Name:
A 27-Year-Old with Leg Swelling
Description:
A 27-Year-Old with Leg Swelling
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Duration:
T00H05M26S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: [Handy] Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener,
CHARLIE: and we're coming to you from the Johns Hopkins School of Medicine. ♪ (music) ♪
CATHY: Episode 33: A 27-Year-Old with Leg Swelling.
CHARLIE: Okay, Cathy. Here's the case. A 27-year-old develops left leg swelling during week 20 of her pregnancy. Left lower extremity ultrasound reveals a left iliac vein deep venous thrombosis, or DVT.
CATHY: So, pregnancy and DVT is an important topic, and it's true that most of the unilateral DVTs occur in the left leg because the left iliac vein can get compressed by the right iliac artery when it crosses in the pelvis. And that's also the anatomic explanation for our May-Thurner syndrome, but in pregnant women you also get this because the uterus can compress the IVC, or the inferior vena cava, and cause diminished blood flow-- which is another risk factor for lower extremity DVT. Pregnancy is also a hypercoagulable state and that adds to the risk of developing DVTs.
CHARLIE: How is pregnancy in a hypercoagulable state? What's the mechanism for that?
CATHY: So, it's associated with an increase in the procoagulant factors, such as factor V and VII, and you also get a decrease in anticoagulant activity, including proteins C and S. Is there anything more to the story?
CHARLIE: Yeah. So, this question is about management, this is not about diagnosis. The question asks: Proper management for this patient would include: A. Bed rest; B. Catheter-directed thrombolysis; C. Enoxaparin; D. IVC filter placement; or E. Warfarin.
CATHY: This is a pretty straightforward question, and the answer is C. So, you do need to know a little bit about the other options. First, let's go through option C. So, heparin and low- molecular-weight heparin are the indicated anticoagulants in pregnancy. Remember that four weeks prior to delivery, you need to switch to unfractionated heparin to decrease the risk of epidural hematoma.
CHARLIE: That's because of the long half-life of the low-molecular-weight heparins?
CATHY: Correct.
CHARLIE: What about warfarin? Why is warfarin an incorrect answer?
CATHY: Yes, so that's absolutely incorrect. It cannot be used during pregnancy, and it's contraindicated in the first trimester of pregnancy because of its association with fetal chondrodysplasia punctata, but in the second and third trimesters it can also cause fetal optic atrophy and mental retardation. Postpartum, it's not contraindicated in breastfeeding women, so if you're in the postpartum setting, it's okay to transition to warfarin, but you wouldn't start that now as this patient's in her 20th week of pregnancy.
CHARLIE: And what about the newer anticoagulants? There's been a plethora of new anticoagulants that have come on the market in the past five to ten years.
CATHY: Yeah, so novel anticoagulants like dabigatran, apixaban, to name a couple. Pregnant women were excluded from most new drug trials, including these. So, there's not a lot of data on the safety of these drugs during pregnancy, so these are not really recommended to be started in the peripartum setting.
CHARLIE: Any thoughts on the procedures that are mentioned: catheter-directed thrombolysis or IVC filter placement?
CATHY: So, there's no role for either of those in this case. In general, the role of IVC filter is controversial, and in this case, there is no contraindication to anticoagulation, so there really wouldn't be a role for IVC filter, and there are few studies that support that now. The only indications are in patients who have documented failure of appropriate anticoagulation or patients who have a high risk of DVTs, such as surgery, and can't receive anticoagulation. But in many of those cases a temporary removable IVC filter would be the best.
CHARLIE: So really, it should not be a consideration on the table.
CATHY: Yeah, I wouldn't consider that. And then in thinking about catheter-directed thrombolysis-- that's also not routinely used. And there was a big trial recently, it was called the ATTRACT Trial, it was published in the New England Journal of Medicine in 2017, and it compared 692 patients with acute proximal venous thromboembolism to either anticoagulation alone or anticoagulation plus catheter-directed thrombolysis. And it didn't meet the primary endpoint of reduction in post-thrombotic syndrome. So, this has really also fallen out of favor and wouldn't be recommended in this case.
CHARLIE: And I suspect the ATTRACT Trial didn't even include patients with pregnancy, so, again, no evidence to help us in this conclusion at all.
CATHY: Yeah, that's absolutely correct.
CHARLIE: What about bed rest? Can you even think of a worse idea?
CATHY: Yeah. So, bed rest is definitely not indicated for this or really anything. So, bed rest isn't indicated for DVT in pregnancy, it's not indicated for patients with DVTs, and in general life, I also wouldn't recommend bed rest. In some cases, patients who are high-risk OB patients may be prescribed bed rest, but there's really nothing that that's used for now.
CHARLIE: Alright, that's a good point. So, the teaching point in this case is that pregnancy is, in general, a hypercoagulable state, and women who are pregnant have increased risk of DVTs because of some of the anatomical considerations. They're more likely to occur on the left side because of the anatomy. The treatment of choice for DVT in a pregnant woman is enoxaparin and unfractionated heparin when getting close to delivery. And another important teaching point in this case is that in pregnant women, warfarin is absolutely contraindicated.
CATHY: And you can read more about this in Harrison's chapter on Medical Disorders During Pregnancy, and then I'll also refer you to the ATTRACT Trial from New England Journal of Medicine that was published December 7th, 2017. ♪ (music) ♪