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Confirmed femoral deep vein thrombosis with suspected pulmonary embolism in pregnancy — MRCEM SBA MCQ

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HardObstetric and gynaecological emergenciesConfirmed femoral deep vein thrombosis with suspected pulmonary embolism in pregnancyMRCEM SBA

A 34-year-old woman at 29 weeks’ gestation presents with sudden pleuritic chest pain and breathlessness. Her right leg has become painful and swollen over the preceding day. Her blood pressure is 118/72 mmHg, pulse 104/min and oxygen saturation 97% on air. ECG and chest radiograph show no alternative explanation for her symptoms. Compression duplex ultrasonography demonstrates thrombus in the right femoral vein. She has no bleeding or contraindication to anticoagulation. What is the most appropriate immediate treatment and further imaging strategy?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Give therapeutic-dose low-molecular-weight heparin without further chest imaging.

The chest symptoms raise concern for pulmonary embolism (PE), while the painful, swollen leg identifies a site for objective testing. Compression ultrasonography has now confirmed a femoral deep vein thrombosis (DVT). In a pregnant patient with suspected PE and confirmed symptomatic DVT, RCOG advises that no further PE investigation is necessary and treatment for venous thromboembolism should continue. Established thrombosis requires **therapeutic-dose**, not prophylactic-dose, low-molecular-weight heparin. ([rcog.org.uk](https://www.rcog.org.uk/media/wj2lpco5/gtg-37b-1.pdf)) A and B are credible PE investigations when PE remains suspected *without* a confirmed symptomatic DVT. The normal chest radiograph may make ventilation–perfusion scanning an option in that different pathway, but it does not override the positive leg scan here. C avoids unnecessary chest imaging but undertreats the confirmed clot. E gives the correct treatment dose, yet repeating a diagnostic positive leg scan adds nothing to the immediate decision. Repeat ultrasonography is considered after a **negative** initial scan when clinical suspicion of DVT remains high; it is not a substitute for acting on this positive result. ([rcog.org.uk](https://www.rcog.org.uk/media/wj2lpco5/gtg-37b-1.pdf))

Reference: RCOG Green-top Guideline No. 37b: Thrombosis and Embolism during Pregnancy and the Puerperium: Acute Management (2015) — https://www.rcog.org.uk/media/wj2lpco5/gtg-37b-1.pdf RCOG guideline page: Thrombosis and Embolism during Pregnancy and the Puerperium: Acute Management (Last reviewed 13 April 2015) — https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/thrombosis-and-embolism-during-pregnancy-and-the-puerperium-acute-management-green-top-guideline-no-37b/