Thromoembolc Disease In Pregnancy/ Puerperium Flashcards
How much LMWH reduces the risk of VTE in- medical patients
- surgical patients?
Medical patients 60%
Surgical patients 70%
If DVT is left untreated how many of them will devlop PE?
15 - 24 %
What is the mortality rate of PE in pregnancy?
15 %
66 % will die in 30 minutes
What is the risk of osteoporosis in women treated with LMWH?
0.04 %
What are the radiation risks related to exposure to CT PE ( pulmonary angiogram ) ?
Increase the risk of breast cancer by 13.6 % of the background risk( during the lifetime)
๐ the risk being greater in younger women
How to reduce the risk of radiation exposure ( breast cancer)related to CTPE?
Bismuth shield
Reduces the risk by 20 - 40 %
In normal pregnancy;most of constituents of blood increase which stay the same , and which of them decrease ?
Stay the same:
F 9 - F 11 - antithrombin - protein C
Decrease:
Protein Sโฌ๏ธ
Platelet โฌ๏ธ
Plasminogen activation inhibitor โฌ๏ธ
How to asses the activation of
Extrinsic pathway
Intrinsic pathway
Fibrin clot formation?
Extrinsic p. ๐ pt
Intrinsic p. ๐ ptt
Fibrin clot formation ๐ INR
Why is pregnancy considered hypercoagulable state ?
1- fibrinogen levels rise up to 50%
2- antithrombin + protein S decrease
3- left iliac vein is compressed between right iliac A. And lumbar vertebra ๐ venous stasis more on the left side.
What are the initial investigations & management for suspected PE in pregnancy or puerperium?
1- clinical assessment
2- perform CXR ( to exclude pneumoniaโฆetc) normal in 50 % of proven PE
&
ECG ( limited value) [ most: T wave inversion]
3- test : FBC + urea + electrolytes (U&E) + LFTs
4- commence LMWH
In a patient suspected of PE , CXR is performed, what to do next?
Normal๐ V/Q scan( ventilation/ perfusion scan)[ perfusion component can be omitted to reduce the radiation exposure to the fetus]
Abnormal ๐ CTPA
What are the symptoms and signs of DVT ?
Leg pain
Swelling
Lower abdominal pain ( reflecting extension of thrombosis into pelvic vessels)
What are the symptoms and signs of PE?
Dyspnoea- chest pain - haemoptysis- collapse
What investigation is needed for the diagnosis of an acute DVT?
Compression duplex ultrasound
If the ultrasound is negative and a high level of clinical suspicion exists
๐1- anticoagulant should be discontinued
2- repeat US on day 3 & day 7
What are the symptoms and signs of iliac vein thrombosis? What investigation is needed for the diagnosis?
Back and buttock pain
Swelling of the entire limb
๐ doppler US of the iliac vein
MR venography
What investigations are needed for the diagnosis of an acute PE?
๐ฉSymptoms and signs of PE ๐ECG & chest X ray
๐ฉ in women with suspected PE + have symptoms & signs of DVT
๐ compression duplex US : DVT confirmed ๐ treatment & no further investigation
๐ฉ suspected PE & no symptoms or signs of DVT ๐ V/Q lung scan or CTPA
๐ด anticoagulant therapy should be continued until PE is definitely excluded.
What abnormal features are caused by PE seen on CXR ?
Atelectasis / effusion / focal opacities / regional oligaemia / pulmonary oedema
/ ุงูุฎู
ุงุต / ุชุฏูู / ุนุชู
ุงุช ุจุคุฑูุฉ/ ููุฉ ุชุฑููุฉ/ ูุฐู
ุฉ ุฑุฆุฉ
What is the main concern for the fetus exposed to V/Q scan in uterus?
Very small risk of childhood cancer
1/ 300,000
What is the role of D - dimer testing in the investigation of acute VTE in pregnancy?
D - dimer should not be performed in the investigation.
๐ normal levels exclude PE
๐ levels are increased in multiple pregnancy + post CS + pph + preeclampsia
What baseline blood investigations should be performed before initiating anticoagulant therapy?
FBC + coagulation screen + urea + electrolytes + LFTs
๐ด thrombophilia testing IS NOT RECOMMENDED
What is % of women who have VTE in pregnancy will have underlying thrombophilia?
Almost half
What is the therapeutic dose of LMWH in pregnancy?
Enoxaparin 1.5 mg / kg once/ d
1 mg / kg twice/ d
Titrated against womenโs booking or early pregnancy weight.
Once or twice a day
<50๐ 60/d
50-69๐90/d
70-89๐120/d
> 125 ๐๐ DISCUSS WITH HEMATOLOGIST
Should blood tests be performed to monitor heparin therapy in pregnancy?
๐Routine measurement of anti Xa IS NOT RECOMMENDED except;
- weight: < 50 or > 90
- renal impairment
- recurrent VTE
๐ routine plt count SHOULD NOT carried out
๐ด patients receiving UFH SHOULD have plt count every 2-3 days from day 4- 14 or until heparin is stopped
How should massive life threatening PE in pregnancy and puerperium be managed?
The woman is collapsed &shocked
FIRST ABC
1- multidisciplinary team
2- IV UFH
3- ๐ด thrombolytic therapy
Or
๐ดthoracotomy& surgical
embolectomy
โค perimortem CS should be performed by 5 min if resuscitation is unsuccessful and pregnancy
> 20w
What is the regimen for administration IV UFH in massive PE?
Loading dose 80 unit/ kg
Continuous Iv 18 unit / kg
* if the patient received thrombolysis ๐ loading dose should be omitted
๐ adjust the infusion according to APTT: should be measured 4- 6 h after the loading dose and then daily.
Therapeutic target of APTT is
1.5 - 2.5 times the control
Should graduated elastic compression stockings be employed in acute management of VTE in pregnancy?
1-Leg should be elevated
2-Graduated elastic compression stockings should be applied to reduce oedema
3- Mobilization should be encouraged
If recurrent thromboembolism occurs despite adequate anticoagulation what to consider?
Inferior vena cava filters
What are the main complications of IVC filters?
1-Migration
Increased risk of lower limb DVT and 2-caval thrombosis
3-Infection
What is the maintenance treatment of DVT or PE?
Treatment with therapeutic doses of LMWH during the remainder of pregnancy and for at least 6 w postnatally and until at least 3 months of treatment has been given in total.
๐ฉif LMWH therapy requires monitoring: the aim is to achieve a peak anti Xa activity 3 h post injection of 0.5 - 1.2 u/ ml
Can vit K antagonists be used during pregnancy for maintenance treatment of VTE?
( such Warfarin)
SHOULD NOT BE USED for antenatal VTE treatment,because of their adverse effects on the fetus.
What are the adverse pregnancy outcomes associated with warfarin?
1- miscarriage
2- prematurity
3- LBW
4- neurodevelopmental problems
5- fetal & neonatal bleeding
๐ด embryopathy in the 1st trimester
Are specific surgical measures required for anticoagulanted patients undergoing CS?
In patients receiving therapeutic doses of LMWH consider:
- wound drains ( abdominal & rectus sheath)
- skin incision should be closed with interrupted sutures.
What anticoagulant therapy should be employed in women at high risk of haemorrhage?
IV UFH
Because:
has shorter half life than LMWH
Completely reserved by protamine sulfate
If the woman chooses to commence Warfarin postpartum, when to start & what to monitor?
๐Avoid warfarin until at least 5th postnatal day and for longer period in women at risk of pph
๐ daily testing INR during the transfer from LMWH to warfarin
