VTE in pregnancy

Question 1

Risk factors for VTE

Answer 1

Smoking
Parity > 3
Age >35 years
BMI >30
Reduced mobility
Multiple pregnancy
Gross varicose veins
Immobility
FH VTE
thrombophilia
IVF pregnancy

Question 2

RCOG guidelines when to start prophylaxis for VTE in pregnancy

Answer 2

28 weeks if there are three risk factors
First trimester if > 4 or more of these risk factors

Question 3

WHat additional scenarios is prophylaxis for VTE required in

Answer 3

Hospital admission
Surgical procesdures
Prev VTE
Medical conditions - cancer, arthritis
High risk thrombophilia
Ovarian hyperstimulation

Question 4

When are risk assessment for VTE performed in pregnancy

Answer 4

At booking
After birth

Question 5

What should women with higher risk of VTE get?

Answer 5

LMW heparin unless contraindicated

Question 6

Examples of LMWH

Answer 6

Enoxaparin
Dalteparin
Tinzaparin

Question 7

When is prophylaxis for VTE started in high risk vs v high risk pregnancies

Answer 7

V high risk - asap
high risk - 28 weeks
Continued throughout antenatal period and for 6 weeks postnatally

Question 8

When is prophylaxis against VTE stopped

Answer 8

When woman goes into labour
Started immediately after delivery UNLESS PPH, spinal anaesthetic or epidurals

Question 9

When is mechanical prophylaxis considered and what are the options

Answer 9

When LMWH contraindicated
Intermittent pneumatic compression
Anti-embolic compression stockings

Question 10

Presentation of DVT

Answer 10

Unilateral
Calf or leg swelling
Dilated superficial veins
Tenderness to the calf - particuarly over deep veins
Oedema
Colour changes to the leg

Question 11

Presentation of DVT

Answer 11

Unilateral
Calf or leg swelling
Dilated superficial veins
Tenderness to the calf - particuarly over deep veins
Oedema
Colour changes to the leg

Question 12

How to measure leg swelling

Answer 12

Measure the cirucmference of the calf 10cm below tibial tuberosity
>3cm difference between calves is significant

Question 13

Presentation of PE

Answer 13

SOB
Cough with or without blood
Pleuritic chest pain
ypoxiaH
Tachycardia
Raised resp rate
Low grade fever
Haemodynamic instability causing hypotension

Question 14

Investigation for DVT

Answer 14

Doppler US
Guideline - repeat negative US scans on day 3 and 7 in patients with high index suspicion for DVT

Question 15

What investigations do women w sus PE need

Answer 15

CXR
ECG

Question 16

Options for definitive diagnosis of PE

Answer 16

CTPA
VQ scan

Question 17

CTPA vs VQ scan

Answer 17

• CTPA is the test for choice for patients with an abnormal chest xray
• CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk)
• VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk)

Question 18

What normal measures are not useful in VTE in pregnant women

Answer 18

Wells score not validated
D-dimers not helpful

Question 19

What is a VQ scan

Answer 19

involves using radioactive isotopes and a gamma camera, to compare the ventilation with the perfusion of the lungs. First, the isotopes are inhaled to fill the lungs, and a picture is taken to demonstrate ventilation. Next, a contrast containing isotopes is injected, and a picture is taken to demonstrate perfusion. The two images are compared. With a pulmonary embolism, there will be a deficit in perfusion, as the thrombus blocks blood flow to the lung tissue. This area of lung tissue will be ventilated but not perfused.

Question 20

When should LMWH be started if VTE suspected

Answer 20

AS soon as suspected - dont wait for diagnosis

Question 21

How long is LMWH continued for

Answer 21

Remainder of pregnancy
Six weeks postnatally or 3 months total - whichevers longer
Can switch to a DOAC after delivery

Question 22

Treatment for massive PE and haemodynamic compromise

Answer 22

Unfractionated heparin
Thrombolysis
Surgical embolectomyy

Question 23

W