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A - MSRA Obstetrics [16] > [30] Thromboembolic Disease > Flashcards

[30] Thromboembolic Disease Flashcards

1
Q

What is meant by VTE?

A

It is a collective term that describes DVT and PE

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2
Q

Why is VTE important in pregnancy?

A

Pregnancy is a major risk factor for VTE, resulting in 4-5x increased risk

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3
Q

Why is there an increased risk of VTE in pregnancy?

A

Thought to be due to changes in levels of some of the proteins in the clotting cascade

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4
Q

What changes are there in the clotting cascade during pregnancy?

A
  • Increased fibrinogen

- Decreased protein S

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5
Q

What happens to the changes in the clotting cascade as the pregnancy progresses?

A

They become more pronounced

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6
Q

What is the period of highest risk for VTE in pregnancy?

A

Post-partum

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7
Q

Describe the relationship between VTE and maternal mortality in the UK

A

It is the leading cause of maternal mortality in the UK, responsible for 1/3 of maternal deaths

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8
Q

What can the additional risk factors for VTE in pregnancy be divided into?

A
  • Pre-existing factors
  • Obstetric factors
  • Transient factors
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9
Q

What are the pre-existing risk factors for VTE in pregnancy?

A
  • Thrombophilia
  • Medical co-morbidities
  • Age >35
  • BMI >30
  • Parity >3
  • Smoking
  • Varicose veins
  • Paraplegia
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10
Q

Give an example of a pre-existing cause of thrombophilia

A

Anti-phospholipid syndrome

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11
Q

Give an example of a medical co-morbidity that can increase the risk of VTE

A

Cancer

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12
Q

What are the obstetric risk factors for VTE?

A
  • Multiple pregnancy
  • Pre-eclampsia
  • C-section
  • Stillbirth
  • Preterm birth
  • PPH
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13
Q

What are the transient risk factors for VTE?

A
  • Any surgical procedure in pregnancy or puerperium
  • Dehydration
  • Ovarian hyperstimulation syndrome
  • Admission or immobility
  • Systemic infection
  • Long distance travel
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14
Q

Give an example of a cause of dehydration in pregnancy

A

Hyperemesis gravidum

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15
Q

What is the most common presentation of DVT?

A

Unilateral leg pain and swelling

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16
Q

What are the other clinical features of DVT?

A
  • Pyrexia
  • Pitting oedema
  • Tenderness or prominent superficial veins
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17
Q

What is it important to note when considering the symptoms of DVT?

A

Some of the symptoms are normal in pregnancy

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18
Q

Where do the majority of DVTs form in pregnant women?

A

In the proximal veins

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19
Q

Which leg is more commonly affected by DVT in pregnant women?

A

Left

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20
Q

Why is the left leg more commonly affected by DVT in pregnant women?

A

Thought to be due to the compression effect of the uterus on the left iliac vein

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21
Q

What are the key clinical features of PE?

A
  • Sudden onset dyspnoea
  • Pleuritic chest pain
  • Cough
  • Haemoptysis
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22
Q

What signs might a patient with PE have?

A
  • Tachycardia
  • Tachypnoea
  • Pyrexia
  • Raised JVP
  • Pleural rub
  • Pleural effusion
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23
Q

What is it important to examine for in any patient with suspected PE?

A

DVT

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24
Q

What are the differential diagnoses for unilateral leg pain and swelling?

A
  • Cellulitis
  • Ruptured Baker’s cyst
  • Superficial vein thrombosis
  • Feature of normal pregnancy
25
Q

Why is the differential diagnosis of PE difficult?

A

Because there are a large number of possible diagnoses for sudden onset dyspnoea and chest pain

26
Q

What should be excluded in a patient presenting with sudden onset chest pain and dyspnoea?

A
  • Acute coronary syndromes
  • Aortic dissection
  • Pneumonia
  • Pneumothorax
27
Q

What investigations should be performed in suspected DVT or PE?

A
  • FBC
  • U&Es
  • LFTs
  • Coagulation screen
28
Q

Are investigations required before treatment is initiated in DVT or PE?

A

Yes

29
Q

Is testing for D-dimers recommended when DVT/PE is suspected in pregnancy?

A

No

30
Q

Why is it not recommended to test for D-dimer when DVT/PE occurs in pregnancy?

A

Because a rise in D-dimer is normal in pregnancy

31
Q

What is the definitive investigation for suspected DVT?

A

Compression duplex ultrasound scan

32
Q

What should be done if the compression duplex ultrasound scan is negative, but clinical suspicion for DVT is still high in pregnancy?

A

The test can be repeated 1 week later, whilst maintaining the patient on anti-coagulation

33
Q

How should women presenting with PE be initially assessed?

A

With ECG and CXR

34
Q

How is the definitive diagnosis of PE in pregnancy made?

A

CTPA or V/Q scan

35
Q

What should pregnant women receiving a VQ scan be informed of?

A

It is associated with an increased risk of childhood cancer

36
Q

What investigation should be performed if a woman presents with clinical features of DVT and PE?

A

Duplex ultrasound scan

37
Q

Why should a duplex ultrasound scan be performed if a woman presents with features of DVT and PE?

A

Because if it is positive, a CTPA or VQ scan doesn’t need to be performed, and it saves the woman from unnecessary radiation exposure

38
Q

How should all women with symptoms of VTE in pregnancy be managed?

A

They should receive LMWH, started immediately until diagnosis is excluded by definitive testing

39
Q

How is the dose of LMWH for suspected VTE in pregnancy determined?

A

It should be titrated against the woman’s booing weight

40
Q

How should pregnant women with confirmed VTE be managed after the acute event?

A

Anti-coagulation should be maintained throughout the pregnancy, until 6-12 weeks post-partum

41
Q

What advice should pregnant women on anti-coagulation for confirmed DVT in pregnancy be given regarding delivery?

A

They should omit their dose 24 hours before any planned induction of labour or C-section. Furthermore, they should not take their dose if they think they are going into labour

42
Q

What is the anticoagulant of choice for VTE in pregnancy in the UK?

A

LMWH

43
Q

What are the alternatives to LMWH for VTE in pregnancy?

A
  • Unfractionated heparin

- New oral anticoagulants (e.g. rivaroxiban)

44
Q

Can warfarin be used for VTE in pregnancy?

A

No

45
Q

Why can warfarin not be used in pregnancy?

A

Because it is teratogenic, and can lead to fetal loss through haemorrhage

46
Q

What treatment should be considered when VTE occurs at term?

A

The use of IV unfractionated heparin

47
Q

When should the use of IV unfractionated heparin be discontinued around delivery?

A

6 hours before planned induction of labour or C-section

48
Q

What is the advantage of the use of IV unfractionated heparin at term compared to LMWH?

A

It is discontinued at 6 hours before delivery, rather than 24

49
Q

When should pregnant women be assessed for risk of VTE?

A

Early in their pregnancy, and again in the intrapartum and postnatal periods

50
Q

When should women be offered thromboprophylaxis in pregnancy?

A

If they have;

  • 4 or more risk factors in first trimester
  • 3 or more risk factors in second trimester
  • 2 or more risk factors in post-partum period
51
Q

How long should a woman receiving thromboprophylaxis antenatally continue anticoagulation for?

A

At least 6 weeks post-partum

52
Q

Why should a woman receiving thromboprophylaxis continue for at least 6 weeks post-partum?

A

As the immediate post-natal period carries the highest risk

53
Q

Should anticoagulation be given to women who have a C-section?

A

Yes, should be considered in all women who have had a C-section, particularly in emergency cases

54
Q

What course of anticoagulation should be given to women who have had a C-section?

A

10-day course of LMWH

55
Q

Who has a particularly high risk of developing a VTE in pregnancy?

A
  • Women with previous VTE

- Known thrombophilia

56
Q

Who should be involved in the management of woman at particularly high risk of VTE in pregnancy?

A

Haematologist

57
Q

How should women who had previous VTE provoked from major surgery be managed in pregnancy?

A

Should have LMWH thromboprophylaxis from 28 weeks onwards

58
Q

How should women with any other previous VTE be managed in pregnancy?

A

LMWH thromboprophylaxis throughout antenatal period

59
Q

How should women with known antithrombin deficiency or antiphospholipid syndrome be managed in pregnancy?

A

Should have thromboprophylaxis with high dose LMWH, usually 50 or 75% of treatment dose, or full treatment dose

A - MSRA Obstetrics [16] (61 decks)

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