Thromoembolc Disease In Pregnancy/ Puerperium

Question 1

How much LMWH reduces the risk of VTE in- medical patients
- surgical patients?

Answer 1

Medical patients 60%
Surgical patients 70%

Question 2

If DVT is left untreated how many of them will devlop PE?

Answer 2

15 - 24 %

Question 3

What is the mortality rate of PE in pregnancy?

Answer 3

15 %
66 % will die in 30 minutes

Question 4

What is the risk of osteoporosis in women treated with LMWH?

Answer 4

0.04 %

Question 5

What are the radiation risks related to exposure to CT PE ( pulmonary angiogram ) ?

Answer 5

Increase the risk of breast cancer by 13.6 % of the background risk( during the lifetime)
📌 the risk being greater in younger women

Question 6

How to reduce the risk of radiation exposure ( breast cancer)related to CTPE?

Answer 6

Bismuth shield
Reduces the risk by 20 - 40 %

Question 7

In normal pregnancy;most of constituents of blood increase which stay the same , and which of them decrease ?

Answer 7

Stay the same:
F 9 - F 11 - antithrombin - protein C
Decrease:
Protein S⬇️
Platelet ⬇️
Plasminogen activation inhibitor ⬇️

Question 8

How to asses the activation of
Extrinsic pathway
Intrinsic pathway
Fibrin clot formation?

Answer 8

Extrinsic p. 👉 pt
Intrinsic p. 👉 ptt
Fibrin clot formation 👉 INR

Question 9

Why is pregnancy considered hypercoagulable state ?

Answer 9

1- fibrinogen levels rise up to 50%
2- antithrombin + protein S decrease
3- left iliac vein is compressed between right iliac A. And lumbar vertebra 👉 venous stasis more on the left side.

Question 10

What are the initial investigations & management for suspected PE in pregnancy or puerperium?

Answer 10

1- clinical assessment
2- perform CXR ( to exclude pneumonia…etc) normal in 50 % of proven PE
&
ECG ( limited value) [ most: T wave inversion]
3- test : FBC + urea + electrolytes (U&E) + LFTs
4- commence LMWH

Question 11

In a patient suspected of PE , CXR is performed, what to do next?

Answer 11

Normal👉 V/Q scan( ventilation/ perfusion scan)[ perfusion component can be omitted to reduce the radiation exposure to the fetus]
Abnormal 👉 CTPA

Question 12

What are the symptoms and signs of DVT ?

Answer 12

Leg pain
Swelling
Lower abdominal pain ( reflecting extension of thrombosis into pelvic vessels)

Question 13

What are the symptoms and signs of PE?

Answer 13

Dyspnoea- chest pain - haemoptysis- collapse

Question 14

What investigation is needed for the diagnosis of an acute DVT?

Answer 14

Compression duplex ultrasound
If the ultrasound is negative and a high level of clinical suspicion exists
👉1- anticoagulant should be discontinued
2- repeat US on day 3 & day 7

Question 15

What are the symptoms and signs of iliac vein thrombosis? What investigation is needed for the diagnosis?

Answer 15

Back and buttock pain
Swelling of the entire limb
📌 doppler US of the iliac vein
MR venography

Question 16

What investigations are needed for the diagnosis of an acute PE?

Answer 16

🚩Symptoms and signs of PE 👉ECG & chest X ray
🚩 in women with suspected PE + have symptoms & signs of DVT
👉 compression duplex US : DVT confirmed 👉 treatment & no further investigation
🚩 suspected PE & no symptoms or signs of DVT 👉 V/Q lung scan or CTPA
🔴 anticoagulant therapy should be continued until PE is definitely excluded.

Question 17

What abnormal features are caused by PE seen on CXR ?

Answer 17

Atelectasis / effusion / focal opacities / regional oligaemia / pulmonary oedema
/ انخماص / تدفق / عتمات بؤرية/ قلة تروية/ وذمة رئة

Question 18

What is the main concern for the fetus exposed to V/Q scan in uterus?

Answer 18

Very small risk of childhood cancer
1/ 300,000

Question 19

What is the role of D - dimer testing in the investigation of acute VTE in pregnancy?

Answer 19

D - dimer should not be performed in the investigation.
📌 normal levels exclude PE
📌 levels are increased in multiple pregnancy + post CS + pph + preeclampsia

Question 20

What baseline blood investigations should be performed before initiating anticoagulant therapy?

Answer 20

FBC + coagulation screen + urea + electrolytes + LFTs
🔴 thrombophilia testing IS NOT RECOMMENDED

Question 21

What is % of women who have VTE in pregnancy will have underlying thrombophilia?

Answer 21

Almost half

Question 22

What is the therapeutic dose of LMWH in pregnancy?

Answer 22

Enoxaparin 1.5 mg / kg once/ d
1 mg / kg twice/ d
Titrated against women’s booking or early pregnancy weight.
Once or twice a day
<50👉 60/d
50-69👉90/d
70-89👉120/d
> 125 👉👉 DISCUSS WITH HEMATOLOGIST

Question 23

Should blood tests be performed to monitor heparin therapy in pregnancy?

Answer 23

📌Routine measurement of anti Xa IS NOT RECOMMENDED except;
- weight: < 50 or > 90
- renal impairment
- recurrent VTE
📌 routine plt count SHOULD NOT carried out
🔴 patients receiving UFH SHOULD have plt count every 2-3 days from day 4- 14 or until heparin is stopped

Question 24

How should massive life threatening PE in pregnancy and puerperium be managed?

Answer 24

The woman is collapsed &shocked
FIRST ABC
1- multidisciplinary team
2- IV UFH
3- 🔴 thrombolytic therapy
Or
🔴thoracotomy& surgical
embolectomy
❤ perimortem CS should be performed by 5 min if resuscitation is unsuccessful and pregnancy
> 20w

Question 25

What is the regimen for administration IV UFH in massive PE?

Answer 25

Loading dose 80 unit/ kg
Continuous Iv 18 unit / kg
* if the patient received thrombolysis 👉 loading dose should be omitted
📌 adjust the infusion according to APTT: should be measured 4- 6 h after the loading dose and then daily.
Therapeutic target of APTT is
1.5 - 2.5 times the control

Question 26

Should graduated elastic compression stockings be employed in acute management of VTE in pregnancy?

Answer 26

1-Leg should be elevated
2-Graduated elastic compression stockings should be applied to reduce oedema
3- Mobilization should be encouraged

Question 27

If recurrent thromboembolism occurs despite adequate anticoagulation what to consider?

Answer 27

Inferior vena cava filters

Question 28

What are the main complications of IVC filters?

Answer 28

1-Migration
Increased risk of lower limb DVT and 2-caval thrombosis
3-Infection

Question 29

What is the maintenance treatment of DVT or PE?

Answer 29

Treatment with therapeutic doses of LMWH during the remainder of pregnancy and for at least 6 w postnatally and until at least 3 months of treatment has been given in total.
🚩if LMWH therapy requires monitoring: the aim is to achieve a peak anti Xa activity 3 h post injection of 0.5 - 1.2 u/ ml

Question 30

Can vit K antagonists be used during pregnancy for maintenance treatment of VTE?

Answer 30

( such Warfarin)
SHOULD NOT BE USED for antenatal VTE treatment,because of their adverse effects on the fetus.

Question 31

What are the adverse pregnancy outcomes associated with warfarin?

Answer 31

1- miscarriage
2- prematurity
3- LBW
4- neurodevelopmental problems
5- fetal & neonatal bleeding
🔴 embryopathy in the 1st trimester

Question 32

Are specific surgical measures required for anticoagulanted patients undergoing CS?

Answer 32

In patients receiving therapeutic doses of LMWH consider:
- wound drains ( abdominal & rectus sheath)
- skin incision should be closed with interrupted sutures.

Question 33

What anticoagulant therapy should be employed in women at high risk of haemorrhage?

Answer 33

IV UFH
Because:
has shorter half life than LMWH
Completely reserved by protamine sulfate

Question 34

If the woman chooses to commence Warfarin postpartum, when to start & what to monitor?

Answer 34

📌Avoid warfarin until at least 5th postnatal day and for longer period in women at risk of pph
📌 daily testing INR during the transfer from LMWH to warfarin