Methotrexate adjuvant therapy should not be used for expectant management as it is of unproven benefit and has significant adverse effects.

Regional techniques should be avoided if possible until at least 12 hours after the previous prophylactic dose of LMWH.

Women receiving antenatal LMWH having an elective caesarean section should receive a thromboprophylactic dose of LMWH on the day prior to delivery and, on the day of delivery, any morning dose should be omitted and the operation performed that morning.

With Remifentanyl PCA- Respiratory depression is reported in up to 32% of patients and
oxygen saturations below 90% are seen in about 5%.

Some suggested contraindications of Remifentanyl PCA include- morbid obesity, clinical features of a chest infection and primigravida women who are at risk of prolonged labour.

• Clinicians should consider the use of intravenous tranexamic acid (0.5–1.0 g), in addition to oxytocin, at caesarean section to reduce blood loss in women at increased risk of PPH.
• Consideration should be given to the use of tranexamic acid in the management of PPH.
• According to a Cochrane review- blood loss greater than 400 or 500 ml was less
  common in women who received tranexamic acid in addition to the usual uterotonic agent after vaginal
  birth or caesarean section in a dosage of 1 or 0.5 g intravenously. Tranexamic acid was effective in
  decreasing the incidence of blood loss greater than 1000 ml in women who had undergone caesarean section but not vaginal birth. Further studies are required to investigate the risk of serious adverse effects, including thromboembolic events.

In the first stage of labour, pain is transmitted via
the spinal nerves of T10–L1 and results from uterine
contractions and dilatation of the cervix. In the second
stage, stretching of the pelvic ligaments causes pain via the
pudendal nerve originating from the S2–S4 nerve roots.

In women with suspected PE who also have symptoms and signs of DVT, compression duplex ultrasound should be performed. If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue.

Pregnant women with suspected PE who have symptoms and signs of DVT should have bilateral compression duplex ultrasound leg studies performed. A diagnosis of DVT may indirectly confirm a diagnosis of PE and since anticoagulant therapy is the same for both conditions, further investigation may not be necessary.

This would limit the radiation doses given to the mother and her fetus.

The algorithm suggested by the RCOG can be viewed HERE

In clinically suspected DVT or PE, treatment with low-molecular-weight heparin (LMWH) should be commenced immediately until the diagnosis is excluded by objective testing, unless treatment is strongly contraindicated.

Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT.
If ultrasound is negative and there is a low level of clinical suspicion, anticoagulant treatment can be discontinued.

If ultrasound is negative and a high level of clinical suspicion exists, anticoagulant
treatment should be discontinued but the ultrasound should be repeated on days 3 and 7.

Intravenous unfractionated heparin is the preferred, initial treatment in massive PE with cardiovascular compromise.