A 37-year-old pregnant woman presented with a swollen and painful left leg, breathlessness, and abdominal pain. Her symptoms and family history were suggestive of venous thrombosis. Evaluation through duplex ultrasonography confirmed deep vein thrombosis in her left leg. As venous thrombosis is a leading cause of maternal mortality, she was treated promptly with low molecular weight heparin according to her weight to prevent pulmonary embolism. Due to her risk factors including obesity, family history, and hyperemesis during pregnancy, she is at high risk for recurrence and will require thromboprophylaxis during any future pregnancies.

1. Pregnancy Complicated by
Venous Thrombosis
Ian A. Greer, M.D.
N Eng J Med, Aug 06, 2015.
Presented by Dr. M. Wajahat

2. Overview
•Case Vignette
•Introduction
•Diagnosis
•Treatment
•Conclusion

3. • A 37-year-old primigravid woman presents at 12 weeks
of gestation with a painful, swollen left leg,
breathlessness, and lower abdominal pain. She has had
hyperemesis for several weeks. She has no personal
history of venous thrombosis, but she reports a family
history of thrombosis in both her mother and her
maternal aunt. On examination, she has a body-mass
index of 36, and the entire leg is dusky and swollen. No
abnormalities are detected on pulmonary examination,
and the oxygen saturation is normal.
• How should her case be evaluated and treated?

4. Introduction
• Venous Thromboembolism is the leading cause of
maternal mortality and morbidity.
• More common before 20 weeks of gestation and
during puerperium.
• The risk of VTE is five times higher during
pregnancy than those of non-pregnant woman.
• DVT occurs more frequently in left leg (85% vs.
55%) and is more often proximal (72% vs. 9% in
ileofemoral veins) during pregnancy

5. Risk Factors of VTE during Pregnancy
• History of previous pregnancy related Venous
thrombosis is the strongest risk factor
• Venous Stasis
• Hypercoagulable State
• Vessel wall Injury

6. Diagnosis
• Symptoms & Signs and Pretest Probability
• Venous Thrombosis Studies
• Electrocardiography
• Blood Tests
• Chest X-Ray
• Ventilation Perfusion Scan (V/Q Scan)
• CT Pulmonary Angiography (CTPA)

7. Symptoms & Signs
• Clinical Diagnosis of DVT is unreliable
• Suggestive symptoms include leg swelling,
non-specific to VT, can be present normally in
pregnancy
• Proximal extension of VT to ileofemoral &
pelvic Veins produce Abdominal pain, can be
present usually in pregnanct.

8. Symptoms & Signs
• Pulmonary Embolism is notoriously difficult to
diagnose.
• No sign/symptom is specific to PE.

9. Pretest Probability
• Well’s Criteria for DVT and PE
• LEFT Rule

10. WELLS CRITERIA /SCORING FOR DVT
• Lower limb trauma or surgery or immobilisation in a plaster cast +1
• Bedridden for more than three days or surgery within the last four week +1
• Tenderness along line of femoral or popliteal veins (NOT just calf tenderness) +1
• Entire limb swollen +1
• Calf more than 3cm bigger circumference,10cm below tibial tuberosity +1
• Pitting oedema +1
• Dilated collateral superficial veins (non-varicose) +1
• Past Hx of confirmed DVT +1
• Malignancy (including treatment up to six months previously) +1
• Intravenous drug use +3
• Alternative diagnosis as more likely than DVT -2
• Pre-test Clinical probability of a DVT with score:
• DVT "Likely" if Well's > 1
DVT "Unlikely" if Wells< 2

11. WELLS CRITERIA / SCORING FOR PE
• Clinical Signs and Symptoms of DVT? +3
• PE is No. 1 Dx or Equally likely Dx +3
• Heart Rate > 100 +1.5
• Immobilization at least 3 days, or Surgery in the Previous 4 weeks +1.5
• 5 Previous, objectively diagnosed PE or DVT? +1.5
• Haemoptysis? +1
• Malignancy with treatment within 6 months, or palliative? +1
• Pre-test clinical probability of a PE:
• Wells Score > 4 - PE likely. Consider diagnostic imaging.
Wells Score 4 or less - PE unlikely. Consider D-dimer to rule out PE.

12. Venous Thrombosis Studies
• Compression Duplex Ultrasonography of both
legs including ileofemoral region.
• High Negative predictive Value (97-99%)
• In normal Studies with high clinical suspicion,
repeat test in 3-7days.
• In case of Ileocaval Thrombosis, if it can’t
detect, go for Magnetic Resonance or
Conventional Venography

13. Electrocardiography
• In 70%, it is abnormal.
• Most common abnormality is Sinus
tachycardia.
• Other non-specific findings include RBBB, right
Ventricular hypertrophy & right axis deviation.

14. Blood Tests
• ABGs: can be normal or may shows hypoxemia
and respiratory alkalosis
• D-dimers: useless to detect thrombosis in
pregnancy

15. Chest X-Ray
• To exclude alternate diagnosis
• To interpret V/Q Scan
• Paradoxically, normal CXR with hypoxemia
suggest Pulmonary Embolism

16. Ventilation Perfusion Scan
• In case of Normal finding on Chest X-ray, V/Q
scan is often recommended.
• High Negative Predictive value.
• It is often chosen over CTPA for diagnosing PE
in pregnancy.
• Ventilation component can be omitted to
minimize fetal radiation exposure.

17. CT Pulmonary Angiography
• First line diagnostic test in non-pregnant
woman.
• Can be considered in patients with Abnormal
chest X-ray and indeterminate V/Q scan.
• The negative predictive value of a Normal
CTPA with high pretest probability is 60%
• It helps to identify alternative diagnosis.

18. Radiation Exposure
• Some clinicians are reluctant to pursue objective
testing for VTE because of concern regarding fetal
radiation exposure, but this concern is not well
founded.
• The fetal radiation dose from chest radiography at any
gestational age is negligible (<0.1 mGy).
• The estimated fetal radiation exposure from CTPA (0.1
mGy) is similar to the estimated fetal radiation
exposure from ventilation–perfusion scanning (0.5
mGy); these exposures are well below the thresholds
associated with teratogenesis.

19. Treatment
• Stocking for Symptoms relief
• Anticoagulation Therapy
• Thrombolytic Therapy
• Caval Filters

20. Anticoagulation Therapy
• It involves Unfractionated Heparin or Low-
Molecular-Weight Heparin.
• It doesn’t cross placenta and present in breast
milk
• LMWH is preferred over UFH.
• Warfarin is contraindicated in pregnancy.
• It can be used in puerperium.

21. Anticoagulation Therapy
• Typical agents of LMWH include
1. dalteparin (at a dose of 200 IU per kilogram of
body weight daily or 100 IU per kilogram twice
daily),
2. enoxaparin (1.5 mg per kilogram daily or 1 mg
per kilogram twice daily),
3. tinzaparin (175 units per kilogram daily).
• Doses are adjusted in patients with clinically
significant renal compromise.

22. Anticoagulation Therapy
• it is recommended to plan delivery in women
who are receiving heparin therapy
• It is recommended to discontinue heparin 24
hours before scheduled delivery.
• After delivery, low-molecular-weight heparin
should not be administered for at least 4 hours
after spinal anesthesia or removal of an epidural
catheter.
• After delivery, anticoagulant treatment is
continued for at least 6 weeks, with a minimum
total duration of 3 months.

23. Thrombolytic Therapy
• Thrombolysis in pregnancy is reserved for
massive life-threatening pulmonary embolism
with hemodynamic compromise or for
proximal deep-vein thrombosis that is
threatening leg viability.

24. Caval filters
• Caval filters are sometimes used in women
1. who have recurrent pulmonary embolisms
despite adequate anticoagulation
2. in whom anticoagulation is contraindicated
3. in whom acute deep-vein thrombosis has
developed close to the time of delivery.

25. Caval filters
• In nonpregnant patients, filters reduce the risk
of pulmonary embolism but increase the risk
of deep-vein thrombosis,with no meaningful
change in the overall risk of venous
thrombosis.

27. Conclusion
• Compression duplex ultrasonographic examination
should be performed. If this test confirms deep-vein
thrombosis, as suspected, pulmonary imaging is not
needed, since it would not alter treatment.
• The patient should be treated promptly with a dose of
low-molecular-weight heparin according to her weight.
• Pregnancy-associated venous thromboembolism is a
strong risk factor for recurrence, and It is
recommended to dothromboprophylaxis in any
subsequent pregnancy from the time the pregnancy is
detected until at least 6 weeks post partum.

28. Thank You