Management of DVT and pulmonary embolism Heparin: unfractionated or LMW heparin does not cross the placenta or into breast milk so there is no added risk to the fetus. Acute therapy - intravenous calcium heparin 40,000 units daily for at least 48 hours. Long-term therapy - subcutaneous heparin. Twice daily unfractionated heparin (10,000 iu bd) or a single daily dose of low molecular weight heparin (40 mg/d enoxaprin). This does not add to the risk of haemorrhage even at caesarean section. Continue for at least 6 weeks post-partum (or Warfarin be substituted after delivery). Side-effects of long-term therapy - allergic reactions, thrombocytopaenia and maternal osteopaenia. Warfarin it crosses the placenta readily but not significantly in breast milk. It is best avoided in the first trimester because of a slight risk of embryopathy chondrodysplasia punctata (abnormal bone and cartilage formation) microcephaly mental retardation, cataracts, optic atrophy nasal hypoplasia, saddle nose, frontal bossing, short stature Even with meticulous control (prothrombin time to 2 to 2.5 times the clotting time for a normal control plasma), there is an increased risk of fetal haemorrhage as liver enzymes immature. Its anticoagulant effect cannot be reversed rapidly. Therefore heparin therapy is preferred . Because of the increased risk of haemorrhage if warfarin is used, change to heparin at 36 weeks’ gestation. If labour supervenes while the patient is taking Warfarin it can be counteracted with fresh frozen plasma Breast-feeding is not contra-indicated. It should be continued for at least 6 weeks after delivery. Dextran 70 the risks of anaphylaxis to the mother and subsequent uterine hypertonus to the fetus may exceed any benefit. Therefore its use is best avoided during pregnancy. Diagnosis Third heart sound, parasternal heave � JVP Chest x-ray may be helpful but can be totally normal ABGs - pO2a < 70 mmHg, pCO2 normal ECG - usually normal except when the embolus is large and has produced acute cor pulmonale. Even these changes may be obscured by the usual ECG changes which occur in pregnancy (RAD) Ventilation - perfusion isotope (VQ) lung scan. Pulmonary angiography may need to be considered.
Posted on: Wed, 23 Oct 2013 09:00:22 +0000
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