Breathlessness

Question 1

What are the causes of breathlessness in pregnancy

Answer 1

Physiological
Thrombosis: VTE, DVT, amniotic fluid embolism
Pulmonary oedema: cardiomyopathy, pre-eclampsia, cardiac disease, HF
Haemorrhage: placental abruption, placenta praevia
Asthma exacerbation
Aortic dissection

Question 2

What investigations should be done for breathlessness

Answer 2

A-E
Bedside: urine pregnancy, peak flow, ECG
Bloods: beta-hCG, FBC, G&S, cross match, Rh status, CRP/ESR
Other: TVUS, CTG, CXR, V/Q, CTPA

Question 3

What is amniotic fluid embolism and what are the risk factors

Answer 3

Amniotic fluid enters the maternal circulation, leading to cardiorespiratory collapse and DIC. (Amniotic fluid is recognised as a foreign body, leading to vasodilation and inflammatory response)

RF:
- Before, during or shortly after birth, which may be vaginal or caesarean
- Amniocentesis
- Rupture of membranes
- D&C
- Termination

Question 4

What is the epidemiology for amniotic fluid embolism

Answer 4

Rare - 1/50,000 pregnancies
Mortality 20%
Accounts for 7-10% of maternal deaths

Question 5

What are the symptoms of amniotic fluid embolism

Answer 5

Triad of:
1. Hypoxia
2. Hypotension or haemodynamic collapse
3. Coagulopathy

Acute foetal compromise
SOB
Numbness
Maternal haemorrhage
Hypotension
Coagulopathy

Question 6

What is the management for amniotic fluid embolism

Answer 6

Management: Supportive, cannot be reversed
1. Anticipate possible cardiopulmonary arrest and emergent C-section
2. Place patient in left uterine displacement (LUD)
3. Establish IV access (large volume lines)
4. Support circulation with IV fluid, vasopressors, and inotropes
5. Prepare for emergent intubation
6. When possible, place arterial line. Consider central venous access
7. Anticipate massive haemorrhage and DIC. Go to haemorrhage/MTG
8. Consider circulatory support: IABP/ECMO/CBP

Question 7

What are the symptoms and signs of DVT

Answer 7

Red, hot, swollen tender calf
Unilateral lower limb oedema
Erythema
Tenderness
Low grade pyrexia

Question 8

What are the symptoms and signs of PE

Answer 8

Pleuritic chest pain
Dyspnoea
Cough
Haemoptysis
Tachycardia
Tachypnoea
Low-grade pyrexia
Reduced O2 saturations
Cardiorespiratory collapse
Chest signs (reduced air entry, crepitations)
Loud P2 sound

Question 9

What investigations should be done for thromboembolism in pregnancy

Answer 9

CTPA (higher breast dose) > V/Q (higher baby dose)

Bedside: ECG (S1Q3T3)

Bloods: FBC, ABG, U&Es, LFTs, coagulation

Other
- Doppler USS legs
- CXR (If doppler -ve)
- CTPA (if CXR abnormal)
- Echo (if unstable)
- V/Q scan (Doppler and CXR normal)
- Venography

Stable
1. Doppler USS legs
- Doppler +ve: start LMWH
- Doppler -ve: CXR
2. CXR
- CXR normal: V/Q scan
- CXR abnormal: CTPA
3. V/Q scan
- V/Q scan +ve: Start LMWH
- V/Q scan -ve: CTPA
4. CTPA
- CTPA +ve: thrombolysis, start LMWH
- CTPA -ve: stop anticoagulation

Unstable
Portable echo

Question 10

What is the treatment for DVT in pregnancy

Answer 10

LMWH + elevate leg + graduated elastic stockings
Compression duplex US
→ negative with low suspicion → stop anticoagulants
→ negative with high suspicion → stop anticoagulants and repeat US days 3 and 7

Extremes of weight (<50,>90) → monitor anti-Xa levels

+ maintenance treatment: SC LMWH until 6 weeks postnatally + >3 months treatment (can breastfeed)

Question 11

What is the treatment for PE in pregnancy

Answer 11

LMWH e.g. enoxaparin SC
Massive → IV unfractionated heparin (+ monitoring with APTT) (2) thrombolytic therapy/thoracotomy/surgical embolectomy

+ maintenance treatment: SC LMWH until 6 weeks postnatally + >3 months treatment (can breastfeed)

Question 12

What is the management for VTE during delivery

Answer 12

IV unfractionated heparin
Already on LMWH maintenance treatment → do NOT inject any more if they go into labour
If delivery is planned, LMWH should be discontinued 24 hours before
Anaesthetics:
- Epidural not given until at ≥24 hours after last dose of LMWH
- LMWH not be given until 4 hours after the epidural catheter has been removed

Question 13

What are the reversal agents for anticoagulants in pregnancy

Answer 13

Unfractionated heparin (IV) → protamine sulphate
LMWH (SC) → irreversible (stop 24 hours before delivery)

Question 14

How is VTE prevented in pregnancy

Answer 14

Consider prolonged use of LMWH >12 weeks and graduated compression stockings

Based on number of risk factors
>4 factors OR VTE event → LMWh from 12w until 10 days/6 weeks post-partum
3 RFs → from 28w until 10 days post-partum
<3 risk factors → conservative

Question 15

What are the antenatal risk factors for VTE

Answer 15

Major: Any previous VTE (except single event related to major surgery) → requires prophylaxis
Intermediate: hospital admission, single VTE related to major surgery, high-risk thrombophilia, co-morbidities (cancer, HF, SLE, IBD), surgical procedures
minor:
- Obesity >30 BMI
- Age >35
- Smoker
- Parity >3
- Gross varicose veins
- Current PET
- Immobility (paraplegia, PGP)
- FHx unprovoked VTE
- Low risk thrombophilia
- Multiple pregnancy
IVF/ART

Question 16

What are the risk factors for VTE postpartum

Answer 16

Major: any previous VTE, antenatal LMWH use. high risk thrombophilia
Intermediate: C-section, BMI >40, readmission/prolonged admission (>3 days), surgical procedure in the puerperium (NOT perineal repair), medical co-morbidities
Minor: same as antenatal + stillbirth, preterm delivery, prolonged labour, PPH >1L