Thromboembolic Disorders: Tate Flashcards
what is the leading cause of death and morbidity in pregnancy?
Thromboembolism
What is the risk of TE in pregnancy compared to normal?
10x
When do most women have TE?
Before delivery, equal across trimesters
What is the 2 fold hit that increases pregnancy TE risk?
- Stasis of veins: IVC by uterus
- Estrogen increase: increased deep vein capacitance secondary to NO and prostacyclin produced by Estrogen effect (smooth muscle relaxation)
What liver enzymes are increased by estrogen?
Fibrinogen: 2x
Factors 7-12: 1000x
vWF: 4x
What liver enzymes are decreased by estrogen?
protein S concentration is decreased 40%
When do liver enzymes return to normal?
By 6 weeks post partum
What increases decimal and hemostatic systems?
Progesterone: decidual TF and PAI-1 enhance homeostatic capability in prepartation of implantation, placentation, and childbirth, BUT promotes thrombosis
What does a decrease in protein S lead to?
Increase in protein C, leading to clot formation
What syndrome is associated with 14% of miscarriages? Buzzword for recurrent miscarriage?
Antiphospholipid antibody sundrome
How do you diagnose antiphospholipid antibody syndrome?
presence of previous OB problem/clot
AND
anticardiolipin or lupus anticoagulant present on 2 or more occasions at least 6 weeks apart
What is the risk of antiphospholipid antibody syndrome in SLE?
30%
Are AAS events just veinous or arterial?
BOTH: DVT and Stroke risk
What is the risk of AAS in pregnancy?
5%
NOTE: What inherited thrombophilia is not autosomal dominant? what is it?
Hyperhomocyeteinemia is autosomal recessive
Others: factor 5 leiden,
What is the most important modifier of thrombosis risk?
Family and personal hisotry
What are high risk clotting disorders?
Uncommon
Factor 5 homozygotes
Antithrombin III deficiency
Prothrombin mutation
What are low risk clotting disorders?
Common
Heterozygotes: 5ledine, prothrombin
Protein C deficiency
Protein S deficiency
Signs of clot?
Asynmetric swelling, pain, redness
What is diagnosis of clot?
D-dimer (pregnant false positive)
Ultrasound
Contrast venography
MRI
How do we diagnose PE?
Clinical signs: SOB, syncope EKG: nonspecific ST changes (EXAM) CXR Spiral CT (gold standard) Pulmonary angiography VQ scan MRA D-Dimer *can't do contrast in bad kidneys
How do we treat clots?
Unfractionated Heparin: increase ATIII, Xa, inhibit platelet
What do you monitor with heparin?
PTT
TEST: what are main side effects of heparin?
Hemorrhage
Osteoporosis
Thrombocytopenia
When does HIT show up?
within 1st week
Keep PTT 1.5 to 2.5 times control
TEST!!!!!!: how do you reverse Heparin?
Protamine sulfate!!!!! TEST!!!!!
What is notable about low molecular weight heparin (lovenox)?
Less side effects: no placenta, no breastfeeding
NOTE: Protamine sulfate does not reverse 80%, dangerous to not be able to reverse. Change to unfractionated heparin before labor.
How do you reverse warfarin?
Vitamin K and fresh frozen plasma
Is warfarin safe in breastfeeding?
Yes! ok to breastfeed on warfarin
What is MOA of warfarin?
Vitamin K antaonist: (1972 war, c and s)
What is side effects of warfarin?
TERATOGENIC: 6-12 weeks
CROSSES PLACENTA!!!!
What is fondaparanox?
Synthetic heparin: ATIII site action
Does not cross placenta, like heparin
Does fondaparinux have the risk of HIT?
No.. no problems with allergies either.
Fondaparinux does not inactivate what?
Thrombin. Inactivates Xa but not thrombin.
