Acute management VTE during pregnancy and puerperium GTG Flashcards
What % of suspected VTE have VTE confirmed?
2-6%
What % of untreated DVT will develop into PE?
15-24%
What % of PE is fatal in pregnancy? When is the death most likely to occur?
Fatal 15%
66% will occur within 30 mins of embolic event
If high clinical suspicion of DVT and USS doppler negative, what should be done?
Re-perform USS on Day 3 and Day 7
(If low clinical suspicion, stop Tx dose Tinz)
What % of ECGs are abnormal in PE?
41%
What are the most common ECG findings in PE?
T wave inversion 21%
S1Q3T3 15%
RBBB 18%
What does the S1Q3T3 finding look like?
What 1st investigations would you consider when Ix PE?
ECG
CXR
If signs of DVT → Leg doppler. If +ve no other imaging required
If CXR is abnormal which chest imaging is preferred?
CTPA>VQ scan if chest XR abnormal
What is the risk with V/Q scanning to the foetus?
Slight increased risk childhood cancer
Risk 1 in 17,000 per mGy
V/Q 0.5mGy
CTPA 0.1 mGy
(1/280,000 vs 1/1,000,000 - according busy SpR)
Risk to mother with CTPA?
High radiation to maternal breast tissue (up to 20mGy)
Increased risk 13.6% above background, background 0.1% → 0.136%
Consider VQ if young women or Fhc BC or previous CT chest
What bloods should be performed before commencing LMWH?
FBC
Coagulation
U+E
LFT
Does LMWH cross the placenta?
No
No increased risk severe PPH
At what creatinine clearance does the dose of Tinz/enoxaprin and dalteparin need to be adjusted?
Tinz if CC <20
Enox/Dalte <30
When should you consider Anti-Xa monitoring?
<50kg
>90kg
Renal impairment
Recurrent VTE
If post-op obstetric patient recieving unfractioned heparin, how often should platelets be measured?
Every 2-3 days from day 4 - 14 until stopped
If massive PE with CV compromise, what is the preferred initial management?
IV unfractioned heparin
If massive PE with CV compromise, what investigations should occur within 1 hours?
Portable ECHO
CTPA
If PE confirmed → Thrombolysis
How may massive PE present?
Shock
Refactory hyperaemia
Right ventricular dysfunction on ECHO
How is IV unfractioned heperin commenced
1) Loading dose 80units/kg
2) Continous infusion 18unit/kg/hour
3) APTT 4-6 hours after loading dose or 6 hours after any dose change
4) APTT target 1.5-2.5
If been thrombolysed does not need loading dose
How long should treatment of PE be continued?
Either 6 weeks PP or 3 months total Tx
What should factor Xa level be?
0.5-1.2
What can be given to reverse unfractionated heparin?
Protamine Sulphate
If VTE at term or near delivery what should be considered?
Unfractioned heparin
When should unfrationed heparin be stopped before IOL of regional?
If IV 6 hours
Subcut 12 hours
When shouldLMWH be stopped before IOL of regional?
24 hours
If patient on TX dose LMWH, how should this managed if ELCS?
Last dose 24 hours pre-op, prophylactic dose 4 hours after and treatment dose 8-12 hours later
What should be considered at CS if patient on TX dose tins?
Consider wound drain (abdominal or rectus), skin incision with interrupted sutures
Give examples of cases where high risk of haemorrhage but need heparin? What should be given?
Anticoagulation required but also
- APH
- Coagulopathy
- Progressive wound haematoma
- Suspected intrabaominal bleeding
- PPH
IV unfractioned heparin
What anticoagulation can be considered in the postnatal period?
Heparin (LMWH/unfractioned)
Warfarin
DOAC - if NOT breast feeding
If women would like to switch to warfarin postnatally, what is the earliest point this can occur?
Day 5
Daily INRs Aiming 2-3
Heparin can be stopped when >2 for 2 days
What is post thrombotic syndrome?
Chronic pain, heaviness, swelling, eczema, chronic pigmentation, ulceration.
42% post DVT in preg
How can risk of post thrombotic syndrome be reduced
Prolonged course of LMWH > 12 weeks and compression stocking for at least 2 years
What follow up and testing should be provided for woman who had VTE in pregnancy?
FU in obstetric medicine or obs team clinic
Consider thrombophilia testing once anti-coagulation testing stopped
Discuss contraception
Look for post thrombotic syndrome
Switching warfarin to heparin?
Stop Warfarin
Give 1st dose LMWH when INR <2
LMWH to warfarin
Continue LMWH for at leat 5 dats until INR in range for 24 hours, stop LMWH immediately if INR greater than upper limit
LMWH to DOAC
stop LMWH and start DOAC at time of next secuedualted LMWH
DOAC to LMWH
Stop apixaban/rivaroxaban/edoxaban, start LMWH at the time of the next dose of DOAC would have been due
Dabigatran - wait 12 hours after last dose before switching to LMWH
