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In the name of GOD

In the name of GOD. How should women with previous VTE be managed in pregnancy?. Dr E Karimi moghaddam Ahvaz Imam Hospital, 2014. Women with previous VTE have an increased risk of recurrence in pregnancy and postpartum, with recurrence rates of 1.4–11.1 %. R ecurrence rate of VTE:

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In the name of GOD

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  1. In the name of GOD

  2. How should women with previous VTE be managed in pregnancy? Dr E Karimimoghaddam Ahvaz Imam Hospital, 2014

  3. Women with previous VTE have an increased risk of recurrence in pregnancy and postpartum, with recurrence rates of 1.4–11.1%. • Recurrence rate of VTE: during pregnancy: 10.9% Outside pregnancy: 3.7% relative risk during pregnancy of 3.5 • The risk of recurrence appears to be constant over the whole period of pregnancy

  4. All women with prior VTE should receive postpartum prophylaxis, as this is the period of greatest risk

  5. For the purposes of antenatal risk assessment, women with previous VTE can be stratified into those with: • Recurrent VTE • single previous VTE: a. unprovoked VTE b. estrogen-provoked (estrogen-containing contraception or pregnancy) VTE c. thrombophilia (heritable or acquired) or family history-associated VTE d. temporary risk factor (e.g. major trauma or surgery) associated VTE.

  6. Recurrent VTE • Individuals with recurrent VTE are at increased risk of further recurrence • Advice should be sought from a clinician with expertise in haemostasis and pregnancy • For women in this category, higher doses of LMWH may be appropriate. Risks of warfarin to the fetus should be counselled and advised to stop warfarin and change to LMWH as soon as pregnancy is confirmed(within two weeks of missed period and before the 6th week of pregnancy). Women not on warfarin should be advised to start LMWH as soon as they have a positive pregnancy test.

  7. Unprovoked previous VTE • In pregnant women with a single prior episode of VTE reported a recurrence rate of 5.9%

  8. Estrogen-provoked VTE: • Recurrence rate of VTE in pregnancy, when the prior episode was provoked by the estrogen-containing contraceptive or pregnancy is 10% • Therefore women with previous estrogen-related VTE as at high risk of VTE in pregnancy and the puerperium

  9. Thrombophilia-associated VTE • Heritable thrombophilia is found in 20–50% of women with pregnancy-related VTE

  10. Temporary risk factor-associated VTE • Outside pregnancy, the risk of recurrence of VTE resulting from a transient major risk factor is considered to be low • the risk of antenatal recurrence is very low if the prior VTE was provoked by a transient major risk factor that is no longer present (a DVT in an intravenous drug user who is no longer injecting or a DVT in association with surgery or major trauma)

  11. Management • recent international guidelines support a recommendation to stratify women with previous VTE into the following categories • Very high risk (recurrent VTE associated with either antithrombin deficiency or the antiphospholipidsyndrome): • These women require thromboprophylaxiswith higher-dose LMWH (either high prophylactic (12-hourly) or weight-adjusted (75% of treatment dose) antenatally and for 6 weeks postpartum or until converted back to warfarin after delivery

  12. Management • recent international guidelines support a recommendation to stratify women with previous VTE into the following categories • High risk: • Women in whom the original VTE was unprovoked, idiopathic or related to estrogen (estrogen-containing contraception or pregnancy) or who have other risk factors, a family history of VTE in a first-degree relative (suggestive of thrombophilia) or a documented thrombophilia. These women require thromboprophylaxiswith LMWH antenatally and for 6 weeks postpartum.

  13. Management • recent international guidelines support a recommendation to stratify women with previous VTE into the following categories • Intermediate risk: • Women in whom the original VTE was provoked by a transient major risk factor that is no longer present and who have no other risk factors • They require close surveillance for the development of other risk factors. They should be offered thromboprophylaxiswith LMWH for 6 weeks postpartum

  14. Testing for thrombophilia in women with prior VTE • There are two reasons for testing women with previous VTE for thrombophilia before or in early pregnancy: ● if detected in a woman with a prior VTE related to a minor temporary risk factor, such as long distance travel, it may influence the decision whether to offer antenatal thromboprophylaxis ● if antiphospholipid syndrome or antithrombin deficiency are detected, this will influence the dose of thromboprophylaxisoffered in pregnancy.

  15. Testing for thrombophilia in women with prior VTE • Women with a previous non-estrogen-related VTE provoked by a minor risk factor should undergo testing for thrombophilia

  16. Women at high risk of VTE in pregnancy, such as those with previous VTE, should be offered prepregnancycounselling and a prospective management plan for thromboprophylaxis in pregnancy.

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