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10-DVT > Reducing the Risk Of VTE > Flashcards

Reducing the Risk Of VTE Flashcards

1
Q

During antenatal assessment for VTE risk , which women are at
HIGH RISK ? What is the management?

A

Any previous VTE ; except a single event related to major surgery
❤ LMWH from the 1st trimest and 6 weeks postpartum.

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2
Q

What medical conditions are considered as a risk factor for VTE?

A

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

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3
Q

During antenatal assessment for VTE risk , what are the factors that should be assessed to calculate the need for thromboprophylaxis?

A

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.

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4
Q

What are the risk factors to VTE that considered low risk and need mobilization and hydration only?

A

Transient risk factors:
Dehydration- hyperemesis - current systemic infection - long distance travel.

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5
Q

During assessment on delivery suite for VTE, which women is considered HIGH RISK? what is the management?

A

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

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6
Q

During assessment on delivery suite for VTE, which women is considered INTERMEDIATE RISK ? what is the management?

A

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

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7
Q

During assessment on delivery suite for VTE risk , what are the factors that should be assessed to calculate the need for thromboprophylaxis?

A

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.

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8
Q

How should women with previous VTE be managed in pregnancy?

A

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.

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9
Q

How should women with previous VTE associated with heritable thrombophilia be managed in pregnancy and postpartum period?

A

🔴 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.

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10
Q

How should women with previous VTE associated with antiphospholipid syndrome APS ( who are on Long term oral anticoagulants) in pregnancy and postpartum period?

A

Thromboprophylaxis with 🚩 higher dose 🚩 of LMWH ( 50-70-or full treatment dose) antenatally and 6 weeks postpartum or until return to oral coagulant.

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11
Q

What extra advice is needed for women with previous recurrent VTE?

A
  • 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 +
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12
Q

How should women with previous VTE be stratified to determine management in pregnancy?

A

❤ 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

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13
Q

Which women with prior VTE require more testing?

A
  • Family Hx of VTE 👉 test antithrombin deficiency
  • unprovoked VTE 👉 test the presence of APS
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14
Q

When to consider thrombophilia testing?

A

Family member age < 50 with history of unprovoked VTE
OR : first degree relative history of estrogen- provoked VTE
Previous unprovoked VTE

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15
Q

How should women with thrombophilia be stratified to determine the risk of VTE?

A

According:
1- level of risk associated with their thrombophilia
2- presence of family Hx
3- presence of other risk factors

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16
Q

How should women with asymptomatic thrombophilia be treated?

A

🔴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

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17
Q

How should women with antiphospholipid antibodies without previous VTE be treated?

A

Just a risk factor / to consider with other risk factors

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18
Q

When should thromboprophylaxis be started as early in pregnancy as practical?

A

1- previous VTE
2- with 4 risk factors

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19
Q

What are the first trimester risk factors for VTE, and how should they be managed?

A

❤ hyperemesis 👉 consider LMWH until hyperemesis resolves
❤ OHSS👉 LMWH in the 1st trimester
❤ IVF + 3 risk factors 👉 LMWH from 1st trimester through pregnancy

20
Q

What is the important advice for women receiving antenatal LMWH?

A

If they have any vaginal bleeding or once labour begins they shouldn’t inject any further LMWH.

21
Q

If regional anesthesia is considered in women receiving antenatal LMWH, how to be managed?

A

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

22
Q

Women receiving antenatal LMWH + having elective CS , what is the management?

A

*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

23
Q

When UFH may be used in stead of LMWH in women at risk of thrombosis?

A

Peripartum in preference to LMWH where:
1- increased risk of haemorrhage
2- regional anesthesia may be required.

24
Q

What to monitor if UFH is used after CS ?

A

Platelet count should be monitored every 2-3 days from days 4 👉 14
Or until UFH is stopped.

25
Q

In women at risk of thrombosis who aren’t tolerant of heparin compounds, what is the management?

A

Fondaparinux
( in conjunction with consultant hematologist)
[ not licensed in pregnancy]

26
Q

When to monitor anti Xa levels if the woman is on LMWH?

A

ONLY if the dose is therapeutic
Or high dose prophylactic ( antithrombin deficiency)

27
Q

Which agents should be avoided for thromboprophylaxis in pregnancy ?

A

🚩- warfarin ( safe in breastfeeding)
🚩- Dextran(anaphylactoid reaction )
🚩- NOACs : non-vitamin K oral anticoagulants: ( rivaroxaban..)
[ also not recommended in breastfeeding]

28
Q

When is anti embolism stockings AES recommended in pregnancy and puerperium?

A

🚩- 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]

29
Q

What is the incidence of PE in pregnancy &puerperium?

A

1 - 2 / 1000

30
Q

When the risk of VTE is maximum in pregnant women?

A

Postpartum by 5 folds
( peak during 3 weeks )

31
Q

What is the recurrence rate of VTE in next pregnancy?

A

2- 11 %

32
Q

What is the antenatal risk of VTE compared to nonpregnant?

A

4 - 6 folds

33
Q

What is the risk of VTE in postpartum compared to nonpregnant women?

A

22 folds

34
Q

What are the symptoms / signs in varicose veins to consider it as a risk factor for VTE?

A

Symptomatic
Above knee
Associated with phlebitis
Oedema
Skin changes

35
Q

Which conditions are scored 4 when calculating the risk of VTE?

A

1- non surgical previous VTE
2- OHSS

36
Q

Which conditions are scored 3 when calculating the risk of VTE?

A

1- surgical VTE
2- medical comorbidity: cancer , diabetes T1 with nephropathy…….
3- Any surgical procedure
4- high risk thrombophilia
5- hyperemesis

37
Q

Which conditions are scored 2 when calculating the risk of VTE?

A

1- emergency CS
2- BMI > 40

38
Q

What is the management depending on the score during risk assessment for VTE?

A

🚩 antenatally: >= 4 👉 LMWH from the first trimester
3 👉 LMWH from 28 w
🚩 postnatally: >= 2👉at least 10 days

39
Q

What are the conditions that need high dose LMWH antenatally and 6w postpartum [ very high risk]?

A

1- previous VTE on long term oral anticoagulant therapy (warfarin)
2- thrombophilia:: antithrombin deficiency
3- APS with previous VTE

40
Q

During antenatal assessment for VTE risk , which women are at
INTERMEDIATE RISK ? What is the management?

A

📌 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

41
Q

When to stop LMWH before labour induction?

A

📌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

42
Q

In obesity the risk is higher for PE or VTE?

A

PE

43
Q

How much The risk of VTE is increased
in age > 35 &
Hospital admission?

A

2 folds age > 35
18 folds by hospital admission

44
Q

What are the side effects of LMWH?

A

1- osteoporosis fracture 0.04 %
2- CS wound hematoma 2%
3- skin reaction 1.8 %

45
Q

When lower doses of LMWH should be employed?

A

If cr clearance < 30 ml/ min
Or less 20 ml / min with tinzaparin

46
Q

What are the doses of prophylactic ENOXAPARIN in pregnancy and postpartum?

A

< 50 👉 20 mg / d
50- 90 👉 40 mg / d
91- 130 👉 60 mg / d

47
Q

What are the advices given to low risk women of DVT with flying?

A

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 )

10-DVT (4 decks)

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