Thromboembolic Disorders

Question 1

SAID WE MIGHT SEE THIS ON TEST:

EKG changes seen with PE

Answer 1

S1, Q3, inverted T3
nonspecific ST changes
right bundle branch branch block
right axis deviation

Question 2

SAID WE MIGHT SEE THIS ON TEST:

chief side effect of unfractionated heparin treatment

Answer 2

osteoporosis

Question 3

SAID WE MIGHT SEE THIS ON TEST:

Treatment for HIT

Answer 3

protamine sulfate

Question 4

when are thromboembolitic events most likely to occur in pregnancy

Answer 4

equal distribution in all 3 trimesters

Question 5

pregnancy is a hypercoagulable state. how? (6)

Answer 5

1. venous stasis due to
   a. compression of IVC and pelvic veins and
   b. increased capacitance of vessels (effect of estrogen, prostacylin, and NO, which are all elevated in pregnancy )
2. increased progesterone
3. doubling of fibrinogen levels
4. in in factors 7, 8, 9, 10, 12 (up 1000%)
5. vWF levels increase 400%
6. decrease in protein S (= resistance to protein C)

Question 6

alterations that make pregnancy a hyper coagulable state return to baseline when?

Answer 6

6 weeks postpartum

Question 7

what are pregnancy specific risk factors for developing a thromboembolic disease

Answer 7

increased parity
postpartum endomyometritis
operative delivery with forceps or vacuum
C/S (9x more risk)

Question 8

what is required for diagnosis of anti-phospholipid Ab syndrome in pregnancy

Answer 8

presence or prior venous thromboembolus/obstetric complication (i.e. a bunch of misscarriages)
AND
at least one lab criterion (anticardiolipn Ab or lupus anticoagulant) present on 2 occasions at least 6 weeks apart

Question 9

All inherited thrombophillias are __(mode of inheritance)__ except _____

Answer 9

AD except hyperhomocysteninemia

Question 10

how are DVTs diagnosed in pregnancy

Answer 10

venous ultrasound: noncompressibility of venous lumen in transverse plane under gentle probe pressure with duplex and color flow doppler

MRIs but expensive and don’t have easy access

Question 11

_____ has 100% specificity and sensitivity for DVT but cannot be used in 20% of pts due to…

Answer 11

contrast venography

intolerance to the dye

Question 12

signs and symptoms of PE

Answer 12

tachycardia and tachypnea and low O2 stats

Question 13

CXR see in with PE

Answer 13

pleural effusions, atelectasis, elevated hemidiaphragm, pulm infiltrate

Question 14

preferred method of screening and diagnostic modality for PE

Answer 14

spiral CT

Question 15

enhances ATII activity + increases Xa inhibitor activity + inhibits platelet aggragation

Answer 15

unfractionated heparin

Question 16

chief side effect of unfractionared heparin

Answer 16

hemorrhage, osteoporosis, thrombocytopenia (HIT)

Question 17

2 types of HIT and how they are different

Answer 17

I: most common, self limited and occurs w/in days–no signifiant risk of thrombosis

II: ocurrs 5-14 days, inc risk of thrombosis, 50% decline in platelet ct from pretreatment max

Question 18

inactivates Xa but not thrombin

Answer 18

fondaparinux

Question 19

why do you switch pts to unfractionated heparin after 36 weeks

Answer 19

there is suboptimal reversal with protamine sulfate = safer to use unfractionated

Question 20

vtiamin K antagonist

Answer 20

warfarin

Question 21

is warfarin safe to use in pregnancy

Answer 21

no but safe during lactation

Question 22

effects of warfarin on fetus

Answer 22

greatest effect btwn 6-12 weeks:
nasal and midface hypoplasia 
microphthalmia
mental retardation
other ocular, skeletal and CNS malformations 
fetal hemorrhage

Question 23

why does warfarin treatment need to be backed up with anti-coagulation

Answer 23

cuases prothrombotic state for first 72 hrs of treatment due to depletion of protein C

Question 24

synthetic heparin that competes with ATIII binding site

Answer 24

fondaparinux

Question 25

has a lower risk of hemorrhage and HIT than unfractionated heparin but is not as good at preventing clots

Answer 25

LMW heparin

Question 26

pts with absolute contraindications to medical anti-coag or failed therapeutic anti-coag get…

Answer 26

IVC filters

Question 27

perioperative prevention of DTVs

Answer 27

compression stockings

left lateral dequibitus position