The smart way to learn. The smart way to teach.

MRCOG PART 2 SBAs and EMQs

Course PAID
notes328
EMQ1470
SBA2072
Do you realy want to delete this discussion?
Forum >>

Essay 298 - DVT

Posted by PAUL A.
Pregnancy is a thrombogenic state and deep venous thrombosis and pulmonary embolism remain a major cause for maternal morbidity not necessary

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 (1) .
I will ask her in detail which specific details? about her previous pregnanc,ies,any previous history history of what? ,the mode of deliveries ? relevance to the question
I will check if she has associated diseases like nephrotic syndrome ,systemic lupus erythematous healthy 40 year old
Her family history with reference to history of thrombophilia ,her own past history of any VTE (1) will be looked into .

Iwil examine her specifically her BMI ,any chest signs what specifically? ,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 (1)

Investigations towards arriving at a defintive diagnosis FBC PT APTT (BASELINE renal & liver function ) compression duplex ultrasound (1) 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 does not rule it out
But I will start her on low molecular weigt heparin while awaiting the resuts ? therapeutic or prophylactic?


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 is there a dose regimen that is three times a day? 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 (1)
Iwill inform her that monitoring of Xa levels is not needed (1) 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 (1)
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 when would you induce labour?
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 (1)
an anaestist should be consulted (1) 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 not asked about post-partum care
Of course general measures of avoiding dehydraton ,early immobilisation and TEDS (1) 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.
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

It is worth reading beyond the recommendations in the guidelines and then basing your answer on the guidelines PLUS accepted clinical practice. This is some of what is written in the guidelines

The average fetal radiation dose with CTPA is less than 10% of that with V/Q scanning during all trimesters of pregnancy.17–19 Cook and Kyriou17 estimated that the risk of fatal cancer to the age of 15 years is less than 1/1,000,000 after in utero exposure to CTPA and 1/280,000 following a perfusion scan. While CTPA is associated with a lower risk of radiation for the fetus, this must be offset by the relatively high radiation dose (20 mGy) to the mother’s thorax and, in particular, breast tissue. The delivery of 10 mGy of radiation to a woman’s breast increases her lifetime risk of developing breast cancer. It has been estimated that the increased risk is 13.6% (background risk 1/200), a figure that has been cited widely.20 More recently, Allen and Demetriades21 have suggested that this risk is an overestimate, at least in the nonpregnant woman. Nevertheless, breast tissue is especially sensitive to radiation exposure during pregnancy and it therefore seems sensible to recommend that lung perfusion scans should be considered the investigation of first choice for young women, especially if there is a family history of breast cancer or the woman has had a previous chest CT scan.17 Pulmonary angiography carries the highest radiation exposure (at least 0.5 mSv to the fetus and 5–30 mSv to the mother).

Faced with a woman with symptoms of PE, the appropriate process will be to investigate the lower extremities and if DVT is identified, treat her as for PE. If there is no DVT and a PE is clinically suspected then CXR and if this is normal do a lung perfusion (Q) scan. This will minimise irradiation to the woman. If you are going to go directly to CTPA, you need to justify this in order not to lose marks
Posted by PAUL 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 accept gestation age as stated in the question otherwise you will need to write this in every answer .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 (1) 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. ? chest symptoms

On examination Blood pressure , pulse rate , temperature and BMI should be done (1) .Left leg should examine for size of swelling, tenderness, skin colour, erythema to exclude infection (1) .
FBC , U&E , LIF and coagulation profile should done as baseline (1) . Doppler U/S of left leg is important to look for evidance of DVT (1) .
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 why not therapeutic? although no evidence of DVT in doppler ultrasound if clinically very suspicious of DVT ? meaning . Repeat u/s doopler in 1 week when a woman has a proven DVT and she is treated, how likely is repeat scan to be positive in 1 week? Why should you then expect a negative scan to become positive after 1 week of treatment?

PART B

I will admit her for inward treatment.Avoid immobilization and dehydration (1) . Give adequate analgesia.start S/C LMWH(low molecular weight heparin) therapeutic dose (1) . Teache patient techique of s/c heparin injection (1) .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 (1) POA ? meaning if undelivered.Caesarean section(C/S) only for obstetric indication.Advice her to stop S/c heparin once she is in labour (1) .Provide her with written information and leaflets.Refer patient to anaestetic clinic (1) (for intarpartum analgesia ).Reduse to prophylactic dose heparin one day before IOL (1) 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 immobility .Inra op avoid dehydration, minimise bleeding,good oxygenation and use pneumotic compretion of lower limb. not asked about post-partum care 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.
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 (1) 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 (1) or thrombophilia disease.
Examination involves obtaining observation for pulse (tachycardia), temperature (pyrexia), respiratory rate (tachypnoea) and blood pressure (1) . 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 (1) . 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 (1) prior to starting LMWH treatment for baseline levels. I’d arrange Doppler USS of L leg (1) 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 (1) 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 (1) and gp. I’d arrange for the woman to meet the anaesthetist (1) to discuss analgesia options in labour including regional anaesthesia. I’d explain the importance of continuing LMWH treatment throughout the pregnancy (1) , use TEDS stockings, elevating the legs at rest, encouraging mobility and avoiding dehydration (1) . Routine monitoring of LMWH therapy in pregnancy is not needed (1) , 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 (1) until assessed in hospital. In a planned delivery (c/s or IOL), I’d advise stopping therapeutic LMWH 24 hours (1) when will you induce labour? 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 (1) . 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%) (1)

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]. (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 (1) , 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 (1) . Boderline high temperature and pulse rate can be there in VTE but not always you are not answering the question – describe your management – what will you do? You were not asked to state the risk factors / signs of VTE . Chest auscultation should be done if any chest symptoms to look for reduced air entry, crackles in pulmonary embolism are crackles indicative of PE?? . 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) (1) immediatley once VTE is suspected until objective testing is negative or unless treatment is contraindicated why should this be in a healthy 40 year old? . It should be given subcutaneously in 2 divided doses according to prepregnancy or early pregnancy weight. Arrange urgent compression duplex ultrasound for leg (1) . Do baseline bloods full blood count, urea and electrolytes, liver function tests, clotting before initiating therapeutic LMWH (1) . 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 ? evidence .It is given 1mg/kg BNF says 1.5mg/kg – no marks for dose but you lose marks for getting it wrong subcutaneously in 2 divided doses according to early pregnancy weight. Educate the patient regarding how to inject clexane and safe disposal of needles (1) . 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 haematologist . Provide graduated elastic compression stocking for legs. Advise her to elevate her legs when possible and encourage mobilisation with stockings (1) . Routine monitoring of peak anti-xa activity is not recommended (1) unless in extremes of weight less then 50kg or more than 90 kg or has renal impairment healthy 40 year old . 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 (1) and not to inject clexane 24 hours prior to induction of labour or elective delivery (1) . Caesarean section is only obstetric indications. Regional anaesthesia should not be given until 24 hours from the last dose of clexane (1) . 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 (1) . Give prophylactic dose of clexane 3 hours from caesarean and therapeutic dose in that evening not asked about postnatal care . 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.
Posted by PAUL A.
A good answer should include the following

(a)
History
• Previous VTE, family history of VTE or thrombophilia (1 mark)
• Trauma. Fever / rigors : fever may occur in DVT or cellulitis. Chest symptoms – SOB, cough with haemoptysis, pleuritic chest pain suggestive of PE (1 mark)

Examination
• Temp / Pulse - (marked pyrexia >38C suggests infective cause) (1 mark)
• Lower limb signs - measure circumference, oedema, tenderness / induration, varicose veins, note extent of erythema, presence of tender groin nodes / lymphangitis suggests cellulites. Identify evidence of ischaemia (Phlegmasia alba dolens) - lower limb pulses (1 mark)

Investigations
• FBC / CRP may indicate infective / inflammatory cause. Coagulation screen, U&E and LFTs recommended before anti-coagulant therapy (1 mark)
• Lower limb compression duplex ultrasound to identify DVT (1 mark)

Initial treatment
• DVT is the most likely diagnosis. Initial treatment with therapeutic LMWH should be commenced while awaiting objective testing - titrate against booking weight (1 mark)

(b)

Antenatal care
• Elevate limb + graduated elastic compression stockings to reduce oedema. Encourage mobilisation (1 mark)
• Continue therapeutic LMWH for rest of pregnancy (1 mark)
• Monitoring of anti-Xa levels not necessary unless woman is overweight / underweight or has history of recurrent VTE (1 mark)
• Teach self-injection and make arrangements for safe disposal of needles and syringes (1 mark)
• Arrange antenatal anaesthetic & senior obstetric assessment with plan documented in notes (1 mark)
• Elective IOL should be planned 38-39 weeks to avoid spontaneous labour while fully anticoagulated. (1 mark)

Intra-partum care
• Aim for vaginal delivery with CS for obstetric reasons (1 mark)
• The woman should be advised to discontinue heparin therapy if she thinks she is in labour and report promptly for medical assessment (1 mark)
• When attending for IOL, therapeutic LMWH should be stopped 24h prior to induction (1 mark)
• Early senior anaesthetic review. Check FBC and clotting (1 mark)
• Regional anaesthesia should not be administered within 24h of therapeutic LMWH (1 mark)
• TEDS in labour and avoid dehydration and immobility (1 mark)
• There is a risk of haemorrhage with post-op use of heparin therefore if Em C/S, fastidious haemostasis, wound drains and interrupted skin sutures should be used (1 mark)

Ref: Thromboembolic disease in pregnancy and the puerperium: acute management. RCOG green-top guideline # 28, Feb 2007. http://www.rcog.org.uk/files/rcog-corp/uploaded-files/GT28ThromboembolicDisease2007.pdf
Posted by AFSHEEN M.
initial management of this patient should include detailed history, clinical examination and conducting relevant investigations.History should include any personal history of thromboembolism in previous pregancies , family history of DVT/PE or personal history of thrombophilias.Intensity,severity and duration of symptoms should also be sought. On clinical examination, her booking weight should be noted.Pulse,BP,temperature and oxygen saturation should be noted.Local examination for presence of any tenderness,redness,swelling,warmth and varicose veins should be checked.Bilateral measurement of leg radius should be performed with a measuring tape.Any chest symptoms should be particularly asked, including shortness of breath,dyspnea or chest pain.Bilateral chest auscultation need sto be conducted for any additional sounds.Obstetric management should include listening to the fetal heart.FBC,coagulation screen,d-dimers should be performed.ECG should be performed in the presence of any chest symptoms.Doppler ultrasound of the leg should be arranged.Medical team should be involved.Therapeutic dose of clexane should be started while waiting for definintive diagnosis, if clinical suspicion high.

Multidisciplinary team approach should be organised with involvement of the medical,hematological and obstetric teams.Therapeutic dose of clexane is 1mg/kg of body weight bd.Woman should be fuuly informed of the potential risks of the therapy including bleeding,thrombocytopenia and bone loss with long term use.Regular visits with the antenatal and hematological clinic should be arranged to monitor the progression of the thrombus.Repeat uss may be necesary.anesthetic review should be arranged prior to delivery. caesarean section is not indicated unless any obstetric reason.She should continue with postnatal clexane for at lkeast 6 weeks.Further follow up must be arranged with the medical team .
dasd Posted by PAUL A.

asdad