Thrombophilias in Pregnancy: Optimizing High Risk Outcomes Through A Team Approach

Thrombophilias are related to many adverse outcomes in pregnancy, including pre- eclampsia, abruption, and intrauterine fetal demise. Only recently has research suggested a strong correlation between thrombophilias and adverse outcomes Screening for risk factors that may be related to thrombophilias is an essential step for the high risk perinatal team. If the women has a thrombophilia, then the care for mother and baby becomes complex. An interdisciplinary protocol for the high risk team was developed to optimize healthy pregnancy outcomes.    

          The protocol was developed by the high risk nurse practitioner, beginning with the ACOG and nursing recommendations for screening. Each discipline provided information regarding their role and responsibilities. This included the maternal fetal medicine physicians, the high risk nurse practitioner, the RN’s, the patient educator, the social worker, the sonographers, and lab technicians. The actions needed to integrate care for the mother and fetus can be demonstrated in an algorithm.      

    Initially, the mother is screened for risk factors. After the labwork is completed and reviewed the high risk perinatal team, the protocol is set in to action. Administration of either heparin or a low molecular weight heparin is essential. A referral is made to the social worker for obtaining the medication if the patient does not have funding. The RN’s also are trained to complete all the paperwork to obtain the medication through the medication program. A referral is made to either the Nurse educator or RN to teach the patient about the medication and administration.  Additionally, the protocol outlines the dosages of medications needed depending on diagnosis, BMI, and gestational age. Depending on the medication and whether it is given as adjusted dose or prophylaxis, determines labs to be drawn to adjust the dosage as pregnancy progresses.      

      Fetal surveillance is a key concept of best practice. This includes serial ultrasounds for growth, non-stress tests weekly beginning at 32 weeks, and delivery by induction or repeat cesarean section by 38 ½ weeks. Patient education is a constant throughout the pregnancy, including preparation for delivery and postpartum follow up. After delivery, the mother is referred to Coumadin clinic at the 6 weeks postpartum visit. This includes a referral to the dietician for dietary counseling regarding Coumadin and diet.    

      Initial outcomes include consistency of health care across the continuum, patient satisfaction at being included in plan of care and knowing “big picture”, and most importantly, positive pregnancy outcomes.