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Gaby’s Green Top Guidelines > 2015 37a VTE Risk Reduction > Flashcards

2015 37a VTE Risk Reduction Flashcards

1
Q

When should VTE risk assessment be undertaken?

A
  1. Prepregnancy
  2. Early pregnancy
  3. Hospital admission
  4. Intrapartum
  5. Postpartum
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2
Q

Which women should be given LMWH throughout pregnancy & then 6 weeks postnatally?

A

4+ risk factors
Previous VTE unprovoked by major surgery

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3
Q

Which women should receive LMWH from 28 weeks to 6 weeks PN?

A

3 risk factors

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4
Q

Which women should receive LMWH for 10 days postpartum?

A

2 risk factors

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5
Q

What are the antenatal risk factors for VTE?

A
  1. BMI > 30
  2. Age > 35
  3. Parity ≥ 3
  4. Smoker
  5. Gross varicose veins
  6. Current PET
  7. Immobility eg paraplegia, PGP
  8. Family hx VTE
  9. Low-risk thrombophilia
  10. Multiple pregnancy
  11. IVF/ART
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6
Q

What are the transient risk factors for VTE?

A
  1. Dehydration
  2. Hyperemesis
  3. Current systemic infection
  4. Long-distance travel
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7
Q

What are the intermediate risk factors for which LMWH is considered in pregnancy?

A
  1. Hospital admission
  2. Single previous provoked VTE
  3. High-risk thrombophilia, no VTE
  4. Medical comorbidities
  5. Surgical procedure
  6. OHSS
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8
Q

For which medical comorbidities is LMWH considered?

A
  1. Cancer
  2. Heart failure
  3. Active SLE
  4. Inflammatory bowel disease
  5. Inflammatory polyarthropathy
  6. Nephrotic syndrome
  7. Type 1 DM with nephropathy
  8. Sickle cell disease
  9. Current IVDU
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9
Q

Which women need 6 weeks postnatal LMWH?

A
  1. Anyone requiring antenatal LMWH
  2. Any previous VTE
  3. High-risk thrombophilia
  4. Low-risk thrombophilia + FHx
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10
Q

What are the intermediate risk factors needing 10 days postnatal LMWH?

A
  1. CS in labour
  2. BMI ≥ 40
  3. Readmission or prolonged PN admission
  4. Surgical procedure in puerperium other than immediate perineal repair
  5. Medical comorbidities
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11
Q

What additional postnatal risk factors score for VTE risk?

A
  1. Elective CS
  2. Current systemic infection
  3. Preterm delivery < 37+0
  4. Stillbirth
  5. Mid-cavity rotational or OVB
  6. Prolonged labour > 24 hours
  7. PPH > 1L or blood transfusion
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12
Q

Which heritable thrombophilia needs a higher dose of LMWH & how is this managed?

A

Antithrombin deficiency
50%, 75% or full treatment dose
In collaboration with haematologist
Consider anti-Xa monitoring, aim 4-hour peak level 0.5-1.0 units/ml
Consider antithrombin replacement

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13
Q

Which acquired thrombophilia needs a higher dose of LMWH, and how much?

A

Antiphospholipid syndrome
50%, 75% or full treatment dose

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14
Q

Which asymptomatic heritable thrombophilias should be referred to a local expert, be considered for antenatal LMWH & given 6 weeks PN?

A
  1. Protein C deficiency
  2. Protein S deficiency
  3. Homozygous factor V Leiden
  4. Homozygous prothrombin gene mutation
  5. Compound heterozygotes
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15
Q

How should LMWH be managed at delivery?

A
  1. Stop if any PVB
  2. Avoid RA for > 12 hours after dose, or 24 for therapeutic dose
  3. Avoid LMWH for > 4 hours after spinal
  4. Stop day before elective CS
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16
Q

What risk factors for haemorrhage may indicate TEDS or UFH over LMWH?

A
  1. Major APH
  2. Coagulopathy
  3. Progressive wound haematoma
  4. Suspected intra-abdominal bleed
  5. PPH
17
Q

If women on warfarin are converted to LMWH in pregnancy, how is the conversion back managed?

A

5-7 days after delivery
With bridging

18
Q

What is the calf pressure of TEDS?

A

14-15mmHg

19
Q

By how much does LMWH reduce VTE risk?

A

60-70%

20
Q

What is the UK incidence of PE?

A

1.3 in 10,000

21
Q

What is the UK incidence of VTE in pregnancy & the puerperium?

A

1-2 in 1000

22
Q

What are the benefits of LMWH over UFH?

A
  1. Just as effective
  2. Risk of heparin-induced thrombocytopenia much lower
  3. Lower risk of osteoporosis & fractures
23
Q

What are the benefits of UFH over LMWH?

A
  1. Shorter half-life
  2. More complete reversal of activity by protamine sulphate
24
Q

What is the dosing regime for enoxaparin?

A

< 50 kg 20mg OD
50-90kg 40mg OD
91-130kg 60mg OD
131-170kg 80mg OD
>170kg 0.6 mg/kg/d

25
Q

What is the dosing regime for dalteparin?

A

< 50 kg 2500 units OD
50-90kg 5000 units OD
91-130kg 7500 units OD
131-170kg 10,000 units OD
>170kg 75 units/kg/d

26
Q

What is the dosing regime of tinzaparin?

A

75 units/kg/day
< 50 kg 3500 units
50-90kg 4500 units
91-130kg 7500 units
131-170kg 9000 units
>170kg 75 units/kg/d

27
Q

What are the characteristics of warfarin embryopathy?

A
  1. Hypoplasia of nasal bridge
  2. Congenital heart defects
  3. Ventriculomegaly
  4. Agenesis of corpus callosum
  5. Stippled epiphyses
28
Q

What proportion of fetuses exposed to warfarin between 6 & 12 weeks of gestation develop warfarin embryopathy?

A

Approx 5%

29
Q

What are the contraindications/cautions to LMWH use?

A
  1. Known bleeding disorders
  2. Active AN or PN bleeding
  3. Increased risk major bleed eg placenta praevia
  4. Thrombocytopenia < 75
  5. Acute stroke in previous 4 weeks
  6. Severe renal disease
  7. Severe liver disease
  8. Uncontrolled HTN, > 200/120

Gaby’s Green Top Guidelines (51 decks)

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