A 30-year-old primigravida at 18 weeks gestation comes to the office due to left calf pain and swelling that developed after a 4-hour car trip. The pain is worse with ambulation. The pregnancy was complicated by first-trimester bleeding. A recent ultrasound showed an 18-week-sized fetus with normal anatomy and no placenta previa.
Examination shows 1+ pretibial edema with pain elicited on plantar flexion of the left lower extremity. The remainder of the examination is unremarkable.
A lower extremity compression ultrasound with Doppler shows a thrombosis in the left popliteal vein.
Which of the following is the best treatment strategy for this patient?

Question

A 30-year-old primigravida at 18 weeks gestation comes to the office due to left calf pain and swelling that developed after a 4-hour car trip.  The pain is worse with ambulation.  The pregnancy was complicated by first-trimester bleeding.  A recent ultrasound showed an 18-week-sized fetus with normal anatomy and no placenta previa.
Examination shows 1+ pretibial edema with pain elicited on plantar flexion of the left lower extremity.  The remainder of the examination is unremarkable.
A lower extremity compression ultrasound with Doppler shows a thrombosis in the left popliteal vein.
Which of the following is the best treatment strategy for this patient?

Quizplus · Accepted Answer

11ec193a_98a4_88aa_853d_9593b488711c_MD0002_00 The hematologic changes in pregnancy (eg, increased procoagulant factor, decreased protein S activity) lead to a hypercoagulable state. In addition, pregnancy-related increases in venous capacity and compression of the inferior vena cava and iliac veins cause lower extremity venous stasis. Therefore, pregnancy and the postpartum period are associated with an increased risk for venous thromboembolism (VTE) that can be exacerbated by inactivity (eg, bed rest). Subcutaneous low-molecular-weight heparin (LMWH) is the first-line anticoagulant during pregnancy due to its high efficacy, ease of use, and safety profile. Delivery is typically scheduled and anticoagulation is held for 24 hours prior to it to minimize the risk of obstetric hemorrhage. During these 24 hours, patients at high risk for VTE recurrence (eg, acute pulmonary embolism, proximal deep venous thrombosis within the past month) are switched to intravenous unfractionated heparin, which is discontinued 4-6 hours prior to delivery. Anticoagulation is restarted 6-12 hours after delivery and continued until >6 weeks postpartum. (Choice A) Inferior vena cava filter placement is indicated for patients who have recurrent VTE or contraindications to anticoagulation (eg, active bleeding). Resolved first-trimester bleeding is not a contraindication to anticoagulation. (Choice B) Thrombolytic therapy (eg, recombinant tissue-type plasminogen activator) is associated with a high risk of maternal hemorrhage and therefore is reserved for severe acute pulmonary embolism. (Choice C) Factor Xa inhibitors (eg, rivaroxaban) are indicated in the management of VTE in nonpregnant patients. However, these medications cross the placenta and are not recommended during pregnancy due to inadequate information regarding safety. Because of difficulty with reversal, use during pregnancy may increase the risk of obstetric hemorrhage. (Choice E) During pregnancy, subcutaneous unfractionated heparin is a second-line anticoagulant as it has more adverse effects, is less efficacious, and is more difficult to use than LMWH. Educational objective: The first-line anticoagulant for pregnant patients with venous thromboembolism is subcutaneous low-molecular-weight heparin. Anticoagulation is continued until at least 6 weeks postpartum. __________ References: Treatment of pregnancy-associated venous thromboembolism - position paper from the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH). (http://www.ncbi.nlm.nih.gov/pubmed/27058796) Diagnosis and management of thrombosis in pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/26404051)

A 30-Year-Old Primigravida at 18 Weeks Gestation Comes to the Office