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OB Final Exam > Module 9: Part 4 (68-88) > Flashcards

Module 9: Part 4 (68-88) Flashcards

1
Q

______ is the most common cause of thrombocytopenia
in pregnancy

A

Gestational thrombocytopenia (GT)

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2
Q

Gestational thrombocytopenia (GT) is usually a PLT count below ____

A

150

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3
Q

What is Gestational Thrombocytopenia?

A

Mild thrombocytopenia occurring during the third trimester with spontaneous
resolution in postpartum period

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4
Q

A small subset of women with GT may develop more significant declines in platelet
count and ________

A

reduction in antithrombin III associated with preeclampsia, HELLP
syndrome or acute fatty liver of pregnancy, ITP

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5
Q

With Autoimmune Thrombocytopenic Purpura (ATP) _______ are responsible for the increased platelet destruction

A

IgG antibodies

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6
Q

Antibodies directed against platelet antigens are produced primarily in the _____, where phagocytosis by macrophages occur. Also can occur in ____ and _____

A

spleen
the liver and bone marrow.

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7
Q

For autoimmune thrombocytopenic purpura (ATP) when would you administer corticosteroids? If there is no response to steroids what would you give?

A

Corticosteroids are administered if the platelet count is < 20-30k before
the onset of labor or <50k at the time of delivery

High dose IV immune globin if no response to steroids

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8
Q

What are the 5 things included in the classic pentad that defines Thrombotic thrombocytopenia purpura (TTP) ?

A
  1. Thrombocytopenia (as low as 20K)
  2. Microangiopathic hemolytic anemia
  3. Fever
  4. Neurologic signs such as photophobia, headache, and seizures
  5. Renal failure
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9
Q

_____ is the hallmark of TTP

A

DIC

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10
Q

Associated with congenital or acquired deficiency of
the enzyme ADAMTS13

A

Thrombotic
thrombocytopenia
purpura (TTP)

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11
Q

ADAMTS13 is responsible for _____

A

cleaving vWF multimers.

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12
Q

Decreased levels of ____ in the acute phase of TTP/normal in remission

A

vWF

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13
Q

What helps differentiate TTP from DIC?

A

The presence of vWF (but not fibrinogen) in
platelet aggregates helps differentiate TTP from
DIC. (In patients with DIC, fibrinogen but not vWF is found in platelet aggregates.)

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14
Q

______ appears to be a precipitating event in both initial and recurrent episodes of TTP

A

Pregnancy

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15
Q

Diagnosis may be confounded by a misdiagnosis of HELLP syndrome although concurrent diagnosis have been reported

A

Thrombotic
Thrombocytopenic
Purpura (TTP)

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16
Q

Is neuraxial anesthesia recommended for pts with Thrombotic Thrombocytopenic Purpura (TTP) ? Why or why not?

A

Because of the coagulopathy present, neuraxial
anesthesia is not recommended

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17
Q

vWF has two primary roles in coagulation. What are they?

A

it forms a complex with factor VIII
it mediates platelet adhesion by binding to platelets and collagen

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18
Q

Which type of Von Willebrand’s Disease is the most common congenital bleeding disorder?

A

Type 1

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19
Q

Von Willebrand’s Disease Type 1

A

vWF functions normally but the level is decreased
Both vWF and factor VIII increase in normal pregnancy so antenatal bleeding is rare

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20
Q

What is Von Willebrand Disease type 2?

A

includes a family of disorders characterized by
qualitative dysfunction of vWF, with normal plasma concentrations

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21
Q

What are Von Willebrand Disease type 2A and 2M? What occurs?

A

Type 2A and 2M lead to platelet aggregation, in type 2B vWF increases binding between platelets leading to accelerated platelet turnover and thrombocytopenia

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22
Q

Von Willebrand disease type 2 is (less/more) common

A

less

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23
Q

Which type of Von Willebrand disease is a severe quantitative deficiency in vWF?

A

type 3

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24
Q

Levels of what factors should be determined during pregnancy especially in the 3rd trimester w/ Von Willebrand disease?

A

factor VIII and vWF ristocetin cofactor

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25
Q

What can be administered for acute bleeding for pts with Von Willebrand disease?

A

FFP or cryoprecipitate

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26
Q

What is administered IV as labor begins for pts with von willebrand diseae types 1 or 2A? When should it be repeated?

A

0.3 mcg/kg of desmopressin (DDAVP) is administered IV as labor begins and the dose is repeated every 12 to 24 hours

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27
Q

What are the classifications of Von Willebrand’s disease?

A
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28
Q

What kind of coagulopathy is DIC?

A

acquired

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29
Q

DIC results from an abnormal activation of the
coagulation system which leads to:

A
  • Formation of large amounts of thrombin
  • Activation of the fibrinolytic system
  • Depletion of coagulation factors
  • Hemorrhage
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30
Q

What are the most frequent causes of DIC?

A

Preeclampsia, placental abruption, sepsis, retained dead fetus syndrome, PPH, acute fatty liver of pregnancy, AFE

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31
Q

Pathogenesis of DIC

A
32
Q

Range of Normal Results for Coagulation Tests in Pregnancy

A
33
Q

What 2 lab findings with DIC are decreased?

A

PLT count
fibrinogen

34
Q

In DIC there are variable increases in ___ and ___

A

PT
aPTT

35
Q

There are higher concentrations of what lab values in DIC?

A

D-dimer, fibrin monomer and fibrin
degradation products

36
Q

Viscoelastic monitoring confirms what 3 things associated with DIC?

A

delayed clot activation, decreased clot strength, and evidence of fibrinolysis

37
Q

What are the therapeutic goals for DIC?

A

 Treat or remove the precipitating cause (evacuation of the uterine contents)
 Replace depleted coagulation factors
 Stop on-going proteolytic activity; i.e., both the coagulation and fibrinolytic pathways
 Provide multi-system support as required

38
Q

What all is included in the treatment of DIC pt in active bleeding or for invasive procedures?

A

 Transfuse FFP (15 – 30 mL/kg) to maintain the PT and aPTT within 1.5 x normal values
 Cryoprecipitate or fibrinogen concentrate to
maintain the fibrinogen concentration above 200 mg/dL
 Platelets to maintain platelet count >50,000/uL

39
Q

How should you transfuse FFP for a DIC pt with active bleeding or for invasive procedures? What do you want to maintain the PT and aPTT within?

A

Transfuse FFP (15 – 30 mL/kg) to maintain the PT and aPTT within 1.5 x normal values

40
Q

Why would you give Cryoprecipitate or fibrinogen concentrate to a pt in DIC with active bleeding or an invasive procedure?

A

to maintain the fibrinogen concentration above 200 mg/dL

41
Q

You would give PLTs to a DIC pt with active bleeding or an invasive procedure to maintain a PLT count > _____

A

50,000/uL

42
Q

Diagnosis + Management of DIC in Pregnancy

A
43
Q

A congenital deficiency in anticoagulant activity
occurs in >____% of women with pregnancy-related venous thrombosis

A

50

44
Q

What are the most common
thrombophilia diagnosed in pregnancy?

A

Factor V Leiden mutation, prothrombin mutation, protein C deficiency, protein S deficiency, and antithrombin III deficiency

45
Q

Venous thromboses are more common than arterial T/F

A

TRUE

46
Q

Incidence of hypercoaguable states increases with:

A

surgery, pregnancy, oral
contraceptive use, immobilization

47
Q

ACOG and ACCP recommend _____ for pregnancies complicated by inherited thrombophilia

A

thromboprophylaxis

48
Q

What is the most common hereditary thrombophilia?

A

Factor V Leiden

49
Q

Individuals with Factor V Leiden have what?

A

have a point mutation in the factor V gene that produces a single amino acid switch (arginine to glutamine) that makes the protein resistant to inactivation by activated protein C.

50
Q

This mutant protein persists longer in circulation owing to its slower degradation by activated protein C, leading to a hypercoagulable state

A

Factor V Leiden

51
Q

Factor V Leiden makes up ___% of all obstetric thromboembolic events

A

40

52
Q

Conflicting data regarding association with placental abruption, severe preeclampsia, IUGR

A

Factor V Leiden

53
Q

Risk for thrombosis in pregnancy is increased up to 5-fold with which deficiencies?

A

antithrombin 3
protein C

54
Q

What all does Antithrombin III inactivate?

A

thrombin and factors IXa, Xa, XIa, and XIIa

55
Q

Where is antithrombin III synthesized?

A

in liver and endothelial cells

56
Q

Antithrombin III activity is potentiated by ____

A

heparin

57
Q

What is the incidence of antithrombin III in the general population?

A

0.02 to 0.4%

58
Q

How much does the risk for thrombosis increase for pregnant pts when they have antithrombin III deficiency?

A

Risk increases from 3% to 7% among those with
Antithrombin III def. and no prior thromboembolism
to 40% in those with prior venous thromboembolism

59
Q

For Antithrombin III deficiency which types is quantitative and which is qualitative?

A

Type 1 = quantitative
Type 2 = qualitative

60
Q

Why might heparin not ensure effective thromboprophlaxis in pts with antithrombin III deficiency?

A

Heparin acts by potentiating activity of antithrombin
III…. If antithrombin III levels are decreased, then
heparin may not ensure effective
thromboprophylaxis

61
Q

What is proposed for perioperative or peripartum therapy for pts with ATIII deficiency and venous thromboembolism history?

A

Antithrombin III replacement, with or without heparin

62
Q

Protein C is a ______-dependent protein

A

vitamin K

63
Q

Where is Protein C synthesized? What does it do?

A

synthesized in the liver and inhibits blood
coagulation by proteolytic activation of factors V and VIII

64
Q

When does Protein C deficiency occur?

A

when the gene for protein C on both chromosomes #2 is affected

65
Q

Deficiency is defined by an activity level of <____%

A

50

66
Q

Incidence in general population of protein C deficiency is approx. ____%

A

0.3

67
Q

Protein C levels increase ____% in pregnancy but
attenuated in Protein C deficiency

A

35

68
Q

How much does the risk for thrombosis increase for pregnant pts when they have protein C deficiency?

A

Risk is less than 1% among those without previous thrombosis to as high as 17 % with a previous history of thrombosis

69
Q

When should a pt with protein C deficiency be treated with LMWH?

A

During delivery and up to 6 weeks after

70
Q

______ acts as a cofactor for protein C

A

Protein S

71
Q

The plasma levels of protein S normally (increase/decrease) during pregnancy

A

decrease

72
Q

The plasma levels of protein C normally (increase/decrease) during pregnancy

A

increase

73
Q

What is the incidence of Protein S deficiency?

A

less than 0.2%

74
Q

2-4 increased risk of VTE with what condition?

A

Protein S Deficiency

75
Q

The risk for antepartum and postpartum venous
thromboembolism is low in patients with protein C or protein S deficiency T/F

A

TRUE

76
Q

Thromboprophylaxis for pts w/ protein C or protein S deficiency is not indicated unless the patient has a history of venous thromboembolism or additional risk factors
are present T/F

A

TRUE

OB Final Exam (15 decks)

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