Pregnancy 2 Flashcards
At what platelet count should you consider another diagnosis aside from gestational thrombocytopenia?
Less than 100. <1% of GT has a platelet count under 100
Most common cause of thrombocytopenia in the first trimester?
ITP
Most common cause of thrombocytopenia (<100k) in the second trimester?
ITP
Most common cause of thrombocytopenia <100 in 3rd timester?
pre-eclampsia
How to make diagnosis of gestational thrombocytopenia?
Diagnosis of exclusion. Mild thrombocytopenia (100-150), no history of TCP outside of pregnancy, no signs of MAHA or coagulopathy. Resolves after delivery
Treatment threshold for ITP in pregnancy?
Platelet 20-30 during first 8 months
Approaching delivery: >50 for L&D, >70 for epidural
First line therapy for ITP in pregnancy?
Prednisone (avoid dexamethasone)
IVIG
Second line therapy options for ITP (3)
TPO agonists
Rituximab
Splenectomy
Diagnostic criteria for Pre-eclampsia
> 20 weeks pregnant with:
HTN + Proteinuria and/or endo organ dysfunction
Diagnostic criteria for HELLP
Hemolysis (MAHA)
Elevated liver enzymes
Low platelets
Occurs after 20 weeks through early postpartum
Clinical features for acute fatty liver of pregnancy
RUQ pain, N/V, jaundice, Rapid onset liver failure
Frequent coagulopathy
Hypoglycemia
Renal failure
Mild-moderate thrombocytopenia, +/- MAHA
Severe TMA presenting prior to 20 weeks should make you think of what two diagnoses?
TTP or aHUS
Send ADAMTS13 activity level
Treatment for TTP in pregnancy
PLEX and steroids
We don’t know if caplacizumab is safe
What is the most common timing of complement-mediated HUS regarding pregnancy?
Most commonly post-partum
Treatment of complement-mediated HUS in pregnancy
Eculizumab
You see severe acute kidney injury and a new onset or worsening TMA post-partum. What diagnosis is most likely?
CM-HUS
What is the most common antibody seen in fetal and neonatal alloimmune thrombocytopenia?
Anti-HPA1a
Treatment for woman with history of fetal and neonatal alloimmune thrombocytopenia?
Maternal IVIG +/- steroids
Definition of anemia throughout pregnancy
1st trimester: Hb <11
2nd trimester: Hb <10.5
3rd timester: Hb <11
Most common disease causing anemia in pregnancy?
IDA
Threshold for ferritin to diagnose IDA in pregnancy?
<30
Management of IDA in pregnancy
Oral iron if early in pregnancy or mild deficiency
IV iron in 2nd or 3rd trimester
What is the mechanism of physiology anemia of pregnancy?
Increase in plasma volume
Anticoagulant option(s) during pregnancy
LMWH and UFH
What 4 anticoagulants are safe during breastfeeding?
LMWH
UFH
Fondaparinux
Warfarin
For those who are on therapeutic LMWH while pregnant, how do you manage anticoagulation for delivery? How do you manage it for neuraxial anesthesia?
Hold LMWH 24 hours prior epidural and delivery. Can consider transition to UFH gtt
For someone on prophylactic LMWH during pregnancy, how do you manage anticoagulation during delivery or neuraxial anesthesia?
Hold 12 hours prior to epidural
Can do spontaneous labor but low certainty of evidence
Who should receive both antepartum and postpartum prophylactic anticoagulation?
Those with:
history of unprovoked VTE
Estrogen associated VTE
What patient population only needs postpartum anticoagulation prophylaxis?
VTE associated with a non-hormonal temporary risk factor
What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of FVL heterozygosity?
No meds, only surveillance
What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of prothrombin gene mutation heterozogosity
No meds, surveillance only
What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of Protein C or S deficiency, and no family history of VTE
No meds, only surveillance
What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of Protein C or S deficiency, but family history of VTE
Postpartum prophylaxis only
What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of Antithrombin deficiency but no family history of VTE
No meds, surveillance only
What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of antithrombin deficiency and a family history of VTE?
Antepartum and postpartum prophylaxis
What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of homozygous Prothrombin gene mutation and no family history of VTE
Postpartum only
What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of homozygous Prothrombin gene mutation and family history of VTE?
antepartum and postpartum prophy
What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of FVL homozygous mutation?
Antepartum and postpartum
What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of multiple thrombophilias (like FVL and PTG2021A)
antepartum and postpartum prophy
What is the treatment of thrombotic APS in pregnancy? (Antepartum and postpartum)
Antepartum: low-dose aspirin + therapeutic LMWH
Postpartum: Therapeutic LMWH (or if on long-term AC, then bridge to warfarin)
What is the antepartum and postpartum management of obstetric APS (APS testing+ without thrombosis hx)?
Antepartum: Prophylactic LMWH + low dose aspirin
Postpartum: Prophylactic LMWH for 6-12 weeks
What are the 4Ts of postpartum hemorrhage?
Tone (uterine atony)
Trauma (laceration, uterine rupture)
Tissue (retained placenta)
Thrombin (Coagulopathies)
In addition to obstetric interventions, what is a medication option to decrease mortality of postpartum hemorrhage?
Antifibrinolytics like TXA
What happens to the levels of VWF, Factor VIII, and fibrinogen during prengnacy?
They increase, peak at delivery
What is the most appropriate pre-conception counseling for a woman on warfarin?
Switch to LMWH prior to conception. highest risk of embryopathy between 6-10 weeks
