Makindo Medical Notes

Related Subjects: | Assessing Breathlessness | Pulmonary Embolism | Deep Vein Thrombosis | DVT/PE in Pregnancy | CTPA

Compression ultrasonography of affected or both legs may be the best first test as no radiation is involved, and if DVT is seen, treatment can be started.

About

• Leading cause of maternal death in the UK.
• Higher risk of pelvic veins involvement.

Aetiology

• Sixfold increased risk of DVT/PE during pregnancy, continuing to approximately 4-6 weeks postpartum.

Risks

• Gestational age.
• Emergency C-section.
• Elective C-section.
• First trimester presentation.
• Obesity, smoking.

Clinical Presentation

• DVT most often affects the left leg due to compression of the left iliac vein.
• Symptoms include chest pain, dyspnea, increased respiratory rate, and tachycardia.
• Severe cases may present with syncope, pulseless electrical activity (PEA), or death.

Differentials

• Always seek expert consultation before dismissing any new physiological symptoms.
• Conditions like cardiomyopathy, myocarditis, and severe asthma can mimic DVT/PE.
• Physiological breathlessness, asthma, or anxiety during pregnancy can mimic PE symptoms.
• Oedema during pregnancy may resemble DVT.

Investigations

• ECG: Look for tachycardia, right ventricular hypertrophy (RVH), and the S1Q3T3 pattern.
• Wells Score: Not validated in pregnancy.
• D-Dimer: Often unhelpful, especially if positive in pregnancy.
• CXR: Always perform to rule out other conditions like pneumonia or pneumothorax.
• Echo: For compromised patients, it can show right ventricular (RV) strain and elevated pressures.
• VQ Scan vs. CTPA: VQ scan is usually preferred in patients with normal chest radiographs and no known pulmonary disease. However, CTPA is often used based on availability, urgency, and local protocols.
• Compression Ultrasonography (CUS): First-line test for suspected DVT as it involves no radiation. If DVT is seen, treatment is started immediately. Note that CUS may miss pelvic DVT.
• Thrombophilia Screening: Consider in cases of suspected thrombophilia.

Management

• Immediately start treatment dose low molecular weight heparin (LMWH) if there is a significant suspicion and no bleeding risk. Dosing is different in pregnant patients; take haematology advice.
• Avoid warfarin and direct oral anticoagulants (DOACs) in pregnancy.
• Consider thrombolysis (e.g., Alteplase) in compromised patients, under senior advice.
• Monitor for late complications such as pulmonary hypertension, post-thrombotic syndrome, and venous insufficiency.

References

• Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium (RCOG)