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MRCOG Part 2 > VTE in pregnancy GT37a, b > Flashcards

VTE in pregnancy GT37a, b Flashcards

(52 cards)

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1
Q

How many DVTs in pregnancy occur on the left?

A

90%

60 when not pregnant

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2
Q

How many DVTs arise in the ileo-femoral veins?

A

70%

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3
Q

How many with a clinical diagnosis go on to have a proven DVT?

A

8%

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4
Q

How many proven DVT patients will have a PE?

A

5%

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5
Q

How much more likely to develop DVT if previous VTE?

A

25 times

Recurrence rate 2-11% in pregnancy

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6
Q

What is the advice if there is a strong clinical suspicion but a negative scan?

A

Repeat 3/7

MRV if still suspicious

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7
Q

Which LFT is affected by tinzaparin?

A

ALT

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8
Q

How many will have a skin allergy to LMWH within 60 days?

A

2%

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9
Q

How does LMWH work?

A

Potentiates antithrombin III which inhibits conversion of X to Xa

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10
Q

What is the advice around delivery for those on antenatal treatment dose LMWH?

A

IOL when favourable or 40/40 - consider prophylactic dose if unfavourable on day IOL
24 hours from dose before regional anaesthetic
Prophylactic dose 1-2 days following VB and 2-3 days following CS
Protamine if labours within 3 hrs of LMWH dose

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11
Q

How much does CS increase the risk of a PE?

A

5 times

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12
Q

How much does VQ scan increase the risk of childhood cancer?

A

1:1000,000 background to 1:280,000

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13
Q

How much does CTPA increase breast cancer risk?

A

14%

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14
Q

How much does antithrombin deficiency increase risk of VTE?

A

10 times - 50% of untreated patients will have a VTE

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15
Q

What % of patients with pregnancy related VTE will have an underlying thrombophilia?

A

50%

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16
Q

How many of general population have factor V leiden deficiency?

What is the risk of VTE in pregnancy?

A

5%

1:100 (1:1000 when not pregnant)

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17
Q

What is the risk of devloping a VTE in subsequent pregnancies?

A

10%

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18
Q

How should anti-Xa levels be measured?

A

A test that does not use exogenous antithrombin, aim for 4 hour peak levels of 0.5-1.0iu/ml

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19
Q

What is the advice for women who are taking warfarin antenatallly and fall pregnant?

A

Stop and change to LMWH as soon as pregnancy confirmed, ideally within 2/52 of missed period and by 6/40

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20
Q

Which women with prior VTE require thrombophilia testing?

A

Only if result will influence Rx - antithrombin/APS may alter dose of LMWH

FHx VTE with antithrombin deficiency or thrombophilia not detected
Unprovoked VTE - test for APL antibodies

Consider if no personal hx but FHx of unprovoked/oestrogen dependent VTE in 1st degree relative <50

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21
Q

How long after prophylactic/therapeutic LMWH should regional anaesthetic be avoided?

Study These Flashcards
A

Prophylactic - 12 hours

Therapeutic - 24 hours

22
Q

How often should platelets be checked if unfractionated heparin is used?

Study These Flashcards
A

Every 2-3 days from days 4-14 or until heparin is stopped

23
Q

What is the recommended calf pressure of graduated compression stockings?

24
Q

What was the mortality rate from VTE in 2006-2008?
What % were BMI >30?

How many had identifiable risk factors?

Study These Flashcards
A

0.70/100,000 maternities
60% obese

Risk factors in 89%

25
What is the incidence of antenatal PE according to UKOSS?
1.3/10,000 maternities
26
What is the absolute risk/incidence of VTE in pregnancy and the puerperium? When does it peak postpartum? And the relative risk?
Incidence 1-2/1000 Peaks week 3 RR 4-6x
27
What % of pregnancy-related VTE are due to heritable thrombophilia?
20-50%
28
By how much is VTE risk increased by admission to hospital?
x18
29
At what level of creatinine clearance does LMWH need to be adjusted?
<30ml/min for enoxaparin and dalteparin | <20ml/min for tinzaparin
30
What are the features of warfarin embryopathy and how many fetuses are affected at 6-12/40 exposure?
``` Hypoplasia of nasal bridge Congenital heart defects Ventriculomegaly Agenesis of corpus callosum Stippled epiphyses 5% ```
31
What are the 'high' risk factors for VTE and what is the LMWH regime?
Any previous VTE except a single event related to major surgery Anyone requiring antenatal LMWH High risk thrombophilia Low risk thrombophilia + FHx LMWH as early as possible 6/52 postnatally
32
What are the high risk thrombophilias?
Antithrombin deficiency Protein C or S deficiency Compound/homozygous for low risk thrombophilias APS with previous VTE
33
What are the low risk thrombophilias?
Heterozygous for Factor V Leiden or prothrombin G20210A mutations
34
What are the 'intermediate' antenatal risk factors for VTE and what is the management?
Hospital admission Single previous VTE related to major surgery High risk thrombophilia + no VTE Medical comorbidities Any surgical procedure e.g. appendicectomy OHSS (T1 only) Consider antenatal LMWH
35
What are the 'intermediate' postnatal risk factors for VTE and what is the management?
``` Caesarean section in labour BMI >= 40 Readmission/prolonged PP admission (>3/7) Surgical procedure in the puerperium Medical comorbidities >= 2 or more moderate risk factors ``` LMWH for 10/7; consider extending to 6/52 if persisting or >=3 moderate risk factors
36
What are the moderate risk factors antenatally for VTE and what is the management?
``` BMI >30 Age >35 Para >=3 Smoker Gross varicose veins Current pre-eclampsia Immobility FHx unprovoked/oestrogen VTE in 1st deg relative Low risk thrombophilia Multiple pregnancy ART/IVF Transient: Dehydration/HG, systemic infection, travel >4hrs ``` >= 4 - prophylaxis from T1 3 RFs - from 28/40
37
What are the moderate postnatal risk factors for VTE and what is the management?
``` BMI >30 Age >35 Para >=3 Smoker Elective CS Gross varicose veins Current pre-eclampsia Immobility incl long distance travel FHx VTE Low risk thrombophilia Multiple pregnancy Systemic infection Prem delivery SB this pregnancy Midcavity rotational operative delivery Labour >24 hours PPH >1L or blood transfusion ``` >= 2 risk factors - treat as intermediate risk
38
What are the top 5 increased risk factors for VTE (by OR)?
``` Heart disease - PE (aOR 43.4) Previous VTE (24.8) Immobility PN (10.8) Obstetric haemorrhage (9) SLE (8.7) ```
39
What is the management of a highly clinically suspicious DVT but negative on compression duplex ultrasound?
Discontinue anticoagulation treatment | Repeat USS on day 3 and 7
40
When should a temporary IVC filter be used?
When there is an iliac vein VTE or patients with proven DVT and recurrent PE despite adequate anticoagulation
41
What is the maintenance treatment for VTE?
Throughout remainder of the pregnancy and 6/52 postnatal, until 3/12 total treatment
42
What is the delay for giving LMWH following spinal/epidural catheter removal?
4 hours | Catheter should not be removed within 12 hours of most recent injection
43
How long should postpartum warfarin be avoided in women at high risk of PPH?
5 days
44
What is the relative risk of VTE in the puerperium?
20x
45
How many patients will develop a PE with untreated DVT?
15-24%
46
What % of women on peripartum anticoagulation develop wound haematoma?
9%
47
What is the prevalence of post-thrombotic syndrome following DVT in pregnancy? What is the guidance re: anti embolism stockings?
42% | >23mmHg worn for 2 years
48
what thromboprophylaxis for 29yr, pri, heterozygous for FV leiden
prophylactic LMWH for 10/7 p/n
49
what thromboprophylaxis for 24yr old pri, no Hx of VTE but homozygous for FV Leiden?
prophylactic LMWH antenatally and 6/52 p/n
50
what thromboprophylaxis for 28 yr old multi, BMI=42, no other RF
prophylactic LMWH for 10/7 post natal
51
32 yr old, multip, DVT in previous pregnancy, no other RF
prophylactic LMWH antenatally and 6/52 p/n
52
27yr old pri, has antiphospholipid syndrome, previous PE
high dose LMWH antenatally and 6/52 p/n plus long term anticoagulation

MRCOG Part 2 (97 decks)

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