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Source: RCOG Green Top Guideline No 37b: The acute
management of thrombosis and embolism in pregnancy and the
puerperium (February 2007, reviewed 2010)
1. Answer -G– Bilateral lower limb Doppler
Explanation: Venous thromboembolism has been an important cause of death of pregnant women in many of the recent
maternal mortality reports. Investigations in this situation are all about balancing risk to
the fetus and to the mother. Chest X-rays are of negligible risk to the fetus, but may show other causes of shortness of
breath. If the chest X-ray is negative, the next step would be to perform a bilateral lower limb Doppler as the presence of
a deep vein thrombosis (DVT) would make the diagnosis of pulmonary embolism highly likely. CTPA and V-Q scan are
both associated with risks to mother and/or fetus. Treatment-dose, low-molecular-weight heparin should be
commenced prior to the results of these investigations, unless there is a contra-indication.
2. Answer- H– Anti-Xa level
Explanation: Therapeutic doses of low-molecular-weight heparin are given to women based on their pre-pregnancy
or booking weight. Satisfaction with treatment is based onanti-Xa levels and most women achieve good therapeutic
coverage if guidelines are adhered to. However, factors such as extremes of body weight (over
90 kg or less than 50 kg), recurrent thrombo-embolism or renal impairment may alter effectiveness, and monitoring of anti-Xa is advised
3. Answer: C– Graduated elastic compression stockings
Explanation: Whilst there is a small absolute risk of venous thromboembolism during a flight, combined with the risks
of pregnancy, this risk is increased for pregnant women, especially in flights over four hours.
General advice, including good fluid intake and mobilisation, reduce the risk and all women undertaking a flight over
four hours should wear compression stockings.
4. Answer: G– Avoid flight after 32 weeks of gestation
Explanation: The main risk with air travel in pregnancy is the risk of labour and facilities not being available to provide care
for women in labour, or the risk of the plane being diverted. Therefore, women with additional risk factors for pre-term
labour such as multiple pregnancy are generally advised not to travel after 32 weeks.
5. Answer: J– Avoid flight altogether Explanation: There are certain conditions, such as sickle cell
disease or recent gastrointestinal surgery or haemoglobin below 7.5 g/dl that can lead to an increased risk of complications with air travel during pregnancy. The patient should be advised not to travel in these circumstances.
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