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MRCOG PART 2 SBAs and EMQs

Course PAID
notes	336
EMQ	1502
SBA	2115

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ESSAY 219 - DVT in pregnancy

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		Posted by Srivas P. Tue Jan 16, 2007 07:07 am
a) There are two issues to be addressed?Repeat section on previous 2 LSCS and Woman on therapeutic LMW heparin for DVT. Both may contribute to possibility of excessive bleeding at caesarean section. The LSCS should be done by consultant with pre operative assessment by senior anesthetist. Consent should explain risk of excess bleeding, possibility of blood transfusion, any additional procedure to deal with it like hysterectomy, internal iliac ligation. Her risk status for a recurring DVT should be assessed from her investigations and notes and to find cause for DVT at 12 weeks?Congenital thrombophilias like anti thrombin deficiency, artificial heart valves or APS carry high risk of VTE and although she has received 6 months of therapeutic anticoagulation, it is safer continuing with same therapeutic dose until one day before delivery without risking repeat DVT and switch to prophylactic dose 1 day prior to C.S and then post delivery with LMWH or warfarin for 6-12 weeks. For isolated DVT at 12 weeks associated with temporary risk factors like dehydration, it may be possible to switch to prophylactic LMWH around 36 weeks after 6 months of therapeutic dose and continue with same dose post delivery also for 6-12 weeks. Her pre operative management should consist of FBC to assess haemoglobin status which should be optimum in anticipation for bleeding at C.S. Clotting profile, Activated Prothrombin Time and Platelet count as LMWH may cause thrombocytopenia and this would influence type of anesthesia?RA would be avoided and she may need platelet concentrates. Any disorder with clotting profile and APPT while on LMWH will require a haematologist opinion and referral. Blood group and crossmatch and 4 units blood should be booked. RFT and LFT to ensure safety of drug administered and as baseline monitoring. USG should be done to see site of placenta and rule out placenta praevia which complicates the surgery further if placenta is anterior and low lying with possibility of adherent placenta. Dates should be confirmed and fetal well being should be noted by BPP. Preoperative anesthetic checks up is essential and if she is on therapeutic LMWH, switch to prophylactic dose pre operatively. RA should not be given for 24 hrs after therapeutic dose and 12 hrs for prophylactic dose. Prophylactic LMWH can be given 4 hrs after siting the RA. GA may be decided at anesthetists? discretion. b) Since she is on anticoagulants at the time of C.S which increases risk of wound haematoma, subsequent sepsis and poor wound healing, meticulous haemostasis , aseptic technique should be maintained. Abdominal drains may be left in place if required and abdomen should be closed by mass closure technique with non-absorbable suture or delayed absorbable sutures like Vicryl or PDS, if opened by midline incision. Use of tension sutures is controversial. Transverse incision should be closed in layers. Haematogist should be involved in case of large volume blood replacements. Immediate blood transfusion if blood loss is excessive can prevent post operative anemia and reduce post operative morbidity. Prophylactic antibiotics should be given. c) Her Vitals should be monitored- Pulse, temp, B.P, RR. Antibiotic prophylaxis must continue. Post operative chest physiotherapy to avoid strain on coughing. Post operative drain management and removal if minimal soakage. Need for blood replacements should be assessed and transfused if there is post operative fall in haemoglobin. Platelet count, aPPT should be assessed again. Early ambulation should be encouraged. Analgesia may be given as top up if epidural is in place. Epidural catheter should not be removed within 10-12 hours of the most recent injection of LMWH. The prophylactic dose of anticoagulation should continue for 6-12 weeks depending on her risk profile for recurrence of DVT. This can be given as continuation of LMWH or with Warfarin . Both can be given with breast feeding. LMWH can continue as before but prolonged LMWH given since 12 weeks pregnancy does increase chances of osteoporosis but is less than with unsaturated heparin and it may be decided to switch to Warfarin after discussing with the woman. LMWH can be continued from home by self injection with monthly platelet monitoring. Warfarin is taken orally and International normalized ratio which should be maintained between 2 and 3 but this needs regular and more intense monitoring which could be cumbersome for her to attend clinic regularly. LMWH should be given until INR is more than 2 for 2 days. She should be told about signs and symptoms of pulmonary embolism and explained to report immediately on such suspicion. Graduated elastic stockings should be worn post operative and may be continued for 2 more years on affected leg to reduce the risk of post-thrombotic syndrome. Post operative contraception with COC should be avoided for 3 months and assessed again. POPs are not contra indicated. IUCD with now 3 caesarean incisions though carries risk of perforation, is not a contra indication but in this case carries additional risk of haemorrhage with anticoagulation and is hence best avoided. She should be reassessed again at 3 months before stopping anticoagulation.
		Posted by Randa E. Tue Jan 16, 2007 12:27 pm
Pre-operatively one of the management would be to reduce the therapeutic dose of LMWH to a prophylactic dose one day before the surgery. This is due to the increased risk of wound haematoma in patients on LMWH following c/s . On the day of delivery the morning dose of heparin should be omitted and the operation performed that same morning. Another important issue to be dealt with preoperatively would be the type of anaesthesia which should be discussed with the senior anaesthetist pre-op and should be in keeping with the local anaesthetist protocols. To minimize the risk of epidural haematoma regional techniques should not be used until at least 12hrs after the previous prophalactic dose of LMWH or 24hrs after a therapeutic dose. LMWH should not be given for at least 4 hrs after the epidural catheter has been inserted or removed and the cannula should not be removed within 10-12hrs of the most recent injection of heparin. These women are at high risk of haemorrhage so pre-op investigations e.g FBC to assess haemoglobin status, clotting profile and blood grp and crossmatch should be taken. 4-6 units of crossmatched blood should be ready before the c/s. A scan for placental localization should be done due to her increased risk of placenta previa especially with her history of 2 previous c/s. The use of TEDS is recommended pre-operatively and all the way into the c/s. All the implications of the surgery including the risks associated with her condition e.g excessive bleeding , need of blood transfusion , need of additional lifesaving procedures that might arise e.g. hysterectomy should all be explained to the patient and a written consent should be obtained pr-operatively. Also the opportunity for her to discuss the form of anaesthesia with the anaethesist should be arranged. Additional measures that may be taken inra-operatively to minimise morbidity are that the surgery should be done by an experienced obstetrician consultant , consultant anaethesist and early liason with haematologist in case need for urgent massive transfusion arises during the surgery. Another pre-caution would be to make sure that all bleeding has been controlled and proper haemostasis has been achieved during the c/s . Also due to the increased risk of wound haematoma there should be liberal use of wound drains and the skin closed with interrupted sutures. In the post-operative period good hydration should be maintained to avoid the formation of clots associated with dehydration. The risk of VTE also decreases with early mobilisation which is encouraged post operatively. A thrombophylactic dose of LMWH should be administered the same evening after surgery . In women with increased haemorrhage risk e.g major antepartum haemorrhage ,coagulapathies or progressive wound haematoma, IV unfractionated heparin is more appropriate because of its shorter half life and easily reversibility using protamine sulphate.Subcutaneous heparin can be commenced once risk of haemorrhage has passed. Drains should only be removed after commencing the therapeutic anti coagulation and after >12hrs of minimal drainage. As the post-thrombotic changes of pregnancy do not revert completely to normal until several weeks after delivery thrombopholaxis should be continued for 6-12wks postpartum. If the women prefers to start warfarin this can usually be initiated in the 2nd or 3rd postnatal day. LMWH should be continued until the INR is >2. Warfarin is known to be safe post-natally and during breast-feeding. TEDS should be prescribed and used postnataly and up to 2 yrs on the affected leg for it reduces the risk of post phlebetic limb syndrome. Contraception should be discussed before discharge. Combined oral contraceptive pill should be avoided in the 1st three mnths postpartum.
		Posted by Farzana N. Tue Jan 16, 2007 05:39 pm
a) This pt with prev 2 cs and h/o dvt is a high risk case and a senior obstetrician and consultant anesthetist should be involved.Antenatal record should be checked to see if thrombophilia screening has been done and if the pt is found to have any thrombophilia.USS should be checked to r/o placenta previa and /or accreta.since there is high risk of these in cases with prev cs.Blood should be cross matched and saved.coagulation profile should be done to ensure that it is within normal range, to avoid risk of hemorrhage.CBC done to check Hb and PLT count in case regional anesthesia is considered,as heprin therpy may have caused thronmbocytopenia. Written cosent should obtained regarding anesthesia ,risk of hemorrhage and in extreme case need of hysterectomy. Dose of heparin should be reduced to prohylactic dose the day before the operation.morning dose of heparin should be omitted on the day of operation.If regional anesthesia is contemplated,pt should be counselled regarding the precautions that would be taken.It should be given 24 hrs after therapeutic dose and 12 hrs after prophylactic dose.Catheter should not be removed until 12-14 hrs of most recent dose and heparin should not be given until at least 4hrs after catheter is rremoved.She should be encouraged to wear TED stockings as thromboprophylaxis. b)Operation sould be performed by senior obstetrician.perfect hemostasis should be secured and drains should be placed liberally to prrevent any collection of blood.In case of severe hemorrhage , an early recourse to hysterectomy should be done, if other measures such as iternal artery ligation, B-lynch sutures have failed .wound should be closed by interrupted sutures. c) In post operative period,vital signs are monitored and care should be taken that the pt remains well hydrated.Early mobilisation should be encouraged.Prophylactic anitibiotics should be continued,and prophylactic dose of heparin shoud be given 3hrs after operation or4hrs after removal of catheter.Therpeutic dose of heparin should be commenced in the evening.Drains should be removed >12hrs after minimal drainage.If there is significant risk of hemorrhage un fractionated heparin may be given since it has short half life and easily reversible.According to RCOG guidelines ,this pt should recieve thromboprophylaxis for 6-12 wks.Warfarin may also be used alternatively.It is started on day2-3 postpartum,Heparin is continued until INR is >2 on two successive days.Breast feeding is not contra-indicated while the pt is on wafarin.She should be encouraged to wear TED stockings for 2yrs since the risk of thrombo phlebitis is reduced significantly.Beforre discharge, contraception is discussed.COCP is avoided for 3 months.She can have POP.
		Posted by Parveen Q. Tue Jan 16, 2007 09:22 pm
This is a high risk patient , due to the previus 2LSCS and on on heparin therapy.Though Lwmt heparin carries less mortality, osteoporesis, fratures, haemorrhage is a serious problem. Her preoperative management involves maintaining the optimum level of haemoglobin, avoiding dehydration.FBc, liver function test, kiney function test and platelet count performed. LMWH is monitored by anti X a activity, the target therapeutic range is 0.4 to 1unit/ml . This is done 3hours post injection. 4-6 units of cross matched blood should be kept ready. Risk of repeat LSCS, increased risk of intra operative and post operative haemorrhage,increased mortality risk due to the above 2 factors, prolonged hospitalisation if needed, should be explained by the consultant and informed consent taken. If she is opting for permanent sterilisation, this should be documentd and consent taken at this stage.Patient should be seen by consultant anaesthetist and , and involved in the choice of anaesthesia. All the discussion should be documented, leaf lets provided and date for the surgery fixed . If she feels any pains before the repeat LSCS date, she should stop taking the haparin and should be hospitalised and further management is like after admission for elective LSCS. The day before the surgery, therapeutic dose of LMWH changed to prophyactic dose. Regional anaesthesia should not be used 24hours after therapeutic and 12 hours after prophylactic dose.On the day of operation, the morning dose is omitted and the operation performed in the morning. Pneumatic calf compression stockings while on surgery and in postoperative period to minimise the the propagation of clot. Minimise the blood loss by active management of oxytocin drip and symtometrine . Early recourse to measures llike internal iliac artery ligation or hysterectomy weighing the risk , balace ratio early involement of extra help, and multidisciplinay team like urologist if bladder or ureter damage occurs. If bleeding occurs, intraoperativvely, involvement of haematologist in further management. Place wound drains to avoid post opearative collection. Wound hematoma is common about 2%, so skin closed by interrupted sutures or skin clips. Post operativly should be cared for in high dependecy unit. Prophylactic antibiotics given. dehydration avoided. Heparin can be started 3-4 hours postoperatively if there is no PPH. Catheter should not be removed within 10-12 hours of the most recent injection. First dose of LMWH can be give after insertion but before removal of catheter. Breast feeding is not contraindicated. After counselling, if she wants alternate therapy, warfarin can be given on the 2 or 3postoperative day, but she should be informed about the frequent clinic visits for monitoring . warfarin is teratogenic , and the continued risk of intracranial hemorrhage and maternal hemorrhage if she gets pregnant is informed. If warfarin is started on the postoperative period, LWMH should be continued till the INR is >2 on 2successive days. Thrmoprophylaxis should be continued for 6-12 months postpartum. Graduated elstic stockings should be worn for 2years to avoid post thrombotic syndrome. contraception provided. with current thromboembolism, hormonal contracetion is not used. With a personal history of DVT , she should not use cocp ,but she can use progestrone only methods,as benefit outweighs the risk. Alternate methods should always be discussed, like barrier contraception, male sterilisation etc. Further review at 3months postpatum to asees the risk of recurrence.
		Posted by Sreekala S. Tue Jan 16, 2007 09:36 pm
a) The woman should be advised to report immediately to the labour ward if she thinks she is in labour before the planned caearean section, she should stop taking heparin until admission with further doses being given by the medical staff after assessment. She should be under a multidisciplinary care consisting of the high risk obstetrician, obstetric anaesthetist, haematologist and an experienced midwife. She should be admitted a day before the caesarean section. Bloods should be sent for FBC, coagulation profile and peak anti Xa levels to obtain baseline values and to help make decisions regarding the type of anesthesia. Ultrasound scan should be performed to confirm the placental site to rule out adherent placenta or placenta preavia. Atleast 4 units of blood should be crossmatched. The dose of LMWH should be reduced to prophylactic dose on the day before the Elective c/s.The morning dose of heparin should be omitted and the surgery performed in the morning. TEDstockings should be worn continuously. Anaesthetic review should be done pre-operatively to plan the appropriate type of anaesthesia and to discuss the implications of regional anaesthesia with LMWH.Her notes should be reviewed to find out the indications for previous sections and the events leading to DVT. Consent should be obtained after full discussion about the increased risk of complications like injury to bowels and bladder following 2pr.c/s, infection, wound hematoma, haemorrhage needing blood transfusions and additional surgical procedures like hysterectomy, internal iliac artery ligation. b) Caesarean section should be performed by the most experienced obstetrician in the presence of consultant anaesthetist as a prolonged surgery by junior staff increases the risk of Haemorrhage and thromboembolism. Crossmatched blood should be available before the start of the operation. The morning dose of LMWH should be omitted and surgery performed in the morning. Regional anaesthesia should not be used within 12hrs following a prophylactic dose of heparin and 24hrs following a therapeutic dose of heparin. Cell salvage procedures should be considered as there is an increased risk of haemorrhage. She should be adequately hydrated during the surgery. Abdominal drain and interrupted sutures should be put to allow drainage of haematoma. Care should be taken to obtain a perfect haemostasis. c) Postoperatively syntocinon infusion should be considered to reduce the risk of PPH. She should be monitored closely for PPH. Early ambulation should be advised. Dehydration should be avoided. Prophylactic doses of Heparin should be given 3hrs following the section (4hrs following epidural catheter insertion or removal) provided there is no PPH.Therapeutic dose of heparin should be given in the evening. Following excessive bleeding, coagulopathy, progressive wound hematoma, intra abdominal bleeding, Unfractinated heparin is preferable to LMWH as unfractionated heparin has a shorter half life and its effects can be easily reversed with protamine sulphate provided the bleeding is settled. Epidual cannula should not be removed within 10-12hrs following LMWH. She should be advised to inform immediately if she suspects DVT or Pulmonary embolism. Blood transfusions may be required post operatively. Adequate analgesia should be provided. Prophylactic antibiotics should be considered in the event of a prolonged surgery. TEDstockings should be worn on the affected leg for a total of 2years to reduce the risk of post thrombotic syndrome. Warfarin can be commenced on the 2nd or 3rd post operative day. LMWH should be continued until INR is >2 on 2 consecutive days. Breast feeding is safe while taking warfarin. INR should be maintained between 2-3. She should be advised follow up in a haematology clinic. Anticoagulation should be continued atleast for 6 weeks postnatally. Contracetptive advice should be given. COCP should not be used within the first 3 months. IUCD should be avoided as there is an increased risk of uterine perforation. She should be debriefed about the events before discharge. At 6 weeks post natal visit, thrombophilia screen should be performed and a prospective management plan made if she wishes another pregnancy. An incident form should filled in the event of complications arising and the events should be clearly documented.
		Posted by Parveen Q. Wed Jan 17, 2007 12:04 am
I am sorry, the correction in my answer, thromboprophylaxis should be continued for 6-12 weeks potnatal, not 6-12 months. thank you.
		Posted by kiria O. Wed Jan 17, 2007 02:25 am
Woman is due to have elective CS and she is on theraputic dose of LMWH, so her informed consent must be taken the week before her elective date , however, her informed consent need to be checked by the obstetrician who will perform the surgery.Also, the woman must be aware of the form of anasthesia after disscusion with anasthatist. Inform theater staff, neonatlogist, anasthatist and heamatologist for the time of elective. Investigations such as CBC to determine her HG and platlets count to exclude thrombocytopnea complicating theraputic LMWH. her blood grouping and crossmatch is justified as she is at increased risk of heamorrhage. It is essential to stop theraputic dose of LMWH 24 hours befor surgery to reduce risk of heamorhage during surgery and antiXa level need to be checked. Prophylactic dose of LMWH must be given 2 hours before surgery to reduce risk of DVT during operative period however, itis associated with increase risk of wound heamatoma. woman should be given antiacid and antiemetic to reduce risk of aspiration and mendlson syndrome. During the operation, bladder cathetrisation may reduce risk of bladder injury. application of intermittent calf compression is not proved to prevent DVT. As the patient is p2CS and is likely to have adhesions and bowel may be sticked into anterior abdominal wall, so great prequation must be exercised to avoid sharp dissection and avoid bladder and bowel injury. Uterine sharp incsion best if avoided and blunt dissection would reduce blood loss. avoid manual removal of placenta to reduce risk of post operative endometrites and ensure that uterus is adequatly contracted by giving uterotonics to reduce risk of bleeding Ensure fastidous heamostasis and close uterine muscle two layers with avoidance of peritoneal closure as this would reduce post operative pain and fever. Wound drain can be justified as there is increase risk of wound heamatoma. Also adequate hydration and intraoperative prophylactic antibiotices would reduce risk of thrombosis and infection respectiveley. Post operative observation of pulse, Bp temperture and urine out put every 15min then half hourly in HDU to ensure that pateint is heamodynamically stable Adequate hydration and TED stocking with early moblisation is essential to reduce risk of recurrance of DVT Prophylactic dose of LMWH can be given12h after removal of epidural cathetr to reduce risk of epidural heamatoma. If thearputic dose of LMWH is still to be continued should be started 24h after removal of epidural cathter. Warfarine canbe started in postnatal period and it is not contraindication for breast feeding. before discharge appropriate form of contraception must be discussed with the pateint such MPA injection or progestagenic implants. Any form used for thromboprophylaxis either LMWH or warfarin must be continued for 6 to 12weeks after delivery in pateint with DVT during pregnancy and arrangment for follow up and testing for inherited thrombophilia is ensured.
		Posted by Sarwat F. Wed Jan 17, 2007 08:59 am
Deep vein thrombosis is a major cause of maternal mortality and morbidity. In this patient preoperative management include regulation of dose of heparin, risk assessment and reviewing the notes of previous caesarean sections. As she is on therapeutic dose of low molecular weight heparin she will be seen by anaesthetist prior to caesarean section to modify the dose of heparin before operation. In most cases hospital protocol is to give prophylactic dose night before operation and to restart 4 hours after operation. Management will be multidisciplinary in collaboration with haematologist. Patient?s platelet count should have been monitored in the antenatal period with the aim of keeping platelet levels above 80 x 109 / liters for caesarean section. Her previous notes should be reviewed for any complications at previous caesarean section or difficulty in entering abdominal cavity. Patient?s serum should be sent for group and hold in case any blood is needed for cross match as use of heparin is associated with increased risk of retroplacental haematomas. Informed consent is taken regarding elective caesarean section according to RCOG guidelines emphasizing the importance of complications associated with repeat caesarean sections and anticoagulant use. Risk of encountering adhesions and subsequent bladder and visceral damage increases with repeat caesarean sections. Risk of haemorrahgic morbidity is increased in patients on therapeutic doses of heparin with increased risk of wound haematoma. Additional measures to minimize the risk to woman during operation include adequate haemostasis, good knowledge of anatomy and careful reflection of bladder. Senior obstetrician should be doing the procedure. Good haemostasis is achieved either with suturing or use of diathermy. In doubtful cases where there is general oozing with no active bleeding use of redivac drain is employed to minimize risk of haematoma formation. Inverted T shaped uterine incision can be given in case there is difficulty in delivery of baby due to extensive adhesions and difficult access. Peritoneal layers can be closed if the edges are bleeding to ensure good haemostasis. Use of clips to close skin incision is also preferred to minimize risk of subcutaneous haematomas. Postoperative management is extremely important in patients with deep vein thrombosis as risk of DVT is highest in puerperium. Risk assessment is done again postoperatively to modify dose of heparin if needed for example with heavy intraprtum blood loss. Postoperative monitoring is done according to hospital protocol as she is at high risk of post partum haemorrhage. Blood pressure, pulse, input output and vaginal bleeding is monitored. Early mobilization is encouraged postoperatively and adequate hydration is maintained. She will continue therapeutic dose of heparin for 6 weeks following delivery. There is 2 % risk of wound haematoma with heparin and she will be explained about this risk. Regular community midwife visits will be arranged for wound followup if there is any suspicion and in case of complication she will be readmitted to hospital. Review with haematologist will also be arranged postnatally to discuss future risks and management. She will be educated about signs and symptoms of pulmonary embolism like chest pain, dyspnoea, palpitations, hemoptysis and to contact hospital with any such complaints. GP is informed of all the treatments given and operative procedures done. Regarding contraception, estrogen containing OCPs are avoided, progesterone only pills or implants can be used.
		Posted by M M A. Wed Jan 17, 2007 01:31 pm
The therapeutic sub-cutaneous LMW Heparin should be discontinued the day before the caesarean section. This is to avoid its unwanted anticoagulant effect during CS. The regional anaeshesia should not be undertaken until at least 24 hours after the last dose of therapeutic LMWH.,to minimize the risk of epidural haematoma. Preoperative anaesthetic review should be carried out by senior anaethetist who must discuss the implications with the patient. Hb% should be checked .Blood sample should be saved for group and cross-match .,blood should be available preoperatively .,to minimize risk of intraoperative bleeding .Ultrasound scan should be performed for placental localization due to increased risk of placenta previa with previous two caesarean sections. Written consent should be taken from the patient which had been fully informed during the antenatal period about the reasons ,risks and benefits of CS. Mobilisation should be encouraged with use of thromboembolic deterrent stockings. A single dose of prophylactic antibiotics such as cephalosporin should be given 1-2 hrs preoperatively to reduce the febrile morbidity and sepsis. The additional measures that may be taken to minimize intraoperative risks ,that the operation should be conducted by consultant obstetrician and consultant anaethetist . The haematologist advice should be sought. There is a risk of haemorrhage with postoperative use of heparin ,therefore fastidious haemostasis should be followed. There is a risk of wound haematoma following CS of around 2%. So,Wound drains ( whether abdominal or rectus sheath ) should be used. The skin incision should be closed with staples or interrupted sutures to allow drainage of any haematoma. Regarding postoperative management : Early mobilization and adequate hydration of the patient ,to overcome the dehydration which is risk factor for DVT. The thromboembolic prophylactic dose of LMWH should be given by 3 hours postoperatively or more than 4 hours post removal of epidural catheter . The epidural catheter should not be removed within 12 hours of the most recent dose.The therapeutic dose of LMWH should be recommenced that evening of CS. If a significant risk of haemorrhage had occurred as coagulopathy or progressive wound haematoma, the patient should be managed with intravenous unfractionated heparin . It has a shorter half-life than LMWH and it is completely reversed with protamine sulphate . Sub-cutaneous LMWH should be commenced once the risk of haemorrhage has resolved .The drains should be removed after commencing therapeutic dose of heparin and after more 12 hrs of minimal drainage. Anticoagulant therapy should be continued for at least 6-12 weeks postpartum. The woman should be offered a choice of LMWH or oral Warfarin. Breast feeding is not contraindicated with warfarin or heparin. If the woman chooses to commence warfarin,it should be started on third postoperative day. The heparin treatment should be continued until the INR > 2.0 on two successive days. GECS should be used on the affected leg for two years to reduce the risk of post-thrombotic syndrome from 23% - 11% over this period. Contraception should be advised before discharge. COCP should be avoided for three months. Progestogen only contraception can be used safely before 21 days postpartum.
		Posted by Abi T. Wed Jan 17, 2007 02:48 pm
a)This lady is at high risk of intraoperative and postpartum hemorrhage and thrombosis and poses a surgical and anaesthetic challenge. Her care should be within a multidisciplinary team setting involving obstetrician, anaesthetist and haematologist. Preoperatively, her hemoglobin should be optimized to reduce the need for transfusion and in anticipation of possible significant blood loss. Blood grouping and cross match of at least 4 units should be available on the day of Caesarean section. LMWH heparin can cause thrombocytopenia hence ,platlet count should be checked to ensure it is at safe levels for regional anaesthesia and if less than 50x100000,she may require a top up of platlets pre-op if adviced by the consultant haematologist. Clotting factors i.e, INR and APTT should also be checked as any derangement will increase her risk of bleeding. The haematology lab should be alerted to ensure adequate blood and blood products are available in anticipation of a massive PPH. It may be prudent to do an ultrasound scan if not already done antenatally to locate the placenta as an anterior placenta previa would further complicate surgery as there is also a risk of morbidly adherent placenta. The caesarean section should be scheduled on a day when the consultant obstetrician and consultant anaesthetist are available as she is a high risk patient. The consent form should be reviewed to ensure that she has been informed of additional procedures such as internal iliac artery ligation and B-lynch sutures as PPH minimizing measures and the possibilty of a hysterectomy as a life saving measure. She must be made aware of the increased risk of bowel and bladder injury as extensive adhesions may be present from her 2 previous sections. She should also be made aware of the likelihood of needing blood transfusion and any objections to this documented and a plan put in place for alternatives. She should be adviced to omit her dose of heparin 24 hours prior to surgery as this reduces risk of bleeding and the need for general anaesthetic. Advice must be given to come in urgently if she has SROM, contractions or bleeding prior to the day of admission. This should be supported by written information. Preoperatively arrangements should be made for her to see an anesthetist to discuss anaesthetic options. A contingency plan should be documented in the notes as to her anticoagulation,operative and anaesthetic management should she present in unexpected labour. b) To minimize her risk of thromboembolism she should have Flowtron boots on and the length of surgery shortened; surgery preferably done by an experienced senior obstetrician. Careful dissection of adhesions should be made to avoid bladder and bowel injury and the bladder should be reflected down adequately prior to the lower segment incision. Hemostasis should be meticulous by use of diathermy and other hemostatic products such as surgicel to minimize blood loss from superficial areas or friable tissue. Intra abdominal and wound drains should be placed to drain any hematomas, which would reduce risk of infections and this measure would also ensure that any postoperative bleeding can be recognized early and promptly managed. Adequate fluid replacement should be ensured to avoid hydration and reduce further risk of thromboembolism. Interrupted skin sutures would allow drainage of any superficial wound hematomas and a pressure dressing should be applied to manage superficial oozing. c) Initial postoperative management includes recording of vital signs and vigilance for PPH. If significant blood loss had occurred intraoperativley then she should be managed in an HDU setting with input from anaesthetist and haematologist, otherwise prophylactic measures should be taken to reduce risk of PPH from uterine atony eg, syntocinon infusion. Early ambulation, early removal of catheter as soon as patient is mobile,adequate hydration and TED stockings should be used to ensure risk of further thromboembolism from immobility is reduced. Although the length of time she is un-anticoagulated should be shortened, resumption of LMWH heparin should be safe if there isn\'t any ongoing bleeding and platlet counts and clotting factors are within normal range. Liaison with the Hematologist should be sought in cases where there is derangement of these values. Anticoagulation should be continued for at least 6-12 weeks postpartum and this can be either subcutaneous LMWH heparin or warfarin according to patient choice. Warfarin use and therapeutic INR maintenance should be in liaison with the anticoagulation clinic. Reassurance should be given that these drugs are safe in breast feeding and breastfeeding encouraged. If a thrombophilia eg. APS was detected then anticoagulation may need to be continued for a longer period and this will have implications for future pregnancies and deliveries as well. A follow-up appointment should be arranged with the Hematologist to discuss and manage this. Appropriate contraception advice should be given prior to discharge. She is more suitable for progesterone only methods or the IUCD or IUS. She should be made aware of the increased risk of morbidly adherent placenta , placenta previa and further pregnancy and surgical complications in future pregnancies and perhaps to consider permanent methods of contraception such as male and female sterilization. Written information should be provided upon discharge advicing her of symptoms and signs of thromboembolism eg, calf pain, swelling,pleuritic chest pain and SOB, and she should seek medical attention urgently.
		Posted by Olubunmi O. Wed Jan 17, 2007 08:10 pm
[:)] Preoperatively there should be multidisciplinary management of this patient involving the consultant obstetician, haematologist and anaesthetist. A FBC to rule out thrombocytopaenia and anaemia, electrolytes and urea and a full coagulation profile as well as anti Xa is done to check her clotting profile. An anaesthetic review is important to discuss mode of analgesia taking into account patients wishes and especially for the obese patient. Heamatology imput is necessary in this anticoagulated patient .Her wishes regarding blood transfusion is noted and a crossmatch of 4 units of blood requested for the day of surgery because she is at risk of intra partum and postpartum haemorrhage. Any atypical antibody is noted and blood requested in advance. An ultrasound scan should be arranged to check for the position of the placenta as placenta praevia and accreta is more common with 2 previous CS. A fully informed consent is taken detailing the name of the operation , the reason why it is being performed and commonly occurring complications like UTI, wound infection. In this anticoagulated patient complications like wound and rectus sheath heamatoma, the risk of intrapartum and PPH neccecitating transfusionmust be discussed.With spinal analgesia the is also a risk of spinal heamatoma with neurological sequelae although this should be minimal with correct adjustment of her LMWH therapy preoperatively. Patient should also be consented for a hysterectomy in case of uncontrollable haemorrage. The risk of injury to the bladder and bowel is higher with repeat sections because of adhesions which may make the operation technically difficult and should be mentioned. Additional procedures which may be necessary should be discussed. Leaflets should be provided and patient allowed to digest all the information given. The patient should be admitted the day prior to surgery and her therapeutic dose of LMWH switched to prophylactic dose. Spinal anaesthesia should not be given within 24 hours of therapetic dose or within12 hours of prophylactic dose .Class 2 Support stockings should be worn. Ranitidine is given the night before and the morning of the sugery to reduce stomach acidity. Intraoperative measures to minimise risk involves the presence of an experienced obstetrician and anaesthetist in theatre in case of difficult anaesthesia surgery or haemorrhage. Heamatology should be aware of the operation and blood and blood products readily available to promptly treat haemorrhage. Good surgical technique and fastidious haemostasis will help to minimise blood loss. Prompt blood transfusion to correct blood loss and fresh whole blood, FFP and cryoprecipitate will correct coagulopathy. Uterotonics, bimanual compression , uterine packing, B lynch suture and uterine or external illiac artery ligation should be promptly used to try and control heamorrhage and hysterectomy done to save life if bleeding is not controlled. Drains left in situ will minimise heamatoma collection .Intraoperative antibiotics will reduce infections .Help should be sought from urology and surgical colleagues in case of dense adhesions or inadvertent damage to bladder and bowel to minimise morbidity. IV syntocinon infusion continued postoperatively will aid uterine contraction. Postoperatively close monitoring is essential to promptly detect complications. High dependency care is indicated if there has been intraoperative complications. Pulse, BP, Temprature and Oxygen saturation are monitored closely. Monitoring of urine output and amount of fluid in the drain will help in detecting intra abdominal haemorrhage. Regular checking of dressing, PV bleeding and anaesthetic review especially if spinal analgesia has been used is essential for bleeding complications. Adequate analgesia is required and symptoms like abdominal pain and neurological symptoms, SOB investigated. Prophylactic dose of LMWH should not be given within 4 hours of epidural catheter insertion or removal and should be done with the advice of the anesthetist. Good hydration ,early mobilization and TEDS stockings will help to minimize further risk of DVT. Patient should be seen and debriefed about surgery before discharge and contraception provided. COCP should be avoided as these are thrombogenic. The need to continue anticoagulation and TED stockings at home should be stressed. LMWH need to be continued for 3 months after delivery as risk of VTE is highest in the postnatal period. Patient may be changed to warfarin and breast feeding is not contraindicated. LMWH may also be continued at patients preference for ease of monitoring. A postnatal check is essential to go over pregnancy events , discuss complications,side effects and contraception.
		Posted by Olubunmi O. Wed Jan 17, 2007 08:27 pm
Dear paul, is it important to mention trombophilia screen at the postnatal check bearing in mind she will still be on LMWH . Bunmi
		Posted by Yasser S. Thu Jan 18, 2007 03:46 am
A. Preoperatively this patient considerd as a high risk case because of increase risk of intraoperative bleeding with added risk being previous 2 c/s ,Risk of hematoma formation and VTE. So the woman should continue receiving a thromboprophylactic dose of LMWH on the day prior to delivery and, on the day of delivery, the morning dose should be omitted on the operation day.Furthermore the type of anaesthesia should be discussed with the patient by involving the senior anaestheist and it should be keeping with local anesthetist protocols. regional techniques should not be employed for at least 24 hours after the last dose of LMWH. LMWH should not be given for at least four hours after the epidural catheter has been removed and the cannula should not be removed within 10-12 hours of the most recent injection.Preoperative investigation which including FBC for Hb level and PLT count to be aware if any anemia or thrombocytopenia especially with the use of regional anaesthesia.Blood cross match should be done according to hospital protocols as the patient at risk of massive haemorrhage.Proper councelling for the patient and informed consent with chart documentation should be done which includs haemorrhage , blood transfusion ,Possibility of massive bleeding which may needs surgical interventions like internal iliac artery ligation or hysterectomy in sever cases . Issue of type of anesthesia should be documented as well with its implication. B. Intraoperativly the procedure should be performed by senior obstetrician or under his supervision and senior anesthesist . Perfect hemostasis should be achived as possible. Drain should be used because of the possibility of collection . Closure of the wound should be either by staples or interrupted sutures to allow drainge for any collection if happened. C. Post operatively, Good hydration should be maintained to minimize risk of hematoma formation.Early mobilization so we can reduce the risk of VTE and use of TED stocking. Strict care about thromboprophylaxis shoud be done by slection of heparin type to be resumed . In cases where considerd at high risk of haemorrhage like APH,coagulopathy,suspected intrabdominal bleeding,progressive wound hematoma and PPH then should be managed with intravenous, unfractionated heparin until the risk factors for haemorrhage have resolved.Unfractionated heparin has a shorter half-life than LMWH and its activity is more completely reversed with protamine sulphate Other wise in non high risk cases LMWH can be resumed on the operation day for evening dose.Postnatal anticoagulant therapy either subcutaneous heparin or warfarin should be continued for six weeks postpartum or until at least three months of anticoagulant therapy has been completed.But if there underlying risk factor like thrombophilia then reassessment befor stopping anticoagulation by involving hematologist is recommended.Regarding type of anticoagulant either warfarin or LMWH is equal as patient option because both not contraindicated in breastfeeding.In cases patient choose warfarin then it should be started in 2nd or 3rd day post nataly in combination with heparin till maintaing INR between 2.0 and 3.0 and heparin will be continued until the INR is 2.0 for two days befor stopping it. TED stocking recommended to be used in affected leg for 2 years so can reduce the risk of post thrombotic syndrome. Contraception should be discussed with the patient and option other than COC can be offered at least for 3 monthes, Then other re evaluation can be done .
		Posted by Freha Z. Thu Jan 18, 2007 04:57 am
(a) This women is at increased risk of repeat thrmboembolism and intraoperative haemorrhage. Her management should be multidiciplinary involving obstetrician, anaesthetist, haematologist, midwife and neonatologist. Her pre op investigations include FBC, Hb to rule out anaemia, renal and liver function test and thrombophilia screen if not performed earlier. Baseline anti Xa levels and platelet count should be performed to moniter LMW Heparin. She should be informed about the risk of infection, accidental injury and higher of haemorrhage because of heparin and atleast 4 units of blood should be arranged prior to surgery. She should be informed that blood transfusion may be required during or after surgery. If she wishes permanant sterilization an informed consent should be taken at this stage. Because of previous caesareans her risk of placenta previa is higher which should be ruled out and she should be counselled about the risk of hysterectomy. All the discussion should be clearly documented and information should be backed up by the leaflets. An anaesthetic review should be done. On the day before surgery thromboprophylactic dose of LMWH should be given and morning dose before surgery should be omitted and surgery performed in the morning. (b)Senior obstetrician should be performing surgery because of risk of haemorrhage and risk of injury due to adhesions. Mode of anaesthesia should be decided by anaesthetist. Regional anaesthesia should be avoidedwithin 12 hours of prophylactic heparin dose and 24 hours of therapeutic dose. Because of risk of haematoma meticulous haemostasis should be done and wound drains and interrupted stitches should be used. Neonatologist should be present at the time of delivery. (c) Post operative antibiotics and analgesia should be given. Uterotonics should be used to reduce risk of haemorrhage. Post operative LMW heparin should be continued until 6 weeks postpartum. Hydration, early mobilization and TED stockings should be advised. If there is high risk of haemorrhage Unfractioned heparin should be started as its action can be reversed by protamine sulphate. LMWH can be changed to warfarin if patient wishes and monitered by INR(>2.5).Breast feeding is not contraindicated. COCPs shouldnt be used until 3 months of stoping heparin. Progerterone only contraception can be used. Postnatal appointment at 6 weeks should be made.
		Posted by Srivas P. Thu Jan 18, 2007 07:05 am
Sir, I have some doubts for which I would like your clarification. 1. Can the contents of a draft guideline be quoted until it is published as a guideline?? I found treatment of Acute DVT in pregnancy at variance in the two documents as you can see in the following paragraphs I gathered from them. 2. Can you clarify if it is necessary to do platelet count as a follow up on a patient only on LMWH? When is it necessary to do Anti Xa levels? Is APTT useful? 3. I am thoroughly confused whether we continue therapeutic doses of LMWH for nearly 9 months in total in this patient who got VTE at 12 weeks. Is this for all patients or is it modified according to overall risk profile for a repeat VTE, based on presence of thrombophilia etc? Should this not be brought out? Guideline 2001:: Where a VTE occurs in pregnancy, therapeutic anticoagulation should usually be continued for at least six months. If the VTE occurs early in the pregnancy then provided that there are no additional risk factors, the dose of LMWH or unfractionated heparin could be reduced to prophylactic levels (40 mg enoxaparin once per day or 5000 iu dalteparin once a day or 10 000 iu of unfractionated heparin twice daily). Following delivery, treatment should continue for at least 6-12 weeks. Warfarin can be used following delivery. From Draft Guideline published in 2006:: 1.Should blood tests be performed to monitor LMWH therapy in pregnancy? Routine platelet count monitoring should not be carried out unless unfractionated heparin) has been given. Guideline documents recommend that routine platelet count monitoring is not required in obstetric patients who have received only LMWH 2. What is the maintenance treatment of DVT or PTE? Treatment with therapeutic doses of subcutaneous LMWH should be employed during the remainder of the pregnancy. I am grateful you made me think and I do hope you will clarify this doubt in my mind. Thanks a lot for guiding us so well. Based on guideline 2001, it is the prophylactic dose which is continued post partum Thanks
		Posted by urmee A. Thu Jan 18, 2007 06:57 pm
Preoperative management should include change of therapeutic dose of LMW heparin to prophylactic dose on the day before operation.The morning dose should be ommited on the of operation. Decision of anaesthesia(epidural) should be taken after dicussion with senior anaesthetist and according to local protocal. Blood should be taken for group and cross matching and atleast 4units should be crossmatched and hematologist should be involved for risk of hemorrage. HB status and platelet count should be checked because of risk of heparin induced thrombocytopenia. Placental position should be checked by USG because presence of 2 previous C/S increase the risk of placenta previa and C/S should be done by senior obstetrician. If family complete with this pregnancy tubal sterilization may be discussed with the patient and informed consent should be taken. TED stocking should be ensured.Epidural anaesthesia should not be sited before 12 hours of prophylactic dose and 24 hours of therapeutic dose. Additional measure during operation should include closure of skin incision with inturrepted suture or staples to allow drainage of any hematoma and wound drain should be sited. If the women is at high risk of hemorrhage(antepartum hemorrhage,coagulopathy)anticoagulant should be continuted with unfractionated I/V heparin because it has shorter half life and action easily reversed by protamine sulphate. During post operative period,early mobilisation and adequate hydration should be ensured. LMWH should not be given for 4 hours after epidural catheter has been removed and cannula should not be removed within 10-12 hours of the most recent injection. If this women wish to start warfarin it can initiate on 2nd or 3rd post natal day But LMWH should be continuted until INR >2.0. Warfarin is not contraindicated in breast feeding. TED stocking should be worn on the affectfed leg for 2 years to prevent post thrombotic syndrome. Contraceptive advice should be given and COC should be avoided to prevent recurrene of VTE.
		Posted by Mary M. Thu Jan 18, 2007 09:17 pm
In pre-operation management, reducing the dose of heparin to thramboprophylatic dose the day before surgery.Counselling to women the potential risks of C.section and effect of heparin during & after surgery. Risks of C.section are haemorrhage infection, injury to bowel,bladder, adherent placenta( if placenta praevia) and risk of wound haematoma afterward.If epidunal or spinal is used as type of anaestheseia then risk of epidual haematoma is explained.The multidisciplinary management in liasation with senior obstetrician, anaesthetist & haematologist. Blood is taken for FBP,clotting profile &gp+cross match . Mode of anaesthetic is discussed with anaesthetist. b) During operation blood should be readily available, if haemorrhage occur.General surgeon and uroglist is informed if there is a risk of adherent placenta.Regular monitoring of B.P pulse & ECG done. Drain is placed. c) Post operatively, dehyaration is avoided by giving i/v fluids.Early mobilization is advised.TED stocking is given & it can be continued for 2 years after surgery.Subcutanous LMWH is given 4 hours after epidural. Epidual catheter should not be removed 12 hours after last LMWH. Anticougulation is continued for 6-12 weeks post operatively.If patient wants to swith over on warfarin it is done on 2nd or 3rd day.Heparin is continued during that time until INR is more than 2. Thramboplilia screen is done in follow up appointment of the whole consequences of pregnancy is discussed & contraceptive issues are discussed avoiding COCP.
		Posted by neera B. Fri Jan 19, 2007 05:46 am
a) I shall counsel the lady regarding her risk of thromdoembolism(TE) in view of previous recurrent thromboembolism, pregnancy and major surgery and discuss the same. A carefully documented care plan for preop, intraop and post op care should be made with involvement of a Multidisciplinary Team (MDT), including a consultant obstetrician, consultant anaesthetist, and a consultant hematologist as this has been found to improve the outcome. Unit protocol should be followed she should be involved in decision making. I shall encourage mobilization and wearing well fitting TED stockings as these reduce venous stasis and thereby the risk of PTE. On the day before the planned Cesarian section , therapeutic dose of heparin shall be redused to prophylactic dose and the dose of heparin on the morning witheld in order to minimize the risk of excessive blood loss at surgery. The cesarian section is scheduled as 1st on the theatre list. Regional anaesthesia is not given till 24 hrs after the therapeutic dose and 12 hrs after thromboprophylactic dose of LMWH to minimize the chance of intraop hemorrhage. b) Consultant Obstetrician should perform the caesarian because adhesions can be present due to previous LSCS.Minimizing operative time is important because prolonged surgery predisposes toVTE. The blood loss thus can be minimized which is associated with increased risk of VTE. Patient must be kept well hydrated. Pneumatic compression devices should be attached to calf muscles as they prevent venous stasis thereby reducing chances of recurrent TE. Interrupted stitches should be given so that any collection drains out. Wound drains are used to reduce the chances of wound hematoma which occurs in 2% of such women. c) I shall restart LMWH 3 hrs after cesarian section or 4 hr after insertion or removal of epidural catheter. Early mobilization, adequate hydration and chest physiotherapy sould be advised because they help to reduce the risk of post op VTE. Anticoagulation should be continued for 6 months after last VTE or 6-12 wks after cesarian section whichever is longer. Well fitting TED stockings should be worn on affected leg for 2 yrs. after the acute episode because it reduces the chances of post thrombotic syndrome. On day 2 or 3 when INR is 2-3 , heparin can be substituted by warfarin because it is oral and has no harmful effect on breast fed infant. Contraception is advised but COC pill is avoided because it increases the risk of VTE. I shall counsel her about the signs and symptoms of TE and pulmonary embolism and advise to rush to hospital if these develop. 24 hr Helpline No. will be provided. Risk of recurrence is discussed and followup visit arranged.
		Posted by sailaja devi K. Fri Jan 19, 2007 08:43 pm
Preoperative management is important to avoid haemorrhage ,thrombosis while the women is on LMWH for DVT .Informed consent to be taken after explaining risk of haemorrhage ,risk with regional anaesthesia ,need to adjust the dose ,need to to do blood test while on heparin.Review the antenatal scan report and see for position of placenta.Preanaesthetic check up with anaesthetist .Discus the risks of haematoma formation with regional anasthesia while on hepain .Preoperatively check haemoglobin,haematocrit,platelet count.If haemoglobin is low counsel the women she may need blood transfusion ,document the same in the notes.Make sure the blood is reserved .Low platelet count contraindicates regional anaesthesia ,places the women at risk of further thrombotic complications so need to check platelet count. Women on LMWH is at risk of haemorrhage during section so measures to be taken to minimize the risk.Women with history of DVT is again at risk of getting DVT during section.So the treatment is to be directed to avoid complications of LMWH ,at the same time avoid further thrombosis.Women should receive thromboprophylactic dose of LMWH on the day prior to section .On the day of surgery omit the dose of heparin as the action of LMWH last for 12 hours. During operation women should be worn graduated compression stockings to pevent deep vein thrombosis.Epidural catheter should be sited after discussing with the senior anaesthetist.Regional anaesthesia should be sited 12 hours after previous prophylactic dose of LMWH.This is to minimize the risk of epidural heamatoma.During surgery check for amount of bleeding,achieve perfect hemostasis.Risk of wound hematoma following section while on LMWH is 2%.To minimize this risk consider wound drains ,close skin with staples or interrupted sutures to drain hematoma. Postoperativly avoid dehydration .Dehydratio is a risk factor for DVT.Continue graduated compression stockings .Advice early mobilsation as immobilisation is a risk factor for venous thromboembolism.Monitor vitals , O2 saturation.Advice chest physiotherapy.Check the abdominal wound for any hematoma.Check the amount of bleeding per vaginum to rule out PPH Start prophylactic dose of LMWH after 3-4 hours.Treatment dose of LMWH recommended from that evening.To minimize risk of epidural hematoma while on LMWH , timing of catheter removal and dose of heparin are important. Do not remove epidural catheter until 10-12 hours after dose of LMWH. Do not administer LMWH within 4 hours of epidural catheter removal.Anticoagulation continued for 6 weeks postpartum as puerparium is most hypercoagulable period. If the women choses warfarin in postpartum period it is started on 2 or 3 postoperative day.The international nomalized ratio checked on 2 day. Warfarin titrated to maintain INR of 2-3.Continue heparin till INR is above 2 for 2 consecutive days. Breast feeding is not contraindicated while on warfarin or heparin. Before discharge discuss about contracetion.COCP is contraindicated in previous thrombosis (WHO group 4).POP is recommended after 21 days.Advice thrombophilia screen after 6 wks.Advice to wear graduated compression stockings for 2 years to avoid post thrombotic syndrome
		Posted by Srivas P. Sat Jan 20, 2007 04:28 am
Sir I understand now that I must manage her the way she has presented-- woman on therapeutic dose of LMWH preoperatively for elective C.S. The preop management is as advised in guideline2001. My doubt is post operatively should she continue the therapeutic dose of LMWH or could she now be given prophylactic dose of LMWH for 6-12 weeks, based on results of thrombophilia screen and if she continues to be high risk for a repeat DVT. In case of single episode of DVT with temporary risk factor like OHSS, hyperemesis in preg with dehydration, are we to continue the higher therapeutic dose post operatively also? Thanks.