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MRCOG PART 2 SBAs and EMQs

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Essay 297 - VTE

Posted by Michelle G.

a.  The initial management involves establishing how unwell the woman is in a step wise assessment of airway breathing and circulation.  Measure the pulse, respiratory rate, oxygen saturations and blood pressure, if the lady is haemodynamically stable proceed to take a history.  If the lady is severe distressed and hypoxic on sats monitoring give oxygen and move to HDU/ICU for continuous vital signs monitoring and involve senior obstetrician, anaesthetist and physician immediately. 

The history includes onset of symptoms, whether proceeded by cough or febrile illness or any flu-like symptoms to establish whether viral/bacterial respiratory tract infection likely.  Note any history of leg swelling or calf pain.  Check if any features consistent with heart failure such as worsening exercise tolerance, orthpneoa, ankle oedema as cardiomyopathy is a differential diagnosis.  Past medical history must be established, especially any pre-existing thrombophilic diseases such as Factor V leiden defieciency, any previous personal history of VTE or any family history of DVT or PE.  Establish drug history and review obstetric notes.  Examination of the patient includes cardiorespiratory system looking for signs of respiratory tract infection such as crackles, any signs of cardiac strain such as gallop rhythm or if any murmur is present and abdominal palpation to exclude pain radiating from the epigastric region.  Palpate the uteris to determine fetal size, lie and presentation as emergency delivery may be needed.   A large bore IV cannula should be inserted.  Treatment should start immediately if PE is a likely diagnosis with treatment dose LMWH (1mg/kg BD) while investigations are carried out to determine whether PE present.  Only once mother stable must consideration to fetal monitoring be made with CTG.  If the patient is extremely unwell and hypoxic with pending collapse then multi-displinery team (physician/ICU/Obstetrician/anaesthetist) must decide immediate manangement which may involve intubation, imaging and if massive PE confirmed then options include radiological intervention to retrieve clot, thrombolysis and thoracotomy.  Perimortum caesarean section may be needed to aid maternal resuscitation.

 

b. Investigations include bloods taken for FBC, CRP to look at inflammatory markers, clotting as baseline as anticoagulants likely to be needed and baseline renal function tests.  If febrile blood cultures shourld be taken.  An arterial blood sample should be taken to assess for respiratory alkalosis most commonly seen in PE and look for hypoxia, seen in massive PE.  An ECG should be performed which most commonly shows sinus tachycardia in PE, though S1Q3T3 can be seen in keeping with right heart strain and PE. 

A CXR show be performed to exclude pneumonia and pnuemothorax and other chest pathology, if the CXR is normal then a V/Q scan can be preformed this is sensitive at diagnosing PE, though small perpheral PE may be missed.  It is associated with a low dose of radiation to the maternal breasts, though does expose the fetus to a higher dose of radiation, therefore increases the risk of childhood cancer in the feture, though childhood cancer in its self is extremely rare.  The risk increases from 1 per 250000 to 1 per 125000.  The alternate is to perform a CTPA, which is very sensitive at diagnosing PE and other chest pathology such as dissecting thoracic aneurysm, however radiation dose to the maternal breast is significant thus increasing the lifetime risk of breat cancer by 12%.  Alternatively if signs and symptoms of DVT present and woman is haemodynamically stable perform leg dopplers to look for DVT, as no risk associated with this test, and if DVT confirmed then treatment with LMWH is indicated and PE can be assumed.  However a negative leg doppler will not exclude PE.  The lady should be consented for either V/Q or CTPA and the risks explained, however if the patient is severely unwell and not able to give consent then the appropriate test should be performed in the patient's best interest.

Answer Posted by aysha Z.
I first establish whether she had a compromised airway, is she was breathing and had a good circulation. I would want her respiratory rate, if it was increased this would be a sign she's working harder to obtain oxygen and exhale co2. I would want her oxygen saturation to see if she is hypoxic. Her pulse is raised also indicates compromise as does a low blood pressure. I would start on her 15 lt of oxygen through a non rebreath mask If she is Hypoxic and obtain I've access with 2 large bore cannula. Iv access is so if she becomes more unwell we have access. I would obtain a full blood count to investigate for anemia and platelets. I would consider giving cleaxane at 1mg/kg bd. I would obtain a history asking if she had any risk factors for thromboembolism eg family history, long haul flight, immobility. I'd ask about leg swelling. I'd ask about respiratory causes eg asthma . I'd ask about cardiac symptoms like sob on lying flat . On examination , id auscultate her chest looking for crackes (infection or cardiac cause) or wheeze ( asthma). I would check for reduced air entry. I woluld listen to her lungs for murmurs. I would check her legs for swelling or tenderness looking for a dvt. Or severe swelling ie heart failure Admit her to hdu. Inform consultants and ask for medical review plus critical outreach team. TWO I obtain a full blood count. The hb will indicate anemia which may further exacerbate her symptoms. A high white cell count can indicate infection as can a high CRP. I would do a coagulation screen to ensure there was no Increased clotting state. I would do an arterial blood gas as this could show us If she was hypoxic or acidotic. This is painful for the pt but important as it points towards a pie or compromise. A chest X-ray would show a pneumonia and possibly signs of right heart strain or an enlarged heart, however in pregnancy heart size is difficult to ascertain. The risks to the fetus are very low with a cxr. Further imaging such as a v/q or ctpa will need to be discussed with radiology. V/q can have less radiation than a ctpa. But ctpa are more accurate. Some units advise a Doppler first of the legs to rule out a dvt before Chest imaging. An echocardiogram can be performed if a cardiac cause is considered. If a large pe is diagnosed it csn look at the function of the ventricles
296. VTE with Pregnancy Posted by Suzi G.

A.

A brief history of concurrent lower limb pain should be enquired 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.

Pulse, Temperature, Bp, oxygen saturation and BMI should be taken, chest examination to rule out infection like pleurisy should be done, examination of both legs regarding redness, cyanosis and swelling to rule out deep vein thrombosis.

Preliminary blood test should be done like CBC, kidney function, liver function and arterial blood gases are mandatory. Chest X ray, ECG, and colour Doppler US on lower limbs are essential. Multidisciplinary team including radiologist, hematologist, and senior obstetrician should be involved. Up on high clinical suspicion of PTE therapeutic LMWH should be instituted awaiting further objective tests like CTPA or V/Q to be available.

B.

 CTPA has better in sensitivityand specificity compared to V/Q. It carries a lower risk of fatal childhood cancerat 15 years of age of 1:1,000,000. Albeit, it includes a high radiation dose to maternal breast which is susceptible to radiation. It increases the risk of breast cancer by 14% above the background lifetime risk of almost 11% (one in nine). 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 has 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. The  risk of fatalchildhood cancer at age 15 years of 1:280,000 compared to CTPA. Pulmonary angiographyis the gold standard but is not recommended 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 Hamdy H.

a-i suspect pulmonary embolism.i take history as pleuritic chest pain and dyspnea shoet of breath. as this will give suspecion of p.e. so i can organise suitable tests.i take pulse as in p.e. patient is tachycardic. blood pressure will be low in sever p.e. sats less thean 96% will indicate possible pe and need to have arterial blood gase i will do ECG for her. clincal assessment like measurement diameter of leg swelling and tenderness and wormth is useful but less specific  and 50% useful in leg clot not pe.

i take blood for fbc  ABG before applying oxygen for resuscitation.i will send for chest xray and doppler both legs and ctpa  anto role out pe .  if sever symptoms i will addmit to atenatal ward and bring medical review. i will give oxygen if low sats as will as maintain airway and breathing.i will start her on LMWH according to her weight. theraputic dose.

b- sats is useful to monitor severity and arrange blood gases and oxygen. blood for fgbc  will rule ou anaemia which can give similar symptos haemacue is useful bed side for that.chext x ray  will be abnormal lat in pe but it is useful to do as need arrangment to transfer patient to x ray department and role out lung cause of symptoms.

ECG will gbe abnormal late but will be useful in diagnosis of sever pe na furter mangment and to exclude cariac cause of symptoms 

CTPA will be better as less radiation than MRI 

MRI will be usful in case CTPA not conclusive

DPPLER legs to exclude clot in legs as source of pe if find clot in leg  and can be dealt with suitable measures as lysis and sieve.

if all above tests excluded p.e we can stop LMWH immediately and discharge home. if pe was confirmed  she needs to stay in and further managment will be with medical to remove thelung clot.

 

 

 

Posted by Namia F.

 

a.  The initial managment should inckude a detailed history, examination, initial investigations while starting venous thromboprophylaxis while awaiting results of investigations. The history should include identifying risk factors of VTE like previous H/o VTE , thrompophilias, immobilization, family h/o of Vte , also history of any renal or liver impairment that can affect the thrombophropylactic dose, also any h/o cardiac or chest disease or symptoms should be excluded .

Examination should include B.p measurment to exclude PIH complications, chest and cardiac auscultaion, and lower limb ex. for calf tenderness or swelling, and  SFH  measurment and FETAL heart rate assement.Thromboprohyxis by LMWH should be started untill  Pulmonary embolism or other Vte excluded, initially  chextxxray can identify abnormalities,then lower limb doppler can exclude DVT  which if present will avoid the need for further inv. and theraputic LMWH  STARTED.Iif lower limb dopller is normal pt. should be offered either CT ANGIOGRAPHY OR LUNG v/Q scanning to confirm pulmonary embolism.    

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Posted by Namia F.

 

b. investigations should include initially cxr which can identify abnormalities like loigaemia, or atelectasis or lung collapse and easily availbe, if Cxr is normal and still high suspicious of thromboembolism Arterial blood gases can detect hypoxaemia and hypercapnia. lower limb doppler us on lower limb veins is important as the majority of thromboembolic events during pregnancy are due to lower limb DVT, it is non invasive and cheaper the VQ SCAN , OR CTPA , and more easily availbale and if Dvt detected treatment for both DVT AND PULMONARY EMB. both are the same.

both CPTA AND VQ scan are the diagnostic for pulmonary embolism with high sensitivity and specificity , but with risk of radiation exposure both to mother and fetus, and more expensive and invasive.Studies has shown higher risk of radiation exposure to the mother from CPTA, particulary to the breast (thus nor preferred if h/o breast cancr or high risk of breast cancer) , while VQ scan caries higher risk of fetal exposure.both should be used aft full discussion of the risks and benfits to the mother to allow for informed consent.

 

Posted by chaitanya M.

intial management

history:any cough ,haeoptysis, chest pain.i will ask for any history of fever,vomitings to rule out any infectious cause for breathlessness and chest pain

examination :i do detailed respiratory examination ascultate for bilateral breath sounds,presence of any murmur,raised jvp, tachycardia,measure spo2

i will order for an ecg- -inverted t waves ,q waves are suggestive of right  ventricular strain and pulmonary embolism.i will gain iv acess and send full blood count,liver enzymes,blood urea ,serum creatinine,prombin time and activated prothrombin time. 

chest xray to rule other pulmonary pathology

an arterial blood gas analysis:shows hypoxia and hypercapnia

duplex color doppler scan of the lower limbs to rule out deep venous thrombosis

if  there strong clinical suspision of pulmonary embolism and presence of deep venous thrombosis ,i will start pateint on LMW heparin therapeutic dose adjusted to her weight 

arrange for V/Q scan or CTPA. Both scans are,expensive, associated with rediation risk to the fetus. both are more sensitive in detecting pulmonary embolism which is life threatening  .v/q scan is associated with incresed risk cancers in children and CTPA is associated with increased breast cancer

 

 

 

 

 

Posted by chaitanya M.

intial management

history:any cough ,haeoptysis, chest pain.i will ask for any history of fever,vomitings to rule out any infectious cause for breathlessness and chest pain

examination :i do detailed respiratory examination ascultate for bilateral breath sounds,presence of any murmur,raised jvp, tachycardia,measure spo2

i will order for an ecg- -inverted t waves ,q waves are suggestive of right  ventricular strain and pulmonary embolism.i will gain iv acess and send full blood count,liver enzymes,blood urea ,serum creatinine,prombin time and activated prothrombin time. 

chest xray to rule other pulmonary pathology

an arterial blood gas analysis:shows hypoxia and hypercapnia

duplex color doppler scan of the lower limbs to rule out deep venous thrombosis

if  there strong clinical suspision of pulmonary embolism and presence of deep venous thrombosis ,i will start pateint on LMW heparin therapeutic dose adjusted to her weight 

arrange for V/Q scan or CTPA. Both scans are,expensive, associated with rediation risk to the fetus. both are more sensitive in detecting pulmonary embolism which is life threatening  .v/q scan is associated with incresed risk cancers in children and CTPA is associated with increased breast cancer

 

 

 

 

 

essay VTE Posted by celine  S.

VTE ESSAY

 

A ) A healthy  pregnant women presenting with the above symptoms ,should alert the clinician of the possible life threatening scenario of Pulmonary embolism  ,until otherwise proved. History of recent fever, cough, will suggest an infective cause, h/o long haul travel, dehydration is a risk factor for VTE(venous thrombo -embolism).A family history of  1st degree relative with  VTE is also a risk factor for this pregnant women. The recommendation is to follow  the hospital protocol ,even if there is just a suspicion of  pulmonary embolism. Call for help the consultant obstetrician, anesthetist ,hematologist and senior midwife. Assess blood pressure ,respiratory rate, pulse ,temperature, oxygen saturation (which if  falling  suggests an ongoing embolism).I will  assess  the respiratory system for deviation of trachea, reduced breathsounds , crepitations in the lower lung fields. The cardiovascular  system is assessed and an ECG is recorded(Typical S1T3Q3 picture is not always elicited in pulmonary embolism),blood gas analysis characteristic of pulmonary embolisim is  hypoxemia, hypocapnea and ,respiratory alkalosis. Blood should be sent for FBC, Liver function test ,serum electrolytes, and coagulation screen before commencing  treatment with anticoagulants .chest x ray will suggest other causes (pneumonia , pneumo thorax , or lobar collapse), but  if normal (50% of women with PTE chest x ray is normal), compression duplex Doppler  is performed .D –dimers tests are not routinely required because of high false positivity  during pregnancy, but  low levels suggests there is no VTE. Thrombophilia  screen should not be done during pregnancy, because  in normal pregnancy protein S falls, activated protein c resistance is found in 40% of normal pregnant women. Anti thrombin levels may be reduced in extensive thrombus. Hence hematologist should interpret the results.

Administer oxygen by mask , Low molecular weight heparin is the drug of choice, it is more effective and has less risk of haemorrhagic complications. Treatment should be continued until the diagnosis is objectively proven otherwise. The fetal heart beat and CTG are taken to note the condition of the fetus. The fetal risks of IUGR, due to maternal disease should be assessed as pregnancy progresses, or delivery may be indicated in view of maternal resuscitation.

   

 

 

b)If the history ,examination  and FBC is suggestive of infection then  definitive diagnosis can be achieved with blood cultures, PCR from throat swabs, or bronchial washings. Chest x-ray will not give any definitive features of PTE , or infection. Definitive diagnosis of pulmonary Embolism depends on the availability of the technique. Either ventilation perfusion (V/Q) scan or CTPA (CT Pulmonary angiogram), the choice is made after discussion with the radiologist and mothers choice (after explain the risks and benefits of both the procedures).

The British thoracic society recommends CTPA in non massive PTE .The advantages of CTPA are better sensitivity and specificity when compared to V/Q Scan, lower  radiation to the fetus, it can also identify aortic dissection. The main disadvantage is the high radiation dose to the maternal breasts, therefore increases the risk of breast cancer risk, background risk being 1/200 or 0.5%,and after CTPA lifetime risk is 13.6%,therefore it is not advisable to women, with family history of breast cancer. Also if iodinated contrasts are used ,the fetal thyroid needs  to be assessed post delivery. Small peripheral  thrombus may not be identified. CTPA has 10% of the radiation dose when compared to V/Q scan.

 

The ventilation perfusion scan is mainly advised as the 1st line investigation in this situation , as it has a high negative predictive value, and low radiation dose to the maternal breasts. Pulmonary angiography carries the highest radiation exposure.The risk of childhood cancer after V/Q scan is 1/280,000 when compared to CTPA it is about 1/1 000,000.V/Q scan can be delayed because of availability of the isotope,the ventilation component can be omitted  to reduce the radiation exposure to the fetus.

Posted by Jill A.

 

A)

I would quickly assess how compromised the patient was by taking her blood pressure, pulse, oxygen saturations, temperature and respiratory rate. If her airway was compromised, or her oxygen saturations were low - less than 90%, or respiratory rate more than 25. The patient needs stabilising first , I would give her oxygen through a re-breathe bag and mask and call for anaesthetic assessment.

Once she is stable a history needs to be taken. I would ask about her chest pain, enquiring about the nature of the pain, the location of the pain and the onset. I would ask about her shortness of breath, including the duration of the SOB, and the extent of the SOB. Is it at rest, is it on mild, moderate or severe exertion.

I would ask if there was an associated cough, if so is the cough productive or dry, and the colour of the sputum if any.  This would be suggestive of an infective cause such as pneumonia. I would ask about any haemoptysis or haematemesis, any flu like symptoms that would suggest an infective cause such as influenza or swine flu. Any symptoms suggestive of heart failure, such as peripheral oedema, although difficult to differentiate from normal pregnancy oedema.

I would ask about any medical problems she has such as asthma, congenital heart disease or other heart problems, renal failure, marfans disease as they are at risk of aortic dissection. I would ask about any recent trauma to the chest that could’ve caused a lung collapse or broken rib.

I would ask about any calf or leg  pain or tenderness or any recent long haul travel all suggestive of a DVT

The most likely cause of her symptoms is a pulmonary embolism. I would therefore enquire about risk factors for VTE. I would want to know her BMI, a raised BMI being a risk factor. I would ask about her age, her parity, age over 35 and parity greater than 4 being risk factors. I would ask if she has ever had a VTE before, or if any of have aher first degree relatives had a VTE. If she has a known clotting disorder such as factor V leiden, antiphospholipid syndrome, protein s or c deficiency, and if so if she is taking is on any anticoagulation therapy antenatally, and if she been taking it properly. I would ask if she smoked, andwhat her mobility was like.

 

I would then examine her. I would listen to her lungs, listening for any crackles indicative of infective cause. Any wheeze indicative of asthma, any reduced air entry indicating fluid or collapsed lung. I would then percuss the lung bases, any dullness indicating fluid on the lung. I would look for equal chest expansion on inspiration. I would listen to her heart listening for any murmurs, the rate and rhythm of her pulse.  I would examine her abdomen looking for any tenderness and measure symphysis fundal height and listen to the FH to check for viability of the fetus.

I would examine her legs, looking for any swelling, erythema, tenderness, that would indicate a deep vein thrombosis.

I would take bloods FBC, a raised WCC may indicate infection, coagulation, U&E’s and LFT’s. for baseline levels incase she requires thromboprophylaxis. A D-dimer is likely to be raised as she is pregnant and therefore is not a valuable test in pregnancy. I would also perform an arterial blood gas, the results of which will indicate if she has any respiratory compromise, a respiratory alkalosis being indicative of P.E.

As the diagnosis of Pulmonary embolism needs to be ruled out, she will need to be on treatment dose LMWH until a diagnosis is made. This is safe in pregnancy as it does not cross the placenta.

 

B) I would perform an ECG, looking for signs of infarction that would suggest a myocardial infarction, or P.E. such as sinus tachycardia or less commonly an S wave in lead 1, a q wave and inverted t wave in lead 3. An echocardiogram may be helpful in diagnosing cardiomyopathy , heart failure or structural problems such as mitral stenosis.

A CXR to look for signs of infection, lung collapse, pulmonary oedema,  aortic dissection. If the CXR is normal I would then go onto do bilateral duplex full leg dopplers, looking for any signs of thrombosis. If this was negative and I had a high index of suspicion for P.E. I would go onto image the lungs for P.E. There are two ways of doing this and I would need to discuss the pros and cons of both methods with the mother and gain her consent to proceed with one or the other. CT pulmonary angiogram is more sensitive for picking up pulmonary embolisms, however there is high radiation to the breast tissue increasing her lifetime risk of breast cancer by approximately 13.6%.  A v/q scan carries a slightly increased risk to the fetus of childhood cancer compared with CTPA. 1 in 280 000, versus 1 in 1 000 000.

If a diagnosis of P.E. is confirmed the patient will need to remain on treatment dose LMWH antenatally and for at least 6 weeks postnatally. She will be a high risk pregnancy and need to be seen in a combined obstetric haematology clinic for the rest of her pregnancy and will need to be followed up postnatally. 

Posted by hoba K.

A healthy 27 year old woman attends the assessment unit at 32 weeks gestation because of a 6 hours history of worsening shortness of breadth and chest pain on inspiration. 

 
(a) Justify your initial management [10 marks]. 

I will ask about the character of pain, a generalized tightness could be due to pulmonary embolism or pulmonary edema,localized pain can be due to pneumonia,stabbing pain can be myocardial infarction and interscapular pain can be a dissecting aortic aneurysm.i will ask about associated symptoms as cough,expectoration and haemoptysis due to pneumonia or pulmory embolism,syncope due to cardiac causes, visual disturbance and epigastric pain and headache due pre eclampsia complicated by pulmonary edema, low pelvic pain or calf pain due to DVT.i will ask about personal history of risk factors of pulmonary embolism as parity and smoking,I will ask about any flu like symptoms in any of the family members to identify possible flu.medical conditions as diabetes,SLE,known thrombophilia or previous VTE as risk factors of pulmonary embolism,history of cardiac disease, history of PIH or PET In previous pregnancies.i will ask about family history of VTE or thrombophilia in a first degree relative as risk factor for PE.i will ask about fetal movements as preliminary assessment of fetal well being. Examination will aim at assessment of haemodynamic compromise and maternal and fetal well being. Airway,breathing and circulation should be assessed.blood pressure could be high if pulmonary edema complicating PET or low if myocardial infarction or pneumonia and sepsis.wide pulse pressure detected with dissecting aortic aneurysm.respiratory rate and oxygen saturation to assess ventilation,lung auscultation for rhonchi,crepitations,pleuritic rub and air entry,cardiac auscultation for murmurs.pelvic examination for tenderness due to pelvic vein thrombosis,neurological examination for hyper reflexia with impending eclampsia, calf muscle for tenderness,redness and edema due to DVT,auscultation of fetal heart to ensure positive Fetal heart.initial investigations aim at establishing base line levels and need for emergency interventions together with clinical findings.a base line FBC for WBC count, platelets and haemoglobin,liver and kidney functions and coagulation profile could be disrupted with sepsis or PET,ABG to assess oxygenation,serum lactate if evidence of sepsis,d-dimer is non specific marker of DVT and PE.CRP as base line marker for infection.CXR to identify causes as pneumonia and pulmonary edema.urgent ECHO to identify possibility of pulmonary embolism and diagnose cardiac causes.CTG for fetal well being.

(b) Critically evaluate the investigations that will enable a definitive diagnosis [10 marks].

If pulmonary embolism is suspected anticoagulation should immediately be started without waiting for definitive diagnosis.a dissecting aortic aneurysm or myocardial infarction will be diagnosed by urgent Echocardiography and will be managed by the cardiology team in conjunction with obstetricians and anaesthetists.a diagnosis of pulmonary embolism can be done through following the RCOG recommendations.CXR should be done first,it has the advantage of identifying other causes of chest pain as pneumonia,pulmonary edema however it is normal in 50 % of cases of pulmonary embolism.ECG can show an inverted T wave in pulmonary embolism however it is not diagnostic.echocardiography can identify evidence of right ventricular strain if massive PE however it is not diagnostic and less sensitive with small peripheral PE.lower limb duplex can diagnose DVT of lower limbs however it can be normal. CTPA is more sensitive and specific than V/Q scan,can identify other causes as dissecting aortic aneurysm and exposes the fetus to less radiation as compared with V/Q scan however it exposes the breast tissue to high radiation dose which increases the life time risk of breast cancer and it can miss small peripheral emboli and uses radioactive iodine which can affect the fetal thyroid so neonatal screening is recommended.V/Q scan exposes the breast tissue to less radiation dose however it exposes the fetus to higher dose which can increase the incidence of childhood cancers as leukemias and can miss small peripheral emboli,the radiation dose of V/Q scan can be reduced by doing perfusion scan .without ventilation scan.pulmonary angiography is the gold standard test for diagnosis of PE with highest sensitivity and doesn’t miss small peripheral PE however it carries the highest radiation risk and is invasive and so is not recommended in pregnancy. 

Posted by Angeldust S.

(A)
Initial management includes resuscitation and stablisation of the woman. I will assess her airway for any obstruction and need for intubation. I will assess her breathing by measuring respiratory rate for tachypnoea and to put on high flow Oxygen 10-15L/min via face mask. I will monitor her oxygen saturation via pulse oximetry to look for hypoxia. I will assess to see if she is in circulatory shock by checking her blood pressure and pulse rate. 2 large bore intravenous lines are inserted and 20mls of blood drawn for initial investigations including FBC for anemia, baseline renal/liver panel, coagulation screen. An ABG is performed to look for hypoxia and respiratory alkalosis. Initial resusitation will be done togehter in a multidiscplinary team consisting of obstetrician, anaesthetist, and intensive care physician. She will be subsequently monitored in the high dependency unit if necessary. After she is stabilised, I will take a history for localising symptoms e.g. cough, fever, phlegm which may signify pneumonia; diaphoresis and crushing chest pain indicating myocardial infarction or aortic dissection; associated calf swelling or tenderness which may raise the suspiscion of DVT and VTE. I will ask for travel history to assess risk for influenza and malaria. I will asses her risk factors for VTE including personal or family history of thromboembolism. I will ask for fetal movements and to confirm gestational age with an early dating scan. I will ask for any sympmtoms of uterine tenderness or per vaginal bleeding to exclude obstetric haemorrhage. On examination, I will assess conjunctival pallor for anemia. Cardiovascular examination includes heart murmurs for vulvular pathologies, muffled heart sounds for pericardial effsion and gallop rhythm for heart failure. Respiratory examination includes creptitations to exclude pulmonary edema, wheezes/rhomchi to exclude bronchospasm, and decreased air entry for consolidation or pleural effusion. I will examine the abdomen for uterine tenderess and perform a vaginal examination to exclude per vaginal bleeding. I will put on a cardiotocography to assess fetal well-being. Initial treatment with LMWH is considered if there is a high suspicion for VTE. The decision for LMWH will be made in conjunction with the haematologist and the dosage dependent on brand specific dosing regime.

 

(B) Investigations include serial cardiac enzymes to look for raised trop I for myocardial infarction. I will perform an ABE to look for hypoxia and respiratory alkalosis as these signs are suggestive but not specific for pulmonary edema. An ECG is performed to look for hyperacute changes (ST elevation, RBBB, T wave inversion) for myocardial infarction and to look for sinus tachycardia and S1Q3T3 which may be suggestive for pulmonary embolism, but again not specific. They may also not be present. I will conduct a CXR to exclude pneumonia, pulmonary edema and pleural effsion. Changes on the CXR whcih may suggest pulmonary embolism are non-specific which may include hyperascular lung markings and increased CT ratio. If the CXR is abnormal, I will then perform a Duplex compression ultrasound of bilateral lower limbs to look for DVT. The presence of DVT is suggestive of PE in presence of respiratory symptoms and treatment for VTE and PE are the same which includes therapeutic LMWH. If CXR and Duplex compression scans are inconclusive, I will counsel the woman for a VQ perfusion scan or CT pulmonary angiogram. A CT PA causes less radiation risk to the fetus but has a higher radiation impact on maternal breasts which increases the lifetime risk of breast cancer to 13%. A CTPA can also exclude other causes such as aortic dissection. A VQ scan has a lower radiation risk to breasts but has a higher risk of fetal radiation and increases risk of childhood cancers although the absolute risk is still low. Both VQ and CTPA may not be sensitive for small peripheral PEs asnd might be missed. I will perform a throat swab for influenxa and send any sputum for culture if any. If a cardiogenic cause is suspected, a 2D echo may be necessary to assess left ventricular function and vulvular function.  

Posted by biba W.

a) I will first assess whether the patient is hemodynamically stable by taking her vital signs which include blood pressure, temperature, pulse rate, respiratory rate and oxygen saturation. I will assess her airway, breathing and circulation and insert 2 large bore intravenous cannulae and give supplemental oxygen via face mask. If the patient is stable, I will take a history of pulmonary embolism which includes pleuritic chest pain, dyspnea, hemoptysis and giddiness. I will also take a history of deep vein thrombosis which includes unilateral calf swelling and pain, edema, tenderness over the calf and induration. I will also ask for risk factors of venous thromboembolism which includes immobility, previous hisotry of thromboembolism, family history of thrombophilia, dehydration from vomiting and preeclampsia. I will also ask for symptoms of infection like cough, flu-like illness, pyrexia and sore throat. I will measure her BMI for obesity. I will perform a respiratory examination to assess air entry, crepitation and rhonchi. I will do a cardiovascular examination to assess for heart sounds and murmurs. I will perform a electrocardiogram to assess for sinus tachycardia which is the commonest finding on ECG for pulmonary embolism. S1Q3T3 on ECG is specific to pulmonary embolism but is rarely seen. D-dimer should not be performed to diagnose pulmonary embolism but a low level in pregnancy has a good negative predictive value. Arterial blood gases should be performed as hypocapnia, hypoxaemia and respiratory alkalosis is present in pulmonary embolism. Baseline investigations like full blood count urea and electrolytes, liver function tests and clotting studies should be performed prior to starting anticoagulation. Raised total whites can be found in infection or pulmonary embolism. Low molecular weight heparin (LMWH) should be started when there is a suspicion of venous thromboembolism before objective testing, unless strongly contraindicated. LMWH should be given subcutaneously in 2 divided doses (for dalteparin and enoxaparin) and titrated to patient's pre-pregnancy weight. Tinzaparin can be given as a single daily dose. LMWH is as effective as unfractionated heparin in the treatment of pulmonary embolism but associated with less bleeding and mortality. It is also assocated with less heparin induced thrombocytopenia and osteoporosis compared to unfractionated heparin. IV unfractionated heparin should be given for massive pulmonary embolism with cardiovasular collapse. In the event of deep vein thrombosis, the affected leg should be elevated and TED stockings applied and mobilisation encouraged to reduce swelling.

b) A chest xray should be performed first to look for atelectasis, effusions, consolidation and oligaemia. If the chest xray is abnormal, a computed tomography pulmonary angiogram should be performed. If the CXR is normal, bilateral duplex compression ultrasound of the legs should be performed to exclude deep vein thrombosis. If both tests are normal, either a ventilation/perfusion lung scan (V/Q scan) or CTPA can be performed. CT PA has better sensitivity and specificity in diagnosing pulmonary embolism and is associated with less than 10% of the radiation dose used by the V/Q scan on the fetus. It can also be used to diagnose other causes like aortic dissection. CT PA causes higher amounts of radiation exposure to maternal breast tissue and increase lifetime risk of breast cancer (13.6% increase in risk of breast cancer compared to 1 in 200 for study population). Therefore, it should be avoided in young women, women with family history of breast cancer and women who had a previous CT PA. The use of iodinated contrast medium in CT PA can also affect fetal/neonatal thyroid function. Need for neonatal examination of thyroid function. The V/Q scan is associated with lesser radiation exposure to breast tissue. However, there is higher radiation exposure to the fetus and it increases early childhood cancer (1/280000 compared to less than 1/1000000 in CT PA). There is also a need to wait for availability of isotopes. Both scans may miss small pulmonary embolism. Pulmonary angiography is the gold standard for diagnosing pulmonary embolism but it is assoicated with the highest amont of radiation exposure. Informed consent should be obtained from the patient before carrying out the investigation.

Posted by John S.
(A) Primary assessment should include assessment of Airway, Breathing and circulation followed by oxygen saturation, pulse, temperature and BP. This may identify sinus tachycardia, hypoxia, indicate infection and indicate urgency or treatment. High flow oxygen should be administered and the patient sat upright. A medical history emphasising risk factors for VTE and cardiovascular disease and systemic examination to identify peripheral thrombus, cyanosis. Respiratory and cardiovascular exam initiation can identify crepitations, eurythmics or abnormal heart sounds. The abdomen should be examined for tone, foetal heart rate auscultation. A MDT consisting of physician, anaesthetists, nursing staff and obstetrician should be called urgently. Bloods should be sent to identify baseline FBC, LFTS, u&es and clotting studies. This will identify any contraindications to therapeutic LMWH therapy at a dose of 1mg/kg Enoxaparin twice daily.this should be started immediately and continued until exclusion of VTE. Ischaemic changes, "s1q3t3" may be identified on ECG. CXR will identify consolidation, cardiomegaly and suitability for subsequent investigations like VQ scan. If the patient is collapsed or shocked or a life threatening massive Pulmonary thromboembolism is suspected, IV un fractionated heparin should be given, although thrombolysis should be given if confirmed within 1 hour. Thoracotamy or surgical embolectomy should be considered by the MDT. Urgent portable echocardiogram or CTPA must be arranged within this timeframe. Ted stockings should be fitted and legs elevated to prevent post thrombotic syndrome. Elector ionic fetal monitoring should be performed following stabilisation of the mother to confirm fetal well being. (B) Chest x ray will identify consolidation, pneumothorax, cardiomegaly and increased lung markings. It will guide subsequent investigations to exclude PE. The infant can be shielded and offers a lower doses of radiation to the maternal breasts. ECG is a quick,safe, portable investigation that will identify ischemia or infarction. It may also pick up the typical "S1Q3T3" pattern suggesting PE although a normal ECG will not exclude VTE. Portable echocardiogram will identify pulmonary hypertension, mural thrombus and ventricular dysfunction. It will aid rapid diagnosis and treatment of PTE and is safe. D dimer studies have a high negative predictive value excluding VTE but are generally raised in pregnancy and therefore have limited use. Lower limb dopplers will identify deep vein thrombosis which may allow treatment to proceed without additional, riskier investigations. However it will not confirm pulmonary thromboembolism. VQ scan confers a risk of childhood cancer of 1:280,000. However, this is low and whilst CTPA has a lower risk of childhood cancer of 1:1,000,000 it increases the risk of breast ca by 13.6. VQ has a significantly lower doses of radiation to the breasts and has a high negative predictive value, but may miss small peripheral emboli. Troponin T is highly sensitive for myocardial infarction. However, this should be done 12 hours after symptom onset and may delay diagnosis.
VTE Posted by farzana S.

A)Most likely diagnosis in this case would be Pulmonary embolism.This needs to be promptly identified and treated  as it is one of the leading causes of maternal   mortality.Associated symptoms of cough and hemoptysis will support the diagnosis. Enquire about pain and swelling in lower limb, suggestive of DVT,as this is associated with pulmonary embolism.

Differential diagnosis of myocardial infarction,though rare in this age,may be suggested by severe left sided  chest  pain radiating to to left arm.History of chest pain radiating  to interscapular region would suggest Aortic dissection

Family history of thrombophilia is taken ,which is associated with higher risk of thromboembolism in pregnancy

On examination general condition .BP,pulse ,Temperature ,SO2 and respiratory  rate is noted.

Respiratory and cardiovascular examination  for air entry,and heart sounds.Abdominal examination is done for fundal height and  Fetal heart sound.

Initial investigations include,FBC  raised WBC  seen.Chest X-ray may show areas of oligemia ,effusion.It may identify other pulmonary disaease i.e pneumonia or pneumothorax.ECG shows sinus tachycardia ,T wave inversion  in case  of pulmonary embolism.ABG  analysis shows hypoxemia and hypercapnia with respiratory alkalosis  ,characteristic of  pulmonary embolism.

Urea electrolytes,LFT,and coagulation screen is done as base line before anticoagulation .

D dimmers are normally elevated in pregnancy.Low levels decrease the level of suspicion of VTE

CT scan or MRI may be  arranged to rule out Aortic dissection

Multidiciplinary team of senior obstetrician,hematologist and radiologist should be involved in treatment.In case of high clinical suspicion of pulmonary embolism,anti coagulation should be started  with LMW heparin . In case of severe pulmonary embolism with cardiovascular compromise,unfractionated heparin is treatment of choice.This is continued until diagnosis is  objectively confirmed .

B) Definitive diagnosis is made by following investigations.Unit protocol  should be followed  .

If chest x-ray is normal  ,Compression duplex USS of lower limbs  is done .If DVT is confirmed,It will indirectly confirm PE,Further investigations are not required and anticoagulation continued.

If USS and chest xray is normal but clinical suspicion is high,anticoagulation is continued  and further investigations are done by ventilation perfusion scan ,or CTPA or pulmonary angiography.Choice will depend upon local availability.

If xray is normal  ,ventilation part can be omitted  and perfusion scan only may be done.This will minimize the radiation dose to the fetus. Breast tissue is particularly sensitive to radiation in pregnancy.V/Q  scan  has advantage in that radiation exposure to breast is substantially low.It is recommended in pregnancy specially if there is family h/o breast cancer It  also has high negative predictive value.

V/Q scanning may be delayed because of availability of  isotope.

CTPA  has a higher sensitivity and specificity than  V/Q scan.Average fetal  exposure to radiation is less than 1/10th  of that with V/Q scan in all trimesters.It can identify other pathology such as Aortic dissection.Risk of childhood cancer is less 1:1,000,000 compared to V/Q scan 1:280,000.

Dis advantages of CTPA are,risk of breast cancer is increased,13.6%,where as background risk is 1in 200.

It can not identify small  peripheral embolisms.Radioactive iodine used as contrast will affect  fetal or neonatal thyroid functions.Neonatal  thyroid functions should be test  after delivery.

Pulmonary angiography  carries highest risk of radiation exposure.

 

 

 

Posted by deva priya dhar M.

The symptoms are suggestive of pulmonary embolism,however it should be confirmed and otherdiagnoses should be excluded If mother is stable,history of any calf muscle tenderness and  leg swelling  unilateral should be asked as DVT     is associated with pulmonary embolism. Other risk factors like family and personnal history of thromboembolism should be asked. Other symptoms like haemoptysis should be asked. A history of  fever, cough with expectoration will point towards pneumonia.Examination of heart and respiratory system should be performed.BP, pulse, respiratory  rate, temporature should be checked. SO2 should be measured.Blood should be sent for Arterial blood gas analysis. FBS,urea and electrolytes,LFT  should be done to see for any dysfunction. Urgent chest xray and ECG taken.Management should be by MDT involving senior obstetritian, physician,anaethetist  radiologist andhaematologist. .It should be by ABC approach.If o2 saturation is low oxygen should be  given .If respiration is compromised anaesthetists involvement is needed. and intubation needed. IF pulmonary embolism is suspected senior obstetrician should take the decision of starting low molecular heparin in therapeutic dose, and further imaging by V?Q scan or CTPT to confirm the diagnosis. If pnemonia  is suspected,broad spectrum antibiotics should be administered. If any cardiac problem is identified treatment should be by the cardiac specialist.

B, Chest x ray  is often normal.It is an essential investigation to  exclude other important causes of breathlessness, chest pain or hypoxia.In  PTE  the findings are areas of translucency in underperfused lung, atelectasis,pleral effusion and wedge shaped infarct.It is easily available.

ECG will show right axis deviation, RBBB,  a pattern of S1Q3T3. It is not always present. Identify other cardiac problems.It is also immediately available.

FBC and leucocytosis not specific .Present in PTE and infections.

ABG will identify hypoxaemia and hypocapnia.

definitive diagnosis by  CTPA or V/Q scan . Both has advantages and disadvantages.

CTPA. advantage it is more sensitive. Detects aortic dissection,  Less radiation to fetus.

Disadvantages is high radiation to maternal breast. 13.6 /100 lifetime risk where as background risk is 1/200

V/Q scan is associated with less radiation to maternal breast but associated with increased risk of childhood cancer. 1 in 280000 with background risk of 1 in 1000000. 

MRI can be safe in pregnancy

Pulmonary angiogarphy  is highly sensitive but associated with high radiation .

D dimers  has high negative predictive value for embolism.

VTE Posted by Sarah S.

a)       I would ask more about any associated cough, haemoptysis, fever as these may indicate pneumonia. Any dizziness or syncopy may be indicating right heart failure in severe cases. History of her parity is to be obtained as parity of 3 or more is associated with higher risk of venous thromboembolism(VTE). The number of fetuses in the current pregnancy should be obtained as multiple pregnancy increases the risk of VTE. History of smoking should also be sought out. Any family history of VTE or thrombophilia should be asked as it has higher risk of developing VTE.

On examination: I will check BP, as systolic BP < 90 may suggest massive Pulmonary embolism Pulse rate looking for tachycardia. Respiratory rate will also be counted to see if the patient has tachypnea. Temperature is to be checked for fever. Oxygen saturation level to be assessed with pulse oxymetry as it may drop. Lung examination to be performed, it may show pleural rub which may indicate embolism in peripheral location in the vasculature. Abdominal palpation will be done measuring symphysio fundal height. Fetal heart will also be auscultated with hand held doppler. Lower limb will be checked for any unilateral leg swelling and tenderness as it will suggest Deep vein thrombosis. O2 therapy is to be initiated. IV line will be secured. Bloods will be taken for base line FBC, coagulation profile, urea,creatinine and liver function test prior to initiation of anticoagulation. D-Dimer can also be sent as if it is negative has negative predictive value; however, if it is positive can’t rule out DVT as it can be normally raised in pregnancy. ABGs will be taken as well to assess if paO2 is less and the patient has acidosis. ECG will be performed; it may be normal, or show sinus tachycardia, AF, if massive PE may show acute ischemic changes.  CXR with abdominal shielding will be helpful in excluding other chest disease. If clinically suggestive of PE, patient needs to be started with therapeutic dose of low molecular weight heparin until thromboemolism confirmed by objective testing. The case is to be managed under multidisciplinary team involving senior obstetrician, anesthetist, specialist midwife, neonatologist and intensive unit team.

b)        

CT- pulmonary angiogram for pulmonary embolism diagnosis offers faster scanning time and better resolution. It carries lower risk of radiation exposure to the fetus hence lower risk of childhood cancers at 15 years of age. It may also detect other abnormalities like aortic dissection. Having said that, it may miss small peripheral emboli, increase life time risk of breast cancer due to higher dose of radiation exposure to the breast. As for the V/Q scan, it has high specificity in detecting PE. It has lower risk of maternal breast cancer as the amount of radiation exposed to it is less. Its drawbacks are it exposes higher radiation to the fetus thus increasing risk of childhood malignancy. If DVT is suspected, Doppler compression ultrasound is the modality of choice as it is highly sensitive and specific for symptomatic proximal vein thrombosis. However, it can’t detect distal vein thrombosis, so if it is negative further testing will be required.

Posted by geeta G.

a)  As the patient is showing rapid worsening of symptoms, she needs to be stabilised first.Admit her to the HDU and inform anaesthetist and intensivist. Start oxygen by face mask and secure 2 wide bore iv lines. Check vitals including pulse, BP, temperature and respiratory rate and measure SpO2 and arterial blood gas analysis. Along with resuscitation, take simultaneous history from woman / relatives regarding duration and onset of symptoms and wheather associated with any productive cough, fever and flu-like symptoms as it may indicate infections like pneumonia. Past history of any cardiac disease or any cardiovascular risk factors like smoking, diabetes, hypertension as it may suggest ischemic heart disease.History of leg pain, swelling, DVT or any blood coagulation disorders as pregnancy itself is a hypercoagulable state. At the same time, continue examination of patient and check for breath sounds,crepitations and rhonchi as it may indicate infection, bronchospasm or pulmonary edema. Examine JVP and heart sounds for any murmers.Patient may need invasive monitoring. Start broad spectrum antibiotics. If pulmonary embolism is suspected start iv LMWH in therapeutic dose without waiting for results of investigations. If pulmonary edema is suspected, give diuretics. If general condition of patient doesn;t improve, she may require intubation and positive pressure ventilation. Assign one member of the team to monitor vitals, and mantain documentation of events, iv fluid and medications and input-output chart. Mantain good comunication with relatives to explain patient's condition.

b) FBC and CRP will indicate infections and inflammatory conditions.Baseline urea, electrolytes, liver function test and clotting screen to be done. If patient is febrile blood culture should be sent. Sputum for gram stain and culture if she has procuctive cough.ECG and troponin for assessment of ischemic heart disease and bedside echocardiography may help for any structural lesions in the heart.CXR may aid in the diagnosis of pneumonia, pulmonary edema and pulmonary embolism. If there is strong suspiscion of PE, further investigations should be carried out while continuing heparin. CTPA has good sensitivity and specificity in the diagnosis of PE as compared to ventilation- perfusion(V/Q) scan, but associated with a high dose of radiation exposure to maternal breast and increased lifetime risk of breast cancer by almost 15%. V/Q scan leads to less radiation exposure but use of iodinated contrast media may alter fetal thyroid function.Both of them might not detect small peripheral PE. Decision for CTPA and V/Q scan should be taken after discussion with mother if possible.

Essay 297 Posted by geeta M.

a)First I will note her vital parameters like pulse,B.P,respiratory rate and oxygen saturation needs  to know whether she needs immediate resuscitation.The  life threatening conditions to be ruled out are pulmonary embolism as VTE is now the most common cause of direct maternal death,and cardiac disease is most common indirect maternal death cause.I will ask her regarding onset of symptoms,any cough,hemoptysis,swelling of lower limbs,any recent long haul travel,any prolonged immobility,calf pain. I will ask her regarding radiation of pain ,if to left limb may suggest ischemic heart disease. I will ask her regarding  any medical history of cardiac disease,any thromophilias,any previous episode of VTE,any chronic respiratory conditions like asthma.I will ask family history of any thrombophilias,VTE in first or second degree relatives.

I will do a general examination including any swelling of lower limbs,tenderness.I will do cardiovascular examination to find out   murmurs,heart rate abnormalities.I will do a respiratory examination to detect any rales,rhonchi and  air entry clarity.I will do a per abdomen examination to detect any uterine activity and do a FHS auscultation to know about fetal condition.

Before any treatment for anticoagulation,we will do a full blood count,coagulation screen,urea,electrolytes,liver function tests.Troponin levels to rule out myocardial ischemia.ECG to detect any changes suggestive of cardiac dysfunction as well pulmonary embolism.Also we will do a blood gas analysis.

CTG to assess  fetal condition if mother is stable.

Her management will involve consultant obstetrician,haematologist,radiologist and medical team if there is high clinical suspicion of thromboembolism.Treatment with low molecular weight heparin started until diagnosis is excluded by objective testing and unless treatment is strongly contraindicated.Give her adequate analgesia.If her oxygen saturation is low,give facial oxygen.Monitoring of pulse,B.P.,R.R and oxygen saturation should be done.

b)Troponin levels will be elevated in myocardial infarction.Chest xray with abdominal  shielding done to detect any abnormalities.It may identify pulmonary conditions like pneumonia and pneumothorax.

Chest xray is normal in over 50% of pregnant with objectively proven PTE.Abnormal features include atelectasis,effusion,focal opacities,pulmonary oedema and regional oligaemia.If chest xray is  normal compression duplex Doppler should be performed.If both negative with persistent clinical suspicion of PTE,a V/Q lung scan or CTPA should be performed.

V/Q scan carries a slightly increased risk of childhood cancer compared to CTPA,but lower risk of maternal breast cancer and has high negative predictive value.Lung perfusion scan should be considered investigation of first choice for young women and  family history of breast cancer.

CTPA carries high radiation dose to maternal breast and associated with increased lifetime risk of developing breast cancer.It may not identify small peripheral PTE.It has better sensitivity and specificity,lower radiation dose to fetus and can identify other pathology as aortic dissection.

D-dimer testing should not be used to diagnose acute VTE in pregnancy as it can be elevated because of physiological changes in coagulation system or in pre-eclampsia.But low levels do reduce index of suspicion of VTE.

Performing thrombophilia screen prior to therapy is not routinely recommended and when undertaken should be interpreted by clinicians with specific expertise in this field.

essay 297 Posted by wafa T.

 

A                                                                                                                                                                                     

Initially I will assess her general condition .  I  will check  her pulse, blood pressure , temperature ,respiratory rate  and oxygen saturation. If she is severely dyspneaic  or hypoxic I will admit her to intensive  care unit. Multidiscplinary team including obstetrician ,physicians ,radiologist and intesive care team  . If  her condition is stable  I will  ask her about history of  fever and cough to exclude pneumonia  also whether she ha s   symptom suggestive of  DVT as pain or  swelling in her lower limb  . Family history of thromboembolism  or thrombophilia .                                                                                                                                                                     

Examination .                                                                                                                                                                

Auscultation of chest for crackles or wheezes  to diagnose pneumonia . Heart sound for gallop rhythm or murmur which suggestive of cardiomyopathy Examination of  Lower limb for swelling or tenderness   which  suggestive of DVT                                                                                                                                                               

 Base line investigations                                                                                                                                                      

Full blood count ,urea and electrolyte , liver function test andcoagulation screen should be done .Blood gas assessment is important in case of hypoxia . Maintain iv line and oxygen supplementation in case of low oxygen saturation.    Therapeutic dose of low molecular weight heparin should be started till objective test exclude vte. Assessment of fetal wellbeing  include CTG ultrasound  for fetal weight  presentation liquor volume should be taken.                                                                                                                                            

B                                                                                                                                                                                        

Chest x ray to identify pneumonia or abnormal feature suggestive of PTE as  atelectasis ,focal opacities ,regional oligaemia or pulmonary oedema.Compression duplex  Doppler lower limb can diagnose dvt . Echocardiography  should be taken to exclude cardiac pathology as cardiomyopathy . If clinical  suspicion of PTE  CTPA OR V/Q scan should be taken. Consent should be obtained before these tests are         undertaken.CTPA increase risk of radiation to maternal breast increase life time risk of breast cancer 13.6% , it is first line investigation in non massive pulmonary embolism in non pregnant women.It has better sensitivity and specificity in diagnosis of PTE and also it can detect another pathology as aortic dissection .Fetal risk of exposure to radiation is  1/1000 000  compared to risk  of exposure to radiation in V/Q scan is 1/280 000  .Use of iodinated CTPA will affect fetal thyroid so thyroid function test should be checked to the neonate. V/Q scan is first  line of investigation in pregnant women it has high negative predictive value and low risk of exposure of maternal breast to radiation . to reduce risk of radiation to the woman during V/Q scan ventilation component can be omitted . D dimer  testing should not be used in diagnosis of PTE in pregnancy because it increase during pregnancy but if it is low level as non pregnant women can exclude VTE.           

 

 

 

Posted by geeta G.

My essay posted on 5/2 has not been marked. Could you plese mark it

Posted by koukab A.

I ll do rapid assessment by history and examination.I ll ask personal and family history of VTE,history of any known thrombophilia,drug history,history of radiation and intensity and localisation of chest pain and any associated symptoms like hemoptysis.I ll do examination for pulse,BP,BMI,oxygen saturation, JVP,and chest auscultation. I ll inform consultant obstetrician and involve chest physician.I ll start oxygen inhalation by face mask and have IV access.I ll send all investigations like FBC, coagulation profile,urea,creatinine,electrolytes,arterial blood gases and LFTs.I ll ask for urgent Xray chest and ECG.I ll arrange urgent echocardiogram within one hour of presentation.My differential diagnosis is pulmonary embolism,myocardial infarction,aortic dissection,pulmonary oedema,pneumonia. I ll start therapeutic dose of IV unfractioned heparin according to unit protocol on clinical suspicion of PTE while waiting for confirmatory tests.         b)For confirmation of my diagnosis I ll ask for CTPA or V/Q scan after informed consent of pt.I ll provide her information about both tests.CTPA has more sensitivity and specificity atleast in nonpregnant pts.It causes more radiation exposure to pregnant breast tissues and incraeses life time risk of breast cancer but it causes low radiation exposure for fetus.It may not detect small peripheral emboli.V/Q scan causes high radiation exposure for fetus and may increase the risk of childhood malignancies for neonate.It has high negative predictive value for PTE.D dimers are of no diagnostic value in pregnancy as they are raised in normal pregnancy.Thrombophilia screen interpretation is difficult in pregnancy as all parameters may be changed in normal pregnancy so should be interpreted by expert if done.I ll do compression duplex scan before all these investigations as ist line investigation and if +ve ll confirm diagnosis of PTE but negative scan does not exclude PTE

Posted by koukab A.

I got v.much upset when i written VTE ist after taking too much time but it was not saved then i ve to write again n now it is saved.I ve done the same thing both times.I want to know is there some special technique to post our essays

Posted by koukab A.

I got v.much upset when i written VTE ist after taking too much time but it was not saved then i ve to write again n now it is saved.I ve done the same thing both times.I want to know is there some special technique to post our essays

quary Posted by koukab A.

I got v.much upset when i written VTE ist after taking too much time but it was not saved then i ve to write again n now it is saved.I ve done the same thing both times.I want to know is there some special technique to post our essays