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Essay 298 - DVT

Essay 298 - DVT Posted by PAUL A.
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].
Posted by DARE A.
A. Initial assessment involves taking detailed history, performing focused physical examination and investigation. Most likely diagnoses include deep vein thrombosis (DVT), cellulites, trauma and ruptured Baker’s cyst. Pregnancy, previous DVT, pulmonary embolism, with a swollen leg suggests DVT. Fever, feeling unwell with increasing pain and swelling suggest cellulites. Whereas, history of trauma with bruises, not weight bearing suggest trauma. Sudden onset of pain and swelling in the leg with history of rheumatoid arthritis suggest ruptured Baker’s cyst.
History should include onset of pain, radiation, progression and associated factors such as chest pain and shortness of breath which may suggest pulmonary embolism. Prolonged bed rest, varicose veins, recent surgery and smoking with family history of DVT and PE in first or second relative are risk factors for DVT and if present, will make the diagnosis probable.
High temperature, tachycardia, a tender and red leg suggest infective cause. However, a tender, pitting leg which is 3cm or more compared to the contra-lateral leg suggests DVT. Bruises on the affected leg with other bodily injuries will support trauma. Abdominal examination should involve the fundal height, lie and foetal heart tone to assess foetal wellbeing.
Baseline full blood count (FBC), renal, liver and clotting screen should be performed as she may need anticoagulant therapy. White blood cells and C - reactive protein should be performed and if raised, will support infective cause. A compression duplex ultrasound of both legs should be requested and if it shows occlusion of left calf vein will confirm the diagnosis of DVT. If negative, it should be repeated in one week. Electrocardiogram, arterial blood gases and spiral CT scan may be necessary if symptoms are suggestive of pulmonary embolism.

B. Antenatal care should be hospital based, joint clinic with Haenatologist, and low molecular weight heparin e.g. clexane 1-1.5mg should be started as soon as possible. This should be continued for 3 months from the diagnosis or till six weeks postpartum. She should be encouraged to ambulate, elevate the leg and wear compression stockings to reduce oedema. Warfarin is relatively contraindicated as it may cause both foetal and neonatal bleeding problems. Detailed counselling must be supported by relevant leaflets.
Patient should be seen regularly; routine FBC and activated factor X not necessary. She should omit the next dose of clexane if she labour begins, 24 hours before induction of labour or scheduled abdominal delivery. Spontaneous vaginal delivery is favoured; caesarean section is for obstetric reasons. No contraindication to oxytocin in labour. Epidural anaesthesia should be delayed till 24 hours after the last dose and the catheter should be removed more than 4 hours after the last dose. Third stage should be managed actively. Clexane should be restarted 2 hours after delivery provided there is no continuous vaginal bleeding.
Posted by Sameena M.
OBTAIN HISTORY OF ANY PERSONAL OR FAMILY HISTORY OF dvt OR KNOWN THOMBOPHILIA.ANY HISTORY OF RECENT LONG HAULT TRAVEL,DEHYDRATION,IMMOBILISATION(Eg,HOSPITALISATION).ANY MEDICAL HISTIORY LIKE MYLOPROLIFERATIVE DISEASES,ULCERATIVE COLITES,SICKLE CELL ANEMIA ETC.
ASK FOR SYMPTOMS OF PE LIKE CHEST PAIN ,SOB,COUGH.CHECK VITAL SIGNS.
EXAMINE BOTH LEGS FOR TENDERNESS SWELLING TEMPERATURE,PRESENCE OF VARICOUS VEINS.
INITIAL DIAGONOSIS IS DVT.
START TREATMENT FOR DVT WHILE WAITING FOR CONFIRMATION BECAUSE IT IS ASSOCIATED WITH HIGH MATERNAL MORBIDITY AND MORTALITY.
START ON THERAPEUTIC DOSE OF HEPARIN -LMWH OR UNFRACTIONATED- DEPENDING ON UNIT PROTOCAL.ONE OF THE COMMONLY USED REGIEMS IS IMG/KG BD OF LMWH.IT IS LESS LIKELY TO CAUSE OSTEOPOROSIS AND THOMBOCYTOPENIA.START TEDS STOCKINGS.SEND BLOOD FOR FBC,U&ES ,LFTS,CLOTTING AND THOMBOPHILIA SCREENING .BE AWARE OF THE EFFECT OF PREGNANCY ON THOMBOPHILIA SCREENING.REQUEST HEMATOLOGIST TO INTERPRET RESULTS.REQUEST FOR AN URGENT COMPRESSION DUPLEX DOPPLER SCAN OF BOTH LEGS.
ONCE THE DIAGNOSIS IS CONFIRMED CONTINUE THERAPEUTIC DOSE OF LMWH AND TEDS THOUGHOUT PREGNANCU AND 6-12 WEEKS POSTPARTUM.THE PLAN SHOULD BE REVIEWED BY HAEMATOLOGIST.
TEACH PATIENT TO DO INJECTIONS AND SAFE DISPOSAL OF NEEDLES .
ASK HER TO STOP INJ AS SOON AS SHE THINKS SHE IS IN LABOUR.
GIVE HER DATE FOR IOL AT 39 WEEKS.
STOP LMWH 24 HRS BEFORE INDUCTION OF LABOUR.GIVE HER EITHER NO HEPARIN OR THERAPEUTIC DOSES FOR THE PERIOD ON INTRAPARTUM-DECISION TO BE MADE IN CONSULTATION WITH HAEMOTOLOGIST.
REGIONAL BLOCK CAN BE GIVEN 24 HRS AFTER THERAPEUTIC DOSE AND 12 HRS AFTER PROPHYLATIC DOSE OF LMWH.
GIVE PROPHYLACTIC DOSE 4 HRS AFTER SITING EPIDURAL AND RESTART THERAPEUTIC DOSE ON THE EVENING OF DELIVERY.
AVOID DEHYDRATION AND TRY TO MOBILISE ASAP.
POST NATALLY THERE IS A CHOICE OF EITHER CONTINUING WITH HEPARIN OR TAKING WARFARIN.BOTH ARE SAFE FOR BREST FEEDING.
GIVE ADVICE ABOUT CONTRACEPTION BEFORE DISCHARGE.NEEDS TO AVOID HARMONAL CONTRACEPTIVES.
ASK TO USE TEDS IN THE EFFECTED LEG FOR 2 YEARS TO PREVENT POST THOMBOPHELIBITIC SYNDROME.
ADVISE THAT SHE WILL NEED THOMBOPROPHYLAXIC IN NEXT PREGNANCY
Posted by Johnson  O.
A/
Venous thromboembolism[VTE] is the leading cause of direct maternal death in UK. There should be high suspcious in pregnant women with leg pain.
I would take detailed history, pain involving calf, thigh or any associated backache. I would ask about any pain or swelling on the right leg. Any history of chest pain, cough, breathlessness which may suggest Pulmonary embolism. Previuos history of venous thromboembolism. I would ask about family history of thromboembolism. Life style habit like cigarette smoking or sedentary life stlye. I would ask about mode of deliveries of all her children.
Examination would include her height, weight and BMI. I would check her blood pressure, pulse, temperature and Oxygen saturation. I would examine her left leg for swelling, reddness and tenderness. It is important to compare both legs with tape measurement. Abdominal examination for any tenderness. Fundal height and fetal heart heart rate.
With Unilateral leg swelling and pain in a pregnant woman, my impression would be Deep vein thrombosis until proven otherwise. Therefore, I will commence therapeutic dose of Low molecular weight heparin while waiting for investigation. Enoxaparin 1mg/Kg twice daily subcut. It is important to do basic blood investigation of Full blood count, Liver function test and Urea and electrolyte because, the level can change with treatment.
I would arrange for Ultrasound Doppler of affected leg. If it comes back as negative and there is still high suspicion, I will continue with the treatment and repeat Doppler in a week.
B/
I would inform her the diagnosis in a sympathetic way, as this may generate anxiety. Multidisciplinary team in her management, involving Senior Obstetrician, haematologist, Physician, Anaesthetist. I would follow the Unit protocol in her management.
She would be on therapeutic dose of Low molecular weight heparin throughout pregnancy and up to minimum of 6weeks postpartum. She would be thought how to inject herself, and disposal of needles. Platelet count would be measured a week after start of treatment because of risk of thromboctopenia.
I would arrange anaesthetic review. I would recommend Thromboembolic detereant[TED] stocking. It is important to avoid immobilization and dehydration.
She would be informed to come to hospital if she develop symptoms of Pulmonary embolism which include cough, chest pain, breathlessness, haemoptysis. Clear management plan in her notes. I would provide her with information leaflet.
I would plan her delivery for 38-39 weeks gestation, by Inductionof labour, to aim for vagina delivery. Caeserean section only for obstetric indication. I would inform her to stop her injection once she noticed she is in labour. The injection would be stopped 24hours before the planned delivery. Omit the morning dose on the day of planned delivery. I would encourage mobilisation and hydration during labour.
There is risk of Post partum haemorrhage, I would take blood for Full blood count, Group and save. Active management of 3rd stage of labour. If she require Ceaserean section, I would insert abdominal and wound drain for any bleeding. I would use Staples or interupted stitches on the skin
The prophylactic dose of heparin would be given 3hours after delivery or 4hours after insertion or removal of epidural catheter, and the therapeutic dose later in the day. Epidural catheter would not be inserted or removed within 12 hours of the injection.
Posted by Sophia Y.
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks].

Pregnancy is a risk factor for deep vein thrombosis (DVT). Complications include pulmonary embolism (PE) & death. Therefore DVT needs to be excluded in pregnant women with swelling & pain in leg.

I will ask her the nature of pain in her leg, site of pain, radiation, precipitating and relieving factors. I will also ask her exclude other causes of unilateral leg pain & swelling such as trauma, infection or thrombophlebitis. I will ask how it has affected her movement. I will ask her any chest symptoms to exclude a PE - pleuritic chest pain & short of breath. I need to ask her any personal history or strong family history of thrombophilia such as Factor V leiden deficiency, anti-thrombin III deficiency. I will ask about family history of DVT or PE. I will ask her if she smokes or recent long haul flight travel.

On examination, i will check her body mass index as high BMI (more than 30) is associated with increasing risk of venous thromboembolism (VTE). I need to exclude signs of PE - unwell, tachycardia, reduced oxygen saturation, reduced air entry on auscultation. I will examine both of legs, checking for varicose veins, measure the diameter where the painful swollen left leg & compare to the healthy right leg. I will examine the left leg for fever, erythematous & tenderness.

I will start her on therapeutic low molecular weight heparin before confirmation of DVT and pain-relief for her leg - paracetamol. Duplex doppler ultrasound of leg is the investigation of choice. Renal & liver function, full blood count (to exclude thrombocytopenia) are needed before commencing heparin treatment. D-Dimer is not required as it is positive during pregnancy. Negative value however can exclude DVT. Thrombophilia screen should not be requested unless result is interpreted by experienced haematologists.

(b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].

I will counsel her about the diagnosis & its implications with written information. She needs to commence on subcutaenous therapeutic low molecular weight heparin eg clexane 1mg/kg twice a day based on her booking weight until at least 6 weeks postpartum. She or her family should be taught how to do the injection & provide sharps disposable box. She should also wear compression stockings & elevate her left leg which may reduce the swelling. She should be counselled against side effects of clexane including very low risk of thrombocytopenia & skin allergy. Regular monitor of anti-Xa level is not required. She should also be advised to watch out signs of PE. She should be seen by consultant anaesthetist at 34 weeks to discuss about mode of pain relief in labour & when to stop clexane in relation to regional anaesthesia.

She should be advised to stop low molecular weight heparin once she thinks that she is in labour. Alternatively, if she is going for elective caesarean section or induction of labour, she should omit the therapeutic dose the day. Consultant obstetrician, anaesthetist and haematologist should be informed delivery at the day of delivery. Regional anaesthesia should be avoided at least 12 hours before last dose of heparin. Thrombocytopenia & prolonged clotting should be excluded before insertion of spinal or epidural anaesthesia. Regional anaesthesia is contra-indicated if platelet is less than 80. In addition, it should be done by experienced anaesthetist. She should be warned about risk of spinal haematoma. She should have active management of third stage to minimise risk of postpartum haemorrhage. If she has a caesarean section, a drain should be considered to be left in pelvic cavity.
Posted by Ron C.
RnRn

A.
A history revealing risk factors like long-haul travel, immobilization, dehydration, varicous veins of legs or more specific, personal or family history of DVT/thrombophilia all point to deep vein thrombosis (DVT) as likely cause. If accompanied by additional symptoms like dyspnoe / chest pain, pulmonary embolism may be present as well. Recent trauma, especially combined with chronic venous insufficiency and/or diabetes could point to erysipelas/cellulitis as alternative diagnosis. Temperature, blood pressure & pulse rate are assessed. A warm, swollen and tender leg on palpation on only one side is suggestive for DVT. Homan’s sign is not very reliable, pulse of tibial or popliteal artery may not be felt. A circumscript eryhtematous lesion, possibly with a small wound, is more suggestive for erysipelas/ cellulitis. Especially in dyspnoe, pulmonary auscultation and assessment of jugular vein are important to identify possible pulmonary embolism. Full blood count and coagulation are done as baseline in case anti-coagulation is needed, and white-blood count & CRP may be raised in infection. D-dimeres are often false-positive in pregnancy and thus not useful. Doppler flow of legs can identify a DVT, but DVT high in upper leg or pelvis may be missed, and even in negative findings treatment will start nevertheless if high suspicion. Cellulites will be treated with flucloxacilline 500 mg qid for 1 week.

B.
Immediate treatment starts with TED-stockings for both legs and LMWH such as subcutaneous Fragmin 100 iu/kg bd. It will be continued throughout pregnancy till at least 6 weeks pregnancy. Mother must be assured it won’t affect the fetus. She needs to be instructed on importance of compliance and its use at home and provided with means to dispose of needles. Routine bloods for anti-factor Xa levels is only needed at extremes of weight. Full blood count after 2 days can show thrombopenia, though this is rare as side-effect of fragmin. Osteoporosis due to fragmin is minimal and readily reversible. Warfarine may be used after initial stage, but must be switched back to fragmin by 36 weeks. If onset of labour starts earlier, it will take too long to revert its action. Warfarine’s risks are fetal intra-cerebral bleed, retroplacental bleed and antepartum hemorrhage and mental retardation and stillbirth are more common.
The fragmin must be omitted as soon as signs of labour onset present (or evening before induction of labour) as it may cause post-partum hemorrhage and interfere with possible epidural use. If stopped too late, protamine-sulphate may partially reverse its action. Third stage must be managed actively with i.m. syntometrine and oxytocine 40 iu as i.v. drip over 4 hours. Fragmin can be re-started 2 hours post-delivery, but not earlier than 2 hours after removal of epidural if present. Warfarine may be initiated at the same time to replace fragmin once INR
Posted by Mohamed A.
a)

Advanced maternal age and high parity are important risk factors for the development of VTE. I highly suspect DVT so I’ll start by asking about other risk factors for DVT including history of previous DVT, known thrombophilias, prolonged immobilization (bed rest for more than 4 days), recent long haul travel, if she is suffering from renal disorders (nephritic syndrome), malignancies or underwent major surgery (eg orthopedic surgery). I will inquire about other causes of limb pain for example trauma , muscle strain rapidly developing pain and swelling together with warm and tender limb may indicate superficial thrombophlebitis. I will ask about symptoms suggestive of PE as chest pain, dyspnoea, haemoptysis and faintness.

Initial assessment should include assessment of weight and BMI, measuring blood pressure pulse rate and temperature. Lower limb examination for gross varicose veins, bruises, redness, warmth and palpable superficial veins may denote superficial thrombophlebitis.

As there is high clinical suspicion of DVT my initial investigation will include compression duplex ultrasound ( after initiating treatment with LMWH) if ultrasound is negative and there is low level of suspicion I will stop LMWH. If ultrasound is negative and there is a high level of suspicion I will continue LMWH and repeat test after 1 week.

Base line tests that should be done before initiating treatment will include full blood count, coagulation screen, urea and electrolytes and liver function tests. Controversial to perform thrombophilia screen as this will not affect management and results my be affected by pregnancy.

Chest X-ray should be performed if suspected pulmonary embolism.

D-dimers is not recommended in pregnancy, however low levels my exclude VTE.

b)
Based upon agreed protocol for diagnosing and management VTE, physicians, haematologists and radiologists may be involved. Patient should be properly counseled and therapy initiated.

Initial therapeutic approach should include leg elevation, graduated elastic compression stockings should be applied and mobilization with the stockings should be encouraged.

I will start therapeutic subcutaneous LMWH enoxaparin 1mg /kg twice daily or dalteparin 100units/kg twice daily or tenzaparin 175 units/kg once daily.

Treatment with therapeutic doses of LMWH should be continued to the rest of pregnancy. She should be instructed how to use and dispose needles. Routine monitoring of peak anti Xa (peak anti-Xa, 3 hours after injection, of 0.5–1.2 units/ml)
is not recommended except in patients >90 kg or <50 kg or those with renal impairment or recurrent DVT.

I will advise her to have no further injections of LMWH whenever she thinks she is in labour. LMWH should be stopped 24 hours before planned delivery. Regional anesthesia should not be undertaken until at least 24 hours after last LMWH dose.

Active management of third stage is recommended, as well as group and save for the risk of postpartum bleeding. Drains might be considered after c.section and skin closure using stapler or interrupted sutures

Thromboprophylactic dose of LMWH, enoxaparin 40 mg or deltaparin 500 IU or Tinzaparin 75u/kg should be given 3 hours after cesarean section or 4 hours after removal of epidural catheter. And epidural catheter should be removed at least 12 hours after last injection.



Posted by Ajith S.
A-I would take more detail history regarding calf swelling, associated calf pain, onset of pain whether it is sudden or gradual , any colour change in skin, high temperature, any chest discomfort, palpitation, shortness of breath , history of varicose veins , similar episodes in the past specially DVT in past pregnancies, family history of DVT and any Clotting disorders like SLE ,Thrombophillias .I will ask any resent immobilisation like long duration flight .As DVT and PE has very high maternal motility and morbidity i will start treatment as soon as possible by I would like examine, I will check BMI , look for any signs of respiratory distress like, Saturation , High RR, Tachycardia, cyanosis, and look for localized evidence of DVT –calf tenderness, distended superficial veins ,Hoffman’s sings swelling –measure diameter compare with other calf, evidence of varicosities and cellulites like redness and enlarge lymph nodes. I will do some basic investigations to confirm my diagnosis of DVT and exclude differential diagnosis My investigations are, ultrasound Doppler studies of left leg veins –to see compressibility of proximal and if possible distal veins, septic screen, FBC-check for elevated WBC and platelet count ,FDP low laves in normal pregnancy but high levels suggestive of VTE, CRP, and if any evidence of dyspnoea I will do CXRPA and CT PA .I will explained to her that my preliminary diagnosis is DVT and need admitted to hospital and necessity of immediate medical care.
B-I will start her on subcutaneous LMWH therapeutic dose -1-1.5mg/kg BD though the evidence in pregnancy is not there non pregnant females it is as effective as unfractunete Heparin and does not need to check anti- Xa levels in normal weight individuals but has small risk of thrombocytopenia which need to be check 1 week after starting medication. I will advice her that LMWH need continue during pregnancy omit during active labour and restart 2 hrs after delivery and need to continue for 6 weeks post partum. I advice her that is she get any labour symptoms and sings she need to contact Midwife and hospital staff and avoid LMWH dose. I will refer her to see consultant anaesthetist prenatally usually after 35 week, in view of pain relief during labour. She need to stop LMWH 24hrs before elective delivery or regional analgesia platelet count need to be check pre regional analgesia. She may need to convert to unfractunate heparin during labour as it is easier to neutralise effects in case of emergency like PPH. Any way she needs s active management of 3rd stage of labour. Alternative is warfarine-has very bad side effect profile oral medication and foetal complications like intra cerebral haemorrhages, retro placental haemorrhage , even though she is out of danger from wayfaring embryopathy. I advice her have TED Stockings above knee though there is no evidence regarding prevention of distal DVT it will prevent post thrombotic leg syndrome ideally she has to where it for next 2 years. I will explain her that Heparin will not cress the placenta and breast feeding is not affected or no danger for neonate and small risk of osteoporosis but reversible soon after stop medication. I will explained to her and give written information regarding this is it life threatening condition if we do not manage well and necessity of compliance regarding medication and further follow up. I advice her to avoid long period of immobilisation, and keep her hydrate well..I advice her that she cannot have COCP as contraceptive because it can cause VTE but progesterone only methods are advisable contraception.
Posted by shipra K.
a)INITIAL ASSESSMENT
A detailed history should be taken regarding the duration of symptoms,if there is any associated fever dyspnoea,breathlessness,hemoptysis as these symptoms suggest associated pulmonary thromboembolism.
If there is any history of excessive vomiting, diarrhoeae as dehydration is a risk factor for deep vein thrombosis. Any urinary complaints As pyelonephritis is another risk factor. History of prolonged immobilization ,trauma.If the patient has had similar problem earlier,if the patient suffers from any medical disorder like nephrotic syndrome, thrombocytosis,thrombophilia.If patient having varicose veins .Past obstetrical history should be nted in detail for any missed abortion before 10 weeks,any premature delivery because of preelapsia as antiphospholipid antibody syndrome too is a risk factor.
Any similar complaint in any other family member.
Examination should include vitals ie pulse, blood pressure,temperature,respiratory rate,anaemia should be checked for as this too is a risk factor, patient weight measured as obesity is a risk factor and the dose of heparin would have to be calculated.Homan’s sign though not always positive should elicited.Chest examination should be done to see for any plural rub ,decreased breath sounds.Obstetrical examination should be done to note fetal wellbeing.
Investigations should be ordered like routine Hb,TLC, DLC,platelet count,LFT,RFT,Urine routine microscopic,D-dimer(though in pregnancy it may not be raised much but if low would rule out DVT),coagulation screen,duplex ultrasound,ultrasound for fetal well being and CTG.
b)Once reasonably sure of diagnosis of DVT treatment should be started immediately.Low molecular weight heparin should be given.enoxaparin dose is 0.6-1iu/kg body weight 12 hourly.Though LMWH causes less thrombocytopenia ,in first month platelet count should be done weekly.factor х a level is not routinely required .Thrombophiliia sceen if not done should be done.TED thromboprophylaxis deterrent stockings advised to be continued 2 months after acute phase and in acute phase patient immobilized for fear of dislodging the clot. Adequate hydration to be maintained.LMWH to be continued throughout pregnancy and 6 weeks postpartum.Labour to be induced as it prevents prolonged exposure to heparin (chances of osteoporosis) and better control of thromboprophylaxis.patient advised not to take heparin if she goes into labour.heparin to stopped 24 hours prior to induction,caesarian section,and restart LMWH as soon after delivery. Except if epidural given LMWH with held for 4 hours after insertion and removal of catheter.Anaesthetist has to be informed regarding thrombopropylaxis being given Increased chances of PPH and should be kept in mind.protamine sulphate might be required as antidote.In case of PPH hematologist consultation can be done.Warfarin should be avoided as it is tetratogenic,but if required like in patients with artificial valve can be given after 6 weeks and stopped at 32-34 weeks . .postpartum contraception should be advised carefully as combined oral contraceptive causes increased chances of VTE should be avoided.This patient should advised not to have any more pregnancy as inceased chances DVT in next pregnancy.Intrauterine contraceptive device would be a good option.
Posted by robina K.
(A) the most likely diagnosis is deep venous thrombosis(DVT) which is associated with increased risk of thromboembolism, maternal morbidity and mortality.She is 40 years old and grand multipara which are risk factors for DVT. I will also inquire about other risk factors like previous DVT , personal and family history of thromboembolism and thrombophilia. I will exclude other conditions of leg swelling like cellulitis, ruptured baker cyst and trauma by taking history, examining and investigations. I will ask her about chest symptoms like pain and breathlessnes .I will chech her Temperature , a very high fever more than 38 degree centigrate suggests cellulitis.I will examine the leg for swelling tenderness, hotness, varicose veins, signs of ischemia like white leg or plegmasia alba dolens and I will measure the girth.

I will send Blood for Full blood count as raised white cell count and CRP indicates infection. A thrombophilia screen is also advised specially Factor 5 Leiden mutation and Anti thrombin 3 defeciency.Though thrombophilia screen at this time is not going to alter management it determines cause and guides duration of treatment. Treatment should not be delayed .I will start Heparin according to unit protocol or guidelines either low molecular weight (LMWH) or unfractionated .Dose is calculated according to body weight.Both are equally effective but unfractionated heparin causes thrombocytopenia and osteopenia which are less caused by LMWH .LMWH is administerd as 1 mg per Kg body weight sub cutaniously .To confirm DVT compretion duplex ultrasound and dopler is advised for the femoral, conventional angiography or MRI for the Iliac vein thrombosis.Calf vein DVT is difficult to diagnose with US and doppler.

Women is advised to wear TED stocking mobilise her leg and avoid dehydration.Daily assesment of temperature, pulse and leg girth measurement is carried out. FBC ,U&E monitored on alternate days . Anti F Xa activity is measured 3-4 hrs of unfractionated heparin and should be 0.5 - 1 iu per ml and further testing is not advised if renal function tests are normal.If she receives un fractionated heparin APTT is advised after 4 hrs and should be 1.5-2.5 of the control.

(B) Delivery should be electively planned at 39 weeks and documented.She is advised and taught self injections of LMWH subcutanously at home and needle disposal. Anticoagulatin is cotinued for the rest of pregnancy with the advise of regular antenatal follow up and to stop injection if labour starts ,membranes rupture or vaginal bleeding starts.

If she starts labour therapeutic dose is stopped and prophylactic dose started .Labour is managed as high risk . ,dehydration and immobility should be avoided. continous electronic fetal monitoring advised . I will ask for anaesthetic assessment, consult haemotologist and inform my consultant for backup support. Before induction of labour therapeutic dose is reduced to prophylactic dose .For an elective cesarean section prophylactic dose is given a night before and morning dose is ommited. Catheter for Regional anesthesia is sited after 12 hrs of prophylactic dose and after 24 hrs of theraputic dose. At cesarean meticulous hemostasis is advised , drains should be used and skin sutured with interupted sutures or stapples as there is 2% risk of wound hematoma. Excesive blood loss should be replaced and good hydration ensured . Pneumatic compression stocking may be used though its efficacy in preventing embolism is not proven. Prophylactic heparin is started 3 hrs after cesarean section and therapeutic dose administered in the evening. Heparin should not be given with in 4 hrs of insertion or removal of epidural catheter and catheter should not be removed with in 12 hrs of last injection.

Posted by H H.
She is 40 years old,pregnant and multiparous,so she has increased risks for deep vein thrombosis(DVT) in her left leg ,but I have to exclude her having cellulitis,ruptured Baker cyst or trauma.Of these DVT is the most serious and thromboembolism is still a leading direct cause of most recent confidential maternal mortality report.
I will ask her of the pain and if it was related to trauma.Will ask of onset and radiation of pain and if there is groin pain suggestive of painful lymph nodes in case of cellulites.Will ask of history of previous vein thrombosis in previous pregnancies and if treatment given and outcome of these pregnancies (thrombophilia and antiphospholipid syndrome).will ask history of varicose veins,immobility due to trauma or paralysis.Will ask of family history of thrombosis.
On examination will measure body mass index, temperature(cellulites), pulse(increased in fever , in pulmonary embolism(PE),and anxiety), respiratory rate (tachypnoea in PE). Will examine lower limbs for tenderness,swelling,redness,edema and measure girth to see if increased.Will examin groin lymph nodes (tender enlarged in cellulites),calf muscles tenderness(Homan sign,not conclusive).Will feel pulsations of dorsalis pedis artery on affected leg(absent in phlegmasia alba dolens).
Will ask for Duplex compression sonography to detect site and help in diagnosis of thrombosis.I would admit the patient and start anticoagulant therapy(therapeutic dose of unfractionated heparin UH 80 iu/kg loading dose 18iu/kg maintenance dose or low molecular weight heparinLMWH 1.4mg/kg body wt) if clinical signs are highly suggestive of deep vein thrombosis with the help of the hematologist for monitoring therapeutic dose of heparin.Venography with shielding of maternal abdomen might be needed to confirm the diagnosis. If I am suspicious of PE would do other test, arterial blood gases, ECG ,chest xray and ventilation perfusion scan or CTPA.If patient has cellulites will treat with antibiotics and analgesics.


B) She will cotinue with the therapeutic dose of heparin during her pregnancy.Care of patient through a multidisciplinary team composed of me, consultant obsterician, hematologist, anesthetist ,midwife, pediatrician and herGP.She is taught how she can give herself subcutaneous heparin.Patient given written information on her case and how to take heparin.Will arrange for her more frequent antenatal visits. In 7-10 days after starting heparin will check her platelets and discuss with hematologist.Will arrange fetal growth scans specially if history of thrombophilia.Will ask her to avoid immobility and get proper hydration.TEDs stockings for affected leg. Elective delivery will be needed as there is risk of bleeding if she goes into labour and is anticoagulated.Will ask her to report immediately to labour ward in case she feel she is in labour before the time of elective delivery which is usually 39-40 weeks.Reversal of heparin effect is done with protamine sulphate.. The patient is admitted the day before the date of elective delivery, when therapeutic dose of heparin is replaced with prophylactic dose. Anesthetist will see and arrange timing of regional anesthesia( 24 hr after last dose of therapeutic heparin or 12 hr after prophylactic dose of heparin ,maternal platelets should be >80,000/ml3 ) or general anesthesia.On day of procedure heparin is omitted.
If patient is induced continuous electronic fetal monitoring required, IV lines are secured, bloods sent for group and save and third stage is managed actively and be watchful for post partum hemmorhage.
If patient was to have an elective cesarean section, Flowtron boats ,proper hemostasis ,use of wound drains and closure of wound with interrupted sutures is done.

Posted by C P.
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].
Possible diagnosis is deep vein thrombosis. I will focus my history on the risk factors which could course deep vein thrombosis. Her BMI, personal history or family history of PTE (pulmonary thrombo embolism), immobility, recent long distance travel, viscosities in her leg are risk factors for to have DVT.
In the history of chest symptoms need evaluating. Shortness or breath, pleuritic chest pain, may suggestive of progression to pulmonary embolism.
On examination along with her vital signs pulse, blood pressure saturation, her constitutional symptoms like fever, malaise, feeling unwell will give some idea of inflammation of the leg. For an example cellulites, thrombo phlebitis could cause pain and swelling of he leg.
Because PTE is a biggest killer, in suspected cases if objective diagnosis is getting delayed, treatment should be started. I will do FBC, CRP to exclude any cause of infection, further LFT, RFT and coagulation profile as a base line to start either heparin or low molecular weight heparin. LMWH has a safety record and possible adverse effects of thrombocytopenia and osteoporosis which is caused by conventional heparin can be avoided.
To confirm the diagnosis I will request for compresion venous Doppler of her left leg. If there is any delay in obtaining this, with the clinical suspicion I will start therapeutic LMWH - clexane depends upon her booking or her very recent body weight. The dose would be 1.5 mg/kg twice daily doses.
Following confirmation of her diagnosis, I will explain to her about her the diagnosis and important of the treatment. Graduated compressive thromboembolic stocking (Class 2) of a correct size to her affected leg should be given.
Therapeutic LMWH twice daily doses need starting. It is given as subcutaneous injection. Patient should be gradually trained to take the injection herself. This helps she can be discharge home.
Routinely I will not do factor Xa assay for monitoring LMWH. However, if the patient weight is either extreme ie: below 50 kg or above 90 kg I will do weekly factor Xa levels and try to maintain between 0.5mg/dl and 1.3 unit/dl. Weekly LFT and RFT will be requiring.
Advice will be given to the patient, in case if she develops any chest symptom she needs medical attention to exclude pulmonary embolism.
If she gets recurrent attack of clots, inferior veno caval filter (IVC filter) to prevent PE. This I will discuss with the haematologist. Expert radiologist should be available to perform this.
Sometime she may requiring thrombolytic treatment with streptokinase or urokinase, Once again expert opinion will be obtained for this.
Patient will be followed up in the consultant led antenatal clinic along with and anaesthetist review and haematologist input. I will tell her, whenever she thinks that she is going in to labour she should stop the medication – LMWH and come to the hospital where she will be asses by the medical staff and if she is in labour LMWH will be stopped.
If the patient is planed for induction of labour or elective caesarean section the therapeutic dose of LMWH should be stopped 24 hours earlier and prophylactic dose will be commence. When she goes in to labour LMWH should be stopped. Epidural or spinal can be administrated 24 hours after the therapeutic dose and 12 hours after prophylactic dose. Senior anaesthetist should be involve in this patient’s care in labour.
I will suggest her to read the patient’s information from the RCOG web site about the PTE.


Posted by Manoj M.

M
(a)
A history to ascertain other risk factors like past history of personal/family history of thrombosis. Past obstetric history with any thrombosis and complications.
Exclude local factors like trauma or injury related pain.
Examination including BMI(>30 another risk factor), localised signs of DVT like swelling with objective assessment with measuring tape, redness and tenderness may suggest DVT.
If clinical suspicion of DVT she should be immediately commenced on treatment dose low molecular weight heparin at 1 mg/kg body weight, subcutaneously with her booking/current body weight.
Prior to LMWH, bloods should be taken for FBC including platelets, LFT, U&E and thrombophilia screen is not required but if done should be interpreted with haematologist.
Objective testing for DVT should be organised and compression duplex ultrasound is the investigation of choice.
If duplex USS is negative and no clinical suspicion then treatment can be discontinued.
If duplex USS is negative and clinical suspicion then continue treatment and need for further testing with Radiologist input.
Proven DVT need continued treatment involving Haematologist for the rest of pregnancy and postnatally.

(b)
Antenatal care under multidisciplinary team with Obstetritian, Physician, Haematologist, Anaesthetist.
Explain diagnosis to patient and need for definite treatment as associated with increased maternal mortality.
Teach her regarding ususage of LMWH administration and safe disposal of sharps.
Treatment dose LMWH continued in 2 divided doses daily as pharmacokinetics changes in pregnancy.
Advice on leg elevation to reduce limb swelling and use of TED stocking to prevent post thrombotic sequales
No need for monitoring anti-Xa unless extremities of weight (<50kg or >90kg) or with renal problems or recurrent thrombosis.
Advice on good hydration and avoid immobility as risk of recurrance of thrombosis.
Organise follow up antenatal care under obstetric consultant 2-4weekly and organise induction of labour at 37-38 weeks gestation so as to time appropriately use of heparin in labour.
Her plan should be clearly documented in her notes.
She should be advised to deliver in consultant led unit as high risk delivery.
She should be advised to stop LMWH if in spontaneous labour to reduce the risk of heamorrhage in labour.
She should be advised to stop heparin 24 hrs before planned delivery.
If she chooses regional anaesthesia this is recommended after 24 hrs of treatment dose heparin.
She should have IV acess in labour and bloods for FBC, clotting, group and save organised as increased risk of haemorrhage, anaesthetist should be notified in labour.
She should be well hydrated in labour and delivery, and avoid prolonged immobility with labour and need for chaging position in labour should be emphasised.
If she has a caesarean section as the mode of delivery, then wound drain should be considered and staples or interrupted skin sutures to allow drainage of any haematoma.
She should have a prophylactic LMWH 3 hrs after caesarean section or 4 hrs after removal of epidural catheter.
Watch for PPH and team should be vigilant with management of PPH with a local protocol in place.
Active management of third stage to reduce risk of PPH and approprite use of oxytocics.
She should be advised regarding her postnatal care and need for continued treatment with anticoagulation and followup.
Posted by Leen K.
LEEN
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].

(a)
The most important differential diagnoses is deep vein thrombosis, and other differentials include muscular-skeletal pain or abscess or lesions of the leg. There must be a high suspicion of DVT and low threshold for treating it until diagnosis can be confirmed.

I would enquire about the nature of the pain (intermittent, constant, aching) and if there are any precipitating or relieving factors. I would also ask her about any associated shortness of breath (SOB) one of the differential diagnosis is deep vein thrombosis(DVT) which may preceed pulmonary embolism(PE).
I would also ask about any previous history of venous thromboembolism(VTE) - and if present, whether it was pregnancy associated, whilst on combined oral contraceptive pill, or in an unsual place as these have a higher risk of recurrence in pregnancy (this or subsequent); or whether it occured post-surgery or temporary immobility. I would ask about any family history of VTE or thrombophilias as well as if she is known to have any thrombophilias because these are risk factors for DVT. Other risk factors for DVT such as smoking and immobility should also be elicited. I would ask about current and previous drug history, whether she has been or is on anti-coagulants. I would also want to find out if she has any potential contra-indications to anticooagulant therapy.

On examination, I would assess her general condition, if she is unwell (eg with SOB) she may have PE and might require resuscitation. I would check her body mass index, as obesity is a risk factor. I would obtain her blood pressure, pulse, respiratory rate and temperature to assess her general condition (pulse and temperature may be raised with DVT). I would examine her legs (looking for redness, warmth) and measure them(circumference). I would also look for signs of other differential diagnoses like abscess or trauma.

I would have a low threshold for commencing her on treatment dose anticoagulants - low molecular weight heparin (LMWH), whilst awaiting for results of investigations.

I would obtain blood samples for full blood count, coagulation screen and urea and electrolytes - for baseline measurement in case theatment is required. D-dimer can be raised in pregnancy, but if negative may mean DVT is unlikely. I would however, consult the local hospital protocol before performing this test.
COmpression duplex ultrasound (USS) of the leg should be done, and if there is a high suspicion of DVT but negative USS, I would continue her LMWH and arrange for either a repeat USS or venography in a week\'s time.

(b)
Her care should be multidisciplinary and I would involve the physician, haematologist, anaesthetist, midwive as well as her obstetric consultant. Treatment dose LMWH should be continued, and the appropriate dosage should be based on her weight and be given as a twice daily regimen. Platelets should be checked 7 days after commencing treastment as it may cause thrombocytopenia; however, unfractionated heparin has a higher risk of this as well as other side effects, and require anti-Xa levels to be checked; thus LMWH tends to be preferred.
I would advice her that LMWH does not cross theplacenta, so is not teratogenic or -toxic.
She will need to be taught how to self-inject and dispose of the needles safely, as LMWH is given subcutaneously.

Warfarin is given orally, but is associated with a higher risk of maternal and fetal bleeding (as it cross theplacenta), so if used, should be replaced with LMWH at 36 weeks to reduce the risk of fetal haemorrhage.

I would give her a leaflet about DVT, and contacxt details of support groups, and counsel her about avoiding dehydration and immobility. I would also counsel her about signs of symptoms of PE to look out for.
She should be advised to stop LMWH if she suspects or goes into labour.

Her delivery should be planned in a multidisciplinary setting, and induction of labour may be advisable to try ensuring that she labours in the hospital and with consultant (obstetrician and anaesthetist) presence if possible - bearing in mind she is multiparous and her labours may be very quick.
Treatment dose LMWH should be stopped one day beforehand and changed to prophylactic dose LMWH. Regional anaesthetic can be administered if her last dose of treatment LMWH is more than 24 hours before or prophylactic dose LMWH is more than 12 hours ago.

Intravenous infusion of unfrationated heparin through labour may be easier to adjust and maintain the optimum anticoagulant state if she has a high risk of recurrent DVT or PE.

If she has a caesarean section, a drain should be sited and interrupted skin suture shoould be put in to allow haematoma to be removed

She should be commenced on prophylactic dose LMWH within 3 hours of delivery or 4 hours after removing the epidural cathether.
Treatment dose should be given once the risk of post partum haemorrhage(PPH) is deemed reduced/passed.
She may either continue treament dose LMWH or oral warfarin (will require INR check until levels stable) post natally for at least 3 months. Both as safe in breastfeeding;.
Followup is importnat to counsel her about her risk of recurrence of VTE and management in her next pregnancy.
Posted by Shalini  M.
Shalini
a)It is essential to begin by taking a detailed history of pain n swelling-any history of trauma or immobilisation prior to its occurance or spontaneous in onset.Any symptoms of dyspnoea,chest pain or unwell feeling.Review her maternity records for pre-eclampsia or any dehydration,immobilisation,smoking to cause thrombosis in this pregnancy as she is >40 years with parity more than 4 which are two major predisposing factors for thrombosis to occur.A detailed history of previous child-births should be taken -any history of thrombosis or treatment for the same;mode of deliveries;contraception used between them.Also ask for family history of thrombosis in first degree relatives or thrombophilias in the family.Her BMI should be calculated as BMI>30 pedisposes to thrombosis.On examination her pulse,BP,temperature,chest examination (for findings suggestive of embolism),abdominal examination for uterine height and local examination of the leg to see for localised redness,warmth tenderness and a positive Homan\'s sign.If clinical suspicion is strong heparin should be started till confirmation is done by objective testing after blood investigations like full blood count(thrombocytopenia),clotting studies(abnormal coagulation),urea,electrolytes,liver function tests should be done for baseline investigations.Also ECG,Chest x-ray should be done to rule out thromboembolism.A compression duplex ultrasonography to confirm deep vein thrombosis.
b)The lady should be counselled about the problem-explained about risks associated with thrombosis-risk of embolism which is a life threatening emergency and the need for anti-coagulants which have side-effects.Low molecular weight heparin should be started without awaiting for confirmation by objective tests.It has the advantage of less side effects like thrombocytopenia,bleeding n risk of osteoporosis as also less need for monitoring and convenient dosing.If compression duplex ultrasonography is positive for DVT therapeutic dose of heparin should be continued till 6 weeks postnatally.However if it is negative but high clinical suspicion is there then heparin should be con tinued till repeat ultrasound 1 week later.TEDD stockings should be worn.Platelet count should be monitored.No need for monitoring dose with anti-xa levels unless BMI ,19 or >30 or renal failure present.She should be explained symptoms of pulmonary embolism and to report if they occur.Vaginal delivery is allowed and only obstetric indications for cesarean sections.She should be taught self injection and also told to with-hold injection is she goes in labour.Anaesthetic review by Consultant should be done for plan in labour.on the day of planned delivery by cesarean section the morning dose should be omitted .Epidural anaesthesia is safe if given after 12hours of prophylactic dose of heparin and after 24 hours of therapeutic dose.heparin can be restarted after consultation with the anaesthetist after 3 hours of cesarean section.Heparin can also be given after 4 hours of epidural catheter insertion or removal although epidural catheter should not be removed 12 hours after last dose of heparin.Dehydration and immobilisation should be avoided and pneumatic compression stockings should be worn during cesarean section.
Posted by Akanksha G.
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].
a)the clinical scenario points towards deep vein thrombosis(DVT) (multiparous, pregnant, unilateral leg pain and edema, left leg) investigating expeditiously and involvement of multidisciplinary team consisting of consultant obstetrician, physician, hematologist, and radiologist is preferable. while arranging for baseline blood investigations and a compression duplex ultrasonography i would start her on therapeutic dose of low molecular weight heparin (LMWH) drug and dose as per the protocol of the unit unless there are strong contraindications for anticoagulation like bleeding disorders. usually LMWH is given in a twice daily regimen .Her baseline blood investigations would include full blood count, urea, electrolytes, LFT, coagulation screen and thrombophilia screen. since coagulation factor levels are differant in pregnancy interpretation of thrombophilia screening is better done in consultation with the hematologist. continuation of anticoagulation would depend on the objective diagnosis of DVT. if on doppler DVT is identified then LMWH is continued. in the absence of DVT finding on the scan and strong clinical suspision i would still continue LMWH and repeat the test after 1 week or go for alternative testing like venography if facilities are available. meanwhile i would enquire for signs and symtoms suggestive of pulmonary thromboembolism like, chest pain, dyspnoea and hemoptysis the presence of which she would require an additional chest x ray. additional measures would include, keeping the lower limbs elevated while lying down, use of graduated compression stockings and encouraging mobility.
b) once diagnosed with DVT therapeutic dose of LMWH has to be continued for the remainder of pregnancy, patient can be managed on outpatient basis, self administration of injections and disposal of needles has to be taught to the patient. LMWH does not require monitoring of plateles or peak factor Xa levels unless at extremes of weight (patient is <50kg or >90kg), or has other complications like renal disease or recurrent thrombosis.monitoring involves measuring peak factor Xa levels after 3 hrs of injection which should be 0.5-1.2 u/ml. patient should be warned of symtoms of recurrent DVT and pulmonary embolism in which situation she should report back. patient should be advised to keep the limbs elevated when at rest and to use the compression stockings regularly. use of compression stocking has shown to reduce the incidence of post thrombotic leg syndrome from 23% to 11%. at term cesarean section is only for obstetric indications. patient should be advised not to take the LMWH injection in the event of labour or if she thinks she is in labour, for epidural catheter to be inserted minimum 24 hrs have to be passed from the last injection. management of ist stage does not differ but in second stage instrumental delivery should be avoided if possible and active management of third stage of labour should be done.if the patient is planned for an elective cesarean section then LMWH has to be stopped for 24 hrs, at cesarean, it is worthwhile to put a drain both at the level of rectus sheath and subcutaneous tissue, skin suture should be closed by staples or intermittent sutures to facilitate draining of an hematoma which may occur in approximately 2% of women. LMWH should be restarted at 3 hrs following cesarean or 4 hrs after an epidural cathetre is removed, similarly removal of cathetre should be 6 hrs after the last injection. post partum patient should be given the option of oral anticoagulation vs LMWH. if patient wishes LMWH it should be started after 3 days of delivery or even longer if there is a risk of hemorrhage. monitoring of INR for the first 10 days of starting warfarin would be required, heparin should be stopped after an INR of 2 is reached. on warfarin INR should be maintained between 2-3. patient should be counselled that neither LMWH nor warferin are contraindicated in breast feeding. anticoagulation should be continued for 6 wks postpartum. the total duration of the anticoagulation after the DVT should be 3 months. if the patient is at risk of hemorrhage then use of unfractionated heparin is better than LMWH peripartum since it has a shorter half life and its effects can be easily reversed with protamins sulfate.
Posted by G. K.
A)
Initial management includes a full clinical history, examination and investigation to establish the cause of the pain and swelling.Ask about the onset and severity of symptoms, any associated aggravating or relieving factors. Inquire about any possible injury secondary to a fall, or pain due to ligament or muscle stretch.
Rule out associated symptoms of palpitations, cough or breathlessness to rule out the possibility of pulmonary embolism(PE)
Inquire about any similar problem in her previous pregnancies.
Inquire about any personal/family history of thrombophilia.
Also ask about any recent surgery which may have limited her mobility.Inquire if she,s a s moker or not.
General examination should include height and weight to calculate the BMI of the patient.
Examination should include inspection of left leg for any obvious bruises, swelling and redness. compare both legs in terms of size.Feel for the temperature in both legs using the back of the hand.Use a measuring tape to assess the size of the effected calf and the uneffected calf and document the circumference of each calf and the difference in her notes.
After making a diagnosis of DVT based on the clinical findings, it is important to initiate the patient on full therapeutic dose of low molecular weight heparin( LMHW) and Thromboembolic deterrent stockings (TEDS) as soon as possible and then arrange for Doppler ultrasound studies of the leg to confirm the clinical suspician of same.
B)
After the establishment of diagnosis, the patient should be explained about the findings and it\'s implications discussed i.e breakage of the clot leading to a pulmonary embolus.She should be given information leaflets about DVT in pregnancy.
Her care should be in multidisciplinary setting involving the Haematologists, Medical team and the consultant obstetrician and the anasthetist.Her plan of management regarding
her antenatal care and during delivery should be clearly documented in her notes.
Baseline investigations should include FBC and coagulation profile, and LFTs. A thrombophilia screen is not recommended during treatment.it can be undertaken after consultation with the haematologist 6 weeks post partum.
She should be continued for the remainder of the duration of pregnancy on therapeutic dose of LMWH. She should be taught to self inject and make appropriate provisions for safe disposal of syringes. There is no need to measure anti Xa levels unless patient is at extremes of weight i.e >90kg or < 40kg.
In case of any suspicion of pulmonary embolism(PE) a CTPA or V/Q scan can be done in consultation with the medical team.
If patient goes into spontaneous labour, she should be asked to omit her usual dose of LMWH and her further doses should be given in the hospital. The anaesthetist should be involved in her care with regards to the use of regional anaesthesia. She should not receive Regional anasthesia if her last injection of LMWH was within 24 hours.After delivery she can have her prophylactic dose of LMWH 4 hours after insertion or removal of epidural atheter.
Incase of planned deliveyby C/sec for any obstetric reasons, she should be told to omit the dose of LMWH one day before surgery and surgery should be performed in the morning. She can have herprophylactic dose of LMWH 4 hours after insertion or removal of epidural catheter.
She should be actively managed for the third stage of labour to reduce the risk of PPH.
Posted by sofi S.
A. This symptoms suggestive of DVT, I will take history specifically I will ask if her symptoms associated of chest pain or dyspnoea, and to enquire about her personal and family history of thromboempolic disease and if she is known case of thrombophilia. I will examine her vital sign pulse, Bpr, respiratory rate and temperature. I will admit her and her management require multidisplinary approach; senior obstetrician, physician, haematologist and radiologist. I will start anticoagulant once result of investigation be ready, which will include blood for renal and liver function test clotting screen and full blood count as anticoagulant therapy can influenced by them.
D dimer, will not help to diagnosis DVT as it usually raised in pregnancy but if it is low level it will help to exclude DVT. Thromophilia screen is not required routinely and where performed will require to be interpreted by haematologist. It will not influence the immediate management but can influence the intensity of anticoagulant for example antithrombin deficiency will require higher dose.
I will start anticoagulant treatment in form of therapeutic dose low molecular weight heparin; the dose will be tittered against booking or more recent weight and according to the local protocol, 12 hrly s.c, until the DVT either objectively diagnosed or excluded, unless woman has strong contraindication for anticoagulant. Unfractionated heparin, i.v 6 hrly used if woman has risk of haemorrhage such as woman with coagulopathy , major antepartum haemorrhage,.
I will arrange compression duplex ultrasongraphy , which is the primary diagnostic tool for DVT , if result negative I will continue with anticoagulant and consider repeat test after one week as this woman apart from pregnancy she also have other risk factors. Age of more than 35 is independent risk factor for thromboemolism and she is also multipara (more than4) and her symptom of unilateral left (which is the most common site) leg pain and swelling is highly suggestive. But if after one week result of repeat test is negative then I will exclude diagnosis and stop anticoagulant.
B
Anticoagulant treatment will continue throughout pregnancy and 6 weeks thereafter (i.e in total at least 3 months).
I will advice her to elevate her leg and to wear graduated elastic compression stocking class 1 to reduce pain and swelling and reduce post thrombotic syndrome, I will instruct her how to wear them correctly and encourage her to be walk.
If her leg viability threatened by venous gangrene, I will continue on therapeutic anticoagulant, ask her to elevate her leg and consider either surgical embolictomy or thrombolytic agent.
Low molecular weight heparin therapy does not require platelet or anti Xa activity to be checked routinely but if woman at extremities of weight (less than50kg or 90kg or more) or has renal impairment anti-Xa activity will be checked and aim is to achieve peak level of anti-Xa 3 hr of 0.5-1.2 units/ml. Unfractionated heparin will require platelets to be checked every 2-3 days from 4 to 14 days or until stopped whatever occur first.
LMWHs, are safe in pregnancy as they do not cross placenta, and are more effective and has reduced risk of osteoporosis and thrombocytopenia compared with unfractionated heparin. They have low risk of haemorrhage , however, unfractionated heparin has short half live so if haemorrhage occur it will be stopped and prothrombin sulphate given to oppose it is action and for that reason and because of the familiarity with it is used it recommended if woman at risk of haemorrhage. If haemorrhage occur while woman on LMWH it should be stopped and advice taken from haematologist.
If thrombocytopenia developed or allergic reaction to heparin, danaproid Na or heparinoid given instead and advice from haematologist is required
Warfarin is associated with embryopathy and central nervous system abnormality and also risk of fetal and neonatal haemorrhage and will not be used in the maintaince therapy.
Once her symptom and sign is resolved she will be managed as out patient. If swelling persists I will advice her to wear graduated elastic stocking class 2 only in the affected leg and to remove it at night for 2 yr as that will reduce the risk of post-thrombotic syndrome.
Before discharge I will be arrange for her to learn safe needle and syringe disposal and self subcutaneous injection and followed up clinically as out patient and where required with plat and antiXa activity. I will advice her that if she feel that she is in labour should not inject her dose and if she required to be delivered electively the treatment will be stopped 24hr before induction or caesarean section.
If epidural anaesthesia required discussion with senior anaesthetist with keeping to the local anaesthesia protocol and catheter should not be inserted until at least 24 hours after last dose of LMWH or after 12hr of unfractionated heparin. The next dose should be given at least more than 4 hr after removal of epidural catheter and catheter should not removed within 12 hours of the most recent injection.
If caesarean section will be required thromboprophylactic dose will be given woman 3 hr after the operation and the therapeutic dose commenced in that evening dose.
Both abdominal and rectus sheath drains will be required and use of staples or interrupted suture when skin closed , to enable drain of haematoma if develop as there is 2% risk of wound haematoma by both LMWH and unfractionated heparin.






Posted by SANCHU R.
Sanchu A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].

History of onset and site of swelling and pain with should be asked for. eg. gradual onset with localised swelling and pain may be due to arthritis. History would be to ask for similar episodes in the past, any provoking factors like long travel, family history of thrombo-embolism. History should also be directed at asking for symptoms of embolism i.e. chest pain, breathlessness.

Her vital signs, BP, pulse rate, RR and Temp are done.

Examination would include inspection with comparison of the unaffected leg for extent of swelling and redness,involvement of thigh would suggest iliac vein thrombosis, palpation for edema and calf tenderness.

Examination of the abdomen looking for any tenderness in iliac fossae indicating pelvic vein thrombosis and obstetric examination.

If DVT is strongly suspected on clinical examination, therapeutic dose of low molecular weght heparin shoul be started immediately according to hospital protocol, eg.Tinzaparin 125 units/kg od.

TED stockings should be provided. Bedrest is not advised and she is encouraged to drink plenty of water and be ambulant.

She must be referred to the DVT clinic or for Colour Doppler ultrasound scanning of her leg to diagnose DVT.

B)She must be continued on Therapeutic dose of LMW Heparin, taught to self-administer, advised to avoid dehydration, provided TED stockings and can be discharged home with advice to come to hospital immediately if she develops chest pain or breathlessness.

She should be followed up every 2 weeks in the antenatal clinic to monitor improvement and compliance and weekly by her community midwife with one consultation with the anaesthetist.
She must be advised to stop heparin once she thinks she is in labour or broken her waters and seek advice.

When induction or Caesarean section is planned, Heparin is stopped before 24 hours. Regional analgesia/anaesthesia is contraindicated until 24 hours after the last therapeutic dose of LMWHeparin.
After C-section or after delivery, prophylactic dose is given 3 hours after delivery, 4 hours after removal of epidural catheter.Therapeutic dose is restarted after 24 hours. The epidural catheter should not be removed within 12 hours of last injection.

A drain is advisable and skin is closed with interrupted sutures or staples. If she is at high risk of bleeding, Unfractionated heparin is used since it is easier to reverse with protamine sulphate.

If there is PPH because of heparin, Coagulation profile is done, Hematologist advice is sought and fresh frozen plasma is used.






Posted by A A.
PART A
DVT is the most likely diagnosis in view of maternal age,high parity and presenting complaints. The differential diagnosis include trauma, cellulites and ruptured Bakers’s cyst. I will ask the woman about previous history of venous thromboembolism (VTE) during pregnancy or outside the pregnancy(site of VTE).I will ask about family history of VTE or thrombophila.I will ask about any trauma to the leg and prolonged immobilisation.A history of high grade fever and rigors might be suggestive of cellulites.I will ask about the presence of chest symptoms like shortness of breath, chest pain and hemoptysis for pulmonary embolism.I will also enquire about previous obstetric history and outcome including use of thromboprophylaxis, antenatal complications, mode of delivery and birth weight. In clinical examination I will check BMI, pulse and temperature (fever >38C is suggestive of infective cause while in DVT there is low grade fever). In local examination of legs I will inspect for swelling, erythema (extent of erythema if cellulites) and presence of gross varicose veins. On palpation I will check for oedema, tenderness / induration,diameter and increase heat in affected leg. I will check lower limb pulses to check for evidence of ischemia. I will check for the presence of tender groin nodes / lymphangitis (suggestive of cellulites). In investigation I will send FBC(leucocytes/platelets) , CRP(infection), Urea and electrolytes,liver function test and coagulation screen (PT/APTT) before starting anticoagulation therapy. I will do throbophilia screen specially factor V Leiden Mutation, prothrombin 20210 A mutation, although it is not recommended routinely and does not affect the immediate management but it can influence the duration and intensity of anticoagulation. Results will be analyzed by haematologist. As DVT is associated with increased morbidity and mortality especially if treatment is delayed, unless there is any alternative diagnosis, signs and symptoms are highly suggestive of DVT so anticoagulation like LMWH will be started while awaiting for objective testing. Legs will be elevated and graduated elastic compression stockings applied to reduce oedma and mobilization will be encouraged. I will arrange for compression Duplex USG of legs. If USG confirm anticoagulation treatment will be continued if it is negative but clinical suspicion is high I will repeat USG after one week.
PART B
A multidisciplinary team approach will be taken involving obstetrician, haematologist, physician, radiologist and anesthesit. Treatment with the LMWH will be continued for the rest of the pregnancy. I will explain the risk and benefit of LMWH to the woman. LMWH is most effective, safer and is associated with lower risk of hemorrhagic complications in antenatal/peripartum period with lower mortality than unfractioned heparin. There is also decreased risk of heparin induced thrombocytopenia. LMWH ( like enoxparin or deltaparine) will be given daily in two subcutaneous divided doses with dosage titrated against woman’s booking or most recent weight according to the unit protocol.Routine measurement of peak anti-xa activity(3hrs post injection of0.5-1.2units) is not recommended except in women with extreme of body weight(<50kg and>90kg or with other complicating factors like renal impairment).Routin platelet count monitoring will not be carried out.I will provide training to the woman for self injections and safe disposal of the needles and advise to avoid immobility and dehydration. I will arrange for out patient follow up in senior obstetrician clinic once women stabilised, that will include clinical assessment and advice( with assessment of platlets/peak anti-xa level if indicated). I will arrange USG for fetal biometry,liquor volume,fetal well being andregular growth scan as there is risk of IUGR. Because of adverse effect of oral anticoagulation to the fetus and the mother it will not be offered. I will advise the woman that if she thinks she is in labour she should not inject further doses of heparin and come to hospital immediately. Timing and mode of delivery will be discussed with the woman. Aim will be for vaginal delivery and cesarean section for obstetric indications. Plan will be for elective induction of labour between 38 and 39 weeks to avoid the woman comes in spontaneous labout with full anticoagulation. I will ensure antenatal anesthetic review and senior obstetric assessment with plan documented in her notes.I will provide written information of above detail, further appointments and hospital contact number.
Regarding intrapartum care, for Elective delivery, LMWH will be discontinued 24 hrs before IOL or Caesarean section.send bloodfor FBC/clotting profile. Early anaesthetic review of the woman will be done. Regional anesthetic or analgesic technique will not be carried out until at least 24 hours after the last therapeutic dose of LMWH and LMWH willnot be given for at least 4 hours after epidural cathetar has been removed and cathetar should not be removed 12 hours after the most recent injection.If women is having labor she should remain mobilized with good hydration.TEDstocking will be applied during the labour.Prolonged labor will be avoided with timely intervention.Active management for third stage of labor will be done.If women comes with spontaneous labor further injection of LMWH will be stopped and epidural analgesia(epidural anesthesia in Em c-section)will not be given if<24hrs of LMWH injection.For elective caesarean section, Continued TED stockings during the operation and fastidious hemostasis will reduce the risk of VTE. Wound drains (Abdominal / rectus sheath) will be left in place and interrupted sutures of the skin will be applied for the drainage of hematoma. A Thromboprophylactic dose of LMWH will be given 3 hrs post operatively (> 4 hrs after removal of epidural cathetar) if appropriate and treatment dose is recommended that evening after discussing with the anesthetist. After surgery good hydration, early mobilization and continued use of TEdstocking will be ensured to decrease the risk of VTE. Therapeutic anticoagulation will be continued for at least 6 weeks postnatally.
Posted by SA M.
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].

a) It is important to assess her by history and examination and she needs immediate treatment as venous thromboembolism(VTE)(probable diagnosis) is associated with maternal morbidity and mortality.
I will take the detail history regarding any history of trauma to leg, any previous episode of swelling and pain, allergies ,insect bites, local infection.I will also enquire about chest symptoms, difficulty in breathing,cough, haemoptysis and chest pain as it may point towards PTE.Any history of lower abdominal pain, low grade pyrexia and dizziness is also very important.Her previous obstetric history is important regarding her mode of deliveries and previous VTE during pregnancy.Any personal history of VTE outside pregnancy, familly history of VTE or thrombophilia screening and their results to be asked.
On examination her B.P,pulse, temperature, respiratory rate, oxygen saturation, BMI should be recorded.
Complete examination of chest and heart should be done,height of fundus and fetal heart should be heard.
Local examination is very important, Iwill look for site ,extent of swelling(involvement of entire limb--iliac vein thrombosis), redness, raised temperature, tenderness and any varicosities. Circumference of both legs at same points like midthigh and calf area should be recorded.
If there is high suspicion of VTE,treatment should be started immediately. I/V line should be maintained and bloods to be collected for FBC to look for WBC and platelet count, coagulation screen, renal and liver function tests. Blood for thrombophilia screen can be send though it is not routinely recommended, results should be interpreted by haematologist as there are physiological changes in coagulation system during pregnancy but it will help in duration and intensity of anti-coag therapy needed.
Anti coagulant therapy with low molecular weight heparin (LMVH) should be started before objective tests for VTE should be done, therapeutic dose should be given in two divided doses, it is equally effective like unfractionated heparin.TED stocking and elevation of leg should be done. Doppler U/S should be arranged,if it is negative and clinical suspicion is high, continue with treatment and either do venogram or repeat dopplers after one week.
X-ray chest , ECG can be done to look for pulmonary thromboembolism.Fibrinogen degradation products should not be checked as they are physiologically raised in pregnancy.

b) This is a high risk pregnancy, hospital protocols should be followed,and care should be given by multidisciplenary team including obstetrician,haematologist and physician.There should be a plan for her antenatal, intrapartum, postnatal and f/u care.
She will need the maintaince therapy in the form of therapeutic dose for 6 months or until at least 6 wks postpartum.LMWH should be contiued as it is convenient to take, decreased risk of haemorrhagic complication,thrombocytopenia and osteoporosis as compared to unfractionated heparin. It does not cross placenta so no harm to baby. Routine platelet count and anti-Xa activity not reuired.Woman should be taught for self injection and safe disposal of needles.
Oral warfarin should not be given as risk of fetal and neonatal haemoorhage and central nervous system abnormalities.
She should be given written information, advised increased fluids orally, mobilization and to report if any signs of DVT or PE again. She should be advised against long travelling.
She should have anaesthetist review and plan should be made keeping in view her analgesia and anaesthesia requirement.
Fetal growth should be assessed by regular scans.
Mode of delivery according to obstetric indication. If she is for vaginal delivery, plan for induction of labour around 38 weeks so that proper management of her anti - coag therapy can be done. She should be advised not to take heparin if feels she is in labour.
Regarding her intrapartum care,if she is for vaginal delivery , her therapeutic dose should be stopped 24 hours before. During labour prophylactic dose to be continued and after delivery therapeutic dose can be re-started.Epidural anaesthesia by senior anaesthetist and according to local protocols and at least after 24 hrs of therapeutic dose of heparin. LMWH should not be given for at least 4 hrs after the cathetar has been removed. In case of elective caesarean section, therapeutic dose should be discontinued 24 hrs before , prophylactic dose should be given 3 hrs after surgery or 4 hrs after removal of epidural cathetar.Therapeutic dose can be re- commenced same evening.
Surgery should be done by consultant and consultant anaesthetist should be present, haemostasis should be secured properly and if risk of bleeding drains should be left intraperitoneal and sub rectal.Interrupted sutures to be applied to the skin to allow drainage of any haematoma.
If there is high risk of haemorrhage then intravenous unfractionated heparin should be considered until the risk factors for haemorrhage are resolved.
Posted by Caithlin N.
a)I would take a full history or her symptoms and enquire about any associated symptoms such as dyspnoea and chest pain to exclude pulmonary thromboembolism (PTE) . I would ask about any personal or family history of thrombophilia or venous thromboembolism (VTE). I would check for any predisposing factors for VTE such as dehydration, immobility, medical conditions, and obesity.
I would examine and measure the patients legs looking for other causes of pain and swelling(eg cellulitis). I would perform respiratory and cardiovascular system examinations looking for signs of heart failure and PTE.
I would gain iv access and perform a full blood count, coagualtion screen and CRP. I would not perfrom Ddimers as these are of little value in the pregnant patient.
I would arrange a compression doppler ultrasound of her leg to diagnoses a deep vein thrombosis. If there will be a long delay before this test can be performed I would commence her on treatment dose low molecular weight heparin (LWMH). I would use her booking weight to administer 1mg/kg bd of enoxaparin. I would fit her for thromboembolic stockings.
I would discuss my diagnosis with the patient and ensure she full understands the need for investigation and treatment.
b) I would explain to the patient what a deep vein thrombosis is and the importance of adequate treatment. I would give her an information leaflet. I would explain to her that LWMH is safe in pregnancy & does not cross the placenta. I would explain to her the greater risks to both her and the fetus from a PTE if she were to decline treatment. I would teach her how to administer LMWH and provide her with a sharps box for the safe disposal of needles. I would proviide her with thromboembolic stockings. I would prescribe 1mg/kg bd enoxaparin based on her booking weight. I may consider involving the haematologists in her management if indicated. I would advise her against smoking.
I would enquire about her previous deliveries and if she has any cesearen sections and her wishes for epidural use. If a cesearean section is indicated for obstetric reasons this should be performed as an elective with adequate time to discontinue her LWMH prior to insertion of spinal analgesia. If she is suitable for vaginal delivery and feels she may request an epidural I would discuss the pros and cons of induction of labour. This would allow a planned delivery in a treatment free window. I would explain my caution in using prostaglandins and oxytocin in a multiparous lady and would hopefully only require artificial rupture of membranes. I would advise her if she thought she was in labour she should omit her next dose of LMWH and contact the hospital. She should have iv access obtained on admission and blood taken for FBC (to examine platelet level), coagulation screen and group and save (in case of post partum haemorrhage-PPH)
I would advise her and the labour ward staff of her increase risk of PPH as she is multiparous and on anticoagulants. We would have equipment prepared.
Posted by GHADA AHMAD  M.
GH M
Part A
I will ask about history of previous DVT and whether it is because of recurrent or non-recurrent cause. Medical history to elucidated regard to diseases predispose to DVT like heart disease,inflammatory bowl disease and nephrotic syndrome. Family history of VTE to be asked. Examination of both legs by inspection for redness swelling and and level of pain. I will ask for immediate Doppler US for leg. If it is normal and there is high suspicion index of DVT, I will start therapeutic dose of enoxaparin 1mg/kg 12-hourly or 1.5mg/kg/24-hours and ask for venogram or repeat Doppler US one weak later after discussion with consultant. If the Doppler is normal with low suspicion index I will discontinue LMWH and assure the patient. If Doppler US is abnormal I will continue therapeutic LMWH.

Part B
As she is proved to be Left Leg DVT, I will explain the need for therapeutic anticoagulant is to be continued during pregnancy and during puerperium. TED stocking and weekly FBC to check platelets count and APPT time is required. I will discuss the plan of delivery and type of analegesia and document her withes. If she opt for Vaginal delivery anticoagulant to be withheld with the early onset of labour or 24 hours before the plan for induction of labour. If she opt for Elective C/S anticoagulant to be stopped 24-hours before. If she opt for epidural anaesthesia or analgesia also anticoagulant to be stopped 24-hours before. If she is on epidural , I will continue anticoagulant 6-12hours after insertion. when epdural catheter to removed this must be done 12-hours after the last dose of anticoagulant. I will inform here that the highest risk will be in the postparum period ( 1st sex weeks). So, the therapeutic anticoagulant to continued for 6 weeks after delivery. I will explain the possible sequels of DVT like post-phlebitic syndrome, leg swelling and ulcers. Screening for thrombophilia to done to identify that DVT is liable to be recurrent or not. On discharge I will provide her with written information leaflet and Hospital contact details.
Posted by Vinutha G.
Pregnancy is a thrombogenic state and deep venous thrombosis and pulmonary embolism remain a major cause for maternal morbidity

Any woman complaining of pain and swelling in her leg should be treated as DVT unles proved otherwise
In addition she is multiparouus and 40 years of age
Iwill ask her about the time duration of her pain and swelling wheter unilateral or both her legs ,any history of trauma ,any vomiting ,any intercurrent infection
I will also ask her if she has any chest pain ,shortness of breath .
I will ask her in detail about her previous pregnanc,ies,any previous history ,the mode of deliveries
I will check if she has associated diseases like nephrotic syndrome ,systemic lupus erythematous
Her family history with reference to history of thrombophilia ,her own past history of any VTE will be looked into .

Iwil examine her specifically her BMI ,any chest signs ,BP
On local examination both legs to be examined carefully for -swelling ,tenderness,raised temperature .Homans sign may not be positive
Presence of any varicosities also to be noted
Any evidence of trauma or genaralised swelling (cellulitis )to be noted

Investigations towards arriving at a defintive diagnosis FBC PT APTT (BASELINE ) compression duplex ultrasound which has ahigh sensitivity but a low speificity
An ECG xray may not show the classical features of pulmonary embolus(q3 t3 v3)
Ddimer if low may rule out DVT
But I will start her on low molecular weigt heparin while awaiting the resuts


b)Once the diagnosis is confirmed ,Iwill tell the patient about the implications of the diagnosis
Iwill inform her of the need to continue with the injections throughout her pegnancy three times in order to prevent further episodes
Towards this end I will educate her on administering the injection and educate her on the safe disposal of the needles
Iwill inform her that monitoring of Xa levels is not needed but will check her platelet count a week after the dose
Iwill inform her that she will need extra fetal surveilliance to check for growth (IUGR more common)
Iwill inform her the need to stop the injection in case she goes into labour
Iwill reserve LSCS only for obstetric indications but would advise her thepros of an induction of labour as the drug can be stopped well in advance and complications of bleeding avoided
Iwill give her aprophylacyic dose during her labour
Epidural anaesthesia can be offered 24 hours after the therapeutic dose and 12 after the prophylactic dose
an anaestist should be consulted regarding the same
restart 3hours after citing or 4 hours after the removal
An overdose can be managed with protamine sulphate (better reversal with unfractionated)

Poatpartum anticoagulation with warfarin should be given foe at least 6 months
Of course general measures of avoiding dehydraton ,early immobilisation and TEDS must be followed throughout her pregnancy and postpartum
The implications for her next pregnancy(hromboprophylaxis needed) and contraception(COCPcontraindicated) should be informed to her
Posted by PAUL A.
A. Initial assessment involves taking detailed history, performing focused physical examination and investigation. Most likely diagnoses include deep vein thrombosis (DVT), cellulites, trauma and ruptured Baker’s cyst. Pregnancy, previous DVT, pulmonary embolism (1) , with a swollen leg suggests DVT. Fever, feeling unwell with increasing pain and swelling suggest cellulites. Whereas, history of trauma with bruises, not weight bearing suggest trauma (1) . Sudden onset of pain and swelling in the leg with history of rheumatoid arthritis healthy 40 year old suggest ruptured Baker’s cyst.
History should include onset of pain, radiation, progression and associated factors such as chest pain and shortness of breath which may suggest pulmonary embolism. Prolonged bed rest, varicose veins, recent surgery healthy 40 year old – this phrase is in the question for a reason and smoking with family history of DVT and PE in first or second relative are risk factors for DVT and if present, will make the diagnosis probable.
High temperature, tachycardia, a tender and red leg suggest infective cause these do not differentiate DVT from cellulitis . However, a tender, pitting leg which is 3cm or more compared to the contra-lateral leg suggests DVT. Bruises on the affected leg with other bodily injuries will support trauma. Abdominal examination should involve the fundal height, lie and foetal heart tone to assess foetal wellbeing.
Baseline full blood count (FBC), renal, liver and clotting screen (1) should be performed as she may need anticoagulant therapy. White blood cells and C - reactive protein should be performed and if raised, will support infective cause. A compression duplex ultrasound (1) of both legs should be requested and if it shows occlusion of left calf vein why just in the calf? will confirm the diagnosis of DVT. If negative, it should be repeated in one week depends on clinical index of suspicion and you will not leave her untreated for 1 week if you strongly suspect DVT clinically . Electrocardiogram, arterial blood gases and spiral CT scan In a pregnant woman??(-1) may be necessary if symptoms are suggestive of pulmonary embolism.

B. Antenatal care should be hospital based, joint clinic with Haenatologist (1) , and low molecular weight heparin (1) e.g. clexane 1-1.5mg there are no marks for writing the dose but you lose marks if you get it wrong. Presume you mean per kg. Therapeutic dose would suffice (-1) should be started as soon as possible. This should be continued for 3 months from the diagnosis or till six weeks postpartum she is 30 weeks pregnant so which of these would you apply? . She should be encouraged to ambulate, elevate the leg and wear compression stockings to reduce oedema (1) . Warfarin is relatively contraindicated as it may cause both foetal and neonatal bleeding problems. Detailed counselling must be supported by relevant leaflets.
Patient should be seen regularly; routine FBC and activated factor X not necessary (1) . She should omit the next dose of clexane if she labour begins, 24 hours before induction of labour or scheduled abdominal delivery (1) . Spontaneous vaginal delivery is favoured so will you just wait for her to go into labour at say 41 weeks?? ; caesarean section is for obstetric reasons. No contraindication to oxytocin in labour. Epidural anaesthesia should be delayed till 24 hours after the last dose (1) and the catheter should be removed more than 4 hours after the last dose if you will not put it in until 24h after last dose, how can you remove it say 6h after last dose? Unless you are going to give her therapeutic heparin in labour?? . Third stage should be managed actively. Clexane should be restarted 2 hours after delivery not asked about post-partum care provided there is no continuous vaginal bleeding.

women on therapeutic / prophylactic heparin should have their labour electively induced at 38-39 weeks to avoid spontaneous onset of labour after the woman has received heparin
Posted by PAUL A.
OBTAIN HISTORY OF ANY PERSONAL OR FAMILY HISTORY OF dvt OR KNOWN THOMBOPHILIA.ANY (1) HISTORY OF RECENT LONG HAULT TRAVEL,DEHYDRATION, IMMOBILISATION(Eg,HOSPITALISATION).ANY MEDICAL HISTIORY LIKE MYLOPROLIFERATIVE DISEASES,ULCERATIVE COLITES,SICKLE CELL ANEMIA ETC healthy 40 year old .
ASK FOR SYMPTOMS OF PE LIKE CHEST PAIN ,SOB,COUGH.CHECK VITAL SIGNS what are these? .
EXAMINE BOTH LEGS FOR TENDERNESS SWELLING TEMPERATURE,PRESENCE OF VARICOUS VEINS (1) .
INITIAL DIAGONOSIS IS DVT.
START TREATMENT FOR DVT WHILE WAITING FOR CONFIRMATION BECAUSE IT IS ASSOCIATED WITH HIGH MATERNAL MORBIDITY AND MORTALITY.
START ON THERAPEUTIC DOSE OF HEPARIN (1) -LMWH OR UNFRACTIONATED- DEPENDING ON UNIT PROTOCAL.ONE OF THE COMMONLY USED REGIEMS IS IMG/KG BD OF LMWH LMWH come in different forms with different dose regimens .IT IS LESS LIKELY TO CAUSE OSTEOPOROSIS AND THOMBOCYTOPENIA.START TEDS STOCKINGS.SEND BLOOD FOR FBC,U&ES ,LFTS,CLOTTING AND THOMBOPHILIA SCREENING (1) before or after starting heparin?.BE AWARE OF THE EFFECT OF PREGNANCY ON THOMBOPHILIA SCREENING.REQUEST HEMATOLOGIST TO INTERPRET RESULTS.REQUEST FOR AN URGENT COMPRESSION DUPLEX DOPPLER SCAN (1) OF BOTH LEGS.
ONCE THE DIAGNOSIS IS CONFIRMED CONTINUE THERAPEUTIC DOSE OF LMWH AND TEDS THOUGHOUT PREGNANCU AND 6-12 WEEKS POSTPARTUM (1) .THE PLAN SHOULD BE REVIEWED BY HAEMATOLOGIST (1) manage in joint clinic .
TEACH PATIENT TO DO INJECTIONS AND SAFE DISPOSAL OF NEEDLES (1) .
ASK HER TO STOP INJ AS SOON AS SHE THINKS SHE IS IN LABOUR (1) .
GIVE HER DATE FOR IOL AT 39 WEEKS (1) .
STOP LMWH 24 HRS BEFORE INDUCTION OF LABOUR. (1) GIVE HER EITHER NO HEPARIN OR THERAPEUTIC DOSES ????? FOR THE PERIOD ON INTRAPARTUM-DECISION TO BE MADE IN CONSULTATION WITH HAEMOTOLOGIST.
REGIONAL BLOCK CAN BE GIVEN 24 HRS AFTER THERAPEUTIC DOSE AND 12 HRS AFTER PROPHYLATIC DOSE OF LMWH (1) .
GIVE PROPHYLACTIC DOSE 4 HRS AFTER SITING EPIDURAL AND RESTART THERAPEUTIC DOSE ON THE EVENING OF DELIVERY.
AVOID DEHYDRATION AND TRY TO MOBILISE ASAP (1) .
Not asked about post-natal care POST NATALLY THERE IS A CHOICE OF EITHER CONTINUING WITH HEPARIN OR TAKING WARFARIN.BOTH ARE SAFE FOR BREST FEEDING.
GIVE ADVICE ABOUT CONTRACEPTION BEFORE DISCHARGE.NEEDS TO AVOID HARMONAL CONTRACEPTIVES.
ASK TO USE TEDS IN THE EFFECTED LEG FOR 2 YEARS TO PREVENT POST THOMBOPHELIBITIC SYNDROME.
ADVISE THAT SHE WILL NEED THOMBOPROPHYLAXIC IN NEXT PREGNANCY
Posted by PAUL A.
A/
Venous thromboembolism[VTE] is the leading cause of direct maternal death in UK. There should be high suspcious in pregnant women with leg pain.
I would take detailed history, pain involving calf, thigh or any associated backache. I would ask about any pain or swelling on the right leg. Any history of chest pain, cough, breathlessness which may suggest Pulmonary embolism (1) . Previuos history of venous thromboembolism. I would ask about family history of thromboembolism (1) . Life style habit like cigarette smoking or sedentary life stlye. I would ask about mode of deliveries of all her children.
Examination would include her height, weight and BMI. I would check her blood pressure, pulse, temperature and Oxygen saturation (1) . I would examine her left leg for swelling, reddness and tenderness. It is important to compare both legs with tape measuremen (1) t. Abdominal examination for any tenderness. Fundal height and fetal heart heart rate.
With Unilateral leg swelling and pain in a pregnant woman, my impression would be Deep vein thrombosis until proven otherwise. Therefore, I will commence therapeutic dose of Low molecular weight heparin while waiting for investigation (1) . Enoxaparin 1mg/Kg twice daily subcut. It is important to do basic blood investigation of Full blood count, Liver function test and Urea and electrolyte (1) before or after starting heparin? Why write it after? because, the level can change with treatment.
I would arrange for Ultrasound Doppler of affected (1) leg. If it comes back as negative and there is still high suspicion, I will continue with the treatment and repeat Doppler in a week in a woman with a DVT, how likely is it that Dopplers will remain positive after a week of treatment? .
B/
I would inform her the diagnosis in a sympathetic way, as this may generate anxiety. Multidisciplinary team in her management, involving Senior Obstetrician, haematologist (1) , Physician, Anaesthetist. I would follow the Unit protocol in her management.
She would be on therapeutic dose of Low molecular weight heparin throughout pregnancy and up to minimum of 6weeks postpartum (1) . She would be thought how to inject herself, and disposal of needles (1) . Platelet count would be measured a week after start of treatment because of risk of thromboctopenia.
I would arrange anaesthetic review (1) . I would recommend Thromboembolic detereant[TED] stocking (1) . It is important to avoid immobilization and dehydration.
She would be informed to come to hospital if she develop symptoms of Pulmonary embolism which include cough, chest pain, breathlessness, haemoptysis. Clear management plan in her notes. I would provide her with information leaflet.
I would plan her delivery for 38-39 weeks gestation, by Inductionof labour (1) , to aim for vagina delivery. Caeserean section only for obstetric indication. I would inform her to stop her injection once she noticed she is in labour (1) . The injection would be stopped 24hours before the planned delivery (1) . Omit the morning dose on the day of planned delivery how is this consistent with your previous statement? (-1) . I would encourage mobilisation and hydration during labour (1) .
There is risk of Post partum haemorrhage, I would take blood for Full blood count, Group and save. Active management of 3rd stage of labour. If she require Ceaserean section, I would insert abdominal and wound drain for any bleeding. I would use Staples or interupted stitches on the skin (1)
The prophylactic dose of heparin would be given 3hours after delivery not asked about post-partum care or 4hours after insertion or removal of epidural catheter, and the therapeutic dose later in the day. Epidural catheter would not be inserted or removed within 12 hours of the injection.
Good answer
Posted by PAUL A.
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks].

Pregnancy is a risk factor for deep vein thrombosis (DVT). Complications include pulmonary embolism (PE) & death. Therefore DVT needs to be excluded in pregnant women with swelling & pain in leg.

I will ask her the nature of pain in her leg, site of pain, radiation, precipitating and relieving factors. I will also ask her exclude other causes of unilateral leg pain & swelling such as trauma (1) , infection or thrombophlebitis. I will ask how it has affected her movement. I will ask her any chest symptoms to exclude a PE - pleuritic chest pain & short of breath. I need to ask her any personal history or strong family history of thrombophilia such as Factor V leiden deficiency, anti-thrombin III deficiency. I will ask about family history of DVT or PE (1) . I will ask her if she smokes or recent long haul flight travel.

On examination, i will check her body mass index as high BMI (more than 30) is associated with increasing risk of venous thromboembolism (VTE). I need to exclude signs of PE - unwell, tachycardia, reduced oxygen saturation, reduced air entry on auscultation (1) . I will examine both of legs, checking for varicose veins, measure the diameter where the painful swollen left leg & compare to the healthy right leg. I will examine the left leg for fever ?? fever in a leg? , erythematous & tenderness.

I will start her on therapeutic low molecular weight heparin (1) before confirmation of DVT and pain-relief for her leg - paracetamol. Duplex doppler ultrasound of leg is the investigation of choice (1) . Renal & liver function, full blood count (to exclude thrombocytopenia) are needed before commencing heparin treatment (1) . D-Dimer is not required as it is positive during pregnancy. Negative value however can exclude DVT. Thrombophilia screen should not be requested unless result is interpreted by experienced haematologists.

(b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].

I will counsel her about the diagnosis & its implications with written information. She needs to commence on subcutaenous therapeutic low molecular weight heparin eg clexane 1mg/kg twice a day based on her booking weight until at least 6 weeks postpartum (1) . She or her family should be taught how to do the injection & provide sharps disposable box (1) . She should also wear compression stockings & elevate her left leg which may reduce the swelling (1) . She should be counselled against side effects of clexane including very low risk of thrombocytopenia & skin allergy. Regular monitor of anti-Xa level is not required (1) . She should also be advised to watch out signs of PE. She should be seen by consultant anaesthetist (1) at 34 weeks to discuss about mode of pain relief in labour & when to stop clexane in relation to regional anaesthesia.

She should be advised to stop low molecular weight heparin once she thinks that she is in labour (1) . Alternatively, if she is going for elective caesarean section or induction of labour what would your plan be assuming everything else is normal? , she should omit the therapeutic dose the day. Consultant obstetrician, anaesthetist and haematologist should be informed delivery at the day of delivery ? meaning . Regional anaesthesia should be avoided at least 12 hours before last dose of heparin before or after? Is this a therapeutic or prophylactic dose? . Thrombocytopenia & prolonged clotting should be excluded before insertion of spinal or epidural anaesthesia. Regional anaesthesia is contra-indicated if platelet is less than 80. In addition, it should be done by experienced anaesthetist. She should be warned about risk of spinal haematoma. She should have active management of third stage to minimise risk of postpartum haemorrhage. If she has a caesarean section, a drain should be considered (1) to be left in pelvic cavity she should be induced at 38-39 weeks. You should look up therapeutic / prophylactic heparin regimens in relation to regional analgesia in the notes section (medical disorders and pregnancy) .
Posted by PAUL A.
RnRn

A.
A history revealing risk factors like long-haul travel, immobilization healthy 40 year old , dehydration, varicous veins of legs or more specific, personal or family history of DVT/thrombophilia (1) all point to deep vein thrombosis (DVT) as likely cause. If accompanied by additional symptoms like dyspnoe / chest pain, pulmonary embolism may be present as well. Recent trauma, especially combined with chronic venous insufficiency and/or diabetes healthy 40 year old could point to erysipelas/cellulitis as alternative diagnosis (1) . Temperature, blood pressure & pulse rate are assessed. A warm, swollen and tender leg on palpation on only one side is suggestive for DVT (1) . Homan’s sign is not very reliable, pulse of tibial or popliteal artery may not be felt. A circumscript eryhtematous lesion, possibly with a small wound, is more suggestive for erysipelas/ cellulitis. Especially in dyspnoe, pulmonary auscultation and assessment of jugular vein are important to identify possible pulmonary embolism (1) . Full blood count and coagulation are done as baseline in case anti-coagulation is needed, and white-blood count & CRP may be raised in infection renal / liver function tests . D-dimeres are often false-positive in pregnancy and thus not useful. Doppler flow of legs can identify a DVT, but DVT high in upper leg or pelvis may be missed so would you do Dopplers?? , and even in negative findings treatment will start what will you use as treatment? nevertheless if high suspicion. Cellulites will be treated with flucloxacilline 500 mg qid for 1 week.

B.
Immediate treatment starts with TED-stockings for both legs and LMWH such as subcutaneous Fragmin 100 iu/kg bd there are no marks for doses but you lose marks for getting it wrong – this is not the dose as stated in the BNF and the examiner will not mark your essay using your hospital guidelines . It will be continued throughout pregnancy till at least 6 weeks pregnancy (1) post-partum. Mother must be assured it won’t affect the fetus. She needs to be instructed on importance of compliance and its use at home and provided with means to dispose of needles (1) teach self-injection. Routine bloods for anti-factor Xa levels is only needed at extremes of weight (1) . Full blood count after 2 days can show thrombopenia, though this is rare as side-effect of fragmin. Osteoporosis due to fragmin is minimal and readily reversible. Warfarine may be used after initial stage, but must be switched back to fragmin by 36 weeks ABSOLUTELY NOT – this regimen must not be used (-2) . If onset of labour starts earlier, it will take too long to revert its action. Warfarine’s risks are fetal intra-cerebral bleed, retroplacental bleed and antepartum hemorrhage and mental retardation and stillbirth are more common so how can you possibly use it given the risks you have listed???? Your answer will fail on this alone .
The fragmin must be omitted as soon as signs of labour onset present (1) (or evening before induction of labour) as it may cause post-partum hemorrhage and interfere with possible epidural use. If stopped too late, protamine-sulphate may partially reverse its action. Third stage must be managed actively with i.m. syntometrine and oxytocine 40 iu as i.v. drip over 4 hours. Fragmin can be re-started 2 hours post-delivery, but not earlier than 2 hours after removal of epidural if present incorrect (-1) – see notes on VTE / thromboprophylaxis (medical disorders & pregnancy . Warfarine may be initiated at the same time to replace fragmin once INR
Posted by PAUL A.
a)

Advanced maternal age and high parity are important risk factors for the development of VTE. I highly suspect DVT so I’ll start by asking about other risk factors for DVT including history of previous DVT, known thrombophilias, prolonged immobilization (bed rest for more than 4 days) healthy 40 year old?? , recent long haul travel, if she is suffering from renal disorders (nephritic syndrome), malignancies or underwent major surgery (eg orthopedic surgery) healthy 40 year old . I will inquire about other causes of limb pain for example trauma , muscle strain rapidly developing pain and swelling together with warm and tender limb this sounds like DVT to me may indicate superficial thrombophlebitis . I will ask about symptoms suggestive of PE as chest pain, dyspnoea, haemoptysis and faintness (1) .

Initial assessment should include assessment of weight and BMI, measuring blood pressure pulse rate and temperature (1) . Lower limb examination for gross varicose veins, bruises, redness, warmth and palpable superficial veins may denote superficial thrombophlebitis (1) .

As there is high clinical suspicion of DVT my initial investigation will include compression duplex ultrasound (1) ( after initiating treatment with LMWH) if ultrasound is negative and there is low level of suspicion I will stop LMWH. If ultrasound is negative and there is a high level of suspicion I will continue LMWH and repeat test after 1 week how likely is this to be positive after 1 week of treatment? .

Base line tests that should be done before initiating treatment will include full blood count, coagulation screen, urea and electrolytes and liver function tests (1) . Controversial to perform thrombophilia screen as this will not affect management and results my be affected by pregnancy.

Chest X-ray should be performed if suspected pulmonary embolism.

D-dimers is not recommended in pregnancy, however low levels my exclude VTE.

b)
Based upon agreed protocol for diagnosing and management VTE, physicians, haematologists (1) and radiologists may be involved. Patient should be properly counseled and therapy initiated.

Initial therapeutic approach should include leg elevation, graduated elastic compression stockings should be applied and mobilization with the stockings should be encouraged (1) .

I will start therapeutic subcutaneous LMWH enoxaparin 1mg /kg twice daily or dalteparin 100units/kg twice daily or tenzaparin 175 units/kg once daily.

Treatment with therapeutic doses of LMWH should be continued to the rest of pregnancy (1) . She should be instructed how to use and dispose needles (1) . Routine monitoring of peak anti Xa (peak anti-Xa, 3 hours after injection, of 0.5–1.2 units/ml)
is not recommended except in patients >90 kg or <50 kg (1) or those with renal impairment or recurrent DVT.

I will advise her to have no further injections of LMWH whenever she thinks she is in labour (1) . LMWH should be stopped 24 hours before planned delivery (1) . Regional anesthesia should not be undertaken until at least 24 hours after last LMWH dose (1) .

Active management of third stage is recommended, as well as group and save for the risk of postpartum bleeding. Drains might be considered after c.section and skin closure using stapler or interrupted sutures (1) labour should be induced at 38-39 weeks

Thromboprophylactic dose of LMWH, enoxaparin 40 mg or deltaparin 500 IU or Tinzaparin 75u/kg should be given 3 hours after cesarean section or 4 hours after removal of epidural catheter. And epidural catheter should be removed at least 12 hours after last injection.
Posted by PAUL A.
A-I would take more detail history regarding calf swelling, associated calf pain, onset of pain whether it is sudden or gradual , any colour change in skin, high temperature, any chest discomfort, palpitation, shortness of breath , history of varicose veins do not write a list , similar episodes in the past specially DVT in past pregnancies, family history of DVT (1) and any Clotting disorders like SLE healthy 40 year old ,Thrombophillias .I will ask any resent immobilisation like long duration flight .As DVT and PE has very high maternal motility and morbidity i will start treatment as soon as possible by I would like examine you are in control of what you write. So why not write your examination BEFORE treatment? , I will check BMI , look for any signs of respiratory distress like, Saturation , High RR, Tachycardia, cyanosis, and look for localized evidence of DVT –calf tenderness, distended superficial veins ,Hoffman’s sings swelling –measure diameter compare with other calf, evidence of varicosities and cellulites like redness and enlarge lymph nodes (1) DO NOT WRITE LISTS – You should group those features that have something in common and add context – explain what they will indicate. I will do some basic investigations to confirm my diagnosis of DVT and exclude differential waste of time / space – simply explain which investigations and why diagnosis My investigations are, ultrasound Doppler studies (1) of left leg veins –to see compressibility of proximal and if possible distal veins, septic screen, FBC-check for elevated WBC and platelet count , FDP not useful low laves in normal pregnancy but high levels suggestive of VTE, CRP, and if any evidence of dyspnoea I will do CXRPA and CT PA will you do a CTPA in a pregnant woman??? (-1) .I will explained to her that my preliminary diagnosis is DVT and need admitted to hospital and necessity of immediate medical care.
B-I will start her on subcutaneous LMWH therapeutic dose - 1-1.5mg/kg is this the dose for every LMWH on the market? You do not need to write a dose but will lose marks if you get it wrong BD though the evidence in pregnancy is not there non pregnant females it is as effective as unfractunete Heparin and does not need to check anti- Xa levels in normal weight individuals (1) but has small risk of thrombocytopenia which need to be check 1 week after starting medication this is one long sentence addressing a variety of issues – you should address every issue in a separate sentence to maximise your marks . I will advice her that LMWH need continue during pregnancy omit during active labour and restart 2 hrs after delivery and need to continue for 6 weeks post partum (1) . I advice her that is she get any labour symptoms and sings she need to contact Midwife and hospital staff and avoid LMWH dose (1) . I will refer her to see consultant anaesthetist (1) prenatally usually after 35 week, in view of pain relief during labour. She need to stop LMWH 24hrs before elective delivery (1) or regional analgesia platelet count need to be check pre regional analgesia. She may need to convert to unfractunate heparin during labour as it is easier to neutralise effects in case of emergency like PPH. Any way she needs s active management of 3rd stage of labour. Alternative is warfarine-has very bad side effect profile oral medication and foetal complications like intra cerebral haemorrhages, retro placental haemorrhage , even though she is out of danger from wayfaring embryopathy THIS IS NOT AN ALTERNATIVE and must not be used – your answer will fail on this alone (-2) . I advice her have TED Stockings above knee though there is no evidence regarding prevention of distal DVT it will prevent post thrombotic leg syndrome ideally she has to where it for next 2 years. I will explain her that Heparin will not cress the placenta and breast feeding is not affected or no danger for neonate and small risk of osteoporosis but reversible soon after stop medication another sentence addressing very different issues . I will explained to her and give written information regarding this is it life threatening condition if we do not manage well and necessity of compliance regarding medication and further follow up. I advice her to avoid long period of immobilisation, and keep her hydrate well (1) ..I advice her that she cannot have COCP as contraceptive because it can cause VTE but progesterone only methods are advisable contraception. not asked about post-partum care

You need to improve your style and use short sentences addressing single or related issues
Posted by PAUL A.
a)INITIAL ASSESSMENT
A detailed history should be taken regarding the duration of symptoms,if there is any associated fever dyspnoea,breathlessness,hemoptysis as these symptoms suggest associated pulmonary thromboembolism (1) .
If there is any history of excessive vomiting, diarrhoeae as dehydration is a risk factor for deep vein thrombosis. Any urinary complaints As pyelonephritis is another risk factor. History of prolonged immobilization ,trauma.If the patient has had similar problem earlier,if the patient suffers from any medical disorder like nephrotic syndrome, thrombocytosis HEALTHY 40 YEAR OLD ,thrombophilia.If patient having varicose veins .Past obstetrical history should be nted in detail for any missed abortion before 10 weeks,any premature delivery because of preelapsia as antiphospholipid antibody syndrome too is a risk factor.
Any similar complaint in any other family member.
Examination should include vitals ie pulse, blood pressure,temperature,respiratory rate (1) BMI,anaemia should be checked for as this too is a risk factor, patient weight measured as obesity is a risk factor and the dose of heparin would have to be calculated.Homan’s sign though not always positive should elicited this is controversial .Chest examination should be done to see for any plural rub ,decreased breath sounds.Obstetrical examination should be done to note fetal wellbeing is Homan’s sign the only thing you would look for in her legs? .
Investigations should be ordered like routine Hb, TLC, DLC what are these???? ,platelet count,LFT,RFT, Urine routine microscopic why??? , D-dimer(though in pregnancy it may not be raised much ??D-dimers may not be raised in pregnancy??? but if low would rule out no, it does not DVT),coagulation screen,duplex ultrasound of what? ,ultrasound for fetal well being and CTG.
b)Once reasonably sure of diagnosis of DVT treatment should be started immediately are you going to wait till you are sure before starting treatment??? (-1).Low molecular weight heparin (1) should be given.enoxaparin dose is 0.6-1iu/kg body weight 12 hourly.Though LMWH causes less thrombocytopenia ,in first month platelet count should be done weekly not recommended .factor х a level is not routinely required (1) .Thrombophiliia sceen if not done should be done.TED thromboprophylaxis deterrent stockings advised to be continued 2 months NO – see notes on VTE after acute phase and in acute phase patient immobilized for fear of dislodging the clot absolutely not – SHE WILL GET MORE DVTs – your answer fails on this (-2) . Adequate hydration to be maintained.LMWH to be continued throughout pregnancy and 6 weeks postpartum (1) .Labour to be induced at what gestation age? as it prevents prolonged exposure to heparin (chances of osteoporosis) this is not the reason for inducing labour and better control of thromboprophylaxis.patient advised not to take heparin if she goes into labour (1) .heparin to stopped 24 hours prior to induction (1) ,caesarian section,and restart LMWH as soon after delivery how soon? . Except if epidural given LMWH with held for 4 hours after insertion and removal of catheter.Anaesthetist has to be informed (1) regarding thrombopropylaxis being given Increased chances of PPH and should be kept in mind.protamine sulphate might be required as antidote.In case of PPH hematologist consultation can be done.Warfarin should be avoided as it is tetratogenic, but if required like in patients with artificial valve can be given after 6 weeks and stopped at 32-34 weeks should not be used – you were asked about a healthy woman . .postpartum contraception not asked about post-partum care should be advised carefully as combined oral contraceptive causes increased chances of VTE should be avoided. This patient should advised not to have any more pregnancy this is completely inappropriate (-2) as inceased chances DVT in next pregnancy.Intrauterine contraceptive device would be a good option.

You have a wide range of misconceptions about VTE and its management – suggest you read the notes in medical disorders & pregnancy
Posted by PAUL A.
(A) the most likely diagnosis is deep venous thrombosis(DVT) which is associated with increased risk of thromboembolism, maternal morbidity and mortality.She is 40 years old and grand multipara which are risk factors for DVT. I will also inquire about other risk factors like previous DVT , personal and family history of thromboembolism and thrombophilia (1) . I will exclude other conditions of leg swelling like cellulitis, ruptured baker cyst and trauma by taking history, examining and investigations which examination / investigations? . I will ask her about chest symptoms like pain and breathlessnes (1) .I will chech her Temperature , a very high fever more than 38 degree centigrate suggests cellulitis.I will examine the leg for swelling tenderness, hotness, varicose veins, signs of ischemia like white leg or plegmasia alba dolens and I will measure the girth (1) .

I will send Blood for Full blood count as raised white cell count and CRP indicates infection renal & liver function tests . A thrombophilia screen is also advised specially Factor 5 Leiden mutation and Anti thrombin 3 defeciency.Though thrombophilia screen at this time is not going to alter management it determines cause and guides duration of treatment. Treatment should not be delayed .I will start Heparin according to unit protocol ? prophylactic or therapeutic? or guidelines either low molecular weight (LMWH) or unfractionated .Dose is calculated according to body weight.Both are equally effective but unfractionated heparin causes thrombocytopenia and osteopenia which are less caused by LMWH . LMWH is administerd as 1 mg per Kg body weight is the dose the same for all brands on the market? sub cutaniously .To confirm DVT compretion duplex ultrasound (1) and dopler is advised for the femoral, conventional angiography or MRI for the Iliac vein thrombosis.Calf vein DVT is difficult to diagnose with US and doppler.

Women is advised to wear TED stocking mobilise her leg and avoid dehydration (1) .Daily assesment of temperature, pulse and leg girth measurement is carried out. FBC ,U&E monitored on alternate days . Anti F Xa activity is measured 3-4 hrs of unfractionated Unfractionated heparin??? APTT heparin and should be 0.5 - 1 iu per ml and further testing is not advised if renal function tests are normal.If she receives un fractionated heparin APTT is advised after 4 hrs and should be 1.5-2.5 of the control.

(B) Delivery should be electively planned at 39 weeks and documented (1) IOL .She is advised and taught self injections of LMWH subcutanously at home and needle disposal (1) . Anticoagulatin is cotinued for the rest of pregnancy (1) with the advise of regular antenatal follow up and to stop injection if labour starts (1) ,membranes rupture or vaginal bleeding starts.

If she starts labour therapeutic dose is stopped and prophylactic dose started .Labour is managed as high risk . ,dehydration and immobility should be avoided. continous electronic fetal monitoring advised . I will ask for anaesthetic assessment (1) , consult haemotologist and inform my consultant for backup support. Before induction of labour therapeutic dose is reduced to prophylactic dose When are you going to be able to administer epidural if you give prophylactic dose? .For an elective cesarean section prophylactic dose is given a night before and morning dose is ommited. Catheter for Regional anesthesia is sited after 12 hrs of prophylactic dose and after 24 hrs of theraputic dose (1) . At cesarean meticulous hemostasis is advised , drains should be used and skin sutured with interupted sutures or stapples as there is 2% risk of wound hematoma (1) . Excesive blood loss should be replaced and good hydration ensured . Pneumatic compression stocking may be used though its efficacy in preventing embolism is not proven. Prophylactic heparin is started 3 hrs after cesarean section and therapeutic dose administered in the evening. Heparin should not be given with in 4 hrs of insertion or removal of epidural catheter and catheter should not be removed with in 12 hrs of last injection.
Posted by PAUL A.
She is 40 years old,pregnant and multiparous,so she has increased risks for deep vein thrombosis(DVT) in her left leg ,but I have to exclude her having cellulitis,ruptured Baker cyst or trauma.Of these DVT is the most serious and thromboembolism is still a leading direct cause of most recent confidential maternal mortality report.
I will ask her of the pain and if it was related to trauma.Will ask of onset and radiation of pain and if there is groin pain suggestive of painful lymph nodes in case of cellulites.Will ask of history of previous vein thrombosis in previous pregnancies (1) and if treatment given and outcome of these pregnancies (thrombophilia and antiphospholipid syndrome).will ask history of varicose veins, immobility due to trauma or paralysis healthy 40 year old .Will ask of family history of thrombosis ? chest symptoms suggestive of PE .
On examination will measure body mass index, temperature(cellulites), pulse(increased in fever , in pulmonary embolism(PE),and anxiety), respiratory rate (tachypnoea in PE) (1) . Will examine lower limbs for tenderness,swelling,redness,edema and measure girth (1) to see if increased.Will examin groin lymph nodes (tender enlarged in cellulites),calf muscles tenderness(Homan sign,not conclusive).Will feel pulsations of dorsalis pedis artery on affected leg(absent in phlegmasia alba dolens).
Will ask for Duplex compression sonography (1) to detect site and help in diagnosis of thrombosis.I would admit the patient and start anticoagulant therapy(therapeutic dose of unfractionated heparin UH 80 iu/kg loading dose 18iu/kg maintenance dose or low molecular weight heparinLMWH 1.4mg/kg body wt is the dose the same for all brands of LMWH? ) if clinical signs are highly suggestive of deep vein thrombosis with the help of the hematologist for monitoring therapeutic dose of heparin.Venography with shielding of maternal abdomen might be needed to confirm the diagnosis. If I am suspicious of PE would do other test, arterial blood gases, ECG ,chest xray and ventilation perfusion scan or CTPA in a pregnant woman? (-1) .If patient has cellulites will treat with antibiotics and analgesics.


B) She will cotinue with the therapeutic dose of heparin during her pregnancy (1) .Care of patient through a multidisciplinary team composed of me, consultant obsterician, haematologist (1) , anesthetist ,midwife, pediatrician and herGP.She is taught how she can give herself subcutaneous heparin (1) .Patient given written information on her case and how to take heparin.Will arrange for her more frequent antenatal visits. In 7-10 days after starting heparin will check her platelets and discuss with hematologist.Will arrange fetal growth scans specially if history of thrombophilia.Will ask her to avoid immobility and get proper hydration.TEDs stockings for affected leg (1) . Elective delivery will be needed as there is risk of bleeding if she goes into labour and is anticoagulated.Will ask her to report immediately to labour ward in case she feel she is in labour before the time of elective delivery which is usually 39-40 weeks (1) IOL at 38-39 weeks.Reversal of heparin effect is done with protamine sulphate.. The patient is admitted the day before the date of elective delivery why is admission necessary? , when therapeutic dose of heparin is replaced with prophylactic dose. Anesthetist (1) will see and arrange timing of regional anesthesia( 24 hr after last dose of therapeutic heparin or 12 hr after prophylactic dose of heparin (1) ,maternal platelets should be >80,000/ml3 ) or general anesthesia.On day of procedure heparin is omitted.
If patient is induced continuous electronic fetal monitoring required, IV lines are secured, bloods sent for group and save and third stage is managed actively and be watchful for post partum hemmorhage.
If patient was to have an elective cesarean section, Flowtron boats ,proper hemostasis ,use of wound drains and closure of wound with interrupted sutures is done (1) .
Posted by H H.
Dear Paul, The green top guidlines NO 28 mention CTPA as one of the investigations for management of venous thrombosis in pregnancy in case of pulmonary embolism and compares it with V/Q scan,Please clarify. Much obliged
Posted by PAUL A.
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].
Possible diagnosis is deep vein thrombosis. I will focus my history on the risk factors which could course deep vein thrombosis. Her BMI, personal history or family history of PTE (pulmonary thrombo embolism) (1) , immobility, recent long distance travel, viscosities in her leg are risk factors for to have DVT.
In the history of chest symptoms need evaluating. Shortness or breath, pleuritic chest pain, may suggestive of progression to pulmonary embolism (1) .
On examination along with her vital signs pulse, blood pressure saturation, her constitutional symptoms you do not look for symptoms on examination like fever, malaise, feeling unwell will give some idea of inflammation of the leg. For an example cellulites, thrombo phlebitis could cause pain and swelling of he leg.
Because PTE is a biggest killer, in suspected cases if objective diagnosis is getting delayed, treatment should be started. I will do FBC, CRP to exclude any cause of infection, further LFT, RFT and coagulation profile (1) as a base line to start either heparin or low molecular weight heparin ? therapeutic or prophylactic . LMWH has a safety record and possible adverse effects of thrombocytopenia and osteoporosis which is caused by conventional heparin can be avoided.
To confirm the diagnosis I will request for compresion venous Doppler of her left leg (1) . If there is any delay in obtaining this, with the clinical suspicion I will start therapeutic LMWH (1) - clexane depends upon her booking or her very recent body weight. The dose would be 1.5 mg/kg twice daily doses.
Following confirmation of her diagnosis, I will explain to her about her the diagnosis and important of the treatment. Graduated compressive thromboembolic stocking (Class 2) of a correct size to her affected leg should be given (1) .
Therapeutic LMWH twice daily doses need starting. It is given as subcutaneous injection. Patient should be gradually trained to take the injection herself (1) disposal of needles . This helps she can be discharge home.
Routinely I will not do factor Xa assay for monitoring LMWH (1) . However, if the patient weight is either extreme ie: below 50 kg or above 90 kg I will do weekly factor Xa levels and try to maintain between 0.5mg/dl and 1.3 unit/dl. Weekly LFT and RFT will be requiring.
Advice will be given to the patient, in case if she develops any chest symptom she needs medical attention to exclude pulmonary embolism.
If she gets recurrent attack of clots, inferior veno caval filter (IVC filter) to prevent PE. This I will discuss with the haematologist. Expert radiologist should be available to perform this.
Sometime she may requiring thrombolytic treatment with streptokinase or urokinase, Once again expert opinion will be obtained for this.
Patient will be followed up in the consultant led antenatal clinic along with and anaesthetist review and haematologist input (1) . I will tell her, whenever she thinks that she is going in to labour she should stop the medication (1) – LMWH and come to the hospital where she will be asses by the medical staff and if she is in labour LMWH will be stopped.
If why IF? What will your plan be? the patient is planed for induction of labour or elective caesarean section the therapeutic dose of LMWH should be stopped 24 hours earlier (1) and prophylactic dose will be commence. When she goes in to labour LMWH should be stopped. Epidural or spinal can be administrated 24 hours after the therapeutic dose and 12 hours after prophylactic dose (1) . Senior anaesthetist should be involve in this patient’s care in labour (1) .
I will suggest her to read the patient’s information from the RCOG web site about the PTE. good answer
Posted by nilasha A.
As we know that this patient has risk factors for DVT ( age 40 yrs, gravida 5).Need prompt diagnosis and treatment to reduce maternal morbidity and mortality.
I will confirm the gestational age with LMP and early scan.I will enquire about severity of the symptoms ,aggrevating factor such as movement.Other associated symptoms like fever , trauma, or insect bite should be enqiured to rule out any infection.I will enqiure her past history of DVT and personal history of smoking and Immobilization.
Family history of DVT ( first and second degree relative),thrombhophilia should be enquired. Past obstetric history and complication should be asked.

On examination Blood pressure , pulse rate , temperature and BMI should be done.Left leg should examine for size of swelling, tenderness, skin colour, erythema to exclude infection.
FBC , U&E , LIF and coagulation profile should done as baseline. Doppler U/S of left leg is important to look for evidance of DVT.
Venography of lower limb is more sensitive. Provide patient with adequate analgesia and avoid dehydration and immobility.stat s/c
LMWH( low molecular weight heparin ) Prophylactic dose although no evidence of DVT in doppler ultrasound if clinically very suspicious of DVT. Repeat u/s doopler in 1 week

PART B

I will admit her for inward treatment.Avoid immobilization and dehydration. Give adequate analgesia.start S/C LMWH(low molecular weight heparin) therapeutic dose . Teache patient techique of s/c heparin injection.Discharge her with TED stockings once symptoms resolved.Follow up her in daycare unit more frequantly combine with physician.Risk of thrombocytopenia and osteoporosis in low with short term use of s/c LMWH.Advice her avoid any trauma and came to hospital immediatly if any PV bleeding.Give IOL date at 39 weeks POA if undelivered.Caesarean section(C/S) only for obstetric indication.Advice her to stop S/c heparin once she is in labour.Provide her with written information and leaflets.Refer patient to anaestetic clinic(for intarpartum analgesia ).Reduse to prophylactic dose heparin one day before IOL or C/S and stop s/c heparin the morning before IOL or C/S and restart prophylactic dose 4 hours after delivery and continue untill 6weeks.Avoid prolong labour and dehydration.Inra op avoid dehydration, minimise bleeding,good oxygenation and use pneumotic compretion of lower limb.Post delivery early mobilisation and avoid dehydration is important.continue TED stockings for 2 years.prompt assesment and treatment is important if she complains of chest pain or shortness of breath.Review her at 6 weeks post delivery for futher plan and contraception.
Posted by PAUL A.
M
(a)
A history to ascertain other risk factors like past history of personal/family history of thrombosis (1) . Past obstetric history with any thrombosis and complications.
Exclude local factors like trauma or injury related pain. ? chest symptoms
Examination including BMI(>30 another risk factor), localised signs of DVT like swelling with objective assessment with measuring tape, redness and tenderness may suggest DVT (1) Temp, pulse...
If clinical suspicion of DVT she should be immediately commenced on treatment dose low molecular weight heparin at 1 mg/kg body weight is the dose the same for all brands of LMWH? , subcutaneously with her booking/current body weight.
Prior to LMWH, bloods should be taken for FBC including platelets, LFT, U&E (1) and thrombophilia screen is not required but if done should be interpreted with haematologist.
Objective testing for DVT should be organised and compression duplex ultrasound is the investigation of choice (1) .
If duplex USS is negative and no clinical suspicion why treat in the first place if there is no clinical suspicion? then treatment can be discontinued.
If duplex USS is negative and clinical suspicion then continue treatment and need for further testing with Radiologist input.
Proven DVT need continued treatment involving Haematologist for the rest of pregnancy (1) and postnatally.

(b)
Antenatal care under multidisciplinary team with Obstetritian, Physician, Haematologist, Anaesthetist (1) .
Explain diagnosis to patient and need for definite treatment as associated with increased maternal mortality.
Teach her regarding ususage of LMWH administration and safe disposal of sharps (1) .
Treatment dose LMWH continued in 2 divided doses daily as pharmacokinetics changes in pregnancy.
Advice on leg elevation to reduce limb swelling and use of TED stocking to prevent post thrombotic sequales (1)
No need for monitoring anti-Xa (1) unless extremities of weight (<50kg or >90kg) or with renal problems or recurrent thrombosis.
Advice on good hydration and avoid immobility (1) as risk of recurrance of thrombosis.
Organise follow up antenatal care under obstetric consultant 2-4weekly and organise induction of labour at 37-38 weeks gestation (1) so as to time appropriately use of heparin in labour.
Her plan should be clearly documented in her notes.
She should be advised to deliver in consultant led unit as high risk delivery.
She should be advised to stop LMWH if in spontaneous labour (1) to reduce the risk of heamorrhage in labour.
She should be advised to stop heparin 24 hrs before planned delivery (1) .
If she chooses regional anaesthesia this is recommended after 24 hrs of treatment dose heparin (1) .
She should have IV acess in labour and bloods for FBC, clotting, group and save organised as increased risk of haemorrhage, anaesthetist (1) should be notified in labour.
She should be well hydrated in labour and delivery, and avoid prolonged immobility with labour and need for chaging position in labour should be emphasised.
If she has a caesarean section as the mode of delivery, then wound drain should be considered and staples or interrupted skin sutures to allow drainage of any haematoma (1) .
She should have a prophylactic LMWH 3 hrs after caesarean section or 4 hrs after removal of epidural catheter.
not asked about post-natal care Watch for PPH and team should be vigilant with management of PPH with a local protocol in place.
Active management of third stage to reduce risk of PPH and approprite use of oxytocics.
She should be advised regarding her postnatal care and need for continued treatment with anticoagulation and followup.

Very good answer
Posted by PAUL A.
LEEN
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].

(a)
The most important differential diagnoses is deep vein thrombosis, and other differentials include muscular-skeletal pain or abscess or lesions of the leg. There must be a high suspicion of DVT and low threshold for treating it until diagnosis can be confirmed waste of time & space .

I would enquire about the nature of the pain (intermittent, constant, aching) and if there are any precipitating or relieving factors. I would also ask her about any associated shortness of breath (SOB) one of the differential diagnosis is deep vein thrombosis(DVT) which may preceed pulmonary embolism(PE) (1) .
I would also ask about any previous history of venous thromboembolism (1) (VTE) - and if present, whether it was pregnancy associated, whilst on combined oral contraceptive pill, or in an unsual place as these have a higher risk of recurrence in pregnancy (this or subsequent); or whether it occured post-surgery or temporary immobility. I would ask about any family history of VTE or thrombophilias as well as if she is known to have any thrombophilias because these are risk factors for DVT. Other risk factors for DVT such as smoking and immobility should also be elicited. I would ask about current and previous drug history, whether she has been or is on anti-coagulants. I would also want to find out if she has any potential contra-indications to anticooagulant therapy like what? healthy 40 year old woman – you have spent too much time and space on Hx and there are only 2 marks (7 marks for the entire section) .

On examination, I would assess her general condition, if she is unwell (eg with SOB) she may have PE and might require resuscitation. I would check her body mass index, as obesity is a risk factor. I would obtain her blood pressure, pulse, respiratory rate and temperature (1) to assess her general condition (pulse and temperature may be raised with DVT). I would examine her legs (looking for redness, warmth) and measure them(circumference). I would also look for signs of other differential diagnoses like abscess or trauma (1) .

I would have a low threshold for commencing her on treatment dose anticoagulants - low molecular weight heparin (LMWH) (1) , whilst awaiting for results of investigations.

I would obtain blood samples for full blood count, coagulation screen and urea and electrolytes (1) LFTs - for baseline measurement in case theatment is required. D-dimer can be raised in pregnancy, but if negative may mean DVT is unlikely. I would however, consult the local hospital protocol before performing this test.
COmpression duplex ultrasound (1) (USS) of the leg should be done, and if there is a high suspicion of DVT but negative USS, I would continue her LMWH and arrange for either a repeat USS or venography in a week\'s time will you expect this to be positive after treatment even in a woman with a proven DVT? .

(b)
Her care should be multidisciplinary and I would involve the physician, haematologist (1) , anaesthetist, midwive as well as her obstetric consultant. Treatment dose LMWH should be continued, and the appropriate dosage should be based on her weight and be given as a twice daily regimen. Platelets should be checked 7 days after commencing treastment as it may cause thrombocytopenia; however, unfractionated heparin has a higher risk of this as well as other side effects, and require anti-Xa levels do you check anti-Xa with unfractionated heparin?? to be checked; thus LMWH tends to be preferred.
I would advice her that LMWH does not cross theplacenta, so is not teratogenic or -toxic.
She will need to be taught how to self-inject and dispose of the needles safely (1) , as LMWH is given subcutaneously.

Warfarin is given orally, but is associated with a higher risk of maternal and fetal bleeding (as it cross theplacenta), so if used, should be replaced with LMWH at 36 weeks to reduce the risk of fetal haemorrhage THIS SHOULD NOT BE USED – RISKS PERSIST EVEN IF STOPPED AT 36 WEEKS AND THERE IS A SAFER ALTERNATIVE (-2) .

I would give her a leaflet about DVT, and contacxt details of support groups ? EXAMPLE?? DO NOT JUST THROW THIS IN – DO YOU ACTUALLY DO THIS? , and counsel her about avoiding dehydration and immobility (1) . I would also counsel her about signs of symptoms of PE to look out for.
She should be advised to stop LMWH if she suspects or goes into labour (1) .

Her delivery should be planned in a multidisciplinary setting, and induction of labour may be advisable ?? may be?? What else could you do? Allow her to go into spont labour at 41 weeks after a therapeutic dose of heparin? to try ensuring that she labours in the hospital and with consultant (obstetrician and anaesthetist) presence if possible - bearing in mind she is multiparous and her labours may be very quick.
Treatment dose LMWH should be stopped one day beforehand (1) and changed to prophylactic dose LMWH. Regional anaesthetic can be administered if her last dose of treatment LMWH is more than 24 hours before or prophylactic dose LMWH is more than 12 hours ago (1) .

YOU WOULD HAVE RUN OUT OF SPACE / TIME HERE Intravenous infusion of unfrationated heparin through labour may be easier to adjust and maintain the optimum anticoagulant state if she has a high risk of recurrent DVT or PE.

If she has a caesarean section, a drain should be sited and interrupted skin suture shoould be put in to allow haematoma to be removed

She should be commenced on prophylactic dose LMWH within 3 hours of delivery or 4 hours after removing the epidural cathether.
Treatment dose should be given once the risk of post partum haemorrhage(PPH) is deemed reduced/passed.
She may either continue treament dose LMWH or oral warfarin (will require INR check until levels stable) post natally for at least 3 months. Both as safe in breastfeeding;.
Followup is importnat to counsel her about her risk of recurrence of VTE and management in her next pregnancy.
Posted by PAUL A.
Shalini
a)It is essential to begin by taking a detailed history of pain n swelling-any history of trauma or immobilisation prior to its occurance or spontaneous in onset.Any symptoms of dyspnoea,chest pain (1) or unwell feeling.Review her maternity records for pre-eclampsia or any dehydration,immobilisation healthy 40 year old ,smoking to cause thrombosis in this pregnancy as she is >40 years with parity more than 4 which are two major predisposing factors for thrombosis to occur.A detailed history of previous child-births should be taken -any history of thrombosis or treatment for the same (1) ; mode of deliveries;contraception used between them ? relevance .Also ask for family history of thrombosis in first degree relatives or thrombophilias in the family.Her BMI should be calculated as BMI>30 pedisposes to thrombosis.On examination her pulse,BP,temperature (1) ,chest examination (for findings suggestive of embolism),abdominal examination for uterine height and local examination of the leg to see for localised redness,warmth tenderness (1) and a positive Homan\'s sign controversial .If clinical suspicion is strong heparin should be started ? therapeutic or prophylactic? till confirmation is done by objective testing after blood investigations like full blood count(thrombocytopenia),clotting studies(abnormal coagulation),urea,electrolytes,liver function tests (1) should be done for baseline investigations. Also ECG,Chest x-ray should be done to rule out thromboembolism do these tests rule it out?? .A compression duplex ultrasonography to confirm deep vein thrombosis (1) .
b)The lady should be counselled about the problem-explained about risks associated with thrombosis-risk of embolism which is a life threatening emergency and the need for anti-coagulants which have side-effects.Low molecular weight heparin should be started without awaiting for confirmation by objective tests just answer the question which tells you what the test results are .It has the advantage of less side effects like thrombocytopenia,bleeding n risk of osteoporosis as also less need for monitoring and convenient dosing. If why IF? THE QUESTION TELLS YOU SHE HAS A DVT compression duplex ultrasonography is positive for DVT therapeutic dose (1) of heparin should be continued till 6 weeks postnatally (1) . However if it is negative you have clearly not read the question but high clinical suspicion is there then heparin should be con tinued till repeat ultrasound 1 week later.TEDD stockings should be worn.Platelet count should be monitored.No need for monitoring dose with anti-xa levels (1) unless BMI ,19 or >30 or renal failure present.She should be explained symptoms of pulmonary embolism and to report if they occur.Vaginal delivery is allowed and only obstetric indications for cesarean sections.She should be taught self injection (1) & disposal of needles and also told to with-hold injection is she goes in labour (1) .Anaesthetic review by Consultant should be done for plan in labour (1) .on the day of planned delivery by cesarean section why should she have CS?? the morning dose should be omitted .Epidural anaesthesia is safe if given after 12hours of prophylactic dose of heparin and after 24 hours of therapeutic dose (1) SHE SHOULD HAVE PLANNED IOL AT 38-39 WEEKS .heparin can be restarted after consultation with the anaesthetist after 3 hours of cesarean section.Heparin can also be given after 4 hours of epidural catheter insertion or removal although epidural catheter should not be removed 12 hours after last dose of heparin.Dehydration and immobilisation should be avoided (1) and pneumatic compression stockings should be worn during cesarean section.
Posted by PAUL A.
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].
a)the clinical scenario points towards deep vein thrombosis(DVT) (multiparous, pregnant, unilateral leg pain and edema, left leg) investigating expeditiously and involvement of multidisciplinary team consisting of consultant obstetrician, physician, hematologist, and radiologist is preferable. while arranging for baseline blood investigations you have not taken a Hx or examined the woman yet you are taking blood and talking to other consultants??? and a compression duplex ultrasonography (1) i would start her on therapeutic dose of low molecular weight heparin what if she had cellulitis or a broken leg? (LMWH) drug and dose as per the protocol of the unit unless there are strong contraindications for anticoagulation like bleeding disorders healthy 40 year old . usually LMWH is given in a twice daily regimen .Her baseline blood investigations would include full blood count, urea, electrolytes, LFT, coagulation screen (1) and thrombophilia screen. since coagulation factor levels are differant in pregnancy interpretation of thrombophilia screening is better done in consultation with the hematologist. continuation of anticoagulation would depend on the objective diagnosis of DVT. if on doppler DVT is identified then LMWH is continued. in the absence of DVT finding on the scan and strong clinical suspision i how? No Hx or examination would still continue LMWH and repeat the test after 1 week or go for alternative testing like venography if facilities are available. meanwhile i would enquire for signs and symtoms suggestive of pulmonary thromboembolism like, chest pain, dyspnoea and hemoptysis the presence of which she would require an additional chest x ray. additional measures would include, keeping the lower limbs elevated while lying down, use of graduated compression stockings and encouraging mobility (1) .
b) once diagnosed with DVT therapeutic dose of LMWH has to be continued for the remainder of pregnancy (1) , patient can be managed on outpatient basis, self administration of injections and disposal of needles has to be taught (1) to the patient. LMWH does not require monitoring of plateles or peak factor Xa levels (1) unless at extremes of weight (patient is <50kg or >90kg), or has other complications like renal disease or recurrent thrombosis.monitoring involves measuring peak factor Xa levels after 3 hrs of injection which should be 0.5-1.2 u/ml. patient should be warned of symtoms of recurrent DVT and pulmonary embolism in which situation she should report back. patient should be advised to keep the limbs elevated when at rest and to use the compression stockings regularly. use of compression stocking has shown to reduce the incidence of post thrombotic leg syndrome from 23% to 11%. at term cesarean section is only for obstetric indications. patient should be advised not to take the LMWH injection in the event of labour (1) or if she thinks she is in labour, for epidural catheter to be inserted minimum 24 hrs have to be passed from the last injection (1) . management of ist stage does not differ but in second stage instrumental delivery should be avoided if possible are there situations when this should not be the case? and active management of third stage of labour should be done.if the patient is planned for an elective cesarean section then LMWH has to be stopped for 24 hrs, at cesarean, it is worthwhile to put a drain both at the level of rectus sheath and subcutaneous tissue, skin suture should be closed by staples or intermittent sutures to facilitate draining of an hematoma which may occur in approximately 2% of women (1) . not asked about post-partum care LMWH should be restarted at 3 hrs following cesarean or 4 hrs after an epidural cathetre is removed, similarly removal of cathetre should be 6 hrs after the last injection. post partum patient should be given the option of oral anticoagulation vs LMWH. if patient wishes LMWH it should be started after 3 days of delivery or even longer if there is a risk of hemorrhage. monitoring of INR for the first 10 days of starting warfarin would be required, heparin should be stopped after an INR of 2 is reached. on warfarin INR should be maintained between 2-3. patient should be counselled that neither LMWH nor warferin are contraindicated in breast feeding. anticoagulation should be continued for 6 wks postpartum. the total duration of the anticoagulation after the DVT should be 3 months. if the patient is at risk of hemorrhage then use of unfractionated heparin is better than LMWH peripartum since it has a shorter half life and its effects can be easily reversed with protamins sulfate.
Posted by PAUL A.
A)
Initial management includes a full clinical history, examination and investigation to establish the cause of the pain and swelling.Ask about the onset and severity of symptoms, any associated aggravating or relieving factors. Inquire about any possible injury secondary to a fall, or pain due to ligament or muscle stretch.
Rule out associated symptoms of palpitations, cough or breathlessness to rule out the possibility of pulmonary embolism(PE) (1)
Inquire about any similar problem in her previous pregnancies.
Inquire about any personal/family history of thrombophilia (1) .
Also ask about any recent surgery which may have limited her mobility.Inquire if she,s a s moker or not.
General examination should include height and weight to calculate the BMI of the patient. T,P,BP
Examination should include inspection of left leg for any obvious bruises, swelling and redness. compare both legs in terms of size.Feel for the temperature in both legs using the back of the hand.Use a measuring tape to assess the size of the effected calf and the uneffected calf and document the circumference of each calf and the difference in her notes (1) .
After making a diagnosis of DVT based on the clinical findings, it is important to initiate the patient on full therapeutic dose (1) of low molecular weight heparin( LMHW) and Thromboembolic deterrent stockings (TEDS) as soon as possible and then arrange for Doppler ultrasound (1) ? any blood tests? studies of the leg to confirm the clinical suspician of same.
B)
After the establishment of diagnosis, the patient should be explained about the findings and it\'s implications discussed i.e breakage of the clot leading to a pulmonary embolus.She should be given information leaflets about DVT in pregnancy.
Her care should be in multidisciplinary setting involving the Haematologists (1) , Medical team and the consultant obstetrician and the anasthetist.Her plan of management regarding
her antenatal care and during delivery should be clearly documented in her notes.
Baseline you are doing them AFTER starting treatment investigations should include FBC and coagulation profile, and LFTs. A thrombophilia screen is not recommended during treatment.it can be undertaken after consultation with the haematologist 6 weeks post partum.
She should be continued for the remainder of the duration of pregnancy on therapeutic dose of LMWH (1) . She should be taught to self inject and make appropriate provisions for safe disposal of syringes (1) . There is no need to measure anti Xa levels (1) unless patient is at extremes of weight i.e >90kg or < 40kg.
In case of any suspicion of pulmonary embolism(PE) a CTPA or V/Q scan which would you do? The medical team might know less about VTE in pregnancy and this is an obstetric issue can be done in consultation with the medical team.
If patient goes into spontaneous labour, she should be asked to omit her usual dose of LMWH (1) and her further doses should be given in the hospital. The anaesthetist ? SHO?? should be involved in her care with regards to the use of regional anaesthesia. She should not receive Regional anasthesia if her last injection of LMWH was within 24 hours (1) .After delivery not asked about post-natal care she can have her prophylactic dose of LMWH 4 hours after insertion or removal of epidural atheter.
Incase of planned deliveyby C/sec for any obstetric reasons, she should be told to omit the dose of LMWH one day before surgery and surgery should be performed in the morning. She can have herprophylactic dose of LMWH 4 hours after insertion or removal of epidural catheter.
She should be actively managed for the third stage of labour to reduce the risk of PPH. labour should be induced at 38-39 weeks
Posted by PAUL A.
A. This symptoms suggestive of DVT, I will take history specifically I will ask if her symptoms associated of chest pain or dyspnoea (1) , and to enquire about her personal and family history of thromboempolic disease (1) and if she is known case of thrombophilia. I will examine her vital sign pulse, Bpr, respiratory rate and temperature (1) ??? WILL YOU EXAMINE HER LEG?? . I will admit her and her management require multidisplinary approach; senior obstetrician, physician, haematologist and radiologist. I will start anticoagulant once result of investigation be ready, which will include blood for renal and liver function test clotting screen and full blood count as anticoagulant therapy can influenced by them will you wait till results are back before starting treatment?? .
D dimer, will not help to diagnosis DVT as it usually raised in pregnancy but if it is low level it will help to exclude DVT do low levels exclude DVT?? . Thromophilia screen is not required routinely and where performed will require to be interpreted by haematologist. It will not influence the immediate management but can influence the intensity of anticoagulant for example antithrombin deficiency will require higher dose.
I will start anticoagulant treatment in form of therapeutic dose low molecular weight heparin (1) ; the dose will be tittered against booking or more recent weight and according to the local protocol, 12 hrly s.c, until the DVT either objectively diagnosed or excluded, unless woman has strong contraindication for anticoagulant healthy 40 year old . Unfractionated heparin, i.v 6 hrly used if woman has risk of haemorrhage such as woman with coagulopathy , major antepartum haemorrhage,. answer the question asked – healthy 40 year old
I will arrange compression duplex ultrasongraphy (1) , which is the primary diagnostic tool for DVT , if result negative I will continue with anticoagulant so do you never stop treatment and send women home? How likely is the test to be positive 1 week after treatment even in a woman with a proven DVT? and consider repeat test after one week as this woman apart from pregnancy she also have other risk factors. Age of more than 35 is independent risk factor for thromboemolism and she is also multipara (more than4) and her symptom of unilateral left (which is the most common site) leg pain and swelling is highly suggestive. But if after one week result of repeat test is negative then I will exclude diagnosis and stop anticoagulant this is incorrect – your management should be base on the clinical index of suspicion, not just on tests .
B
Anticoagulant treatment will continue throughout pregnancy (1) and 6 weeks thereafter (i.e in total at least 3 months).
I will advice her to elevate her leg and to wear graduated elastic compression stocking (1) class 1 to reduce pain and swelling and reduce post thrombotic syndrome, I will instruct her how to wear them correctly and encourage her to be walk.
If her leg viability threatened by venous gangrene, I will continue on therapeutic anticoagulant, ask her to elevate her leg and consider either surgical embolictomy or thrombolytic agent.
Low molecular weight heparin therapy does not require platelet or anti Xa activity (1) to be checked routinely but if woman at extremities of weight (less than50kg or 90kg or more) or has renal impairment healthy 40 year old anti-Xa activity will be checked and aim is to achieve peak level of anti-Xa 3 hr of 0.5-1.2 units/ml. Unfractionated heparin will require platelets to be checked every 2-3 days from 4 to 14 days or until stopped whatever occur first.
LMWHs, are safe in pregnancy as they do not cross placenta, and are more effective and has reduced risk of osteoporosis and thrombocytopenia compared with unfractionated heparin. They have low risk of haemorrhage , however, unfractionated heparin has short half live so if haemorrhage occur it will be stopped and prothrombin sulphate given to oppose it is action and for that reason and because of the familiarity with it is used it recommended if woman at risk of haemorrhage. If haemorrhage occur while woman on LMWH it should be stopped and advice taken from haematologist.
If thrombocytopenia developed or allergic reaction to heparin, danaproid Na or heparinoid given instead and advice from haematologist is required
Warfarin is associated with embryopathy and central nervous system abnormality and also risk of fetal and neonatal haemorrhage and will not be used in the maintaince therapy.
Once her symptom and sign is resolved she will be managed as out patient. If swelling persists I will advice her to wear graduated elastic stocking class 2 only in the affected leg and to remove it at night for 2 yr as that will reduce the risk of post-thrombotic syndrome.
Before discharge I will be arrange for her to learn safe needle and syringe disposal (1) and self subcutaneous injection and followed up clinically as out patient and where required with plat and antiXa activity. YOU WOULD HAVE RUN OUT OF SPACE / TIME HERE I will advice her that if she feel that she is in labour should not inject her dose and if she required to be delivered electively the treatment will be stopped 24hr before induction or caesarean section.
If epidural anaesthesia required discussion with senior anaesthetist with keeping to the local anaesthesia protocol and catheter should not be inserted until at least 24 hours after last dose of LMWH or after 12hr of unfractionated heparin. The next dose should be given at least more than 4 hr after removal of epidural catheter and catheter should not removed within 12 hours of the most recent injection.
If caesarean section will be required thromboprophylactic dose will be given woman 3 hr after the operation and the therapeutic dose commenced in that evening dose.
Both abdominal and rectus sheath drains will be required and use of staples or interrupted suture when skin closed , to enable drain of haematoma if develop as there is 2% risk of wound haematoma by both LMWH and unfractionated heparin.
Posted by Nur Sakina K.
NSK
from A:
I’d enquire re onset of pain and site on her leg as 80% of DVT’s usually occur in the left (L) leg. I’d also ask whether the swelling is localized to one or both legs. Symptoms such as erythema and swelling are suspicious of DVT. I’d enquire re associated pleuritic chest pain, dyspnoea, hemoptysis or pyrexia suggesting pulmonary embolism (PE). I’d assess her risks for thromboembolic disease (TED) such as parity (multiparae), BMI (obesity) , age( older mum) and a family history of TED especially in 1st or 2nd degree relatives or thrombophilia disease.
Examination involves obtaining observation for pulse (tachycardia), temperature (pyrexia), respiratory rate (tachypnoea) and blood pressure. If hx suggests respiratory symptoms, I’d listen to the heart (for tachycardia) and lungs for reduced air entry suggestive of PE. I’d examine her legs for site of tenderness, palpate for induration, temperature and swelling. I’d measure both calves to assess size differences. A > 2 cm difference in circumference is suspicious of DVT.
Investigation involves a full blood count (FBC) for platelets and elevated WCC, biochemistry (U+E, LFT’s), coagulation screen prior to starting LMWH treatment for baseline levels. I’d arrange Doppler USS of L leg exclude DVT. If chest symptoms are present, I’d arrange a V/Q scan to exclude PE. A CXR and ECG can be done but results may be nonspecific and signs not present all the time.
I’d start therapeutic doses of LMWH until Doppler excludes a DVT. My choice of treatment is enoxaparin (clexane) 1 mg/kg body weight BD. Codeine or paracetamol analgesia is given for leg pain and I’d advise TEDS stockings to be worn throughout the pregnancy.

From B;
I’d explain the risks associated with DVT to both her (death, post phlebitis syndrome, PE) and baby (stillbirth, IUGR) and the importance of compliance to anticoagulant treatment. I’d manage her in the high risk antenatal clinic with multidisciplinary team input from the anaesthetist, obstetrician, hematologist and gp. I’d arrange for the woman to meet the anaesthetist to discuss analgesia options in labour including regional anaesthesia. I’d explain the importance of continuing LMWH treatment throughout the pregnancy, use TEDS stockings, elevating the legs at rest, encouraging mobility and avoiding dehydration. Routine monitoring of LMWH therapy in pregnancy is not needed, but if done anti X a levels 3 hours post injection is targeted at 1iu/ml. Platelet monitoring for risk of HIT (heparin induced thrombocytopenia) rarely occurs with LMWH, thus not usually done. LMWH treatment for at least 3 months in total and at least 6 weeks postnatal is needed. Thrombophilia screen is not routinely done antenatally and if performed during pregnancy requires hematologist interpretation. It should be repeated 6 weeks postnatal.
I’d explain that if she thinks she is in labour to stop further LMWH injections until assessed in hospital. In a planned delivery (c/s or IOL), I’d advise stopping therapeutic LMWH 24 hours prior and switching to prophylactic dose throughout labour.
If regional anesthesia used, insertion should be done at least 24 hours after last therapeutic dose or 12 hours after last prophylactic dose. Removal of epidural catheter should not be within 12 hours of last injection and not to administer prophylactic dose post delivery for at least 4 hours after catheter removed. This is to reduce the risk of epidural site hematoma. Therapeutic dose can be restarted that night. If she were to have a c/s, I’d explain the need for wound drain and staples or interrupted subcutaneous skin stitches for skin closure to reduce the risk of developing wound hematoma (2%).
Posted by PAUL A.
Sanchu A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].

History of onset and site of swelling and pain with should be asked for. eg. gradual onset with localised swelling and pain may be due to arthritis. History would be to ask for similar episodes in the past, any provoking factors like long travel, family history of thrombo-embolism (1) . History should also be directed at asking for symptoms of embolism i.e. chest pain, breathlessness (1) .

Her vital signs, BP, pulse rate, RR and Temp are done (1) .

Examination would include inspection with comparison of the unaffected leg for extent of swelling and redness,involvement of thigh would suggest iliac vein thrombosis, palpation for edema and calf tenderness (1) .

Examination of the abdomen looking for any tenderness in iliac fossae indicating pelvic vein thrombosis and obstetric examination.

If DVT is strongly suspected on clinical examination, therapeutic dose of low molecular weght heparin shoul be started immediately according to hospital protocol, eg. Tinzaparin 125 units/kg od there are no marks for dose but you lose a mark for getting it wrong – 175 u/kg .

TED stockings should be provided. Bedrest is not advised and she is encouraged to drink plenty of water and be ambulant (1) .

She must be referred to the DVT clinic or for Colour Doppler ultrasound (1) scanning of her leg to diagnose DVT.

B)She must be continued on Therapeutic dose of LMW Heparin till when? , taught to self-administer (1) , advised to avoid dehydration, provided TED stockings and can be discharged home with advice to come to hospital immediately if she develops chest pain or breathlessness.

She should be followed up every 2 weeks in the antenatal clinic to monitor improvement and compliance and weekly by her community midwife with one consultation with the anaesthetist (1) .
She must be advised to stop heparin once she thinks she is in labour (1) or broken her waters and seek advice.

When induction or Caesarean section is planned why is CS needed? , Heparin is stopped before 24 hours (1) . Regional analgesia/anaesthesia is contraindicated until 24 hours after the last therapeutic dose of LMWHeparin (1) .
After C-section or after delivery, prophylactic dose is given 3 hours after delivery, 4 hours after removal of epidural catheter.Therapeutic dose is restarted after 24 hours. The epidural catheter should not be removed within 12 hours of last injection.

A drain is advisable and skin is closed with interrupted sutures or staples (1) . If she is at high risk of bleeding, Unfractionated heparin is used since it is easier to reverse with protamine sulphate.

If there is PPH because of heparin, Coagulation profile is done, Hematologist advice is sought and fresh frozen plasma is used. not asked about post-natal care
Posted by PAUL A.
PART A
DVT is the most likely diagnosis in view of maternal age,high parity and presenting complaints. The differential diagnosis include trauma, cellulites and ruptured Bakers’s cyst. I will ask the woman about previous history of venous thromboembolism (VTE) during pregnancy or outside the pregnancy(site of VTE).I will ask about family history of VTE or thrombophila (1) .I will ask about any trauma to the leg and prolonged immobilisation healthy 40 year old .A history of high grade fever and rigors might be suggestive of cellulites.I will ask about the presence of chest symptoms like shortness of breath, chest pain and hemoptysis for pulmonary embolism (1) .I will also enquire about previous obstetric history and outcome including use of thromboprophylaxis, antenatal complications, mode of delivery and birth weight. In clinical examination I will check BMI, pulse and temperature (1) (fever >38C is suggestive of infective cause while in DVT there is low grade fever). In local examination of legs I will inspect for swelling, erythema (extent of erythema if cellulites) and presence of gross varicose veins. On palpation I will check for oedema, tenderness / induration,diameter and increase heat in affected leg (1) . I will check lower limb pulses to check for evidence of ischemia. I will check for the presence of tender groin nodes / lymphangitis (suggestive of cellulites). In investigation I will send FBC(leucocytes/platelets) , CRP(infection), Urea and electrolytes,liver function test and coagulation screen (PT/APTT) (1) before starting anticoagulation therapy. I will do throbophilia screen specially factor V Leiden Mutation, prothrombin 20210 A mutation, although it is not recommended routinely you will not get marks for doing something which is not recommended and does not affect the immediate management but it can influence the duration and intensity of anticoagulation if this is so important, why is testing not recommended? . Results will be analyzed by haematologist. As DVT is associated with increased morbidity and mortality especially if treatment is delayed, unless there is any alternative diagnosis, signs and symptoms are highly suggestive of DVT so anticoagulation like LMWH (1) will be started while awaiting for objective testing. Legs will be elevated and graduated elastic compression stockings applied to reduce oedma and mobilization will be encouraged. I will arrange for compression Duplex USG of legs (1) . If USG confirm anticoagulation treatment will be continued if it is negative but clinical suspicion is high I will repeat USG after one week If a woman has a proven DVT and is treated, how likely is it that the Doppler test will remain positive after 1 week? Yet you will stop treatment after 1 week?? .
PART B
A multidisciplinary team approach will be taken involving obstetrician, haematologist (1) , physician, radiologist and anesthesit. Treatment with the LMWH will be continued for the rest of the pregnancy (1) . I will explain the risk and benefit of LMWH to the woman. LMWH is most effective, safer and is associated with lower risk of hemorrhagic complications in antenatal/peripartum period with lower mortality than unfractioned heparin. There is also decreased risk of heparin induced thrombocytopenia. LMWH ( like enoxparin or deltaparine) will be given daily in two subcutaneous divided doses with dosage titrated against woman’s booking or most recent weight according to the unit protocol.Routine measurement of peak anti-xa activity(3hrs post injection of0.5-1.2units) is not recommended (1) except in women with extreme of body weight(<50kg and>90kg or with other complicating factors like renal impairment healthy 40 year old – focus on the question asked ).Routin platelet count monitoring will not be carried out.I will provide training to the woman for self injections and safe disposal of the needles (1) and advise to avoid immobility and dehydration (1) . I will arrange for out patient follow up in senior obstetrician clinic once women stabilised, that will include clinical assessment and advice( with assessment of platlets/peak anti-xa level if indicated). I will arrange USG for fetal biometry,liquor volume,fetal well being andregular growth scan as there is risk of IUGR. Because of adverse effect of oral anticoagulation to the fetus and the mother it will not be offered. I will advise the woman that if she thinks she is in labour she should not inject further doses of heparin (1) and come to hospital immediately. Timing and mode of delivery will be discussed with the woman. Aim will be for vaginal delivery and cesarean section for obstetric indications. Plan will be for elective induction of labour between 38 and 39 weeks (1) to avoid the woman comes in spontaneous labout with full anticoagulation. I will ensure antenatal anesthetic review (1) and senior obstetric assessment with plan documented in her notes.I will provide written information of above detail, further appointments and hospital contact number.
Regarding intrapartum care, for Elective delivery, LMWH will be discontinued 24 hrs before IOL or Caesarean section (1) .send bloodfor FBC/clotting profile. Early anaesthetic review of the woman will be done. YOU WOULD HAVE RUN OUT OF SPACE / TIME HERE Regional anesthetic or analgesic technique will not be carried out until at least 24 hours after the last therapeutic dose of LMWH and LMWH willnot be given for at least 4 hours after epidural cathetar has been removed and cathetar should not be removed 12 hours after the most recent injection.If women is having labor she should remain mobilized with good hydration.TEDstocking will be applied during the labour.Prolonged labor will be avoided with timely intervention.Active management for third stage of labor will be done.If women comes with spontaneous labor further injection of LMWH will be stopped and epidural analgesia(epidural anesthesia in Em c-section)will not be given if<24hrs of LMWH injection.For elective caesarean section, Continued TED stockings during the operation and fastidious hemostasis will reduce the risk of VTE. Wound drains (Abdominal / rectus sheath) will be left in place and interrupted sutures of the skin will be applied for the drainage of hematoma. A Thromboprophylactic dose of LMWH will be given 3 hrs post operatively (> 4 hrs after removal of epidural cathetar) if appropriate and treatment dose is recommended that evening after discussing with the anesthetist. After surgery good hydration, early mobilization and continued use of TEdstocking will be ensured to decrease the risk of VTE. Therapeutic anticoagulation will be continued for at least 6 weeks postnatally.

good answer. However, if you spend too much time on one question, you may find you do not have time to complete another question and that could be costly
Posted by PAUL A.
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].

a) It is important to assess her by history and examination and she needs immediate treatment as venous thromboembolism(VTE)(probable diagnosis) is associated with maternal morbidity and mortality.
I will take the detail history regarding any history of trauma to leg, any previous episode of swelling and pain, allergies ,insect bites, local infection.I will also enquire about chest symptoms, difficulty in breathing,cough, haemoptysis and chest pain as it may point towards PTE (1) .Any history of lower abdominal pain, low grade pyrexia and dizziness is also very important.Her previous obstetric history is important regarding her mode of deliveries and previous VTE during pregnancy.Any personal history of VTE outside pregnancy, familly history of VTE (1) or thrombophilia screening and their results to be asked.
On examination her B.P,pulse, temperature, respiratory rate, oxygen saturation, BMI should be recorded (1) .
Complete examination of chest and heart should be done,height of fundus and fetal heart should be heard.
Local examination is very important, Iwill look for site ,extent of swelling(involvement of entire limb--iliac vein thrombosis), redness, raised temperature, tenderness and any varicosities. Circumference of both legs at same points like midthigh and calf area should be recorded (1) .
If there is high suspicion of VTE,treatment should be started immediately. I/V line should be maintained and bloods to be collected for FBC to look for WBC and platelet count, coagulation screen, renal and liver function tests (1) . Blood for thrombophilia screen can be send though it is not routinely recommended, results should be interpreted by haematologist as there are physiological changes in coagulation system during pregnancy but it will help in duration and intensity of anti-coag therapy needed.
Anti coagulant therapy with low molecular weight heparin (LMVH) (1) should be started before objective tests for VTE should be done, therapeutic dose should be given in two divided doses, it is equally effective like unfractionated heparin.TED stocking and elevation of leg should be done (1) . Doppler U/S should be arranged,if it is negative and clinical suspicion is high, continue with treatment and either do venogram or repeat dopplers after one week how likely is it that test will be positive if the woman is treated, even if she had a proven DVT? .
X-ray chest , ECG can be done to look for pulmonary thromboembolism.Fibrinogen degradation products should not be checked as they are physiologically raised in pregnancy.

b) This is a high risk pregnancy, hospital protocols should be followed,and care should be given by multidisciplenary team including obstetrician,haematologist (1) and physician.There should be a plan for her antenatal, intrapartum, postnatal and f/u care.
She will need the maintaince therapy in the form of therapeutic dose for 6 months or until at least 6 wks postpartum (1) .LMWH should be contiued as it is convenient to take, decreased risk of haemorrhagic complication,thrombocytopenia and osteoporosis as compared to unfractionated heparin. It does not cross placenta so no harm to baby. Routine platelet count and anti-Xa activity not reuired (1) .Woman should be taught for self injection and safe disposal of needles (1) .
Oral warfarin should not be given as risk of fetal and neonatal haemoorhage and central nervous system abnormalities.
She should be given written information, advised increased fluids orally, mobilization and to report if any signs of DVT or PE again. She should be advised against long travelling.
She should have anaesthetist review (1) and plan should be made keeping in view her analgesia and anaesthesia requirement.
Fetal growth should be assessed by regular scans.
Mode of delivery according to obstetric indication. If she is for vaginal delivery, plan for induction of labour around 38 weeks (1) so that proper management of her anti - coag therapy can be done. She should be advised not to take heparin if feels she is in labour (1) .
Regarding her intrapartum care,if she is for vaginal delivery , her therapeutic dose should be stopped 24 hours before (1) . During labour prophylactic dose to be continued and after delivery therapeutic dose can be re-started.Epidural anaesthesia by senior anaesthetist and according to local protocols and at least after 24 hrs of therapeutic dose of heparin what about prophylactic dose since you are going to use it in labour?. LMWH should not be given for at least 4 hrs after the cathetar has been removed. In case of elective caesarean section, therapeutic dose should be discontinued 24 hrs before , prophylactic dose should be given 3 hrs after surgery or 4 hrs after removal of epidural cathetar.Therapeutic dose can be re- commenced same evening.
Surgery should be done by consultant and consultant anaesthetist should be present, haemostasis should be secured properly and if risk of bleeding drains should be left intraperitoneal and sub rectal.Interrupted sutures to be applied to the skin to allow drainage of any haematoma (1) .
If there is high risk of haemorrhage then intravenous unfractionated heparin should be considered until the risk factors for haemorrhage are resolved. GOOD answer
Posted by PAUL A.
a)I would take a full history or her symptoms and enquire about any associated symptoms such as dyspnoea and chest pain to exclude pulmonary thromboembolism (PTE) (1) . I would ask about any personal or family history of thrombophilia or venous thromboembolism (VTE) (1) . I would check for any predisposing factors for VTE such as dehydration, immobility, medical conditions healthy 40 year old , and obesity.
I would examine and measure the patients legs looking for other causes of pain and swelling(eg cellulitis) how will you identify DVT? . I would perform respiratory and cardiovascular system examinations looking for signs of heart failure and PTE.
I would gain iv access and perform a full blood count, coagualtion screen and CRP renal / liver function tests . I would not perfrom Ddimers as these are of little value in the pregnant patient.
I would arrange a compression doppler ultrasound of her leg (1) to diagnoses a deep vein thrombosis. If there will be a long delay before this test can be performed I would commence her on treatment dose low molecular weight heparin (LWMH) (1) . I would use her booking weight to administer 1mg/kg bd of enoxaparin. I would fit her for thromboembolic stockings (1) .
I would discuss my diagnosis with the patient and ensure she full understands the need for investigation and treatment.
b) I would explain to the patient what a deep vein thrombosis is and the importance of adequate treatment. I would give her an information leaflet. I would explain to her that LWMH is safe in pregnancy & does not cross the placenta. I would explain to her the greater risks to both her and the fetus from a PTE if she were to decline treatment. I would teach her how to administer LMWH and provide her with a sharps box for the safe disposal of needles (1) . I would proviide her with thromboembolic stockings. I would prescribe 1mg/kg bd enoxaparin based on her booking weight. I may consider involving the haematologists in her management if indicated what will make this indicated? . I would advise her against smoking.
I would enquire about her previous deliveries and if she has any cesearen sections and her wishes for epidural use. If a cesearean section is indicated for obstetric reasons this should be performed as an elective with adequate time how long is adequate? to discontinue her LWMH prior to insertion of spinal analgesia. If she is suitable for vaginal delivery and feels she may request an epidural I would discuss the pros and cons of induction of labour ? meaning?? Is epidural only needed if labour is induced?? . This would allow a planned delivery in a treatment free window. I would explain my caution in using prostaglandins and oxytocin in a multiparous lady and would hopefully only require artificial rupture of membranes. I would advise her if she thought she was in labour she should omit her next dose of LMWH (1) and contact the hospital. She should have iv access obtained on admission and blood taken for FBC (to examine platelet level), coagulation screen and group and save (in case of post partum haemorrhage-PPH)
I would advise her and the labour ward staff of her increase risk of PPH as she is multiparous and on anticoagulants. We would have equipment prepared. SEE GOOD ANSWERS ABOVE
Posted by PAUL A.
GH M
Part A
I will ask about history of previous DVT and whether it is because of recurrent or non-recurrent cause. Medical history to elucidated regard to diseases predispose to DVT like heart disease,inflammatory bowl disease and nephrotic syndrome healthy 40 year old . Family history of VTE to be asked (1) . Examination of both legs by inspection for redness swelling and and level of pain how will you differentiate from other causes of sewlling? . I will ask for immediate Doppler US for leg (1) . If it is normal and there is high suspicion index of DVT, I will start therapeutic dose (1) of enoxaparin 1mg/kg 12-hourly or 1.5mg/kg/24-hours and ask for venogram or repeat Doppler US one weak later how likely is repeat test to be positive after 1 week of treatment? after discussion with consultant. If the Doppler is normal with low suspicion index I will discontinue LMWH and assure the patient. If Doppler US is abnormal I will continue therapeutic LMWH.

Part B
As she is proved to be Left Leg DVT, I will explain the need for therapeutic anticoagulant is to be continued during pregnancy and during puerperium. TED stocking (1) and weekly FBC to check platelets count and APPT time is required do you need APTT for LMWH?? . I will discuss the plan of delivery and type of analegesia and document her withes. If she opt for Vaginal delivery anticoagulant to be withheld with the early onset of labour or 24 hours before the plan for induction of labour. If she opt for Elective C/S why should she have a choice betewwn vaginal delivery and CS?? Do you give this choice to all women with a normal pregnancy? anticoagulant to be stopped 24-hours before (1) . If she opt for epidural anaesthesia or analgesia also anticoagulant to be stopped 24-hours before. If she is on epidural , I will continue anticoagulant 6-12hours after insertion where did you get 6-12h from? This is not appropriate for prophylactic or therapeutic doses . when epdural catheter to removed this must be done 12-hours after the last dose of anticoagulant anticoagulant implies therapeutic dose and you will not use this in labour (-1). You should use therapeutic or prophylactic . I will inform here that the highest risk will be in the postparum period ( 1st sex weeks). So, the therapeutic anticoagulant to continued for 6 weeks after delivery not asked about post-partum care . I will explain the possible sequels of DVT like post-phlebitic syndrome, leg swelling and ulcers. Screening for thrombophilia to done to identify that DVT is liable to be recurrent or not. On discharge I will provide her with written information leaflet and Hospital contact details.

See good answers above
Posted by Prem S.
A healthy 40 year old mother of 5 children presents at 30 weeks gestation with a 12 hours history of pain and swelling in her left leg. (a) Describe your initial management of the patient [7 marks]. (b) She is found to have a left deep vein thrombosis. Discuss your subsequent antenatal and intra-partum care [13 marks].

a) Elderly age and parity of 5 increases the risk of venous thromboembolism (VTE) further in pregnancy. History of trauma, long travel, personal or family history of VTE and thrombophilia, high BMI increases the chance of VTE further. Chest symptoms like dyspnoea, chest pain should be asked to make sure that there is no pulmonary embolism clinically. Boderline high temperature and pulse rate can be there in VTE but not always. Chest auscultation should be done if any chest symptoms to look for reduced air entry, crackles in pulmonary embolism. Fetal heart to be listened to reassure the patient regarding baby. Redness, tenderness, increase calf circumference in the affected leg is highly suggestive of DVT. Homans sign is not highly significant in diagnosis of DVT so its not recommended to perform routinely. Start therapeutic low molecular weight heparin (LMWH) immediatley once VTE is suspected until objective testing is negative or unless treatment is contraindicated. It should be given subcutaneously in 2 divided doses according to prepregnancy or early pregnancy weight. Arrange urgent compression duplex ultrasound for leg. Do baseline bloods full blood count, urea and electrolytes, liver function tests, clotting before initiating therapeutic LMWH. D-dimer gives false positive result in pregnancy hence it should not be performed. Thrombophilia screen should not be performed in pregnancy as it also gives false positive result. If it done it has to be interpreted by clinician expert in this area and discuss with haematologist.

b) Continue or start LMWH immediately. Clexane is the commonest drug used in most of the hospitals in UK .It is given 1mg/kg subcutaneously in 2 divided doses according to early pregnancy weight. Educate the patient regarding how to inject clexane and safe disposal of needles. Oral anticoagulants are contraindicated in pregnancy as more prone PPH, neonatal haemorrhage. Patient can be managed as an outpatient if not acutely unwell with regular follow ups in the clinic by multidisciplinary approach including consultant obstetrician, specialist midwife and physician. Provide graduated elastic compression stocking for legs. Advise her to elevate her legs when possible and encourage mobilisation with stockings. Routine monitoring of peak anti-xa activity is not recommended unless in extremes of weight less then 50kg or more than 90 kg or has renal impairment. Platelet count is also not recommended unless has unfractioned given before. Advise the patient to stop clexane if she thinks that she is in labour and not to inject clexane 24 hours prior to induction of labour or elective delivery. Caesarean section is only obstetric indications. Regional anaesthesia should not be given until 24 hours from the last dose of clexane. Epidural catheter should not be removed until atleast 4 hours from last injection. Use drains to pelvic cavity and to rectus, staples or interrupted skin stitches in caesarean. Give prophylactic dose of clexane 3 hours from caesarean and therapeutic dose in that evening. Encourage good hydration, mobilisation postoperatively as woman tend to care less for her after delivery. LMWH has to be given until 6 weeks postpartum and until 3 months of total duration of treatment. Give options of continuing clexane or to swith over to warfarin provided she understands that it needs regular blood monitoring for warfarin. Both are not contrainidacted for breast feeding. Warfarin should not be started until 3 days after delivery. INR should be maintained between 2 and 3. Heparin should be discontinued only when the INR is more than 2 in 2 successive days. Advise her to wear stocking on the affected leg for 2 years to reduce the risk of post thrombotic leg syndrome. See her in the clinic in 6 weeks time to check post thrombotic venous damage, offer her thrombophilia screen, advise on thromboprophylaxis in next pregnancy or in any events that increases the risk of VTE and advise on contraception.