VTE In Pregnancy Flashcards
In what part of pregnancy is the risk of VTE this highest?
Highest in 3rd trimester and first.6 weeks postpartum
Where do most DVTs in pregnancy occur?
80% left leg
60% iliofemoral vein (back, buttock, thigh pain rather than calf pain)
What were the 3 criteria of the YEARS algorithm used in the ARTEMIS study?
- Signs or symptoms of DVT (Wells criteria applied)
- D-dimer Measurement (< 500 or < 1000)
- PE felt to be the most likely Dx by MRP
What radiation dose is associated with teratogenicity or miscarriage?
10 rads
What is the upper limit of rad accepted in pregnancy?
< 5 rad
What is the management of acute VTE in pregnancy?
LMWH for a minimum 3 months including 6 weeks postpartum, whichever ends later.
What fetal abnormalities is warfarin associated with in the first trimester?
Contraindicated in the first trimester due to warfarin embryopathy (mid-facial and limb hypoplasia and stippled bone).
What fetal abnormalities is warfarin associated with in the 2nd and 3rd trimester?
Neurological Abnormalities
Microcephalic
Optic Atrophy
Neonatal Hemorrhage
When would you consider an SVC filter in pregnancy?
If VTE is newly Dx close to delivery (i.e., < 2-4 weeks)
How would you manage full dose anticoagulation peri-delivery in patients with VTE?
- Plan for delivery (induce vaginal delivery or C-section)
- Withhold LMWH x 24 hours pre-neuraxial analgesia.
- Admit for UFH if VTE Dx < 4 weeks of delivery, hold 6 hours pre-neuraxial analgesia
When would you restart anticoagulation in the postpartum period?
Restart anticoagulation at least 4 hours post removal of neuraxial anesthesia. Generally, re-start 4-6 hours post vaginal delivery and 6-8 hours post c-section if hemostasis is achieved.
If a pregnant patient has had a previous VTE, but is no longer on anticoagulation, in which clinical situations and at what point in pregnancy would you start VTE prophylaxis?
Antepartum AND postpartum x 6 weeks:
- Prior unprovoked VTE
- estrogens related VTE (in pregnancy, OCP)
- associated with low risk thrombophilia
Postpartum Only
- prior provoked VTE with reversible or temporary risk factor
If a women has a previous history of VTE, what do you recommend for anticoagulation during pregnancy?
Prior unprovoked, estrogen related (pregnancy/OCP) or associated w/low risk thrombophilia -> DVTp throughout pregnancy & 6 weeks postpartum.
Prior provoked VTE (non-estrogen, reversible or temporary risk factor) -> DVTp postpartum x 6 weeks only.
For which thrombophilias, WITHOUT a history of VTE, would you recommend DVTp throughout pregnancy and for 6 weeks postpartum, regardless of family history of VTE?
Combine thrombophilias
Homozygous FVL
APLA w/history of recurrent pregnancy loss (also give ASA in this scenario).
If a pregnant woman has anti-thrombin deficiency, but no history of VTE, how should you manage her DVTp in pregnancy?
(A) No family hx VTE = no need for DVTp at any point during pregnancy.
(B) Family Hx of VTE = DVTp throughout pregnancy & 6 weeks postpartum.
