Coagulation and Bleeding in Pregnancy

Question 1

Protein S Fxn and Change in Pregnancy

Outcome

Answer 1

Fxn: anticoagulant
Pregnancy: decrease

Outcome: higher clot risk

Question 2

Protein C Fxn and Change in Pregnancy

Outcome

Answer 2

Fxn: anticoagulant
Pregnancy: no change

Outcome: little-no impact

Question 3

Antithrombin Fxn and Change in Pregnancy

Outcome

Answer 3

Fxn: anticoagulant
Pregnancy: no change

Outcome: little-no impact

Question 4

Highest risk of peripregnancy VTE?

Answer 4

postpartum

up to ~50% of all VTEs in pregnancy occur postpartum

esp in first week postpartum

Question 5

Which anticoagulants cross placenta?

Answer 5

warfarin

Question 6

warfarin effect in pregnancy

Timing

When you might use in pregnancy?

Answer 6

hypoplastic nose
stippled epiphyses / limb shortening
ID
CNS / eye issues

6-12wks GA

mechanical valves (with change to another method during 6-12w GA)

Question 7

Anticoagulants that can be used postpartum / breastfeeding

Answer 7

can be used:
heparins
warfarin

Question 8

Anticoagulants that cant be used breastfeeding

Answer 8

1. direct thrombin inhibitor (dabigatran)
2. anti-XA inhibitor (rivaroxaban, apixaban)

insufficient safety data

Question 9

Tx for acute VTE in pregnancy

How long?

Answer 9

adjusted (full-dose) heparin

up to 6wk postpartum

Question 10

Pregnancy ppx if hx provoked VTE?

Answer 10

No (can consider postpartum ppx)

Question 11

Pregnancy tx if hx unprovoked VTE?

Answer 11

Yes (ppx vs intermed. vs full dose up to 6wk pp)

Question 12

Pregnancy tx if low-risk thrombophilia?

Answer 12

No

can consider postpartum!

Question 13

Pregnancy tx if low-risk thrombophilia + 1st deg relative VTE?

Answer 13

maybe. consider it. (ppx vs intermed. up to 6wk pp)

Question 14

Pregnancy tx if low-risk thrombophilia + hx VTE x1?

Answer 14

Yes (ppx vs intermed)

Question 15

Pregnancy tx if high-risk thrombophilia?

Answer 15

Yes (ppx vs intermed)

Question 16

Pregnancy tx if iigh-risk thrombophilia with hx or family hx VTE?

Answer 16

Yes (ppx vs intermed. vs full dose)

Question 17

Pregnancy tx if 2+ VTE hx?

Answer 17

intermediate vs full dose heparin

Question 18

Low-risk Thrombophilias

Answer 18

Protein C or S Deficiency
Factor V Leiden (heterozyg.)
Prothrombin (heterozyg)

Question 19

High risk thrombophilias

Answer 19

Antithrombin Def.
APS
Factor V (homozyg)
Prothrombin (homozyg)

Question 20

Unreliable thrombophilia testing during pregnancy

MoA

Answer 20

Factor S deficiency

MoA: naturally decrease in pregnancy (Factor C stays same)

Question 21

Unreliable thrombophilia testing during acute VTE

MoA

Answer 21

Protein C, Protein S, Antithrombin

b/c test using protein assays ( used up during coagulation cascade)

Question 22

Unreliable thrombophilia testing during anticoagulation

Answer 22

Protein C, Protein S, antithrombin

b/c test using protein assays ( used up during coagulation cascade)

Question 23

Stop / Start timing of ppx UFH intrapartum

(ideally)

Answer 23

Stop: ~12hrs before neuraxial analgesia
Start: ~1hr after neuraxial catheter removed

*4-6hrs after VD
*6-12hrs after c/s

Question 24

Stop / Start timing of adjusted dose UFH intrapartum

(ideally)

Answer 24

Stop: ~24hrs before neuraxial analgesia
Start: ~1hr after neuraxial catheter removed

*4-6hrs after VD
*6-12hrs after c/s

Question 25

Stop/Start timing of ppx lovenox intrapartum

Answer 25

Stop: ~12hrs before neuraxial analgesia Start: ~4hrs after catheter removed | *4-6hrs after VD *6-12hrs after c/s

Question 26

Stop/Start timing of intermed./full-dose lovenox intrapartum | and after delivery

Answer 26

Stop: ~24hrs before neuraxial analgesia Start: ~4hrs after catheter removed | *4-6hrs after VD *6-12hrs after c/s

Question 27

PE sx

Answer 27

dyspnea (most common) chest pain cough syncope hemoptysis

Question 28

Thrombocytopenia incidence in pregnancy

Answer 28

10% of pregnant ppl

Question 29

Maternal thrombocytopenia sx | most common?

Answer 29

*epistaxis bruising gingival bleeding petechiae heavy menstrual bleeding | *most common

Question 30

Therapeutic LMWH during pregnancy: -titration measure / goal? -timing of measure?

Answer 30

goal: anti-Xa level (0.6-1.0 U/mL timing after dosing: 4hrs after

Question 31

Half-life of UFH

Answer 31

30m-4hr | dose dep

Question 32

LMWH half-life

Answer 32

2-4hrs (dose independent)

Question 33

LMWH advanctages in pregnancy

Answer 33

longer half-life less bone mineral density loss predictable therapeutic response lower risk HIT

Question 34

UFH reversal agent

Answer 34

protamine sulfate

Question 35

Massive transfusion definition: -blood volume replacement -# units PRBCs

Answer 35

-replacement of complete blood volume -4U PRBC w/i 1hr with ongoing need -10U PRBC w/i 24hrs

Question 36

Anticoagulation used for pregnant patient w/ hx of HIT? | MoA

Answer 36

fondaparinux | MoA: binds antithrombin and accelerates factor Xa inhibitor ## Footnote indirect XA inhibitor; safe in pregnancy b/c doesnt cross placental barrier

Question 37

DIC lab findings: fibrinogen D Dimer platelets PT/aPTT | MoA

Answer 37

fibrinogen: low D-Dimer: high plt: low PT/aPTT: high | fibrinogen cand plts onsumed in coagulation process ## Footnote PT, PTT increased becausetakes longer for cascade to occur (2/2 depletion)

Question 38

Personal Hx VTE increases VTE risk in pregnancy by ___

Answer 38

3-4x | highest risk factor

Question 39

___mLs in 1u RBC?

Answer 39

~350mL

Question 40

FFP contains

Answer 40

all plasma proteins, clotting factors

Question 41

FFP use

Answer 41

bleeding when dificient in multiple coag factors (i.e. DIC, massive transfusion)

Question 42

Cryoprecipitate contains

Answer 42

-fibrinogen -FVIII -FXIII -vWF

Question 43

cryoprecipitate use?

Answer 43

-acquired hypofibrinogenemia -DIC

Question 44

Plt transfusion prior to CS?

Answer 44

if plt <50,000 per mm3

Question 45

plt transfusion in pregnancy (not prior to surgery?)

Answer 45

plt <30,000/mcl

Question 46

meds that cause thrombocytopenia

Answer 46

heparin zidovudine sulfonamides

Question 47

conditions that cause thrombocytopenia

Answer 47

SLE PEC APLS

Question 48

ITP dx cx

Answer 48

1. plt <100,000/uL 2. dx exclusion (no causative meds/medical conditions) 3. bone marrow bx: increased megakaryocytes (immature plt) 4. no splenectomy

Question 49

MoA transfusion-assoc citrate toxicity

Answer 49

sodium citrate, citric acid used to prevent products from coagulating | Citrate binds with calcium -> hypocalcemia

Question 50

S/S citrate toxicity

Answer 50

prolonged QT dec ventricular contractility dec PVR ->hypotension muscle tremors arrythmia

Question 51

citrate toxicity acid-base status | and MoA

Answer 51

metabolic alkalosis | citrate metabolized -> bicarbonate (high HCO3 -> high pH)

Question 52

tx citrate toxicity

Answer 52

calcium chloride calcium gluconate | cant use calcium carbonate! (wont correc)

Question 53

massive transfusion effect on calcium | MoA?

Answer 53

hypocalcemia | MoA: citrate binds to calcium

Question 54

massive transfusion effect on potassium | MoA

Answer 54

hyperkalemia | MoA: RBC will release potassium

Question 55

TXA MoA | what does it inhibit ## Footnote binds?

Answer 55

antifibrinolytic | inhibits plasminogen -> plasmin ## Footnote TXA = synthetic lysine; binds lysine site on plasminogen

Question 56

TXA benefit after delivery

Answer 56

reduction in mortality if <3hrs delivery

Question 57

TXA: IV vs PO?

Answer 57

either (no difference)

Question 58

TXA pregnancy thrombosis risk?

Answer 58

not significant!