[CG] Care of pregnant women with suspected VTE during the COVID-19 pandemic (CLYDE)

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Principles of care:

  • Venous thromboembolism (VTE) is uncommon in pregnancy and the puerperium, but remains a leading cause of maternal death in well-resourced countries.
  • Pregnant women with suspected VTE should be anticoagulated using therapeutic doses of low molecular weight heparin (LMWH) and diagnostic testing undertaken to confirm or exclude the diagnosis.
  • During the COVID-19 pandemic, clinically stable patients should, whenever possible, undergo treatment and investigation on an out-patient basis.
  • Patient safety should not be compromised by any changes to the current guidance.

Suspected deep vein thrombosis (DVT) during pregnancy (during COVID-19)

During pregnancy and the puerperium, woman with suspected deep vein thrombosis (DVT) should attend the triage department in Paisley Maternity Unit.

An assessment should be undertaken in line with the current GGC Obstetric VTE guideline (history, examination, and blood tests).  If DVT is suspected, prescribe and administer treatment doses of enoxaparin (1mg/kg twice daily or 1.5mg/kg OD, subcutaneous), as soon as possible, and within 4 hours.

The obstetric registrar or consultant should book an urgent outpatient Leg Doppler ultrasound scan on Trakcare; this investigation should be undertaken within 72 hours of clinical suspicion.  The clinician should remember to state that the patient is pregnant (in clinical details box). The requesting clinician should also phone the relevant department (RAH radiology extension 06630 and ask to speak with a ‘leg Doppler sonographer’) to state a request has just been submitted for a pregnant patient, (if in daytime hours). The request should include obstetric on-call contact numbers (obstetric registrar: #56014)

If a Leg Doppler scan appointment is not available on the same day that the patient presents, then she may go home with a supply of therapeutic enoxaparin as long as she is clinically stable, lives locally, has transport and is considered reliable to return for scan.  She should be shown how to self-administer the medication and be given a sharps disposal box.

Once known, the time of the Leg Doppler scan should be conveyed to the woman along with directions to access the RAH Radiology Department. The date of the scan should also be conveyed to the relevant on call team.

The woman should report to the Radiology department at the appointment time using her own transport.  After the scan she should attend Maternity Triage to discuss the result.

It is crucially important that the on call team and staff in Maternity Triage are aware that an out-patient Doppler scan is being undertaken and that the woman will return to Triage after the scan to discuss the result.

  • If the report is negative, the woman can discontinue her LMWH therapy.
  • If the report is negative but significant clinical suspicion of DVT remains: stop the enoxaparin & arrange an outpatient repeat leg Doppler in 5-7 days. Process as above. Medical staff who review the patient on presentation should document in the patient record if a repeat Doppler should be performed in the event of the initial Doppler being negative (i.e. they have significant clinical suspicion).
  • If the report is positive, the woman can go home with a supply of LMWH therapy, instructions on how to self-administer and with a follow up appointment at the obstetric medicine clinic (Monday afternoon, Paisley Maternity).

Suspected pulmonary embolus (PE) during pregnancy (during COVID-19)

1. Initial contact: COVID-19 NOT SUSPECTED

Patients with symptoms of PE and NO suspicion of COVID-19 infection, should attend maternity triage (1st floor, Paisley Maternity Unit). Patients can self-refer or be referred by their GP, ‘out-of-hours’ service or from other hospital departments (eg emergency medicine or respiratory medicine).

Women who are clinically unstable should be regarded as a medical emergency and have their investigations and treatment undertaken where possible in the Royal Alexandra Hospital, in line with current guidance (eg CTPA +/- echocardiogram).

2. Initial investigations: COVID-19 NOT SUSPECTED

The initial investigation of women with suspected VTE in pregnancy or the puerperium (including blood tests, clinical observations and chest x-ray) is described on Staffnet guidance.

The woman should be reviewed by the on call Consultant (8am until 8pm) or registrar (8pm until 8am) who will determine whether therapeutic doses of LMWH and further imaging are required.

3. Ongoing care: COVID-19 NOT SUSPECTED

If PE is considered by the obstetric team, therapeutic doses of LMWH should be commenced immediately and continued. If the woman lives locally (NHS GG&C but not NHS Highland) and is clinically stable, she can return home with a supply of LMWH and needle disposal equipment. Women from NHS Highland who cannot source accommodation locally, should be admitted to the antenatal ward.

A V/Q scan should be requested by the oncall Consultant and ideally be undertaken as soon as possible (ideally no later than 72 hours after presentation) to prevent a false negative result. Staff contact numbers must be included on the request including the obstetric registrar page number (#56014) and the midwife station in maternity triage (extension 06067/06741).

The Consultant obstetrician on call should contact the Nuclear Medicine (NM) Technologist (QEUH) on 0141 452 3669 (Monday to Friday, 9am until 4.30pm) to arrange a time for the scan, and this should be conveyed to the woman along with directions to access the NM Department. The date of the scan should also be conveyed to the relevant on call team.

The woman should report to the NM department at the appointment time using her own transport. A provisional scan report will be given by the Clinical Scientist and a formal report issued later that day by the Radiologist.

It is crucially important that the on call team is aware that an out-patient V/Q scan is being undertaken and it is their responsibility to chase-up and act on the result.

  • if the provisional report is negative, the woman can go home and discontinue her LMWH therapy. Once the formal report is available, she will receive a telephone call from the on call obstetric team (registrar or Consultant) to discuss her results and symptoms.
  • If the provisional report is positive, the woman can go home to continue her LMWH therapy. Once the formal report is available, she will receive a telephone call from the on call obstetric team to discuss her results and to arrange a follow up appointment at the obstetric medicine clinic (Monday afternoon, Paisley Maternity).

4. Initial contact: COVID-19 ALSO SUSPECTED

COVID-19 should be suspected when the patient has a new persistent cough and/or a fever (note a new, continuous cough means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If the patient usually has a cough, it may be worse than usual).  Patients with symptoms of PE who also have suspected COVID-19 infection should attend the maternity acute assessment unit (ground floor, Paisley Maternity Unit).  Guidance is in place regarding the use of PPE in this area.

The woman should be reviewed by the on call Consultant (8am until 8pm) or registrar (8pm until 8am) who will determine whether testing should be undertaken for COVID-19 and whether therapeutic doses of LMWH are required.

The initial ‘routine’ investigations of women with suspected VTE in pregnancy or the puerperium should be performed, including clinical observations a chest x-ray and blood tests.

5. Ongoing care: COVID-19 ALSO SUSPECTED

If PE is considered by the obstetric team, therapeutic doses of LMWH should be commenced immediately and continued. If the woman lives locally (NHS GG&C but not NHS Highland) and is clinically stable, she can return home with a supply of LMWH and needle disposal equipment, and await the result of the COVID-19 test. Women from NHS Highland who cannot source accommodation locally, should be admitted and isolated in the maternity unit.

If the COVID-19 test is positive and PE is still suspected, the Consultant should discuss further imaging, using CTPA with the Radiology Department in the Royal Alexandra Hospital.

If the COVID-19 test is negative, a V/Q scan should be requested by the on call Consultant and ongoing care undertaken as outlined in section 4.

Last reviewed: 15 April 2020

Next review: 15 April 2021

Version: 5