Antenatal - VTE in pregnancy Flashcards
what are some risk factors for VTE in pregnancy?
- Smoking
- Parity ≥ 3
- Age > 35 years
- BMI > 30
- Reduced mobility
- Multiple pregnancy
- Pre-eclampsia
- Gross varicose veins
- Immobility
- Family history of VTE
- Thrombophilia
- IVF pregnancy
what is the RCOG guidelines on VTE prophylaxis in pregnancy?
28 weeks if there are 3 risk factors
first trimester if there are 4 or more risk factors
what are some other scenarios where vte prophylaxis is considered even in the absence of other risk factors?
- Hospital admission
- Surgical procedures
- Previous VTE
- Medical conditions such as cancer or arthritis
- High-risk thrombophilias
- Ovarian hyperstimulation syndrome
what medication is used for VTE prophylaxis in pregnancy?
low molecular weight heparin
deltaparin
Prophylaxis is started as soon as possible in very high risk patients and at 28 weeks in those at high risk. It is continued throughout the antenatal period and for six weeks postnatally.
Prophylaxis is temporarily stopped when the woman goes into labour, and can be started immediately after delivery (except with postpartum haemorrhage, spinal anaesthesia and epidurals).
what are the mechanical prophylaxis options considered in women who have contraindications to LMWH
intermittent pneumatic compression with equipment that inflates and deflates to massage the legs
anti-embolic compression stockings
what is considered significant when measuring calf circumference?
(measure 10 cm below tibial tuberosity)
More than 3cm difference between calves is significant
how is VTE diagnosed in pregnancy?
doppler uss for suspected DVT (repeat on day 3 and 7 when negative findings in high index of suspicion)
PE - CXR and ECG
what are the 2 options for definitive diagnosis of PE?
CT pulmonary angiogram
Ventilation-perfusion scan
- CTPA is the test for choice for patients with an abnormal chest xray
- CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk)
- VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk)
Patients with a suspected deep vein thrombosis and pulmonary embolism should have a Doppler ultrasound initially, and if a DVT is present, they do not require a VQ scan or CTPA to confirm a PE. The treatment for DVT and PE are the same.
if pt has confirmed DVT and start having chest symptoms then assume PE without any further investigations
management of PE and DVT in pregnancy
LMWH based on woman weight at booking clinic - can use anti Xa level in very over or underweight pt
started immediately before diagnosis is confirmed
continue for remainder of pregnancy + 6 wks postnatal (or 3 months total whichever is longer)
can switch to DOAC after delivery
how are women with a massive PE and haemodynamic compromise managed?
need immediate management
- Unfractionated heparin
- Thrombolysis
- Surgical embolectomy
- TED
