VTE DVT PE in Pregnancy

Related Subjects: |Assessing Breathlessness |Pulmonary Embolism | Deep Vein Thrombosis | DVT/PE in pregnancy | CTPA

Compression ultrasonography of affected or both legs may be the best first tests as no radiation involved and if DVT seen then treatment is started.

About

• Leading cause of maternal death in the UK
• Higher risk of pelvic veins involved

Aetiology

• Six fold increased risk which continues to approximately 4-6 weeks postpartum

Risks

• Gestational age
• Emergency C-section
• Elective C- section
• First trimester presentation
• Obesity, smokers

Clinical

• DVT most are in left leg due to compression of left iliac vein
• Chest pain and dyspnoea, Increased Resp rate and Heart rate
• Syncope, PEA, Death

Differentials

• Take expert help before dismissing any new symptoms physiological.
• Cardiomyopathy, Myocarditis, Severe asthma may be seen
• Physiological Breathlessness or Asthma or Anxiety in pregnancy can mimic PE
• Oedema seen in pregnancy may mimic DVT

Investigations

• ECG : tachycardia, RVH, S1Q3T3
• Wells score not validated in pregnancy
• Dimer - unhelpful especially if positive
• CXR - in all patients can diagnose pneumonia, PTX
• Echo if compromised to show RV and pressures
• VQ scan or CT PA - usually VQ preferred if no known pulmonary disease and a normal chest radiograph but depends on local availability and radiology preference as well as urgency in making a diagnosis. CT PA can be done quickly.
• Compression ultrasonography (CUS) of the lower extremity veins may be the best first tests as no radiation involved and if DVT seen then treatment is started. If the CUS is negative and the dimer then DVT may be excluded. CUS can miss pelvic DVT.
• Thrombophilia screen

Management

• Start treatment dose LMWH immediately if significant no bleed risk and continue if confirmed diagnosis. LMWH doses are different in pregnant patients. Take haematology advice. Some patients may have thrombophilia.
• Warfarin and DOACs are avoided in pregnancy
• Consider thrombolysis if the patient is compromised. Alteplase has been used in pregnancy. Take senior advice.
• Late complications: pulmonary hypertension, post-thrombotic syndrome, and venous insufficiency.

References

• Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium