Thromboembolism in Pregnancy Flashcards
When should VTE be treated?
Any signs or symptoms suggestive of VTE → objective testing and treatment with LMWH
What is the aetiology of VTE in pregnancy?
- Pregnancy tilts you into a pro-coagulant state
- Higher: F7, F8, VWF, PAI-1, PAI-2, fibrinogen
- Lower: Protein S
- Virchow’s triad – endothelial injury, hypercoagulable state, stasis
What are the signs and symptoms of DVT?
- Red, hot, swollen tender calf
- Unilateral lower limb oedema
- Erythema
- Tenderness
- Low grade pyrexia
What are the signs and symptoms of PE?
- 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
What are the the appropriate investigations for suspected DVT?
Duplex USS
What investigation normally done for VTE should not be done in pregnancy?
-
D-dimer
- Naturally elevated in pregnancy so cannot be used to exclude
What are the appropriate investigations for suspected PE in pregnancy?
-
General
- ABG = hypoxia or hypercapnia
- ECG = sinus tachycardia or S1Q3T3
-
Imaging
- CXR
- Duplex USS
- If both negative → do V/Q or CTPA
- CTPA (higher breast dose) > V/Q scan (higher baby dose)
-
Bloods – before anticoagulation
- FBC
- U&Es
- LFTs
- Clotting
What is the immediate management of DVT in pregnancy?
-
LMWH + elevate leg and apply graduated elastic stockings
- Monitor treatment with anti-Xa levels in women of extreme weight (<50kg, >90kg) or if complicating factors (i.e. renal impairment or recurrent VTE)
-
Compression duplex ultrasound if clinical suspicion of DVT
- If -ve and low clinical suspicion → stop anticoagulants
- If -ve and high clinical suspicion → stop anticoagulants and repeat USS on days 3 and 7
What is the immediate management of a minor PE in pregnancy?
- LMWH (SC, BD, 1mg/kg; i.e. enoxaparin)
-
ECG + CXR
- If CXR abnormal and clinical suspicion of PE → CTPA
- Suspected DVT + PE → compression duplex USS
- If no DVT suspected with PE → VQ scan or CTPA
- If CXR abnormal and clinical suspicion of PE → CTPA
- Repeat testing if VQ scan and CTPA normal, but clinical suspicion of PE remains
- Anticoagulant treatment should be continued until PE is definitively excluded
What is the immediate management of a massive PE in pregnancy?
- 1st line = IV unfractionated heparin (monitor with APTT)
- 2nd line = thrombolytic therapy, thoracotomy or surgical embolectomy
Which sinus is most commonly affected in central venous sinus thrombosis in pregnancy?
Sagittal sinus
What are the signs and symptoms of central venous sinus thrombosis?
- Headache
- Varying neurology
What are the appropriate investigations for suspected central venous sinus thrombosis?
MRI
- CT can be first done to exclude stroke etc
What is the management of a central venous sinus thrombosis in pregnancy?
- IV unfractionated heparin → thrombolysis → 3-6m anticoagulation
What is the maintenance management of VTE in pregnancy?
-
Subcutaneous LMWH
- Until at least 6 weeks postnatally and/or ≥3 months of treatment
- Breastfeeding is fine
- 2nd line = oral anticoagulants (requires routine INR monitoring)
- SEs = heparin-induced thrombocytopaenia, heparin allergy
How is delivery managed in patients with VTE?
- If VTE at term = IV unfractionated heparin
- If on LMWH maintenance treatment = no more injections 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 epidural catheter removal
How is VTE prevented in at risk patients?
- Prevention at 12w booking
- Prolonged use of LMWH (>12 weeks)
- Graduated elastic compression stockings
- LMWH + stockings will be based on
- ≥4 risk factors or VTE event = 12w until 10 days to 6 weeks post-partum
- 3 risk factors = 28w until 10 days post-partum
- <3 risk factors = conservative
