Pregnancy 2

Question 1

At what platelet count should you consider another diagnosis aside from gestational thrombocytopenia?

Answer 1

Less than 100. <1% of GT has a platelet count under 100

Question 2

Most common cause of thrombocytopenia in the first trimester?

Answer 2

ITP

Question 3

Most common cause of thrombocytopenia (<100k) in the second trimester?

Answer 3

ITP

Question 4

Most common cause of thrombocytopenia <100 in 3rd timester?

Answer 4

pre-eclampsia

Question 5

How to make diagnosis of gestational thrombocytopenia?

Answer 5

Diagnosis of exclusion. Mild thrombocytopenia (100-150), no history of TCP outside of pregnancy, no signs of MAHA or coagulopathy. Resolves after delivery

Question 6

Treatment threshold for ITP in pregnancy?

Answer 6

Platelet 20-30 during first 8 months
Approaching delivery: >50 for L&D, >70 for epidural

Question 7

First line therapy for ITP in pregnancy?

Answer 7

Prednisone (avoid dexamethasone)
IVIG

Question 8

Second line therapy options for ITP (3)

Answer 8

TPO agonists
Rituximab
Splenectomy

Question 9

Diagnostic criteria for Pre-eclampsia

Answer 9

> 20 weeks pregnant with:
HTN + Proteinuria and/or endo organ dysfunction

Question 10

Diagnostic criteria for HELLP

Answer 10

Hemolysis (MAHA)
Elevated liver enzymes
Low platelets
Occurs after 20 weeks through early postpartum

Question 11

Clinical features for acute fatty liver of pregnancy

Answer 11

RUQ pain, N/V, jaundice, Rapid onset liver failure
Frequent coagulopathy
Hypoglycemia
Renal failure
Mild-moderate thrombocytopenia, +/- MAHA

Question 12

Severe TMA presenting prior to 20 weeks should make you think of what two diagnoses?

Answer 12

TTP or aHUS
Send ADAMTS13 activity level

Question 13

Treatment for TTP in pregnancy

Answer 13

PLEX and steroids
We don’t know if caplacizumab is safe

Question 14

What is the most common timing of complement-mediated HUS regarding pregnancy?

Answer 14

Most commonly post-partum

Question 15

Treatment of complement-mediated HUS in pregnancy

Answer 15

Eculizumab

Question 16

You see severe acute kidney injury and a new onset or worsening TMA post-partum. What diagnosis is most likely?

Answer 16

CM-HUS

Question 17

What is the most common antibody seen in fetal and neonatal alloimmune thrombocytopenia?

Answer 17

Anti-HPA1a

Question 18

Treatment for woman with history of fetal and neonatal alloimmune thrombocytopenia?

Answer 18

Maternal IVIG +/- steroids

Question 19

Definition of anemia throughout pregnancy

Answer 19

1st trimester: Hb <11
2nd trimester: Hb <10.5
3rd timester: Hb <11

Question 20

Most common disease causing anemia in pregnancy?

Answer 20

IDA

Question 21

Threshold for ferritin to diagnose IDA in pregnancy?

Answer 21

<30

Question 22

Management of IDA in pregnancy

Answer 22

Oral iron if early in pregnancy or mild deficiency
IV iron in 2nd or 3rd trimester

Question 23

What is the mechanism of physiology anemia of pregnancy?

Answer 23

Increase in plasma volume

Question 24

Anticoagulant option(s) during pregnancy

Answer 24

LMWH and UFH

Question 25

What 4 anticoagulants are safe during breastfeeding?

Answer 25

LMWH UFH Fondaparinux Warfarin

Question 26

For those who are on therapeutic LMWH while pregnant, how do you manage anticoagulation for delivery? How do you manage it for neuraxial anesthesia?

Answer 26

Hold LMWH 24 hours prior epidural and delivery. Can consider transition to UFH gtt

Question 27

For someone on prophylactic LMWH during pregnancy, how do you manage anticoagulation during delivery or neuraxial anesthesia?

Answer 27

Hold 12 hours prior to epidural Can do spontaneous labor but low certainty of evidence

Question 28

Who should receive both antepartum and postpartum prophylactic anticoagulation?

Answer 28

Those with: history of unprovoked VTE Estrogen associated VTE

Question 29

What patient population only needs postpartum anticoagulation prophylaxis?

Answer 29

VTE associated with a non-hormonal temporary risk factor

Question 30

What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of FVL heterozygosity?

Answer 30

No meds, only surveillance

Question 31

What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of prothrombin gene mutation heterozogosity

Answer 31

No meds, surveillance only

Question 32

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

Answer 32

No meds, only surveillance

Question 33

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

Answer 33

Postpartum prophylaxis only

Question 34

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

Answer 34

No meds, surveillance only

Question 35

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?

Answer 35

Antepartum and postpartum prophylaxis

Question 36

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

Answer 36

Postpartum only

Question 37

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?

Answer 37

antepartum and postpartum prophy

Question 38

What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of FVL homozygous mutation?

Answer 38

Antepartum and postpartum

Question 39

What is the recommended thromboprophylaxis for someone without a personal history of VTE but with a history of multiple thrombophilias (like FVL and PTG2021A)

Answer 39

antepartum and postpartum prophy

Question 40

What is the treatment of thrombotic APS in pregnancy? (Antepartum and postpartum)

Answer 40

Antepartum: low-dose aspirin + therapeutic LMWH Postpartum: Therapeutic LMWH (or if on long-term AC, then bridge to warfarin)

Question 41

What is the antepartum and postpartum management of obstetric APS (APS testing+ without thrombosis hx)?

Answer 41

Antepartum: Prophylactic LMWH + low dose aspirin Postpartum: Prophylactic LMWH for 6-12 weeks

Question 42

What are the 4Ts of postpartum hemorrhage?

Answer 42

Tone (uterine atony) Trauma (laceration, uterine rupture) Tissue (retained placenta) Thrombin (Coagulopathies)

Question 43

In addition to obstetric interventions, what is a medication option to decrease mortality of postpartum hemorrhage?

Answer 43

Antifibrinolytics like TXA

Question 44

What happens to the levels of VWF, Factor VIII, and fibrinogen during prengnacy?

Answer 44

They increase, peak at delivery

Question 45

What is the most appropriate pre-conception counseling for a woman on warfarin?

Answer 45

Switch to LMWH prior to conception. highest risk of embryopathy between 6-10 weeks