VTE in pregnancy

Question 1

Risk factors for VTE in pregnancy

Answer 1

• Smoking
• Parity ≥ 3
• Age > 35 years
• BMI > 30
• Reduced mobility
• Multiple pregnancy
• Pre-eclampsia
• Gross varicose veins
• Immobility
• Family history of VTE
• Thrombophilia
• IVF pregnancy

Question 2

When should VTE prophylaxis be started in pregnancy

Answer 2

• 28 weeks if 3 risk factors
• 1st trimester if ≥4 risk factors

Question 3

When may VTE prophylaxis be given in the absence of risk factors?

Answer 3

• Hospital admission
• Surgical procedures
• Previous VTE
• Medical conditions such as cancer or arthritis
• High-risk thrombophilias
• Ovarian hyperstimulation syndrome

Question 4

When is VTE risk assessed in pregnancy

Answer 4

Booking appointment

Question 5

What is used for VTE prophylaxis in pregnancy

Answer 5

LMWH (E.g. Dalteparin)

Question 6

VTE prophylaxis in those in whom LMWH is contraindicated

Answer 6

Intermittent pneumatic compression
Anti-embolic compression stockings

Question 7

When is VTE prophylaxis temporarily stopped in pregnancy

Answer 7

During labour

Question 8

Presentation of DVT

Answer 8

• Calf or leg swelling
• Dilated superficial veins
• Tenderness to the calf (particularly over the deep veins)
• Oedema
• Colour changes to the leg

Question 9

Presentation of PE

Answer 9

• Shortness of breath
• Cough with or without blood (haemoptysis)
• Pleuritic chest pain
• Hypoxia
• Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy)
• Raised respiratory rate
• Low-grade fever
• Haemodynamic instability causing hypotension

Question 10

Investigations in DTV

Answer 10

Doppler ultrasound

Question 11

Investigations for PE

Answer 11

CXR
ECG
CTPA or VQ scan

Question 12

What is involved in CTPA

Answer 12

chest CT scan with anintravenous contrastthat highlights the pulmonary arteries to demonstrate any blood clots.

Question 13

What is involved in VQ scanning

Answer 13

radioactive isotopesand agamma camera,to compare the ventilation with theperfusionof the lungs. First, the isotopes areinhaledto fill the lungs, and a picture is taken to demonstrateventilation.

Next, a contrast containing isotopes isinjected, and a picture is taken to demonstrateperfusion. The two images are compared. With a pulmonary embolism, there will be a deficit inperfusion, as the thrombus blocks blood flow to the lung tissue. This area of lung tissue will beventilatedbutnotperfused.

Question 14

Management of VTE in pregnancy

Answer 14

LMWH during pregnancy and 6 weeks after

Question 15

Management of massive PE with haemodynamic compromise

Answer 15

• Unfractionated heparin
• Thrombolysis
• Surgical embolectomy