinent.
INTRODUCTION: Peripartum cardiomyopathy (PPCM) is an uncommon form of congestive heart failure, affecting obstetric patients around the time of delivery. The epidemiology of PPCM is infrequently reported. This study was undertaken to define the prevalence, presentation and outcome of PPCM among women giving birth in a teaching hospital in Malaysia.
METHODS: A retrospective case record analysis was conducted on all patients admitted and diagnosed with PPCM at the University Malaya Medical Centre, Kuala Lumpur, Malaysia, from 1 January 2000 to 31 December 2009. All deliveries were undertaken in the same hospital.
RESULTS: A total of 12 patients were diagnosed with PPCM during the ten-year study period. The prevalence of PPCM was 2.48 in 100,000 (1 in 40,322) live births. Nine women were diagnosed with PPCM within five months of delivery. Three women had twin pregnancies. There was one death in the group (mortality rate 8.3%). The mean left ventricular ejection fraction at the time of diagnosis was 28.9% ± 8.5% (range 15%-40%). Following the index event, left ventricular function normalised in six of the nine patients (66.7%) who underwent subsequent echocardiography one year later. All patients were treated with standard heart failure therapy. Two patients with normalised left ventricular function had subsequent pregnancies - one pregnancy was terminated at seven weeks and the other patient delivered uneventfully at full term.
CONCLUSION: PPCM is uncommon. The outcome in our series was favourable, with 66.7% of patients with PPCM recovering their left ventricular function. The mortality rate was 8.3%.
A 30-year-old Malay lady, with no previous or family history of bleeding, presented with severe gum bleeding 25 days post-partum. The factor VIII:c was 0.03 iu/ml with evidence of a slow-acting factor VIII inhibitor. Von Willebrand factor antigen (VWF:age) varied from less that 0.05 to 0.17 iu/ml, and there was absent ristocetin-induced platelet aggregation. Anti-nuclear and anti-DNA antibodies were present, but there were no other features of systemic lupus erythematosus. There was some clinical response to cryoprecipitate and tranexamic acid, and slight improvement with corticosteroid. Fifteen months later, the patient has no active bleeding problem, and her VWF-ag is increasing spontaneously. However, factor VIII:c is less than 0.01 iu/ml and her factor VIII inhibitor titre is still > 20 Bethesda units/ml.