Reducing the Risk Of VTE Flashcards
During antenatal assessment for VTE risk , which women are at
HIGH RISK ? What is the management?
Any previous VTE ; except a single event related to major surgery
❤ LMWH from the 1st trimest and 6 weeks postpartum.
What medical conditions are considered as a risk factor for VTE?
medical comorbidity:
Cancer- heart failure- active SLE
IBS or inflammatory polyarthropathy - nephrotic syndrome- type 1 diabetes with nephropathy - sickle cell disease- Current IVDU
❤CONSIDER LMWH Antenatal prophylaxis
Score -3
During antenatal assessment for VTE risk , what are the factors that should be assessed to calculate the need for thromboprophylaxis?
1- obesity ( BMI > 30 ) 2- smoking
3- age > 35 4- parity >3
5-gross varicose veins(symptomatic)
6- current preeclampsia
7- immobility ( paraplegia - PGP)
8- family history of unprovoked or estrogen provoked VTE in first degree relative.
9- low risk thrombophilia
10- multiple pregnancy
11- IVF / ART
❤ 4 or more 👉 prophylaxis from first trimester +6w PN
3 factors 👉 prophylaxis from 28 w+ 6w PN
0- 2 factors 👉 prophylaxis if admitted to the hospital.
What are the risk factors to VTE that considered low risk and need mobilization and hydration only?
Transient risk factors:
Dehydration- hyperemesis - current systemic infection - long distance travel.
During assessment on delivery suite for VTE, which women is considered HIGH RISK? what is the management?
1- any previous VTE
2- anyone requiring antenatal LMWH
3- high risk thrombophilia
4- low risk thrombophilia+ family Hx
❤ LMWH prophylactic at least 6 weeks postnatal
During assessment on delivery suite for VTE, which women is considered INTERMEDIATE RISK ? what is the management?
Any of these :
1- CS in labour
2- BMI > 40
3- readmission or prolonged admission in the puerperium
4- any surgical procedure in the puerperium except: immediate repair of the perineum.
5- medical comorbidity: cancer - heart failure- active SLE
IBS or inflammatory polyarthropathy - nephrotic syndrome- type 1 diabetes with nephropathy - sickle cell disease- current IVDU
❤ LMWH prophylactic: 10 days postnatal
During assessment on delivery suite for VTE risk , what are the factors that should be assessed to calculate the need for thromboprophylaxis?
1- age > 35 2- obesity BMI > 30
3- parity >3 4- smoker
5- elective CS 6- family H for VTE
7- low risk thrombophilia
8- gross varicose
9- current systemic infection
10- immobility: paraplegia/ pgp / long travel distance
11- current preeclampsia
12- multiple pregnancy
13- preterm delivery in this pregnancy < 37 w
14 - stillbirth in this pregnancy
15 - midcavity or rotation operative delivery
16 - prolonged labour > 24 h
17- pph > 1 liter or blood transfusion
❤ > 3 or persisting 👉 extending LMWH
> 2 👉 prophylactic LMWH (10 d)
< 2 👉 mobilization and hydration.
How should women with previous VTE be managed in pregnancy?
1- prepregnancy counseling
2- previous VTE ( except single previous VTE related to major surgery & no other risk factors)
👉 thromboprophylaxis with LMWH
Throughout antenatal period
3- if documentation is not available
👉 good history & received prolonged ( > 6w) anticoagulation 👉 VTE can be assumed.
How should women with previous VTE associated with heritable thrombophilia be managed in pregnancy and postpartum period?
🔴 Previous VTE + antithrombin deficiency 👉thromboprophylaxis 🚩higher dose 🚩LMWH antenatally and for 6 weeks postpartum ( 50- 75 % or full treatment dose)
🔴 previous VTE + other heritable thrombophilic defects 👉 standard dose.
How should women with previous VTE associated with antiphospholipid syndrome APS ( who are on Long term oral anticoagulants) in pregnancy and postpartum period?
Thromboprophylaxis with 🚩 higher dose 🚩 of LMWH ( 50-70-or full treatment dose) antenatally and 6 weeks postpartum or until return to oral coagulant.
What extra advice is needed for women with previous recurrent VTE?
- some of them may need higher dose of LMWH
- if she is on Warfarin 👉 switch to LMWH as soon as the pregnancy is confirmed
- if she isn’t 👉 start LMWH as soon as pregnancy test +
How should women with previous VTE be stratified to determine management in pregnancy?
❤ 1- VTE + antithrombin deficiency
2- VTE +APS
3- Recurrent VTE
🔴 thromboprophylaxis with higher dose of LMWH (50-75-full)
Antenatally & 6 w postpartum
❤ 1- unprovoked VTE / idiopathic
2- VTE related to estrogen (oc / p)
3- related to transient risk other than major surgery
4- who have other risk factors
🔴 thromboprophylaxis with LMWH throughout antenatal period + 6w postnatal
❤ VTE provoked by major surgery and recovered and have no other risk factors
🔴 Thromboprophylaxis with LMWH antenatally from 28 w + 6w postnatal
Which women with prior VTE require more testing?
- Family Hx of VTE 👉 test antithrombin deficiency
- unprovoked VTE 👉 test the presence of APS
When to consider thrombophilia testing?
Family member age < 50 with history of unprovoked VTE
OR : first degree relative history of estrogen- provoked VTE
Previous unprovoked VTE
How should women with thrombophilia be stratified to determine the risk of VTE?
According:
1- level of risk associated with their thrombophilia
2- presence of family Hx
3- presence of other risk factors
How should women with asymptomatic thrombophilia be treated?
🔴Asymptomatic with:
- antithrombin deficiency
- protein C or S deficiency
- more than one thrombophilic defect including:
- homozygous factor v leiden
- homozygous prothrombin gene mutation
- compound heterozygotes
👉👉 Consider antenatal +
Recommend 6 w postnatal
🔴Asymptomatic with:
- heterozygosity for :
- factor v leiden
- prothrombin gene mutation
- APA
👉👉 just a risk factor
* 3 R Fs 👉antenatal LMWH
* 2 RFs 👉 from 28 w LMWH
* 1 RFs👉 10 days postnatal
How should women with antiphospholipid antibodies without previous VTE be treated?
Just a risk factor / to consider with other risk factors
When should thromboprophylaxis be started as early in pregnancy as practical?
1- previous VTE
2- with 4 risk factors
What are the first trimester risk factors for VTE, and how should they be managed?
❤ hyperemesis 👉 consider LMWH until hyperemesis resolves
❤ OHSS👉 LMWH in the 1st trimester
❤ IVF + 3 risk factors 👉 LMWH from 1st trimester through pregnancy
What is the important advice for women receiving antenatal LMWH?
If they have any vaginal bleeding or once labour begins they shouldn’t inject any further LMWH.
If regional anesthesia is considered in women receiving antenatal LMWH, how to be managed?
1- Avoid ( insert & remove)for at least 12 h after the last prophylactic dose
2- avoid for at least 24 h after the last therapeutic dose.
3- after regional anesthesia:
avoid prophylactic LMWH for 4h
avoid therapeutic LMWH for 8- 12 h
Women receiving antenatal LMWH + having elective CS , what is the management?
*Thromboprophylaxic dose on the day prior to delivery
* no morning dose on the day of the delivery
* after CS : the first thromboprophylaxic dose should be given as soon as possible if -regional anesthesia hasn’t been used
- no pph
When UFH may be used in stead of LMWH in women at risk of thrombosis?
Peripartum in preference to LMWH where:
1- increased risk of haemorrhage
2- regional anesthesia may be required.
What to monitor if UFH is used after CS ?
Platelet count should be monitored every 2-3 days from days 4 👉 14
Or until UFH is stopped.
In women at risk of thrombosis who aren’t tolerant of heparin compounds, what is the management?
Fondaparinux
( in conjunction with consultant hematologist)
[ not licensed in pregnancy]
When to monitor anti Xa levels if the woman is on LMWH?
ONLY if the dose is therapeutic
Or high dose prophylactic ( antithrombin deficiency)
Which agents should be avoided for thromboprophylaxis in pregnancy ?
🚩- warfarin ( safe in breastfeeding)
🚩- Dextran(anaphylactoid reaction )
🚩- NOACs : non-vitamin K oral anticoagulants: ( rivaroxaban..)
[ also not recommended in breastfeeding]
When is anti embolism stockings AES recommended in pregnancy and puerperium?
🚩- who are hospitalized and have a contraindication to LMWH
🚩- ( combined with LMWH) : post CS + high risk of VTE
[ previous VTE
- >4 risk factors antenatally
- >2 risk factors postnatally ]
🚩- women traveling > 4 h
Calf pressure prophylactic 14-15
Therapeutic( in the presence of VTE) 23 at the ankle
[ stockings below the knee]
What is the incidence of PE in pregnancy &puerperium?
1 - 2 / 1000
When the risk of VTE is maximum in pregnant women?
Postpartum by 5 folds
( peak during 3 weeks )
What is the recurrence rate of VTE in next pregnancy?
2- 11 %
What is the antenatal risk of VTE compared to nonpregnant?
4 - 6 folds
What is the risk of VTE in postpartum compared to nonpregnant women?
22 folds
What are the symptoms / signs in varicose veins to consider it as a risk factor for VTE?
Symptomatic
Above knee
Associated with phlebitis
Oedema
Skin changes
Which conditions are scored 4 when calculating the risk of VTE?
1- non surgical previous VTE
2- OHSS
Which conditions are scored 3 when calculating the risk of VTE?
1- surgical VTE
2- medical comorbidity: cancer , diabetes T1 with nephropathy…….
3- Any surgical procedure
4- high risk thrombophilia
5- hyperemesis
Which conditions are scored 2 when calculating the risk of VTE?
1- emergency CS
2- BMI > 40
What is the management depending on the score during risk assessment for VTE?
🚩 antenatally: >= 4 👉 LMWH from the first trimester
3 👉 LMWH from 28 w
🚩 postnatally: >= 2👉at least 10 days
What are the conditions that need high dose LMWH antenatally and 6w postpartum [ very high risk]?
1- previous VTE on long term oral anticoagulant therapy (warfarin)
2- thrombophilia:: antithrombin deficiency
3- APS with previous VTE
During antenatal assessment for VTE risk , which women are at
INTERMEDIATE RISK ? What is the management?
📌 asymptomatic high risk thrombophilia: homozygous factor v leiden/ compound heterozygotes protein C or S deficiency
🚩CONSIDER antenatal LMWH
RECOMMENDED postnatal LMWH for 6 weeks
📌1- single previous VTE associated with surgery( without thrombophilia - family history- other risk factors)
🚩
CONSIDER antenatal LMWH ( not routinely)
RECOMMENDED LMWH from 28 w and 6 w postnatal
When to stop LMWH before labour induction?
📌Stop prophylactic LMWH 12 h before the induction
📌Stop therapeutic LMWH 24 h before the induction
📌 stop IV UFH 6 h before
📌 stop subcutaneous UFH 12 h before
In obesity the risk is higher for PE or VTE?
PE
How much The risk of VTE is increased
in age > 35 &
Hospital admission?
2 folds age > 35
18 folds by hospital admission
What are the side effects of LMWH?
1- osteoporosis fracture 0.04 %
2- CS wound hematoma 2%
3- skin reaction 1.8 %
When lower doses of LMWH should be employed?
If cr clearance < 30 ml/ min
Or less 20 ml / min with tinzaparin
What are the doses of prophylactic ENOXAPARIN in pregnancy and postpartum?
< 50 👉 20 mg / d
50- 90 👉 40 mg / d
91- 130 👉 60 mg / d
What are the advices given to low risk women of DVT with flying?
1- the true incidence of DVT in pregnancy with long travel is unknown ( as 1/ 4600 flights in the month following a flight >4h)
2- small increased risk in the incidence by 3 folds
3- 18 % higher risk for each 2 h of flight duration
4->4 h 👉 stockings reduce the risk ( relative risk 0.1 )
