Thromboembolic Disorders: Tate

Question 1

what is the leading cause of death and morbidity in pregnancy?

Answer 1

Thromboembolism

Question 2

What is the risk of TE in pregnancy compared to normal?

Answer 2

10x

Question 3

When do most women have TE?

Answer 3

Before delivery, equal across trimesters

Question 4

What is the 2 fold hit that increases pregnancy TE risk?

Answer 4

1. Stasis of veins: IVC by uterus
2. Estrogen increase: increased deep vein capacitance secondary to NO and prostacyclin produced by Estrogen effect (smooth muscle relaxation)

Question 5

What liver enzymes are increased by estrogen?

Answer 5

Fibrinogen: 2x
Factors 7-12: 1000x
vWF: 4x

Question 6

What liver enzymes are decreased by estrogen?

Answer 6

protein S concentration is decreased 40%

Question 7

When do liver enzymes return to normal?

Answer 7

By 6 weeks post partum

Question 8

What increases decimal and hemostatic systems?

Answer 8

Progesterone: decidual TF and PAI-1 enhance homeostatic capability in prepartation of implantation, placentation, and childbirth, BUT promotes thrombosis

Question 9

What does a decrease in protein S lead to?

Answer 9

Increase in protein C, leading to clot formation

Question 10

What syndrome is associated with 14% of miscarriages? Buzzword for recurrent miscarriage?

Answer 10

Antiphospholipid antibody sundrome

Question 11

How do you diagnose antiphospholipid antibody syndrome?

Answer 11

presence of previous OB problem/clot
AND
anticardiolipin or lupus anticoagulant present on 2 or more occasions at least 6 weeks apart

Question 12

What is the risk of antiphospholipid antibody syndrome in SLE?

Answer 12

30%

Question 13

Are AAS events just veinous or arterial?

Answer 13

BOTH: DVT and Stroke risk

Question 14

What is the risk of AAS in pregnancy?

Answer 14

5%

Question 15

NOTE: What inherited thrombophilia is not autosomal dominant? what is it?

Answer 15

Hyperhomocyeteinemia is autosomal recessive

Others: factor 5 leiden,

Question 16

What is the most important modifier of thrombosis risk?

Answer 16

Family and personal hisotry

Question 17

What are high risk clotting disorders?

Answer 17

Uncommon

Factor 5 homozygotes
Antithrombin III deficiency
Prothrombin mutation

Question 18

What are low risk clotting disorders?

Answer 18

Common

Heterozygotes: 5ledine, prothrombin
Protein C deficiency
Protein S deficiency

Question 19

Signs of clot?

Answer 19

Asynmetric swelling, pain, redness

Question 20

What is diagnosis of clot?

Answer 20

D-dimer (pregnant false positive)
Ultrasound
Contrast venography
MRI

Question 21

How do we diagnose PE?

Answer 21

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

Question 22

How do we treat clots?

Answer 22

Unfractionated Heparin: increase ATIII, Xa, inhibit platelet

Question 23

What do you monitor with heparin?

Answer 23

PTT

Question 24

TEST: what are main side effects of heparin?

Answer 24

Hemorrhage
Osteoporosis
Thrombocytopenia

Question 25

When does HIT show up?

Answer 25

within 1st week

Keep PTT 1.5 to 2.5 times control

Question 26

TEST!!!!!!: how do you reverse Heparin?

Answer 26

Protamine sulfate!!!!! TEST!!!!!

Question 27

What is notable about low molecular weight heparin (lovenox)?

Answer 27

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.

Question 28

How do you reverse warfarin?

Answer 28

Vitamin K and fresh frozen plasma

Question 29

Is warfarin safe in breastfeeding?

Answer 29

Yes! ok to breastfeed on warfarin

Question 30

What is MOA of warfarin?

Answer 30

Vitamin K antaonist: (1972 war, c and s)

Question 31

What is side effects of warfarin?

Answer 31

TERATOGENIC: 6-12 weeks

CROSSES PLACENTA!!!!

Question 32

What is fondaparanox?

Answer 32

Synthetic heparin: ATIII site action

Does not cross placenta, like heparin

Question 33

Does fondaparinux have the risk of HIT?

Answer 33

No.. no problems with allergies either.

Question 34

Fondaparinux does not inactivate what?

Answer 34

Thrombin. Inactivates Xa but not thrombin.