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MRCOG PART 2 SBAs and EMQs

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ESSAY 279 - Thrombophilia in pregnancy

Posted by Farzana N.
VTE is the leading cause of maternal mortality in the UK.This woman with previous DVT and thrombophila is at high risk of VTE during pregnancy,which itself is a procoagulant state.
a)A careful history,examination and investigations should be centered around identification of risk factors and her risk assessment,so that adequate thomboprophylaxis may be given.
Obstetric history is taken about her parity and outcome of previous pregnancies. High parity is a risk factor for VTE and poor outcome of her pregnancies would warrant increased fetal surveillance. Medical history is taken about the previous DVT and treatment she received. If she is on long term warfarin therapy,it should be changed to heparin as warfarin is teratogenic.H/o hyperemesis during this pregnancy should be enquired so that it is adequately treated to avoid dehydration. Presense of chronic medical illnesses such as IBD,sickle cell disease or nephrotic syndrome increase the risk of VTE.
Examination should include weight and height.BMI >30 is risk factor.presense of gross varicositie should be noted.
b)Antenatal care should be in a consultant led clinic as she is a high risk pregnancy. According to RCOG recommendations ,this woman with previous DVT and positive thrombophilia would require thromboprophylaxis during pregnancy and for 6weeks postpartum .This should be started from the early pregnanacy.Heparin is the ideal anticoagulant during pregnancy and the woman should be reassured that it does not cross placenta and is not harmful for the baby.Heparin can be given as UF heparin or LMWH.Long term UF heparin use during pregnancy may result in osteoporosis and fractures,but this risk is low with LMWH.Risk of hemorrhage and thrombocytopenia is also less with LMWH.Hence it is the preferred anticoagulant in pregnancy. Twice daily s/c dose is also convenient for the patient. She should be taught self injection and safe disposal of syringe.
Woman should be advised to avoid dehydration and immobility. She should be informed about the symptoms of DVT and advised to report immediately if she feels any symptoms. Baseline investigations e.g FBC, Clotting profile,U&E,LFT,RFT and urinalysis should be done, prior to starting anticoagulation therapy.LMWH levels should be checked by measuring antiXa levels. Platelet count is checked after one week. Dating scan should be done.
Woman should have more frequent antenatal visits, so that any complications or infections arising during pregnancy can be adequately treated.
c)Woman should receive her prophylactic dose of heparin on the day before delivery. Morning dose should be omitted on the day of surgery and operation performed in the morning.Thromboprophylactic dose of heparin should be given 3hours after postoperatively or4hours after insertion or removal of epidural catheter. Canula should not be removed within10-12 hours of most recent injection.
There is increased risk of hematoma following c- section ,so fastidious homeostasis is secured and drains kept. Skin should be closed by interrupted sutures.
Postpartum thromboprohylaxis may be continued with warfarin.Breastfeeding is not contraindicated. Early mobility and good hydration should be ensured.Contraception should discussed and advised against COCP,as it is contraindicated.

Posted by A S.
Pulmonary embolism is a direct cause of 33 % of maternal mortality in UK . Inherited thrombophilia predispose to many risks as PE , miscarriage and still birth . The relative risk for thrombosis in factor V leiden deficeincy is 7 .
The lady presented while 8 ws pregnant with previous history of VTE , she is considered at high risk of developing another VTE .
History will include details about previous pregnancies and their outcome , history of PET and if she is currently on anticoagulation since her VTE as this will be considerd very high risk recquiring therapeutic doses of anticoagulation. we have to ask about vomiting and drinking enough fluids .
We will examine for weight ( 90 Kg or less ) ,BMI (30 or more ) , BP,varicose veins and signs of recent DVT as leg swelling becuase the risk will increase once she is pregnant.
Management plan must be explained to her and documented in her records . She will be started enoxoparin 1 mg/kg daily or tinizaparin 75 IU/Kg daily . Graduted elastic stockings will be offered . No role for warfarin because of its trratogenic effects unless she prosthetic heart valves . Advice about having enough fluid intake , avoiding immobilization , chest pains and pain and swelling of her legs .
She must be warned if she will develop labour pains before the date for elective CS to stop her injections and go toi the hospital .
The day before the operation she will be admitted ,routine preoperative work done , kept NPO starting midnigt and IV fluids started to avoid dehydration .Intraoperative pneumatic stockings will be worn .
She will start anticoagulation 6 hrs postoperative unless epidural catheter is in place then 4 hrs after removal . Early mobilization and adequate hydration are important.
Anticoagulation will continue for 6 ws postpartum withe the same dose or with warfarin as it is safe durring breast feeding . The target is INR 2-3 .
Regarding contraception ,advice against COC and offer longacting reversible methods or intrauterine device .
Stress on the importance of wearing GES for 2 years and the importance of prenatal counslling as in this pregnancy she presented late .
Posted by Joshimin F.
a.
She should be assess for risk of thromboemboli and this assessment should be repeated if she is admitted to hospital or develop other intercurrent problem. Her parity and body mass index should be obtained as parity of four or more and body mass index of 30 or more are associated with increase risk of venous thromboembolism. Gross varicose vein should be noted and she should have assessment of post thrombotic leg syndrome. Her previous and current medical problem should be explored such as inflammatory bowel disease , nephrotic syndrome, myeloproliferative disorders with regards to follow up, disease progress and treatment. Her medication should be reviewed. If she is still on warfarin, she should be advised to stop and change to heparin.
b.
She should be managed within multidisciplinary care including obstetrician and haematologist. Advice from haematologist should be sought if there is uncertainties about thromboprophylaxis. She should be offered thromboprophylaxis preferably low molecular weight heparin as early in pregnancy as practical and continue until six weeks post partum. Low molecular heparin is as effective as and safer than unfractionated heparin in pregnancy. Warfarin should be avoided during pregnancy. Unfractionated heparin is associated with heparin induced thrombocytopaenia, increased risk of osteoporosis and fracture. She should be provided with needles and syringes and advise on how to store and dispose them. She should be advised not to inject any further heparin if she is in labour or thinks she is in labour. She should be advised to stop smoking, minimize immobilisation and avoid dehydration during pregnancy. She should be encouraged to wear graduated elastic compression stocking throughout pregnany and six weeks post partum. She should be informed about signs and symptoms of venous thromboembolism including leg pain, swelling, lower abdominal pain, dyspnoea, chest pain, haemoptysis. She should seek doctor’s advice immediately if she notice any of these symptoms. She should be provided with written information on venous thromboembolism
c.
She should receive a thromboprophylactic dose of lower molecular weight heparin on the day before surgery. On the day of delivery, the morning dose should be omitted and the operation performed that morning. The thromboprophylactic dose of low molecular weight heparin should be given by three hours post operative or four hours after insertion or removal of epidural catheter. Regional anaesthesia should not be given until at least 12 hours after the previous prophylactic dose of lower molecular weight heparin. The epidural catheter should not be removed within 12 hours of the most recent injection. She should be offered to wear leg stockings preoperatively. Antibiotic prophylaxis should be given during surgery to prevent infection. She should received thromboprophylactic dose of low molecular weight heparin six weeks post delivery. Warfarin is safe after delivery and for breast feeding. It should be commenced on the third day post partum and low molecular weight heparin should be continued until international normalised ration is greater than 2.0.
Posted by Osman A.
a) Previous history of DVT (deep vein thrombosis) and the presence of thrombophillia is associated higher risk to develop recurrent VTE. History of previous prolonged anticoagulation should be asked as this will put the patient into category of very high risk (may require higher dose or treatment dose of thromboprophylasis). Presence of medical illness like SLE or hypertension will add on in her risk to develop VTE. Previous family history of VTE should be asked as this would make her risk risk is higher to develop VTE. Her BMI should be calculated as BMI > 30 is consider moderate risk factor and presence of varicous vein should be noted.
b) She should be given antenatal and 6 weeks post natal thromboprophylaxsis in a form of LMWH or unfractionated Heparin. LMWH is associated with less of bleeding. Platelate count should be monitored if unfractionated Heparin is given. IF she was on prolonged anticoagulation, she is classified as very high risk, thus she may need higher dose or threatment dose of thromboprophylaxsis. In this case hematologist opinion should be sought. Educate the patient that if she thinks she is in labour, she should stop her injection. Avoid dehydration and immobilization. Presence of symptom and sign of DVT or Pulmonary embolism should prompt proper investigation. Ted stoking is useful for the patient especially those with high BMI. Ensure that the management of this patient follows local guideline.
c) Thromboprophylaxsis dose can be given one day before her elective CS (Caesarean Section). Morning dose of thromboprophylaxsis before going for SC should be omitted. If she receive therapeutic dose of LMWH ( for those with history of prolonged anticoagulation or homogenous factor V Laden), the injection should be reduce to thrombophylasis LMWH on day before the CS. Regional sthesia should not be given within 12 hours of last thromboprofilasis dose of LMWH. Ensure good haemostasis during surgery and closed the skin using interrupted suture to drain any formation of haematoma. Avoid dehydration and immobilization. Ted stoking should be applied during surgery.
Posted by Manoj Babu  R.
Pulmonary Embolism arising as complication of deep vein thrombosis is the leading cause of maternal mortality in the UK. Pregnancy increases the risk of developing thromoebolic complication which is substantially modified by various risk factors. Hence an assessment of risk is mandatory in every pregnacy, ideally as a preconceptional counselling as the risk manifests early in pregnancy.

The assesment should include history cilnical examination and investigations. Maternal age (greater than 35 years), parity(>4), obesity, previous obstetric, medical, surgical histiory and family are important. The history of past DVT is important in this case. otherwise Heterozygous factor V Leiden is low risk thrombophilia. The duration since the last episode of DVT, atypical sits like axillary veins, and current or past treatment for the same are important. XClinical examination should include mesuring BMI, look for evidance of varicise veins etc. This patient is only 30 years of age, but the combination of heterozygous factor V leiden along with previous history of DVT puts her at high risk.

Considering the risk factors and need of careful montoring during pregnancy she should be having a consultant led care woth involvement of mulidiciplinary team comprising of haematologist. If she already on Warfarin is should be changed to low molecular weight heparin (LMWH) as the former is teratogenic. If not on antithrombotic treatment she should given option of prophylatic LMWH and should be continuied till 6 weeks postpartum.She should be told that this will reduce the risk o0f developing DVT and also complications like IUGR AND Preeclampsia This is because even though heterozygous factor V leiden is low risk factor, her history of previous DVT is an indication fot LMWH. She should be reassured that LMWH is a known teratogen and does not require and monitoring. She should have the routine bookong bloods and folic acid supplementaion at the standard doses. She should have more frequent antenatal visis to detect complications like gestaional hypertension, intruterinr growth restriction, preterm labour. She shold le counselled about the importance regular ambulation and good hydration.

If she opts for an elective LSCS after couselling she should explained athe it puts her at a slightly higher risk of developing thromoembolic complications compared to noirmal delivery anf the various mesaures availabble ti reduced. One should avoid preoperative admissiona nd prolonged bed rest which may increase the risk of thrombosis. proper hydation should be maintained through out the perioperative period. She should adviced not to take any further heparin injections once labour pain starts and to report to the delivery suite. Further doses should be gien only under supervision. Avoid giving LMWH 4 hours before and after insertion or removal of epidural. Graduated TED stocking should be used durind surgery and in the post operastive period, Encourage early ambulation during the post operative perod to prevent venous stasis.
Posted by DR N.
clinical assessment for this woman started with detailed history about the previouse DVT ,time?during pregnancy,associated with cocp intake,hx.of anticoagulant drug,recrrence of DVT.risk assessment age,parity if >4 kids,smoking,immobility,previouse surgery,fracture,hx. of medical illness like nephrotic syndrom.review symptoms related to venousethromboembolism like SOB,chest pain,leg swelling and pain.clinical examination started with general exam;P/BP/RR/TEMP.chest+cardiac exam.leg exam for swelling,varicosity.
TheANC needs multidisciplinary team as she is ahigh risk pregnant,to councell the pt of the need to start antenatal prophylactic anticoagulant after full basic ix.FBC,U+E,LFT,PT+APTT.LMWH vs unfractionated heparine.heparine vs warfarine.need of follow up +complications of each to be discussed.LMWH is preferred with F/U of atixa,less osteoperosis.NEED of fetal survillance for good outcome
ELECTIVE C.S take written consent.discuss with anasthetist options of anasthesia+advantage of each.haematologist F/U.omit heparin 12 hrsbefore surgery +restart 4 hrs after surgery+12hrs after epidural anasthesia+4 hrs after removal of cathetor.continue on heparin for 6 wks postnatal or change on warfarine after discussion with haematologist.no C.I withbreastfeeding with watfarine.avoid contraception with COCP
Posted by S D.
a) Detailed history about previous DVT, whether spontaneous or provoked in association with COCP / trauma should be asked. It should also be asked if it\'s objectively confirmed or if she had taken prolonged anticoagulation as this influences whether she needs to take heparin antenatally in this pregnancy. Previous obstetric history and their outcomes, any medical disorders that she suffers with such as SLE, Diabetes, inflammatory bowel disease should be asked. Any medications being currently taken such as warfarin should be asked and this needs to be changed to heparin as warfarin is teratogenic.
b) Management is multidisciplinary with involvement of obstetrician, haematologist, anaesthetist and GP. She should be started on prophylactic heparin during pregnancy and for 6 weeks postpartum in close liasion with haematologist. She should be referred to anaesthetist to discuss epidural analgesia during labour and other techniques for operative deliveries. The management plan should be clearly documented in the notes. Irrespective of the risk, she should be advised to avoid dehydration and immobility during pregnancy. Signs and symptoms of VTE should be explained and be advised to present promptly for medical assessment if any symptoms develop. She should be taught about safe disposal of needles and syringes as she would be using heparin at home. Routine antenatal investigations such as dating scan, screening tests for Downs and neural tube defects and detailed anatomy scan at 20 weeks should be offered. In addition because of thrombophilia, she is at increased risk of preeclampsia and IUGR. Frequent antenatal visits should be advised for closer monitoring of BP and urine for protein. Also if there is suspicion of IUGR, serial growth scans+/- dopplers should be arranged.
c) Thromboprophylactic dose of heparin should be given a day before C/S and the morning dose of heparin should be withheld on the day of C/S. Regional anaesthetic techniques should be avoided for 12 hrs after prophylactic dose of heparin.Intra-operatively, pneumatic compression stockings should be used. Meticulous haemostasis should be ensured, wound drains should be used liberaly as there is increased risk of haematoma and skin should be closed with interrupted stitches. Heparin should be given by 3 hrs after C/S. It should not be given within 10 hrs of insertion or removal of epidural catheter. If there is PPH, then unfractionated heparin should be given rather than LMW heparin as it is easier to reverse with protamine sulphate. Post-op, TED stockings should be fitted, dehydration and immobility should be avoided. If there is suspicion of VTE, then therapeutic heparin should be given till confirmation with objective testing obtained. Estrogen containing contraceptives should be avoided in this woman.
Posted by Sowmithya B.
Venous thromboembolism is the one of the leading causes for maternal mortality in the UK.
It is a high risk pregnancy in view of her FVL carrier status and previous history of DVT. Clinical assessment should start with complains. Since the risk of thromboembolism starts from first trimester itself she should be enquired about symptoms suggestive of the same. Also she should be enquired about hyperemesis as dehydration accompanying it can predispose to thromboembolism. Detailed history including her age, parity, ethnicity, detailed obstetric history to exclude poor obstetric performance like recurrent miscarriages, severe early onset preeclampsia or IUGR, late fetal loss and abruption should be assessed. Detailed medical history including the site of DVT and how it was diagnosed and treatment given should be evaluated. If she is on warfarin it has to be changed to heparin in view of 33% risk of warfarin embropathy if taken between 6 and 12 weeks. Clinical examination should be directed to assess her risk of thromboembolism like obesity.
Multidisciplinary team involving obstetrician, haematologist and specialist midwife is essential
Pregnancy should be accurately dated by ultrasound.FVL is associated is 5-10 fold increased risk if heterozygous and more than 100 fold increased risk if homozygous. With previous history of DVT antenatal heparin therapy is indicated and hence FBC, urea, electrolytes, liver function test are to be checked before starting heparin. Subcutaneous low molecular weight heparin is more effective than unfractionated heparin with lesser side effects like thrombocytopenia , osteoporosis and haemorrhage. Since pregnancy is associated with greater variation in heparin binding proteins monitoring with anti xa level is indicated (ideal is 0.6 – 1u/ml 3 -4 hours after last dose) .platelet count should be monitored every month as thrombocytopenia is also associated with thrombosis. Mother should be taught about self injections and safe disposal. She also should be advised about symptoms and signs of DVT and advised to stop taking heparin injection if she thinks that she is going into labour and to report to the hospital immediately.
Anomaly scan is advised between 18-20 weeks. Preeclampsia screen by BP, maternal weight and urine protein should be checked every visit. Serial fetal growth scan every 4-6 weeks from 20 weeks should be done. From 32 weeks non stress test and biophysical profile should be done along with maternal monitoring of fetal movements.
Prior to delivery the therapeutic dose of heparin should be reduced to prophylactic dose. Dose on the day of surgery should be withheld. Regional anaesthesia should be given 12 hours after prophylactic and 24 hours after therapeutic dose of heparin. Removal of catheter should not be done within 12 hours of last dose. Heparin should not be given within 4 hours of insertion or removal of epidural catheter. Therapeutic dose can be started on the same day evening. Excess blood loss and dehydration should be avoided. Risk of wound haematoma is about 2% . Meticulous haemostasis should be achieved. Drains can be kept. Skin closed by interrupted sutures.
If patient was already on warfarin , it can be restarted. But heparin should be given for first 4 days of warfarin therapy until INR stabilises to avoid skin necrosis and rebound thromboembolism. Breast feeding is safe. Contraception should be advised. COCP to be avoided
since FVL is autosomal dominant should baby be offered PCR to check its status? thank you sir.
Posted by Ron C.
A.
Patients with factor V Leiden mutation are more prone to develop DVT, especially in pregnancy which is a hyperthrombogenic state itself. All these patients will require prophylactic LMWH in the 6 weeks following delivery. History taking and physical examination will be targeted on identification of risk factors, as in these cases LMWH will also be given during the entire pregnancy;
Is she homozygous, did her previous DVT occur during pregnancy, is she above age 35 ? Physical examination should focus on presence of varicose veins and obesity (BMI >30).
Information regarding previous pregnancie(s) is important, in particular occurrence of pregnancy-related hypertensive problems, PET, IUGR or even IUD, which are more likely to occur and will affect management. Further history taking needs to identify other medical problems that may interfere with her factor V mutation or which may affect the pregnancy in general.
Last but not least a more general historytaking and examination is important to identify other potential problems.
B.
If indicated by presence of additional risk factors, she will be started on LMWH (ie Fragmin 5000 od sc in average weight woman) till 6 weeks post-delivery. If previous pregnancy was complicated by hypertension or PET, low dose aspirin (75 mg od) is started till 36 weeks. Bloods for serology, FBC, blood-grouping and irregular antibodies are taken as routine in first trimester. In presence of varicose veins, stockings are recommended. Ultrasound and screening bloods for antenatal chromosome screen are arranged, as well as a 20-weeks anomaly scan. Standard bloods (FBC and irr. Antibodies) at 28 weeks. If previously there had been IUGR (or IUD), serial ultrasound growth + Doppler flow is arranged for 28, 32 and 36 weeks. Blood pressure and screen for proteinuria is done on every visit; if blood pressure rises, more frequent follow-up is indicated. Vaginal delivery will be allowed provided no complications occur.
C.
Caesarean will be done at 39 weeks. Liaison with anesthetist in pre-op assessment clinic. Regional anesthesia is preferred provided no contra-indications, as it will reduce chances for DVT. LMWH will be omitted on morning of surgery. Bloods are taken for group and save, FBC and to ensure a normal coagulation profile, so that the anesthetist can be confident that regional anesthesia is safe. Patient will have TED stockings throughout procedure and post-surgery.
LMWH will be restarted 2-4 hours post-delivery to continue for 6 weeks. Moving the legs and early ambulation are encouraged. Family planning needs to be discussed, as COCP are not a suitable option for this patient.
Posted by Mark D.
a)

Clinical assesment is with the aim of identifying the other high risk factors. History of present symptoms if any like hyperemesis or dehydration should be enquired as it predisposes to thrombosis.History of the past episode of DVT should be taken. the site,any precipitating factor other than inherited thrombophilia like, pregnancy, coc pill, long haul travel.History of present medications like warfarin if nay should be asked.if so it need to be changed to heparin to avoid warfarin embryopathy.
History of any past illness like inflamatory bowel disease or sickle cell disease should be asked as they may precipitate thrombosis.
Her thrombophilia screen report should be reviewd to rule out any combination defect with prothrombin gene mutation,antiphospholipid antibody and to check if factor 5 leiden mutation is homozygous or heterozygous.
General examination should be done to check Bp,varicose veins ,wt and BMI and chest and per abdominal examination.baseline investigation like CBC, liver and renal function tests and coagulation profile should be sent.
A dating scan should be arranged at 10-11 weeks to confirm period of gestation and viability and to moniter growth at later gestation.

b)

Management should be under a multidisciplinary team consisting of Hematologist,
consultant Obstetrician and Anesthetist.
Patient should be started on thromboprophylaxis with low molecular weight heparin as soon as possible and be continued till 6 week post partum.timzaparin,daltaparin,or enoxaparin can be used according bodyweight by the hematologist and according to the local protocol.
She should be counselled regading need for regular ANC, compliace with injections and risks of discointnuing the treatments. she should be informed of the signs and symptoms of DVT and pulmonary embolism and asked o report to hospital immediately in case of such symptoms. A 24 hour contact number and written information should be provided.
Low molecular weight heparin (LMWH) should be preffered over unfractionated heparin due to equal efficacy and lower risk of thrombocytopenia and osteoporosis.
there is no need for routine monitering with anti Xa levels with prophylactic dose.Instructions on safe disposal of syringes and needles ahould be provided.Warfarin should not be used due to the risk of warfarin embryopathy.
serum screeing for aneuploidy and anomaly scan at 18-20 weeks should be done as routine.She should be reasured that heparin does not cross placenta and is not teratogenic.
Dehydration and infection should be avoided.TED grade II stockings should be worn if she has varicose veins.
she should be instructed not to inject any further dose of LMWH if she has symptoms of labour.

c)

Patient should not be given the usual prophylatic dose of heparin on the day of surgery. Baseline investigations of CBC and coagulation profile and blood group and save should be done.
Consent should be taked including the risk of wound hematoma, and hemorrage and any objections to it noted and advance directive taked if so.

Senior Anesthetist, hematologist should be consulted.Regional anesthesia can be given after 12 hours of last dose of prophylactc LMWH.Surgery should be done by a senior obstetrician and meticulous hemostasis achieved.
Intraperitoneal and subcutaneous drain can be placed if there is risk of hemorrage.TED stockings should be used during and after surgery.

Post operatively,adequate hydration should be maintained and early ambulation encouraged.
The prophylactic dose should be resumed 4 hours after epidural insertion/ removal and 3 hours of surgery. If there is risk of hemorrage then iv unfractionated heparin should be used due to its easy reversal with protamin sulphate and short half life.
If epidural is continued for post operative pain relief LMWH can continue with catheter in situ but the catheter should be removed after 12 hours of last dose of heparin. Next dose of lmwh can be given 4 hrs after catheter removal.
Warfarin can be used postnatally after counselling regarding the need for monitering the with bloodtests.It should be started 3-5 days after surgery when the risk of hemorrage has decreased.
Breast feeding is safe with heparin or warfarin.Further advise on contraception should be given.COC pill should be avoided. She should be reviewed at 6 weeks post partum for risk assesment and need for further anticoagulation with the hematologist.




Posted by M M.
a) History of previous DVT and thrombophilia are associated with high risk of venous thromboembolism (VTE) in pregnancy and puerperium. History of her previous DVT and the duration of treatment received should be noted. History of long-term warfarin therapy puts her at very high risk of VTE that requires high dose of prophylaxis. Her thrombophilia status should be clarified as homozygous Factor V Leiden or combined thrombophilia defects that also require higher thromboprophylaxis dose. The woman should be assessed for other VTE risk factors such as parity more than 4, obesity (BMI more than 30), gross varicose veins, paraplegia and also co-morbidities such as inflammatory bowel disease, nephotic syndrome or myeloproliferative disorders.

b) The woman will require a hospital based antenatal care and a multidisciplinary approach involving the obstetrician & haematologist. She should be counselled the need for antenatal & postnatal thromboprophylaxis. Risk of long term heparin treatment such as thrombocytopenia, osteoporosis and fractures explained to the patient and documented. However these risks are low with low molecular weight heparin (LMWH) compared to unfractionated heparin. Thromboprophylaxis should be started as soon as possible or warfarin changed to heparin. FBC, renal and liver function tests should be obtained as baseline. Platelet count should be checked one week after starting LMWH and repeated monthly thereafter. Provided that the woman\'s renal function is normal, monitoring of anti-Xa level is not required. The woman should be taught self-administration of heparin and safe disposal of sharps. Advise should be given regarding TEDS use and avoidance of dehydration or immobilisation. She should also be explained the symptoms and signs of VTE such as leg pain or swelling, chest pain, shortness of breath or haemoptysis and advised to seek immediate medical attention. Any of the above symptoms should prompt thorough investigation. The woman should be advised to omit heparin dose if she is in labour or thinks she is in labour until she is properly assessed.

c) The delivery of the woman should be planned with the anaesthetist. Blood should be crossmatched as appropriate. The woman should take her prophylactic heparin dose as usual on the day before surgery. On the day of delivery, the morning dose should be omitted. Epidural or spinal anaesthesia should be sited only after discussion with senior anaesthetist and the woman properly counselled of benefits & potential risks. Regional anaesthesia should not be given at least 12hours after the last prophylactic dose. Prophylactic LMWH should be recommenced by 3 hours post-operatively or 4 hours after insertion or removal of epidural catheter. Unfractionated heparin should be used if there are any bleeding or potential complications such as progressive wound haematoma, suspected intra-abdominal bleeding or postpartum haemorrhage. Patient should continue thromboprophylaxis until 6 weeks postpartum. Warfarin is safe after delivery and for breastfeeding, although it requires closer monitoring and has increased risk of postpartum haemorrhage. It may be commenced on day 2 or 3 if the woman wishes.
Posted by Neelam A.
A. We need to take a detailed history and examination about this episode enquiring whether it was provoked or unprovoked, family history of similar illness, treatment taken. We should also take other risk factors in-to considerations such as age, BMI > 30, multiparity, smoking, immobilization and hyperemesis.
We need to take booking bloods in addition to liver function test and urea & electrolytes before starting treatment.
A dating scan should also be organized to check viability and to calculate EDD.
B. Her care should involve multidisciplinary approach including obstetrician, haematologist, anaesthetist and paediatrician. After liaising with haematologist, she should be started on prophylactic dose of low molecular weight heparin (LMWH) in addition to folic acid supplement. She should be counseled and assured that this drug does not cross the placenta and non-terratogenic to fetus. Advantages of LMWH over un-fractioned heparin are single daily dose, low risk of osteoporosis and thrombocytopenia. It does not require any monitoring tests either. On the other hand, warfarin does cross the placenta and a terratogenic drug. Hence, it should be avoided in pregnancy.
She should be provided monthly injections supply and also taught how to inject and safe disposal of sharps. She should also avoid dehydration, immobilization as well as long-haul flights. She should also report to hospitals in case if she experienced any symptoms and signs of DVT or pulmonary embolism. She also needs frequent antenatal visits in combined clinics. She would also require growth scans, liquor volume and Doppler from 28 weeks as she is at high risk of growth retardation.
C. LMWH should be stopped 12 hours before regional anaesthesia for surgry. We should also liaise with anaesthetist and haematologist. She should be counseled for an increase risk of bleeding per-operative. All precautions should be taken to reduce to amount of blood loss at the time of surgery. Bloods should be done to check Hb, platelets, and cross match. Interrupted skin sutures or clips should be used as there is a increased risk of wound haematoma. Drains should be left both in peritoneal cavity and in subcutaneous tissue. Early mobilization, adequate hydration and TED stockings should be encouraged. LMWH should be re-started 4 hours after surgery provided there is no postpartum haemorrhage. In 2-3 day time it should be switched to warfarin. Both heparin and warfarin should be continued until INR is maintained at level of 2.0-2.5. Infant should receive injection vitamin K. She can breast feed the baby. She would need warfarin at least 6 weeks post-partum. She should be followed up under haematologist care.
She should also be advised to avoid COCP for contraception.
Posted by Manoj M.
a) Factor V leiden is an inherited thrombophilia and with a past history of deep vein thrombosis(DVT) increases the risk of thromboembolism in pregnancy.
Clinical assessment incudes taking history of details of DVT episode and if currently on warfarin as this is contraindicated antenatally.
History of smoking and history of other medical conditions like cardiac diseases, myeloproliferative diseases, inflammatory bowel diseases should be excluded as these will increase the risk of thromboembolism.
Details of previous pregnancy and parity should be taken as parity of >4 will increase the risk of thromboembolism.
Examination should include blood pressure assessment as hypertension contribute to thromboembolism, body mass index(BMI) obtained as BMI >30 increases the risk of thromboembolism and examine legs for varicose veins as may contibute to DVT.

b) Antenatal care should be under multi disciplinary team including obsteticians, haematologist, anaesthetics.
Ideally her antenatal care should be in a combined obstetric-haematology clinic.
Initial dataing scan should be organised and viability confirmed.
Low molecular weight heparin (LMWH) prophylactic dose should be started as soon as possible antenatally and LMWH is effective and safer compared to unfractionated heparin and this should be continued throughout antenatal paeriod and continued 6 weeks postnatally.
Dosing and treatment regimen as per hospital protocol, baseline bloods done prior to staring LMWH including haemoglobin levels, platelets, liver function and renal function tests.
Patient should be taught to administer LMWH and explained regarding safe disposal of needles and sharp bins provided.
If patient is on warfarin this should be changed to LMWH antenatally as warfarin causes embropathy.
Detailed anomaly scan should be offered between 18-20 weeks to exclude fetal anomaly especially if patient was on warfarin antenatally.
She should be advised to avoid immobility and good hydration as this increases the risk of thromboembolism.
class2 elastic stocking should be recommended throughout pregnancy and 6-12 weeks postnatally.
And advice against smoking to reduce the risk of thromboembolism.
Low dose aspirin is safe in pregnancy but the role of concurrent ususage with LMWH in prevention of thromboembolism is unclear.

c)She should have a pre-operative anaesthetic assessment as incresed risk of anaesthetics.
For delivery by elective caesarean section(cs) she should have her thromboprophylactic dose of LMWH on the day before of her operation and on the day of operation not to have have the morning dose and have the operation on the day in the morning.
Thromboprophylaxis should be continued 3-4 hours after cs for 6 weeks postnatally.
Increase risk of wound haematoma with usuage of thromboprophylaxis should be explained to the patient.
Consent should be obtained prior to cs and operation done preferrably under regional anaesthesia(epidural/spinal)
During operation minimise blood loss and avoid blood transfusion as this increases the risk of thromboembolism. usuage of automated pneumatic compression during cs also reduces the risk of thromboembolism.
Good hydration, avaoid prolonged immobility and thromboembolic deterrant stocking reduces risk of thromboembolism.
Post natally thromboprophylaxis can be done by LMWH or warfarin as both is safe with breast feeding and the switch from LMWH to warfarin done from day 2-3 postnatally.
Contraception should be discussed and cocp avoided as contraindicated with increased risk of thromboembolism.
Post natal haematology appointment ideally around 6-8 weeks should be organised.
Posted by Priti T.
a]VTE is the leading cause of maternal mortality in U.K.in the current triannual reports.Pulmonary Embolism is responsible for 33% of the direct Maternal Deaths.This 30 years Old pregnant patient wit FVL mutaion and previous Hx of DVT is a high risk for the development of VTE in the current pregnancy.Thrombophilia FVL mutation increases this risk by 4 fold in the heterzygous state;but the exact effect of FVL on foetal growth and pregnancy outcome remains uncertain otherwise.Patient should be asked in Hx about her parity and the prevoius obstetric losses.Parity greater than 4 increases the chance of VTE and bad obstetric hx requires more intensive foetal monitoring.Other medical risk factors like sickle cell disorders,SLE,Myloproliferative disorders may be excluded.Patient should have the relevent physical examination like Hydration,BMI[weight and height],Varicose veins.Obesity,smoking,dehydration increases the risk for VTE.


b] Patient should attend high risk antenatal clinic under the multidisciplinary team of Consultant Obstetrician and the Haematologist.She should have frequent Antenatal visits every 2 weeks.Warfarin is stopped if she was taking before and switched with Heparin.She should have a dating USG scan to confirm the viability of the foetus.Thromboprophylaxis with Heparin is started immediately after the scan and she should be informed that it will be continued till 6 weeks postpartum.She should be given the written instruction and contact no of the clinic to report immediately in view of symptoms of chest pain ,calf swelling or any other complaints.Adequate hydration is adviced and she should report and be treated early for hyperemesis.Folic acid 5mg is given till 12 weeks .Compressed Stockings[TEDs]are adviced to be worn and she is intructed to avoid immobolisation and long haul flights.
Various Investigations are done Like Blood G&Save,FBC ,U&E,RFT,LFT.UrineMSU analysis before starting the heparin therapy.Weekly Platelet count should be done for the monitoring.The Choice of Thromboprophylaxis is s/c LMWHeparin or I/V UH[Unfractionated Heparin]Warfarin is a teratogenic drug and is not given in the pregnant patient.It causes chondrodysplasia punctata,nasal hypoplasia in the foetus especially in the first trimester.
LMWH is preferred because of easy administration and does not require monitoring.Patient herself can be taught self injection and the safe disposal of the needles.It does not have the adverse effects associated witi UH like thrombocytopenia and osteoporosis.Monitoring by Anti Xa level is not required.
UH has the advantage of rapid reversal by Injection Protamine in view the patient goes in preterm labor or emergency CS.It has adverse effects like thrombocytopenia,osteoporosis.It is monitored by weekly platelet counts and APTT is generally not required.
Foetus should have anomaly scan at 20 weeks and growth is monitored regulary by biometry 2 weekly and amniotic fluid volume deepest pocket/doppler uterine artery velocity scan in the last trimester.
Patient should be adviced to omit the injection of Heparin if she goes in Preterm labor and report immediately

c]This patient with thrombophilia should stop LMWH Injection 12 hours before the elective CS at 39 weeks of pregnancy.Elective CS should be done by the consultant Obstetrician ,in consultation with senior anasthetist.The morning dose of LMWH is omitted and CS done in the Epidural Anasthesia.Patient is adequately hydrated and Teds should be applied peroperatively also.During Surgery adequate haemostasis is achieved to prevent wound haematoma,with gentle tissue handling and the prophylactic antibiotics.Epidural cannula should not be removed until 10-12 hours after the last injection of Heparin.Thromboprophylaxis with LMWH should be started 3 hours after the operation or 4hours after the removal of the epidural cannula.It is continued till 6 weeks post partum.Patient can be switched to warfarin as it can be given orally and is safe in breast feeding.Early mobilisation is adviced with good hydration and TEDs .COCP are not advised but patient can be put on progestrone only pills .
Posted by J P.
j wrote
a.Venous thromboembolism is an important cause for maternal morbidity and mortality. Clinical assessment includes careful elicitation of history and clinical examination. I will enquire regarding previous deep vein thrombosis, it’s site, duration of treatment and occurrence of any association with OCP or pregnancy. Eliciting site of occurrence is important since DVT in unusual sites are of prognostic significance. Past obstetric history like recurrent fetal losses will also be enquired.On examination I will look for her height, weight, BMI and blood pressure which may be other independent factors in this pregnancy.
B] Antenatal care involves a multidisciplinary care involving hematologist. Drug modification if needed, if patient taking warfarin will be done. Early USG will be done to find out fetal viability since there is increased risk of fetal loss in thrombophilia. The maternal risk due to anticoagulation, recurrent VTE, pulmonary embolism, post phlebitis syndrome and PIH will be explained. Fetal risks are fetal loss, IUGR, still birth, anomalies due to warfarin. Patient will be anticoagulated with subcutaneous low molecular weight heparin (dosing after consultation with hematologist) continued till 6 weeks postpartum.Precipitating factors like dehydration, immobility, infection will be avoided. Investigations that will be done include booking blood tests for Hep B, C, HIV, FBC, urea and electrolytes ,liver function test, clotting profile before initiating anticoagulation.USS will be done at 18 – 20 to rule out anomalies. Since there is a risk of IUGR, fetal growth will be monitored every 2 weeks from the 28th week by USS. LMWH will be monitored with APTT.
C] Early anaesthetist assessment will be done for regional anaesthesia .If regional anaesthesia is opted catheter will not be administered 12 hours before the last dose of prophylactic heparin. Heparin can be given 4 hours after removal of catheter. Morning dose of heparin before C/S will be omitted. Intraoperatively fastidious hemostasis ,drains and interrupted skin sutures will be done. If there is risk of excess bleeding Unfractionated heparin can be substituted for LMWH. Postpartum thromboprophylaxis should be continued for 6 weeks. Postpartum warfarin can be initiated on the 2nd or 3rd day. LMWH will be continued till INR>2. Drain will be removed if kept, after a minimum of 12 hours. Early ambulance, avoiding dehydration and TED stockings will be ensured.
Posted by T A.
A) careful history is needed with proper examination in order to allocate the risk group of the patient.time, type and duration of treatment of her previous DVT,whether it was during or outside pregnancy,any current medications,her obestetric history parity more than 4& adverse outcome( 3 consecutive miscarreges,fetal death,PET,IUGR) assoceated with Aquired& inherited thrombophilea,homo(less)or hetro type of leiden mutation,age more than 35 yrs,chronic inflammatory diseases,immobility more than 4 days,presence of varicose veins,BMI more than 30, all of these are associated with increased her risk of VTE,previous Hx of DVT & leiden mutation makes her at high risk oh VTE,she should be reassessed if admitted to hospital or other condtions arise (hyperemesis..dehydration icrease the rick).
B)she should be managed with multidisiplinare team(heamatologist,obestet.,neonatologist)booking investigations(Hb,group&save serum,VDRL,clotting screen,HbsAg,HIV(after councelling),dating scan, frequent follow up and monitor fetal growth with USG BPP,CTG,dopplar,as there ts increased risk of ealy and late fetal loss,PET,IUGR, preterm delivary,thromboprophylaxis shuold be started at the end of 1st trimester if possible till 6 wks PNC with(LMWH) < thromboeneacytop,donot cross the placenta, less allergic reaction,if patient was on warfarin,switch to LMWH as it is associated with congenital anomaly in baby with > perinatal & maternal morbidity,advise to were ted stoking if varicosity present
C)If the patient on theraputic dose of LMWH,the dose shuld be redused to prophylactic dose one day before surgury and omit the morning dose in the day of surgury,antibiotic injetion at the time of anesthesea induction,epidural catheter should not be inserted or removed within 12 hrs of the last prophylactic dose& 24 hrs of the last theraputic dose,thromboprophylaxis can be restarted 4 hrs after epidural induction with LMWH & can be swtch to warfarin PNC, breast feeding is not contraindicated, pnemonatic calf is used during surgury to prevent venous stasis,there is increased risk of PPH , thus careful monitoring of vital signs & rehydration with early mobilization is needed.
Posted by T A.
A) careful history is needed with proper examination in order to allocate the risk group of the patient.time, type and duration of treatment of her previous DVT,whether it was during or outside pregnancy,any current medications,her obestetric history parity more than 4& adverse outcome( 3 consecutive miscarreges,fetal death,PET,IUGR) assoceated with Aquired& inherited thrombophilea,homo(less)or hetro type of leiden mutation,age more than 35 yrs,chronic inflammatory diseases,immobility more than 4 days,presence of varicose veins,BMI more than 30, all of these are associated with increased her risk of VTE,previous Hx of DVT & leiden mutation makes her at high risk oh VTE,she should be reassessed if admitted to hospital or other condtions arise (hyperemesis..dehydration icrease the rick).
B)she should be managed with multidisiplinare team(heamatologist,obestet.,neonatologist)booking investigations(Hb,group&save serum,VDRL,clotting screen,HbsAg,HIV(after councelling),dating scan, frequent follow up and monitor fetal growth with USG BPP,CTG,dopplar,as there ts increased risk of ealy and late fetal loss,PET,IUGR, preterm delivary,thromboprophylaxis shuold be started at the end of 1st trimester if possible till 6 wks PNC with(LMWH) < thromboeneacytop,donot cross the placenta, less allergic reaction,if patient was on warfarin,switch to LMWH as it is associated with congenital anomaly in baby with > perinatal & maternal morbidity,advise to were ted stoking if varicosity present
C)If the patient on theraputic dose of LMWH,the dose shuld be redused to prophylactic dose one day before surgury and omit the morning dose in the day of surgury,antibiotic injetion at the time of anesthesea induction,epidural catheter should not be inserted or removed within 12 hrs of the last prophylactic dose& 24 hrs of the last theraputic dose,thromboprophylaxis can be restarted 4 hrs after epidural induction with LMWH & can be swtch to warfarin PNC, breast feeding is not contraindicated, pnemonatic calf is used during surgury to prevent venous stasis,there is increased risk of PPH , thus careful monitoring of vital signs & rehydration with early mobilization is needed.
Posted by syeda sajida M.
a.Thromboembolism is a leading cause of maternal mortality in the U.K. In the recent confidential inquiry more deaths are reported with thromboembolism in 1st. trimester.Therefore the proper assessment and the treatment in pregnancy is essential as early as possible. I would take proper history regarding the causes of previous thrombosis in pregnancy, COCP, no recurrent factors or whether the thrombosis was on unusual site. History of combined defects should be asked as she may need high prophylactic or therapeutic doses. I will ask her if she is on any anti thrombotic medication. I will take her obstetric history regarding her parity, BOH ,information of multiple miscarriages, IuGR,still birth, placental abrupt ion since it would give an idea for the outcome of current pregnancy. I would ask about her medical problem like SLE, Sickle cell disease, diabetes or IBS. I would also ask her family history of thromboembolism as it will increase her risk of getting thromoboembolism in pregnancy. I will record her weight, BMI as it would increase the risk factors. I would do the baseline investigation which would include FBC, Renal and Liver funtions and coagulation profile. Ultrasound for fetal viability, gestational age and number of fetuses since multiple gestation is also a risk factor.
b.This patient is a high risk for thromboembolism as she is pregnant and had previous history of DVT and carrier of factor V mutation. She needs hospital based antenatal care under multidisciplinary team i.e Hematologist, obstetrician. She would be advised mobilization, hydration, TED stockings and thromboprophylaxis. Warfarin is contraindicated because of teratogenecity at this gestation. Unfractioned Heparin is not suitable because of it\'s risk of osteoporosis, thrombocytopenia with long term use.Therefore low molecular weight heparin in prophylactic dose is a safe option.. It should be started immediately if not already on any treatment. Aspirin can be given if there is a bad obstetric history. Folic acid to be continued. If admitted anytime in the hospital needs reassessment for her risks and treatment. I would explain her about the signs and symptoms of DVT, PE and advise her to report to the hospital immediatelyin that case. If she is planning for along haul flight or a long car traveling then needs an expert advice before that. Close fetal survellience is needed if she is with bad obstetric history. She should be advised that if she is in labor, not to take her heparin injections and to immediately report to the hospital. If planned for IOL or elective C/S omit her therapeutic doze 24 hours before the date and it will be change to the prophylactic dose. If on prophylactic dose it should be stopped 12 hours before the date. She should be given information leaflets and support group numbers.
C.If she is on high prophylactic dose of LMWH it should be discontinued 24 hours before and prophylactic dose 12 hours prior to surgery. Omit the dose of heparin on morning of surgery. Consultant anesthetist and consultant obstetrician should be present for surgery. Haemostasis should be secured. Drain should be kept if there is a chance of bleeding. Close skin with interuppted sutures. Pneumatic calf compression during surgery and early mobilization. proper hydration and TED stocking in post operative period. Thromboprophylaxis can be started3 hours post operation or 4 hours after the removal of catheter. Cannula should,t be removed with in 10-12 hours of the last heparin injection. 2% chance of wound haematoma so heparin should be given away from the wound. drain can be removed 12 hours of minimal drainage. Anticoagulation should be for 6/52 postpartum. If history of PPH unfractionated heparin should be used. Heparin can be changed to warfarin day 2-3 of post operation until INR>2 for 2 days. Breast feeding is not contraindicated with heparin and warfarin. Contraception should be discussed as COCP are contraindicated but can have POP. She should be advised to attend prepregnancy clinic before next pregnancy.
Posted by sara S.
A 30 years old woman with previous DVT& carrier for factor V Leiden mutation is high risk for recurrent DVT.
(a) Further clinical assessment will be made by taking her weight & booking BMI, her general health, mobility condition, any pre existing disease such as nephrotic syndrome or IBD. Her cause of previous DVT is asked.Her obstetrical history for previous pregnancy with DVT or recurrent miscarriages. Any family history of thromophilia or DVT. Any new condition such as hyperemesis & planning for long haul flights will make her a more suitable candidate for thromboprophylaxis
(b) Risk of DVT is higher from start of prgnancy until puerperium in high risk pregnancies. Haematologist & consultant obstetrician is involved in her care.As this lady is coming at 8 weeks gestation, thromboprophylaxis should be commenced as soon as possible. If this is the first pregnancy then patient shold be counselled about this condition & its consequences if prophylaxix is not given. If previous DVT was due to not recurrent condition & presence of hetrozygocity of factor V Leiden mutation make this prophlaxis less favourable. As pregnancy is itself increasing risk of thrombotic event, i will give her thromboprophylaxis through out pregnancy. The enoxaparin is commenced & self administration & safe disposal is taught. A baseline investigation for FBC, U&E , LFT & coagulation profile is done before start osf tratment. After a week platelets counts checked to see for thrombocytopenia. Patient is advised for keeping herself mobile & told about symtoms of DVT & PE. If she suffers from any of them consult hospital immediately for starting theraputic doses. Patient is also advised to contiue self administration until she is in labour.
(c) She will be adviced to inject her prophylactic dose day before C Section & omitting the dose on the day of operation. C Section is done on this morning.Thrombotic deterrent stockings will be given during procedure and pnumotic pressure cuffs if required.. LMWH is continued afterward 4 hours after insertion or removel or three hours after procedure or the canula should be removed 12 hours after last injection. There is 2% chance of wound haematoma. If there is PPH or chances of intraperitoneal bleeding then unfractioned heparin will be used because of reverasal with protamine sulfate. Thromoprophylaxis will be continued for 6 weeks. LMWH can be replaced by Warfarin. Breast feeding is not contraindicated. Contraception is discussed & future pregnancy & plans dicussed.Leaflets , information & address of support group provided.
.
Posted by G. K.
Since she has a past history of Deep vein thrombosis( DVT) along with a known history of Factor five Leiden mutation, it places her in the higher bracket for recurrence of thrombosis during pregnancy.
A thorough history should be sought regarding the previous episode of DVT, whether it was spontaneous or associated with a provocative event such as a previous pregnancy, trauma, surgery or immobility from any cause.

A full medical history should be taken to rule out disorders that might ad to her risk such as inflammatory bowel disease, myyeloproliferative disorders, sickle cell disease etc.
Take a full obstetric history regarding her parity, since parity of 4 or more is asociated witha high risk of recurence of thrombosis when present in combination with other risk factors.
Age of 35 and above is also an independent risk factor for same, and shouldbe inquired about during history taking.
Any family historyof such eevnts should be sought.
General examination should include the patients, , blood pressure, and BMI. If her BMI is above 30kg/m2, it places herat a hihg risk of thrombosis.
Her legs should be checked for presence of gross vericose veins, any tenderness, redness or swelling etc.
She should have an ultrasound to establish her gestational age.
She should be screened for other thrombophilias such as protein c, protein s deficency, antiphopholipid syndrome etc.
She should be commenced on Heparin therapy as soon as possible if not done already.Warfarin should be discontinued if she was on it previously and the risk of teratogenecity explained to her.She should be commenced on high prophylactic or therapeutic dose of heparin if she\'s homozygous for FVL mutation or if there are otherrisk factors present as mentioned previously.
She should have regular A/N visits with the obstetricians and advice from haematology sought when considered necessary.
Her B.P and urine should be checked regularly since these patients are at high risk of pe eclampsia and other adverse outcomes such as placental abruption IUGR etc.
She should have an anomaly scan at 20 weeks gestation, and regular growth scans.
If she\'s obese, she should be seen by a dietician as well during the course of her A/N care.
Since her baby is breech presentation and she has opted for a C- section, her preoperative and perioperative care should be in conjunction with the anaethetic team.
If she\'s on LMWH, the dose sould be omitted on the day of surgery an operation performed in the morning.Thromboprphylaxix should begin 4 hours after removal of epidural catheter if regional anasthesia was used to reduce the risk of wound haematoma.
In adtion to that , she should wear TED stockings throughout the procedure as well.


Posted by H H.
I would ask her of her pevious history of the disease,the number of previous deep vein thrombosis(DVT) with sites and previous treatments.Is she already on treatment for DVT and what anticoagulant she is using.I would ask if she has symptoms of DVT as leg pain and swelling or pelvic discomfort or she has any chest symptoms as pulmonary embolism is fatal in 1st 3 months of pregnancy.I would ask her of her previous obstetric history and outcomes and wether anticoagulation was used. I would examine her pulse , temp, resp rate( suspect PE if increased) , BP and lower limb for varicose veins , swelling, edema or post phlebetic limb syndrome. If she is on anticoagulants I would see hematomas at injection sites

Antenatal care should be under multidisciplinary care including consultant obstetrician team, hematologist ,midwife and GP and would follow local guidelines and protocols for achieving best service to patient.Patient with such a history should be put on prophylactic anticoagulation with low molecular weight heparin(LMWH) throughout the antenatal care with twice daily subcutaneous dose.Patient is taught how to inject themselves and is followed up with weekly measurement of platelets.She is told that she would expect to have subcutaneous mematomas at injection site so as not to panic.A dating scan is done and routine antenatal tests done to her including screening tests for chromosomal abnormalities and infections.An anomaly scan is done at 20wk spcially if the patient was on warfarin at time of being seen which we should have changed to LMWH in consultation with hematologist. She should have more frequent antnatal visits and and a growth fetal scan from 28wk. Patient is given written information of her condition and treatments given.


There is danger of bleeding at surgery and at same time there is rish of thrombosis and embolism. Blood taken for group and save and blood should be available at time of surgery in consultation with blood bank. Patient informed consent is taken.On day before surgery if she is on therapeutic dose of heparin this should be changed to prophylactic dose.The anaesthetist should see the patient and plan his type of anesthesia. If regional anesthesia , last therapeutic heparin dose should be 24hr before giving anesthesia, and this is 12hr for proph doses. On day of surgery ,omit heparin dose and patient fitted with two large bore canulaes. An experienced person should do or be there at time of surgery with prompt hemostasis, drainage of wound might be needed and closure of wound with interrupted stitches would valuable specially if patient is obese. Prophylactic antibiotics would be needed if other risk factors present such as diabetes. Patient urged to move and dehydration is avoided in post operative recovery.Drains removed and proph heparin given 3hr post surgery (4hr after removal of epidural catheter). Hematoloist consulted for post operative prophylaxis with LMWH which should be given for at least 6wk postdelivery. If patient was on therapeutic dose this can be switched to warfarn
Posted by Arun J.
a-Appropriate assessment starts with good history_with regards to her LMP,regularity of cycles(to confirm dates),obstetric hist(no;of children,mode of delivery)to plan management,R/o medical and surgical disorders(D.M,H.T,renal,liver,cardiac and sickle cell disease)which would complicate the management,social hist(smoking, alcohol intake And use of recreational drugs)which affects treatment and use of other medications which interferes with anticoagulants pharmakokineticsand finally regarding her thrombosis (no; of episodes,F/H of thrombosis)to asses severity of the patients status.Then examination needs to be done( to asses vitals,ht ,BMIand R/O medical and surgical disorders)-to adjust anticoagulant dose and treatment.Base line blood tests to assess liver and renal function(LFT,RFT) and FBC done-which affects anticoagulant drug excretion if function deranged.USS done to assess G.A and no; of fetuses.
b-She is a high risk pregnancy,so needs multidisciplinary care involving senior obstetrician anaesthetist and paediatrician and haematologist.Uss done to confirm G.A.Counselling regarding the patients disease and the risks and benefits of treatment with anticoagulant drugs needs to be done,Ensure adequate AN visits.She needs to be started on LMWH antenatally and continued postnatally for 6 wks.Monitoring of blood platelets needed to R/O HIT.monthly platelet count done . APTT done regularly to assess status of anticoagulation.Anomaly USS done at 20 wks and fetal surveillence started by 28 wks .Maternal surveillence done to pick up superimposed complications.Prior appointment with anaesthetist and paediatrician arranged.I would provide her with written information and document it and inform primary care team.
c-Anticoagulant needs to be stopped the day prior to surgery(evening dose).Senior obstetrician,anaesthetist and paediatrician called for.Blood bank alerted and theater staffs informed in advance.Prophylactic antibiotics administered and bladder needs to be catheterised.Check maternal pl.count and APTT levels(1.5-2 times normal is ideal). Consent should be obtained. Epidural catheter sited ideally 12 hrs after prophylactic LMWH dose.Consideration needs to be given for placement of subcutaneous drains and interrupted sutures for skin to prevent haematma formation.
Posted by shree D.
A 30 year old woman with a previous deep vein thrombosis is known to be a carrier of the factor V Leiden mutation. She is referred to the antenatal clinic at 8 weeks gestation. (a) Justify your clinical assessment [6 marks].

I would take a full history to find any associated medical problems (such as recurrent miscarriage, previous pregancies, history of deep vein thrombosis-if in pregnancy, location of clot), and ascertain other risk factors for thrombosis (eg. Family history of thrombosis). I would make sure that she is a non-smoker, and check which medications she is currently taking. I would check the patient\'s BMI, as a BMI over 35 is known to predispose to thromboembolism, look for varicose veins and check her general hydration.

I would obtain a FBC to check platelet count, and clotting to check prothrombin time/ APTT. I would perform LFTS to check liver function. I would perform a transvaginal ultrasound to exclude twin pregnancy, which would increase the risk of thromboembolism.


b) Outline your plan for her antenatal care given that no other problems are identified [8 marks].
I would highlight the fact that she is at risk of developing another thrombosis, and emphasise that she must be mobile, wear thromboembolic deterrent stockings and keep well hydrated. She should avoid long haul flights. I would advise her to continue to take 0.4mg folic acid/day until 12 weeks gestation, and undertake a 20 week anomaly scan and serum screening. She should be advised to present to hospital early if she develops symptoms of leg swelling and tenderness, chest pain or shortness of breath. As she is only a carrier for factor V leiden mutation, I would not advocate anticoagulation in pregnancy prophylactically, unless her previous DVT was in pregnancy. She should have a routine FBC performed at 28 weeks.

She should aim for a normal vaginal delivery with an active third stage, and be advised to mobilise as soon as possible after delivery.


(c) She is found to have a breech presentation and opts for an elective caesarean section. Justify your peri-operative care with specific reference to her thrombophilia [6 marks].
In view of her thrombophilia, this patient will need iv fluids perioperatively to keep her well hydrated and minimise blood coagulation. She should be given TED stockings, with leg compression during the operation. The duration of the operation should be kept to a minimum, and the operation performed by an experienced surgeon. She should be given post-natal thromboprophylaxis, with the first dose at least 6hours after the operation (if under regional anaesthesia). She should be encouraged to mobilise as soon as possible after the operation.
Posted by Sarwa H.
A~
Adequate clinical history and examination is done, also if possible we try to review her previous medical records. We try to explore her previous attack whether has been confirmed by Doppler US or venous angiography or not, also if it occurs during a previous pregnancy . We ask about type of medication she took , dose and duration and whether she develop any complication like chest problem, post thrombotic leg syndrome or leg ulcer. We ask for other risk factors like smoking and occupation that require prolong standing. General examination is done including BMI as obesity is an additional risk factor. Affected limb should be examined for sings of venous insufficiency.

B~

If she is kept on warfarin tablet, we advice to stop it and change to heparin as warfarin is associated with increased risk of fetal congenital anomaly. LMWH is preferred to UH as it is taken as a single dose with less risk of thrombocytopenia and osteoporosis. Adequate counselling is done and the patient given written information about her disease and its risks. Management done jointly with Multidisplanary team including consultant obstetrician, senior anesthetist, physician and hematologist. Heparin given in a prophylactic dose and monitoring is done by measuring Anti aXI activity. The patient advised of early report if she experience symptoms like leg pain, shortness of breath or chest pain. In the mid trimester, warfarin can be re-introduced as organogenesis had complete, then return back to heparin in the third trimester. The patient advised also to stop medication if she feel contraction or bleeding per vaginum. Therapeutic dose of heparin is given when DVT suspected or diagnosed. Regular antenatal visit is encouraged.

C~

Heparin should be stopped the day before operation and we advice the patient to avoid prolong immobility and to use thrombo-embolic deterrent stockings. We ensure adequate hydration. Heparin should be re-introduced 3 hours after the operation. If epidural anaesthesia used, heparin should be given 12 hours after epidural catheter insertion or removal and is continued for 6 weeks. Follow up appointment is arranged.
Posted by clarice M.
a) The clinical assessment should include a detailed history relating to the deep venous thrombosis (DVT) and Factor V Leiden status, as well as an obsteric and past medical history. With regards to the DVT, additional information should be sought about when it occured as well as its location. The timing of the DVT is important as the patient may still be on anti-coagulation. If she is on anti-coagulation in the form of warfarin then this must be stopped as it is teratogenic and she should be treated with heparin instead. Modifiable risk factors for DVT such as smoking and a raised BMI should also be ascertained. If the patient is not on anticoagulation, she will require prophylactic heparin in the antenatal and post-partum period, hence contraindications for this should be sought. Her obstetric history will dictate the frequency of her antenatal visits and if growth scans are required. Other important points in the history include contraindications to a vaginal delivery, such as a classical caesarean section, 2 previous caesarean sections, or myomectomy for example. A history of post-partum haemorrhage should indicate active management of the 3rd stage. Finally, the site of the DVT should be examined, and the patient should have her height and weight checked.
b) A history of a DVT in association with heterozygous Factor V Leiden status necessitates prophylactic anti-coagulation in the antenatal period and for at least 6 weeks post-partum. The treatment of choice is a low molecular weight heparin (LMWH) as this has the advantage of once-daily adminstration and no need for monitoring of clotting time. It is also associated with a lower risk of osteporosis compared to unfractionated heparin. Close liaison with a haematologist is important as the patient has an inherited thrombophilia and monitoring of anti-Xa may be necessary. Additionally, treatment with heparin is associated with heparin induced thrombocytopaenia and hence a platelet count should be checked between 5-10 days of starting treatment. Tha patient should receive clear instructions of how to administer the LMWH, dispose of sharps, and to rotate sites to avoid bruising. She should also receive clear instructions of when to stop the heparin, for example, if she has an antepartum haemorrhage and as soon as she thinks she is in labour. A referral to the anaesthetist is required to discuss options for analgesia. Regional anaesthesia is not contraindicated with LMWH use provided the most recent dose was administered at least 4 hours prior to insertion. Finally, she should be advised to wear graduated compression stockings for the duration of her pregnancy and for at least 2 years after her previous DVT.
c) The patient should be informed to stop heparin the day before the operation. She should be admitted the day before the operation for intravenous hydration. During the operation, antibiotic prophylaxis should be given to reduce the risk of infection, particularly, sepsis, as this increases the risk of a DVT. During the operation, care should be taken to avoid excessive blood loss and an oxytocin infusion should be started following delivery of the placenta. A senior obstetrician and anaesthetist should be present at delivery as the patient is at increased risk of haemorrhage. If there were no complications following the operation, she should continue to have prophylactic LMWH for at least 6 weeks post-natally. Sufficient analgesia should be prescribed to encourage to early mobilisation. The patient should be advised to continue wearing the graduated compression stockings.
Posted by clarice M.
a) The clinical assessment should include a detailed history relating to the deep venous thrombosis (DVT) and Factor V Leiden status, as well as an obsteric and past medical history. With regards to the DVT, additional information should be sought about when it occured as well as its location. The timing of the DVT is important as the patient may still be on anti-coagulation. If she is on anti-coagulation in the form of warfarin then this must be stopped as it is teratogenic and she should be treated with heparin instead. Modifiable risk factors for DVT such as smoking and a raised BMI should also be ascertained. If the patient is not on anticoagulation, she will require prophylactic heparin in the antenatal and post-partum period, hence contraindications for this should be sought. Her obstetric history will dictate the frequency of her antenatal visits and if growth scans are required. Other important points in the history include contraindications to a vaginal delivery, such as a classical caesarean section, 2 previous caesarean sections, or myomectomy for example. A history of post-partum haemorrhage should indicate active management of the 3rd stage. Finally, the site of the DVT should be examined, and the patient should have her height and weight checked.
b) A history of a DVT in association with heterozygous Factor V Leiden status necessitates prophylactic anti-coagulation in the antenatal period and for at least 6 weeks post-partum. The treatment of choice is a low molecular weight heparin (LMWH) as this has the advantage of once-daily adminstration and no need for monitoring of clotting time. It is also associated with a lower risk of osteporosis compared to unfractionated heparin. Close liaison with a haematologist is important as the patient has an inherited thrombophilia and monitoring of anti-Xa may be necessary. Additionally, treatment with heparin is associated with heparin induced thrombocytopaenia and hence a platelet count should be checked between 5-10 days of starting treatment. Tha patient should receive clear instructions of how to administer the LMWH, dispose of sharps, and to rotate sites to avoid bruising. She should also receive clear instructions of when to stop the heparin, for example, if she has an antepartum haemorrhage and as soon as she thinks she is in labour. A referral to the anaesthetist is required to discuss options for analgesia. Regional anaesthesia is not contraindicated with LMWH use provided the most recent dose was administered at least 4 hours prior to insertion. Finally, she should be advised to wear graduated compression stockings for the duration of her pregnancy and for at least 2 years after her previous DVT.
c) The patient should be informed to stop heparin the day before the operation. She should be admitted the day before the operation for intravenous hydration. During the operation, antibiotic prophylaxis should be given to reduce the risk of infection, particularly, sepsis, as this increases the risk of a DVT. During the operation, care should be taken to avoid excessive blood loss and an oxytocin infusion should be started following delivery of the placenta. A senior obstetrician and anaesthetist should be present at delivery as the patient is at increased risk of haemorrhage. If there were no complications following the operation, she should continue to have prophylactic LMWH for at least 6 weeks post-natally. Sufficient analgesia should be prescribed to encourage to early mobilisation. The patient should be advised to continue wearing the graduated compression stockings.
Posted by H H.
Please do not forget my essay TSH , much obliged
Posted by Ahmed A. Hamid A.
(a)
History of deep venous thrombosis and thrombophilia is associated with an increased risk of developing venous thromboembolism during the current pregnancy.

The clinical assessment would involve a detailed medical history and thorough examination in order to identify the risk factors for venous thromboembolism.

I will take detailed history about her previous deep venous thrombosis including its site and the duration passed since such episode. I will find out if she is on anticoagulant therapy.

I will enquire about the obstetric history including her parity , the mode and the outcome of previous deliveries.

I will ask about family history of similar conditions, I will ask about the history of medical disease like congestive heart failure and nephritic syndrome.

I will do a general examination including her height, weight, blood pressure, pulse, temperature and her body mass index. I will do an abdominal examination to rule out pelvic masses. I will do lower limbs examination to find out if there is any calf pain, discomfort, oedema, tenderness, induration and to detect any gross varicosities.


(b)

Regarding her antenatal care, multidisciplinary team including a haematologist should be involved.
I will provide the patient with written information about the venous thromboembolism and thromboprophylaxis.
I will advice her to avoid dehydration, immobilization, concurrent infections and long distance travel.
Antenatal LMW heparin should be started as early as possible during the pregnancy. The patient should be taught about the self injection and proper disposal of syringe.
The platelets count should be checked one week after the start of the anticoagulant therapy.
Routine antenatal laboratory investigations and ultrasound scan should be done as for the other pregnant women.
I will advice the patient not to inject further dose if she think that she is labour.

(C)

I will take an informed consent for the operation explaining to the patient the associated risks.
The prophylactic dose of LMW heparin to be administrated one day before the surgery.
The morning dose of LMW heparin on the day of surgery should be omitted.
I will discuss the anaesthesia with a senior anaesthetist and I will discuss the implications with the woman.
Regional anaesthesia not to be used until 12 hours after LMW heparin injection. The TED stockings should be used during the operation.


Posted by Maayka ..
a) History should elicit any other risk factors for VTE in pregnancy. Medical disorders such as SSdisease, myeloproliferative disorders and inflammatory bowel disease. If the patient is homozygous for Factor V Leiden then it is of a reduced risk for VTE than if homozygous. Was the previous DVT recent and is she still on therapeutic treatment - this will determine the need to continue therapeutic treatment vs. thromboprophylactic dosing. Ask if it was just one previous DVT or recurrent DVTs as the latter further increases the risk of VTE. Was the DVT associated with an earlier pregnancy, COCP or in an unusual site like the axilla - these further increases the risk. Is her parity greater than 4 and does she have a sedentary lifestyle, again further additional risk factors.
Examination will reveal if she has a BMI greater than 30 or weight greater than 90kg, which is another risk factor. Also, are there any signs of varicosities and dehydration – all predisposing to VTE.


b) Thrombopropylaxis should be started as soon as possible with the history of previous DVT and thrombophilia (FVL mutation). Joint care will be held in conjunction with a multi disciplinary team, including a haematologist. Information about the risks involved and the drug of choice of drugs available should be imparted. If she was on warfarin (while on therapeutic doses at booking), she should be advised of the risk of teratogenensis and offered an early as well as a routine anomaly scan. LMWH is best choice vs. unfractionated heparin because it avoids monitoring for thrombocytopenia and risk of osteoporosis. Once started on LMWH, a platelet count should be done one week later. It is important to always reassess patient for change in risk factors because the risk increases if hyperemesis gravidarum occurs or prolonged immobilization/hospitalization or development of pre-eclampsia. Antenatal advice should also include avoiding immobilation, dehydration and using grade2 TED stockings. Avoidance of long haul travel and if necessary, to seek medical advice before those plans. She would need to be shown proper use of syringes / needles and disposable. A consultation with the anaeasthetist should be held later in the pregnancy to discuss the use of LMWH and limitations with epidural timing. If in labour, she should be advised to withhold further doing of LMWH and the catheter should only be sited 12hrs after a prophylactic dose.


c) One day prior to surgery the last dose of LMWH should be taken and further doses withheld until following surgery. It can be resumed 3hrs post op or 4 hrs following insertion of an epidural catheter. This is because its use is associated with haematoma at epidural site and small risk of wound haematoma. Use of TED stockings and early mobilization will reduce venous stasis and reduce risk of VTE. Adequate hydration before, during and after surgery will also reduce risks. The surgery should be performed by an experienced doctor or supervised by a senior to ensure reduced blood loss as this would otherwise increase risks of dehydration and associated risks of VTE. The LMWH needs to be continued for 6 weeks post partum
Posted by Srivas  P.
a) In view of history of previous VTE and identification of heritable thromophilia she is at high risk of recurrent VTE in present pregnancy and would require both antenatal and post partum thromboprophylaxis. However her risk status should be reassessed in early pregnancy to determine severity of her risks so that appropriate dose and other measures can be taken. Family history of VTE, number prior episodes of her VTE, any VTE at unusual sites like axillary vein increase her risk profile. Presence of medical illnesses like IBD, SLE, and cardiac illnesses should be asked. Long haul flights, severe urinary infections all add on to her risks and may need a reevaluation of the dose of thrombophylaxis she would need. If she is already on thromboprophylaxis it may need a change from Warfarin to heparin as warfarin is teratogenic. Obstetric history of recurrent miscarriages may indicate higher risk of repeat VTE.
Examination may reveal varicose veins, increased BMI both adding to higher risk profile.

b) She should have multidisciplinary care involving senior obstetrician, Physician, anesthetist and hematologist reviewing her if possible at joint clinics. This woman with previous VTE and heterozygous Leiden mutation would require antenatal thrombo prophylaxis. But whether she should receive higher or usual prophylactic dose will be individualized on risk assessment and current BMI, by the hematologist. She should also be encouraged to wear class-II graduated elastic compression below knee stockings throughout her pregnancy. If she has to travel on long haul flights she should review with hematologists regarding any need for modification in treatment.
LMWH is ideal for antenatal thrombophrophylaxis and is preferred over UFH because while it is equally effective, the risks of fractures, osteoporosis and thrombocytopenia are lower. Warfarin is not indicated antenatally due to risk of teratogenesis, risks of miscarriage and risk of fetal and maternal bleeding. She should be taught self injection of LMWH and also told about symptoms of VTE so that she can report early if she has symptoms.

Her baseline renal, liver profile, clotting profile including platelet count should be taken and reviewed at monthly intervals. Platelet count should be done 1 week after starting LMWH to detect heparin allergy which may need discontinuation of heparin.

c) Since she is for C.S, her increased risks of developing VTE due to surgery, has to be balanced with risk of hemorrhage during surgery with use of LMWH. If she is on higher prophylactic dose, it should be reduced to prophylactic dose one day prior to surgery. LMWH should be omitted on the day of surgery but it should be given as early as possible, usually 3 hours after surgery if it has been done under GA. If the woman had epidural anesthesia LMWH should not be given for at least four hours after the epidural catheter has been inserted or removed. If the epidural cannula has been left in for postpartum analgesia, it should not be removed within 10–12 hours of the most recent injection. LMWH is continued for atleast 2 days post operatively even if changeover to Warfarin which is safe in breast feeding woman is contemplated for later treatment.

At surgery, hemostasis should be meticulous as there is 2% risk of would hematoma. Hydration should be maintained after surgery and early mobilization advised. TED stockings, should be encouraged during and after operation and for 6 wks postpartum.
Posted by Neelam A.
Hi Paul,

I posted my essay on thrombophilia on 2nd Februray, unfortunately it has not been corrected.
However, the essays which were posted after me, have been corrected.
I would like to know, what I should know?
I look forward to hearing from you soon.
Thanks,
Regards,
Neelam