TEALE FENNING

Xerxes I

Try this (self made!)

You are seeing a 30 year old woman at booking visit. She has a history of an episode of deep vein thrombosis 3 years ago.

What are the improtant points to be elicited in her history? (4 points)

What examinations and investigations would you consider? (3 points)

How should you modify her antenatal care? (6 points)

how would you manage her in her peripartum period? (7 points)

shachi · Joined: 10 Jun 2008 Posts: 16

[b]You are seeing a 30 year old woman at booking visit. She has a history of an episode of deep vein thrombosis 3 years ago.

What are the improtant points to be elicited in her history? (4 points)

A history of previous DVT increases the patient's risk for thromboembolism.I would get details of the number of episodes of thromoembolism and events around the deep vein thrombosis, if she was pregnant at that time, did she have other risk factors like major surgery or prolonged immobilisation, and if she was on oral contraceptive pills at that time.
An obstetrics history of previous intrauterine death, recurrent miscarriages, early onset preeclampsia, might prompt investigations for thrombophilias.
Grand multiparity, smoking, obesity , gross varicose veins, nephrotic syndrome, imflammatory bowel disease, cardiac diseases are all risk factors for thmboembolism and should be elicited in the history.

shachi · Joined: 10 Jun 2008 Posts: 16

What examinations and investigations would you consider? (3 points)

A general examination should include measuring blood pressure as PET increases the risk of thromboembolism. Scars for major surgery and varicose veins should be looked for in the examination.
Women with previous history of VTE are at increased risk of recurrence and should have thrombophilia screening , if it has not already been done.This should check for factor v leiden mutation, anticardiolipid antibodies, anti thrombin 3 deficiency, protein C deficiency, protein S deficiency, prothrombin gene mutation.
Dunno what else to say...........

shachi · Joined: 10 Jun 2008 Posts: 16

How should you modify her antenatal care? (6 points)

Modification of antenatal care will depend on the assessment of risk factors based on history and the results of thrombophilia screening.
She should be advised of the signs and symptoms of DVT & PE and asked to seek help if she develops symptoms. General advice should given regarding avoiding dehydration, exercising etc.
A patient with single episode of DVT and a negative thrombophilia screen should be advised thromboprophylaxis with LMW heparin postnatally for 6 weeks.
Patients who should receive antenatal and postnatal heparin thromboprophylaxis are those who have a positive thrombophilia screen with a sinlge episode of VTE, women with recurrent episodes of VTE, or who have family history of VTE with a past history of VTE.
Women with acquired or inherited thrombophilias may need antenatal or postnatal LMW thromboprophylaxis depending upon the type of thrombophilia and the presence ar absence of risk factors.
Women with antiphoshpholipid syndrome shoud receive antenatal and postnatal LMW thromboprophylaxis as well as low dose aspirin as aspirin is known to improve fetal outcome in these patients.
The assessment of risk factors like high BMI, dehydration, cesarean section prologed immobilisation, long labour and instrumental delivery,should be ongoing in these patients and LMW thromboprohylaxis should be offered if they develop 3 or more risk factors. In patients with 1 or more risk factors, TEDS stockings should be advised.

Xerxes I

shachi · Joined: 10 Jun 2008 Posts: 16

No....u r just being sensible.
Sorry for not concentrating.

shachi · Joined: 10 Jun 2008 Posts: 16

how would you manage her in her peripartum period? (7 points)[/b][/quote]

A complete plan for intrapartum and postnatal care of the patient should made and documented in the notes by a senior obstetrician, and if required, a haematologist.
This patient should deliver on labor ward, with facilities for monitoring baby by CTG if she has IUGR, pre-eclampsia or other risk factors. Dehydration and immobilisation increase the risk of thromboembolic episodes hence should be avoided. Adequate pain relief in early labour should promote mobilisation.
Women who are on LMW heparin thromboprophylaxis should stop the medication once they go in labour. Should they require epidural/ spinal, at least 24 hours should have elapsed since the last dose of LMW heparin.
LMW heparin should be restarted as soon as possible after delivery. However, if the patient has had an epidural or spinal, one should wait for 4 hours after the removal of epidural catheter or insertion of spinal before injecting LMW heparin.
If the patient has high risk of haemorrhage, like major antepartum haemorrhage, wound haematoma, coagulopathy, she can be managed with unfractionated heparin, which has a shorter half life than LMW heparin, and its action can be easily reversed by protamine sulphate.
Early mobilisation,TEDS stocking and clexane prophylaxis should be continued postnatally for 6 weeks in moderate and high risk women.
If the patient has very high risk of DVT, and is on long term warfarin, it should be changed to LMW heparin antenatally as warfarin is teratogenic. This patient to should be switched over to warfarin after delivery, with the help and supervision of anticoagulant nurses and haematologist, as it is safe in breast feeding.
Postnatally, contraception should be discussed especially with women who are on warfarin. Combined oral contraceptive pills are contraindicated as they increase the risk of VTE.

premgunny · Joined: 09 Apr 2008 Posts: 16

In the antenatal care, self injection of LMWH and safe disposal of sharps to be taught to the women.

apart from thromboprophylaxis, management of pregnancy like frequent 2weekly BP and urinalalysis from 28weeks by midwife as increased risk of preeclampsia and symphysio fundal height and if needed serial growth scan as risk of IUGR is important.

In peripartum period, the women should be given the choice of continuing LMWH or swithching to warfarin as the pros and cons are heparin needing daily injections and warfarin needs multiple blood tests to maintain INR(2-3) and both safe in breastfeeding.