Pregnancy and Venous Thromboembolism Risk Factors

VTE & Pregnancy Eimear McClenaghan

Case History A 38-year-old woman, Jane, is gravida 5 and para 4. How many children does Jane have? How many pregnancies (including this one) has Jane had?

Case History A 38-year-old woman, Jane, is gravida 5 and para 4. How many children does Jane have? Para or parity is the number of completed pregnancies beyond 20 weeks gestation (whether viable or nonviable). Jane has had 4. How many pregnancies (including this one) has Jane had? Gravida is the number of pregnancies a woman has had. A multiple gestation, e.g. twins or triplets, counts as a single pregnancy. Jane has had 5 pregnancies, including her current pregnancy.

Case History A 38-year-old woman is gravida 5 and para 4. What are the risks of smoking in pregnancy? She is an active smoker. She has no other medical background. She has come in for a routine ultrasound at 13 weeks.

Case History A 38-year-old woman is gravida 5 and para 4. What are the risks of smoking in pregnancy? She is an active smoker. Miscarriage Ectopic pregnancy Foetalabnormalities such as cleft lip Smaller babies Premature babies Third trimester bleeding e.g. placenta accreta, placenta praevia She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Differential Diagnoses A 38-year-old woman is gravida 5 and para 4. What are the differential diagnoses of calf swelling in pregnancy? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Differential Diagnoses A 38-year-old woman is gravida 5 and para 4. What are the differential diagnoses of calf swelling in pregnancy? She is an active smoker. Deep Vein Thrombosis (DVT) Cellulitis Calf muscle tear/Achille s tendon tear Calf muscle haematoma Large or ruptured popliteal cyst (Baker s cyst) Venous outlet obstruction (pregnancy, pelvic/thigh mass) She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Cellulitis A 38-year-old woman is gravida 5 and para 4. What signs/symptoms differentiate cellulitis? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Cellulitis A 38-year-old woman is gravida 5 and para 4. What signs/symptoms differentiate cellulitis? She is an active smoker. Patients with cellulitis usually present with redness, heat, and swelling in the dermis of the affected leg. The affected area is likely to be smaller than in DVT (which may involve the entire foot, calf, or thigh), but the signs more pronounced. The demarcation of the skin margins affected by cellulitis is more defined than in DVT. Portal of infection entry may be identified. Fever and prior history of cellulitis is common. May occur with a concurrent DVT. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Cellulitis A 38-year-old woman is gravida 5 and para 4. What investigations differentiate cellulitis? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Cellulitis A 38-year-old woman is gravida 5 and para 4. What investigations differentiate cellulitis? She is an active smoker. Leukocytosis is common, with a WBC count >10 10 /L (10,000 cells/microlitre). Fluid collection seen if abscess present. Ultrasound differentiates from a DVT. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Calf muscle/tendon tear A 38-year-old woman is gravida 5 and para 4. What signs/symptoms differentiate calf muscle/tendon tear? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Calf muscle/tendon tear A 38-year-old woman is gravida 5 and para 4. What signs/symptoms differentiate calf muscle/tendon tear? She is an active smoker. History of trauma or sudden onset of calf pain. Muscle tear is difficult to differentiate from DVT on examination. Although defect or spasm of calf muscles is noted on examination, calf DVT may occasionally be associated with spasm. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Calf muscle/tendon tear A 38-year-old woman is gravida 5 and para 4. What investigations differentiate calf muscle/tendon tear? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Calf muscle/tendon tear A 38-year-old woman is gravida 5 and para 4. What investigations differentiate calf muscle/tendon tear? She is an active smoker. No DVT seen on MRI or ultrasound. Oedema associated with muscle tear makes it very difficult to visualise the calf veins using ultrasonography. Furthermore, extreme tenderness associated with a muscle tear makes it difficult to compress with the ultrasound probe. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History: Calf muscle haematoma A 38-year-old woman is gravida 5 and para 4. What signs/symptoms differentiate calf muscle haematoma? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling. What investigations differentiate calf muscle haematoma?

Case History: Calf muscle haematoma A 38-year-old woman is gravida 5 and para 4. What signs/symptoms differentiate calf muscle haematoma? She is an active smoker. Calf injury or sudden onset of calf pain. There may be ecchymosis on the skin. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling. What investigations differentiate calf muscle haematoma? Venous ultrasound shows no thrombosis, and there may be ultrasound evidence of a haematoma.

Case History: Popliteal cyst A 38-year-old woman is gravida 5 and para 4. What signs/symptoms differentiate large or ruptured popliteal cysts (Baker s cysts)? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling. What investigations differentiate large or ruptured popliteal cysts (Baker s cysts)?

Case History: Popliteal cyst A 38-year-old woman is gravida 5 and para 4. What signs/symptoms differentiate large or ruptured popliteal cysts (Baker s cysts)? She is an active smoker. Sudden onset of calf pain. Tenderness in popliteal fossa. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling. What investigations differentiate large or ruptured popliteal cysts (Baker s cysts)? Ultrasound shows fluid in the soft tissues of the calf or visualises cyst.

Case History: Venous outlet obstruction A 38-year-old woman is gravida 5 and para 4. What signs/symptoms differentiate venous outlet obstruction? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling. What investigations differentiate venous outlet obstruction?

Case History: Venous outlet obstruction A 38-year-old woman is gravida 5 and para 4. What signs/symptoms differentiate venous outlet obstruction? She is an active smoker. Oedema usually occurs without pain in venous outlet obstruction. Difficult to distinguish from iliac or caval DVT (which may co-exist). She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling. What investigations differentiate venous outlet obstruction? Venous ultrasound, or CT/MRI of abdomen, pelvis, and thigh may show obstructing mass impinging on venous vessels.

Case History A 38-year-old woman is gravida 5 and para 4. What signs/symptoms diagnose a DVT? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What signs/symptoms diagnose a DVT? She is an active smoker. Symptoms and signs of DVT are usually unilateral, and include: She has no other medical background. Calf swelling (or, more rarely, swelling of the entire leg) Localised pain along the deep venous system Oedema Dilated superficial veins over the foot and leg Redness and warmth Coolness Blue discoloration (cyanosis). She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What investigations diagnose a DVT in pregnant patients? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What investigations diagnose a DVT in pregnant patients? She is an active smoker. Ultrasound Do not use a Well s score, do not use a d- dimer She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What are risk factors for DVT? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History What are risk factors for DVT? A 38-year-old woman is gravida 5 and para 4. Significant risk factors include: She is an active smoker. Recently bedridden for 3 days or more, or major surgery within 12 weeks requiring general or regional anaesthesia Medical hospitalisation within the preceding 2 months Active cancer (treatment ongoing, within 6 months, or palliative) Previous venous thromboembolic event Recent trauma or fracture Increasing age She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What are risk factors for DVT? She is an active smoker. Significant risk factors include: She has no other medical background. Pregnancy and the postnatal period Paralysis, paresis, or recent plaster immobilisation of the lower extremities Hereditary thrombophilia (e.g., factor V Leiden, prothrombin gene G20210A mutation, protein C or protein S deficiency) Presence of medical comorbidities Certain drugs (e.g., oestrogen-containing oral contraceptives) She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What are potential short term complications of DVT? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What are potential short term complications of DVT? She is an active smoker. Pulmonary embolism Phlegmasia curalea dolens Is characterised by marked swelling, significant pain, and cyanosis.It s a rare life- threatening complication that may lead to arterial ischaemia and can ultimately cause gangrene with high amputation and mortality rates. If you suspect PCD, start immediate treatment and refer the patient to a vascular surgeon.This is a life-and limb-threatening emergency. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What is the treatment of DVT in pregnancy? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What is the treatment of DVT in pregnancy? She is an active smoker. Anticoagulation Physical activity Compression stockings She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What anticoagulation would you use in a pregnant patient? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What anticoagulation would you use in a pregnant patient? She is an active smoker. Low molecular weight heparin (LMWH) as they do not cross the placenta Enoxaparin or Dalteparin (weight based) Anticoagulation should continue for 3 months She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What anticoagulation would you not use in a pregnant patient? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What anticoagulation would you not use in a pregnant patient? She is an active smoker. Do not give a direct oral anticoagulant (DOAC) or vitamin K antagonist (e.g., warfarin) during pregnancy as they may cross the placenta. Never give a DOAC if the patient is breastfeeding. Warfarin is safe in breastfeeding but in practice it may not be preferred (over LMWH) by the patient because it requires regular monitoring of international normalised ratio (INR). She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What are absolute contraindications to anticoagulation? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What are absolute contraindications to anticoagulation? She is an active smoker. Active bleeding Recent intracranial haemorrhage Recent, planned, or emergent surgery or procedure with high bleeding risk Platelet count <50,000/uL Severe bleeding diathesis. Remember that each anticoagulant may have its own contraindications (e.g. heparin is contraindicated in patients with a history of heparin-induced thrombocytopenia). She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What are relative contraindications to anticoagulation? She is an active smoker. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What are relative contraindications to anticoagulation? She is an active smoker. Recurrent but inactive gastrointestinal bleeding Intracranial or spinal tumour. Recent, planned, or emergent surgery or procedure with intermediate bleeding risk Major trauma including cardiopulmonary resuscitation Aortic dissection. She has no other medical background. She has come in for a routine appointment at 13 weeks with right calf swelling.

Case History A 38-year-old woman is gravida 5 and para 4. What are the differential diagnoses of breathlessness in pregnancy? She is an active smoker. She has been diagnosed with a right lower limb DVT at 13 weeks, and has completed her course of anticoagulation. She has come in with breathlessness and pleuritic chest pain at 30 weeks.

Case History A 38-year-old woman is gravida 5 and para 4. What are the differential diagnoses of breathlessness in pregnancy? She is an active smoker. Physiological changes (uterus begins to press against diaphragm at ~30 weeks) Pulmonary embolism Oedema -see pre-eclampsia Cardiomyopathy Asthma Anaemia Infection e.g. community acquired pneumonia She has been diagnosed with a right lower limb DVT at 13 weeks, and has completed her course of anticoagulation. She has come in with breathlessness and pleuritic chest pain at 30 weeks.

Case History A 38-year-old woman is gravida 5 and para 4. What are the signs/symptoms of PE? She is an active smoker. She has been diagnosed with a right lower limb DVT at 13 weeks, and has completed her course of anticoagulation. She has come in with breathlessness and pleuritic chest pain at 30 weeks.

Case History A 38-year-old woman is gravida 5 and para 4. What are the signs/symptoms of PE? She is an active smoker. Breathlessness +-hypoxaemia Haemoptysis Pleuritic chest pain Palpitations Signs of a DVT She has been diagnosed with a right lower limb DVT at 13 weeks, and has completed her course of anticoagulation. She has come in with breathlessness and pleuritic chest pain at 30 weeks.

Case History A 38-year-old woman is gravida 5 and para 4. What investigations would you perform when assessing a PE pregnancy? She is an active smoker. She has been diagnosed with a right lower limb DVT at 13 weeks, and has completed her course of anticoagulation. She has come in with breathlessness and pleuritic chest pain at 30 weeks.

Case History A 38-year-old woman is gravida 5 and para 4. What investigations would you perform when assessing a PE pregnancy? She is an active smoker. Bloods -FBC, U&E, CRP, Coag (to establish baseline values) ABG (to check hypoxia) ECG (tachycardia S1Q3T3 pattern) Echo in unstable patients for RV failure VQ Scan as imaging of choice in obstetric patients She has been diagnosed with a right lower limb DVT at 13 weeks, and has completed her course of anticoagulation. She has come in with breathlessness and pleuritic chest pain at 30 weeks. CTPA is the gold standard in non-pregnant patients

Case History A 38-year-old woman is gravida 5 and para 4. How would you treat a confirmed PE in pregnancy if they are haemodynamically unstable and/or hypoxaemic? She is an active smoker. She has been diagnosed with a right lower limb DVT at 13 weeks, and has completed her course of anticoagulation. She has come in with breathlessness and pleuritic chest pain at 30 weeks. How would you treat a confirmed PE in pregnancy if they are haemodynamically stable?

Case History A 38-year-old woman is gravida 5 and para 4. How would you treat a confirmed PE in pregnancy if they are haemodynamically unstable and/or hypoxaemic? She is an active smoker. She has been diagnosed with a right lower limb DVT at 13 weeks, and has completed her course of anticoagulation. Resuscitation including senior help +-escalation to critical care Start unfractionated heparin (it has a shorter half life and can be reversed with protamine) She has come in with breathlessness and pleuritic chest pain at 30 weeks. How would you treat a confirmed PE in pregnancy if they are haemodynamically stable? Start low molecular weight heparin

Case History A 38-year-old woman is gravida 5 and para 4. What are absolute contraindications to thrombolysis? She is an active smoker. Haemorrhagic stroke or stroke of unknown origin at any time Ischaemic stroke in the preceding 6 months Central nervous system damage or neoplasms Recent major trauma/surgery/head injury (in the preceding 3 weeks) Gastrointestinal bleeding within the last month Known bleeding risk. She has been diagnosed with a right lower limb DVT at 13 weeks, and has completed her course of anticoagulation. She has come in with breathlessness and pleuritic chest pain at 30 weeks.

Case History A 38-year-old woman is gravida 5 and para 4. She is an active smoker. She has been diagnosed with a right lower limb DVT at 13 weeks, and had completed her course of anticoagulation for that when she presented with a PE at 30 weeks. She continues on dalteparin for that. She is booked for an elective c-section at 38 weeks. Which goes as planned.