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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

Course PAID
notes	336
EMQ	1502
SBA	2115

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ESSAY 189 - VTE

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		Posted by Sreekala S. Sat Feb 25, 2006 03:33 am
Although pregnancy increases the risk of VTE by 10 folds, the presence of risk factors considerably increases the risk further. Therefore, risk assessment plays an important role. Women at high risk of VTE or previous history of VTE should be offered pre-pregnancy counselling whenever possible. GPs and midwives should have protocols so that women at risk are identified and referred early. Referral to a haematologist or a combined obstetric and haematology clinic is recommended in the presence of risk factors. Women with previous VTE should have screening for both inherited and acquired thrombophilias ideally before pregnancy. The women should have a risk categorization into mild/moderate or high risk .The risk assessment should be repeated if the woman is admitted to the hospital or develops other intercurrent problems. Regardless of the risk factors, immobility and dehydration should be avoided during pregnancy. Age>35 years, parity>4, obesity-BMI>30, Previous VTE, acquired or inherited thrombophilias, paraplegia, dehydration, hyperemesis, cardiac failure, sickle celldisease, malignancy, nephritic syndrome, PET, inflammatory conditions, pyelonephritis are some of the risk factors for VTE. Advice about regular mobilization, adequate hydration, TED stockings and the use of aspirin/LMWH should be discussed with all women planning to go on long-haul flights. Antenatal thromboprophylaxis is recommended and should be continued postnatally for 6 weeks in the presence of high risk factors like recurrent VTE or previous VTE and family history of VTE or previous VTE and thrombophilia or DVT at an unusual site such as the axillary vein or high risk thrombophilias like antithrombin three deficiency or homozygous or multiple defects. Women with previous VTE and no thrombophilia or thrombophilia but no previous VTE should be advised post partum anticoagulation for 6 weeks. Antenal thromboprophylaxis should be commenced as early in pregnancy as practical in high risk patients. LMW Heparins are the anticoagulants of choice for antenatal thromboprophylaxis as they are as effective as Unfractionated heparins and safer thatn them with a lesser need for monitoring. The advantages and potential side effects like rash, thrombocytopenia and osteoporosis should be explained and documented in the notes. Low dose aspirin 75mg should be considered when there is an increased risk of VTE but is not high enough to warrant the use of antenatal LMWH. Following vaginal delivery, the woman should be advised early ambulation and avoid dehydration. TED stockings and LMWH for 3-5 days should be given if she has a prolonged labour or Mid cavity instrumental delivery in the absence of other risk factors.Post partum thromboprophylaxis should be started as soon as possible after delivery provided there is no PPH and after anaesthetists advice if she had an epidural during delivery. Presence of 3 or more moderate risk factors requires antenatal LMWH along with post partum anticoagulation for 3-5 days. Presence of 2 or more moderate risk factors requires the use of anticoagulation for 3-5 days post partum. Puerperal women undergoing surgery or those who develop severe infection or choose to travel long-haul are at an increased risk of VTE and should be advised to avoid dehydration, immobility and may require warfarin or LMWH. Warfarin is safe after delivery and during breast feeding. COCP should not be prescribed during the first 3 months post partum for women with risk factors for VTE. Information leaflets should be given and advised to seek urgent medical advice if DVT/VTE is suspected. Local protocols should be followed based on national guidelines and the practice audited regularly to improve the management.
		Posted by hala M. Sat Feb 25, 2006 04:07 am
Pregnancy is a state of hypercoagulopathy which starts from the first trimester to 6 weeks post partum and VTE is the leading cause of maternal deaths. In the latest CEMD it was noted that the VTE related deaths in patient undergoing CS was reduced significantly after the implementation of the pervious guidelines. Mothers are still dying due to VTE antenataly and after vaginal delivery; therefore there is a need for a guideline to prevent these deaths. VTE assessment should ideally starts prepregnancy because there is a possibility for the Thrombophilia screening before the start of pregnancy. When this is not possible then this risk assessment should be done early in the first trimester and this needs the health care workers awareness (GP and community midwife) of this association in order to educate the pregnant woman and to refer the high risk cases early on pregnancy. General advice about the avoidance of dehydration and immobilisation through out pregnancy and Purperium reduce the risk of VTE development. The pregnant woman should be told about the symptoms which should lead her to seek medical advice (leg swelling, reddens and pain in addition to chest symptoms of pain, SOB and haemoptysis). In case of suspected VTE/PTE the prompt treatment along side the investigation is necessary to reduce the morbidity and mortality associated with VTE. The pre-existing risk factors for VTE are the previous VTE, Thrombophilia, age> 30, BMI> 30, parity>4, varicose veins, IBD and medical condition like sickle cell, nephritis and cardiac diseases. This risk assessment should be reviewed regularly for the development of transient risk factors such as immobility, in patient admission, pre eclipse, and OHSS and hyperemesis gravidarum. Antenatal thromboprophylaxis should be given in the following patients: 3 or more risk factors, previous recurrent VTE, single personal VTE with another first line family member had VTE, Personal VTE and Thrombophilia and the person with a Thrombophilia (combined or homozygous) not associated with VTE. The drug of choice for the antenatal prophylaxis is LMWH as it is as effective as UH with fewer side effects (osteoporosis and thrombocytopenia). The surveillance in patient on long term prophylaxis for the complication of thrombocytopenia and its consequences of thrombosis is necessary for the minimisation of VTE risks. Patients undergoing caesarean section should be assessed for the risk of VTE and given the appropriate prophylaxis. The high risk patient who should be given thromboprophylaxis at CS is: 3 or more risk factors, previous VTE, Thrombophilia and Caesarean hysterectomy. Low risk patients need TED stockings, hydration and early mobilisation. The patient who is on antenatal VTE prophylaxis/therapeutic should be given the advice about what to do when she thinks that she is in labour and her care should be arranged by the senior obstetrician and anaesthetist. The insertion and removal of the epidural cannula should be done with reference to the prophylactic/ therapeutic dose. Patients who started antenatal thromboprophylaxis should continue for 6-12 weeks (3-5 days in patients with 2 or more risk factors) post partum. In the woman with high risk of PPH a haematologist should be involved in her care and the use of UH during labour is safer than LMWH. The patient who started LMWH antenataly is advised about its safety in breast feeding and can switch to warfarin if she likes. Continuous audits of the adherence of the guidelines would identify the gaps in the practice and helps further in reducing the risk of VTE in pregnancy.
		Posted by QWER R. Sat Feb 25, 2006 03:25 pm
Screening women through an antenatal history will identify women of higher risk of vte. Woman with a prior VTE should be screened for aquired/inherited thrombophilia - ie Protein S deficiency, protien C deficiency, APCR, factor V leiden deficiency, antithrombin III mutation. This is because women without a thrombophila + DVT, pregnancy VTE recurrence rate is 3%, and low molecular weight heparin (lmwh) is not justified; but the increased risk with a thrombophilia + previous DVT makes recurrence risk much higher ,therefore justified. With a VTE and no thrombophilia, just postnatal thromboprophlaxis is required, unless the VTE was in an unusual place (ie axillary vein), more than one DVT, or DVT + family history; in which case again lmwh justified. Without a VTE, screening for thrombophilia is not justified. But a known thrombophilia, if \'high risk\' ie antithrombin III deficiency, or combinations of deficiency, or with associated other risk factors would warrant antenatal lmwh. Liason with a haemotologist is essential, thrombophila screening is readily available, lmwh is acceptable as a treatment option to patients; and is safe. Being aware of conditions unique to pregnancy that carry high risk of VTE. ie OHSS, where TEDS,hydration and lmwh are essential components of treatment, Likewise, severe hyperemesis, sickle crisis, infective crises all require VTE risk assessment. A low threshold for considering DVT/PE in pregnacy required, and therapeutic treatment minimises risk of progression whilst awaiting fomal investigation. It is safe to do CXR, VQ scan in pregnancy with appropriate shielding; where index of suspicion high regards a DVT; further investigation in form of venogram, or rpt doppler after 1 week is appropriate. LMWH is more effective and safe compared with IV heparin, (in non pregnant), it is assumed that this applies to pregnant people as well. No monitering is required in form of Xa levels (except if antiIII thrombin deficiency exists) - but a platelet count in one week is required. Following vaginal delivery, any previous VTE, should get thromboprophylaxis for 6/52, if a known thrombophilia for 3 to 5days. Women with multiple risk factors (ie obese,smoker,PET) should be kept hydrated, TED\'s supplied and given lmwh till mobile. OCP should be delayed for 3 weeks post delivery
		Posted by adnan S. Sat Feb 25, 2006 07:57 pm
Venous thromboembolism is currently the commonest & first direct cause of maternal mortality .Increased risk occurs in the first trimater with the greatest risk being in the puerparium.All woman should under go an assessment of risk factors for VTE in early pregnancy or before pregnancy.This assessment should be repeated if the woman is admitted to hospital or develops intercurrent illness. To minimize the risk of VTE during the antenatal period woman with previous VTE should be screened for inherited and acquired thrombophilia ideally before pregnancy .Woman at high risk of VTE like multiple thromboembolic episodes /known thrombophilia should have a early referral when they fall pregnant.These woman should be seen in the joint clinic with a heamatologist.Woman with previous recurrent VTE or a previous VTEand a family h/o VETin a first degree relative should be offered thromboprophylaxis with LMWH.Woman with asymptomatic thrombophilia like anti-thrombin defeciancy.homozygous FVL mutation&combined defects should receive thromboprophylaxis with LMWH. Woman with 3 or more persisting risk factors like age>35yrs ,BMI>30kg/m2,parity>4,gross varicose veins ,paraplegia, sickle cell disease etcshould be concider for thromboprophylxis with LMWH..Regardless of their risk of VTE ,immobilization of woman should be minimized &dehydration should be avoided.Risk of VTE assessment should be done during admission in every pregnant woman like hyperemesis,pre-eclampsia etc. Pregnant woman presenting with chest /leg symptoms suggestive of VTE should be anti-coagulated with heparin until objective testing under taken using doppler studies/venography and lung perfusion scan.Induction of labour /c-section should be planned in anti-coagulated woman at 39wks to minimize heamorrhagic complications .Antenatal aneasthetic &senior obstetric assessment with plan should be documented in notes.Antenatal thromboprophylaxis should be started as early in pregnabcy as practicable.LMWH are the drug of choice, they are as effective as and safer than unfractionated heparin in pregnancy.Warfarin should usually be avoided during pregnancy,it is safe after delivery &during pregnancy. Following delivery the risk of VTE is minimized by early mobilization ,avoiding dehydration .Thromboprophylaxis should begin as soon as possible after delivery .after use of regional aneasthesia LMWH should not be given for atleast 4hrs afterb the epidural catheter has been inserted or removed and the canula should not be removed within 10-12hrs of the most recent injection.Thrombprophylaxis should be considerd for 6wks in woman with recurrent VTE,asymptomatic thrombophilia,VTE without thrombophilia.Thromboprophylaxis for 3-5days should be consider in woman with 2or more persistant risk factors &transient risk factors like pre-eclampsia,excessive blood loss ,prolong labour,mid cavity instrumental delivery and immobility after delivery. .Age>35yrs,BMI>30kg/m2 are independent risk factors .thromboprophylxis should be given for 3-5 days .Warfarin is safe can be used from 2nd day in woman who require thromboprophylaxis for 6wks.Any chest pain ,SOB ,calf muscle pain and heamoptysis suggestive of VTE should be anti-coagulated with heparin until objective testing under taken using Doppler stidies /venography and lung perfusion scans.COCP should not be prescribed for first 3months for woman with risk factor for VTE.Local protocols/guidelines should be used which are based on national guidelines and are audited on a regular basis to improve compliance.
		Posted by Farzana N. Sat Feb 25, 2006 08:14 pm
Venous thromboemboembolism is the most common direct cause of maternal death in U.K.As compared to non pregnanat women ,risk of VTE is increased tenfold in pregnancy due to increased clotting factors and decreased fibrinolysis. RCOG recommends that all pregnant women should undergo risk assessment at the booking visit.GPs and midwives should pay attention to risk factors obtained from hist and examination.These include- high risk factors ,personal or family h/oVTE ,moderate risk facrors-age over 35,parity>4,gross varicose veins. This risk assessment should be repeated if the patient is admitted to hospital or develops any intercurrent illness. Thrombophilia screening should be done in pts with personal or family h/o VTE.for congenital factors such as antithrombin deficiency, protein C or protein S deficiency or factor V Leiden.Acquired factors(APS)lupus anticoagulant /anticardiolipin antibodies.These factors are affected in pregnancy ,so an expert hematologist should interpret the findings During pregnancy high risk pts should be referred to joint clinic with hematologist receive should receive thromboprophylaxis. . . Unfractionated Heparin or LMWH can be given.Adequate blood levels should be monitored by APTT or anti Xa levels respectively.Side effects include thrombocytopenia and osteoporosis.These risks are lower with LMWH than unfractionated Heparin.Warfarin should be avoided in pregnancy.Its use is safe after delivery and during breastfeeding. Pregnant women should be advised to avoid dehydration and prolonged immobility. Symptoms of leg pain or chest pain suggestive of VTE should be anticoagulated until objective testing is done using Doppler studies/venography and ventilation perfusion scan.Induction of labour or C>S should be planned in anti coagulated women to reduce risk of hemorrhagic compications. Postpartum thromboprophylaxis should be given as soon as possible after delivery provided there is no PPH.Those with PPH should be given TED stockings.If epidural anesthesia has been sited LMWH should be withheld for 4hrs after insertion or removal of catheter. Low risk pts ?those with two risk factors i.e (age >35,obesity with,pre eclamsia or immobility, or asymptomayic thrombophilias ) should receive thromboprophylaxis for 3-5days.High risk women with h/o personal/family h/o VTE/thrombophilias should receive thomboprphylaxis for six weeks.LMWH or warfarin can be given.
		Posted by Aroosha B. Sat Feb 25, 2006 11:52 pm
The risk of thromboembolism in a non pregnant patient is 5/100000 while it increases to 60/100000 in pregnancy. Ideally every patient should be evaluated before pregnancy and a management strategy may be planned for those at high risk of TE but many women present for booking late in first trimester. The risk of TE has equal distribution through out pregnancy. A high vigilance should be taken and women presenting with signs and symptoms suggestive of thromboembolism, Thromboproplylaxis should be started although objective diagnosis of TE in pregnancy is poor and will result in unnecessary intervention in 50% of cases. It is important as in many cases of antenatal TE symptoms and signs were not accurately recognized. It was outlined in recent confidential inquiry in maternal deaths. Dehydration and immobilization during pregnancy from any reason should be minimized. A detailed history should be taken and BMI calculated to evaluate the risk. Age over 35 and BMI greater than 30 constitute independent risk factors because most of deaths which occurred during antenatal period were among those with age > 35 and BMI >4. Other risk factors are multiparity PE aquired thrombophilia like lupus anticoagulant anticardiolipin antibodies and congenital thrombophilia like protein C protein S factor 5 leiden deficienc. TE has a recurrent risk of 10%. , thrombophilia screening should be donein women with previous history and results interpreted carefully in pregnancy because of changes in coagulation system i In case where no thombophilia is identified and the TE was due to non recurrent cause then antenatal thromboprophylaxis can be omitted and patient given TE 6 weeks post partum. Women with history of recurrent TE or those with TE and in the presence of thrombophilia should receive both antenatal thromboprophlasis and in post partum period. Women in whom thrombophilia is identified because of family history, thromboproplylaxis should be given on the basis of underlying thrombophlia with women having a deficiency of antithrombin need ante and post natal throomboprophylaxis. Other thrombophilia where thromboprophylaxisa required are homozygous facts V leiden deficiency or the presence of more than one thrombophlia defect. Very high risk women are those with preexisting thrombophilia and previous TE on highdose of heparin , high risk factors those with recurrent TE or previous TE and thrombolphilia not on long acting warfarin , ant thrombin deficiency combined defects, homozygous factor V leiden. Moderate risk factors are single provoked TE without thrombophlia and asymptomatic thrombophlia. All these women require combined management by heamatologist and obstetrician. Women with three or more pre-existing risk factors hould be considered for thromboprophylaxis with LMWH antenatally and 3-5 days post partum. Women with acquired thrombophilia like APS and previous TE have 70% chance of recurrence and should receive thromboprophylaxis both antenatally and after delivery. LMWH should be given in antenatal period as it has been found to be equally effective as UH and have low incidence of osteoprosis and thrombocytopenia Education pf gp and mid wife is necessaryfor early referral and these women should be managed in combined clinics with heamatologist. Women with extreme obesity r high risk and should receive thromboprophylaxis in case of admission in hospital Women undergoing Emergency and elective should be evaluated for for thromboprophylaxis. A regular audit and adherence to shoud be adhered for best ourcomelocal guidelines The risk after delivery can be minimized by early mobilization and avoiding dehydration all women with previous VTE and thrombophlia should encouraged to wear graduated elastic compression stocking 6-12 weeks after delivery. Women with moderate risk given thromboprophlaxis 3-5 days and those with high risk 6-12 weeks postnatally. Estrogen containing contraception should be avoided six weeks postpartum in those high risk -- TE.
		Posted by Vaani M. Sun Feb 26, 2006 12:04 am
Measures to minimise risk of VTE during pregnancy are important and include the use of general and specific measures as heparin, warfarin, aspirin, and graduated elastic compression stockings. General measures include avoiding dehydration and immobilisation as these add to the risk of thrombosis in addition to the hypercoagulable state of pregnancy. Heparin could be used as unfractionated heparin or low molecular weight heparin. Both are equally effective to reduce risk of VTE. Heparin has the advantage that it can be used antenatally, intrapartum and postnatally. It has no risks for the fetus or neonate. LMWheparin is preferred for longer term use in pregnancy as it is associated with less risk of bone loss and thrombocytopenia seen with unfractionated heparin. If thrombocytopaenia occurs with heparin treatment, it needs to be changed to heparanoids as danaparoid. Unfractionated heparin needs monitoring with APTT levels to maintain adequate levels for anti-thrombotic effect. LMWH requires less monitoring, with anti - factor Xa levels especially if at high risk as in antithrombin III deficiency. A minor risk of wound haematoma is seen with use of heparin, but it is not associated with any risk of increase in need for blood transfusion or fall in haemoglobin. Warfarin is an oral anticoagulant which may be used in pregnancy in women at very high of thrombosis especially with prosthetic heart valves already on treatment. It has the risk of teratogenesis in the fetus especially in early pregnancy causing stippled epiphysis, hypoplasia of digits and haemorrhagic risk in fetus and neonate. It needs frequent monitoring with INR for maintainence of adequate levels. Warfarin may be used for very high risk women from 14 to 34 weeks of pregnancy with adequate monitoring after appropriate counselling of the woman. Postnatally warfarin is safe and effective as anticoagulant especially if required for a longterm as woman with VTE during pregnancy or at high risk. Short term prophylaxis for 3 to 5 days is better with heparin than warfarin. Aspirin in low doses of 75mg daily has anticoagulant effect but there are no adequate studies in pregnancy. Since it does not cause any harm aspirin is to be used antenatally in all high risk women especially those with acquired risk of antiphospholipid syndrome where it has proven effect it improving outcome of livebirth. Graduated elastic compression stockings are useful in thromboprophylaxis although adequate studies are not present. It is to be used in all women at high risk of thrombosis, and pregnant women travelling by air. There are no harmful effects. Dextran is to be avoided in pregnancy as it leads to histamine release, hypertonic uterus and intrauterine fetal death. Following vaginal delivery all women should be given thromboprophylaxis as per risk assessment done earlier and again at delivery. Early mobilisation and hydration should be encouraged. Heparin is to be preferred for 3-5 days treatment and warfarin for longterm treatment. Warfarin is to be started 2-3 days after delivery with heparin and heparin stopped after INR has been stabilised if at high risk. Treatment should be started as soon as practical after delivery. If at high risk of bleeding as women with antepartum haemorrhage, postpartum haemorrhage, intraperitoneal bleeding treatment is to be started as soon as risk is reduced. Adequate precautions with epidural catheter is to be taken. No anti coagulant is to be given for 4 hours after insertion or removal of an epidural catheter. Epidural catheter is to be inserted after 12 hours after a prophylactic dose and 24 hours after a therapeutic dose of heparin, catheter can be removed only 10 hours after last dose of heparin. Coordination with haemotology clinic and a joint obstetric haematology consultation in all problems or difficulties is to be taken for appropriate management.
		Posted by Sreekala S. Sun Feb 26, 2006 10:55 pm
Dear Paul, Thank you very much for correcting my answer and for your comments.May I remind you that role of aspirin has been mentioned in the RCOG guideline on thromboprophylaxis. \"7.2- Aspirin 75mg may be appropriate in situations where the risk of VTE is increased but is not deemed high enough to warrant the use of antenatal LMWH; for example in women with previous proked VTE without thrombophilia\" I do agree that I have not mentioned this indication in my answer. Best wishes, Sreekala
		Posted by Kiran R. Tue Feb 28, 2006 10:38 am
Thromboembolism is a major cause of maternal mortality in the UK. The incidence of thromboembolism can be reduced by identification of high risk population. This can easily be done at the booking clinic. Health education via primary care will also help, this might be costly but will assist in minimising the mortality by early presentation and treatment. High risk patients can be screened for thrombophilia i.e, protien s and c deficiency, antithrombin iii deficiency and by identifying factor v laiden mutation. Such patients can be treated with clexane throughout pregnancy followed by postnatal warfarin therapy till six weeks postnatal. These measures will reduce the incidence of mortality, significantly. But inspite of all efforts, some patients can still be missed. All the obstetrics units up and down thhe country should have their own protocols in accordance with the RCOG and NICE guidelines. Clinical governance of missed cases and near misses by incident reporting and acting upon relevant flaws can help in reducing the mortality risk. Regular audits of patients with deep vein thrombosis and pulmonary embolism can help in assessing the units practice. These tools are quite effective in standardizing the care and help in reducing mortality. Early mobilization and proper hydraation in patients after normal vaginal delievery and in absence of added risk factors also help in reducing the incidence. High risk patients with obesity, previous DVT and aged more than 40 etc will benefit from early mobilization, hydration and prophylactic dose of clexane until full mobility. Prophylactic clexane can be considered in instrumental vaginal delievery especially if the delievery was traumatic. Care of episiotomy wounds, infection control, early mobilization and hydration will help in control of thromboembolism in all vaginal delievery.