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Yr 4 - GOSH > Antenatal Care: Anaemia & VTE in Pregnancy > Flashcards

Antenatal Care: Anaemia & VTE in Pregnancy Flashcards

1
Q

What is haemoglobin?

A

Haemoglobin is a protein found in red blood cells.

It is responsible for picking up oxygen in the lungs and transporting it to the cells of the body.

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2
Q

Role of iron in haemoglobin?

A

Iron is an essential ingredient in creating haemoglobin and forms part of the structure of the molecule.

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3
Q

When are women routinely screened for anaemia in pregnancy?

A

Twice:

1) Booking clinic
2) 28 weeks gestation

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4
Q

Describe haem conc in pregnancy

A

During pregnancy, the plasma volume increases.

This reduces the haemoglobin conc (blood is diluted due to higher plasma volume).

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5
Q

Why is it important to optimise the treatment of anaemia during pregnancy?

A

So that the woman has reasonable reserves, in case there is significant blood loss during delivery.

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6
Q

Presentation of anaemia in pregnancy?

A
  • Often asymptomatic
  • Shortness of breath
  • Fatigue
  • Dizziness
  • Pallor
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7
Q

Normal Hb conc level during pregnancy at:

1) booking bloods
2) 28 weeks gestation
3) post partum

A

1) >110 g/l
2) >105 g/l
3) >100 g/l

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8
Q

What is the MCV?

A

An MCV blood test measures the average size of your red blood cells.

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9
Q

The MCV may indicate the cause of anaemia.

What would the following MCVs indicate:

1) low MCV
2) normal MCV
3) raised MCV

A

1) may indicate iron deficiency

2) may indicate a physiological anaemia due to the increased plasma volume of pregnancy

3) may indicate B12 or folate deficiency

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10
Q

Woemn are offered haemoglobinopathy screening at the booking clinic.

What 2 conditions are screened?

A

1) thalassaemia (all women)

2) sickle cell disease (women at higher risk)

These are causes of significant anaemia in pregnancy.

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11
Q

What investigations may be done in anaemia in pregnancy?

A

1) Screening for haemoglobinopathies e.g. thalassaemia and sickle cell

2) Ferritin

3) B12

4) Folate

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12
Q

What are the 5 different types of anaemia in pregnancy?

A

1) Iron deficiency

2) Anaemia of pregnancy (blood volume increases)

3) Vit B12 deficiency

4) Folate deficiency

5) Haemoglobinopathies

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13
Q

Management of iron deficiency anaemia in pregnancy?

A

Iron replacement therapy e.g. ferrous sulphate 200mg three times daily

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14
Q

When pregnant women are not anaemic, but they have a low ferritin, what may they be started on?

A

supplementary iron

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15
Q

What should women with low B12 in pregnancy be tested for?

A

pernicious anaemia (checking for intrinsic factor antibodies).

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16
Q

Management of B12 deficiency in pregnancy?

A

1) Advice should be sought from a haematologist regarding further investigations and treatment of low B12

2) IM hydroxocobalamin injections

3) Oral cyanocobalamin tablets

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17
Q

Management of folate deficiency in pregnancy?

A

All women should already be taking folic acid 400mcg per day.

Women with folate deficiency are started on folic acid 5mg daily.

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18
Q

How does pregnancy affect clotting?

A

Pregnancy is a hypercoaguable state (i.e. risk factor for VTE)

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19
Q

PE is a significant cause of death in obstetrics.

When is the risk highest?

A

Postpartum period

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20
Q

Risk factors for VTE in pregnancy?

A
  • Smoking
  • Parity ≥ 3
  • Age > 35 years
  • BMI > 30
  • Reduced mobility
  • Multiple pregnancy
  • Pre-eclampsia
  • Gross varicose veins
  • Immobility
  • Family history of VTE
  • Thrombophilia
  • IVF pregnancy
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21
Q

When is VTE prophylaxis recommended in pregnancy?

A

1) At 28 weeks if there are three risk factors

2) 1st trimester if there are four or more of these risk factors

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22
Q

If there are 3 VTE risk factors, when is prophylaxis recommended?

A

Started at 28 weeks

23
Q

If there are 4 or more VTE risk factors, when is prophylaxis recommended?

A

1st trimester

24
Q

In what situations is VTE prophylaxis considered, even in the absence of other risk factors?

A

1) Hospital admission

2) Surgical procedures

3) Previous VTE

4) Medical conditions such as cancer or arthritis

5) High-risk thrombophilias

6) Ovarian hyperstimulation syndrome

25
Q

When is a VTE risk assessment done in pregnancy?

A

Booking clinic & again after birth.

Additional risk assessments are necessary at other times, such as if they are admitted to hospital, undergo a procedure or develop significant immobility.

26
Q

Women at increased risk of VTE should receive prophylaxis with what?

A

Low molecular weight heparin (LMWH) unless contraindicated e.g. enoxaparin, dalteparin and tinzaparin

27
Q

Give 3 examples of LMWH

A

1) Enoxaparin
2) Tinzaparin
3) Dalteparin

28
Q

How long is VTE prophylaxis continued for in pregnancy?

A

It is continued throughout the antenatal period and for 6 weeks postnatally.

29
Q

When is prophylaxis temporarily stopped in pregnancy?

When is it started again?

A

Prophylaxis is temporarily stopped when the woman goes into labour, and can be started immediately after delivery (except with postpartum haemorrhage, spinal anaesthesia and epidurals).

30
Q

What can be considered for VTE prophylaxis in women with contraindications to LMWH?

A

Mechanical prophylaxis:

1) Intermittent pneumatic compression with equipment that inflates and deflates to massage the legs

2) Anti-embolic compression stockings

31
Q

Management of a pregnant woman with a previous VTE history?

A

A woman with a previous VTE history is automatically considered high risk and requires LMWH throughout the antenatal period and also input from experts.

32
Q

What 2 anticoagulants should be avoided in pregnancy?

A

1) DOACs
2) Warfarin

33
Q

Presentation of DVT?

A
  • Unilateral*
  • Calf or leg swelling
  • Dilated superficial veins
  • Tenderness to the calf (particularly over the deep veins)
  • Oedema
  • Colour changes to the leg

*Bilateral DVTs are rare, and bilateral symptoms are more likely due to an alternative diagnosis such as chronic venous insufficiency or heart failure.

34
Q

How can you examine for leg swelling?

A

Measure the circumference of the calf 10cm below the tibial tuberosity.

35
Q

What size difference between calves is significant in suspected DVT?

A

> 3cm difference between calves

36
Q

Presenting features of PE?

A

Pulmonary embolism can present with subtle signs and symptoms.

  • SOB
  • Cough with or without blood
  • Tachycardia
  • Tachypnoea
  • Pleuritic chest pain
  • Hypoxia
  • Low grade fever
  • Haemodynamic instability causing hypotension
37
Q

What is the investigation of choice for patients with suspected deep vein thrombosis?

A

Doppler US

38
Q

If a doppler US is negative in suspected DVT, what is next steps?

A

Repeat negative ultrasound scans on day 3 and 7 in patients with a high index of suspicion for DVT.

39
Q

What 2 investigations do women with suspected PE require?

A

1) CXR
2) ECG

40
Q

What are the 2 main options for establishing a definitive diagnosis of PE?

A

1) CT pulmonary angiogram (CTPA)

2) Ventilation-perfusion (VQ) scan

41
Q

What does a CTPA involve?

A

CT pulmonary angiogram involves a chest CT scan with an intravenous contrast that highlights the pulmonary arteries to demonstrate any blood clots.

42
Q

What does a VQ scan involve?

A

Ventilation-perfusion (VQ) scan involves using radioactive isotopes and a gamma camera, to compare the ventilation with the perfusion of the lungs.

1) First, the isotopes are inhaled to fill the lungs, and a picture is taken to demonstrate ventilation.

2) Next, a contrast containing isotopes is injected, and a picture is taken to demonstrate perfusion.

3) The two images are compared.

43
Q

VQ scan results in a PE?

A

There will be a deficit in perfusion, as the thrombus blocks blood flow to the lung tissue. This area of lung tissue will be ventilated but not perfused.

44
Q

What is test of choice for PE in those with abnormal CXR?

A

CTPA

45
Q

What risk may CTPA or VQ scan carry in pregnant women:
a) to mother?
b) to child?

A

a) CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk)

b) VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk)

46
Q

Which PE investigation carries a higher risk of breast cancer?

A

CTPA

47
Q

Which PE investigation carries a higher risk of childhood cancer for the foetus?

A

VQ scan

48
Q

Is the Wells score used in pregnancy?

A

No

49
Q

Are d-dimers used in pregnancy?

A

No - pregnancy is a cause of a raised d-dimer

50
Q

1st line management of VTE in pregnancy?

A

LMWH

LMWH should be started immediately, before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in getting the scan. Treatment can be stopped when the investigations exclude the diagnosis.

51
Q

What is the dose of LMWH in pregnancy based on?

A

The dose is based on the woman’s weight at the booking clinic, or from early pregnancy.

52
Q

How long is LMWH continued in pregnancy (after being started for established VTE)?

A

When the diagnosis is confirmed, LMWH is continued for the remained of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer).

53
Q

Management of pregnant women with a massive PE and haemodynamic compromise?

A

Need an experienced team of medical doctors, obstetricians, radiologists and others. This is life-threatening.

  • Unfractionated heparin
  • Thrombolysis
  • Surgical embolectomy
54
Q
A

Yr 4 - GOSH (45 decks)

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