Reducing risk VTE pregnancy and puerperium GTG Flashcards
Was is the AN risk of VTE?
1.3/10,000
What is the postpartum risk of VTE?
1-2/1000
List the minor AN risk factors:
Obesity BMI >30
Age >35
Parity > 3
Gross varicose veins
Immobility (paraplegia, PGP)
Fix unprovoked VTE in 1st degree relative
Multiple pregnancy
Low risk thrombophilia (
IVF/ART
How many minor risk factors should be present to consider prophylaxis from 28 weeks?
3
How many minor risk factors should be present to consider prophylaxis from 1st trimester?
4
What are the intermediate AN risk factors?
Hospital admission
Single previous VTE related to major surgery
High risk thrombophilias + no VTE
Medical co-morbidity
Any surgical procudure
OHSS
If any one intermediate RF present?
Consider AN prophylaxis
Which medical conditions are listed?
Cancer
Heart failure
Active SLE/IBD/inflammatory polyarthropathy
Nephrotic syndrome
T1DM with nephropathy
Sickle cell disease
Current IVDU
What are considered low risk thrombophlias
Heterozygous for factor V leiden, prothrombin G20210A mutations.
What are considered high risk thrombophilias
Anti-thrombin deficiency
Protein C or S deficiency
Compound/homozygous for low risk thrombophilias
What are high risk factors for AN VTE?
Previous VTE (except single event related to surgery)
What transient RF should be consider when calculating VTE?
Dehydration/hyperemsis, infection, long distance travel (equal or > 4hrs)
What are the single risk postpartum risk factors?
Age > 35
BMI >30 <40
Parity equal >3
Smoker
ELCS
Fhx VTE
Low risk thrombophilia
Immobility
Current PET
Multiple preg
Preterm delivery <37weeks
Stillbirth in this pregnancy
Mid cavity/rotational delivery
Prolonged labour >24 hrs
PPH > 1 L or blood transfusion
What are the PN intermediate risk factors (2 points)
CS in labour
BMI > 40
Readmission or prolonged (>3 days) to hospital
Any surgical procedure in puerperium (except immediate perineal repair)
Medical co-morbidity
What are the PN high risk factors?
Any previous VTE
AN LMWH
High risk thrombophilia
Low risk thrombophilia + FHx
When is 10 days LMWH given in PN period
2+ minor risk factors
Any intermediate RF
When is 6 weeks LMWH given in PN period?
If persisting to > 3 risk factors
High risk factor present
Recurrence rate of previous VTE not related to surgery?
2-11%
If previous VTE and anti-thrombin deficiency?
From 1st trimester until 6 weeks PN higher dose LMWH 50-75% full dose (until PO anticoagulation is restarted), consider anti-Xa monitoring
What is target anti X-a levels previous VTE?
4 hour peak 0.5-1.0 iu/ml
If previous VTE and other inheritable thrombophilia?
Same dose
What other VTE conditions should higher dose LMWH in pregnancy been considered
Anti-thrombin deficiency
Anti-phospolipid syndrome
Recurrent VTE
If unprovoked/oestrogen realated VTE, when to commence LMWH
1st trimester
If provoked VTE (after surgery) and no other RF< when to commence LMWH
28 weeks
Women who have an unprovoked VTE should be tested for which condition?
APS
Women with what Family Hx should be considered for thrombophilia screening?
Unprovoked/oestrogen related VTE in 1st degree < age 50
Do you need to treat homozygous MHTFR in pregnancy?
No not associated with VTE in pregnancy
What % of AN VTE occurs before 15 weeks?
40-50%
How long should we wait to given regional anaesthetic following last dose of prophylactic dose LMWH?
12 hours
When can prophylactic LMWH be given after spinal or epidural catheter removed?
4 hours
How long should we wait to given regional anaesthetic following last dose of treatment dose LMWH?
24 hours
Relative to vaginal delivery, how much is the VTE risk increases compared to
- ELCS
- EMCS
- ELCS - 2 times
- EMCS - 4 times
Dose of
Enoxaparin
Deltaparin
Tinzparin
If < 50kg
<50kg
Enoxaparin 20mg OD
Deltaparin 2500IU
Tinzparin 3500IU
Dose of
Enoxaparin
Deltaparin
Tinzparin
If 50-90kg
50-90
Enoxaparin 40mg
Deltaparin 5000 IU
Tinzparin 4500IU
Dose of
Enoxaparin
Deltaparin
Tinzparin
If 90-130kg
90-130kg
Enoxaparin 60mg
Deltaparin 7500IU
Tinzparin 7000 IU
Dose of
Enoxaparin
Deltaparin
Tinzparin
If 130-170
130-170
Enoxaparin 80mg
Deltaparin 10,000IU
Tinzparin 9000IU
Dose of
Enoxaparin
Deltaparin
Tinzparin
If >170
> 170
Enoxaparin 0.6mg/kg/day
Deltaparin 75 u/kg/day
Tinzparin 75 u/kg/day
When to use unfractionated heparin?
Risk of haemorrhage or regional anaesthetics may be required
How long must wait between UFH and regional?
4 hours
Major risk of UFH?
Heparin induced thrombocytopenia (HIT)
Postpartum, when can LMWH be converted to warfarin?
Day 5-6
Is breastfeeding safe in warfarin?
yes
What congenital abnormalities does warfarin cause?
Hypoplasia of nasal bridge
Congenital heart defect
Ventriculpmegalt
Agenisis corpus callous
Stippled epiphyses
Risk 5% 6-12 weeks, dose dependant
Can NOACs be given in pregnancy or breast feeding?
No
TEDS should create a compression of what pressure?
14-15mmHg
What are the contraindications to LMWH?
Known bleeding disorder (haemophilia, von willebrands, acquired coagulopathy
Active AN/PP bleeding
Women with increased risk of major haemorrhage (praevia)
Thrombocytopenia <75
Active stroke in previous 4 weeks
Severe renal disease eGFR < 30
Severe liver disease
Uncontrolled HTN >SBP 200, >120 DBP
