Thromboembolism in pregnancy

Question 1

What are 2 types of thromboembolism?

Answer 1

DVT: Blood clot in deep veins, usually leg

PE: Distal spread of thrombus into lung

Question 2

What is the significance of previous VTE in a pregnant woman?

Answer 2

Immediately considered high risk
Start on LMWH

Question 3

List 9 pre-existing risk factors for VTE in pregnancy

Answer 3

Previous VTE
Thrombophilia
Age > 35
BMI > 30
Parity > 3
Smoker
Gross varicose veins
Immobility
FH of unprovoked VTE

Question 4

List 6 obstetric risk factors for VTE in pregnancy/ postpartum

Answer 4

Multiple pregnancy
IVF pregnancy
Current pre-eclampsia
C section
Prolonged labour >24h
PPH

Question 5

Give 3 transient risk factors for VTE in pregnancy/ postpartum

Answer 5

Long haul travel
Admission/ immobility e.g. Pelvic girdle pain
Hyperemesis + dehydration

Question 6

What criteria indicates initiation of LMWH in pregnancy?

Answer 6

> ,4 RFs: immediate LMWH continued until 6w postnatal.

3 RFs: LMWH from 28w + continued until 6w postnatal

Question 7

When is the highest risk of VTE in pregnancy?

Answer 7

Postnatal

Question 8

What is the leading direct cause of maternal mortality in the UK?

Answer 8

PE

Question 9

Give 4 signs and symptoms of DVT in pregnancy

Answer 9

Leg pain + discomfort (left more common)
Leg swelling, tenderness + oedema
Increased temperature
Raised WCC

Question 10

Give 5 signs and symptoms of PE in pregnancy

Answer 10

Dyspnoea
Pleuritic chest pain
Haemoptysis
Faintness/ collapse.
+/- Sx or signs of a DVT.

Question 11

Give 4 measurable signs of PE on examination

Answer 11

Tachypnoea
Raised JVP
ECG changes.
ABG: respiratory alkalosis and hypoxaemia.

Question 12

How should women with suspected VTE be managed?

Answer 12

Immediate referral to hospital
Start LMWH until dx excluded with imaging

Question 13

What investigations are required for suspected DVT in pregnancy?

Answer 13

Compression duplex USS

If -ve + low clinical suspicion, anticoagulant Tx can be discontinued.

If -ve + high clinical suspicion, anticoagulant Tx should be discontinued but USS repeated on days 3 + 7

Question 14

What management other than LMWH can be used in women with DVT?

Answer 14

Leg elevation
Compression stockings
Keep active

Question 15

What investigations should be performed in suspected PE?

Answer 15

ECG (T wave inversion) + CXR

If also Sx/ signs DVT:
Compression duplex USS. If +ve no further Ix required. Tx should continue

If no Sx/ signs of DVT: CTPA or V/Q scanning

Question 16

Give 3 advantages of CTPA

Answer 16

More readily available
Lower radiation risk to foetus
Can identify other pathology e.g. pulmonary oedema, pneumonia

Question 17

What is the main disadvantage of CTPA?

Answer 17

Increased risk maternal breast cancer

Question 18

What is the main disadvantage of V/Q scanning?

Answer 18

Increased risk of childhood cancer

Question 19

What test should NOT be performed in VTE in pregnancy?

Answer 19

D-dimer
D-dimer rises progressively through pregnancy with advancing gestation

Question 20

Are pretest probability scores indicated in VTE in pregnancy?

Answer 20

No evidence to support use of Wells score

(Wells score used in non-pregnant)

Question 21

What bloods should be taken before initiating anticoagulant therapy?

Answer 21

FBC
Coagulation screen
U+Es
LFTs

Question 22

What are the risks of LMWH in pregnancy?

Answer 22

heparin does NOT cross the placenta + can’t harm baby
No increased risk of severe PPH
Bruising at site of injection

Question 23

For what duration must LMWH be taken in pregnancy from VTE event?

Answer 23

For the rest of the pregnancy + >,6w after birth, until at least 3/12 tx has been given in total

Question 24

How does LMWH affect birth plans?

Answer 24

If go into labour, cannot have epidural if within 24h of last LMWH (but there is alternate pain relief)

If plan is to induce labour/ C section stop LMWH 24h before. LMWH will be restarted within 4h

Emergency CS: GA if last LMWH <24h

Question 25

What is the aetiology of thromboembolism in pregnancy?

Answer 25

Virchows triad: Injury, stasis, hypercoaguablity.

Commonly deep veins of leg and pelvis and embolises to pulmonary vasculature. Pregnancy is procoagulant.

Question 26

What are risk factors of thromboembolism in pregnancy?

Answer 26

General: Maternal age, thrombophilia, obesity, personal/FHx, msmoking immobility.

Pregnancy: C-section, instrumental, infection, PREC, multiple, HEG/dehydration.

Question 27

What is the management of thromboembolism in pregnancy?

Answer 27

Prevent: Movement, evaluate thromboprophylaxis, compression stockings, LMWH.

Treat: LMWH, initiate even only on clinical suspicion. Continue for rest of pregnanct and discontinue on labor initiaiton. Continua 6/52 postnatal.

Massive PE: ABC, MDT management, IV unfracHep. Early thrombolysis, thoracotomy or surgical embolectomy.