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Reducing risk of VTE - Maternal medicine Module part2

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1)

You are seeing a 30-year-old primigravida at her booking visit. Her sister had deep vein
thrombosis in her legs last year and suffered much pain and discomfort. She has heard that
pregnancy increases risk for venous thrombosis and wants you to address her concern. What is
the most appropriate action to take?

2)

A 36-year-old multiparous woman attends the antenatal clinic for a review at 20 weeks'
gestation. A general examination reveals a body mass index of 41 and varicose veins. Her
anomaly scan and booking bloods are normal.

3)

A 4O-year old nulliparous woman attends the maternal medicine clinic for a consultation at
13weeks' gestation. A dating ultrasound scan at 12weeks' gestation reveals a single viable
intrauterine fetus. She gives a history of a single episode of deep venous thrombosis following a
road traffic accident 5years ago. A recent thrombophilia screen prior to pregnancy is negative.

4)

A 28-year-old woman with a BMI of 25 kg/m2 books into the antenatal clinic at 12 weeks.
Two years previously she had a confirmed unprovoked ilio femoral thrombosis in her left leg.
Your advice regarding thromboprophylaxis during this pregnancy is:

5)

Ms XY is 38-year-old G5P4 with a BMI of 32. She presents to the consultant-led ANC at 28
weeks with a fetal growth scan, which is normal. She is otherwise fit and well. She takes routine
pregnancy supplements.
In terms of VTE prophylaxis, which of the following is best suited to her?

6)

A 36-year-old nulliparous woman attends the early pregnancy assessment unit at 10 weeks'
gestation with minimal vaginal bleeding. A transvaginal Scan reveals triplets. Medical history
unveils that she had single episode of axillary venous thrombosis 3 years ago. She was
investigated adequately but no cause was found.

7) Women with OHSS are specially prone to:

8)

A 28-year-old woman with a BMI of 35 kg/m2 presents to the antenatal clinic for a booking.
She has confirmed anti-phospholipid syndrome (APLS). She has no previous history of venous
thrombosis, but was tested after a stillbirth at term and was found to have a positive lupus
anticoagulant test on two occasions, 12 weeks apart. She is a non-smoker.
She asks about the risk of venous thrombosis and the role of LMWH in her pregnancy.
You advise her that she should

9)

A 26-year-old primigravida is discussing her fears of pregnancy complications with you at
the booking visit. She has heard that pregnancy and childbirth increase the risk of
thromboembolism. You will be correct to tell her that the incidence of VTE in pregnancy and
puerperium is:

10)

A 36-year-old obese nulliparous woman attended the antenatal clinic for her first
consultation with the doctor at 20 weeks' gestation (her ultrasound scan shows a low-lying
placenta). A further review was carried out at 34 weeks' gestation because her repeat scan also
showed a low lying placenta. Subsequently, she underwent an elective Caesarean section at
38weeks' gestation because of the increased vaginal bleeding (Sheloses2000mLofblood). She
recovered well following 3 units of blood transfusion. The senior house officer discharged her
on postnatal day 3. However, 5 days later she presents to the emergency department with a
spildng temperature due to a Caesarean section wound infection and is admitted to the
gynaecology ward for intravenous antibiotic therapy.

11)

What is the background rate of venous thromboembolism (VTE) in women of reproductive
age?

12)

A 40-year-oldwoman attends her antenatal appointment at 12weeks' gestation.She gives
history of three miscarriages (<10weeks) with a single episode of a venous thromboembolism (VTE) following major surgery of the hip. Her blood test is positive for anticardiolipin antibody. A vaginal swab shows growth of group B Streptococcus.

13)

A 25-year-old woman presents at 12 weeks gestation. Four years earlier she presented
with a deep vein thrombosis after fracturing her femur and undergoing a major orthopaedic
operation. Her thrombophilia screen result is negative, she has no family history of thrombosis
and she has a body mass index of 23 kg/m.
What thromboprophylaxis should be offered to this woman?

14)

A 37-year-old para 0, who has undergone controlled ovarian stimulation for IVF treatment 3
weeks previously, presents with abdominal pain, bloating, nausea and vomiting. She is known
to have PCOS and had not ovulated previously with clomifene citrate treatment. She went on to
receive antagonist recombinant FSH protocol and was later given human chorionic
gonadotropin to trigger ovulation. Ultrasound has shown evidence of ascites with an ovarian
size of 14 cm. Her haematocrit was 46%. The patient was admitted to hospital for inpatient
treatment.
What is the recommended regime of thromboprophylaxis?

15)

A 3I-year-old woman attends the antenatal clinic for review at 20 weeks' gestation. She
suddenly remembers to tell you that she had superficial thrombophlebitis 6 months prior to
pregnancy which resolved with no residual signs.

16)

37-year-old primigravida, 102 kg, and a BMI of 40 kg/m2 is seen in the antenatal clinic for
booking. She has conceived following a long period of subfertility through assisted conception.
Ultra- sound scan had confirmed a di-chorionic, di-amniotic twin pregnancy of 11+ 5 days
gestation. Prophylactic LMWH had been given throughout pregnancy. A category 3 caesarean
section had been performed at 37 weeks.
What is recommended as the best practice with regard to reducing maternal risk of VTE in the
puerperium?

17)

A 32-year-old woman with a body mass index (BMI) of 35 kg/m2 has just delivered
vaginally at term. She is a known carrier of a prothrombin gene mutation.
For how many days postnatally should she have thromboprophylaxis?

18)

A 40-year-old Asian woman attends her antenatal clinic appointment at 12weeks' gestation.
She gives a history of eclampsia in her last pregnancy at 28 weeks' gestation and hence she
had a Caesarean section. Now her blood pressure is 120/60 and her urine shows absence of
protein.

19)

A 40-year-old woman attends her antenatal appointment at 12 weeks' gestation. She gives
a history of a stillbirth at 28 weeks' gestation and DVT 7 days following that delivery. Her blood
test reveals an antithrombin III deficiency. She has been treated for toxoplasmosis in the past
and her blood shows IgG antibodies for toxoplasmosis.

20)

A 40-year-old nulliparous woman attends the early pregnancy assessment unit at 12 weeks'
gestation with mild vaginal bleeding. A transvaginal scan reveals a viable dichorionic diamniotic
twin pregnancy. Medical history reveals that she had an episode of DVT and a pulmonary
embolism 2 years and 1year ago respectively. A recent thrombophilia screen is negative.

21) All of the following are advantages of unfractionated heparin (UH) except:

22)

Ms XY is 38-year-old G5P4 with a BMI of 32. She is also a smoker but has cut down after
referral to the NHS smoking cessation services. She presents to the consultant-led ANC at 6
weeks with a TV scan for threatened miscarriage, which is normal. She is 6 weeks pregnant as
per the TV scan. She is otherwise fit and well. She takes routine pregnancy supplements.
Which of the following treatment options are best suited to her?

23)

A36-year-old obese nulliparous woman (body mass index >30kglm2) attends the maternal
medicine obstetric clinic for a review at 38 weeks' gestation to discuss mode of delivery,
because her ultrasound scan shows a breech presentation. Subsequently, she undergoes an
elective Caesarean section at 39 weeks' gestation and is discharged home on the second
postoperative day.

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