Safety of withholding anticoagulation in pregnant women with suspected deep vein thrombosis following negative serial compression ultrasound and iliac vein imaging

Chan, Wee‐Shian; Spencer, Frederick A.; Lee, Agnes Y.Y.; Chunilal, Sanjeev; Douketis, James D.; Rodger, Marc; Ginsberg, Jeffrey S.

doi:10.1503/cmaj.120895

Cited by 56 publications

(37 citation statements)

References 19 publications

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“…Their data were in agreement with those of a retrospective cohort study performed by the same study group in pregnant and postpartum patients [59]. Another prospective cohort study performed in 4 Canadian centres included 221 pregnant women with a suspected DVT [60]. All of the patients underwent compression ultrasound of the femoral and popliteal veins up to the calf trifurcation and duplex ultrasound of the external iliac vein.…”

Section: Suspected Dvt -Imaging Studies Compression Ultrasoundsupporting

confidence: 85%

Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

Linnemann¹,

Scholz

Rott

et al. 2016

Vasa

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EpidemiologyVTE is a leading cause of maternal morbidity in the developed world and, in the case of PE, of mortality as well [1]. While the relative risk of VTE is greatly increased during pregnancy compared with that in non-pregnant women, the absolute risk remains low: estimates of the incidence of pregnancy-associated VTE have varied from 1:500 to 1:1500 pregnancies [2 -7]. The risk of VTE is approximately 5-fold greater in pregnant women than in non-pregnant women.Approximately 80 % of pregnancy-associated VTEs are isolated DVTs, and approximately 20 % are PEs or both DVTs and PEs [5]. Although a systematic review reported weighted event rates for DVT of 21.9 %, 33.7 % and 47.6 % for the fi rst, second and third trimesters, respectively [6], a recent study suggested that the risk might in fact increase exponentially over the duration of the pregnancy [7], with 12.4 % of VTEs diagnosed in the fi rst trimester, 15.3 % in the second trimester and 72.3 % in the third trimester. This detailed risk assessment for each gestational week demonstrated a 21-fold increased risk for the last two weeks before delivery [7]. Summary: Pregnancy and the postpartum period are associated with an increased risk of venous thromboembolism (VTE). Over the past decade, new diagnostic algorithms have been established, combining clinical probability, laboratory testing and imaging studies for the diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in the non-pregnant population. However, there is no such generally accepted algorithm for the diagnosis of pregnancy-associated VTE. Studies establishing clinical prediction rules have excluded pregnant women, and prediction scores currently in use have not been prospectively validated in pregnancy or during the postpartum period. D-dimers physiologically increase throughout pregnancy and peak at delivery, so a negative D-dimer test result, based on the reference values of non-pregnant subjects, becomes unlikely in the second and third trimesters. Imaging studies therefore play a major role in confi rming suspected DVT or PE in pregnant women. Major concerns have been raised against radiologic imaging because of foetal radiation exposure, and doubts about the diagnostic value of ultrasound techniques in attempting to exclude isolated iliac vein thrombosis grow stronger as pregnancy progresses. As members of the Working Group in Women's Health of the Society of Thrombosis and Haemostasis (GTH), we summarise evidence from the available literature and aim to establish a more uniform strategy for diagnosing pregnancy-associated VTE. Review Diagnosis of pregnancy-associated

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Section: Suspected Dvt -Imaging Studies Compression Ultrasoundsupporting

confidence: 85%

Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

Linnemann¹,

Scholz

Rott

et al. 2016

Vasa

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“…Compression maneuvers of the symptomatic leg were conducted at 1-cm intervals along the length of the femoral vein (from the inguinal ligament) and popliteal veins to the level of the calf vein trifurcation (20).…”

Section: Treatmentmentioning

confidence: 99%

“…Intraluminal echogenic masses consistent with a thrombus were noted on B-mode imaging, and spontaneous venous flow was assessed using Doppler interrogation. Absent or reduced flow was further evaluated via ultrasound apparatus (20). DVT was diagnosed based on noncompressibility at any two contiguous segments of the femoral or popliteal vein.…”

Section: Treatmentmentioning

confidence: 99%

Low-molecular-weight heparin and intermittent pneumatic compression for thromboprophylaxis in critical patients

Wan

Yin

et al. 2015

Experimental and Therapeutic Medicine

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Abstract. The efficacy and safety of physiotherapeutic prophylaxis for venous thromboembolism in critically ill patients with heparin contraindication remains unclear. In the present study it was hypothesized that physiotherapy prophylaxis with intermittent pneumatic compression (IPC) would be safe and effective for patients unable to receive low-molecular-weight heparin (LMWH). In addition, this study investigated whether a combined therapy of IPC with LMWH would be more effective for the prophylaxis of deep vein thrombosis (DVT) in critical patients. A total of 500 patients were divided into four groups according to the prophylaxis of DVT. The IPC group consisted of 95 patients with heparin contraindication that received IPC treatment; the LMWH group consisted of 185 patients that received an LMWH injection; the LMWH + IPC group consisted of 75 patients that received IPC treatment and LMWH injection; and the control group consisted of 145 patients that received no IPC treatment or injection of LMWH. Each patient was evaluated clinically for development of DVT and the diagnosis was confirmed by Doppler study. Venous thromboembolism was a common complication among the trauma patients with severe injuries. Patients responded positively to the treatment used in the intervention groups. Patients exhibited an improved response to LMWH + ICP compared with IPC or LMWH alone, while no significant difference was detected between the IPC and LMWH groups. These results were applicable to patients that had a Wells score of ≥3; however, no significant differences in DVT incidence were observed among the patients who had a Wells score of <3. In this observational study, LMWH + ICP appeared to be more effective than either treatment alone in treating critically ill trauma patients with severe injuries that are at high risk for VTE and bleeding simultaneously.

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“…46 Three management studies do support the use of either serial proximal ultrasound or one whole-leg ultrasound, both combined with a Doppler examination of the iliac veins, to rule out DVT in pregnant women. [47][48][49] In the largest study with a 7.7% prevalence of DVT (17/221 patients), 65% (11/17) of patients had isolated iliofemoral DVT, and 12% (2/17) had isolated iliac DVT. 49 If no Doppler examination is available, shielded CT venography or MR venography are alternative imaging methods.…”

Section: Workup Of Suspected Dvt In Pregnancymentioning

confidence: 99%

“…[47][48][49] In the largest study with a 7.7% prevalence of DVT (17/221 patients), 65% (11/17) of patients had isolated iliofemoral DVT, and 12% (2/17) had isolated iliac DVT. 49 If no Doppler examination is available, shielded CT venography or MR venography are alternative imaging methods. Finally, the role of pretest probability assessment and D-dimer testing in the diagnosis of suspected DVT in pregnancy has yet to be defined.…”

Section: Workup Of Suspected Dvt In Pregnancymentioning

confidence: 99%

Current challenges in diagnostic imaging of venous thromboembolism

Huisman

Klok

2015

Hematology

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Because the clinical diagnosis of deep-vein thrombosis and pulmonary embolism is nonspecific, integrated diagnostic approaches for patients with suspected venous thromboembolism have been developed over the years, involving both non-invasive bedside tools (clinical decision rules and D-dimer blood tests) for patients with low pretest probability and diagnostic techniques (compression ultrasound for deep-vein thrombosis and computed tomography pulmonary angiography for pulmonary embolism) for those with a high pretest probability. This combination has led to standardized diagnostic algorithms with proven safety for excluding venous thrombotic disease. At the same time, it has become apparent that, as a result of the natural history of venous thrombosis, there are special patient populations in which the current standard diagnostic algorithms are not sufficient. In this review, we present 3 evidence-based patient cases to underline recent developments in the imaging diagnosis of venous thromboembolism. Learning Objectives• In a first episode of deep-vein thrombosis, compression ultrasonography is a very accurate imaging method. In recurrent deep-vein thrombosis, this accuracy is less because residual thrombosis is present. A reference compression ultrasonography may help establish an accurate diagnosis. Direct thrombus imaging by magnetic resonance technique, a technique that can actually differentiate between old and new thrombi, is now being validated for this purpose and may become the gold standard.• In elderly patients, the use of an age-adjusted D-dimer cutoff will lead to less need for imaging without jeopardizing safety. For elderly patients with suspected pulmonary embolism and severe renal insufficiency, compression ultrasonography of the legs is a reasonable way to start imaging.• All pregnant patients with clinically suspected pulmonary embolism should undergo a full diagnostic workup; this includes imaging with computed tomography-pulmonary angiography or ventilation-perfusion scan as an alternative.Venous thromboembolism (VTE), which refers to a diagnosis of deep-vein thrombosis (DVT) and/or pulmonary embolism (PE), is worldwide the third most frequently diagnosed cardiovascular disorder. VTE may be complicated by recurrent thrombosis, anticoagulant associated bleeding, post-thrombotic syndrome, and chronic thromboembolic pulmonary hypertension. 1-3 Over the years, the diagnostic approach has evolved from clinical diagnosis to fully standardized diagnostic management algorithms, in which validated pretest clinical decision rules, D-dimer testing, and foremost straightforward diagnostic imaging allow for safe, convenient, and cost-effective management of patients. 4 Patients with a low pretest probability and a normal D-dimer can have VTE excluded without the need for imaging, although there is a trend for increased imaging taking place, leading to ever-increasing demands on busy emergency departments. 5 Despite all advancements during the past decade, the imaging diagnosis of VTE remains challenging ...

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Safety of withholding anticoagulation in pregnant women with suspected deep vein thrombosis following negative serial compression ultrasound and iliac vein imaging

Abstract: Interpretation: Serial compression ultrasonography with Doppler imaging of the iliac vein performed over a 7-day period excludes deep-vein thrombosis in symptomatic pregnant women.

Cited by 56 publications

References 19 publications

Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

Diagnosis of pregnancy-associated venous thromboembolism - position paper of the Working Group in Women’s Health of the Society of Thrombosis and Haemostasis (GTH)

Low-molecular-weight heparin and intermittent pneumatic compression for thromboprophylaxis in critical patients

Current challenges in diagnostic imaging of venous thromboembolism

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