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MRCOG PART 2 SBAs and EMQs

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Essay 310 - VTE

Posted by Chitra.s M.
A. Pulmonary thromboembolism(PTE) has to ruled out as venous thomboembolism is a major direct cause of maternal mortality.suspected PTE is managed by a team of obstetrician,radiologist & hematologist.History of cough & hemoptysis is enquired as they can be an associated symptoms.Previous obstetric history ,parity and history of ante or postpartum VTE is enqiured as high parity & previous confirmed Vte increse the risk for PTE.History of recent long haul travel is enquired as it can predispose to VTE.
.A family history of thromboembolism is important as it might point towards inherited thrombophilia.
On examination i would look for,BMI(increased BMI increases risk of VTE) ,temperature-pyrexia,pulse(tachycardia),tachypnea,BP,Raised JVP and right ventricular heave.Auscultation for reduced air entry & pleural rub.Bilateral lower limb examination for any tenderness or swelling which points towards DVT.
Investigations would include a FBC,clotting screen,LFT ,urea & electrolytes as a base line before instititing anticoagulant therapy.Pulse oximeter might show resting hypoxia.A chest xray is done which can identify other diseases like pneumonia,pleural effusion.It may reveal oligemia, atelectasis or focal opacities-suggestive of PTE.However it may be normal even in PTE.The radiation dose to the fetus is negligible.If the Xray i s normal bilateral lower limb dopplers are done abnormal Xray warrants objective testing for PTE.Presence of DVT may be an indirect evidence for PTE.Further testing involving radiation exposure to mother & fetus could be avoided as both conditions have same treatment-anticoagulation.
Prompt anticoagulation treatmentin therapeutic doses is started if there is a high clinical suspicion inspite of negative chestXray & leg dopplers.LMWH is a safe & effective option.It has the convinience of twice daily dosing,reduced incidence of thrombocytopenia & osteoporosis compared to unfractionated heparin.The dose is guided by the body weight & maximum doses by unit protocols.The treatment is continued till PTE is ruled out by objective testing.
B.The objective tests to confirm or refute PTE are ventilation;perfusion scan(V/Q scan) and CTpulmonary angiography(CTPA).The choice of investigation depends on the local availability & protocols.It has to be discussed with the radiologist.The woman has to be counselled regarding the advantages & diadvantages of each procedure & her wishes considered.This is important as very few cases of suspected PTE are confirmed by objective testing.Informed consent should be taken before these investigations whenever feasible.
V/Q scan has a high negative predictive value.It exposes the mother\'s breast tissue to less radiation dose compared to CTPA.however the woman has to be counselled that there is a small increase in the risk of childhood cancer compared to CTPA.The radiation exposure to fetus may be minimised by omitting the ventilation part of the scan.Nonavailability of isotope may delay the scan.V/Q scan might be more suitable for young women with a family history of breast cancer.
CTPA is more sensitive and specific compared to V/Q scan for diagnosis of PTE.The radiation dose to the fetus is less.However CTPA exposes the maternal breast tissue to more radiation.This is important as breast tissue is more sensitive to radiation in pregnancy.The woman has to be counselled that there is an increased lifetime risk of Ca breast.CTPA may miss small peripheral PTEs.CTPA involves use of iodinated contrast media.Neonatal thyroid function has to be monitored.
Pulmonary angigraphy which is performed outside of pregnancy is not done as it carries a radiation exposure to mother & fetus.












Pulmonary thromboembolism
Posted by L S.
LS:
a) I would to assess if she is stable and has no signs of impending collapse. Important differential diagnosis would be pulmonary embolism (PE), myocardial infarction, pneumonia or musculoskeletal pain. From her history, I would like to establish the duration of her symptoms, any leg pain or swelling, any lower abdominal pain or hemoptysis. Any relevant personal or family history of venous thromboembolism(VTE) and any risk factors for it should be established. Her general examination performed with her vital signs, pulse oxymetry and chest signs identified. Her abdomen and lower limbs should be examined to rule out occult abruption and deep vein thrombosis of lower limbs. Her anxiety and pain recognized and reassured that investigations are needed to confirm on cause of her symptoms along with adequate analgesia given. Low molecular weight heparin (LMWH) therapeutic doses twice daily should be started as PE cannot be ruled clinically in pregnancy it is unreliable and need objective testing like chest X ray and duplex compression ultrasound need to be arranged urgently. LMWH has been proven to be as effective for both DVT and PE in non pregnant woman. However if massive PE is suspected intravenous unfractionated heparin would be better option of treatment. Full blood count and total white differential, coagulation profile along with urea, electrolytes and liver function test as baseline before anti-coagulation. TWC can be raised in both VTE and infection. ECG will have pregnancy related non specific changes but presence of sinus tachycardia could be suggestive of PE. Arterial blood gases to look for signs of hypoxaemia and hypocapnia with respiratory alkalosis are characteristic of PE should be done. D-dimer if negative will make PE unlikely but if positive will be unreliable to interpret. Facial oxygen and TED stocking advocated appropriately.

b) Definitive diagnosis is via computer tomography pulmonary angiogram (CTPA), lung perfusion scan (Q), lung ventilation-perfusion scan (VQ) which should be carried out if clinical suspicion of PE is high and both CXR and duplex compression ultrasound is negative. VQ scan is usually done as first line in pregnancy due to its high negative predictive value and has a lower radiation dose to breast tissue. Women should be advised that this scan carries slight increased risk of childhood cancer but lower risk of maternal breast cancer. However availability of isotopes delays this test. CTPA are more sensitive and specific in non pregnant women with lower radiation exposure to fetus which is 10 percent less than that of VQ scan. Its main disadvantage is high radiation dose to maternal breast which is associated to increased lifetime risk of breast cancer. The use of iodinated agents in CTPA can potentially affect neonatal thyroid function and neonate’s thyroid function should be checked if administered. Both VQ and CTPA may not identify small peripheral PE. Women should be involved in decision to undergo either of these scan and informed consent obtained before the test.
Posted by H H.
This is an emergency situation associated with increased maternal mortality (mm)if not acted upon promptly. It could be pulmonary thromboembolism which is the commenest direct cause of mm or cardiac cause which is the commenest indirect cause of mm in the confidential mm report.
There should be local guidelines and protocols acted upon in such cases which are regularly rehearsed and audited.
Proper communication and call for help from midwives,porters,anesthetist,consultant and hematologist and ensure a safe surrounding.
Start resuscitation if situation necessitates, airway should be patent,see if breathing and feel carotid pulse, if absent start basic life support( 30 compressions and 2 ventilations while patient in left lateral position and apply pads of automated electrical defibrilator).Two wide borred IV cannulas are fitted and blood sent for FBC, clotting screen, urea and electrolytes,liver function tests., cardiac enzymes and troponins. Patient fitted with pulse oximetry for capillary oxygen saturation
Assess patient for other symptoms as cough,hemoptyses and see if had a history of heart disease or thrombophilia. Examination include,pulse rate, BP, temperature(pneumonia), position of trachea(pneumothorax), chest for airway entery and percussion for dullness.
The lower limbs examined for deep vein thrombosis.
I will ask for for chest X ray, ECG, arterial blood gases, compression duplex scan (cds)of lower limb. If chest Xray and cds are negative ,will ask for perfusion lung scan.
If clinical data point to pulmonary thromboembolism I will commence with a therapeutic dose of heparin even if tests are not conclusive. If pneumothorax diagnosed ,insert needle and put under water seal. Cardiologist is called for cardiac conditions ,but initial management in cardiac pain is analgesia.



Advantage of ECG is to detect abnormal electrical signals in cases of myocardial infarction or pulmonary embolism ,but has the disadvantage that it can be normal despite the presence of the condition , giving false negative results.
Advantage of cardiac enzymes are to detect early myocardial ischemia for early treatment ,but also they can be negative despite the damage. Troponins detect cardiac infarction ,but here damage has occurred.
Compression duplex ultrasound has the advantage of being non invasive and has a diagnostic accuracy that compare with venography which is an invasive test and expose the patient to radiation, however, (cds) can give false negative results and also need machine and experience.
Chest X ray is a simple investigation and can detect pneumothorax, or show reduced vascular markings in pulmonary embolism, despite fact this is not conclusive which is a disadvantage.
Perfusion lung scan for diagnosis of pulmonary thromboembolism has the advantage of less exposure of the mother to radiation which can harm the baby as seen with the ventilation perfusion scan (V/Q), and less chance of having breast cancer as seen with the CTPA (computerized tomography pulmonary angiography). CTPA has more chance of patient having breast cancer than V/Q scan but less radiation exposure of baby than V/Q scan.
Arterial blood gases has advantage of giving us idea of arterial oxygen saturation but has the disadvantage of how to obtain the arterial blood, need experienced person.






Posted by Ulduz A.
a)The symptoms are suggestive of PE.PE is a major cause of maternal death in UK.According to the last report \"Saving Mother\'s live\" there was 41 death due to thromboembolism. Prompt diagnosis and management is neccessary to decrease mortality.
Clinical assessment includes clinical history taking and examination.
Clinical history includes asking about duration,severity of symptoms,associated symptoms as cough,haemoptysis,previous episodes and treatment.History of previous DVT and PE,sigarette smoking,long-haul travel,inflamatory disaese as IBD,recent operations and immobilisation,cardiac disease,family and personal history of thrombophilias,sickle cell disease inquired.
Examination includes BP,pulse,temperature,SO2,respiratory rate,BMI measurements.Tachycardia,tachypnoe,pyrexia,low O2 saturation and high BMI(more than 35)associated with PE.
Inspection can reveal incraesed JVP,lower limb varicosites,swelling and erythema.
Auscultation helps to hear pleural rub,crepitations and rales.
b) Coagulation screen can show abnormal values of PT and APTT.
Arterial blood gases can reveal hypoxia and hypercapnia suggestive of PE.
Chest X-ray is simple,widely available ,easy to perform.features of suggestive of PE include atelectasis,effusions,pulmonary oedema.however,50% of women with proven PE has normal X-ray.
If CXR is abnormal with suspicion of PE computer tomography pulmonary angiogram should be performed.CTPA is having high sensitivity and specifity and lower radiation dose.But it is not widely available,risk of radiation to breast tissue and effect of contrast on neonatal thyroid can be a concern.
V/Q scan can give definitive diagnosis.Ventilation component can be omitted during pregnancy because of radiation risk to the fetus,especially if CXR is normal.It has high negative predictive value and many autorities rtecommend V/Q scan as a first-line investigation in pregnancy for PE.
D-dimer testing should not be performed during pregnency due to increased value but negative value can be reassuring.
Performing thrombiphilia screen is contraversial due to effect of pregnancy on thrombophilia screen.

Posted by SYAMALRANJAN S.
VTE
A healthy 23 year old woman presents to the maternity assessment unit at 26 weeks gestation complaining of sudden onset shortness of breadth and stabbing chest pain on inspiration. (a) Discuss and justify your initial management [9 marks]. (b) Discuss the advantages and disadvantages of the available objective tests to establish a definitive diagnosis [11 marks].


a. Airway , breathing ,circulation (ABC) policy must be applied here initially as in emergency patient. Facial oxygen if appropriate must be commenced initially. Pulmonary thromboembolism has to be ruled out as it is the major direct cause of masternal death
Thorough and prompt history taking from patient and attending person ( family person or friend). Previous history (personal or family ) suggestive of VTE must be enquired. Medical problems like asthma , heart diseases are present or not. Any previous hormonal contraceptive causing blood clotting problems or any history of smoking or other provocative factors likely to be associated with VTE. Previous medication and treatment record if present must be noted as relevant to this problems.
Careful examination of pulse , blood pressure, respiratory rate must be noted which could be helpful for diagnosing any heart diseases or respiratory diseases. Presence of temperature might be suggestive of any infection and also suggestive of VTE Lower limb swelling, presence of varicosity may be related to VTE.
Primary investigation lke full blood count , ECG, chest X-ray , arterial blood gas analysis would be helpful for diagnosing heart or lung diseases or any infection presence of infection
If VTE is suspected then I will start LMWH in therapeutic doses till the objective tests reports are available with close liaison with haematogist. LMWH is safe and effective option and has got advantages of twice daily doses with less chance of thrombocytopenia os osteoporosis compared with unfractionated heparin
Other appropriate referral ( like cardiologist, chest specialist) after symptomatic initial treatment according to diagnosis.


b.
Investigations must be planned after having idea form clinical assessment.
ECG is helpfull for diagnosing heart diseases and also presence of right heart strain in pulmonary embolism but pregnancy associated changes ( axis deviation,rate )must be kept in mind. Echocardiography similarly may be helpful.
Chest Xray ( with proper shielding of abdomen ) might be helpful for diagnosing pneumonia , lung congestion , collapse, emphysema but anxiety and concerns of radiations hazards is to be addressed appropriately.
Ventilation/perfusion (V/Q)scan and computed tomographic pulmonary angiography(CTPA) are two important objective tests for diagnosing or refuting PTE . Tests should be done according local availablibilty and protocol
V/Q scan is helpful for diagnosing pulmonary embolism, it has high negative predictive value but there is concerns related to fetal radiation and increase in childhood cancer .
CTPA is helpful and better than V/Q scan but concerns about more radiation to maternal breasts , slight increase in breasts cancer. It may miss the peripheral smaller PTE.
Lower limb compression Doppler ultrasonography is needed to diagnose the presence of lower limb VTE because it has relation with PTE. But it is unable to dignose the pelvic vein thrombosis.
Conventional Xray venography is sometimes better to diagnose lower limb VTE but uses are decreased because of radiation concerns.
Arterial blood gas analysis is helpful for diagnosing saturation of carbondioxide and oxygen but not always present in mild non-fatal embolism.
Others like full blood count and liver function tests , renal functions tests , clotting screen are to be requested for basal records and treatment comparisons.
Posted by ASB -.
ASB
(a) The most likely diagosis is pulmonary thromboembolism (PTE).Venous thromboembolism (VTE) is the commenest cause of maternal mortality in the UK.LMWH should be started and continued until the diagnosis is objectively excluded.Prior to heparin therapy , blood sample should be obtained for FBC and coagulation profile . Because heparin thrapy is affeced by liver and renal function , they should be assessed before commencing heparin therapy.Objective investigations should be requested rapidly . Chest X ray (CXR) may identify dignosis. If CXR is abnormal with clinical suspicion of PTE, computed tomography pulmonary angigram (CTPA) should be performed. If CXR is normal , bilateral doppler ultrasound legs should be performed . If diagnosis of DVT is confirmed , this indirectly confirm a diagnosis of PTE and further investigations may be unnecessary.If both doppler ultrasound and CXR are normal , definitive diagnosis is required using V/Q scan or CTPA . the woman should be informed that V/Q scan has slightly higher risk of childhood cancer and lower maternal breast cancer compared to CTPA and informed consent should be obtained .

(b) CXR can identify abnormalities associated with PTE like atelectasis and focal opacities .It may identify pulmonary pathology like bronchitis or pneumonia . The radiation dose to the fetus is negligible. However it is normal in about 50% of objectively proven PTE. Doppler Ultrasound leg is helpful in diagnosis of lower limb DVT , however it has poor sensitivity for below knee DVT . D dimers are unrelaible test during pregnancy because it physiologically increase in pregnancy and may be high with other conditions like pre eclampsia .However when it is normal in pregnancy , this may exclude VTE . CTPA , compared to V/Q scan, has higher sensitivity and specificity , lower radiation to the fetus and may diagnose pulmonary pathology. However, it give higher radiation dose to maternal breast than V/Q scan and may not identify peripheral PTE
Posted by Bindi J.
BJ:

A)

There is a high index of clinical suspicion for Pulmonary thromboembolism (PTE) in this woman. She should be admitted in High dependency unit for close monitoring using MEOWS chart. A multidisciplinary care should be provided to her by senior Obstetrician, Anesthetist and midwife. Airway should be assessed and 5L/min oxygen should be provided via face mask. Two 16 gauge cannula should be inserted( in preparation for emergency). Blood should be taken for full blood count (for Anaemia, thrombocytopenia and leucocytosis) and group and save. History of unilateral leg pain and swelling for DVT should be taken. Family history of PTE should be taken . Arterial blood gas analysis should be done for oxygen saturation. ECG to look for rare S1 Q3T3 phenomenon due to thrombus. Therapeutic dose of subcutaneous anticoagulant(LMWH) should be commenced immediately. The dose used should be according to her most recent body weight. The treatment should be continued until diagnosis is excluded by objective testing.

B)
Chest X-ray, a noninvasive and cheap test, is done to identify other pulmonary diseases(like pneumonia). Radiation dose is negligible but it is not sensitive or specific for diagnosing PTE. If Xray is normal, bilateral compression duplex doppler should be performed. Diagnosis of DVT by this test may indirectly confirm a diagnosis of PTE. Since anticoagulant therapy is same for PTE and DVT, further investigations may not be necessary thus limiting radiation doses to mother and her fetus. It is not 100% specific. Advanced imaging tests to exclude PTE are ventilation perfusion(V/Q) and computed tomography pulmonary angiogram(CTPA). V/Q has a high negative predictive value and low radiation dose to maternal breasts. It is isotope dependent and so may delay the investigation. There is increased risk of childhood cancer. CTPA has decreased risk of latter condition and identifies other pathologies like aortic dissection.. It causes increased radiation to pregnant breast and cannot identify small peripheral emboli. There are concerns regarding the safety of contrast iodinated media. Informed consent should be obtained from the woman prior to these tests. Alternative or repeat testing should be carried out where V/Q or CTPA and duplex doppler are negative but clinical suspicion of PTE is high.
Posted by SRABANI M.
SM
a. The clinical features of this pregnant lady are highly suspicious of PE. VTE is the commonest cause of maternal mortality in UK. So any pregnant woman with signs and symptoms of VTE/PE should have baseline & objective testing performed immediately & treatment with LMWH should be started straightaway ( if there is no contraindication for LMWH present ) until the diagnosis of VTE has been excuded.
After taking history to exclude any other cause of these signs and symptoms ,initial management should be started quickly by doing baseline investigations like FBC, U&E, LFTs,clotting screen,ECG ,ABG and d-dimer before starting LMWH. Raised WBC may be due to infection or VTE, ECG may be nonspecific , sinus tachycardia may be present, S1Q3T3 not usually present. ABG may show hypoxaemia, hypocapnia and respiratory alkalosis in VTE.D- dimer may be elevated in pregnancy, postpartum or PET but low level may decrease index of suspicion of VTE during pregnancy. Thrombophilia screening is not recommended in this situation.
As discussed above LMWH should be started immediately & should be continued until the diagnosis is completely excluded ( if there is no contraindication).LMWH given S/C in two divided doses ( for dalteparin & Enoxaparin) or once daily ( for Tinzaparin) after titrating the dose with her recent weight. LMWH is as effective as unfractionated heparin and it has got lower risk of haemorrhage, thrombocytopenia and osteoporosis than unfractionated heparin. That is why LMWH is preffered although unfractionated heparin is recommended in massive PE with cardiac compromise. General advice like leg elevation, TED stocking,mobilisation & hydration should be encouraged.Temporary IVC filter should be consider if she continuing PE inspite of adequate anticoagulation.
b.After starting baseline investigation as mentioned above,this lady will have objective testing to establish correct diagnosis.Although only 5% of women with PE will have positive result. If chest Xray is normal, compression duplex USS should be performed.If both are negative , either V/Q scan or CTPA should be done in clinically suspicious conditions. Anticoagulant should be continued until the diagnosis is completely excluded after repeated testing. The woman should be involved in the decision of V/Q scan or CTPA & informed consent should be obtained as there are few risk factors involved with these investigations.CTPA has got better sensitivity & specificity than V/Q scan also it has got lower radiation dose to fetus than V/Q scan. Disadvantage of CTPA is risk of Ca breast in mother for its high radiation dose.Also it has got risk of altering neonatal thyroid function due to iodinated contrast medium used in CTPA. V/Q scan is recommended by many authorities as it has got lower radiation risk than CTPA to maternal breast and also high negative predictive value.Diadvantage og V/Q scan are slightly increased risk of childhood malignancy than CTPA and also treatment may be delayed due to availability of isotope.
Pulmonary angiography causes highest radiation exposure.as v/Q scan has got less effect on maternal breast tissue, this should be first choice of investigationin young woman like this lady & also in women who has got family Hx of Ca breast.
Posted by Nadira N.
VTEis the main cause of direct maternal mortality in UK.Pregnacy increase the risk of VTE to 10 fold.Iwill call for help,on duty colleagues ,senior anesthetist and ssenior midwives should be called.I,ll urgently inform consultant obstetrician consultant anesthetist and radiologist.I,ll take care ao airway maintain the patency and apply oxygen 15L per min.I,ll assess breathing and need to ventilate.I,ll evaluate pulse and blood pressure if abscent initiate CPR and call the arrest team.I,ll save iv line with two large bore iv caulas and take blood for CBC,urea and creatinie ,liver function test and coagulation profile.Thrombophilia screen is not required as it will no change the immediate management.Pulse oximetry and ECG initiated.In case of cardiopulmonary collapse I will use un fractioned heparin as loading dose of 80 units per kg followed by 18 units per kg per hour.Thrombolytic therapy with sterptokinase may be considered by medical team in case of massive PE to clear the burdon of clot.In such case loading dose of heparin is omitted and infusion with 18units/kg/hr cnotinued.It is mandatory to measure APTT 4 to 6 hour after the loading dose .the target ratio should be between 1.5 to 2.5 times the laboratory control value.If APTT resistance and subsequent heamorrhagic problem is expected antiXa level should be used to monitor the dose of heparin.
Clinical suspicion of PE should be confirmed with objective testing.Chest Xray should be performed .chest Xray is normal in 50% of women with objectively proven PTE. when it is abnormal it has features of atelectasis,effusion ,focal opacities and pulmonary oedema.the radiation dose to the fetus is negligible.Ionising radiation of less than 5 rads to a pregnant woman is not associated with significant fetal risk.The dose more than 5 rads is associated with increase in childhood cancers.
If chest Xray is normal compression duplex ultrasound should be performed.If both the tests are normal I,ll counsell her for further testing with ventilation perfusion V/Q or computed tomography pulmonary angiography CTPA.
V/Q scanning remains the initial diagnostic modality of choice.The amount of radiation varies between 0.006 to 0.018 for the perfusion and 0.001 to 0.035 for the ventilation scan.ventilation component can be omitted if the perfusion scan is normal to minimise the dose.The technitium 99 used iin V/Q scan is excreated by the kidneys and collects in bladder ,which increase fetal radiation exposure therefore woman should be encouraged fluid intake and frequent voiding for 4 to 6 hours.
V/Q scan increase the risk of childhood cancer slightly.Compared to CTPA the increase is 1/280,000 versus 1/1000,000.
V/Q testing may be delayed due to avialability of isotope.
CTPA has better sesitivity and specificity than V/Q scan.It gives lower radiation dose to fetus between 3 to 131 micrograys.It is less than 10 % of that with V/Q scanning.In addition it can identify other pathology ,such as aortic dissection.
The main disadvatage of CTPA is realativly high dose of radiation to maternal breasts (20mGy) which increase her lifetime risk of developing breast cancer to 13.6% over background risk of 1/200.CTPA may not identify small peripheral emboli.
It is reasonable to recommend that lung perfusion scan should be considerd as investigation of first choice especially for young women and when there is a family history of breast cancer or the woman has had a previous CT scan of chest.
Iodinated contrast medium used in CTPA can alter fetal or neonatal thyroid function.
Posted by Bgk H.
:-)

A.She should be attended immediately. Thorough assessment and timely management are essential to prevent maternal morbidity and mortality. Serious conditions like pulmonary embolism, status asthmaticus or cardiac event need to be excluded. Her airway should be assessed and intubation may be considered if necessary to maintain the airway patency. Her blood pressure and pulse rate need to be taken and recorded throughout the event. Paramedic including SHO, midwives and porter need to be mobilised. Senior obstetrician and anaesthetist need to be warned that this patient may need urgent attention. An arterial blood gas should be measured and other blood investigations including full blood count, urea and electrolytes need to be taken. D dimer level has negative predictive value for embolism. It may be normal to be raised in pregnancy. ECG need to be done to elicit any abnormal or ischaemic changes. Chest Xray need to be done with abdominal shield if consented.
Clinical examination starting from general condition should be done either she is cyanosed or pale. Full respiratory examination should be done and recorded to elicit any sig suggestive of asthmatic attack and infection. Help from respiratory physician may be sougt. Calves tenderness should be elicited that may indicate deep vein thrombosis. Fetal heart need to be taken and documented.
Her past medical history needs to be taken. If she is a known bronchial asthma, the control of the disease is important and this may suggest another attack. History of inherited or acquired thrombophilia may suggest risk of developing pulmonary embolism. Recent fever, cough and contact with patient with chest symptom ma suggest an infective cause. Her underlying medical roblem like hypertension and diabetes mellitus may lead to cardiac event which is less likely but possible for this patient

B. Available objective test s is V/Q scan or CTPA. The advantage is the ability to exclude any serious potential problem like embolism. Negative objective test will prevent the further patient exposure to therapeutic dose of the anticoagulant that may already be started while waiting the test. Therapeutic dose of thrombo-prophylaxis may difficult to be monitored and associate with complications such as bleeding, thrombocytopenia.
To compare between both tests, VQ scan has high negative predictive value and does not need contrast. But it may take long time to perform. However in CTPA even tough is a quicker test and easily reproducible, it involves more cost and patient is exposed to risk of contrast allergies and radiation exposure. It also has poor sensitivity in detecting sub-segmental PE.
However these objective testing not readily available in all centre and it need a special machine to perform this test. The result may difficult to interpret and it has inter observer variation. Patient also must be stable enough as she needs to be lied down flat for a while to enable the test to be done. The test can only be done at the radiology department as the machine is not portable and involves cost.
Eventhough these two tests are negative, if high clinical suspicion still present, thromborophylaxis may need to be continued. And these test may need supplementary test like ecg chest xray as an adjunct to the diagnosis.
Posted by Im F.
A

Most likely diagnosis is pulmonary embolism. this patients warrants admission to high dependency unit needs close monitoring. Conditions such as acute myocardial infarct, abruption placenta need to be ruled out.
Maintain airways and give oxygen via high flow mask .short history of events preceding the symptoms should be taken to help make an initial diagnosis .history of trauma or per vaginal bleeding is suggestive of abruption ,history of leg swelling or pain in abdomen suggestive of deep venous thrombosis an iv access should be obtain and baseline investigation including full blood count coagulation studies, urea and electrolytes and liver function tests before initiating heparin and group and cross match ,as in case of abruption may require blood transfusion.
Inform consultant obstetrician ,anesthetist, radiologist and alert peadiatrician.low molecular heparin to be started after reviewing investigation. Examination of the abdomen ,as a tense abdomen suggest abruption .ultrasound to confirm fetal heart activity. catheterization to monitor urine output . ECG and chest x ray to help in diagnosis.


B
When there a clinical suspicion of pulmonary embolism chest x ray should be performed .its normal in 50% of cases but an abnormal finding such as atlectesis,effusion focal opacities and pulmonary edema suggest pulmonary embolism.advantage of x ray is that radiation dose is low.
ECG is simple and easy to perform .it can help to rule out cardiac event but finding of pulmonary embolism S1Q3T3 s rare.
Compression duplex scan should be performed when chest xray is normal .it is safe in pregnancy ventilation perfusion scan and computed tomography pulmonary angiogram should be done if the above test are normal. both these these are expensive require expertise with high exposure to radiation dose.ideally before doing these tests woman’s consent should be taken informing her that risk of childhood cancer with ventilation perfusion scan and low risk of breast cancer and CTPA higher risk of breast cancer lifetime risk of 13 %.ventilation component of ventilation perfusion scan can be omitted reducing the radiation exposure.cumputed tomography pulmonary angiogram has more sesitivityand specificity with lower radiation dose to fetus with a disadvantage of high dose to breast.
D dimmers are elevated in pregnancy should not be performed in acute condition.

Ultrasound scan of abdomen for fetal well being and look fo retroplacental clots,absence of which does not rule out abruption.scan is less expensive and easily available but requires a trained person.
Screening for thombophelia is not routinely recommended only hepful in long term management and requires interpretation by heamatologist.

im
Posted by F N.
A healthy 23 year old woman presents to the maternity assessment unit at 26 weeks gestation complaining of sudden onset shortness of breadth and stabbing chest pain on inspiration. (a) Discuss and justify your initial management [9 marks]. (b) Discuss the advantages and disadvantages of the available objective tests to establish a definitive diagnosis [11 marks].
The diagnosis in this lady may be Pulmonary embolisim unless proven otherwise.History of cough with or without sputum may be suggestive of chest infection.History of pain and swelling in legs along with presenting symptoms may be indicative of venous thromboembolisim (VTE).Family history of thrombophilia may further increase the possibility of VTE.
Blood presuure and pulse should be recorded as tachycardia may be suggestive of PE . Temprature should be recorded as low grade prexia may be present in DVT/PE. The oxygen saturations in the blood may be low.Cardiovascular and respiratry system evaluation might help further in the diagnosis. swelling,redness and tenderness in lower limbs might be suggestive of DVT.
Full blood count should be requested as raised white cell count may be suggestive of pulmonary disease. D-dimers can be requested,though the levels are raised in normal pregnancy but low levels may be helpful to exclude the VTE.Arterial blood gases analysis may indicate hupoxia. Shielded Chest xray should be requested,it might help to exclude other pulmonary disease.S1Q3T3 pattern on ECG might be suggestive of PE.Doppler Uss of lower limbs may be requested if on clinical examination there is suspicion of DVT and a positive doppler will indirectly confirm the diagnosis of PE.Lungs ventilation perfusion(V/Q) or CT pulmonary angiogram should be requested if there is raised clinical suspicision for PE.The woman should be fully involved in the decsision making about the scans.she should be made aware of the fetal and maternal risks.
Treatment with low moleculer heparin(LWMH) should be initiated promptly when there is raised clinical suspicisionof PE.The results of the V/Q scans/CTPA should not delay in initiating the treatment unless strongly contraindicated.
b:The available objective tests for the definite diagnosis are V/Q scans and CTPA.The choice of any one of these depends on local availibilty and should be requested after discussion with the radioligists.
ventilation perfusion scan is associated with slightly increased radiation dose to the fetus compared to CTPA and carries slightly increased risk(1:280,000 versus less than 1:1000,000) of childhood cancers compared to CTPA.However the ventilation part of the scan can be ommitted to reduce the radiation dose.V/Q scan can be delayed at times due to availibility of isotopes.The V/Q scan has a high negative pedictive value to exclude PE in pregnancy and also exposes the breast tissue to lower radiation dose thus associated with lower risk of breast cancer.
The avarage radiation dose to the fetus with CTPA is roughly less than 10% that of V/Q scans at all trimesters. It has better sensitivity and specificity than V/Q scans especialy in nonpregnant women and it can diagnose other conditions like aortic dissection.THe main disadvantage of CTPA is that it is associated with a higher radiation dose to maternal breast tissue and increases the risk of breast cancer.increse in risk is approximately 13% (back groung risk is 1:200).CTPA might not be able to diagnose small peripheral PEs.The Iodinated contrast media used in CTPA affect the fetal thyroid gland and neonatal thyroid function should be checked.
Posted by Shamita S.
A healthy woman at 26 wks of breathlessness and chest pain should be managed as pulmonary embolism unless proven otherwise,as P.E remains the leading cause of maternal mortality and chances of embolism is increased 6 folds . she needs to be seen by the consutant , senior haematologist ,cardiologist and radiologist. she needs inpatient management till treatment started and patient is stable.patient may need intensive care if massive embolism suspected,
A history about previous embolic episodes or presence of tromophilia in the patient or family makes the suspision stronger ,a history of smoking is also associated with embolic episodes ,history ofcough haemoptysis pain in the leg could be there
the woman should be examined as general examination would show tachycardia ,tachypnoea ,raised jugular venous pressure ,chest auscultation would reveal a loud seconr heart sound and left ventriculer heave all suugestive of a P.E.The legs should be examined for swelling and tenderness.weight to be recorded as weight >80kgs is a risk for developing embolic episodes
intial investigations to be done a pulse oximetr would show hypoxia,blood to be sent for FBC ,arterial blood gases would reveal hypoxaemia and hypocapnia.ECG may be normal but for sinus tachycardia in cases of large PTE would show right axis deviation RBBB.A chest x ray to be done to rule out other causees of breathlessness and chest pain like pneumonia ,for chest x ray may be normal in P.E,or may show areas of infarction oa effusion.
treatment with heparin should be commenced in therapeutic doses ,which depends on the weigth of the patient and is more than non pregnant doses .The choise between s.c. LMWH heprin or i.v unfractionated heparin would be according to the unit protocol ,as LMWH is associated with longer interval dosing ,low risk of thombocytopenia and low risk of osteoporosis ,where as unfractionated heparin is used in cases of masssive embolism where rapid reversibility is required.definte test to be carried for confirmation of P.E and to plan further treatment. ,


(B)
The diagnosis must be confirmed with either a lung scan or aCTpulmonary angiography as per the hospital protocal,if the chest x ray is normal a perfusion scan alone(Tc 99m)may demonstrate underperfused lungs ,but if chest x ray is abnormal the cause is uncertain an additional ventilation (Xe133)should be performed to detect ventilation perfusion mismatch in cases of P.E.The total radiation to the foetus from the lung scan would be minimal and well below the recommended total pregnancy maximal dose for radiations (5 rads).a CTPA is advised if a proximal PTE is suspected .the radiation dose to the foetus is mimmum in CTPA but there is a signioficant radiation to the mothers breast.MRI can also help in diagonosis and is not associated with radiation exposure .A transthoracic echocardiogram may aid in diagonosis though this is not a very sensitive test ,.pulmonary angiogram is reserved for severe cases where localisation of the embolus prior to surgical or medical embolectomy is required.if vte is suspected a doppler study of leg can be done as it is convenient less invasive and widely available and can be repeated to exclude thrombi above the knee,although limited venography b(performed with abdominal sheild)remains the gold standard.for detection of DVT,which should be also excluded.
Posted by Lilantha W.
(a) Presenting symptoms are highly suggestive of a massive pulmonary embolism (PE) which is associated with very high maternal mortality although it is important to rule out other important differential diagnosis such as tension pneumothorax or cardiac tamponade. Treatment for the working diagnosis of PE should be initiated promptly, whilst the diagnosis is being made, as inadequate diagnosis and treatment have caused many maternal deaths.

The need for urgent senior help should be communicated to the consultant obstetrician, anaesthetist, and senior physician. Radiologist’s and haematologist’s advice should be sought regarding investigations, as required. Patient should be admitted either to the obstetric high dependency unit or medical ITU. She should be nursed pro-up position to facilitate breathing effort. Oxygen 15L/min via face mask attached to a reservoir bag should be administered as hypoxia is very likely which should be corrected promptly. Continuous, ambulatory monitoring of pulseoxymetry, ECG, blood pressure should be commenced. Continuous monitoring would enable early detection of deteriorating condition and complications of PE such as arrhythmias (AF, VT & VF) and myocardial infarction. Venous access is gained with 16G cannula for resuscitation and treatment purposes. Blood should be sent for FBC to find platelet count and Hb, coagulation screening as this may be deranged with PE or will be altered with its treatment. Similarly, renal and liver function can interact with anticoagulation treatment. Hence, LFT and U&E are tested. Arterial blood gas testing may have to be done serially to objectively assess the extent of hypoxia and to determine the type of respiratory failure that she is having. A formal ECG should be done. It will aid diagnosing PE which might reveal right heart strain pattern or arrythmias, universally low amplitude of QRS complexes may suggest pericardial effusion. Once these are ensured, patient can be reassured appropriately and strong analgesia e.g. morphine should be given.

Decision for administering therapeutic dose of LMWH should be taken soon. Appropriate LMWH regimens are subcutaneous enoxaparin 1mg/kg bd with maximum of 100mg bd and dalteparin 100 units/kg bd (10000 units bd Max.). However, if the clinical assessment suggests of signs of life threatening pulmonary embolism with severe cardiopulmonary compromise, decision for thrombolytic therapy followed by unfractionated heparin or surgical thrombolectomy should be taken by consultants. This should be followed by continuous infusion of unfractionated heparin 18 units/kg/h, maintaining APTT ratio of 1.5-2.5. Clinical assessment includes BP (hypotension), PR (tachycardia), Temp (low-grade pyrexia), JVP (elevated with a J wave), palpation, percussion and auscultation of the chest and auscultation of the precodium. General examination would recognise signs of deep vein thrombosis e.g. oedema, mottled appearance, bruising, warmth, tenderness in her legs. Unilateral pelvic pain, backache and leg swelling may indicate ileac vein thrombosis. Enquiry should be made regarding the foetal viability as it might alter the management. Foetal heart should be auscultated.

CTPA and compression duplex ultrasound of the leg veins should be arranged. CVP/arterial line may be required.

(b) A chest X ray (CXR) is the basic radiological investigation that will narrow down differential diagnosis. A pneumothorax, pneumonia, pulmonary oedema can be readily diagnosed with a CXR. It will also guide the further investigation path. It is cheap, readily available everywhere and carries a negligible radiation injury to the mother and the foetus. Detection of a massive PE is possible with a CXR, if associated with a central mass in the pulmonary trunk resulting in distal oligaemia. The main disadvantage is that it is not very sensitive or specific diagnosing PE. However, if CXR is clear, a PE can be ruled out with a highly negative predictive value in the presence of a negative perfusion scan. This provides the advantage of avoiding a ventilation scan which may expose the foetus to unnecessarily high radiation of radio active isotopes. Although the perfusion scan highly exposes the foetus to radiation, which may increase the incidence of childhood cancer, the maternal exposure to radiation is significantly less than that of the CTPA.

A computed tomography pulmonary angiogram (CTPA) is highly sensitive and specific diagnosing even a small, centrally located PE. It is also very useful in diagnosing pathologies such as aortic dissection and interstitial lung disease. The main disadvantage is that the radiation exposure to maternal breasts in pregnancy is very high with the CTPA. Although CTPA is a sensitive diagnostic tool, it might miss a peripheral PE. However, the foetal exposure to radiation is significantly lower than a VQ scan, which should, ideally, be discussed with the mother. Magnet resonance imaging pulmonary angiography (MRA) is an alternative to CTPA, if maternal radiation exposure is deemed unacceptable. Its sensitivity and specificity may be comparable to that of the CTPA. However, it is not widely available, not suitable for women with metallic implants or claustrophobia and is expensive.

An echocardiogram will readily pick up a large, proximal PE. It is very useful in detecting complications of PE such as left atrial thrombus, ejection fraction of the right heart, cardiac failure, valvular regurgitation and also excluding possibilities like pericardial effusion, endocarditis or aortic dissection.

Arterial blood gas would quantify degree of hypoxia and type of respiratory failure enabling right treatment. However, it will not directly reveal the origin of hypoxia. Although formal 12-lead electrocardiogram (ECG) is normal in many minor PEs, detection of the right heart strain pattern (a big S wave in lead-I, a big Q wave in lead-II, inverted T wave in lead-III plus right axis deviation) is the characteristic ECG finding in a massive PE.

Compression duplex ultrasound of leg veins is important to detect the underlying cause of the PE, which is usually a deep vein thrombosis (DVT). The main advantage is that there is no radiation risk and finding of a DVT would prompt commencing anticoagulation therapy, which is similar to the treatment of PE. However, it is not a very sensitive test. It is not very useful in detecting an ileac vein thrombosis, which may require a venogram; that carries the highest risk of foetal radiation exposure.
Posted by shmaila S.
DR SAS.
a)This is a medical emergency and life threatening conditions like Myocardial infarction,Pneumonia,Pneumothorax and Pulmonary embolism.Her airway and breathing should be assesed.If her airway is compromised,then anaesthetic assistance shoul be sought urgently.Oxygen shoul be administered via face mask to prevent hypoxia.Her circulation should be evaluated and I/V line should be established.20ml of blood should be taken and sent for FBC,coagulation screen,urea and electrolytes,liver function tests,group and save.Arterial blood gases should also be assesed.These investigations will assist in reaching diagnosis and monitoring.Her BP,pulse,temperature,respiratory rate,SPO2,ECG should be monitored continuosly(using pulse oximeter,electrocardiogram and automated BP recording).ECG may show changes suggestive of MI.Her chest should be auscultated for signs like crepitations,rhonchi and cardiac murmur,which may be sugesstive of pneumonia,cardiac disease ,mediastinul shift suggestive of tension pneumothorax or PTE.Lower limbs should be examined for vericose veins,swelling or redness(suggestive of DVT).Chest X-ray should be arranged which may identify other diseases like pneumonia,pneumothorax and lobar collapse.Abnormal features caused by PTE including atelactasis,effusions and pulmonary edema can be seen.Urgent portable echocardiogram should be arranged to look for any cardiac disease.CTPA or V/Q SCAN should be arranged as there is high clinical suspicion of PTE.I/V unfractionated heparin should be strated according to local protocol,since it is the preferred treatment for PTE.It has rapid effect and there is extensive experience of its use in PTE.Transfer and monitoring in HDU or ITU should be considered.Documentation of all procedures and drugs adminstered shoul be done.

b)Objective tests includes Computed tomography pulmonary angiogram(CTPA) and Ventilation perfusion scan(V/Q SCAN).CTPA is recommended as the first-line investigation in non pregnant women.It has better sensitivity and specifity than V/Q scan.It is associated with 10% lower radiation dose as compared to V/Q scan.It can detect other pathologies like aortic dissection.The disadvantege is that it is associated with increased radiation exposure to maternal breasts,which increases her life time risk of breast cancer to 13.6%(background risk 1/200).Since breast tissue is spcialy sensitive to radiation exposure during pregnancy,CTPA is not recommended as first-line investigation in pregnancy.CTPA may not identify small peripheral PTE.There is concern about the saftey of iodinated cotrast medium with CTPA.It can alter fetal and neonatal thyroid function,so neonatal thyroid function should be tested.It requires especial equipment and trained radiologist which may not be available widely.V/Q scan is the first-line investigation in pregnancy,because of its high negative predictive value in pregnancy and reduced radiation exposure to pregnant breast tissue.The ventilation component of V/Q scan can be ommited,especially if chest x-ray is normal.It will minimise the radiation exposure to the fetus.Disadvantage is that it associated with increased risk of childhoold cancer as compare to CTPA ( 1/280000 vs 1/100000 ) V/Q scan may be delayed due to availaibility of isotope.Pulmonary angiography is also an objective test but it is associated with highest radiation exposure ( as compared to V/Q scan and CTPA ) both to fetus and mother.Therefore it is not recommeded during pregnancy.
Posted by Dr Dyslexia V.
X
a) I would do a quick assessment by taking a history in regards to do the onset of the complaint as is it the first episode, or associated with wheezing such as asthma. Is there any underlying history of infection such as fever, coughing or hemoptysis which could be attributed to pneumonia.

The risk of thromboembolism in pregnancy is 12 times of the background risk. History of previous episodes of thromboembolic event, family history of thromoboembolism underlying thrombophilia or usage of COCP is taken to point to diagnosis. History of calf or leg pain or swelling should also be attributed to a underlying deep vein thrombosis.

Initial examination which include airway, breathing and circulation assessed. Tachycardia could occur in thromboembolism and also infection. Respiratory rate and oxygen saturation taken to assess respiratory function and requirement of oxygen supplementation. A basic chest examination include auscultation to rule out any murmur in heart or crepitation in lung. An ECG done to rule out any underlying myocardial infarction or ischemia. The pattern of S1, Q3 and T3 could be seen from ECG tracing to support the diagnosis of thromoboembolism which invariably never present. A baseline arterial blood gas to assess respiratory failure or acidosis should be taken. A chest x-ray arranged to rule out underlying infection or any lung hypoprofusion or wedge shaped infarct in a massive pulmonary embolism. Blood should be taken for coagulation profile for baseline prior to starting any anti-coagulation treatment. A baseline renal profile and liver function test should also be taken. D-dimer level can be taken to negative predict the presence of pulmonary embolism. An ultrasound Doppler for presence of venous thromboembolism of bilateral lower limbs should be arranged.

Subsequently, the physician and anesthetist team should be called in for assessment while empirically starting patient on unfractionated heparin or low molecular weight heparin based on hospital protocol. An ultrasound of the fetus done for the assessment of fetal well being as well. Her further management should be entailed in the high dependency ward or ICU based on her condition.

b) The available objective test include computer tomography and pulmonary endiography (CTPA) and ventilation perfusion scan (V/Q scan). CTPA which is more commonly available in most centers could be used to identify pulmonary embolism. It is also beneficial as to diagnose other condition such as lung infection, aortic dissection as well. The only disadvantage is it has increased risk of breast cancer by 13.6% with a background risk 1 in 200. The risk of childhood cancer is relatively less which is one in a million for the fetus compared to V/Q scan which is 1 in 280,000.

V/Q scan has the advantage of able to diagnose smaller embolism and unfortunately available in only few centers. This modality will be more suitable for women with strong family history of breast cancer or carrier BRCA gene. It has the disadvantage of not able to pick up other conditions such as infection and aortic embolism. An ultrasound Doppler or bilateral lower limb will be beneficial to diagnose underlying venous thrombolism which could aid in the diagnosis of pulmonary embolism. Other test also include venous angiography but with a higher radiation exposure to the fetus.
Posted by Seham S.
SS
(a) clinical picture is highly suggestive of pulmonary embolism(PE) ,although other causes of chest pain should be excluded.PE is the leading direct cause of maternal mortality in UK according to the last CEMACH. Help should be asked from cosultant obstetrician,senior physician,haematologist and radiologist.Rapid history taking from relatives or accompaning person about leg pain before onset of symptoms,smoking,history of thrombo-embolic disease VTE in this pregnancy or before.Family history of thrombophilia,hitory of cardiac disease.then general examination include temperature for pyrexia,pulse for tachycardia,BP ,BMI for risk factor assessment and calculation of anticoagulant dose.chest auscultation for breathing sounds,crepitations. heart auscultatin for abnormal sounds or murmers.blood should be taken for FBC,U&E.clotting screen,liver and kidney function and for arterial blood gases.hypoxia and hypocapnia with respiratory alkalosis are suggestive of PE.ECG should be done to help in diagnosis of PE and cardiac causes ,however it may be of little help due to ECG changes associated with pregnancy.pulse oximetry for O2 saturation. Chest x-ray should be done to help in diagnosis although it is usually normal. compression duplex u/s is non invasive and can diagnose DVT.RCOG recommend to start treatment with therapeutic dose of heparin (LMWH) till diagnosis is confirmed by objective tests.LMWH has fewer side effects than unfractionated heparin (UH) however UH is preferred in massive PE.1 mg/ kg / 12h s.c is the treatment dose.In case of life threatening PE thrombolysis and embolectomy are recommended.Objective tests are V/Q scan and CTPA which are highly diagnostic although it carry small risk to mother or baby .,that is why informed consent should be signed before commencing procedure.

(b) Chest x-ray is available and have less rad exposure ( < 10 rad).abdominal sheild should be used. It can show atelectasis,wedged pulmonary infarction,pnemothorax.However it is usually normal.V/Q which is vetilation perfusion scan is diagnostic in 25% of cases only.Mother should be informed that there is slight increase in incidence of childhood cancer due to higher dose of radiation affecting fetus.this dose can be reduced by doing perfusion scan only.
CTPA is safe to the fetus but it carry slight increase in incidence of breast cancer.it may not help in diagnosis of peripheraly located embolus.MRI is safe for use in pregnancy to mother and fetus.
Pulmonary angiography is invasive procedure and not indicated in pregnancy except before surgery for embolectomy for detecting site of embolus.
Posted by drvimaladkm@yah K.
Sudden onset of shortness of breath with chest pain in a pregnant woman could be a life threatening disorder due to pulmonary embolism or rarely due to Myocardial infarction. These symptoms may also occur due to obstetrical conditions like acute preeclampsia with ARDS(adult respiratory distress syndrome), Amniotic fluid embolism or non-obstetrical conditions like acute pneumonia or acute pleural effusion, thyroid storm , diabetic ketoacidosis.
Patient to be admitted in intensive care unit. Requires multidisciplinary care including consultant obstetrician,Physician, Anaesthetist & hematologist.
Brief history regarding parity & LMP & regularity of menstrual cycles,Family H/O thromboembolism is to be collected.Previous or current history of leg pain (left more often)with swelling & low grade pyrexia in deep vein thrombosis and lower abdominal pain & backache in iliac vein thrombosis may be found as a causative factor. Other known medical conditions like Hypertension,Diabetes & Sicklecell disease or long hours of traveling to be noted. General condition of pulse, blood pressure, conciousness,rate & type of breathing is assessed quickly.Systemic examination of cardiac & respiratory assessment& abdominal examination is done for fetal assessment. Propped up or lateral position is given. Airway, breathing & circulation is established with IV fluids & 12 to 15 litres of Oxygen in low oxygen saturation with pulse oximetre . Intubation done by anaesthetist in cases of no response to oxygen therapy.20 ml of blood is collected for FBC, acid base gas analysis, renal(urea & electrolytes) & Liver function tests, coagulation profiles including Prothrombin time, Activated Partial thromboplastin time,Fibrinogen levels. increase in 3rd trimester pregnancy. ECG & Chest X-Ray(shielding the abdomen)is requested for cardiac & respiratory assessment. Injection Morphine is given for the relief of pain & anxiety.With strong clinical suspicion of pulmonary embolism therapeutic doses of IV Heparin 1unit/Kg or Injn.Low molecular weight heparin enoxaparin (1mg/kg twice a day Sc),Dalteparin or Tinzaparin is started. Physician’s consultation required for management of hypotension with pressors(Dopamine & Dobutamine). Specific investigations like Duplex Doppler scan,V-Q scan or CT scan to be further done to establish the definite diagnosis.
B)Duplex Doppler scan for suspected lower limb deep vein thrombosis is a noninvasive investigation for confirmation of thrombosis. If negative, it may have to be repeated 1 week later..MRvenography or contrast venography may be required in cases of iliac vein thrombosis.MRvenography is safe in pregnancy however contrast venogrphy is not advisable during pregnancy. . Ddimer estimation has negative predictive value & not to be done &D-dimer levels as such increase in 3rd trimester pregnancy more so in preeclampsia.4 to 17% of DVT maynot be identified by Ddimer. detect VQscan or CTscan are specific for the diagnosis of pulmonary embolism.VQscan has high negative predictive value. It carries lower risk of breast cancer with less radi. Ddimer estimation has negative predictive value & not to be done &D-dimer & FDP levels as such increase in 3rd trimester pregnancy more so in preeclampsia.It may detect in about 17%cases ation to breast tissue & higher risk of developing childhood cancer compared to CTscan.It requires Isotope. CTscan involves more radiation(20mGy) to maternal breasts with higher risks of breast cancer. During pregnancy breasts are more sensitive to radiation. It can not detect peripheral pulmonary thrombosis.It has advantage over VQscan as it gives lower radiation(10% less to VQscan) to the fetus. It has better sensitivity & specificity. It can identify other pathology like aortic dissection.CT involves iodinated contrastmedium which may suppress neonatal thyroid function,so neonatal thyroid function has to be checked at a later stage.If there is family H/O Breast cancer,VQscan may be more suitable. If woman’s condition is permissible,her wish has to be considered for selection of investigation.Pulmonary angiography involves highest radiation exposure to the mother.
Posted by Green K.
a) History will be obtained regarding parity as risk of venous throboembolism (VTE) increases with parity 3 or more. The number of fetus in this current pregnancy needs to be determined as risk of VTE increased with multiple pregnancies. History of concurrent lower limb pain which may suggest presence of deep vein thrombosis(DVT). Recent history of long haul travel exceeding 4 hours as it is a risk factor for VTE. Past history of VTE will be obtained as it is associated with increased risk of recurrence in pregnancy. Family history of VTE at the age of onset below 45 years and if patient is known to have thrombophilia also increases her risk of VTE. History of smoking will be obtained as it associated with an increased risk of VTE.

On examination, I will obtain her blood pressure and body mass index (BMI) as obesity (BMI> 30 kg/m-2) and hypertension (blood pressure exceeding 140/90 mmHg) is associated with an increased risk of VTE. Chest will be examined to assess presence of crepitations which may suggest pulmonary thromboembolism (PTE) or pneumonia. A reduced air entry would suggest pneumothorax. Abdominal palpation and measurement of symphysio- fundal height to exclude possibility of multiple pregnancy. Her legs will be examined to look for presence of prominent leg veins which is a risk factor for DVT. Presence of unilateral leg swelling with tenderness and inflammation would suggest presence of DVT as well. An ECG will be done to detect features of PTE.

Patient\'s features are suggestive of PTE and she would require admission with involvement of a multidisciplinary team consisting of on- call obstetrician, anesthetist, radiologist and hematologist. Her oxygen saturation would be checked with a pulse oximetry and oxygen therapy initiated immediately to correct her saturation if needed. Arterial blood gas will be obtained if desaturation is found. Blood would be obtained for full blood count and coagulation profile as a baseline. Blood for renal profile and liver profile will be obtained. Patient needs to be started with therapeutic dose of low molecular weight heparin (LMWH) until objective tests done to exclude PTE. A chest X ray (CXR) will be done to look for features of pulmonary embolism such as atelectasis, effusion, oligaemic areas or focal opacities. It may also show up features of other pulmonary disease.
If the CXR is negative but clinically suspicious then ultrasound doppler of the lower limbs will be done to exclude presence of DVT. Presence of DVT may indirectly confirm diagnosis of PTE and treatment would be the same for both condition. If the CXR is positive, then a definitive test will be done such as computed tomography pulmonary angiography (CTPA) or ventilation perfusion scan (V/Q).


b) CTPA: Advantage of being better in sensitivity and specificity compared to V/Q. Able to identify other lesions such as dissecting aortic aneurysm. Carries a low risk of fatal childhood cancer at 15 years of age of 1: 1,000,000.

Disadvantage includes a high radiation dose to maternal breast which is susceptible to radiation. It increases the risk of breast cancer by 13.6% above the background risk of 1/200. It should be avoided especially patient has previous history of chest CT or a family history of breast cancer. It may not detect small peripheral pulmonary embolus. The iodine contrast medium used can potentially lead to fetal/ neonatal hypothyroidism and thus fetal thyroid levels needs to be checked upon delivery.

V/Q: Advantage of having a high negative predictive value. Can be done without the ventilation component of the test can be omitted and therefore reduce the radiation dose to the fetus. Less risk to maternal breast tissue.

Disadvantage includes possible delay in performing the test due to isotope unavailability. Increased risk of fatal childhood cancer at age 15 years of 1: 280,000 compared to CTPA.

Pulmonary angiography is the gold standard but is not advocated in pregnancy due to the high dose of radiation to the patient and the fetus. It is associated with 0.5% risk of mortality, technically demanding and result may be difficult to interpret and costly to perform.
Posted by Roba R.
A) Impression Pulmonary embolism. Therefore, urgent attention required within multidisciplinary team including Obstetricion, radiologist, anesthetist, neonatologist, MW
History of current symptoms, duration, similar history in the past, pain, swelling in lower limbs, however pulmonary embolism can presented without previous DVT. History of issues in the current pregnancy. Past Obstetric history in particular thromboembolism Past medical history of thrombotic events. History of thrombophilia . Family history of thromboemboloic. Any medication
Examination: BP, Pulse ( Tachycardia suggest PE) , Tempreature , Respiratory rate ( Increase in PE) , pulse oxymeter ( Decrease saturation) . Insert IV line, collect blood for FBC, APTT, PT, D-Dimer ( if low decrease risk of PE, if high doesn’t confirm PE as increase in pregnancy) , blood gases. It is also important to check the Fetal heart
Reassurance of the mother
Provide pain relief
At this stage, if clinical suspicion support PE therapeutic LMWH initiated and continue until confirm diagnosis.

B) Chest Xray: cheape, non-invasive, if normal PE (Increase suspicion). Shielded abdomen will protect from radiation. If abnormal will give other ideas of the possible cause of pain. However, if negative further tests and more exposure to radiation in patient with high suspicion of PE

V/Q scan positive in 25% of PE so is not diagnostic. Exposure to radiation, however the radiation is not at dangerous level. If positive , confirm diagnosis and no further study to be done. If negative or equivocal further tests to be done.

CTPA it carries risk of radiation to the fetus and to the mother in particular breast tissues. Effective in diagnosis. If negative exclude PE. The risks of PE as the most common cause of death during pregnancy vs risk of radiation , this needs to be discussed with the patient

The gold standard for diagnosis is pulmonary angiography. However it is to be avoided during pregnancy .
Posted by fluffy F.
a) A brief , quick history regarding the nature of pain and shortness of breath , sudden onset is highly suggestive of pulmonary thromboembolism . History of leg swelling or if she is on any anticoagulation therapy will suggest deep vein thrombosis which is a risk factor for pulmonary embolism.History of palpitations , chest pain which is progressive suggestive of valvular heart disease. History of retrosternal burning sensation with the chest pain suggestive of gastritis.
This is a obstetric emergency , and the most likely diagnosis is pulmonary thromboembolism . The basic resuscitation must be a priority.A multidisciplinary approach together with the physician , anesthetist and hematologist is needed . The consultant on call should be informed regarding the happenings.Assess her general condition , a obese patient will have a higher risk of pulmonary thromboemebolism and deep vein thrombosis .If she is able to breath spontaneouly , tachypnoic , if she is tachypnoic high flow mask oxygen 10l/min should be started. Insert 2 large bore branulas for good venous access as her condition can deteriorate rapidly.A bed side pulse oxymeter monitoring , blood pressure and pulse rate should be recorded at 5-10 minutes interval. Tachycardia with reduced oxygen saturation is suggestive of pulmonary thromboembolism.Auscultate lungs for air entry , reduced air entry at a segment - suggestive of lobar collapse and crepitations suggestive of pneumoniae.If high clinical suspicion of pulmonary thromboembolism , treatment should be started immediately .Low molecular weight heparin has been proven to be effective , therapeutic dosage 1mg/kg body weight in 2divided doses. However , in a life threatening situation unfractionated heparin can also be used as its rapid effect and extensive experience in usage.A baseline full blood count , coagulation screen , liver function test and renal function should be done before commencement of treatment.A chest xray to look for lung colapse of evidence of pneumonia.If her condition deteriorates she will need intubation and intensive care monitoring.

b) Doppler duplex ultrasound of the lower limbs, is a easy and safe test to be done, as deep vein thrombosis is a risk factor for pulmonary thomboembolism.If negative , the ventilation perfusion scan ( V/Q scan) or computed tomography pulmonary angiography ( CTPA ) should be done depending on the availability, after discussion with patient and radiological expertise available.A V/Q scan has the advantage of lower risk of breast cancer to the patient and has a high negative predictive value.The disadvantage is higher risk of childhood cancers for the fetus. The CTPA , has a advantage of higher sensitivity and specificity , lower radiation to the fetus and it is able to identify other pathology such as aortic aneurysm.However , the disadvantages are increased risk of breast cancer to the patient and it is unable to identify small peripheral pulmonary thromboembolism.D Dimer should not be done in pregnancy as it can be raised due to physiological changes in pregnancy.
Posted by Harry B.
HB

A healthy 23 year old woman presents to the maternity assessment unit at 26 weeks gestation complaining of sudden onset shortness of breadth and stabbing chest pain on inspiration. (a) Discuss and justify your initial management [9 marks]. (b) Discuss the advantages and disadvantages of the available objective tests to establish a definitive diagnosis [11 marks].

A. Initial management of this patient should include the basic life support protocol of Airway, Breathing and Circulation assessment and resuscitation. Patient’s maternity notes should be reviewed and any risk factors such as high BMI, smoking, past or family history of thromboembolism, thrombophilia, recurrent miscarriages, cardiac diseases, asthma/other respiratory diseases, high blood pressure/ pre-eclampsia should be noted. History of long haul travel, lower limb swelling and pain should be asked.
Maternal pulse, temperature, blood pressure, oxygen saturation, respiratory rate should be checked. Any evidence of pyrexia, hypoxia, tachycardia, tachypnoea should be noted and oxygen should be admistered via a face mask at 15 L/min. One or two wide bore cannula/ae should be inserted and the bloods should be taken for FBC (to check the haemoglobin, WBC and platelets), clotting profile and baseline renal and liver function tests. A thorough examination of the respiratory and cardio-vascular system should be undertaken to rule out any obvious causes. Fetal heart should be heard using sonicaid for maternal reassurance. Arterial blood gas analysis will be useful in assessing this patient and as well as the chest X-ray in ruling out pneumonia, collapse, pleural effusion etc. An ECG should be done to rule out the cardiac causes of these symptoms.
Venous thromboembolism should be suspected in a pregnant woman with history of SOB and chest pain and a therapeutic dose of low molecular weight heparin should be started according to the body weight as per the RCOG guidelines (enoxaparin 1mg/kg, BD or tinzeparin 175 IU/kg OD) until further objective testing is done. Unfractionated heparin can also be used


B. The initial investigation in this patient should be a chest x-ray and bilateral Doppler assessment of lower limb veins. Chest x-ray to rule out pneumonia, atelectasis and pleural effusion and the Doppler assessment to rule out the presence of lower limb venous thromboembolism. If these tests are negative and the patient is clinically VTE, then objective testing should include either a V/Q scan (ventilation:perfusion scan) or a CTPA (computed tomography pulmonary angiogram). Both these procedures need appropriate counselling by an experienced obstetrician and/or a radiologist as to the effects on the patient and the fetus and an informed consent should be obtained.
CTPA has a better sensitivity and specificity than V/Q scan and also can detect other pathologies such as aortic dissection. It is associated with a increased risk of exposure of the maternal breasts to radiation and increases the risk of maternal braest cancer (13.6% increase on a background risk of 1 in 200). It should be avoided if the patient had had CT chest in the last year and a past/family history of breast cancer. The other disadvantage is that it may not detect small peripheral emboli.
V/Q scan has a advantage of high negative predictive value, no effect on maternal breast tissue and the ventilation component can be avoided to decrease the risks to the fetus. It increses the risks of developing childhood cancer (1:1,000,000 when compared to 1:280,000)
Pulmonary angiography is not recommended in pregnancy in view of high radiation exposure and should not be used in this patient.
Posted by Mohammad A.
(MA)
a) Patient should be admitted to maternity unit with involvement of cardiologist, physician, and radiologist. Intensive care unit should be informed of possibility a referral the case under their direct care, there is high possibility of acute pulmonary embolism (PE). Patient should be evaluated clinically after taking full history of her case of fever, cough, leg pain, tenderness, hotness and redness, signs of Deep venous thrombosis (DVT). Initial examination of her general condition, vital signs, temperature, pulse rate (tachycardia), blood pressure and O2 saturation of possible desaturation. Invistigations should be ordered in form of full blood count, evaluation of platlets count, electrolytes, arterial blood gases, urea, creatinine, and liver function tests. Coagulation profile is not mandatory to confirm or exclude acute DVT. ECG and chest X ray can be offered as the later may confirm pneumonia. Dublex ultrasound should be offered to rule out DVT. Invistigations should be included to rule out pulmonary embolism (PE), there are 2 highly sensitive tests, ventilation perfusion scan (V/Q) and pulmonary angiogram (CTPA). Hazards of both tests should be discussed with consent. In case of highly suspicious PE, heparin should be started in therapeutic dose. Unfracionated heparin is superior to be used over low molecular weight heparin in acute PTE. Initial platlets count should be checked with follow up.


b) Chest X ray may rule out pneumonia, however it is out of use for PTE diagnosis. Full blood count, platlet count is essential in cases of unfractionated heparin use. Follow up of platlets count should be every 5 days in such cases. Dulplex ultrasound may have false negative results, however with highly clinical suspicious, heparin should be continued. Venography may have radiation exposure for foetus, however with 26 weeks gestational age and abdominal shield, the exposure rate is significantly low.
V/Q scan and CTPA are the most important diagnostic tests of acute PTE. V/Q scan needs for isotope availability which may delay the diagnosis. There is increase incidence of child cancer in case of V/Q scan more than CTPA. However the incidence of breast cancer is higher in cases of CTPA more than V/Q scan. Both tests are not available in many units. Consent should be obtained before doing the test.
Posted by tahira jabeen J.
T he most likely diagnosis of this patient is pulmonary thromboembolism .PTE is main cause of direct maternal death .as it acute emergecy should be managed i n collaboration with consultant obstetrician,hematologist,radiologist,chest physician. pt history should be enquired to assess her risk for VTE.her case notes can be revised if she had any documeted assessment of risk factors for VTE as recomended by GREEN TOP GUIDELINES.patient should be asked about hemoptysis with chest painas it is with P.E or fever,cough to rule out peumonia,or any heart disease,leg swelling to rule out DVT.through examination including blood pressure,pulse,oxygen saturation,to assess the condition of patient.patient will be admitted,will be started on oxygen by nasal canula intravenous acsess will be takenbefore starting LMW heparin base line blood investigations like full blood count to see if leucocytosis,to see platelet count,coagulation profile as baseline ,urea & electrolytes,liver funtion tests.routine thrombophilia screening is not advisable.ECG should be done to rule out IHD and arterial blood gases may help as it will show respiratory alkalosis. As symptoms are suggestive of PTE she should have objective testing performed and treatment with low molecular heparin will be started until the diagnosis is excluded by objective testing unless treatment is strongly contraidicated.
x-ray chest will be performed as it can rule out other causes like pneumonia,pneumothorax,.it can be normal in 50% cases but can show abnormal features of PTE like,etelactasis,pulmonary odema,oligemia and radiation dose to fetus is negligible.if x-ray is normal compression duplex uss should be done if it is normal but there is high suspision of PTE ventilation perfusion scan or computed tomography pulmonary angiogram will be done according to availibilty.Patient should be involved in decision to under go CTPA or VQ scaning informed consent should be obtained.VQ scan has good negative predictive value but CTPA is preffered choice by BRITISH THORACIC SCOCIETY as better sensitivity & specificity but it is associated with high radiation dose to maternal breast.while incidence of childhood cancer is more with VQ scan.if patient has family history of breast cancer VQ scan is better choice.D_dimer is of not help in acute PTE as it is raised in preg & pre eclampsia.but if low will rule out VTE.If patient stable to start & monitor on bolus followed by maintaainence dose of unfractionated heparin or LMW heparin according to local unit protocolswill be done.If patient unstable
thrombolysis,or thrombolytic surgery will be done.if patient on LMW heparin risk of thrombocytopenia ,osteoprosis,will be less and no monitoring will be required until if pt has renal failure or recurrent VTE & high dose of LMW heparin is required we should monitor antiXa factor.if pt will be started on unfractional heparin needs to monitor platelet every 2-3 days after 4 days to rule out thrombocytopenia and should be monitored APTT.if clinical suspision high but objective testing is negative we will continue treatment .if test confirmed PTE will continue treatment 6 months
or 6 weeks post partum which ever is longer.documented plan for antenatal,intra partum and post partum will be documented in her notes.
B) ECG can be non specific but can rule out ischamia,other heart problems.arterial blood gases can help to find out respiratory alkalosis but its not specific as normal PO2 PaCo2 can be found in PTE.
x-ray chest is normal in 50 % cases but help to find other pathology like pneumonia,pneumothorax.D.dimer is non specific as it is high in normal preg,preeclampsia,preterm labour but if it is low suggest no VTE.CTPA has good specificity and sensitivity and also helps to diagnose other pathology like aortic disection but less diagnostic to peripheral emboli,increased radiation exposure to maternal breast,increases risk of breast cancer by 13.6% so should not be used in patient with family history of breast cancer or who already had CTPA.iodine is used as contrast so neonatl thyroid functions needs to be assessed.VQ scanning has good negative predictive value but investigation can be delayed due to non availibility of isotope.Tecnicium is used in it which wil be excreted by kidneys so accumulated in bladder increases exposure of baby to radiation patient should be advised to take ample water to pass it out.VQ scanning increases incidence of childhood cancer.tecnecium is also secreted in milk so if done i post partum period there should be no breast feeding for 2 days.MRI and arteriography can be used to diagnose PTE but data is lacking to prove specificity and sensitivity.
Posted by Bee N.
A healthy 23 year old woman presents to the maternity assessment unit at 26 weeks gestation complaining of sudden onset shortness of breadth and stabbing chest pain on inspiration. (a) Discuss and justify your initial management [9 marks]. (b) Discuss the advantages and disadvantages of the available objective tests to establish a definitive diagnosis [11 marks].
Answer:(BN)
A) Pulmonary embolism is one of the major leading causes of maternal mortality though other differentials such as myocardial infarction, pnuemonia, spontanoeus pneumothorax and acute panic attack must be borne in mind. This being my differentials, I will call for help of senior obstetrician and inform the hematologist and radialogist as well as on call anaesthetist and paediatricians about this patient and possible diagnosis.This are specialists who will potentially be involved in her management.I will access the patients airway to ensure patency and access breathing as initial step towards resuscitation. I will then take blood for investigations. This will include full blood count and C- reactive protein to rule out infection and access platelet count. I will do a liver function test and electrolyte and urea which are basal investigations before a patient is started on anticoagulant as well as coagulation screening which may detect clotting problems. I will establish an intravenous line for drug administration.Opiods which may depress respiration are better avoided for pain relief The patients blood pressure, pulse and oxygen saturation will be monitored continuously initially, but this can be extended to every 30 minutes or hourly depending on clinical situation. Tachycardia may be a feature of pulmonary embolism and blood pressure may be low if patient is going into shock. I will commence facial oxygen 15L/min. I will attach an ECG to rule out myocardial infarction and check for signs of Pulmonary embolism(s1Q3T3 waves)
A quick physical examination will include measuring the BMI to access risk for venous thromboembolism and to calculate therapeutic dosage of low molecular weight heparin. I will examine her legs for any signs of calf swelling/tenderness and check for Hofmann\'s sign. I will then examine her abdomen and listen for presence of fetal heart beat. I will arrange immediate administration of therapeutic dose of clexane following the local protocol. I will then arrange for tranfer to an intensive care unit while making arrangement to organise objevtive tests to confirm diagnosis.

B)Objevtive test will include D-dimer. The D- dimers are elevated in other conditions such as pre eclampsia. Pregnancy also increases it and this makes its usefulness limited in pregnancy.
Chest-X-Ray may be useful in large PE but unlikely to be abnormal in small or early PE. It can also be abnormal in other chest conditions such as pneumonia and hydrothorax and therefore is useful in ruling out other differentials even if negative for PE.
Leg Dopplers are useful in that if positive, no further tests are required and assumption of PE as a cause of the chest pain is accepted. However It has limited use because most deep venous thrombosis causing PE in pregnancy arise from the iliac vessels which are not picked by routine leg dopplers. Thrombus situated at the calf are also poorly picked. They are more sensitive for thrombus located at the thighs.
Ventilation-perfusion scan have high sensitivities/specificities but are limited by the fact that they are not reliable in the presence of chest infection. They also expose the fetus to significant amount of radiation. If negative with high index of suspicion, treatment can be continued and test repeated after a week.
CTPA can be used even in presence of chest infection but it increases the maternal risk of breast cancer. The choice of investigation to be used depends on the patient after proper information has been given to her. The Gold standard in treatment is angiography but this is not widely available and not routinely recommended for pregnant women due to high radiation dose.
Posted by Atashi S.
a)Symptom suggestive of pulmonary embolism which is more common in pregnancy following deep vein thrombosis. It is a major cause of maternal mortality she should be managed in a acute and emergency unit.Other cause of acute chest pain should be excluded such as acute myocardial infraction, Pulmonary infection, Pneumothorax, Musculo skeletal pain and neuropsychiatric pain.Quick history should be taken including parity, any H/O VTE in previous pregnancy or during pill use. Symptoms associated with haemoptysis, pyrexia , trachycardia ,faintness, collapse should be looked for as it give rise to clinical suspicion of PE. Leg symptoms like leg/calf pain or discomfort, swelling,Odema, calf tenderness and induration should be enquired which is suspicious of DVT. Initial investigaton include white blood cell count which may increase in VTE or in infection.ECG is to be done which is usually show pregnancy induce nonspecific change ,sinus tachycardia is the most common finding,SIQ3T3 not usually present.Arterial blood gas analysis hypoxia,hypocapnea and respiratory alkalosis highly suggestive of PE.If high clinical suspicion of PE then I will start low molecular weight heparin subcutanuously in divided dose while awaiting for objective testing.Before starting anticoagulaton I will check full biood count,Urea and Electrolyte,Liver function test and clotting screen.Routine thrombophillia screen is not to be done.

b) Only around 5% women investigated with PE will have a positive result.Chest X-ray is to be done.If normal then compression dopplar ultrasound is to be done.If negative but clinical suspicion of PE then a ventilation -perfusion(V/Q)lung scan,a lung perfusion (Q scan )or a CTPA(Computed tomography pulmonary angiogram) is to be done.Alternative or repeat testing should be carried out when investigation are normal but clinical suspicion is high and anti coagulation treatment is to be continued.CTPA has a better sensitivity and specificity than V/Q scan and lower radiation dose to the fetus.The average fetal radiation dose is less than 10% of that of V/Q scanning.CTPA can identify other pathology such as aortic dissection.The main disadvantages of CTPA is the high radiation dose to the maternal breasts, which is associated with increase life time risk of devoloping breast cancer.There have been concern over the safety of use of iodinated contrast medium in CTPAas it alter the fetal and neonatal thyroid function.Following its use in pregnancy neonatal thyroid function must be checked.V/Q scanning may be delayed because of availability of isotope.CTPA and V/Q scanning can not identify small peripheral PE.Women with suspected PE should be advised that V/Q scanning associated with small increase risk of childhood cancer. Women should involved in the decision undergo CTPAorV/Q scan and informed concent must be taken.
Posted by R S.
R S

a.Management should be prompt as it’s a medical emergency and can be fatal. Rapid history and examination is done to help reaching the diagnosis. Bloody stained sputum can be a clue of pulmonary embolism. The patient examined for the presence of cyanosis with measuring of pulse rate, blood pressure, temperature and respiratory rate. The chest is examined to detect areas of poor air entry and presence of crackles. The heart is also examined for sign of heart failure like Gallop rhythm or pericardial friction rub which goes with myocardial infarction or pericarditis. Along side, liberal oxygen is provided and we call for help. ECG can reveal signs of myocardial infarction or pulmonary embolism like sinus tachycardia or S1Q3T3. The patient is put on pulse oximeter to measure oxygen saturation with assessment of consciousness and general condition. If there is high suspicion of pulmonary embolism, intravenous unfractionated heparin is given immediately while a waiting to confirm diagnosis by objective test. Heparin can prevent extension of thrombus. Multidisplinary team is involved in the management including consultant physician, heamatologist, anaesthetist and pediatrician. Portable chest X-ray can be done with abdominal shield, it can reveal signs of pulmonary atelactasis, pneumothorax, pneumonia or cardiomyopathy. Thrombolytic therapy can also be used instead of heparin; it can dissolve the thrombus and improve patient general condition. Blood is aspirated for a base line investigation.

b.Compression Duplex US of the lower limbs can diagnose DVT and subsequently gives a clue for pulmonary thromboembolism. It’s safe and acceptable but it requires skills in interpretation. It can be repeated after one week of the diagnosis is still suspicious.
Ventilation –perfusion scan can be offered after taking patient’s consent, it carries high sensitivity and can diagnose pulmonary embolism, however, it involve exposure to radiation with increase likelihood of developing childhood cancer. It also takes long time till arrangement of the test. The ventilation part can be omitted to reduce the amount of radiation exposure. It is safe on maternal aspect.
Computerized tomography pulmonary angiography is another option, it does not associated with increased childhood cancer, it can diagnose other causes of chest pain like dissecting aortic aneurysm, but it can miss peripheral embolism and it carries an increased risk of developing breast cancer in future.
Measuring D-dimer is not specific as it’s usually raised in pregnancy, however, it has high negative predictive value i.e. if it is low, this can preclude thromboembolism.
Posted by AFSHEEN M.
A healthy 23 year old woman presents to the maternity assessment unit at 26 weeks gestation complaining of sudden onset shortness of breadth and stabbing chest pain on inspiration. (a) Discuss and justify your initial management [9 marks]. (b) Discuss the advantages and disadvantages of the available objective tests to establish a definitive diagnosis [11 marks].


a)PE is the commonest cause of maternal death in UK.A detailed history should be undertaken for chest tightness,hemoptysis, pleuritic chest pain.I would also ask about leg/calf pain /discomfort,swelling (especially left sided) and abdominal pain.Also, I would exclude any history of infection or trauma.
Initial examination should include all observations including oxygen saturations and checking for tachycardia, hypotension, pyrexia and maternal respiratory rate.I would auscultate chest and examine abdomen and legs in detail, looking for any abdominal mass ,varicose veins, swelling, redness and tenderness.
Initial investigations should include baseline bloods such as FBC,U&Es,LFTs and coagulation screen. D-dimers are usually raised in pregnancy but low levels decrease chances of VTE.I would request arterial blood gases which may show hypoxia,hypocapnia and respiratory alkalosis.Chest X- ray should be considered; ECG should be arranged; however non specific pregnancy changes may be observed ;sinus tachycardia is quite common.Duplex compression scan of the legs may also be required.
Initial treatment with low molecular weight heparin should be started while waiting for definitive diagnosis, because of high maternal mortality associated with PE, if untreated.LMWH should be administered in twice daily doses, by subcutaneous injections in therapeutic doses.Dose should be calculated according to mother\'s booking/most recent body weight.LMWH is effective, associated with less haemorrhagic complications and thrombocytopenia nad osteoporosis ,as compared to unfractionated heparin.
Legs should be elevated,TED stockings provided alongwith adequate hydration and mobilisation.Mother should be reassured about its safety in pregnancy.


B)Chest X ray should be initially organised; If negative ,Compression duplex scan should be considered as it is easily available and no radiation risk. If negative, and clinical suspicion low,treatment may be stopped. However, may be repeated after a week or alternative tests requested if high index of clinical suspicion.

Other objective investigations available are CTPA, V/Q(ventilation perfusion scan) scan,lung perfusion scan,or pulmonary angiography.

Computed tomographic pumonary angiogram has good sensitivity and specificity for detection of PE; is associated with less fetal radiation dose(approx 10% less radiation as compared to V/Q scan) and helpful in identification of other pathology such as aortic dissection.However, is associated with radiation to maternal breast tissue and increases lifetime risk of breast cancer.It, therefore, should be avoided in women with family history of breast cancer or who have had previous chest CT scans.There have been concerns regarding contrast medium which may cause fetal thyroid problems and therefore, noenatal thyroid function tests should be checked after CTPA.

V/Q scan may be employed as a first line investigation due to its high negative predictive value and association with less radiation dose for maternal breasts.However, it may be delayed to availability of isotope.It is also associated with a slight increase in child hood cancers (1 in 280,000 as compared to less than 1 in 100,000 with CTPA).

Both CTPA and V/Q scan may miss small peripheral PEs.

Pulmonary angiography is associated with maximum radiation exposure, but is seldom used.

Women should be advised that V/Q scan is associated with a slightly increased risk of childhood cancer (1 in 280000, as compared to less than 1 in 100,000) with CTPA, but less radiation exposure for maternal breasts.CTPA increases lifetime risk for maternal breast cancer by 13% (background risk 1: 200).Written information should be provided and informed consent ontained prior to these inestigations.
Posted by Roba R.
Dear Dr Paul,

How can I know that you commented on my answer ?
Roba
Posted by Roba R.
Dear Dr Paul,

How can I know that you commented on my answer ?
Roba
Posted by SUNDAY A.
SOS answers
aI would follow agreed protocol for management of the patient by calling for help from senior midwife, anaesthetist and SHO and proceed to ensuring airway is patent and applying oxygen by facemask. I would then proceed to taking detailed history including the time of onset and duration of shortness of breath ( SOB)- clarifying if it is aggravated with exertion and relieved by rest, any associated cough-which may be productive of sputum or not and may be blood stained. The duration and time of onset of chest pain should be established including severity, radiation to the back and sternum. History of non specific symptoms such as generalised abdominal pain, fever, feeling unwell, nausea and vomiting should be ascertained. Associated lower limb pain, swelling or calf tenderness should be discussed with patient to exclude DVT. History of reduced fetal movements should also be ascertained. Thereafter a general examination checking the vital signs including Blood pressure, respiratory rate, temperature and oxygen saturation. Dehydration and pallor should be excluded. The cardiovascular and respiratory system should be assessed and any added sounds, murmur, rib pain ( on palpation) should be noted. Abdominal examination to check the fundal height and any epigastic tenderness or right hypochondrial tenderness and to check fetal heart. The lower limbs should be checked for any swelling or tenderness which may point to a deep vein thrombosis. Blood with iv access should then be taken for FBC, U/Es, LFT, D-Dimers, Arterial blood gases (ABG) and ECG , CXR (with fetal shielding ) should be requested as baseline. Bilateral lower limb Doppler scan should be requested and based on the result a V/Q scan or CTPA may be required. I would then start patient on therapeutic LMWH ( clexane) until pulmonary embolism is objectively excluded. TED stockings and adequate hydration would be encouraged.
b) Arterial blood gases (ABG) analysis is one of the objective test that can be done to aid diagnosis. Its easy to do, cheap and can be done at the bed side. The drawback is that it is not specific test and requires a skilled personnel to take the samples. A plain chest -X ray (CXR) is cost effective, readily available and can pick up lung pathology including pulmonary embolism, lobar pneumonia . The drawback is the exposure of the fetus to radiation and occasional false negative which may necessitate further investigation. The Doppler’s scan is easy to do and with a high sensitivity to detecting deep venous thrombosis, and no risk of exposure to radiation. The disadvantage is that it is operator dependent and at times false negative result can occur leading to increased morbidity and mortality. Another objective test available is the ventilation/perfusion lung scan which can objectively exclude pulmonary embolism. It is specific, sensitive and able to pick up peripheral clots. The disadvantage is the increased risk of childhood cancer in the fetus though still very low. Further risk include exposure to contrast and radiation with its subsequent risk such as allergic reaction and risk of breast cancer though overall risk still low compared with CTPA. It’s an expensive test and the equipments are not readily available is smaller units and trained personnel required. The CT pulmonary angiogram (CTPA) is the gold standard for excluding pulmonary embolism, it’s more sensitive than V/Q scan and injection of contrast medium is not required. There is reduced risk of childhood cancer but the drawback of CTPA is the high risk of maternal breast cancer due to increased radiation dose to the breast tissue. It’s an expensive test with the equipment and personnel not readily available.

Posted by tahira jabeen J.
dear PAUL
i have metioned clearly advantages& disadvantages of CTPA &VQ but you did not saw them and did not mark them.please see it again.

NO, you did not. Look through your answer and see if the words advantage / disadvantage or any words with a similar meaning appear in your answer. Do you expect the examiner to read your answer and decide what is an advantage / disadvantage anf give you marks? If a patient asked you: what are the advantages and disadvantages? Will you expect them to make sence of what you wrote? You will say: the advantages are...
Posted by sutha  C.
SC

a) Pulmonary embolism is the most likely diagnosis in this case. However other possible diagnosis like pneumonia, cardiomyopathy and muscle spasm would need to be ruled out first. A quick history is obtained enquiring if she has had cough with fever which is associated with sputum production which may suggest pneumonia. History of palpitation, orthopnoea and dizziness may suggest cardiomyopathy though further test is required as most of these symptomps are normal in pregnancy.

Patient is put in propped up position and monitoring of the oxygen saturation , blood pressure and pulse is done. If her oxygen saturation is low , less than 95%, I would start her on high flow oxygen mask of 15l/min. Examination of both her lower limbs for any evidence of swelling. If unilateral swelling and the limb is warm and tender to touch, most probably she has deep vein thrombosis which has lead to pulmonary embolism.

Auscultation of her lungs and cardiovascular system, is done. If crepitation is present and they are coarse most likely she has pneumonia. If the crepitation is bilateral and basal and fine, the possibility is she has a cardiac problem. In most cases of pulmonary embolism, auscultation of the lung would have a negative finding. Electrocardiogram is done looking for any abnormal changes. Blood investigation is sent for full blood counts, urea and electrolytes and a coagulation profile. In the suspicion of pulmonary embolism, anticoagulant therapy like heparin or low molecular weight heparin is started at therapeautic dose once the other cause have been ruled out while waiting for further investigation.

b) Compression duplex ultrasound of the lower limb is performed . If there is evidence of deep vein thrombosis, then the diagnosis is confirmed. However thrombus in the iliac veins may be difficult to visualize due to the gravid uterus and may give a false negative result.

Ventilation perfusion (VQ) scan is the first line investigation for pregnant mothers. This method has the advantage of high negative predictive value and has lower radiation exposure to the maternal breast tissue. However the mother must be explained that, there is a increase risk of childhood cancer.

Alternate method of testing is the CT Pulmonary Angiogram. It has better sensitivity and specificity and the exposure to radiation to the fetus is reduced by 10%. Other pathology like aortic dissection can also be detected during the angiogram. However due to higher radiation exposure to the mother there is an increase lifetime risk of developing breast cancer for the mother. Contrast medium used during the procedure can alter the function of the fetal thyroid making it necessary to test the thyroid of the neonate.

However both the method cannot detect small peripheral emboli and in cases of high clinical suspicion, treatment should be continued.
Posted by M E.
SAM
a) Clinical assessment is necessary to differentiate between pulmonary embolism, pneumothoraz and pneumonia. History of leg pain and swelling or abdominal pain may be symptoms of a DVT. Symptoms associated with pulmonary embolism such as hemoptysis, faintness and palpitations. History of trauma or high grade fever with cough can help differentiate from other causes. Previous history of venothromboembolism, sickle cell disease and thromboplilia increases the risk of thromboembolism.

On examination assessment of respiratory rate, oxygen stauration and blood pressure is essential. Presence of hypoxia and tachypnoea and hypotension may be present with PE. On chest examination, presence of crepitations may be present with PE. Absence of breath sounds may be present with a pneumothorax. Examination of lower limbs for swelling and tenderness may be present with a DVT. Abdominal examination to assess fetal well being.

Patient with a high suspicion of pulmonary embolism should be admitted under the care of the obstetrician, anaesthetic team, hematologist. If low oxygen saturation detected, a ABG should be performed, presence of hypoxia would indicate PE. Oxygen should be commenced at 5 litres per minute. Baseline blood investigation of full blood count, clotting screen, renal function, liver function should be performed prior to commencing anticoagulant treatment. Therapeutic dose of Low molecular weight heparin should be commenced until thromboembolism is confirmed by objective testing.

CXR should be performed since it may identify the presence of pneumonia, lobar collapse or pneumothorax. Atelectasis, effusion, pulmonary edema indicate PE. Doppler ultrasound of both lower limbs should be perfomed if the CXR is normal. THe presence of a DVT indirectly indicates the presence of a pulmonary emolism and further investigation is not necessary since they both require the same treatment. If the doppler leg ultrasound is negative definitive diagnosis is necessary.

b) CTPA has the advantage of having a higher specifity and sensitivity than a V/Q scan for detection of PE. It has a lower level of radiation exposure to the fetus with a 1 in 1,000,000 risk of the a fatal fetal neoplasm before age 15. Another advantage is that it allows identification of other pathology such as aortic dissection.

Disadvantage of CTPA is the high level of radiation that the maternal breasts are exposed to which increases the lifetime risk of breast cancer. Also iodine contrast used affects fetal thyriod function , throid function needs to be performed after delivery.

Advantage of V/Q scan has a higher negative predictive value for detection of VTE. It also has lower levels of radiation to the maternal breast than the CTPA.

Disadvantages include higher level of exposure of radiation to the fetus. There is a 1 in 280,000 risk of the fetus developing fatal tumour before age 15. There may also be a delay in obtaining a V/Q scan due to availability of isotope.

Both CTPA and V/Q scans have the disadvantage of missing small peripheral emboli.

Pulmonary angiography also has the advantage of having a high level of radiation

Posted by armughan A.
Dear PAUL, Could you write key points to essays also please.Thanks
Posted by R S.
Dear Dr Paul,
Thanks a lot for your corrections. Please I need your help in the following issues:
- It has been stated in RCOG guideline [Intravenous unfractionated heparin is the traditional method of heparin administration in acute VTE and
remains the preferred treatment in massive PTE because of its rapid effect and extensive experience of its use] , so please I think that the majority of PE are life threatening and we need rapid action of heparin, how can we wait for the start of action of LMWH while the patient having stab like chest pain with shortness of breath. We need your help please.

-Does the traditional pulmonary angiography still implemented in pregnant patient ? or it has been replaced by CTPA ? I mean does the risks of Pulm. angiography outweigh its use in pregnancy ?

Thank you.
where the mark sheet for this Q like befor in old sit Posted by ghada M.

in old sit we can see the marke sheet at the end of the Q. Why we cant know?