VTE in pregnancy

Question 1

Mx of VTE in preg

Scenario 1 - 33yo, hx of RMC, multi, hx of massive PPH, now spont conception, some point in preg develops LL DVT

Scenario 2 - 24yo, 22/40, pw chest pain + SOB

Scenario 3 - 27yo, 20/40 DVT then LLP

Scenario 4- 28yo, G5P0, 28/40, FVL/PT compound heterozygote, x4 T1 MC

Answer 1

DDx of chest pain
- pulmonary embolus
- dissecting aortic aneurysm
- atypical pneumonia

• M risk - T2RF/HF/Hypoxia/emCS
• F risk - hypoxia/fetal distress/SB
• MDI - Obs/Haem/Ano/Card
• Admit for observe & rx
  +/- steroid loading
• Inform senior obs
• FBE/UEC/LFT/ABG/Coag + ECG +/- TTE +/- ABG
• LL USS vs CXR +/- VQ+/-CTPA
• therapeutic anticoag dosing d/w Haem
  (LMWH vs Heparin - based on bleeding risk)
• referral to anos for rv
• LMWH self-injection instruction
• LMWH daily until 6/52 postpartum
• minimum of 6/12 in total
• anti-Xa at extremes of BMI or renal issues
• mobilize + teds, avoid bed rest
• monitor sx (VTE) +/- HITS
  +/- IVC filter if sig risk of bleeding
• cease at first sign of contraction
• cease 24/24 pre-IOL or CS
• cease 24/24 pre-regional anesthetic
• IV heparin 6/24 pre-IOL
• +/- reverse heparin (protamine) if emergency CS
• MOD - not affected
• consider wound drain +/- interrupted sutures of staples to avoid collection
• Contraception - avoid E containing
• Encourage breastfeeding
• Ongoing VTE rx +/- rpt USS
• OP F/U +/- thrombophilia screen with Haem

Question 2

Warfarin in preg

Answer 2

• 5-10% fetal anomaly rate
  T1 - nasal and limb hypoplasia
  T2-3 - microhemorrhage & CNS defect
• safe with breastfeeding

Question 3

Thrombophilia Mx

Scenario 1 - 38yo G5P0, hx of RMC, compound FVL/PT heterozygote

Scenario 2 - 32yo G1P0, FVL heterozygote

Answer 3

Significant Thrombophilia
- antithrombin def
- FVL or PT homo
- compound FVL/PT hetero
- Protein C or S def

• M risk - RMC/PET/Abruption
• F risk - MC/IUGR/SB
• MDI …Haem
• LMWH + LDA
• tertiary morph, serial G/S
• LMWH education + plan
• Monitor sx & for HITS
• peripartum anticoag plan
• PP anticoag plan