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Practice bulletins > #196 Thromboembolism in Pregnancy > Flashcards

#196 Thromboembolism in Pregnancy Flashcards

1
Q

What is the risk of thromboembolism in pregnant women compared to non pregnant (fold change)?

A

4-5 fold increase

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2
Q

What % of thromboembolic events in pregnancy are venous?

A

80%

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3
Q

What is the prevalence of thromboembolic events in pregnancy?

A

0.5-2 per 1,000 pregnant women

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4
Q

What % of all maternal deaths in US are caused by VTE?

A

9.3%

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5
Q

What % of VTE are due to PE during pregnancy?

A

20-25%

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6
Q

When during pregnancy/postpartum period is greatest risk for VTE?

A

Greatest within the weeks immediately after delivery

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7
Q

What is May-Thurner anatomy?

A

Compression of the left iliac vein by the right iliac artery, leading to increased venous stasis in the left leg

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8
Q

Is fibrinogen increased or decreased during pregnancy?

A

Increased

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9
Q

Is factor VII increased or decreased during pregnancy?

A

Increased

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10
Q

Is Factor VIII increased or decreased during pregnancy?

A

Increased

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11
Q

Is Factor X increased or decreased during pregnancy?

A

Increased

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12
Q

Is Von Willebrand factor increased or decreased during pregnancy?

A

Increased

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13
Q

Is Plasminogen activator inhibitor-1 increased or decreased during pregnancy?

A

Increased

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14
Q

Is Plasminogen activator inhibitor-2 increased or decreased during pregnancy?

A

Increased

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15
Q

Is Factor II increased or decreased during pregnancy?

A

No change

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16
Q

Is Factor V increased or decreased during pregnancy?

A

No change

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17
Q

Is Factor IX increased or decreased during pregnancy?

A

No change

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18
Q

Is free protein S increased or decreased during pregnancy?

A

Decreased

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19
Q

Is protein C increased or decreased during pregnancy?

A

No change

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20
Q

Is antithrombin increased or decreased during pregnancy?

A

No change

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21
Q

What is the most important individual risk factor for VTE in pregnancy?

A

Personal history of thrombosis

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22
Q

What % of all cases of VTE in pregnancy are recurrent events?

A

15-25%

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23
Q

What is the second most important individual risk factor for VTE in pregnancy?

A

Presence of thrombophilia. (first is personal hx)

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24
Q

What % of women with VTE in pregnancy have a thrombophilia?

A

20-50%

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25
Q

Does preeclampsia affect the risk of VTE?

A

Increases risk

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26
Q

Does heart disease affect the risk of VTE?

A

Increases risk

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27
Q

Does sickle cell disease affect the risk of VTE?

A

Increases risk

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28
Q

Does multiple gestation increase the risk of VTE?

A

Increases risk

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29
Q

Does autoimmune disease affect risk of VTE?

A

Increases risk

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30
Q

What is the incidence of VTE after cesarean delivery?

A

3 in 1000

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31
Q

What is the risk of VTE after cesarean compared with vaginal delivery (fold change)?

A

4 fold increase

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32
Q

Does heparin cross the placenta?

A

No

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33
Q

What is the % increase in maternal blood volume during pregnancy?

A

40-50%

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34
Q

How does pregnancy affect the use of heparin (due to changes of maternal physiology)?

A

Increased GFR leads to increased renal excretion. Increase in protein binding of heparin. Overall shorter half life and lower peak plasma concentrations; usually necessitating higher dose and increased frequency

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35
Q

What is the dosing of prophylactic enoxaparin?

A

40mg SC once daily

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36
Q

What is the dosing of prophylactic dalteparin?

A

5,000u SC once daily

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37
Q

What is the prophylactic dosing of Tinzaparin?

A

4,500u SC once daily

38
Q

What is the prophylactic dosing of Nadroparin?

A

2,850u SC once daily

39
Q

What is the intermediate-dose of enoxaparin?

A

40mg SC q12h

40
Q

What is the intermediate-dose of dalteparin?

A

5,000u SC every 12h

41
Q

What is the therapeutic dose of enoxaparin?

A

1mg/kg q12h

42
Q

What is the therapeutic dose of dalteparin?

A

200u/kg once daily

43
Q

What is the therapeutic dose of Tinzaparin?

A

175u/kg once daily

44
Q

What is the therapeutic dosing of Dalteparin?

A

100u/kg every 12h

45
Q

What is the target anti-Xa level for therapeutic anticoagulation?

A

0.6-1.0 unit/mL 4 hr after last injection for BID regimen; slightly higher doses may be needed for once daily regimen

46
Q

What lab test can you check in someone receiving LMWH to assess if they are therapeutic?

A

Anti-Xa levels

47
Q

What is the prophylactic dosing of unfractionated heparin per trimester?

A

First: 5-7.5k SC q12h

2nd: 7.5-10k SC q12h
3rd: 10k SC q12h, unless aPTT is elevated

48
Q

What is the therapeutic dose of unfractionated heparin?

A

10k units or more SC q12h adjusted to target aPTT in therapeutic range (1.5-2.5x control) 6h after injection

49
Q

What are the benefits of LMWH compared to UFH?

A

Fewer bleeding episodes, more predictable therapeutic response, lower risk of heparin-induced thrombocytopenia, longer half-life, less bone mineral density loss.

50
Q

What is the mechanism of action of warfarin?

A

Vitamin K antagonist

51
Q

During which weeks of gestation is warfarin exposure at highest risk of fetal harm?

A

6-12wks

52
Q

In which patients would you consider continuing warfarin in pregnancy?

A

Patients with mechanical heart valves (high risk of thrombosis even with heparin and LMWH therapy)

53
Q

How would you manage a woman with mechanical heart valve during pregnancy?

A

Multidisciplinary team. Consider adjusted-dose LMWH or UFH from 6 wk until 13 wk > warfarin until close to delivery when switch to LMWH or UFH.

54
Q

What is the concern for women receiving warfarin near time of delivery, what should you consider?

A

Apart from maternal bleeding; risk for fetal hemorrhage. Cesarean delivery may be required and the neonate may require administration of vitamin K and FFP

55
Q

What medication is an oral direct thrombin inhibitor?

A

Dabigatran

56
Q

What type of medication is dabigatran?

A

Oral direct thrombin inhibitor

57
Q

What are anti-Xa inhibitors?

A

Rivaroxaban, apixaban, edoxaban, betrixaban

58
Q

Can oral direct thrombin inhibitors and anti-Xa inhibitors be used in pregnancy? Lactation?

A

Avoided in pregnancy and lactation d/t insufficient data on safety

59
Q

What are the two most common initial symptoms of DVT and in what % of women with pregnancy-associated DVT do these present?

A

Pain and swelling in an extremity. In more than 80% of women.

60
Q

A difference in calf circumference of what cm is suggestive of DVT in lower extremity?

A

2cm or more

61
Q

What is the initial recommended diagnostic test for pregnant/postpartum woman with sign/symptoms suggestive of new onset DVT?

A

Compression ultrasonography of the proximal veins

62
Q

In a non pregnant population, are DVTs typically proximal or distal?

A

Distal

63
Q

In pregnant patients with DVT, what is the frequency of ileofemoral and iliac thromboses?

A

Ileofemoral (64%), iliac (17%)

64
Q

What is next step if pregnant woman with signs/symptoms highly suggestive of DVT, but compression ultrasonography is negative?

A

Additional imaging with doppler ultrasonography of the iliac vein, venography, or MRI; alternatively, empiric anticoagulation may be a reasonable option

65
Q

What lab is a useful screening tool to exclude DVT?

A

D-dimer level, not useful for pregnant women or postpartum

66
Q

Is D-dimer recommended in pregnancy/postpartum in evaluation for DVT?

A

Not recommended as part of evaluation

67
Q

Does a V/Q scan or helical CT for work up for PE during pregnancy expose the fetus to lower radiation?

A

Helical CT has a lower radiation exposure for fetus

68
Q

Does a V/Q scan or helical CT for work up for PE have lower radiation exposure for mom (particularly the breast)?

A

VQ scan has lower radiation exposure for mom

69
Q

What does the American Thoracic Society and the Society of Thoracic Radiology recommend for the evaluation of suspected PE in pregnancy?

A

Chest XRay as initial evaluation with progression to VQ scan if CXR normal, and CTA is CXR is abnormal.

70
Q

How should you treat someone with acute VTE during pregnancy; for how long do you treat?

A

Full-dose anticoagulation for 3-6 months (dependent upon type of VTE), anticoagulation intensity can be decreased to intermediate or prophylactic dose for the remainder of the pregnancy and for at least 6wks postpartum

71
Q

What is the risk of heparin-induced thrombocytopenia in the obstetric population?

A

Estimated at less than 0.1%

72
Q

Do obstetric patients placed on heparin need to undergo platelet monitoring?

A

Most will not require platelet monitoring as risk is < 0.1%; only need to monitor if risk >1% (in absence of other risk factors do not need monitoring)

73
Q

At what % risk of heparin-induced thrombocytopenia do you need to start platelet monitoring?

A

> 1%

74
Q

In cases of severe cutaneous allergies or heparin-induced thrombocytopenia in pregnancy, what may be the preferred anticoagulant?

A

Fondaparinux

75
Q

Do pregnant patients with newly diagnosed VTE need to be hospitalized?

A

May be indicated in cases of hemodynamic instability, large clots, or maternal comorbidities

76
Q

In which pregnant patients with PE, should initial treatment be with IV unfractionated hepatin?

A

In situations in which delivery, surgery, or thrombolysis (indicated for life-threatening or limb-threatening thromboembolism)

77
Q

Do weight-based anticoagulation (therapeutic) regimens need to be adjusted throughout pregnancy?

A

Evidence is not clear.

78
Q

Do pregnant patients requiring prophylactic anticoagulation require monitoring (anti Xa levels) during treatment? Why or why not?

A

Not required, optimal antifactor Xa levels during LMWH ppx in pregnancy have not been determined

79
Q

For women who are receiving prophylactic LMWH when should you discontinue in setting of scheduled IOL or CS?

A

12h before

80
Q

For women who are receiving therapeutic LMWH when should you discontinue in setting of scheduled IOL or CS?

A

24h before

81
Q

What is the reason for transitioning to unfractionated heparin closer to delivery?

A

Less to do with any risk of maternal bleeding at time of delivery, but rather the risk of an epidural or spinal hematoma with regional anesthesia

82
Q

What can be used to reverse unfractionated heparin?

A

Protamine sulfate

83
Q

What can be used to reverse LMWH?

A

Protamin sulfate, although less predictable than when reversing UFH

84
Q

What is the risk of VTE with cesarean delivery compared o vaginal delivery (fold increase)? What is incidence of VTE after CS?

A

4 fold increase in VTE with cesarean section. VTE in 3 per 1,000 patients.

85
Q

In healthy pregnancy woman without any additional VTE risk factors going for CS, what DVT ppx should be given?

A

Pneumatic compression devices before CS and early ambulation. Pneumatic compression devices in place until ambulatory

86
Q

Can you place an IVC filter during pregnancy?

A

Yes, if high risk of recurrent VTE. Risks include filter migration and IVC perforation

87
Q

When should you resume anticoagulation therapy postpartum?

A

No sooner than 4-6h after vaginal delivery or 6-12h after cesarean delivery

88
Q

When can you initiate therapeutic anticoagulation with LMWH after neuroaxial blockade and after epidural catheter removal?

A

24h after neuroaxial blockade. 4 hours after catheter removal

89
Q

Can you start someone on warfarin postpartum?

A

Yes, after heparin bridge; typically wait until 1-2 pp once postpartum bleeding has subsided

90
Q

How do you do a heparin bridge to start warfarin?

A

Therapeutic LMWH or UFH until an INR of 2-3 is achieved for 2 consecutive days with warfarin started concurrently

91
Q

What is the risk of starting warfarin without heparin bridge, why?

A

Paradoxical thrombosis and skin necrosis from the early antiprotein C effect

92
Q

Is warfarin compatible with breastfeeding?

A

Yes

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