Women over the age of 40 years are at a higher risk of early pregnancy complications such a miscarriage or ectopic pregnancy. They are also more likely to have pre-existing medical conditions which further increase their risk of early pregnancy pathology, for example, previous pelvic inflammatory disease leading to a tubal ectopic, or uncontrolled diabetes increasing the risk of a miscarriage. Women in this age group are also more likely to have conceived through fertility treatment, and may present with complications of this, such as multiple pregnancy or ovarian hyperstimulation syndrome. A woman’s history of assisted reproductive technology and pre-existing subfertility is significant not only in accurately dating the pregnancy but also with regards to the psychological impact in case of a poor outcome. Early pregnancy units have become well established in most hospitals as a dedicated department providing specialist early pregnancy care. This chapter provides an overview of the optminal management of the first trimester of pregnancy for women over 40 and the management of the common conditions.

Key Learning Points

1. 1. The critical care population is at high risk of venous thromboembolism.

2. 2. Classification of pulmonary embolism is based on mortality risk.

3. 3. The clinical presentation of pulmonary embolism in the critical care environment is atypical and diagnosis remains difficult.

4. 4. Computed tomography pulmonary angiography is the investigation of choice for pulmonary embolism.

5. 5. Anticoagulation is the mainstay of acute treatment, with thrombolysis being reserved for high-risk pulmonary embolism.

The direct oral anticoagulants (DOACs) are a relatively new class of drug. This chapter provides prescribers with some general rules for their use, describes which patients are eligible and which are not, and discusses dosing regimens for atrial fibrillation and venous thromboembolism. In addition, the reader can learn about monitoring, interactions and reversal.

Warfarin is highly effective in killing rats, and in the hands of the uneducated, is just as effective in killing humans. The author provides tips for getting it right every time, including how to initiate treatment, how to reverse its effects, and drug and food interactions to watch out for.

Successful anticoagulation is a fine balance between clotting and bleeding, which can easily go wrong. The good news is that basic principles can help manage this scenario effectively. The author provides background information on low molecular weight heparins, their use in the treatment and prevention of deep vein thrombosis and pulmonary embolism, its monitoring and reversal, and dose adjustment for body weight and renal function.