Reducing risk VTE pregnancy and puerperium GTG

Question 1

Was is the AN risk of VTE?

Answer 1

1.3/10,000

Question 2

What is the postpartum risk of VTE?

Answer 2

1-2/1000

Question 3

List the minor AN risk factors:

Answer 3

Obesity BMI >30
Age >35
Parity > 3
Gross varicose veins
Immobility (paraplegia, PGP)
Fix unprovoked VTE in 1st degree relative
Multiple pregnancy
Low risk thrombophilia (
IVF/ART

Question 4

How many minor risk factors should be present to consider prophylaxis from 28 weeks?

Answer 4

3

Question 5

How many minor risk factors should be present to consider prophylaxis from 1st trimester?

Answer 5

4

Question 6

What are the intermediate AN risk factors?

Answer 6

Hospital admission
Single previous VTE related to major surgery
High risk thrombophilias + no VTE
Medical co-morbidity
Any surgical procudure
OHSS

Question 7

If any one intermediate RF present?

Answer 7

Consider AN prophylaxis

Question 8

Which medical conditions are listed?

Answer 8

Cancer
Heart failure
Active SLE/IBD/inflammatory polyarthropathy
Nephrotic syndrome
T1DM with nephropathy
Sickle cell disease
Current IVDU

Question 9

What are considered low risk thrombophlias

Answer 9

Heterozygous for factor V leiden, prothrombin G20210A mutations.

Question 10

What are considered high risk thrombophilias

Answer 10

Anti-thrombin deficiency
Protein C or S deficiency
Compound/homozygous for low risk thrombophilias

Question 11

What are high risk factors for AN VTE?

Answer 11

Previous VTE (except single event related to surgery)

Question 12

What transient RF should be consider when calculating VTE?

Answer 12

Dehydration/hyperemsis, infection, long distance travel (equal or > 4hrs)

Question 13

What are the single risk postpartum risk factors?

Answer 13

Age > 35
BMI >30 <40
Parity equal >3
Smoker
ELCS
Fhx VTE
Low risk thrombophilia
Immobility
Current PET
Multiple preg
Preterm delivery <37weeks
Stillbirth in this pregnancy
Mid cavity/rotational delivery
Prolonged labour >24 hrs
PPH > 1 L or blood transfusion

Question 14

What are the PN intermediate risk factors (2 points)

Answer 14

CS in labour
BMI > 40
Readmission or prolonged (>3 days) to hospital
Any surgical procedure in puerperium (except immediate perineal repair)
Medical co-morbidity

Question 15

What are the PN high risk factors?

Answer 15

Any previous VTE
AN LMWH
High risk thrombophilia
Low risk thrombophilia + FHx

Question 16

When is 10 days LMWH given in PN period

Answer 16

2+ minor risk factors
Any intermediate RF

Question 17

When is 6 weeks LMWH given in PN period?

Answer 17

If persisting to > 3 risk factors
High risk factor present

Question 18

Recurrence rate of previous VTE not related to surgery?

Answer 18

2-11%

Question 19

If previous VTE and anti-thrombin deficiency?

Answer 19

From 1st trimester until 6 weeks PN higher dose LMWH 50-75% full dose (until PO anticoagulation is restarted), consider anti-Xa monitoring

Question 20

What is target anti X-a levels previous VTE?

Answer 20

4 hour peak 0.5-1.0 iu/ml

Question 21

If previous VTE and other inheritable thrombophilia?

Answer 21

Same dose

Question 22

What other VTE conditions should higher dose LMWH in pregnancy been considered

Answer 22

Anti-thrombin deficiency
Anti-phospolipid syndrome
Recurrent VTE

Question 23

If unprovoked/oestrogen realated VTE, when to commence LMWH

Answer 23

1st trimester

Question 24

If provoked VTE (after surgery) and no other RF< when to commence LMWH

Answer 24

28 weeks

Question 25

Women who have an unprovoked VTE should be tested for which condition?

Answer 25

APS

Question 26

Women with what Family Hx should be considered for thrombophilia screening?

Answer 26

Unprovoked/oestrogen related VTE in 1st degree < age 50

Question 27

Do you need to treat homozygous MHTFR in pregnancy?

Answer 27

No not associated with VTE in pregnancy

Question 28

What % of AN VTE occurs before 15 weeks?

Answer 28

40-50%

Question 29

How long should we wait to given regional anaesthetic following last dose of prophylactic dose LMWH?

Answer 29

12 hours

Question 30

When can prophylactic LMWH be given after spinal or epidural catheter removed?

Answer 30

4 hours

Question 31

How long should we wait to given regional anaesthetic following last dose of treatment dose LMWH?

Answer 31

24 hours

Question 32

Relative to vaginal delivery, how much is the VTE risk increases compared to - ELCS - EMCS

Answer 32

- ELCS - 2 times - EMCS - 4 times

Question 33

Dose of Enoxaparin Deltaparin Tinzparin If < 50kg

Answer 33

<50kg Enoxaparin 20mg OD Deltaparin 2500IU Tinzparin 3500IU

Question 34

Dose of Enoxaparin Deltaparin Tinzparin If 50-90kg

Answer 34

50-90 Enoxaparin 40mg Deltaparin 5000 IU Tinzparin 4500IU

Question 35

Dose of Enoxaparin Deltaparin Tinzparin If 90-130kg

Answer 35

90-130kg Enoxaparin 60mg Deltaparin 7500IU Tinzparin 7000 IU

Question 36

Dose of Enoxaparin Deltaparin Tinzparin If 130-170

Answer 36

130-170 Enoxaparin 80mg Deltaparin 10,000IU Tinzparin 9000IU

Question 37

Dose of Enoxaparin Deltaparin Tinzparin If >170

Answer 37

>170 Enoxaparin 0.6mg/kg/day Deltaparin 75 u/kg/day Tinzparin 75 u/kg/day

Question 38

When to use unfractionated heparin?

Answer 38

Risk of haemorrhage or regional anaesthetics may be required

Question 39

How long must wait between UFH and regional?

Answer 39

4 hours

Question 40

Major risk of UFH?

Answer 40

Heparin induced thrombocytopenia (HIT)

Question 41

Postpartum, when can LMWH be converted to warfarin?

Answer 41

Day 5-6

Question 42

Is breastfeeding safe in warfarin?

Answer 42

yes

Question 43

What congenital abnormalities does warfarin cause?

Answer 43

Hypoplasia of nasal bridge Congenital heart defect Ventriculpmegalt Agenisis corpus callous Stippled epiphyses Risk 5% 6-12 weeks, dose dependant

Question 44

Can NOACs be given in pregnancy or breast feeding?

Answer 44

No

Question 45

TEDS should create a compression of what pressure?

Answer 45

14-15mmHg

Question 46

What are the contraindications to LMWH?

Answer 46

Known bleeding disorder (haemophilia, von willebrands, acquired coagulopathy Active AN/PP bleeding Women with increased risk of major haemorrhage (praevia) Thrombocytopenia <75 Active stroke in previous 4 weeks Severe renal disease eGFR < 30 Severe liver disease Uncontrolled HTN >SBP 200, >120 DBP