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Panel 7: Needs of Special Populations

Surgeon General's Workshop on Deep Vein Thrombosis

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 SLIDE 1: Needs of Special Populations

Andra H. James MD, MPH
Andra H. James MD, MPH
Comprehensive Hemostasis and Thrombosis Center
&
Department of Obstetrics and Gynecology
Duke University Medical Center

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 SLIDE 2: Special Needs of Women

  • Contraception
    • Birth control pills increase the risk of thrombosis 3 to 4-fold
    • Patches expose women to 60% more estrogen
    • Progestin-only contraceptives do not increase the risk
  • Menopausal symptoms
    • Postmenopausal hormone therapy increases the risk of clots
    • Progestin, in doses to treat abnormal bleeding increases the risk 5 to 6-fold
  • Heavy menstrual bleeding
    • May affect half of women on anticoagulants
  • Hemorrhagic ovarian cysts

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 SLIDE 3: Special Needs of Pregnant Women

  • Women on warfarin must convert to heparin
  • Women with a history of thrombosis will require heparin during pregnancy and for at least 6 weeks postpartum
  • Women with thrombophilia are at risk for poor pregnancy outcome
  • Women with thrombophilia and a history of poor pregnancy outcome will likely require heparin
  • Women with thrombophilia but no history of thrombosis or poor pregnancy outcome do not require anticoagulation.

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 SLIDE 4: Thromboses in Unborn Babies

  • Vascular disruptions
  • Renal veins
  • Vena cavae
  • Cerebral venous sinuses
  • Umbilical veins
  • Placental vessels

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 SLIDE 5: Thromboses in Infants

  • 80% catheter-related
    • Lines in upper body
    • Lines in umbilical vein
  • 20% spontaneous
    • Renal veins
    • Cerebral veins
  • Treat with anticoagulants or thrombolysis
  • Neonatal purpura fulminans

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 SLIDE 6: Special Needs of Children

  • The coagulation system changes with age
  • High circulatory demands
  • Different illnesses and different medications
  • Inability to cooperate
  • Intravenous access
  • No pediatric formulations of any anticoagulants
  • No liquid warfarin or pediatric doses of pre-filled syringes
  • Different diets and formulas contain different amounts of vitamin K
  • Different level of understanding
  • Dependent on their parents

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 SLIDE 7: Assembling a Team to Meet the Needs of Individuals

  • No specialist for venous thromboembolism
  • Community hematologists devote 90% of their time to cancer patients
  • The ideal team:
    • Expert in coagulation
    • Pharmacist knowledgeable in anticoagulation
    • Nurse to educate the patient
    • Primary provider

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 SLIDE 8: Assembling a Team to Meet the Needs of Families

  • Young adults and children with spontaneous DVT or PE often have thrombophilia
  • Questions arise regarding:
    • Whom to test
    • Whom to treat
  • Ideal team includes a knowledgeable genetic counselor

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 SLIDE 9: Creating a Center that Meets the Needs of the Community

  • Consultative services for inpatients and outpatients
  • Direct care in complex cases
  • Coagulation laboratory support
  • Educational materials for patients
  • Continuing medical education
  • Websites
  • Protocols
  • Publications

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 SLIDE 10: Meeting the Needs of the Nation

  • Spyropoulos and Haire described the Clinical Thrombosis Center
  • Needs of special populations were not considered
  • In 2001, the CDC initiated a pilot program of thrombophilia centers to:
    • Determine the value of a multi-disciplinary team in providing care to persons with coagulation disorders.
    • Assess unmet needs and identify outreach strategies to improve access to care.
    • Develop effective messages aimed at disease management and prevention.
    • Foster the development of training programs to enhance provider skills.
  • 8 receiving funding, networking and modeling care

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