Covid-19 Care of pregnant women with suspected PE QEUH, Obstetrics (832)

• 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 pulmonary embolus (PE) 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.

Patients with symptoms of (PE) and NO suspicion of COVID-19 infection, may present at QEUH to the physicians (IAU – Immediate Assessment Unit) or maternity triage depending on the original route of referral.  It has been agreed with nuclear medicine by both specialties on the QEUH site that the Trakcare request for VQ scan has to be made by a consultant.  Irrespective of which specialty performs the initial assessment of the patient, when outpatient management is deemed appropriate this will be facilitated by the obstetric team.

All women who are clinically unstable should be regarded as a medical emergency and have their investigations and treatment undertaken in the Immediate Assessment Unit, QEUH, as happens currently.

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 who will determine whether therapeutic doses of LMWH and further imaging are required.

If PE is considered a potential diagnosis following consultant review, therapeutic doses of LMWH should be commenced immediately and continued. If the woman lives locally (NHS GG&C) and is clinically stable, she can return home with a supply of LMWH and needle disposal equipment.

A V/Q scan should be requested by the on call Consultant (physician or obstetrician depending on place of initial assessment) and ideally be undertaken as soon as possible (preferably 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 (17111) and the midwife station in MAU (extension 64363/64377).

Women reviewed in IAU (ie by physicians) will be notified to the on-call obstetric registrar or consultant and the obstetric team will take over the outpatient arrangements.  The Trakcare VQ request will have been made by the IAU team.

The on call obstetric team 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 be recorded on a board in MAU.  On a day that an outpatient VQ scan is taking place MAU must liaise with the obstetric on-call team to ensure follow up of the result.

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 haematology clinic.

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, and have no obstetric complications, will be directed to attend SATA as per GG&C guidelines.  Women with ?PE plus ?COVID and obstetric complications should attend MAU, QEUH.  Guidance is in place regarding the use of PPE in this area.

Consultant review is required to 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 and blood tests and CXR

If PE is considered a potential diagnosis following consultant review, therapeutic doses of LMWH should be commenced immediately and continued. If the woman lives locally (NHS GG&C) 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.

If the COVID-19 test is positive and PE is still suspected, the Consultant should discuss further imaging, CTPA, with the Radiology Department at QEUH.

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.