Acute Management of TE during Pregnancy & Puerperium, Flashcards
1
Q
How is acute VTE diagnosed in pregnancy?
A
- Any with symptoms and/or signs suggestive of VTE objective testing performed expeditiously & treatment with LMWH given.until diagnosis excluded by objective testing, unless treatment is strongly contraindicated.
- Individual hospitals agreed protocol for objective diagnosis of suspected VTE during pregnancy. This may recommend involvement of obstetricians, radiologists, physicians and haematologists.
2
Q
What investigations are needed for the diagnosis of an acute DVT?
A
- Compression duplex ultrasound; where clinical suspicion of DVT.
- If ultrasound negative & low level of clinical suspicion, anticoagulant treatment can be discontinued.
- If ultrasound negative & high level of clinical suspicion exists, anticoagulant treatment discontinued but US repeated on days 3 and 7.
3
Q
What investigations are needed for the diagnosis of an acute pulmonary embolism (PE)?
A
- presenting with symptoms and signs of acute PE should have ECG & CXR.
- with suspected PE, also symptoms and signs of DVT, compression duplex US perform. If compression ultrasonography confirms the presence of DVT,
no further investigation necessary & treatment VTE continue. - with suspected PE without symptoms and signs of DVT, V/Q lung scan or CTPA performed.
- chest X-ray: abnormal & clinical suspicion of PE, CTPA perform, in preference to a V/Q scan.
- Alternative or repeat testing carried out where V/Q scan or CTPA is normal but clinical suspicion of PE remains. Anticoagulant treatment should be continued until PE is definitively excluded.
- with suspected PE: advise that, compared with CTPA, V/Q scanning may carry slightly increased risk of childhood cancer but is associated with a lower risk of maternal breast cancer; in both situations, absolute risk is very small.
- Where feasible, women should be involved in decision to undergo CTPA or V/Q scanning. Ideally, informed consent obtained before tests are undertaken.
4
Q
Should D-dimer testing be performed prior to objective diagnosis?
A
- not performed in investigation of acute VTE in pregnancy.
5
Q
What baseline blood investigations should be performed before initiating anticoagulant therapy?
A
- Before anticoagulant therapy is commenced, blood should be taken for a full blood count, coagulation screen, urea and electrolytes, and liver function tests.
- Performing a thrombophilia screen prior to therapy is not recommended.
6
Q
What is the initial treatment of VTE in pregnancy?
A
- In clinically suspected DVT or PE, treatment with LMWH commence immediately until diagnosis excluded by objective testing, unless treatment is strongly contraindicated.
7
Q
What is the therapeutic dose of LMWH in pregnancy?
A
- doses titrated against booking or early pregnancy weight.
- insufficient evidence to recommend dose of LMWH once daily or in two divided doses.
- should be clear local guidelines for dosage of LMWH
8
Q
Should blood tests be performed to monitor heparin therapy in pregnancy?
A
- Routine measurement of peak anti-Xa activity for LMWH treatment of acute VTE in pregnancy or postpartum is not recommended except
1 - extremes of body weight (< 50 kg & 90 kg or more)
2 - with other complicating factors (for example,
A - with renal impairment or
B - recurrent VTE). - Routine platelet count monitoring not carried out.
- Obstetric postoperative and receiving unfractionated heparin platelet count monitoring performed every 2–3 days from days 4 to 14 or until heparin is stopped.
9
Q
How should massive life-threatening PE in pregnancy and the puerperium be managed?
A
- Collapsed, shocked. pregnant orpuerperium assess by team of experienced clinicians including on-call consultant obstetrician.
- managed on an individual basis regarding:
1 - IV UFH
2 - thrombolytic therapy or thoracotomy and
3 - surgical embolectomy. - MX involve MDT including senior physicians, obstetricians and radiologists.
- IV UFH preferred, initial treatment in massive PE with
cardiovascular compromise. - Maternity units develop guidelines for administration of intravenous unfractionated heparin.
- on-call medical team contacted immediately.
- urgent portable echocardiogram or CTPA within 1 hour of presentation arranged. If massive PE is confirmed, or in extreme circumstances prior to confirmation, immediate thrombolysis should be considered.
10
Q
Should graduated elastic compression stockings be employed in the acute management of VTE in pregnancy?
A
- initial management of DVT, leg elevated & graduated elastic compression stocking applied to reduce oedema.
- Mobilisation with graduated elastic compression stockings should be encouraged.
11
Q
What is the role of inferior vena cava filters in the management of VTE in pregnancy?
A
Consider: temporary inferior vena cava filter in peripartum period for patients with iliac vein VTE to reduce risk of PE or in patients with proven DVT & who have recurrent PE despite adequate anticoagulation.
12
Q
What is the maintenance treatment of DVT or PE?
A
- Treatment with therapeutic doses of subcut. LMWH during remainder of pregnancy & for at least 6 weeks postnatally and until at least 3 months of treatment has
been given in total. - Women taught to self-inject LMWH and arrangements made to allow safe disposal of needles and syringes.
- Outpatient follow-up should include clinical assessment and advice with monitoring of blood platelets and peak anti-Xa levels if appropriate.
- who develop heparin-induced thrombocytopenia or heparin allergy and require continuing anticoagulant therapy managed with an alternative anticoagulant
under specialist advice.
13
Q
Can vitamin K antagonists be used during pregnancy for the maintenance treatment of VTE?
A
- Because of adverse effects on fetus, vit. K antagonists, as warfarin, not be used for antenatal VTE treatment.
14
Q
Is there a role for the new anticoagulants in the treatment of VTE in pregnancy?
A
- Consideration given to use of newer anticoagulants (fondaparinux, argatroban or r-hirudin) in pregnant women who are unable to tolerate heparin (LMWH or unfractionated heparin) or danaparoid and who require continuing anticoagulant therapy.
15
Q
Should anticoagulant therapy be altered during labour and delivery?
A
- VTE at term, consider IV UFH, more easily manipulated
- woman on LMWH for maintenance therapy advise that once she is in established labour or thinks that she is in labour, she should not inject any further heparin.
- delivery is planned, either by elective CS or IOL, LMWH maintenance therapy should be discontinued 24 hours prior to planned delivery.
- Regional anaesthetic or analgesic techniques not be undertaken until at least 24 hours after last dose of therapeutic LMWH.
- LMWH not be given for 4 hours after use of spinal anaesthesia or after epidural catheter has been removed, and epidural catheter should not be removed within 12 hours of most recent injection.
