A pregnant female has past history of embolism in puerperium. What medical management she should take in next pregnancy to avoid this:
Correct Answer: To take warfarin after delivery
Description: Ans. is b, i.e. To take warfarin after deliveryRef. Williams 23/e, p 1028, 29, Table 47.6Friends venous thromboembolism in pregnancy, is one of those topics which we do not study in detail during under graduation.So, I am giving in brief, all the important points you need to remember;Venous thromboembolism in pregnancyVenous thromboembolism is the leading cause of maternal deaths in developed countries.Pregnancy increases the risk of thromboembolism 6 times as all components of Virchow's triad are increased. QA, Deep vein thrombosis:Left sided DVT is more common than right sided DVT.Homans sign-i.e. pain in calf muscles on dorsiflexion of foot is positive.InvestigationsRecommended method during pregnancy: Doppler ultrasoundGold standard (in conditions other than pregnancy); VenographyThough objective evidence is ideal, treatment should be started on clinical grounds, if confirmatory tests are not available.ManagementDrug of choice in pregnancy is unfractionated heparinLow molecular weight heparins (enoxaparin, dalteparin) are safe during pregnancy and breastfeeding. But they should not be used ini. Women with prosthetic valvesii. Renal failureiii. With regional analgesiaWarfarin is not safe during pregnancy as it crosses placenta and can cause fetal malformations (Conradi syndrome). The single undisputed use for warfarin in pregnancy is in women with prosthetic heart valves.Monitoring is done by - APTT and Platelet count.ProtocolFor postpartum venous thrombosis, treatment with IV heparin and warfarin are started simultaneously 6-8 hours after vaginal delivery and 24 hours after cesarean section and once INR is between 2 and 3, heparin is discontinued and warfarin is continued for 6 weeks.Note: Warfarin is absolutely safe in lactation.ThromboprophylaxisWomen at risk of venous thromboembolism during pregnancy have been grouped into different categories depending on the presence of risk factors. Thromboprophylaxis to such a woman depends on the specific risk factor and the category. (1) A low risk woman has no personal or family history of VTE and are heterozygous for factor V Leiden mutation. Such a woman need no thromboprophylaxis, (2) A high risk woman is one who has previous VTE or VTE in present pregnancy, or antithrombin--III deficiency. Such a woman needs low molecular weight heparin prophylaxis throughout pregnancy and postpartum 6 weeks. Women with antithrombin-III deficiency can be treated with antithrombin-III concentrate prophylactically.Now lets have a look at the question: It says a female with previous history of embolism becomes pregnant, what medical management should be given to her.Option 'a' i.e. Compulsory prophylaxis with warfarin at 10 weeks.It is absolutely wrong as warfarin is not given during pregnancy.Option 'b' i.e. to take warfarin after delivery - As discussed above, in all high risk patients, post partum prophylaxis with warfarin has to be given as peuperium is the time of greatest risk for embolism/thromboembolism. Thus option b is correct.During pregnancy: A women with previous H/O embolism becomes high risk patient. In such patients prophylaxis with heparin needs to be given. Hence option 'd' is incorrect.
Category:
Gynaecology & Obstetrics
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