VTE in pregnancy - Hazra notes

Question 1

What is the most common direct maternal mortality during pregnancy?

Answer 1

Venous thrombo-embolism (VTE)

VTE is a significant concern due to increased risk factors during pregnancy.

Question 2

How do factors VII, VIII, and X change during normal pregnancy?

Answer 2

Increase in concentrations from 12 weeks

Fibrinogen concentrations also increase.

Question 3

What is the status of fibrinolysis by one hour after delivery?

Answer 3

Normal

However, the postpartum period is the most hypercoagulable.

Question 4

What percentage of VTE cases occur in the left leg?

Answer 4

80%

This is a common site for thrombus formation.

Question 5

What is the incidence of VTE in pregnancy compared to non-pregnant women?

Answer 5

1-2 per 1000, 10 times more than non-pregnant

This highlights the increased risk during pregnancy.

Question 6

List some risk factors for VTE in pregnancy.

Answer 6

• Age > 30
• BMI > 35
• White ethnicity
• O blood group (protective)

These factors contribute to the likelihood of developing VTE.

Question 7

What is Anti-thrombin III deficiency?

Answer 7

An inherited condition that significantly increases VTE risk

It is one of the thrombophilias associated with high risk.

Question 8

What is the commonest thrombophilia associated with VTE?

Answer 8

Factor V Leiden mutation

This single point mutation affects 20-60% of women.

Question 9

What is the increase in VTE risk for heterozygotes with Factor V Leiden mutation?

Answer 9

6-8 fold increase

Homozygotes have a 30-140 fold increase.

Question 10

What is the prothrombin gene variant’s effect on VTE risk?

Answer 10

3-5 fold increase in heterozygotes

It leads to increased prothrombin levels.

Question 11

What is hyperhomocystinaemia?

Answer 11

A condition that can be genetic or acquired, increasing VTE risk by 2-3 fold

It may be associated with vitamin deficiencies.

Question 12

What is Anti-phospholipid antibody syndrome (APLA)?

Answer 12

An acquired condition that significantly increases VTE risk (>70%)

It can be primary or secondary to other autoimmune diseases.

Question 13

What initial investigations are performed for suspected VTE?

Answer 13

• ECG for non-specific changes
• D-dimer test (not useful in pregnancy)

Routine thrombophilia screening is not recommended.

Question 14

What is the initial treatment for VTE in pregnancy?

Answer 14

Dalteparin and enoxaparin BD or tinzaparin OD

Low molecular weight heparins (LMWH) are preferred.

Question 15

What is the complication associated with UFH?

Answer 15

Paradoxical arterial and venous thrombosis

This is a significant risk factor when using unfractionated heparin.

Question 16

What imaging is used to diagnose DVT?

Answer 16

Compression duplex ultrasound

It is often repeated in one week.

Question 17

What is the fetal radiation exposure associated with CTPA?

Answer 17

0.1 mGy

This is lower than V/Q scan exposure.

Question 18

What is the recommended treatment plan after DVT?

Answer 18

Therapeutic anti-coagulation for at least 3-6 months and for at least 6 weeks after delivery

This is crucial for preventing recurrence.

Question 19

What complications can arise from warfarin use during pregnancy?

Answer 19

• Warfarin embryopathy
• Hypoplasia of nasal bridge
• Agenesis of corpus callosum
• Stippled epiphyses

These are significant risks associated with warfarin.

Question 20

True or False: Both heparin and warfarin can be used during breastfeeding.

Answer 20

True

Both medications are considered safe for breastfeeding.

Question 21

What is the treatment for cerebral venous sinus thrombosis?

Answer 21

IV heparin, thrombolysis, then oral warfarin for 6 months

Good prognosis is expected with appropriate treatment.