Reducing the Risk Of VTE Flashcards by Siba Kherbek

During antenatal assessment for VTE risk , which women are at
HIGH RISK ? What is the management?

Any previous VTE ; except a single event related to major surgery
❤ LMWH from the 1st trimest and 6 weeks postpartum.

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What medical conditions are considered as a risk factor for VTE?

medical comorbidity:
Cancer- heart failure- active SLE
IBS or inflammatory polyarthropathy - nephrotic syndrome- type 1 diabetes with nephropathy - sickle cell disease- Current IVDU

❤CONSIDER LMWH Antenatal prophylaxis
Score -3

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During antenatal assessment for VTE risk , what are the factors that should be assessed to calculate the need for thromboprophylaxis?

1- obesity ( BMI > 30 ) 2- smoking
3- age > 35 4- parity >3
5-gross varicose veins(symptomatic)
6- current preeclampsia
7- immobility ( paraplegia - PGP)
8- family history of unprovoked or estrogen provoked VTE in first degree relative.
9- low risk thrombophilia
10- multiple pregnancy
11- IVF / ART
❤ 4 or more 👉 prophylaxis from first trimester +6w PN
3 factors 👉 prophylaxis from 28 w+ 6w PN
0- 2 factors 👉 prophylaxis if admitted to the hospital.

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What are the risk factors to VTE that considered low risk and need mobilization and hydration only?

Transient risk factors:
Dehydration- hyperemesis - current systemic infection - long distance travel.

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During assessment on delivery suite for VTE, which women is considered HIGH RISK? what is the management?

1- any previous VTE
2- anyone requiring antenatal LMWH
3- high risk thrombophilia
4- low risk thrombophilia+ family Hx
❤ LMWH prophylactic at least 6 weeks postnatal

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During assessment on delivery suite for VTE, which women is considered INTERMEDIATE RISK ? what is the management?

Any of these :
1- CS in labour
2- BMI > 40
3- readmission or prolonged admission in the puerperium
4- any surgical procedure in the puerperium except: immediate repair of the perineum.
5- medical comorbidity: cancer - heart failure- active SLE
IBS or inflammatory polyarthropathy - nephrotic syndrome- type 1 diabetes with nephropathy - sickle cell disease- current IVDU
❤ LMWH prophylactic: 10 days postnatal

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During assessment on delivery suite for VTE risk , what are the factors that should be assessed to calculate the need for thromboprophylaxis?

1- age > 35 2- obesity BMI > 30
3- parity >3 4- smoker
5- elective CS 6- family H for VTE
7- low risk thrombophilia
8- gross varicose
9- current systemic infection
10- immobility: paraplegia/ pgp / long travel distance
11- current preeclampsia
12- multiple pregnancy
13- preterm delivery in this pregnancy < 37 w
14 - stillbirth in this pregnancy
15 - midcavity or rotation operative delivery
16 - prolonged labour > 24 h
17- pph > 1 liter or blood transfusion
❤ > 3 or persisting 👉 extending LMWH
> 2 👉 prophylactic LMWH (10 d)
< 2 👉 mobilization and hydration.

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How should women with previous VTE be managed in pregnancy?

1- prepregnancy counseling
2- previous VTE ( except single previous VTE related to major surgery & no other risk factors)
👉 thromboprophylaxis with LMWH
Throughout antenatal period
3- if documentation is not available
👉 good history & received prolonged ( > 6w) anticoagulation 👉 VTE can be assumed.

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How should women with previous VTE associated with heritable thrombophilia be managed in pregnancy and postpartum period?

🔴 Previous VTE + antithrombin deficiency 👉thromboprophylaxis 🚩higher dose 🚩LMWH antenatally and for 6 weeks postpartum ( 50- 75 % or full treatment dose)
🔴 previous VTE + other heritable thrombophilic defects 👉 standard dose.

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How should women with previous VTE associated with antiphospholipid syndrome APS ( who are on Long term oral anticoagulants) in pregnancy and postpartum period?

Thromboprophylaxis with 🚩 higher dose 🚩 of LMWH ( 50-70-or full treatment dose) antenatally and 6 weeks postpartum or until return to oral coagulant.

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What extra advice is needed for women with previous recurrent VTE?

some of them may need higher dose of LMWH
if she is on Warfarin 👉 switch to LMWH as soon as the pregnancy is confirmed
if she isn’t 👉 start LMWH as soon as pregnancy test +

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How should women with previous VTE be stratified to determine management in pregnancy?

❤ 1- VTE + antithrombin deficiency
2- VTE +APS
3- Recurrent VTE
🔴 thromboprophylaxis with higher dose of LMWH (50-75-full)
Antenatally & 6 w postpartum
❤ 1- unprovoked VTE / idiopathic
2- VTE related to estrogen (oc / p)
3- related to transient risk other than major surgery
4- who have other risk factors
🔴 thromboprophylaxis with LMWH throughout antenatal period + 6w postnatal
❤ VTE provoked by major surgery and recovered and have no other risk factors
🔴 Thromboprophylaxis with LMWH antenatally from 28 w + 6w postnatal

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Which women with prior VTE require more testing?

Family Hx of VTE 👉 test antithrombin deficiency
unprovoked VTE 👉 test the presence of APS

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When to consider thrombophilia testing?

Family member age < 50 with history of unprovoked VTE
OR : first degree relative history of estrogen- provoked VTE
Previous unprovoked VTE

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How should women with thrombophilia be stratified to determine the risk of VTE?

According:
1- level of risk associated with their thrombophilia
2- presence of family Hx
3- presence of other risk factors

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How should women with asymptomatic thrombophilia be treated?

🔴Asymptomatic with:
- antithrombin deficiency
- protein C or S deficiency
- more than one thrombophilic defect including:
- homozygous factor v leiden
- homozygous prothrombin gene mutation
- compound heterozygotes
👉👉 Consider antenatal +
Recommend 6 w postnatal
🔴Asymptomatic with:
- heterozygosity for :
- factor v leiden
- prothrombin gene mutation
- APA
👉👉 just a risk factor
* 3 R Fs 👉antenatal LMWH
* 2 RFs 👉 from 28 w LMWH
* 1 RFs👉 10 days postnatal

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How should women with antiphospholipid antibodies without previous VTE be treated?

Just a risk factor / to consider with other risk factors

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When should thromboprophylaxis be started as early in pregnancy as practical?

1- previous VTE
2- with 4 risk factors

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What are the first trimester risk factors for VTE, and how should they be managed?

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❤ hyperemesis 👉 consider LMWH until hyperemesis resolves
❤ OHSS👉 LMWH in the 1st trimester
❤ IVF + 3 risk factors 👉 LMWH from 1st trimester through pregnancy

What is the important advice for women receiving antenatal LMWH?

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If they have any vaginal bleeding or once labour begins they shouldn’t inject any further LMWH.

If regional anesthesia is considered in women receiving antenatal LMWH, how to be managed?

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1- Avoid ( insert & remove)for at least 12 h after the last prophylactic dose
2- avoid for at least 24 h after the last therapeutic dose.
3- after regional anesthesia:
avoid prophylactic LMWH for 4h
avoid therapeutic LMWH for 8- 12 h

Women receiving antenatal LMWH + having elective CS , what is the management?

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*Thromboprophylaxic dose on the day prior to delivery
* no morning dose on the day of the delivery
* after CS : the first thromboprophylaxic dose should be given as soon as possible if -regional anesthesia hasn’t been used
- no pph

When UFH may be used in stead of LMWH in women at risk of thrombosis?

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Peripartum in preference to LMWH where:
1- increased risk of haemorrhage
2- regional anesthesia may be required.

What to monitor if UFH is used after CS ?

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Platelet count should be monitored every 2-3 days from days 4 👉 14
Or until UFH is stopped.

In women at risk of thrombosis who aren't tolerant of heparin compounds, what is the management?

Fondaparinux ( in conjunction with consultant hematologist) [ not licensed in pregnancy]

When to monitor anti Xa levels if the woman is on LMWH?

ONLY if the dose is therapeutic Or high dose prophylactic ( antithrombin deficiency)

Which agents should be avoided for thromboprophylaxis in pregnancy ?

🚩- warfarin ( safe in breastfeeding) 🚩- Dextran(anaphylactoid reaction ) 🚩- NOACs : non-vitamin K oral anticoagulants: ( rivaroxaban..) [ also not recommended in breastfeeding]

When is anti embolism stockings AES recommended in pregnancy and puerperium?

🚩- who are hospitalized and have a contraindication to LMWH 🚩- ( combined with LMWH) : post CS + high risk of VTE [ previous VTE - >4 risk factors antenatally - >2 risk factors postnatally ] 🚩- women traveling > 4 h Calf pressure prophylactic 14-15 Therapeutic( in the presence of VTE) 23 at the ankle [ stockings below the knee]

What is the incidence of PE in pregnancy &puerperium?

1 - 2 / 1000

When the risk of VTE is maximum in pregnant women?

Postpartum by 5 folds ( peak during 3 weeks )

What is the recurrence rate of VTE in next pregnancy?

2- 11 %

What is the antenatal risk of VTE compared to nonpregnant?

4 - 6 folds

What is the risk of VTE in postpartum compared to nonpregnant women?

22 folds

What are the symptoms / signs in varicose veins to consider it as a risk factor for VTE?

Symptomatic Above knee Associated with phlebitis Oedema Skin changes

Which conditions are scored 4 when calculating the risk of VTE?

1- non surgical previous VTE 2- OHSS

Which conditions are scored 3 when calculating the risk of VTE?

1- surgical VTE 2- medical comorbidity: cancer , diabetes T1 with nephropathy....... 3- Any surgical procedure 4- high risk thrombophilia 5- hyperemesis

Which conditions are scored 2 when calculating the risk of VTE?

1- emergency CS 2- BMI > 40

What is the management depending on the score during risk assessment for VTE?

🚩 antenatally: >= 4 👉 LMWH from the first trimester 3 👉 LMWH from 28 w 🚩 postnatally: >= 2👉at least 10 days

What are the conditions that need high dose LMWH antenatally and 6w postpartum [ very high risk]?

1- previous VTE on long term oral anticoagulant therapy (warfarin) 2- thrombophilia:: antithrombin deficiency 3- APS with previous VTE

During antenatal assessment for VTE risk , which women are at INTERMEDIATE RISK ? What is the management?

📌 asymptomatic high risk thrombophilia: homozygous factor v leiden/ compound heterozygotes protein C or S deficiency 🚩CONSIDER antenatal LMWH RECOMMENDED postnatal LMWH for 6 weeks 📌1- single previous VTE associated with surgery( without thrombophilia - family history- other risk factors) 🚩 CONSIDER antenatal LMWH ( not routinely) RECOMMENDED LMWH from 28 w and 6 w postnatal

When to stop LMWH before labour induction?

📌Stop prophylactic LMWH 12 h before the induction 📌Stop therapeutic LMWH 24 h before the induction 📌 stop IV UFH 6 h before 📌 stop subcutaneous UFH 12 h before

In obesity the risk is higher for PE or VTE?

How much The risk of VTE is increased in age > 35 & Hospital admission?

2 folds age > 35 18 folds by hospital admission

What are the side effects of LMWH?

1- osteoporosis fracture 0.04 % 2- CS wound hematoma 2% 3- skin reaction 1.8 %

When lower doses of LMWH should be employed?

If cr clearance < 30 ml/ min Or less 20 ml / min with tinzaparin

What are the doses of prophylactic ENOXAPARIN in pregnancy and postpartum?

< 50 👉 20 mg / d 50- 90 👉 40 mg / d 91- 130 👉 60 mg / d

What are the advices given to low risk women of DVT with flying?

1- the true incidence of DVT in pregnancy with long travel is unknown ( as 1/ 4600 flights in the month following a flight >4h) 2- small increased risk in the incidence by 3 folds 3- 18 % higher risk for each 2 h of flight duration 4->4 h 👉 stockings reduce the risk ( relative risk 0.1 )

Reducing the Risk Of VTE Flashcards

(47 cards)