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OBGYN 4MB > Thromboembolic Disease in Pregnancy > Flashcards

Thromboembolic Disease in Pregnancy Flashcards

1
Q

Define VTE

A

Condition in which a thrombus formed at one point the circulation, becomes detached, is propelled by blood flow and lodges in a distal vessel

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2
Q

What causes a VTE?

A

Virchow’s triad:

  1. Endothelial injury
  2. Stasis
  3. Hypercoagulability

Commonly occurs in deep veins of legs/pelvis and embolises to pulmonary vasculature

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3
Q

Why are VTEs more common in pregnancy?

A

Pregnancy is a prothrombotic state:

  1. Increased clotting factors (VIII, IX, X)
  2. Reduced fibrinolytic activity
  3. Altered blood flow from mechanical obstruction and immobility

May-Thurner syndrome - narrowed left iliac vein (by pressure from right iliac artery)

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4
Q

List the risk factors for VTE

A
  1. Age >35
  2. Obesity
  3. High parity
  4. Varicose veins
  5. PET
  6. Thrombophilia
  7. Immobility
  8. C-section
  9. Family/personal hx VTE
  10. Infection
  11. Smoking
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5
Q

What is the incidence of VTE in pregnancy?

A

0.1% pregnancies

Leading direct cause of maternal death

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6
Q

What would be present in a hx of DVT?

A
  1. Calf pain
  2. Leg swelling
  3. Lower abdominal pain
  4. Very rarely vaginal bleed (if iliofemoral)
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7
Q

What would be present in a hx of PE?

A
  1. Pleuritic chest pain
  2. Dyspnoea
  3. Cough
  4. Haemoptysis
  5. History (DVT/PE)
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8
Q

What would be present on examination of a DVT?

A
  1. Unilateral leg oedema
  2. Calf tenderness (Homan’s sign = calf tenderness on dorsiflexion of the foot - DO NOT DO THIS AS CAN THROW CLOT)
  3. Tachycardia
  4. Low grade pyrexia
  5. Palpable veins in vaginal fornices/lower abdomen (if iliofemoral thrombosis)
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9
Q

What would be present on examination of a PE?

A
  1. Tachycardia, hypotension
  2. Tachypnoea, cyanosis
  3. Gallop rhythm
  4. Elevated JVP
  5. Coarse crackles
  6. Pleural rub
  7. Sudden collapse
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10
Q

Describe the pathology of a DVT

A

Venous thrombi usually form in iliofemoral veins - esp left

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11
Q

Describe the pathology of a PE

A

Thrombus occlusion of a pulmonary vessel

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12
Q

What investigations should be done for a DVT?

A

Doppler US +/- venography

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13
Q

What investigations should be done for PE?

A

Maternal:

  1. Bloods:
    - D-dimers (not specific as elevated in pregnancy)
    - FBC
    - Coag
    - ABG
  2. Other:
    - ECG - sinus tachy, rt heart strain, rt bundle branch block, classical S1 Q3 T3 is rarely seen
    - CXR (normal in 50%)
    - CTPA - higher level of radiation than V/Q scan, increase lifetime risk of breast ca up to 13.6%
    - +VQ scan (slight increase risk of childhood cancer but less breast maternal cancer than CTPA)
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14
Q

How can VTE be prevented?

A

Risk assessment:

  • Low risk = TEDS
  • Moderate risk = pre/post operative/post delivery prophylactic LMWH
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15
Q

How is VTE treated?

A

Anticoagulation with LMWH or IV heparin

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16
Q

How is a PE in pregnancy managed?

A
  1. ABC - CPR if collapsed
  2. Thrombolysis (limited data in pregnancy)
  3. Heparin IV
  4. Anticoagulation
17
Q

How long do patients remain on treatment for VTE in pregnancy?

A
  • Throughout the pregnancy and for 6wks postnatally
  • Has to be treated for >3mths in total
  • Postnatal = can change to warfarin
18
Q

List the complications of DVT

A
  1. Deep vein insufficiency
  2. Leg oedema
  3. Cramps, discolouration
  4. Ulceration
  5. PE
19
Q

List the complications of PE

A
  1. Shock
  2. Cardiovascular collapse
  3. Death
20
Q

What is the prognosis of VTE in pregnancy?

A
  • Mortality rate of 1.13 per 100’000 pregnancies (MBBRACE 2017)
  • Leading direct cause of maternal death MBBRACE 2017
  • Improved survival in the last few years as now thromboprophylaxis post c/s
21
Q

List the high risk factors for VTE in pregnancy

Place on thromboprophylaxis is have any of these

A
  1. Single previous VTE +
    * Thrombophilia or family hx
    * Unprovoked/oestrogen related
  2. Previous recurrent VTE (>1)
22
Q

List the intermediate risk factors for VTE in pregnancy

Consider thromboprophylaxis if have any of these

A
  1. Single previous VTE with no family history or thrombophilia
  2. Thrombophilia + no VTE
  3. Medical comorbidities (heart/lung disease, SLE, cancer, inflammatory conditions, nephrotic syndrome, sickle cell disease, intravenous drug user)
  4. Surgical procedure
23
Q

List the low risk factors for VTE

Consider thromboprophylaxis if have three or more of these; 2 or more if admitted

A
  1. Age >35
  2. Obesity (BMI > 30)
  3. Parity >/=3
  4. Smoker
  5. Gross varicose veins
  6. Current systemic infection
  7. Immobility
  8. Pre-eclampsia
  9. Dehydration/hyperemesis/OHSS
  10. Multiple pregnancy or ART

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