Royal Cornwall Hospital

Truro

Cornwall TR1 3LJ

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© 2023 by Acute GP Service, CPFT. 

PE in Pregnancy

 

Click here for the full Investigation and Management of Pulmonary Embolism in Pregnancy Clinical Guideline, RCHT

 

 

Updated for Acute GP website 30 June 2014

 

Incidence       10.6 per 100,000

 

Symptoms:    Dyspnoea 62%

                        Pleuritic Chest Pain (55%)

                        Cough (24%)

                        Sweating (18%)

 

Community assessment by GP or Midwife

 

When a GP suspects PE in pre-pregnancy or the puerperium, clinical assessment needs to be carried out in order to decide whether outpatient investigation and management is appropriate.

 

If the patient is severely ill, with any of the following, admission is indicated:

  • Altered level of consciousness

  • BP <90 mmHg systolic

  • HR >130/min

  • Sats <91%

  • Temp  <35 degree C

  • RR >25/min

 

 

If the patient is normotensive and stable at presentation, then the Acute GP will see the patient for assessment, investigation and management.

The GP may wish to give LMWH if there is likely to be a delay before investigation i.e. at weekends.

See Dosage schedule for LMWH in pregnancy either in BNF or as outlined below.

 

 

Assessment of the Pregnant Patient at Acute GP service will include the following:

 

Review of history and examination

 

Screening:

                      Wells Score  (as per non-pregnant PE)

(Not validated in Pregnancy but still being used as part of the assessment)

Clinical assessment for DVT

 

Investigations:

 

  • D-dimer should not be used in pregnant patient, if there is a high index of suspicion of PE discuss with the AGP service

  • FBC, U&E, LFTS, Coagulation Profile

  • Troponins

  • CXR

  • CUS (Doppler) if evidence of DVT or Leg symptoms present

  • Q Scan is only recommended if CXR and PEFR Normal, see linked algorithm.

Q scanning can be arranged Monday to Friday provided the request is made before 11:30.

At weekends if an urgent Q scan is required the GP will need to speak to the Consultant radiologist or SPR

 

Treatment

 

The patient should be commenced on anticoagulation on presentation, provided there are no absolute contraindications.

 

 

The agents preferred are either Dalteparin or Enoxaparin as per early pregnancy body weight, in a twice-daily schedule. Prefilled syringes should be used. Click here for dosing information.

 

 

Management of a Confirmed PE in pregnancy

 

Arrange for the patient to have twice daily LMWH in the community.

Ensure follow up by GP and referral the Joint Haematology/Obstetric Clinic

 

 

 

Follow up and Onward referral

 

  • All confirmed cases should be referred to the Joint Haematology /Obstetric Clinic.

  • Treatment should be continued for the duration of pregnancy and

  • For at least 6 weeks postnatally or

  • Until at least 3 months of treatment given in total.

  • Women should be offered a choice of either LMWH or oral anticoagulant for postnatal therapy.

  • Postpartum warfarin should be avoided until at least the third day and for longer in women at risk of bleeding. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnostic algorithm for suspected PE in clinically stable pregnant patients

 

CUS: Bilateral venous compression ultrasound scans.

Q: Perfusion scan

 

 

References

 

  • Heit JA, Kobbervig CE, James AH, Petterson TM, Bailey KR, Melton LJ III. Trends in the incidence of venous thromboembolism during pregnancy or postpartum:                     a 30-year population-based study. Ann Intern Med 2005;143:697–706.

  • Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med 2008;359:2025–2033.

  • Gherman RB, Goodwin TM, Leung B, Byrne JD, Hethumumi R, Montoro M. Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy. Obstet Gynecol 1999;94:730–734.

  • Bourjeily G, Paidas M, Khalil H, Rosene-Montella K, Rodger M. Pulmonary embolism in pregnancy. Lancet 2010;375:500–512.

  • An Official American Thoracic Society/Society of Thoracic Radiology Clinical Practice Guideline-Evaluation of Suspected Pulmonary Embolism in Pregnancy. Am J Respir Crit Care Med.  2011 Nov 15;184(10):1200-8.

  • BTS guideline for emergency oxygen use in adult patients. Thorax 2008;63:              Suppl 6 vi1-vi68.