What is...
Most common inherited thrombophilia
Factor V Leiden
Personal history of VTE without prior evaluation
First-degree relative with high risk thrombophilia
Pregnancy
Labor/Delivery
Postpartum
Plot explained badly:
A captain falls in love with a teenager accompanied by a spirit dragon and an insect, and almost loses the country to a guy with a wild mustache.
Mulan
Timing of delivery
Standard obstetric indications
Induction can be used at term for discontinuation to allow neuraxial anesthesia if desired
Most common implicated in pregnancy
Factor V Leiden heterozygote (40% of all VTE)
Thrombophilia evaluation for 30 year old G3P0030 with three prior 10-12w losses and no prior evaluation
Anti-phospholipid antibodies (anti-cardiolipin, anti-beta2 glycoprotein, lupus anticoagulant)
No inherited thrombophilia evaluation
At what risk level is VTE prophylaxis recommended by consensus opinion
3%
Plot explained badly:
Little boy harasses an old guy so much that they go on an accidental vacation together and end up on another continent
Up
Prophylactic enoxaparin has to be held for this long for neuraxial placement
12 hours
Other common inherited thrombophilias in pregnancy (name two)
Prothrombin G20210A
Protein C deficiency
Protein S deficiency
Antithrombin deficiency
Factor V Leiden
Prothrombin gene mutations
Antithrombin, protein C & S levels
These populations should receive prophylaxis with no other risk factors
Factor V Leiden homozygotes
Prothrombin G20210A homozygotes
Antithrombin deficiency
Factor V/Prothrombin heterozygotes
Plot explained badly:
Country girl has to choose between guy who wants to control her life and guy who wants to keep her hostage. The latter is marginally nicer, but the deciding factor is his library.
Beauty and the Beast
Unfractionated heparin should be held for this long to allow for epidural placement
12 hour from last dose if >7500 units and lab testing for normal aPTT
Highest risk with personal history of VTE
Antithrombin deficiency
When thrombophilia evaluation should ideally occur
Remote from event (>6 weeks)
Not pregnant or taking hormonal medications
Not on anticoagulation
When to start prophylaxis
Upon confirmation of viable pregnancy, or as early as possible
Plot explained badly:
Very cute aliens invade Hawaii and emotionally manipulate orphans
Lilo & Stitch
Risk factors that increase postpartum risk (name 3)
Obesity, cesarean delivery, preeclampsia, multiple gestation, PPH >1L, Age >40
Implication of MTHFR mutation
Nothing
Tests that are reliable during pregnancy (name 2)
Activated protein C resistance assay
DNA analysis
Protein C activity
Antithrombin activity
Prophylactic regimens
Low molecular weight heparin
Unfractionated heparin
Plot explained badly:
A gospel choir tells the story of a child put up for adoption who leaves his loving foster family to figure out who he is, then changes everything about himself to be accepted by a birth family that rejects him anyway. Also gets into a fight with an uncle with anger issues.
Hercules
Postpartum prophylaxis timing
6-12 hours after cesarean