{"version":"1.0.0","segments":[{"startTime":1.239,"endTime":3.269,"body":"♪ (music) ♪"},{"startTime":3.269,"endTime":5.659,"body":"(Cathy Handy) Hi, welcome"},{"startTime":3.269,"endTime":5.659,"body":"to \u003ci\u003eHarrison's Podclass\u003c/i\u003e,"},{"startTime":5.659,"endTime":8.719,"body":"where we discuss important concepts"},{"startTime":5.659,"endTime":8.719,"body":"in internal medicine."},{"startTime":8.719,"endTime":11.029,"body":"- I'm Cathy Handy."},{"startTime":8.719,"endTime":11.029,"body":"- (Charlie) And I'm Charlie Wiener,"},{"startTime":11.029,"endTime":14.099,"body":"and we're coming to you"},{"startTime":11.029,"endTime":14.099,"body":"from the Johns Hopkins School of Medicine."},{"startTime":14.099,"endTime":15.859,"body":"♪ (music) ♪"},{"speaker":"(Cathy) Episode 33","startTime":15.859,"endTime":19.189,"body":"A 27-Year-Old with Leg Swelling."},{"speaker":"(Cathy) Episode 33","startTime":19.972,"endTime":22.372,"body":"(Charlie) Okay, Cathy. Here's the case."},{"speaker":"(Cathy) Episode 33","startTime":22.372,"endTime":27.252,"body":"A 27-year-old develops left leg swelling"},{"speaker":"(Cathy) Episode 33","startTime":22.372,"endTime":27.252,"body":"during week 20 of her pregnancy."},{"speaker":"(Cathy) Episode 33","startTime":27.255,"endTime":28.783,"body":"Left lower extremity ultrasound"},{"speaker":"(Cathy) Episode 33","startTime":28.783,"endTime":33.153,"body":"reveals a left iliac vein"},{"speaker":"(Cathy) Episode 33","startTime":28.783,"endTime":33.153,"body":"deep venous thrombosis, or DVT."},{"speaker":"(Cathy) Episode 33","startTime":33.153,"endTime":35.473,"body":"(Cathy) So, pregnancy and DVT"},{"speaker":"(Cathy) Episode 33","startTime":33.153,"endTime":35.473,"body":"is an important topic,"},{"speaker":"(Cathy) Episode 33","startTime":35.473,"endTime":39.223,"body":"and it's true that most of the unilateral"},{"speaker":"(Cathy) Episode 33","startTime":35.473,"endTime":39.223,"body":"DVTs occur in the left leg"},{"speaker":"(Cathy) Episode 33","startTime":39.223,"endTime":41.727,"body":"because the left iliac vein"},{"speaker":"(Cathy) Episode 33","startTime":39.223,"endTime":41.727,"body":"can get compressed"},{"speaker":"(Cathy) Episode 33","startTime":41.727,"endTime":44.607,"body":"by the right iliac artery"},{"speaker":"(Cathy) Episode 33","startTime":41.727,"endTime":44.607,"body":"when it crosses in the pelvis."},{"speaker":"(Cathy) Episode 33","startTime":44.607,"endTime":47.738,"body":"And that's also the anatomic explanation"},{"speaker":"(Cathy) Episode 33","startTime":44.607,"endTime":47.738,"body":"for our May-Thurner syndrome,"},{"speaker":"(Cathy) Episode 33","startTime":47.738,"endTime":49.788,"body":"but in pregnant women you also get this"},{"speaker":"(Cathy) Episode 33","startTime":49.788,"endTime":53.438,"body":"because the uterus can compress the IVC,"},{"speaker":"(Cathy) Episode 33","startTime":49.788,"endTime":53.438,"body":"or the inferior vena cava,"},{"speaker":"(Cathy) Episode 33","startTime":53.438,"endTime":55.159,"body":"and cause diminished blood flow--"},{"speaker":"(Cathy) Episode 33","startTime":55.159,"endTime":58.029,"body":"which is another risk factor"},{"speaker":"(Cathy) Episode 33","startTime":55.159,"endTime":58.029,"body":"for lower extremity DVT."},{"speaker":"(Cathy) Episode 33","startTime":58.029,"endTime":60.113,"body":"Pregnancy is also"},{"speaker":"(Cathy) Episode 33","startTime":58.029,"endTime":60.113,"body":"a hypercoagulable state"},{"speaker":"(Cathy) Episode 33","startTime":60.113,"endTime":63.213,"body":"and that adds to the risk"},{"speaker":"(Cathy) Episode 33","startTime":60.113,"endTime":63.213,"body":"of developing DVTs."},{"speaker":"(Cathy) Episode 33","startTime":63.213,"endTime":65.393,"body":"(Charlie) How is pregnancy"},{"speaker":"(Cathy) Episode 33","startTime":63.213,"endTime":65.393,"body":"in a hypercoagulable state?"},{"speaker":"(Cathy) Episode 33","startTime":65.393,"endTime":66.853,"body":"What's the mechanism for that?"},{"speaker":"(Cathy) Episode 33","startTime":66.853,"endTime":68.573,"body":"(Cathy) So, it's associated"},{"speaker":"(Cathy) Episode 33","startTime":66.853,"endTime":68.573,"body":"with an increase"},{"speaker":"(Cathy) Episode 33","startTime":68.573,"endTime":71.763,"body":"in the procoagulant factors,"},{"speaker":"(Cathy) Episode 33","startTime":68.573,"endTime":71.763,"body":"such as factor V and VII,"},{"speaker":"(Cathy) Episode 33","startTime":71.763,"endTime":74.503,"body":"and you also get a decrease"},{"speaker":"(Cathy) Episode 33","startTime":71.763,"endTime":74.503,"body":"in anticoagulant activity,"},{"speaker":"(Cathy) Episode 33","startTime":74.503,"endTime":76.483,"body":"including proteins C and S."},{"speaker":"(Cathy) Episode 33","startTime":76.483,"endTime":78.267,"body":"Is there anything more to the story?"},{"speaker":"(Cathy) Episode 33","startTime":78.267,"endTime":80.637,"body":"(Charlie) Yeah. So, this question"},{"speaker":"(Cathy) Episode 33","startTime":78.267,"endTime":80.637,"body":"is about management,"},{"speaker":"(Cathy) Episode 33","startTime":80.637,"endTime":82.477,"body":"this is not about diagnosis."},{"speaker":"The question asks","startTime":83.864,"endTime":87.092,"body":"Proper management"},{"speaker":"The question asks","startTime":83.864,"endTime":87.092,"body":"for this patient would include:"},{"speaker":"The question asks","startTime":87.092,"endTime":89.261,"body":"A. Bed rest;"},{"speaker":"The question asks","startTime":89.261,"endTime":92.182,"body":"B. Catheter-directed thrombolysis;"},{"speaker":"The question asks","startTime":92.182,"endTime":94.526,"body":"C. Enoxaparin;"},{"speaker":"The question asks","startTime":94.526,"endTime":97.276,"body":"D. IVC filter placement;"},{"speaker":"The question asks","startTime":97.28,"endTime":99.126,"body":"or E. Warfarin."},{"speaker":"The question asks","startTime":99.126,"endTime":101.126,"body":"(Cathy) This is a pretty"},{"speaker":"The question asks","startTime":99.126,"endTime":101.126,"body":"straightforward question,"},{"speaker":"The question asks","startTime":101.126,"endTime":102.466,"body":"and the answer is C."},{"speaker":"The question asks","startTime":102.468,"endTime":105.128,"body":"So, you do need to know a little bit"},{"speaker":"The question asks","startTime":102.468,"endTime":105.128,"body":"about the other options."},{"speaker":"The question asks","startTime":105.128,"endTime":107.206,"body":"First, let's go through option C."},{"speaker":"The question asks","startTime":107.206,"endTime":109.326,"body":"So, heparin and low-"},{"speaker":"The question asks","startTime":107.206,"endTime":109.326,"body":"molecular-weight heparin"},{"speaker":"The question asks","startTime":109.326,"endTime":112.416,"body":"are the indicated anticoagulants"},{"speaker":"The question asks","startTime":109.326,"endTime":112.416,"body":"in pregnancy."},{"speaker":"The question asks","startTime":112.416,"endTime":114.676,"body":"Remember that four weeks"},{"speaker":"The question asks","startTime":112.416,"endTime":114.676,"body":"prior to delivery,"},{"speaker":"The question asks","startTime":114.676,"endTime":116.719,"body":"you need to switch"},{"speaker":"The question asks","startTime":114.676,"endTime":116.719,"body":"to unfractionated heparin"},{"speaker":"The question asks","startTime":116.719,"endTime":119.209,"body":"to decrease the risk of epidural hematoma."},{"speaker":"The question asks","startTime":119.209,"endTime":121.049,"body":"(Charlie) That's because"},{"speaker":"The question asks","startTime":119.209,"endTime":121.049,"body":"of the long half-life"},{"speaker":"The question asks","startTime":121.049,"endTime":122.649,"body":"of the low-molecular-weight heparins?"},{"speaker":"The question asks","startTime":122.649,"endTime":123.649,"body":"(Cathy) Correct."},{"speaker":"The question asks","startTime":123.649,"endTime":126.599,"body":"(Charlie) What about warfarin?"},{"speaker":"The question asks","startTime":123.649,"endTime":126.599,"body":"Why is warfarin an incorrect answer?"},{"speaker":"The question asks","startTime":126.599,"endTime":128.539,"body":"(Cathy) Yes, so that's"},{"speaker":"The question asks","startTime":126.599,"endTime":128.539,"body":"absolutely incorrect."},{"speaker":"The question asks","startTime":128.539,"endTime":130.365,"body":"It cannot be used during pregnancy,"},{"speaker":"The question asks","startTime":130.365,"endTime":133.165,"body":"and it's contraindicated"},{"speaker":"The question asks","startTime":130.365,"endTime":133.165,"body":"in the first trimester of pregnancy"},{"speaker":"The question asks","startTime":133.165,"endTime":136.605,"body":"because of its association"},{"speaker":"The question asks","startTime":133.165,"endTime":136.605,"body":"with fetal chondrodysplasia punctata,"},{"speaker":"The question asks","startTime":136.605,"endTime":138.375,"body":"but in the second and third trimesters"},{"speaker":"The question asks","startTime":138.375,"endTime":141.815,"body":"it can also cause fetal optic atrophy"},{"speaker":"The question asks","startTime":138.375,"endTime":141.815,"body":"and mental retardation."},{"speaker":"The question asks","startTime":141.815,"endTime":145.185,"body":"Postpartum, it's not contraindicated"},{"speaker":"The question asks","startTime":141.815,"endTime":145.185,"body":"in breastfeeding women,"},{"speaker":"The question asks","startTime":145.185,"endTime":148.775,"body":"so if you're in the postpartum setting,"},{"speaker":"The question asks","startTime":145.185,"endTime":148.775,"body":"it's okay to transition to warfarin,"},{"speaker":"The question asks","startTime":148.775,"endTime":150.035,"body":"but you wouldn't start that now"},{"speaker":"The question asks","startTime":150.035,"endTime":152.335,"body":"as this patient's"},{"speaker":"The question asks","startTime":150.035,"endTime":152.335,"body":"in her 20th week of pregnancy."},{"speaker":"The question asks","startTime":152.335,"endTime":154.335,"body":"(Charlie) And what about"},{"speaker":"The question asks","startTime":152.335,"endTime":154.335,"body":"the newer anticoagulants?"},{"speaker":"The question asks","startTime":154.335,"endTime":156.695,"body":"There's been a plethora"},{"speaker":"The question asks","startTime":154.335,"endTime":156.695,"body":"of new anticoagulants"},{"speaker":"The question asks","startTime":156.695,"endTime":159.355,"body":"that have come on the market"},{"speaker":"The question asks","startTime":156.695,"endTime":159.355,"body":"in the past five to ten years."},{"speaker":"The question asks","startTime":159.355,"endTime":163.32,"body":"(Cathy) Yeah, so novel anticoagulants"},{"speaker":"The question asks","startTime":159.355,"endTime":163.32,"body":"like dabigatran, apixaban,"},{"speaker":"The question asks","startTime":163.32,"endTime":164.67,"body":"to name a couple."},{"speaker":"The question asks","startTime":164.67,"endTime":168.53,"body":"Pregnant women were excluded from most"},{"speaker":"The question asks","startTime":164.67,"endTime":168.53,"body":"new drug trials, including these."},{"speaker":"The question asks","startTime":168.53,"endTime":169.89,"body":"So, there's not a lot of data"},{"speaker":"The question asks","startTime":169.89,"endTime":171.99,"body":"on the safety of these drugs"},{"speaker":"The question asks","startTime":169.89,"endTime":171.99,"body":"during pregnancy,"},{"speaker":"The question asks","startTime":171.99,"endTime":173.878,"body":"so these are not really recommended"},{"speaker":"The question asks","startTime":173.878,"endTime":175.868,"body":"to be started in the peripartum setting."},{"speaker":"The question asks","startTime":175.868,"endTime":178.228,"body":"(Charlie) Any thoughts"},{"speaker":"The question asks","startTime":175.868,"endTime":178.228,"body":"on the procedures that are mentioned:"},{"speaker":"The question asks","startTime":178.228,"endTime":181.398,"body":"catheter-directed thrombolysis"},{"speaker":"The question asks","startTime":178.228,"endTime":181.398,"body":"or IVC filter placement?"},{"speaker":"The question asks","startTime":181.398,"endTime":184.128,"body":"(Cathy) So, there's no role"},{"speaker":"The question asks","startTime":181.398,"endTime":184.128,"body":"for either of those in this case."},{"speaker":"The question asks","startTime":184.128,"endTime":186.889,"body":"In general, the role"},{"speaker":"The question asks","startTime":184.128,"endTime":186.889,"body":"of IVC filter is controversial,"},{"speaker":"The question asks","startTime":186.889,"endTime":190.829,"body":"and in this case, there is"},{"speaker":"The question asks","startTime":186.889,"endTime":190.829,"body":"no contraindication to anticoagulation,"},{"speaker":"The question asks","startTime":190.829,"endTime":193.269,"body":"so there really wouldn't be"},{"speaker":"The question asks","startTime":190.829,"endTime":193.269,"body":"a role for IVC filter,"},{"speaker":"The question asks","startTime":193.269,"endTime":195.469,"body":"and there are few studies"},{"speaker":"The question asks","startTime":193.269,"endTime":195.469,"body":"that support that now."},{"speaker":"The question asks","startTime":195.469,"endTime":197.099,"body":"The only indications are in patients"},{"speaker":"The question asks","startTime":197.099,"endTime":200.109,"body":"who have documented failure"},{"speaker":"The question asks","startTime":197.099,"endTime":200.109,"body":"of appropriate anticoagulation"},{"speaker":"The question asks","startTime":200.109,"endTime":203.187,"body":"or patients who have"},{"speaker":"The question asks","startTime":200.109,"endTime":203.187,"body":"a high risk of DVTs, such as surgery,"},{"speaker":"The question asks","startTime":203.187,"endTime":205.407,"body":"and can't receive anticoagulation."},{"speaker":"The question asks","startTime":205.407,"endTime":206.679,"body":"But in many of those cases"},{"speaker":"The question asks","startTime":206.679,"endTime":209.959,"body":"a temporary removable"},{"speaker":"The question asks","startTime":206.679,"endTime":209.959,"body":"IVC filter would be the best."},{"speaker":"The question asks","startTime":209.959,"endTime":212.409,"body":"(Charlie) So really, it should not be"},{"speaker":"The question asks","startTime":209.959,"endTime":212.409,"body":"a consideration on the table."},{"speaker":"The question asks","startTime":212.409,"endTime":214.039,"body":"(Cathy) Yeah, I wouldn't consider that."},{"speaker":"The question asks","startTime":214.039,"endTime":217.015,"body":"And then in thinking"},{"speaker":"The question asks","startTime":214.039,"endTime":217.015,"body":"about catheter-directed thrombolysis--"},{"speaker":"The question asks","startTime":217.015,"endTime":218.635,"body":"that's also not routinely used."},{"speaker":"The question asks","startTime":218.635,"endTime":221.635,"body":"And there was a big trial recently,"},{"speaker":"The question asks","startTime":218.635,"endTime":221.635,"body":"it was called the ATTRACT Trial,"},{"speaker":"The question asks","startTime":221.635,"endTime":224.855,"body":"it was published in the \u003ci\u003eNew England"},{"speaker":"The question asks","startTime":221.635,"endTime":224.855,"body":"Journal of Medicine\u003c/i\u003e in 2017,"},{"speaker":"The question asks","startTime":224.855,"endTime":229.985,"body":"and it compared 692 patients with"},{"speaker":"The question asks","startTime":224.855,"endTime":229.985,"body":"acute proximal venous thromboembolism"},{"speaker":"The question asks","startTime":229.985,"endTime":231.835,"body":"to either anticoagulation alone"},{"speaker":"The question asks","startTime":231.835,"endTime":235.245,"body":"or anticoagulation"},{"speaker":"The question asks","startTime":231.835,"endTime":235.245,"body":"plus catheter-directed thrombolysis."},{"speaker":"The question asks","startTime":235.245,"endTime":239.415,"body":"And it didn't meet the primary endpoint"},{"speaker":"The question asks","startTime":235.245,"endTime":239.415,"body":"of reduction in post-thrombotic syndrome."},{"speaker":"The question asks","startTime":239.415,"endTime":241.494,"body":"So, this has really also"},{"speaker":"The question asks","startTime":239.415,"endTime":241.494,"body":"fallen out of favor"},{"speaker":"The question asks","startTime":241.494,"endTime":243.284,"body":"and wouldn't be recommended"},{"speaker":"The question asks","startTime":241.494,"endTime":243.284,"body":"in this case."},{"speaker":"The question asks","startTime":243.284,"endTime":245.044,"body":"(Charlie) And I suspect the ATTRACT Trial"},{"speaker":"The question asks","startTime":245.044,"endTime":246.884,"body":"didn't even include"},{"speaker":"The question asks","startTime":245.044,"endTime":246.884,"body":"patients with pregnancy,"},{"speaker":"The question asks","startTime":246.884,"endTime":250.034,"body":"so, again, no evidence to help us"},{"speaker":"The question asks","startTime":246.884,"endTime":250.034,"body":"in this conclusion at all."},{"speaker":"The question asks","startTime":250.034,"endTime":251.824,"body":"(Cathy) Yeah, that's absolutely correct."},{"speaker":"The question asks","startTime":251.824,"endTime":254.604,"body":"(Charlie) What about bed rest?"},{"speaker":"The question asks","startTime":251.824,"endTime":254.604,"body":"Can you even think of a worse idea?"},{"speaker":"The question asks","startTime":254.604,"endTime":258.634,"body":"(Cathy) Yeah. So, bed rest is definitely"},{"speaker":"The question asks","startTime":254.604,"endTime":258.634,"body":"not indicated for this or really anything."},{"speaker":"The question asks","startTime":258.634,"endTime":261.494,"body":"So, bed rest isn't indicated"},{"speaker":"The question asks","startTime":258.634,"endTime":261.494,"body":"for DVT in pregnancy,"},{"speaker":"The question asks","startTime":261.494,"endTime":264.314,"body":"it's not indicated for patients with DVTs,"},{"speaker":"The question asks","startTime":264.314,"endTime":267.514,"body":"and in general life, I also"},{"speaker":"The question asks","startTime":264.314,"endTime":267.514,"body":"wouldn't recommend bed rest."},{"speaker":"The question asks","startTime":267.514,"endTime":271.074,"body":"In some cases, patients"},{"speaker":"The question asks","startTime":267.514,"endTime":271.074,"body":"who are high-risk OB patients"},{"speaker":"The question asks","startTime":271.074,"endTime":272.794,"body":"may be prescribed bed rest,"},{"speaker":"The question asks","startTime":272.794,"endTime":275.364,"body":"but there's really nothing"},{"speaker":"The question asks","startTime":272.794,"endTime":275.364,"body":"that that's used for now."},{"speaker":"The question asks","startTime":275.364,"endTime":277.134,"body":"(Charlie) Alright, that's a good point."},{"speaker":"The question asks","startTime":277.134,"endTime":278.64,"body":"So, the teaching point in this case"},{"speaker":"The question asks","startTime":278.64,"endTime":282.2,"body":"is that pregnancy is, in general,"},{"speaker":"The question asks","startTime":278.64,"endTime":282.2,"body":"a hypercoagulable state,"},{"speaker":"The question asks","startTime":282.2,"endTime":284.89,"body":"and women who are pregnant"},{"speaker":"The question asks","startTime":282.2,"endTime":284.89,"body":"have increased risk of DVTs"},{"speaker":"The question asks","startTime":284.89,"endTime":287.6,"body":"because of some"},{"speaker":"The question asks","startTime":284.89,"endTime":287.6,"body":"of the anatomical considerations."},{"speaker":"The question asks","startTime":287.6,"endTime":290.68,"body":"They're more likely to occur"},{"speaker":"The question asks","startTime":287.6,"endTime":290.68,"body":"on the left side because of the anatomy."},{"speaker":"The question asks","startTime":290.681,"endTime":293.641,"body":"The treatment of choice for DVT"},{"speaker":"The question asks","startTime":290.681,"endTime":293.641,"body":"in a pregnant woman"},{"speaker":"The question asks","startTime":293.641,"endTime":297.291,"body":"is enoxaparin and unfractionated heparin"},{"speaker":"The question asks","startTime":297.291,"endTime":298.871,"body":"when getting close to delivery."},{"speaker":"The question asks","startTime":298.871,"endTime":300.831,"body":"And another important"},{"speaker":"The question asks","startTime":298.871,"endTime":300.831,"body":"teaching point in this case"},{"speaker":"The question asks","startTime":300.831,"endTime":305.091,"body":"is that in pregnant women,"},{"speaker":"The question asks","startTime":300.831,"endTime":305.091,"body":"warfarin is absolutely contraindicated."},{"speaker":"The question asks","startTime":305.091,"endTime":306.795,"body":"(Cathy) And you can read more about this"},{"speaker":"The question asks","startTime":306.795,"endTime":310.045,"body":"in \u003ci\u003eHarrison's\u003c/i\u003e chapter"},{"speaker":"The question asks","startTime":306.795,"endTime":310.045,"body":"on Medical Disorders During Pregnancy,"},{"speaker":"The question asks","startTime":310.045,"endTime":312.765,"body":"and then I'll also refer you"},{"speaker":"The question asks","startTime":310.045,"endTime":312.765,"body":"to the ATTRACT Trial"},{"speaker":"The question asks","startTime":312.765,"endTime":314.365,"body":"from \u003ci\u003eNew England Journal of Medicine\u003c/i\u003e"},{"speaker":"The question asks","startTime":314.365,"endTime":317.305,"body":"that was published December 7th, 2017."},{"speaker":"The question asks","startTime":317.305,"endTime":319.625,"body":"♪ (music) ♪"}]}