VTE in Pregnancy

Question 1

VTE in Pregnancy Pathophysiology

Answer 1

Increased venous stasis, other factors such as coagulation and fibrinolytic systems implicated

Question 2

VTE in Pregnancy Epidemiology

Answer 2

• 10 times more common in pregnant women
• Inherited thrombophilia present in 30-50% of women with pregnancy associated VTE
• 10-20% are PEs

Question 3

VTE in Pregnancy Mortality

Answer 3

• Leading cause of maternal deaths

- 62% of women with fatal VTEs die in first trimester although risk per day is greatest in weeks following delivery

Question 4

VTE in Pregnancy RFs

Answer 4

• Postpartum
• Antepartum (weak)
• Inherited
• Obesity, immobilisation, PHx, trauma, inflammatory disease, cancer, oestrogen therapy…
• Factors from pregnancy; venous stasis, maternal age>35, gestation <36, C-section, haemorrhage, pre-eclampsia, prolonged labour

Question 5

VTE in Pregnancy Presentation

Answer 5

• Similar to that of non pregnant patients

- DVT and PE presentations

Question 6

VTE in Pregnancy Differentials

Answer 6

• DVT- muscle strain, ruptured Baker’s cyst, cellulitis, superficial
• PE- extensive, rule out infection and abdominal bleed

Question 7

VTE in Pregnancy Ix

Answer 7

LMWH as soon as VTE suspected

• Suspected DVT- Urgent compression duplex ultrasound , if suspicion high but nothing on scan, repeat in 1 weeks time. If suspicion low and scan negative, discontinue treatment
• Suspected PE- CXR (to exclude pneumonia, pneumothorax) and compression USS, if normal arrange V/Q and discuss with radiologist, if normal but suspicion high, repeat in 1 week
• D-unreliable, pregnancy alters coagulation systems

Question 8

VTE in Pregnancy Management

Answer 8

• If massive and life threatening PE; urgent CTPA, immediate thrombolysis with IV UFH
• Avoid warfarin, if on warfarin switch to heparin before 7th week of conception
• In VTE use twice daily SC LMWH, start treatment before diagnosis unless strongly contraindicated
• Give treatment until diagnosis disproven
• Advise mother to stop injecting when labour starts
• Continue therapy for at least three months then reassess for ongoing risk factors

Question 9

VTE in Pregnancy Complications

Answer 9

• Thrombophilia complications; fetal loss, IUGR, HELLP syndrome
• Post-thrombotic syndrome; up to 60% of patient’s with DVT develop this, damage to lumen of the vein, signs similar to those of varicose veins
• Prolonged UFH may lead to osteoporosis

Question 10

VTE in Pregnancy Prophylaxis

Answer 10

Antenatally
-Avoid immobilisation and dehydration
-Women at high risk should be offered pre-pregnancy counselling
-All women with previous VTE should receive postpartum prophylaxis
-If previous VTE was unprovoked, idiopathic, related to oestrogen or have FHx in first degree relative or documented thrombophilia, LMWH antenatally and six weeks postpartum
-In recurrent VTE, warfarin should be switched to LMWH
Intrapartum
-Stop LMWH if contractions or PV bleeding, further anticoagulation should be given by staff
Postpartum
-Women with obesity should be considered for prophylactic LMWH
-If C-section, LMWH for seven days