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MRCOG PART 2 SBAs and EMQs

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ESSAY 159 - VTE IN PREGNANCY

Posted by jyoti D.
The most probable dignosis is deep venous thrombosis.There should be high index of suspicion as thromboembolism remains the major cause of maternal mortality in the UK as per the recent confidential enquiries.
The intial assesment includes detailed history about previous VTE,others symptoms like chest pain ,dysnoea,hemoptysis to rule out PTE.Examination to elicit signs of DVT like tenderness,increased temperature.JVP measurement ,chest auscultation for any signs of PTE.


Posted by Nitin P.
a)The initial presentation of this case suggests that she has a Deep Vein Thrombosis (DVT). Thromboembolism continues to be the leading cause of Direct Deaths in the latest CEMD. Other non-obstetric causes need to be ruled out.
It is important to confirm the DVT to avoid the costs, risk and inconvenience of inappropriate anticoagulation.
History of past DVT or Family history of DVT will affect the duration of treatment. Travel to filarial endemic areas may suggest filariasis and history of fall or trauma may suggest a fracture or sprain.
On examination, the BMI is noted as a high BMI is not only a significant risk factor but would also affect the dose and duration of treatment. The blood pressure should be checked, if there are other signs of pre eclampsia. The chest is auscultated to rule out any signs of pulmonary thromboembolism. The left leg is more prone to DVT than the right. It should be checked locally for signs of trauma. The abdomen is palpated for fetal lie, presentation and size.
Investigation FBP to check for leucocytosis as it is associated with DVT. Platelets are checked to determine a baseline and monitor treatment. Urea and electrolytes and Liver function tests are checked if there is a history suggestive of any renal, hepatic problems. Heparin is used cautiously in case of renal, hepatic diseases. D-Dimers is not reliable in pregnancy as the value is normally elevated. However, a low value is reassuring. Treatment is started on the grounds of a high degree of suspicion.
Dopplers are the confirmatory test and may need repeated 7 days later if initially negative but a high degree of suspicion persists. Venography is used if the suspicion remains and the Dopplers are still normal.
If there is doubt about fetal growth a ultrasound scan with follow up scans is arranged.
Treatment is instituted after admission. Initial leg elevation followed by early ambulation once the edema subsides. Thromboembolic stockings are used and should be used for 2 years to prevent post DVT syndrome. Anticoagulation is with heparin or low molecular weight heparin (LMWH). Warfarin is avoided due to risk of haemorrhage in labour and intracranial haemorrhage in baby.The therapeutic dose of LMWH or heparin is used. LMWH is preferred to heparin because of easier dosage, administration, less complications and no need for monitoring treatment. The dose and duration is decided in consultation with the haematologist, and in this case would be for at least 6 weeks postpartum.
b)Inspite of the normal pregnancy, this case is considered a high risk case. She is at higher risk of having bleeding complications. Consultant care is advised and duty consultant informed once she presents in labour. A plan should be in place in her notes. This should have been discussed with the haematologist and anaesthetist i.e. multidisciplinary input.
She is advised to omit the dose of LMWH once she is in labour. If for induction, the previous night dose is reduced to prophylactic dose. In labour, the doses may be omitted or prophylactic doses given depending on the persistence of risk factors and in consultation with haematologist. Epidural/ Spinal anaesthesia carry risks, and should be used only if the duration since last dose is > 12 hrs for prophylactic doses. The catheter should not be removed within 12 hours of the most recent dose and the dose not given for 6 hours after catheter insertion or removal.
There is no contraindication to invasive fetal monitoring.
In case, of operative deliveries there is a higher risk of bleeding complications. A caesarean section is done only for obstetric reasons and carries a higher risk of adominal wall haematoma.
If there is suspected intra abdominal bleeding or progressive abdo wall haematoma, better to start heparin rather than LMWH as effect easily reversed with protamine sulphate.
LMWH is started as early as possible after delivery.
No contraindication to breast feeding and warfarin started later on if continued anticoagulation is needed
Posted by jyoti D.
The patient should be adviced admission pulse, blood pressure checked for preeclampsia ,oxygen saturation noted ,arterial blood gases fro hypocapnia and respiratory alkalosis ,full blood count as DVT is associated with leucocytosis ,platelets count ,full thrombophilia screen,urea and electrolytes ,liver function tests and renal function test checked if any deterioration in function anticoagulation should be prescribed with caution.D-dimer if they are low suggests no VTE.Asses fetal well being by CTG or scan for growth and liquor volume .
X-ray venograohy or bilateral doppler ultrasound and if the test is positive continue anticoagulation if negative but high clinical suspicion continue anticoagulation for a week and repeat the doppler if again negative discontinue anticoagulation.
Anticoagulation (after checking the patients weight )in the form of unfractionated heparin or LMWH can be used but requires monitoring ,APTT ratio AND ANTI Xa levels which should be between 1.5-2.5 and .35-.7u/ml.The sideeffects like haemorragic complications,osteoporosis and thrombocytopenia are more with unfractionated heparin and requires strict monitoring with LMWH the complications are less and platelets can be monitored after 7-9 days.Consult the Haematologist before making management plans.
Therefore objective confirmation of DVT is a must to avoid risk, cost and inconvience of inappropriate anticoagulation.
General measures like mobilisation and TEDS should be adviced.

Once DVT is confirmed patient should be put on maintainance dose either oral warfarin or Subcutaneous LMWH fro uptill 6-12 weeks post delivery and TEDS for 2 years to avoid postthrombotic syndrome.Usually warfarin avoided as it is associated with CNS abnormalities at any gestation.If patient is put on LMWH she should be taught about proper needle disposals.
Once she goes into established labour she should be adviced to omit the dose of heparin and onadmission dose can be reassesed.If she is for elective Caesarian section she should be told to omit the morning dose if on prophylactic if on therapeutic dose she should omit it 24 hrs prior to regional anaesthesia,inform the anaesthetist to decise about regional anaethesia.Same protocal applies if she wants epidural analgesia and epidural cannula not removed untill 12 hrs of last injection.In case of caesarian section there is chance of wound haematoma so drain should be sited in. and heparin commenced after 4 hrs of epidural removal.She is at risk of PPH and so close monitoring is a must .
If this was a recurrent DVT she should be referred to Vascular surgeons as she may require venacaval filters or in whom anticoagulation is an absolute contraindication.
post natally she should continue fro 6-12 weeks and further continuation depends upon her risk factors.
Proper documentation in the notes about the events is important.
Posted by jyoti D.
sorry the first paragraph is in the different place before nitins kindly accept it as acontinuation.
Posted by rakhshinda Z.
Initial assessment will include history, examination and investigations to determine the cause. It is important to ask about symptoms and Signs like lower abdominal pain, Dyspnoea, collapse, pleuritic chest pain, haemoptysis, faintness, Oedema, calf tenderness / induration, pyrexia, tachycardia. It is also important to check for the risk factors like Increasing parity, Immobility / long haul travel, Obesity (BMI>30), Previous VTE, Sickle cell disease, White ethnic group, Thrombophilia, Dehydration hyperemesis, Blood group (Group O protective), Medical disorders polycythaemia vera, essential thrombocythaemia, Pre-eclampsia, Inflammatory disorders (bowel disease, UTIs)
Women with symptoms and signs of VTE should have objective testing as soon as possible to avoid the risk, cost and inconvenience of inappropriate anti-coagulation. Investigations which are helpful in establishing a diagnosis of DVT include Raised white cell count, ECG showing - sinus tachycardia, S1Q3T3 - not usually present, although pregnancy related non-specific changes reduce usefulness. CXR is usually normal. Doppler ultrasound is less sensitive in calf thrombosis, non-invasive and can be repeated. venogram should be considered if Doppler negative and high clinical index of suspicion. Base-line assessment before anti-coagulation includes blood for thrombophilia screen, FBC, U&E, LFT, clotting screen.
Regarding treatment in clinically suspected VTE, treatment with heparin should be given until the diagnosis is excluded by objective testing. General measures include elevate leg, use TED stockings and encourage mobilization. Continuation of anticoagulant therapy depends on the results of objective testing and clinical index of suspicion. For high clinical index of suspicion of DVT and negative Doppler - continue heparin, consider venogram or repeat Doppler one week later. Sub-cutaneous unfractionated heparin is an effective alternative to intravenous unfractionated heparin in the initial management of DVT. APTT ratio 1.5-2. Low molecular weight heparin (LMWH) is more effective and associated with fewer haemorrhagic complications than unfractionated heparin in the management of DVT.

For the management of rest of pregnancy use sub-cutaneous LMWH or unfractionated heparin for maintenance therapy. The simplified therapeutic regimen of LMWH makes it more convenient. Teach self-injection and disposal of needles. Check platelet count monthly - heparin-induced thrombocytopaenia is associated with further thrombotic complications use danaparoid sodium if thrombocytopaenic.
Maintain therapeutic anti-coagulation for the rest of pregnancy and for at least 6 weeks after delivery.
Once a woman thinks she is in labour, she should be advised not to administer further heparin injections. The dose should be reduced to a prophylactic dose the night of admission for induction of labour and through labour and the therapeutic dose reinstated after delivery and continued for at least 6 weeks.
Discuss regional anaesthesia with senior anaesthetist and with the woman prior to labour / delivery and avoid until at least 12 hours after prophylactic dose of LMWH or 24h after therapeutic dose. Do not remove epidural catheter until 10-12h after dose and do not administer LMWH within 4h of removing catheter.
There is a 2% risk of wound haematoma if caesarean section is performed. Give prophylactic LMWH day before surgery then prophylactic dose 3h post-op (or 4h after removal of epidural cannula) then therapeutic dose that evening. Use wound drains and interrupted sutures. If there is significant risk of haemorrhage, use iv unfractionated heparin which can be reversed with protamine sulphate. Breast feeding is not contraindicated and warfarin can be instituted after delivery.
Posted by Mangala sundari R.
The most probable diagnosis is Deep Venous thrombosis (DVT) of the left leg.She is at high risk for Venous thromboembolism (VTE),and PE which is the leading cause of maternal mortality.
The risk factors are obesity(BMI>35) , increasing age, pregnancy, multiple pregnancy, smoking, white race, personal history of VTE or family history in first or second degree relatives, Screen positive for thrombophilia ( acquired or congenital), airtravel, immobility for >4 days, gross varicose veins, dehydration, and .post operative period.
History is taken to evaluate the risk factors.
She will be admitted to the hospital, Pulse BP, Temperature, cyanosis, dyspnea, tachycardia and tachypnea noted, Calf measurements on both legs, positiveHoman?s sign , femoral, popliteal and dorsal pedis pulses are noted on both the lower limbs . Obsteric examination for fundal height, FHS checked.
Investigations include CBC, Coagulation profile, U&E, LFT, Gr & Rh and cross match, Arterial blood gas analysis( ABG) , Venous Doppler flow studies for both lower limbs for blood flow and thrombosis requested. If there is any hypoxemia in ABG or chest pain, dyspnea she will need VQ scan and ICU care.
If the clinical suspicion is high for DVT, she will be started on LMWH even before the objective tests results are available.If the Doppler studies are negative for thrombosis, but the clinical suspicion is high, she should continue to be on LMWH and repeat the doppler after 2 /3 days. The hematologist will be consulted to monitor the dosage and the progression or resolution of DVT.
She is high risk for thrombo embolism, post phlebitic leg syndrome and complications of anticoagulation.
Elevation of the limbs , TED stockings, Hydration and early mobilistaion are encouraged.LMWH is found to be effective than unfractionated heparin.The dosage is simple once or twice daily to be injected subcutaneously, , Monitoring with Anti xa level is not necessary. Hemorrhagic and osteoporosis complications are minimal than unfractionated heparin. Patient is monitored with CBC, platelets,clinical improvement of symptoms, calf measurements, and with Doppler studies. Fetal growth is assessed. Patient will be expalained about the condition and discharged with the advise to continue LMWH daily and to come for regular antenatal and hematology follow up once in 2 weeks till 36 and then weekly. Monthly platelet count and CBC will be done , fetal growth monitored.
Patient will be advised to with hold the therapeutic dose if for induction or if she feels she is in labour. Prophylactic dose will be continued during induction and labour. Senoir anesthetist will be consulted regarding the epidural analgagesia for labour. Epidural catheter should not be incited within 24 hours of therapeutic or 12 hrs of prophylactic dose of LMWH.and it should not should not be removed with in 4 hours of las t dose of heparin and the next does to be given 4 hours after the removal of the catheter. If she goes for C section proper hamostasis and adequate drains to be kept. Wound hematoma may be a problem. Start heparin 4 hours after the surgery. Early mobilization ,adequate hydration, antibiotics prophylaxis as required.Breast feeding notcontraindicated. Thromboprophylaxis to be continued for 6 weeks postpartum in consultation with hematologist whether LMWH or oral warfarin.
Posted by uma M.
VTE is commonest cause of maternal mortality as reported by CEMD.Low index of suspicion shoud be there for identification & management of VTE.
Pain ful,red swollen leg during pregnancy is most likely due to DVT.However other causes like trauma , cellulitis, filariasis should be kept in mind .Initial assessment should include history- symptom history for -any chest pain ,palpitations,SOB,haemoptysis, duration of symptoms, any assossiated fever ,h/o of VTE in the past related to or unrelated to pregnancy.H/o thromboplilia, personal or in the family is noted. Any h/o travel to filaria endemic country, trauma is asked.
Assess for risk factors - h/o any immobility, any surgeries, parity, preeclampsia ,long travel ,sickle cell disease etc.
Examine the woman for general condition, any obesity , PR,BP, SO2, Respiratory system and CVS , raised JVP .Tachycardia ,with raised JVP are suggestive of PE. Examine the lower limbs , for edema, calf tenderness, induration all suggestive of DVT. Perform obstetric examination.
Investigations include FBC , TC will be raised but non specific, ECG -changes not aLWAYS SEEN but S1 Q3 T3 ,sinus tachycardia is charecteristic of PE ,ABG -hypoxaemia, hypocapnea,respiratory alkalosis,s/o PE, CXR -will be usually normal.
Thromboplilia screen is to be done to guide the treatment .Baseline assessment prior to anticoagulation include LFT,U&E,FBC,Clotting screen .
If woman has signs and symptoms suggestive of DVT she should be started on immediate anticoagulation.Regular heparin or LMWH can be given untill diagnosis is excluded by further objective testing , to reduse the risk of further TE and extension.
Warfarin is avoided due to risk of haemorrhagic complications in fetus .Therapeutic doses of LMWH or heparin is used. LMWH is preferred to heparin because of easier dosage, administration, less complications especially less effect on plateletts. and bone loss on continued use . While on treatment Platelets checked every month, and monitor therapy with anti Xa activity. Any doubts about anticoagulation , haematologist opinion should be asked.
As soon as possible DVT/PE should be confirmed by objective testing as subjective assessment is unreliable .Testing avoids cost and inconvenience of treatment.
Unit protocol is followed. Doppler studies of legs confirms the diagnosis of DVT. But if US is negative with high index of clinical suspicion then she should continue anticoagulation and test repeated after 1 week. If USG -ve AND CLICIcal susoicion is low stop treatment. For confirmation of PE V/Q scan pereformed, which gives probabilitty of PE. IF low probability with low index of clinical suspicion and -ve leg doppler stop anti coaghulation . If low probability but high index of clinical suspicion or positive leg doppler continue treatment and repeat testing after 1 week.
leg should be elevated, graduated elastic compression stockings applied to reduce edema.Mobilisation with stockings is encouraged .She should continue with anti coagulation for rest of her pregnancy till at least 6 weeks postpartum.Advise her regarding safe disposal of needles and syringes.

Labour management poses problems due to risk of haemorrhage especially if women is fully anticoagulated in labour. Plan of management of labour should be made well in advance in antenatal period in consultation with haematologist,Anaesthetist ,discussed with her and documented in case notes.
She should be advised to stop taking further doses of heparin if she thinks she is in labour. She should report immediately, and further doses are given after assessment by medical staff.If she is for Induction of labour or elective caessarean section change to prophylactic dose on day prior ,continue through out labour.
Senior consultant should deceide regarding regional anaesthesia.Epidural anaesthesia carry risk of haematoma , and catheter should only be inserted if the duration since last dose is > 12 hrs for prophylactic doses, >24 hrs for therapeutic doses. The catheter should not be removed within 10- 12 hours of the most recent injection and the injection should not be given for 6 hours after catheter insertion or removal.
If she delivers by caessarean section then she should be given injection 3-4 hrs after procedure(depending on removal of epidural catheter.). Wound Haematoma complicates 2% of cases, to avoid this consider wound drains,close skin incision with interrupted sutures..Caesarean section only for obstetric indication.TED stockings are used intra operatively.
If she develops haemorrhagic complications like wound haematoma which is progressing, intra abdominal bleeding, PPH , IV unfractionated heparin is started as this can be easily reversed with protamine sulphate.Haematologist opinion seeked if woman develops haemorrhagic problems with LMWH.
Post natal she should be started on her regular dose of anticoagulation . Timing should take into consideration epidural catheter removal ,risk of haemorrhage post partum. She can be changed to warfarin gradually overnext 2-4 days
Posted by Shakira B.
The most probable diagnosis is Deep Venous Thrombosis/Iliofemoral Thrombosis, putting the patient at risk of PE and even maternal death. Thromboembolism is a major cause of mortality worldwide.
Pregnant female presenting with chest or leg symptoms suggestive of VTE should be anticoagulated with heparin until objective testing is done with Doppler or Venography shielding the abdomen and lung perfusion scan.
Initial Assessment begins with a detail history of DVT or Thrombophilia in herself or in family, and was it objectively proved? We should go through medical records of patient or family, whether VTE diagnosis was proved.
If history of Thrombophilia in the family is present then do screening for protein C, S, ATIII, prothrombin 20210gene deficiency. Close liason with hematologist is must in these cases.
Treatment started immediately while undertaking imaging studies. Before starting anticoagulant take blood for FBC, coagulation screen, LFT, KFT.
Initial Treatment: - Heparin in therapeutic doses must be started immediately.
Alternatives are: - LMWH SC twice daily or UH given IV at least initially. Monitoring is by factor Xa assay, (LMWH) or APTT for (UH). Platelet count is checked every week. Affected leg is elevated and a graduated elastic compression stocking is used. Gradual mobilisation should be encouraged. Depending upon her risk status she will be on prophlytic heparin throughout her pregnancy.
Treatment in Labour and Delivery: - Once the women is in labour or thinks she is in labour she should be advised not to inject any further heparin. She must be assessed an admission and further doses given by medical staff. If she is on LMWH (Prophylaxis) antenatally continue during labour and delivery. Women with previous VTE and no thrombophilia should be given prophylaxis for six weeks after delivery. In female with previous VTE who have inherited thrombophilia, the risk depends upon specific thrombophilia. They need AN thromboprophylaxis with LMWH and six weeks postpartum.
Female with inherited thrombophilia should always receive thromboprophylaxis in pregnancy and puerperium. If elective CS is being done for obstetric reason she should receive thromboprophylaxis dose of LMWH on the day before delivery. On the day of delivery morning dose is omitted. Thromboprophylaxis restarted three hours post op. (Or 4 hours after insertion/removal of epidural catheter)
There is increase risk of wound haematoma 2% with both types of heparin. Interrupted skin stitches in CS and wound drain in patient undergoing CS is advised.
Female with high risk of hemorrhage APH, PPH, may be given UH due to its shorter half life and can be easily reversed with protamine sulphate. For female receiving high prophylactic or therapeutic doses of LMWH, dose should be withheld if she goes into labour or reduced to prophylactic dose on the day before IOL. Dose of UH 5000 units/12houra and LMWH (enoxaprin) 40mg daily.
Epidural anesthesia can be sited after discussion with senior anesthetist. Also discuss its implication with the patient. To reduce the risk of epidural heamatoma, regional anesthesia should not be given until at least 12hour, 24hours after the previous prophylactic and therapeutic dose of LMWH respectively. When female presents on therapeutic dose of LMWH regional anesthesia not given at least 24 hours after the last dose.
Postpartum: - Thromboprophylaxis for six weeks in high risk pregnancy. In low risk, 3 to 5 days prophylaxis with LMWH. If she choose to start warfarin, second postpartum day and continue LMWH until INR more than 2.

Posted by Deirdre C.
This patient needs risk assessment for a possible DVT. Venothromboembolism (VTE) is the leading direct cause of maternal deaths, according to the latest confidential enquiry. There should be a high index of suspicion of VTE in pregnancy, and a relative low threshold for thrombolysis. Clinical assessment alone is unreliable in 50% of cases, and the risk of extension rises from 0.5% with treatment to 8-10% if treatment is withheld.
A detailed history is essential to identify pre-existing risk factors for VTE which affect diagnosis, duration of treatment and recurrence risk .These include inherited or acquired thrombophilias, past history of clot, strong family history, raised BMI, preeclampsia, immobility, increased age or systemic infection.
Targeted examination should look for deep calf tenderness, diameter difference greater than 1.5cm and reduced pedal pulse volume. Homan?s test may precipitate embolisation .Differential diagnoses such as thrombophlebitis or Baker?s cyst can be ruled out.
The presence of symptoms such as dyspnoea, haemoptysis or pleuritic pain, or signs including tachopnoea,tachycardia, raised JVP or pleural rub are suggestive of pulmonary embolism and consideration must be given to immediate thrombolysis prior to results from ECG,CXR,ABG or VQ scan.
D dimmer levels are unreliable in pregnancy, but have a high negative predictive value. A baseline platelet count is required in monitoring for heparin induced thrombocytopenia antenatally.
The gold standard for diagnosis is ascending venography with abdominal shielding, but this is not widely available. Duplex Doppler ultrasound is less sensitive in diagnosing an above-knee DVT but is less invasive and more easily repeated. If initially negative in a convincing case, therapeutic treatment should continue and venography or ultrasound scan repeated in one week.
LMW heparin provides similar anticoagulation to unfractionated with less complications such as haemorrhage or thrombocytopenia. Peak dose anti 10a levels of 0.4 - 1 u/ml indicate therapeutic concentrations.

Prophylactic heparin should be continued following treatment to provide cover antenatally and postnatally for 6 ? 12 weeks. Warfarin is avoided (unless high risk maternal artificial heart valve) due to maternal and fetal haemorrhagic risk, especially form 36 weeks.
The risk of haematoma formation with epidural insertion in labour is negligible if platelet count and clotting are normal, but it is advisable to avoid epidural placement for 6 ? 12 hours following heparin administration. In spontaneous labour or rupture of membranes, prompt attendance for medical assessment is required and heparin omitted when in active labour. The morning dose can be omitted in induction of labour and caesarean section cases. LMW heparin may be given 2 hours post epidural insertion. Similarly, the epidural cathedar must remail in situ for 6 ? 12 hours following heparin administration.
General measures to reduce risk of VTE in labour include adequate hydration, graduated elastic stockings, and mobilisation in early labour. A combined spinal epidural will allow maximum mobility. If assisted delivery necessary , time spent in lithotomy position should be minimised and pressure points avoided.
If platelet and clotting studies are normal, there is no increased risk of postpartum or intraoperative haemorrhage or need for transfusion. However, there is evidence of increased risk of wound haematoma formation, and if haemostasis is an issue, a rectal sheath drain and interrupted sutures should be used.
Following delivery, warfarin may be commenced if desired as is safe breastfeeding but requires regular monitoring and anticoagulant clinic attendance. If other risk factors for osteoporosis such as heavy smoker, strong family history or long term steroid treatment, a postnatal dexa scan should be performed. If the DVT was an isolated event, the recurrence risk in future pregnancies is 5-10% and heparin prophylaxis will be required.,
Posted by khalid M.
A) The symptoms are highly suggestive of DVT, however the differential diagnosis include local injury, phelibitis and cellulitis.

A complete history to ascertain the risk factors for DVT should be obtained including personal and family history of DVT, thrombophilia history, parity ( >4) and medical disorders( SLE & sickle cell disease).

Clinical examination should include checking for general well being, local examination of leg(temperature, redness, tenderness and swelling compared with oher leg) and obstetrics examination. BMI >30 is a risk factor for VTE and should be checked.

Early objective diagnosis is vital due to implications of treatment on current & future pregnancies as well as use of combined oral contraceptives and HRT in future.

Dopplers studies of leg are convenient, less invasive and widey available and thus the preferred choice. Venography, however is the gold standard with additional risk of clot dislodgement and fetal radiation exposure( can be reduced with abdominal shielding). D-dimers in pregnancy are unreliable as the levels are raised in normal pregnancy , however a low level is suggestive of no VTE. A full thromblia screen prior to treatment should be performed although less reliable in pregnancy. Test for factor V Leiden are useful. Renal and hepatic function test are important as abnomalities will effect anticoagulation therapy.

A multidisciplinary approach involving haematologist, anaesthetist, obstetrics and paediarician is vital.Initial therapy can be with IV/ SC unfractionated heprin( UH) or SC LMWH in therapeutic doses. LMWH is frequently used (although not licensed) in pregnancy. It is easy to administer, once daily dose, doesnot cross placenta and is monitored by
anti-Xa levels. Heparin therapy is associated with risks of thrombocytopenia and osteoporosis although with LMWH. Oral anticoagulants are contraindicated in pregnancy as they cross the placenta and can lead to haemorrhagic probems in the fetus. Supportive measures like leg elevation,TED stockings, early mobilisation and avoidance of deydration are indicated. The treatment should be continued throughout the pregnance and
6-12 weeks postnatal. Patient should be educated regarding the use and disposal of injections.

B) The labour and delivery should be conducted as high risk with multidisciplinary input, continuous maternal & fetal monitoring.During labour no heparin should be used. where induction is planned, the dose of heparin should be reduced to prophylactic levels the day before the procedure and recommenced at therapeutic levels after delivery. Generally epidural and spinal anaesthesia is not recommende but can be used 12 hours after the prophylactic dose of heparin and no further anticoagulation should be given atleast 4 hours after the removal of epidural catheter. These measres reduce the risk of local haematoma formation. In case of caesarean delivery wound drainage to reduce haematoma formation, ans skin closure with interrupted sutures is recommended.

Maintenance therapy can be either with heparin or oral anticoagulation for 6-12 weeks. Breast feeding is not contraindicated. Risk of recurrence VTE is high.
Posted by Yusuf K.
a) The possiblity of DVT/VTE can\'t be ruled out in this 24 year old lady.The initial assessment will be to look for risk factor for DVT/VTE and assess whether or not there is complication arising.
The assessment will include detail history-personal or family history of VTE,history of VTE in index pregnancy,family history of thrombophillias-presence of those risk factor is strongly in support of possiblity of DVT/VTE.Also parity and weight of the patient are important as parity of 4 or more and weight over 80kg are strong risk factors.Also establish if there is pleuritic chest pain, shortness of breath and haemoptysis will signify the presence of Pulmonary embolism complicating the suspicion of VTE.
Care3ful examination of the general condition such as presence of shortness of breath may warrant giving oxygen by face mark, chest examination for chest signs for pleuritic chest pain.Examination of the leg including measurement of the calf girth on the affected leg and compare with the right leg.Homan\'s sign should be elicited.All tjhis are necessary to further confirm the suspicion of DVT/VTE
Necessary investigation include,measurement of the arterial blood gases depending on the presentation if there is associated Pulmonary embolism,Chest X-ray is indicated at least to have a baseline.For the leg,Duplex ultrasonography /venography are gold standard for diagnosis.
Treatment-Most DVT/VTE are subclinical, therefore clinical diagnosis are unreliable.However, if the clinical suspicion is very high,thromboprophylasix can be started until the diagnosis is established.This clinical suspicion is discussed with the patient and the need for consult to Haematologist,Paediatrician is discussed to advised on anticoagulation.Low molecular weight heparin may be advised by the haematologist together with thromboembolic deterrents stocking.
b)Femoral DVT confirmed-the ilio-femoral vein is the commonest site and 80% occur on the left.This finding is again discussed with this patient and need for joint review with the haematologist,Paediatrician,Anaesthetist and senior midwife in charge of labour ward.
Depending on the anticoagulant of choice,anticaogulation is continued till onset of labour.In labour,discuss risk of haematoma following spinal or epidural with the patient and offer other means of pain relief.If epidural is requested,the anticoagualnt is stopped 12hrs after the last dose before sitting of epidural catheter,then delay the next dose by further 2 hours after the catheter.
After delivery, remove catheter 12 hours after the last dose of anticoagulation and delay the next dose till after 2 hours later.If the patient wishes to change to warfrin this can be started after 2 days of when all parameters-INR and other caogulation screen PT,APPT are within normal limit.and continue for the next 6-12 weeks.
She can breast feed if she so wish.
Subsequent pregnancy, she should be advised to book as soon as pregnancy is diagnosed and a leeter to her GP and community midwife stating this fact will be sent.