Venous thromboembolism in pregnancy

Question 1

What is VTE?

Answer 1

A collective term that describes deep vein thrombosis and pulmonary embolism

Question 2

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

Answer 2

VTE - 1/3 of maternal deaths

Question 3

Describe how pregnancy increases the risk of VTE

Answer 3

X4-5 increased risk

Changes in the levels of proteins in the clotting cascade (Increased fibrinogen and decreased protein S)

Question 4

What happens to the risk of VTE during pregnancy?

Answer 4

Increases as pregnancy progresses

Highest risk post-partum

Question 5

List the risk factors of VTE in pregnancy

Answer 5

Pre-existing factors:

• Thrombophilia
• Medical comorbidity
• Age >35
• BMI>30
• Parity >3
• Smoking
• Varicose veins
• Paraplegia

Obstetric factors:

• Multiple pregnancy
• Pre-eclampsia
• C-section
• Prolonged labour
• Preterm birth
• Stillbirth
• PPH

Transient factors:

• Surgery
• Dehydration (hyperemesis)
• Ovarian hyperstimulation syndrome
• Admission/immobility
• Systemic infection
• Long distance travel

Question 6

Describe the clinical features of DVT

Answer 6

Unilateral leg pain
Swelling
Pyrexia
Pitting oedema
Tenderness
Prominent superficial veins

Question 7

Which leg is most commonly affected by DVT in pregnant women and why?

Answer 7

Left leg - compression effect of the uterus on the left iliac vein

Question 8

Describe the clinical features of PE

Answer 8

Sudden onset dyspnoea
Pleuritic chest pain
Cough
Haemoptysis (rare)

Question 9

What signs on examination may a person with a PE have?

Answer 9

Tachycardia
Tachypnoea
Pyrexia 
Raised JVP
Pleural rub
Pleural effusion
Signs of DVT

Question 10

What are the differentials for VTE

Answer 10

DVT:

• Cellulitis
• Ruptured bakers cyst
• Superficial vein thrombophlebitis

PE:

• Acute coronary syndromes
• Aortic dissection
• Pneumonia
• Pneumothorax

Question 11

What investigations should be ordered for VTE in pregnancy?

Answer 11

FBC
U&Es
LFTs
Coagulation screen 
Compression duplex ultrasound 
ECG 
CXR
ABG
CTPA or V/Q scan

Question 12

What is a V/Q scan associated with?

Answer 12

Higher risk of childhood cancer

Question 13

Which radiation sparing investigation can be done if a woman is presenting with both DVT and PE

Answer 13

Duplex USS

Question 14

How are women with symptoms of VTE managed?

Answer 14

Low molecular weight heparin immediately until diagnosis is excluded

Question 15

How long should anticoagulation be maintained in confirmed VTE?

Answer 15

Throughout pregnancy, until 6-12 weeks post partum

Question 16

When should women omit their dose of anticoagulation?

Answer 16

24 hours before planned induction of labour or C-section

Question 17

Describe the management of VTE at term

Answer 17

IV unfractionated heparin - discontinue 6hrs before planned induction/C-section

Question 18

What type of shock may patients suffer from as a result of PE?

Answer 18

Cardiogenic

Question 19

How are patients with cardiogenic shock secondary to massive PE treated?

Answer 19

ABCDE approach

Thrombolysis - IV unfractionated heparin

Question 20

Describe VTE prophylaxis in pregnancy

Answer 20

Risk assessed early in pregnancy and repeated intrapartum and postnatal periods

Thromboprophylaxis offered if >4RF in first two trimesters, >3 RF in 3rd trimester and >2 in post-partum period

Any woman receiving thromboprophylaxis antenatally should continue >6 weeks post partum
10 day course of LMWH for all C-section women

Question 21

Which test can not be used to diagnose VTE in pregnancy and why?

Answer 21

D-dimer

Pregnancy increases this anyway