2015 37a VTE Risk Reduction Flashcards
When should VTE risk assessment be undertaken?
- Prepregnancy
- Early pregnancy
- Hospital admission
- Intrapartum
- Postpartum
Which women should be given LMWH throughout pregnancy & then 6 weeks postnatally?
4+ risk factors
Previous VTE unprovoked by major surgery
Which women should receive LMWH from 28 weeks to 6 weeks PN?
3 risk factors
Which women should receive LMWH for 10 days postpartum?
2 risk factors
What are the antenatal risk factors for VTE?
- BMI > 30
- Age > 35
- Parity ≥ 3
- Smoker
- Gross varicose veins
- Current PET
- Immobility eg paraplegia, PGP
- Family hx VTE
- Low-risk thrombophilia
- Multiple pregnancy
- IVF/ART
What are the transient risk factors for VTE?
- Dehydration
- Hyperemesis
- Current systemic infection
- Long-distance travel
What are the intermediate risk factors for which LMWH is considered in pregnancy?
- Hospital admission
- Single previous provoked VTE
- High-risk thrombophilia, no VTE
- Medical comorbidities
- Surgical procedure
- OHSS
For which medical comorbidities is LMWH considered?
- Cancer
- Heart failure
- Active SLE
- Inflammatory bowel disease
- Inflammatory polyarthropathy
- Nephrotic syndrome
- Type 1 DM with nephropathy
- Sickle cell disease
- Current IVDU
Which women need 6 weeks postnatal LMWH?
- Anyone requiring antenatal LMWH
- Any previous VTE
- High-risk thrombophilia
- Low-risk thrombophilia + FHx
What are the intermediate risk factors needing 10 days postnatal LMWH?
- CS in labour
- BMI ≥ 40
- Readmission or prolonged PN admission
- Surgical procedure in puerperium other than immediate perineal repair
- Medical comorbidities
What additional postnatal risk factors score for VTE risk?
- Elective CS
- Current systemic infection
- Preterm delivery < 37+0
- Stillbirth
- Mid-cavity rotational or OVB
- Prolonged labour > 24 hours
- PPH > 1L or blood transfusion
Which heritable thrombophilia needs a higher dose of LMWH & how is this managed?
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
Which acquired thrombophilia needs a higher dose of LMWH, and how much?
Antiphospholipid syndrome
50%, 75% or full treatment dose
Which asymptomatic heritable thrombophilias should be referred to a local expert, be considered for antenatal LMWH & given 6 weeks PN?
- Protein C deficiency
- Protein S deficiency
- Homozygous factor V Leiden
- Homozygous prothrombin gene mutation
- Compound heterozygotes
How should LMWH be managed at delivery?
- Stop if any PVB
- Avoid RA for > 12 hours after dose, or 24 for therapeutic dose
- Avoid LMWH for > 4 hours after spinal
- Stop day before elective CS
What risk factors for haemorrhage may indicate TEDS or UFH over LMWH?
- Major APH
- Coagulopathy
- Progressive wound haematoma
- Suspected intra-abdominal bleed
- PPH
If women on warfarin are converted to LMWH in pregnancy, how is the conversion back managed?
5-7 days after delivery
With bridging
What is the calf pressure of TEDS?
14-15mmHg
By how much does LMWH reduce VTE risk?
60-70%
What is the UK incidence of PE?
1.3 in 10,000
What is the UK incidence of VTE in pregnancy & the puerperium?
1-2 in 1000
What are the benefits of LMWH over UFH?
- Just as effective
- Risk of heparin-induced thrombocytopenia much lower
- Lower risk of osteoporosis & fractures
What are the benefits of UFH over LMWH?
- Shorter half-life
- More complete reversal of activity by protamine sulphate
What is the dosing regime for enoxaparin?
< 50 kg 20mg OD
50-90kg 40mg OD
91-130kg 60mg OD
131-170kg 80mg OD
>170kg 0.6 mg/kg/d
