History and Physical Examination (DVT)
Signs and symptoms of VTE are nonspecific and common in pregnancy. Most pregnant women experience mild tachycardia, tachypnea, dyspnea, and lower extremity edema. Diagnosis of VTE by physical examination is frequently inaccurate.
The 2 most common symptoms of DVT are pain and swelling of the lower extremity. 80% of pregnant women with DVT experience these symptoms, [30] although few of them are diagnosed with DVT. Up to 70% of women experience dyspnea in pregnancy, [31] although only a few have PE.
In a cohort of 53 women diagnosed with a DVT either antepartum (n=34) or postpartum (n=19), the 2 most common symptoms were edema (80-88%) and discomfort in the extremity (80-95%). [30]
A cross-sectional study of 194 pregnant women with no prior history of VTE evaluated the reliability of 3 variables in assessing risk of DVT by physical examination. Chan et al used the mnemonic LEFt [32] :
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L- Symptoms in the left lower extremity
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E-Edema: Mid-calf circumference difference of ≥ 2cm
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Ft- First trimester presentation
DVT was not diagnosed in women in the absence of any of these factors. Of the women with one finding, 16% had DVTs; 58% of the women with 2 or 3 findings were diagnosed with DVT. [32]
Although no commonly used scoring system for prediction of DVT has been studied prospectively in pregnancy, the above studies highlight that DVT is common in pregnant women presenting with symptoms of pain and or swelling in the lower extremity. Since the risk of VTE is increased in pregnancy and postpartum, and the morbidity and mortality is appreciable, a low threshold for initiation of evaluation is recommended. Women presenting with these findings warrant further evaluation. If DVT or PE is suspected, the patient should begin anticoagulation treatment until further investigation excludes VTE.
History and Physical Examination (PE)
Clinical signs and symptoms of PE are nonspecific. The classic symptoms of PE are dyspnea (82%), abrupt onset chest pain (49%), and cough (20%). [3] The most common presenting signs are tachypnea, crackles, and tachycardia. No commonly used scoring system for the prediction of PE has been studied systematically in pregnancy.
All of these signs and symptoms of PE are only rarely encountered together. These symptoms and signs are also commonly found in the pregnant patient, confounding the clinician’s ability to make the diagnosis of this life-threatening process. Therefore, if the clinician suspects PE, anticoagulation therapy and appropriate immediate diagnostic testing should be performed until the diagnosis is made or eliminated as a possibility.
Patients with massive PE may present with syncope, hypotension, pulseless cardiac electrical activity, or death.
Electrocardiogram
An electrocardiogram may exhibit findings, such as right ventricular strain and the S1Q3T3 pattern suggestive of pulmonary embolism, but these findings are infrequent and generally nonspecific. Seventy percent of patients with PE have nonspecific EKG abnormalities, findings such as tachycardia, nonspecific ST segment, and T-wave abnormalities.
Risk Factors
Risk factors for development of VTE in pregnancy include normal physiologic alterations pregnancy (see Pathophysiology), personal or family history of VTE, and the presence of a thrombophilic disorder.
The most important risk factor for a women experiencing pregnancy-related VTE is prior personal history of VTE, which increases the risk of VTE 3-fold to 5-fold. [5] The next most common risk factor is thrombophilia, which is present in 20-50% of women with VTE in pregnancy. [30, 33, 34] Other common risk factors include cesarean delivery, which conveys twice the risk of VTE as vaginal delivery, [35] obesity, maternal cardiac disease, premature delivery, and smoking. [26, 27, 16, 36, 37, 38]
Thrombophilia
Thrombophilia is a common risk factor for VTE in pregnancy and can be found in 20-50% of pregnant women presenting with VTE. [30, 33, 34] Screening for thrombophilias should be done if the results are likely to alter management. Screening is unnecessary when treatment is indicated for other reasons. The results of screening may be affected if the patient is currently pregnant, currently has an acute VTE, or is currently receiving anticoagulation therapy. For further discussion on thrombophilias in pregnancy, please see Anticoagulants and Thrombolytics in Pregnancy.
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Estimated gestational age at time of diagnosis of antepartum deep venous thrombosis (n=94).
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May-Thurner syndrome
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Factors affecting thrombosis in Pregnancy
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Diagnostic algorithm for suspected Deep-Vein Thrombosis and Pulmonary Embolism during pregnancy.
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Suspected pulmonary embolism
Tables
Risk Factor |
Recommendations |
Women with a single episode of VTE associated with a transient risk factor that is no longer present |
Clinical surveillance and anticoagulant prophylaxis postpartum* |
Women with a single episode of VTE and thrombophilia (confirmed laboratory abnormality) and a strong family history of thrombosis who are not receiving long-term anticoagulants |
Prophylactic or intermediate-dose LMWH or unfractionated heparin (UFH), plus postpartum anticoagulation for at least 6 wk (for a total minimum duration of therapy of 6 mo) |
Women with antithrombin deficiency and no previous VTE |
Antepartum and postpartum prophylaxis |
Women with thrombophilia (other than antithrombin deficiency) and no previous VTE |
Clinical surveillance or prophylactic LMWH or UFH and anticoagulant prophylaxis postpartum* |
Women with multiple (≥ 2) episodes of VTE who are not receiving long-term anticoagulants |
Prophylactic, intermediate-dose or adjusted-dose UFH or adjusted-dose LMWH followed by long-term anticoagulation postpartum |
Women with multiple (≥ 2) episodes of VTE who are receiving long-term anticoagulants |
Adjusted-dose UFH or LMWH followed by resumption of long-term anticoagulation postpartum |
All women with previous DVT, antenatal and postpartum |
Use of graduated elastic compression stockings |
Women with recurrent pregnancy loss (≥ 3 miscarriages) and women with severe or recurrent preeclampsia, placental abruption, or otherwise unexplained intrauterine growth retardation |
Screen for thrombophilia and antiphospholipid antibodies |
Women with antiphospholipid antibody syndrome and a history of multiple (≥ 2) early pregnancy losses or ≥ 1 late pregnancy losses, preeclampsia, intrauterine growth retardation (IUGR), or abruption |
Antepartum aspirin plus prophylactic or intermediate-dose UFH or LMWH |
Women with APLAs and a history of VTE who are usually receiving long-term oral anticoagulation therapy |
Adjusted-dose LMWH or UFH therapy plus low-dose aspirin and resumption of long-term oral anticoagulation therapy postpartum |
* If the previous risk factor is pregnancy or estrogen-related or additional risk factors (such as obesity) are present, antenatal anticoagulant prophylaxis is recommended. |
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