Venothromboembolism during pregnancy and puerperium

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Venous Thromboembolism
during Pregnancy and the
Puerperium
By
Ahmed Elbohoty MD, MRCOG
Assistant professor of obstetrics and gynecology
Ain Shams University
Causes of maternal death
0.00
0.50
1.00
1.50
2.00
2.50
OtherIndirectcauses
Cardiacdisease
Neurological
Throm
bosis
PsychiatriccausesGenitaltractsepsis
Haem
orrhage
Pre-eclam
psia
Am
nioticfluid
em
bolism
Earlypregnancydeaths
AnaesthesiaIndirectm
alignancies
Rateper100,000maternities
3/21/20 elbohotySolid bars show indirect causes, hatched bars show direct causes
Maternal deaths have decreased from 11 (2006-2008) to 10 (2010-2012) in 100000
maternaties
2009-2012:

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2013-2015
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December 2018 (2014-16)
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Indirect causes: 56% Direct causes: 44%

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Causes of maternal death 2015-
2017 in UK
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Long term sequaelae of VTE
•35% venous insufficiency 3-10 years later
•65% further DVT / venous insufficiency later
life in affected leg vs 22% unaffected
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VTE increases CV diseases
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Incidence
•Absolute incidence of VTE in
pregnancy and the puerperium is 1
per 100 0 person-years
•The UK incidence of PE is 1.3 per
10 000 maternities.
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Normal hemostasis
• Disruption of vascular endothelial lining allows exposure of
blood to
• subendothelial connective tissue:
• Primary hemostasis (seconds)
• Platelet plug formation at site of injury
• Stops bleeding from capillaries, small
• arterioles and venules
• Secondary hemostasis (minutes)
• Fibrin formation by reactions of
• the plasma coagulation system
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Coagulation Inhibitors:
In addition to the clotting factors there are many
substances that inhibits coagulation:
-Anti- thrombin III (AT III)
-Alpha 2 globulin inhibits Thrombin & factors Xa, XIIa
,XIa and IXa.
-Protein C (endothelial cell ) .
-Protein S (endothelial cell & platelets ) .
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Protein C and
Protein C Deficiency
• Protein C is a vitamin K dependent glycoprotein produced in the liver
• In the activation of protein C, thrombin binds to thrombomodulin, a structural
protein on the endothelial cell surface
• This complex then converts protein C to activated protein C (APC), which degrades
factors Va and VIIIa, limiting thrombin production
• For protein C to bind, cleave and degrade factors Va and VIIIa, protein S must be
available
• Protein C deficiency, whether inherited or acquired, may cause thrombosis when
levels drop to 50% or below
• Protein C deficiency also occurs with surgery, trauma, pregnancy, OCP, liver or renal
failure, DIC,or warfarin

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Pregnancy-Associated Changes in Hemostatic
and Fibrinolytic Proteins
Increase in Clotting Factors:
20 to 200% increase in levels of fibrinogen
and factors II, VII, X, VIII and XII
Decrease in Anticoagulant and Fibrinolytic
Activity:
Protein S levels (free and total) decrease by 40%
PAI-1 levels increase two to three-fold in pregnancy
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v
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Pathogenesis of VTE in Pregnancy
Hyper-
coagulability
Vascular
Damage
Venous
Stasis
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Thrombosis
Hereditary
thrombophilia
Acquired
thrombophilia
Surgery
traumaImmobility
Inflammation
Malignancy
Estrogens
Risk Factors for Thrombosis
Atherosclerosis

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Score Risk for VTE
• All women should undergo a documented assessment of
risk factors for VTE in
• prepregnancy
• early pregnancy
• admitted to hospital
• intrapartum
• immediately postpartum
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Time of prophylaxis
• Many fatal antenatal VTE events occur in the first trimester
and therefore prophylaxis for women with previous VTE
should begin early in pregnancy.
• The risk for VTE increases with gestational age, reaching a
maximum just after delivery.
• The relative risk postpartum is five-fold higher compared to
antepartum.
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incidence of VTE per 10,000 deliveries by
postpartum week
• 9.2 for week 1
• 2.42 for week 2
• 1.43 for week 3
• 0.94 for week 4
• 0.56 for week 5
• 0.11-0.34 for weeks 6-12
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Evidence
•Available evidence does not allow an accurate
risk estimation of VTE to be determined from
combinations of the different risk factors.
•Therefore, as a pragmatic approach to women
with risk factors (except previous VTE)
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Score Risk for VTE
• If admitted to hospital antenatally (18-fold increased risk of
first VTE) consider thromboprophylaxis.
• If prolonged admission (≥ 3 days) or readmission to hospital
within the puerperium consider thromboprophylaxis
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MangementRisk
Recommend antenatal high-dose LMWH
and at least 6 weeks’ postnatal LMWH or
until switched back to oral anticoagulant
therapy
> 4 antenatally
antenatal prophylactic LMWH and at least
6 weeks’ postnatal LMWH
4 antenatally
thromboprophylaxis from 28 and at least
6 weeks’ postnatal LMWH weeks
3 antenatally
thromboprophylaxis for at least 10 days≥ 2 postnatally

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> 4
• Previous VTE +
• Antithrombin deficiency
• APS
• Other Thrombophilia
• offered thromboprophylaxis with higher dose LMWH (either
50%, 75% or full treatment dose) antenatally and for 6
weeks postpartum or until returned to oral anticoagulant
therapy after delivery.
• Pregnant women with APS and prior VTE or arterial
thromboses should be managed in collaboration with a
haematologist and/or rheumatologist with expertise in this
area.
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4
•Previous VTE (except a single event
related to major surgery)
•Antithrombin deficiency
•OHSS (first trimester only)
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3
• Previous VTE provoked by major surgery
• Known high-risk thrombophilia
• protein C & protein S deficiency
• homozygous factor V Leiden
• homozygous prothrombin gene mutation
• compound heterozygotes
• Medical comorbidities e.g. cancer, heart failure; active systemic
lupus erythematosus, inflammatory polyarthropathy or
inflammatory bowel disease; nephrotic syndrome; type I
diabetes mellitus with nephropathy; sickle cell disease; current
intravenous drug user
• Any surgical procedure in pregnancy or puerperium except
immediate repair of the perineum, e.g. appendicectomy,
postpartum sterilisation
• Hyperemesis (during hospital admission)
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• BMI > 40
• Caesarean section in labour
• Thalathemia
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1
• Family history of unprovoked or estrogen-related VTE in first-degree relative
• Asymptomatic low-risk thrombophilia (no VTE)
• heterozygous prothrombin gene mutation
• heterozygous factor V Leiden
• Sickle cell trait
• Asymptomatic APS antibodies (NO VTE, NO collagen diseases)
• Age (> 35 years)
• BMI > 30 but < 40
• Parity ≥ 3
• Smoker
• Gross varicose veins
• Pre-eclampsia in current pregnancy
• ART/IVF (antenatal only)
• Multiple pregnancy
• Elective caesarean section
• Mid-cavity or rotational operative delivery
• Prolonged labour (> 24 hours)
• PPH (> 1 litre or transfusion)
• Preterm birth < 37+0 weeks in current pregnancy
• Stillbirth in current pregnancy
• Current systemic infection
• Immobility, dehydration
• Long travel> 4 hours3/21/20 elbohoty
Summary
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Thromboprophylaxis in women with
previous VTE and/or thrombophilia
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Thrombophilia
• Inherited
• Acquired
• Lupus anticoagulant
• ß2-glycoprotein antibodies
Anticardiolipin antibodies
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Inherited thrombophilias:
• Activated protein C (APC) resistance
• factor V Leiden mutation
• Prothrombin G20210A mutation
• Antithrombin deficiency
• Protein C deficiency
• Protein S deficiency
• Factor XIII mutation
Hereditary
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Screening Evaluation
to detect thrombophilia
• Test for Factor V Leiden
• Genetic test for prothrombin gene mutation 20210A
• Functional assay of antithrombin III
• Functional assay of protein C
• Functional assay of protein S
• Testing for Anti-phospholipid antibody syndrome :
Clotting test for lupus anticoagulant ( mixing studies, DRVVT,
STACLOT-LA) /ELISA for cardiolipin antibodies.
A complete hypercoagulability work – up as above is recommended in
strongly thrombophilic patients.
Antithrombin deficiency
• 70-90% life-time risk of VTE
• prevalence 1/3000
• accounts for 2-20% of VTE in pregnancy
• > 50 fold increase risk of VTE in pregnancy
• 50% risk of VTE per pregnant patient
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Anticoagulation in Antithrombin
deficiency
• It should be undertaken in collaboration with a
haematologist with expertise in thrombosis in pregnancy
with anti-Xa monitoring and the potential for antithrombin
replacement at initiation of labour or prior to caesarean
section.
• If anti-Xa levels are measured, a test that does not use
exogenous antithrombin should be used and 4-hour peak
levels of 0.5–1.0 iu/ml aimed for.
• Heparins may not be as effective in antithrombin deficiency
as their mode of action is antithrombin-dependent.
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Factor VLeiden mutation
30% life-time risk of VTE for homozygos
prevalence > 5 % in European population
10-fold increase risk of VTE in pregnancy
Risk of VTE in asympt. heterozygotes= 0.2%
Risk of VTE in homozygotes= 16 to 17%
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ProthrombinG20210A
mutation
30% life-time risk of VTE for homozygos
prevalence 2 % in European population
15-fold increase risk of VTE in pregnancy
Risk of VTE in heterozygotes = 0.5%
Risk of VTE in homozygotes = 15%
Risk with compound heterozygotes = 4-10%
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Protein C Deficiency:
Life-time risk of VTE > 30%
Prevalence is 0.2-0.5%
> 20-fold increased risk of VTE
Risk of VTE in pregnancy is 4%
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Protein S Deficiency
• Life-time risk of VTE > 30%
• Prevalence of primary deficiency is 0.08%; of acquired
deficiency is 7%
• > 20-fold increase risk of VTE
• Risk of VTE in pregnancy is 4%
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Hyperhomocystinemia in
Thrombophilia
§ In the past, homocysteine levels were recommended in thrombophilic patients.
§ Measurement of fasting total plasma homocysteine is no longer recommended
§ There are no data supporting a change in the duration or type of therapy for a
patient with hyperhomocysteinemia and a past history of VTE, since
hyperhomocysteinemia may be a marker of thrombotic disease rather than a
cause.
§ Results from the Leiden MEGA study indicate that the presence of
methylenetetrahydrofolate reductase (MTHFR) mutation which mildly increases
homocysteine levels, is not associated with an increased risk for venous
thrombosis.
§ Hence, there is no clinical rationale for measurement of plasma homocysteine
levels or for assaying for presence of the MTHFR mutation when screening for
the risk of VTE.

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Previous recurrent VTE
• Advice from a clinician with expertise in haemostasis and
pregnancy.
• Some women may require higher doses of LMWH.
• Women on long-term warfarin or other oral anticoagulants
should be counselled about the risks of these agents to the
fetus and advised to stop their oral anticoagulant therapy
and change to LMWH as soon as pregnancy is confirmed,
ideally within 2 weeks of the missed period and before the
sixth week of pregnancy.
• Women not on warfarin or other oral anticoagulants should
be advised to start LMWH as soon as they have a positive
pregnancy test.
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Testing for thrombophilia
• Prior to testing; women should be counselled regarding
the implications for themselves and family members of a
positive or negative result.
• The results should be interpreted by clinicians with specific
expertise in the area.
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•A family history of an unprovoked or estrogen-
provoked VTE in a first-degree relative when
aged under 50 years.
•A family history of VTE and either
antithrombin deficiency or where the specific
thrombophilia has not been detected should
be tested for antithrombin deficiency.
•Women with an unprovoked VTE should be
tested for the presence of antiphospholipid
antibodies.
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Which agents should be used for
thromboprophylaxis?
• Anti-embolism stockings
• Low-molecular-weight heparin (LMWH)
• Unfractionated heparin
• Hepranoids
• Warfarin
• Oral thrombin and Xa inhibitors
• Aspirin
• Dextran
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Anti-embolism stockings
• The use of properly applied anti-embolism stockings
(AES) of appropriate size and providing graduated
compression with a calf pressure of 14–15 mmHg is
recommended in pregnancy and the puerperium for
women who are
1. More than four risk factors antenatally
2. More than two risk factors postnatally
3. Previous VTE
4. Hospitalised and have a contraindication to
LMWH.
5. Women travelling long distance for more than 4
hours.
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Low-molecular-weight heparin (LMWH)
• LMWHs are the agents of choice for antenatal and postnatal
thromboprophylaxis.
• Doses of LMWH are based on weight (booking or most
recent weight can be used to guide dosing).
• It is only necessary to monitor the platelet count if the
woman has had prior exposure to unfractionated heparin
(UFH).
• Monitoring of anti-Xa levels is not required when LMWH is
used for thromboprophylaxis.
• Doses of LMWH should be reduced in women with renal
impairment.
• LMWH is safe in breastfeeding.
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Doses
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Contraindications/cautions to
LMWH use
• Known bleeding disorder (e.g. haemophilia, von Willebrand’s
disease or acquired coagulopathy)
• Active antenatal or postpartum bleeding
• Women considered at increased risk of major haemorrhage (e.g.
placenta praevia)
• Thrombocytopenia (platelet count < 75 × 109/l)
• Acute stroke in previous 4 weeks (haemorrhagic or ischaemic
• Severe renal disease (glomerular filtration rate [GFR] < 30
ml/minute/1.73m2)
• Severe liver disease (prothrombin time above normal range or
known varices)
• Uncontrolled hypertension (blood pressure > 200 mmHg systolic
or > 120 mmHg diastolic)3/21/20 elbohoty

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Unfractionated heparin
• In women at very high risk of thrombosis, UFH may
be used peripartum in preference to LMWH where
there is an increased risk of haemorrhage or where
regional anaesthetic techniques may be required as
it has a shorter half-life than LMWH and there is
more complete reversal of its activity by protamine
sulfate.
• So, for example, if no LMWH has been given for 24
hours but the woman has not yet delivered and
there is concern about delaying further doses of
anticoagulants, a prophylactic dose of 5000 iu
subcutaneously of UFH could be used and repeated
every 12 hours until LMWH can be resumed after
delivery.3/21/20 elbohoty
•The required interval between a prophylactic
dose of UFH and regional analgesia or
anaesthesia is less (4 hours) than with LMWH
(12 hours) and there is less concern regarding
neuraxial haematomas with UFH.
•The platelet count should be monitored every
2–3 days from days 4–14 or until heparin is
stopped as any exposure to UFH is associated
with an increased risk of HIT.
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Heparin side effects
• In most of cases are minor 40% of women
• local skin reactions (pain, itching, swelling, bruising)
• an increased risk of bleeding
• heparin-induced thrombocytopenia
• osteopenia or osteoporotic fractures
• precluding epidural analgesia if not discontinued in time.
Danaparoid
• Potential use of danaparoid should be in conjunction with
a consultant haematologist with expertise in haemostasis
and pregnancy.
• Danaparoid is a heparinoid that is mostly used in patients
intolerant of heparin, either because of HIT or a skin allergy
to heparins.
• There were no adverse fetal outcomes attributed to
danaparoid.
• The half-life of danaparoid is long (24 hours) and regional
anaesthesia should be avoided in women receiving it for
thromboprophylaxis.
• Breastfeeding would be safe while on danaparoid since little
if any appears in breast milk and oral absorption is unlikely.
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Fondaparinux
• Fondaparinux should be reserved for women intolerant of heparin
compounds.
• Fondaparinux use in pregnancy should be in conjunction with a
consultant haematologist with expertise in haemostasis and
pregnancy.
• Fondaparinux is a synthetic pentasaccharide that acts through
inhibition of factor Xa via antithrombin.
• It is licensed in the UK for the prevention and treatment of VTE
outside pregnancy
• There is limited experience of its use in pregnancy but it has been
used in the setting of heparin intolerance with no reported
hypersensitivity reactions or adverse effects on the fetus.
• No adverse effects were observed in the newborns. It does not seem
necessary to alter the dose in pregnancy.
• It is unknown whether fondaparinux is excreted in breast milk but oral
absorption seems unlikely.
• The half-life of fondaparinux is long (18 hours) and 36–42 hours
should pass following the previous dose before it becomes acceptable
to consider regional anaesthesia.3/21/20 elbohoty
Warfarin
• Warfarin use in pregnancy is restricted to the few situations
where heparin is considered unsuitable, e.g. some women
with mechanical heart valves.
• Women receiving long-term anticoagulation with warfarin
can be converted from LMWH to warfarin postpartum when
the risk of haemorrhage is reduced, usually 5–7 days after
delivery.
• Warfarin is safe in breastfeeding.
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Antenatal risks
• Warfarin crosses the placenta leading to an increased risk of
congenital abnormalities including a characteristic warfarin
embryopathy in approximately 5% of fetuses exposed
between 6 and 12 weeks of gestation
• hypoplasia of nasal bridge
• congenital heart defects
• Ventriculomegaly
• agenesis of the corpus callosum
• stippled epiphyses.
• It is dose-dependent with a higher incidence in women
taking greater than 5 mg/ day.
• It also increase the risk of spontaneous miscarriage,
stillbirth, neurological problems in the baby and fetal and
maternal haemorrhage.
3/21/20 elbohoty
Postnatal risks
• Warfarin can be safely used following delivery from day 5
and in breastfeeding mothers, although it requires close
monitoring and visits to an anticoagulant clinic and carries
an increased risk of postpartum haemorrhage and perineal
haematoma compared with LMWH.
• It is not appropriate for those women requiring only 10
days’ postpartum prophylaxis. However, it is appropriate for
those on maintenance warfarin outside pregnancy.
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Oral thrombin and Xa inhibitors
• Non-vitamin K antagonist oral anticoagulants (NOACs)
should be avoided in pregnant women & women who are
breastfeeding.
• such as dabigatran, rivaroxaban and apixaban work through
direct inhibition of thrombin or factor Xa.
• The effects last approximately 8–12 hours, but factor Xa
activity does not return to normal within 24 hours so once-
daily dosing is possible.
• If an invasive procedure or surgical intervention is required,
Xarelto 20 mg should be stopped at least 24 hours before
the intervention, if possible and based on the clinical
judgement of the physician.
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Low-dose aspirin
• Aspirin is not recommended for
thromboprophylaxis in obstetric patients.
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Dextran
• Dextran should be avoided antenatally and intrapartum
because of the risk of anaphylactoid reaction.
• Although dextran may reduce the risk of postoperative DVT
outside pregnancy, the evidence is weak, it is less effective
than LMWH and it appears to increase the risk of bleeding.
• Anaphylaxis to dextran has been associated with uterine
hypertonus, fetal distress, fetal neurological abnormalities
and death.
3/21/20 elbohoty
When should thromboprophylaxis be
started?
• Antenatal thromboprophylaxis for those with previous VTE
should begin as early in pregnancy as practical.
• Women without previous VTE and without particular first
trimester risk factors or admission to hospital, but with four
other risk factors, should be considered for antenatal
prophylaxis throughout pregnancy.
• Women without previous VTE and without particular first
trimester risk factors or admission to hospital, but with
three other risk factors, can start antenatal prophylaxis at 28
weeks of gestation.
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What are the first trimester risk factors for
VTE and how should they be managed?
• Women admitted with hyperemesis should be considered
for thromboprophylaxis with LMWH and can discontinue
thromboprophylaxis when the hyperemesis resolves.
• Women with ovarian hyperstimulation syndrome should be
considered for thromboprophylaxis with LMWH in the first
trimester.
• Women with an IVF pregnancy and three other risk factors
should be considered for thromboprophylaxis with LMWH
starting in the first trimeste
3/21/20 elbohoty
When should thromboprophylaxis be
interrupted for delivery?
• Women receiving antenatal LMWH should be advised that if
they have any vaginal bleeding or once labour begins they
should not inject any further LMWH.
• They should be reassessed on admission to hospital and
further doses should be prescribed by medical staff.
• Regional techniques should be avoided if possible until at
least 12 hours after the previous prophylactic dose of
LMWH.
• LMWH should not be given for 4 hours after use of spinal
anaesthesia or after the epidural catheter has been
removed and the catheter should not be removed within 12
hours of the most recent injection.3/21/20 elbohoty

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• When a woman presents while on a therapeutic regimen of
LMWH, regional techniques should be avoided if possible
for at least 24 hours after the last dose of LMWH.
• The first thromboprophylactic dose of LMWH should be
given as soon as possible after delivery provided there is no
postpartum haemorrhage and regional analgesia has not
been used.
• In some women, particularly those on high-dose
prophylactic or treatment doses of LMWH, there may be an
indication for induction of labour to help plan
thromboprophylaxis around delivery and facilitate a 24-hour
window between the last dose of LMWH and regional
analgesia.
• If LMWH precludes regional techniques (in, for example, the
woman who presents in spontaneous labour within 12
hours of taking a LMWH dose), alternative analgesia such as
opiate-based intravenous patient-controlled analgesia can
be offered.3/21/20 elbohoty
Guidance for regional block in patients taking drugs affecting haemostasis
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Women at high risk of haemorrhage
• Risks:
• major antepartum haemorrhage
• Coagulopathy
• progressive wound haematoma
• suspected intra-abdominal bleeding and postpartum haemorrhage
• Management:
• Anti-embolism stockings (AES), foot impulse devices or
intermittent pneumatic compression devices.
• Thromboprophylaxis should be started or reinstituted as soon as
the immediate risk of haemorrhage is reduced (Unfractionated
heparin (UFT) may also be considered).
• If a woman develops a haemorrhagic problem while on
LMWH the treatment should be stopped and expert
haematological advice sought.
3/21/20 elbohoty
Example
• If LMWH is routinely prescribed at 6 p.m., this allows for an
elective caesarean section the next morning, removal of the
epidural catheter before 2 p.m. and a first postnatal dose of
LMWH at 6 p.m. the same day.
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Thromboembolic Disease in
Pregnancy and the Puerperium:
Acute Management
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• 40 years P5 BMI 33 pregnant at 30 weeks was admitted
because of Acute pyelonephritis. On the 2nd day of
admission: pain, swelling and redness in the left calf
muscles.
• What is the appropriate management:
• A. perform D dimer & LL duplex
• B. Start HMWH prohylactic dose& do LL duplex
• C. Start HMWH therapeutic dose& do LL duplex
• D Start LMWH prohylactic dose and do LL duplex
• E. . Start LMWH therapeutic dose and do LL duplex
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• You Started LMWH therapeutic dose and ordered LL duplex
and the result was normal and you suspected cellulitis what
is your next step:
a. contiue therpeutic
b. contiue therpeutic and repeat LL duplex
c. stop therpeutic and repeat LL duplex
d. Shift to prphylactic
e. Shift to prphylactic and repeat LL duplex
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• 40 years P5 BMI 33 pregnant at 30 weeks was admitted
because of Acute pyelonephritis. On the 2nd day of
admission: swelling and redness in the left calf muscles
and sudden onset of dyspnea and chest pain.
• What is the appropriate management:
• A. perform D dimer & LL duplex
• B. Start HMWH prohylactic dose& do LL duplex
• C. Start LMWH therapeutic dose& do LL duplex
• D Start LMWH therapeutic dose and do CTPA on chest
• E. Start LMWH therapeutic dose and do V/Q scan
3/21/20 elbohoty
• 40 years P5 BMI 33 pregnant at 30 weeks was admitted
because of Acute pyelonephritis. On the 2nd day of
admission: sudden onset of dyspnea and chest pain and
examination of lower limbs was unremarkable
• What is the appropriate management:
• A. perform D dimer & LL duplex
• B. Start HMWH prohylactic dose& do LL duplex
• C. Start LMWH therapeutic dose& do LL duplex
• D Start LMWH therapeutic dose and do CTPA on chest
• E. . Start LMWH therapeutic dose and do V/Q scan
3/21/20 elbohoty

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Suggestive symptoms and signs of DVT:
• unilateral leg pain(reflecting extension of thrombus
into the pelvic vessels and/or development of a
collateral circulation)
• swelling, tenderness
• increased temperature
• pitting oedema
• prominent superficial veins
• Lower abdominal pain
3/21/20 elbohoty
Suggestive symptoms and signs of PE:
• Breathlessness, chest pain,
haemoptysis, collapse,
tachycardia, hypotension,
tachypnoea, raised jugular
venous pressure, focal signs in
chest, hypoxia/cyanosis
• A low-grade pyrexia and
leucocytosis can occur with VTE
3/21/20 elbohoty

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DD
• Collapse
3/21/20 elbohoty
3/21/20 elbohoty

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3/21/20 elbohoty
Chest pain
3/21/20 elbohoty

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3/21/20 elbohoty
3/21/20 elbohoty

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Management on suspicion
• Any woman with symptoms and/or signs suggestive of VTE
should have
• treatment with low-molecular-weight heparin (LMWH) given until
the diagnosis is excluded by objective testing, unless treatment is
strongly contraindicated.
• objective testing performed expeditiously
• blood should be taken for a full blood count, coagulation screen,
urea and electrolytes, and liver function tests.
• Performing a thrombophilia screen prior to therapy is not
recommended.
3/21/20 elbohoty
Investigation and initial management of suspected
DVT in pregnancy and the puerperium
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Investigations for the diagnosis of an acute
DVT
• Compression duplex ultrasound
• If ultrasound is negative:
• a low level of clinical suspicion, anticoagulant treatment can be
discontinued.
• a high level of clinical suspicion exists, anticoagulant treatment should be
discontinued but the ultrasound should be repeated on days 3 and 7.
• When iliac vein thrombosis is suspected (back and buttock
pain and swelling of the entire limb), Doppler ultrasound of
the iliac vein, magnetic resonance venography or
conventional contrast venography may be considered
3/21/20 elbohoty
on days 3 and 7
Lower Ext Doppler Exam
3/21/20 elbohoty
Doppler U/S demonstrating
non-compressible femoral vein
with central clot.

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3/21/20 elbohoty
Upper extremity DVT
• 11% of all DVTs in general population
• Most case reports in pregnancy are following ART
• Incidence after ART: 1/1200 cycles
• 30% of cases not preceded by OHSS
• Mean gestational age at presentation: 7 weeks
• Diagnosis by ultrasound
• Bilateral disease in 14%
3/21/20 elbohoty

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Untreated DVT
• If DVT remains untreated, 15–24% of these patients will
develop PE.
• PE during pregnancy may be fatal in almost 15% of patients,
and in 66% of these, death will occur within 30 minutes of
the embolic event.
3/21/20 elbohoty
Diagnosis of VTE in pregnancy
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Investigations for the diagnosis of an acute
pulmonary embolism (PE)
• Women presenting with symptoms and signs of an acute PE
should have an electrocardiogram (ECG) and a chest X-ray
(CXR) performed.
• When the chest X-ray is abnormal and there is a clinical suspicion of PE,
CTPA should be performed
• For who have symptoms and signs of DVT, compression duplex ultrasound
should be performed. If compression ultrasonography confirms the
presence of DVT, no further investigation is necessary and treatment for
VTE should continue.
• For who have not any symptoms and signs of DVT, a
ventilation/perfusion (V/Q) lung scan or a computerised
tomography pulmonary angiogram (CTPA) should be
performed.
3/21/20 elbohoty
investigation and initial management of suspected PE
in pregnancy and the puerperium
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3/21/20 elbohoty
3/21/20 elbohoty

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CXR
• Chest X-ray (CXR) may identify other pulmonary
disease such as pneumonia, pneumothorax or lobar
collapse.
• While the CXR is normal in over half of pregnant
patients with objectively proven PE, abnormal
features caused by PE include atelectasis, effusion,
focal opacities, regional oligaemia or pulmonary
oedema.
3/21/20 elbohoty
Arterial Blood Gases Analysis
• ABG analysis showed that only 10% had arterial P O2
levels less than 60 mmHg and 2.9% had oxygen saturation
levels less than 90%
• A respiratory alkalosis (PCO2 < 35mmHg).
HOWEVER:
• Other etiologies are more likely to lower the PO2 than is
PE chronic obstructive pulmonary disease [COPD],
pneumonia, CHF affect oxygen exchange more than PE.
• 15% of patients with PE have a normal PO2 (>95%).
3/21/20 elbohoty

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Electrocardiogram
• the ECG was abnormal in 41% of women with acute PE; the most common
abnormalities were
• T wave inversion (21%)
• S1Q3T3 pattern (15%) and right bundle branch block (18% during pregnancy and
4.2% in the puerperium) (Right Strain Pattern )
• Sinus tachycardia
• Given the increasing incidence of ischaemic heart disease in pregnancy, the ECG may
also be helpful in identifying alternative diagnoses.
VQ versus CTPA

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Ventilation / Perfusion Scanning
• Good PPV (high probability
scan)
• Good NPV (normal scan)
• Poor P/NPV (low,
intermediate scans)
3/21/20 elbohoty
Q
V
Q
V
/
/
• A Q scanning is probably the safest for the mother & fetus
with a ventilation scan being performed only if the
perfusion scan is abnormal.
• Treatment should be continued when the V/Q scan reports a
'medium' or 'high' probability of PTE.
3/21/20 elbohoty

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•Alternative or repeat testing should be carried
out where V/Q scan or CTPA is normal but the
clinical suspicion of PE remains. Anticoagulant
treatment should be continued until PE is
definitively excluded.
•Women with suspected PE should be advised
that, compared with CTPA, V/Q scanning may
carry a slightly increased risk of childhood
cancer but is associated with a lower risk of
maternal breast cancer; in both situations, the
absolute risk is very small.
3/21/20 elbohoty
recent diagnosis
• A SPECT scan is a type of nuclear imaging test, which means
it uses a radioactive substance and a special camera to
create 3-D pictures using gamma rays
3/21/20 elbohoty

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massive pulmonary embolism (PE)
• acute PE with any of the following sustained
hypotension
• systolic blood pressure < 90 mm Hg for ≥ 15
minutes or requiring inotropic support not due to
a cause other than PE, such as arrhythmia,
hypovolemia, sepsis, or left ventricular
dysfunction
• persistent profound bradycardia (heart rate < 40
beats per minute with signs or symptoms of
shock)
• pulselessness
3/21/20 elbohoty
Massive life-threatening PE in
pregnancy and the puerperium
• Collapsed, shocked women who are pregnant or in
the puerperium should be assessed and manged
by a team of experienced clinicians including the
on-call consultant obstetrician and other
multidisciplinary team including senior physicians,
obstetricians and radiologists.
• The on-call medical team should be contacted
immediately.
• An urgent portable echocardiogram or CTPA within
1 hour of presentation should be arranged.
3/21/20 elbohoty

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Cardiac Imaging in PE
Normal PA Pressures
Systolic Pressure 25mmHg
Diastolic Pressure 10mmHg
Mean PAP 20mmHg
RV Failure (no prior CPD)
Mean PAP > 40mmHg
RV Strain (no prior CPD)
Mean PAP 30-40mmHg with
decreased CO
3/21/20 elbohoty
Treatment
• Intravenous unfractionated heparin is the preferred, initial
treatment in massive PE with cardiovascular compromise.
• If massive PE is confirmed, or in extreme circumstances
prior to confirmation, immediate thrombolysis should be
considered.
• Women should be managed on an individual basis
regarding:
• intravenous unfractionated heparin
• thrombolytic therapy or
• thoracotomy and surgical embolectomy.
3/21/20 elbohoty

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Evidence for use of thrombolysis during the
pregnancy
3/21/20 elbohoty
Additional therapies for VTE
• In the initial management of DVT, the leg should be elevated
and a graduated elastic compression stocking applied to
reduce oedema.
• Mobilisation with graduated elastic compression stockings
should be encouraged.
• Consideration should be given to the use of a temporary
inferior vena cava filter in the peripartum period for patients
with iliac vein VTE to reduce the risk of PE or in patients
with proven DVT and who have recurrent PE despite
adequate anticoagulation.
3/21/20 elbohoty

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Maintenance treatment of DVT or PE?
• Treatment with therapeutic doses of subcutaneous LMWH
should be employed during the remainder of the pregnancy
and for at least 6 weeks postnatally and until at least 3
months of treatment has been given in total.
• Women should be taught to self-inject LMWH and
arrangements made to allow safe disposal of needles and
syringes.
• Outpatient follow-up should include clinical assessment and
advice with monitoring of blood platelets and peak anti-Xa
levels if appropriate.
• Pregnant women who develop heparin-induced
thrombocytopenia or have heparin allergy and require
continuing anticoagulant therapy should be managed with
an alternative anticoagulant under specialist advice.3/21/20 elbohoty
USE of intravenous HMWH
• Massive PE
• Women at high risk of haemorrhage and in whom
continued heparin treatment until the risk factors for
haemorrhage have resolved.
• Acute DVT at term as it is more easily manipulated.
3/21/20 elbohoty

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Manipulations of LMWH before the delivery
• The woman on LMWH for maintenance therapy should be
advised that once she is in established labour or thinks that
she is in labour, she should not inject any further heparin.
• Where delivery is planned, either by elective caesarean
section or induction of labour, LMWH maintenance therapy
should be discontinued 24 hours prior to planned delivery.
• Regional anaesthetic or analgesic techniques should not be
undertaken until at least 24 hours after the last dose of
therapeutic LMWH.
• LMWH should not be given for 4 hours after the use of
spinal anaesthesia or after the epidural catheter has been
removed, and the epidural catheter should not be removed
within 12 hours of the most recent injection.
3/21/20 elbohoty
• In patients receiving therapeutic doses of LMWH, wound
drains (abdominal and rectus sheath) should be considered
at caesarean section and the skin incision should be closed
with interrupted sutures to allow drainage of any
haematoma.
3/21/20 elbohoty

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Postnatal anticoagulation
• Therapeutic anticoagulant therapy should be continued for
the duration of the pregnancy and for at least 6 weeks
postnatally and until at least 3 months of treatment has
been given in total.
• Postpartum warfarin should be avoided until at least the
fifth day and for longer in women at increased risk of
postpartum haemorrhage.
• Women should be offered a choice of LMWH or oral
anticoagulant for postnatal therapy after discussion about the
need for regular blood tests for monitoring of warfarin,
particularly during the first 10 days of treatment.
• No data on NOACs in breast feeding
• Before discontinuing treatment the continuing risk of
thrombosis should be assessed.
3/21/20 elbohoty
Prevention of post-thrombotic syndrome
• Women should be advised that prolonged use of LMWH
(more than 12 weeks) is associated with a significantly lower
chance of developing post-thrombotic syndrome.
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3/21/20 elbohoty
Lower doses of LMWH should be employed if the creatinine clearance is less than 30 ml/minute
(enoxaparin and dalteparin) or less than 20 ml/minute with tinzaparin.
3/21/20 elbohoty

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Upper limb DVT
• Management of upper extremity DVT needs to be on an
individual patient basis and should include management of
any underlying condition.
• Patients with upper extremity DVT without underlying risk
factors (such as antiphospholipid antibodies) do not require
prolonged (more than 3-6 months) anticoagulant treatment.
3/21/20 elbohoty
superficial thrombophlebitis
• Patients with clinical signs of superficial thrombophlebitis
affecting the proximal long saphenous vein should have an
ultrasound scan to exclude concurrent dvt.
• Patients with superficial thrombophlebitis should have anti-
embolism stockings and can be considered for treatment
with prophylactic doses of lmWh for up to 30 days or
fondaparinux for 45 days.
• if LMWH is contraindicated, 8-12 days of oral nsaids should
be offered.
• Patientswithsuperficialthrombophlebitisat,orextendingtowa
rds,thesapheno-femoral junction can be considered for
therapeutic anticoagulation for 6-12 weeks.3/21/20 elbohoty

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Antiphospholipid
Syndrome in Pregnancy
3/21/20 elbohoty

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pathology
pathogenesis

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Antiphospholipid Antibodies
• It was originally thought that aPL is directed against
negatively charged phospholipid, but it is now clear that
they target plasma proteins with affinity to these
phospholipids.
• The main antigens involved are
• b2-glycoprotein (b2GPI) also known as apolipoprotein H
• Prothrombin,
• Many more antigenic target have been described
3/21/20 elbohoty
A multisystemic disease, characterized by venous or arterial thromboses, or certain
obstetric complications, & the presence of antiphospholipid antibodies (APAs)
APAs are a heterogeneous group of autoantibodies that bind to negatively
charged phospholipids, phospholipid-binding protein, or a combination of the
two.
Lupus anticoagulant (LA), anticardiolipin antibodies (aCL) & anti-beta 2
glycoprotein 1 (anti-β2GP1) antibodies are the main types.
occurs in isolation as a primary APS in > 50% of the cases, or associated with
other autoimmune diseases, most often with systemic lupus erythemathosus
(SLE).
occurs > in young women of fertile age (rarely in children, and only 12% of all APS
occur after 50 years of age)

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Pathophysiology & Aetiology
Multiple mechanisms are responsible for the varying clinical
manifestations.
• b2GPI antibody disrupt normal coagulation mechanisms in several
ways
• Direct cellular effects caused by bound b2GPI-antibody complexes
• Activation of platelets
• Endothelial cells & monocytes activation
• Leading to induction of tissue factor expression
• Interference of haemostatic factors
• Resistance to activated protein C
• Reduction in fibrinolysis
3/21/20 elbohoty
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3/21/20 elbohoty
3/21/20 elbohoty
Multiple Strokes
in a Young Woman
(Brain MRI)
Occlusion of Right Middle Cerebral Artery
In a 3 Years Old Child with
Severe Headache and Hemiparesis
With aCL Antibodies +

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3/21/20 elbohoty
Digital Necrosis and Gangrene
Livedo reticularis
3/21/20 elbohoty

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Livedo reticularis with necrotic finger tips
in Antiphospholipid syndrome
3/21/20 elbohoty
Prevalence
• The syndrome occurs most commonly in young to middle-
aged adults.
• Women are more frequently affected
• Female to male ratio is 5:1
• There is NO racial predominance for primary APS, although
a higher prevalence of SLE occur in the black & Hispanic
populations.
3/21/20 elbohoty

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1. Primary antiphospholipid syndrome
APS occurs in the absence of any other related disease.
2. Secondary antiphospholipid syndrome
APS occuring in the context of other autoimmune
diseases, such as systemic lupus erythematosus (SLE).
3. Catastrophic antiphospholipid syndrome
In rare cases, APS leads to rapid organ failure due to generalised
thrombosis; this is termed (CAPS) and is associated with a high
risk of death.
APS morbidity
• APS is the most common cause of acquired thrombophilia.
Prevalence in general population: 2-1%
• 15-20% of all DVT with or without PE.
• 1/3 of new strokes in patients < 50 years age.
• 10-15% women with recurrent pregnancy losses.
• APS: significant proportion of thromboembolic disease and
pregnancy loss in SLE.
• APL Abs present in 30-40% SLE. One third of those patients
have clinical manifestations of APS.
• aCL positivity may precede a more severe form of SLE.
3/21/20 elbohoty

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Epidemiology of antiphospholipid antibodies
• in the normal population: 2 - 12 %
prevalence increases with age and chronic disease
• in SLE: 30 - 40 %
LAC: 11-30% aCL: 24-86%
• 15-20% of all DVT with or without PE.
• 1/3 of new strokes in patients < 50 years age.
• 10-15% women with recurrent pregnancy losses.
3/21/20 elbohoty
Clinical Features
• Diagnosis of APS is made by finding at least 1 of the
clinical criteria plus at least 1 of the laboratory criteria.
• Provided the combination of the clinical criteria & the
laboratory criteria is not < 12 weeks or > 5 years.
• Clinical criteria:
• Vascular thrombosis
• Pregnancy morbidity
• Laboratory criteria:
• Lupus anticoagulant
• Anti-cardiolipin antibody (IgG &/or IgM)
• Anti-b2-glycoprotein I antibody (IgG &/or IgM)
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In Pregnancy
IUGRRecurrent
miscarriage
Preeclampsia
Placental
abruption
In addition:
Arterial /
Venous
thrombosis
Premature
delivery or fetal
death
Obstetric Complications
• Pregnancy loss
• About 15 % of women with recurrent pregnancy loss, defined as ≥
3 first trimester miscarriages, have detectable aPL.
• These women have a potential 90% risk of further fetal loss if left
untreated.
• The diagnostic criteria for APS suggest that evaluation should
begin after the 3rd consecutive early miscarriage, defined by less
than 10 weeks of gestation.
• However, in practice, evaluation after 2 miscarriages is often initiated.
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Obstetric Complications
• Late complications of aPL in pregnancy
• These relate to placental insufficiency caused by aPL.
• Gestational hypertension/preeclampsia occurs in 30–50% of
untreated women with known APS.
• This falls to 10% with effective treatment.
• By contrast, there is no increase in aPL incidence in general
obstetric patients representing with preeclampsia.
• HELLP syndrome may occur usually associated with
preeclampsia/eclampsia;
• This seems to occur earlier than in women without APS, often in the 2nd
trimester.
3/21/20 elbohoty
Obstetric Complications
• Other clinical manifestations
• In addition to thrombosis & obstetric morbidity, there
are additional clinical manifestations that are no
included in the official definition of APS.
3/21/20 elbohoty

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Diagnosis: 1 Clinical + 1 Laboratory
• Diagnostic criteria for the classification of definite
APS are agreed by an international panel in 1999, &
updated in 2006.
3/21/20 elbohoty
3/21/20 elbohoty
Test Details Anticardiolipin Antibodies Anti-beta2Glycoprotein I
Antibodies
Lupus Anticoagulant
Antibodies detected IgG and IgM antibodies
against cardiolipin and
cardiolipin-bound
beta2 glycoprotein I
IgG and IgM antibodies
against cardiolipin-bound
beta2 glycoprotein I
Immunoglobulins that cause
prolonged clotting times in
vitro but are associated with
thrombosis in vivo
Titres considered positive Medium to high: > 99th
percentile, or > 40 IgG or IgM
phospholipid units*
Medium to high: > 99th
percentile, or IgG or IgM
phospholipid units*
Not applicable
Influenced by anticoagulation
therapy?
No No False positive test if on
heparin and may prolong
prothrombin time if on
warfarin
Abbreviations: IgG, immunoglobulin G; IgM, immunoglobulin M.

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Management of APS in Pregnancy
• General issues
• A detailed past medical & obstetric history should be taken & the
circumstances of any past thrombotic event (provoked or
spontaneous, arterial or venous) assessed.
• Any associated conditions should be assessed, such as SLE.
• Evidence of any organ damage sought.
• Other risk factor contributing to thrombotic risk, such as obesity &
maternal age should be taken into account in the overall
assessment, as it will contribute in making an appropriate
individualised treatment plan.
3/21/20 elbohoty
Pre-Pregnancy Planning
• There may circumstances where pregnancy should
be discouraged; for example
• If pulmonary hypertension is present the risk of
maternal death is > 35%
• A clear plan for pregnancy management should be
developed.
3/21/20 elbohoty

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Management of APS in Pregnancy
• General issues
• It may be that the conflicting results are due to
heterogeneity of the cause of disorder, & that further
stratification is necessary in treatment according to clinical
phenotype, as suggested by Bramham et al.
• A summary of management of women with APS or aPL is
given in the following table:
3/21/20 elbohoty
How should women with antiphospholipid
antibodies be treated?
• Persistent antiphospholipid antibodies (lupus anticoagulant
and/or anticardiolipin and/or β2-glycoprotein 1 antibodies)
in women without previous VTE should be considered as a
risk factor for thrombosis such that if she has other risk
factors she may be considered for antenatal or postnatal
thromboprophylaxis as above.
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Fetal monitoring
• Fetal growth scan + Umblical artery doppler from 26 and follow up
every 4 weeks
3/21/20 elbohoty
Management of women with aPL &
multiple previous venous events, or venous plus
arterial events
• This group of women will be on long-term warfarin, possible
at higher range international normalised ratio (INR).
• They are at very high risk in pregnancy.
• Pre-pregnancy counselling is particularly important, so that
the extent of risk can be clarified on an individual basis, pre-
pregnancy health optimised, & the risk with clear plan
convoyed to the woman & documented.
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Management of women with APS as
part of SLE
• Women with SLE may have flare-up of symptoms during
pregnancy & requires steroids.
• Hydroxychloroquine & azathioprine are regularly used in
SLE.
• They are safe in pregnancy & so should be continued as necessary.
3/21/20 elbohoty
Management of women with APS &
thrombocytopenia
• Many patients with APS have thrombocytopenia (platelets <
100 x 109/l).
• The pathogenic antibodies are directed toward platelet
membrane glycoprotein & are distinct from aPL.
• Patients should be managed in the same way for immune
thrombocytopenia.
• When there have been previous thromboses, the fine
balance between bleeding & thrombotic risk must be
carefully managed.
• A platelet count of > 50 x 109/l should be to allow safe
pharmacological thromboprophylaxis.
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CATASTROPHIC ANTIPHOSPHOLIPID
SYNDROME (CAPS)
Catastrophic APS
• This term defines a severe, accelerated form of
APS resulting in multi-organ failure from
widespread thromboses, which are usually
microvascular rather than large-vessel occlusions.
• The syndrome is of acute onset, defined by the
involvement of at least 3 different organ systems
over a period of days to weeks.
• Triggers such as infection or surgery exacerbate
an already pro-coagulable state.
3/21/20 elbohoty

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Catastrophic antiphospholipid syndrome
• It is a life- threatening disease conferring 50% mortality.
• It complicates less than 1% of antiphospholipid syndrome
cases
• It is characterised by
• the onset of rapidly progressive and
• widespread thrombotic microangiopathy and
• by multi- organ failure.
• The severity of the maternal impact of this condition
justifies aggressive therapy, included
• Anticoagulation
• high-dose steroids and
• plasma exchange.

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Management:
• Current treatment guidelines suggest, in addition to early
diagnosis, aggressive therapies to avoid the potentially fatal
outcome.
• The combination of:
- high doses of intravenous (i.v.) heparin,
- i.v. steroids,
- i.v. immunoglobulins and/or
- Repeated plasma exchanges
are the basic treatment of choice for all patients with this
severe condition

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A case of catastrophic antiphospholipid
syndrome
• A 25-year-old para 0 books in for antenatal care at 15 weeks of
gestation. Her first pregnancy four years previously was complicated
by a fetal death in utero at 18 weeks of gestation as a consequence of
catastrophic antiphospholipid syndrome with strongly positive ß2-
glycoprotein and anticardiolipin antibodies.
• She developed significant microangiopathic haemolysis which
responded to plasma exchange and steroid treatment.
• Placental histology revealed accelerated villous maturation, infarction
and maternal vasculopathy. She attended pre- pregnancy counselling
with a plan for antenatal thromboprophylaxis with aspirin 150 mg
nocte and LMWH (enoxaparin 60 mg subcutaneously daily).
• Apart from mild thrombocytopenia she had an uneventful antenatal
course, receiving high-risk care in a multidisciplinary setting.
• Following induction of labour at 38 weeks of gestation, she delivered a
healthy baby boy weighing 3480 g. She received postpartum
thromboprophylaxis for 6 weeks.
The role of thrombophilia testing in women
with adverse pregnancy outcomes

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• Thrombophilias are a diverse group of coagulation
disorders associated with a predisposition to
thrombotic events and placenta-mediated
pregnancy complications.
• Evidence-based evaluation and treatment of patients with
adverse pregnancy outcomes is often impeded by two factors:
• understandably emotionally charged parents who would ‘do anything’ to
have a successful pregnancy outcome, and are thus accepting of
unproven and unnecessary invasive treatments, and
• clinicians’ uncertainty and the willingness to ‘try anything’ in this
context.
• At present, within a heterogeneous set of underlying causes,
inherited thrombophilias appear to be, at best, a weak
contributor to adverse pregnancy outcomes.
• As always, association does not prove causation, and even if
causation is established, effective therapies need to be available
before routine testing can be justified.
• This is not the case for heritable thrombophilias, and as a result,
testing for them in women who have sustained adverse
pregnancy outcomes cannot currently be recommended.

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• Their increased prevalence in this population does not
justify testing with a view to improving long-term maternal
health outcomes either, as this approach has not been
shown to confer a net benefit, and has potential harms
associated with insurance risk profiles and familial
consequences of this genetic information.
• In recent years, numerous studies, trials and meta-analyses
have been published.
• Most recently, the well-conducted TIPPS trial clearly
demonstrated negative evidence for heparin treatment in
improving pregnancy outcomes among women with
thrombophilias.
thrombophilia testing
• should only be performed when results will be used to
improve or modify management.
• testing is performed far more frequently than can be
justified based on available evidence and that the majority
of testing is not of benefit to the patient, but may actually
be harmful
• In its 2016 Choosing Wisely initiative, the Society for
Maternal and Fetal Medicine in the USA has urged clinicians
to refrain from thrombophilia evaluation for women with
histories of pregnancy loss, fetal growth restriction, severe
pre-eclampsia and abruption.

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To test?
• The problem with testing for underlying thrombophilias and
modified management in a subsequent pregnancy can be
illustrated with an example:
• evidence provided in a systematic review and meta-
analysis reported an 81% increased risk of recurrent
pregnancy loss in women with prothrombin gene
mutation; while this significant relationship is
acknowledged, there is currently no evidence that acting
on these test results alters pregnancy course and
outcome.
• The same argument applies to factor V Leiden mutation
(FVL) status and the small increased risk of late
pregnancy loss
In APS
• It is imperative to note that antiphospholipid
antibodies may be present in healthy patients
without disease.
• Although women with antiphospholipid antibodies
had higher rates of low birthweight and placental
infarctions, there was no difference in rates of fetal
loss or maternal disease overall when compared
with the control group.
• It seems plausible that the primary cause of adverse
pregnancy outcome in antiphospholipid syndrome
relates to inflammation, rather than thrombosis.

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APs
• Based on somewhat limited data aspirin and LMWH are
recommended for obstetrical antiphospholipid syndrome,
although there is no clear evidence that additional
treatment with LMWH improves live-birth rates.
• The first-line treatment for women with obstetrical
antiphospholipid syndrome should be low-dose aspirin.
• Although the use of LMWH in women with obstetrical
antiphospholipid syndrome has been widely adopted,
significant methodological heterogeneity between studies
exists with regard to study population, intervention dose
and timing, inclusion criteria and composite outcomes,
leading to lack of conclusive evidence to support or
withhold treatment.
Subsequent pregnancy care
• Prenatal care in women with previous adverse pregnancy
outcomes should be provided in an empathetic, high-quality
clinical care setting including emotional and mental health
support, increased ultrasound surveillance, frequent visits and
timely delivery.
• Treatment with LMWH in women with inheritable
thrombophilias is currently not recommended.
• Efforts should be made to optimise treatment with aspirin,
taking into account recent evidence to suggest that treatment
with higher doses of aspirin (100–150 mg) administered ideally
at nighttime and commenced before 16 weeks of gestation
improves subsequent pregnancy outcome.
• Although these data are derived from studies evaluating the
recurrence reduction in the setting of pre-eclampsia and fetal
growth restriction, dosing regimens may be adopted for the
purpose of risk reduction in other placenta-mediated pregnancy
complications as outlined above.

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Additional thromboprophylaxis
with LMWH may be indicated in
• women with positive antiphospholipid syndrome antibodies
• a history of catastrophic antiphospholipid syndrome or
venous thromboembolism;
• ideally these women should be cared for in a
multidisciplinary care setting with haematology input
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acquired
20%

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30 – 50%
at least one
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10 – 20 %
Previous obstetric outcome
Thromboprophylaxis in surgical patients
• All surgical interventions carry a risk of VTE and attention
should be paid to modifiable risk factors.
• a 2-fold increased risk in women using a combined pill.
• So stoppage of CHC prior to planned surgery reduces the
risk of VTE.
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RISK OF VTE for abdominal surgery in
patients who did not receive specific
thromboprophylaxis
• asymptomatic DVT at post operative screening 25%
• asymptomatic proximal DVT at post operative screening 7%
• symptomatic DVT 6%
• symptomatic non-fatal PE 1-2%
• fatal PE 0.5%
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VTE prophylaxis for surgery
• Patients undergoing abdominal surgery who are at risk due to the procedure
or personal risk factors should receive thromboprophylaxis with mechanical
methods and either subcutaneous LMWH, UFH or fondaparinux.
• In patients undergoing gynaecological surgery, when assessment of risk
favours pharmacological thromboprophylaxis, UFH or LMWH may be used.
• Mechanical methods can be considered in addition to pharmacological
methods.
• Anti-embolism stockings AES or intermittent pneumatic compression
devices are recommended for prophylaxis in surgical patients.
• In patients undergoing abdominal surgery Anti Embolic Stocking (AES) can be
used alone when pharmacological agents are contraindicated, for example
due to high bleeding risk.
• Aspirin is not recommended as the sole pharmacological agent for VTE
prophylaxis in surgical patients, as other available agents are more effective.
• Pharmacological thromboprophylaxis is typically continued until discharge.
Extended prophylaxis should be considered on a case-by-case basis, for
example when multiple thrombosis risk factors are present.
• The use of AES should continue until there is a return to the pre-morbid level
of mobility.
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