MATERNAL COLLAPSE DUE TO EMBOLISM

4,180 views

Published on

Highlights the predisposition of the pregnant patient to embolic disorders and about the management guidelines of such disorders.

Published in: Health & Medicine
0 Comments
6 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
4,180
On SlideShare
0
From Embeds
0
Number of Embeds
308
Actions
Shares
0
Downloads
189
Comments
0
Likes
6
Embeds 0
No embeds

No notes for slide

MATERNAL COLLAPSE DUE TO EMBOLISM

  1. 1. Maternal Collapse due to Embolism<br />Dr Unnikrishnan P<br />P.G.Student<br />Medical College, Trivandrum<br />
  2. 2. IMPORTANT CAUSES<br />THROMBOEMBOLISM<br />AMNIOTIC FLUID EMBOLISM<br />VENOUS AIR EMBOLISM<br />Anaestesiologist is often involved in the resuscitation of patients with embolic disorders<br />
  3. 3.
  4. 4. VENOUS THROMBOEMBOLISM<br /> Deep Vein Thrombosis [DVT] & Pulmonary Thrombo Embolism [PTE] are the important manifestations<br />DVT is the most common etiology for Pulmonary Thrombo Embolism<br />15-24% of women with untreated DVT experience a pulmonary embolus<br />PTE accounts for 15% of direct maternal mortality<br />CHESTNT’S OBSTETRIC ANESTHESIA, 4/e[2009],p:837,838<br />
  5. 5. AETIOLOGY<br />Changes in coagulation<br />SHNIDER AND LEVINSONS ANESTHESIA FOR OBSTETRICS,4/e<br />
  6. 6. AETIOLOGY <br />Venous stasis<br />Vascular damage: caesarean > vaginal<br />Obstetric conditions: <br />PIH<br /> Multiplepregnancy<br />
  7. 7. RISK FACTORS<br />Increasing age<br />Prolonged immobilization<br />Obesity<br />Thrombophilia<br />Previous thromboembolism<br />Cesarean delivery<br />ASRA GUIDELINES [THIRD EDITION];RegAnesth Pain Med 2010<br />
  8. 8. PATHOPHYSIOLOGY<br />
  9. 9. PATHOPHYSIOLOGY<br />
  10. 10. CLINICAL FEATURES: SYMPTOMS<br />
  11. 11. CLINICAL FEATURES: SIGNS<br />
  12. 12. The Wells score<br />clinically suspected DVT - 3.0 points <br />alternative diagnosis is less likely than PE - 3.0 points <br />Tachycardia - 1.5 points <br />immobilization/surgery in previous four weeks - 1.5 points <br />history of DVT or PE - 1.5 points <br />hemoptysis - 1.0 points <br />malignancy (treatment for within 6 months, palliative) - 1.0 points<br />Traditional interpretation<br />Score >6.0 - High <br />Score 2.0 to 6.0 - Moderate <br />Score <2.0 - Low <br />Alternate interpretation<br />Score > 4 - PE likely. Consider diagnostic imaging. <br />Score 4 or less - PE unlikely. Consider D-dimer to rule out PE. <br />
  13. 13. DIAGNOSTIC EVALUATION<br />ECG<br />
  14. 14. DIAGNOSTIC EVALUATION<br />CHEST X-RAY<br />
  15. 15. HAMPTON’S HUMP<br />
  16. 16. DIAGNOSTIC EVALUATION<br />INVASIVE HEMODYNAMIC MONITORING<br />ARTERIAL BLOOD GAS ANALYSIS<br />ELISA FOR D-DIMER<br />
  17. 17. DIAGNOSTIC EVALUATION<br />VENTILATION PERFUSION SCAN<br />
  18. 18. DIAGNOSTIC EVALUATION<br />SPIRAL CT<br />
  19. 19. DIAGNOSTIC EVALUATION<br />PULMONARY ANGIOGRAPHY<br />INVASIVE<br />INTRALUMINAL FILLING DEFECT<br />MAGNETIC RESONANCE VENOGRAPHY<br />
  20. 20. DIAGNOSTIC EVALUATION<br />ECHOCARDIOGRAPHY<br />COMPRESSION USG<br />
  21. 21. PROPHYLAXIS<br />Decreases the risk 10 fold<br />Begun when the high risk period begins and continued for 5-10 days<br />UFH : 5000 U subcutaneously Q12H<br />Enoxaparin : 40 mg subcutaneously Q24H<br />Ensure availability of FFP at the time of delivery<br />
  22. 22. THERAPY - DVT<br />UNFRACTIONATED HEPARIN [UFH]#<br />#Sipes SL,Venous thromboembolic disease in pregnancy ;Semin Perinatol 1990<br />#American College of Obst & Gyn Comm. on practice;ACOG Practice bulletin no:19,AUG2000<br />
  23. 23. THERAPY - DVT<br />LOW MOLECULAR WEIGHT HEPARIN [LMWH]<br />Enoxaparin<br /> 40 MG OD-BD [1 MG = 100 U] PROPHYLAXIS<br /> 30-80 MG BD THERAPEUTIC ANTICOAGULATION<br />Dalteparin<br /> 2500-5000 U OD-BD THROMBOPROPHYLAXIS<br />100 U/KG BD THERAPEUTIC ANTICOAGULATION<br />#Sipes SL,Venous thromboembolic disease in pregnancy ;Semin Perinatol 1990<br />#American College of Obst & Gyn Comm. on practice;ACOG Practice bulletin no:19,AUG2000<br />
  24. 24. PULMONARY EMBOLISM-TREATMENT: GOALS<br />
  25. 25. PULMONARY EMBOLISM-TREATMENT #<br />#American College of Obst & Gyn Comm. on practice;ACOG Practice bulletin no:19,AUG2000<br />#Weiner CP et al; management of thromboembolic disease during pregnancy; Clinical ObstetGynecol 1985<br />
  26. 26. CONTRA INDICATIONS- ANTICOAGULATION<br />
  27. 27. INFERIOR VENACAVAL INTERRUPTION<br />Transvenous implantation of an IVC filter<br />
  28. 28. THROMBOLYSIS<br />
  29. 29. THROMBOLYSIS<br />Monitoring of coagulation: <br /> Thrombin time [Most sensitive]<br /> aPTT<br /> FDP<br />Complications:<br />Maternal hemorrhage, Placental abruption<br />
  30. 30. THROMBOLYSIS<br />STREPTOKINASE<br />UROKINASE<br />RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR [ rt- PA ]<br />
  31. 31. SURGICAL EMBOLECTOMY<br />
  32. 32. ANAESTHETIC IMPLICATIONS- ANTICOAGULATED PATIENT<br />
  33. 33.
  34. 34. AMNIOTIC FLUID EMBOLISM<br />INCIDENCE 1 IN 8000- 1 IN 30,000<br />25-80% MATERNAL MORTALITY<br />50% FOETAL DEATH<br />
  35. 35. PATHOPHYSIOLOGY<br />HOW DOES IT STARTS?<br />
  36. 36. BIPHASIC RESPONSE<br />FIRST PHASE[30 MIN] SECOND PHASE<br />
  37. 37. “ANAPHYLACTOID SYNDROME OF PREGNANCY”<br />
  38. 38. CLINICAL FEATURES<br />More details: AFE Registry Criteria by Clark et al 1983-1995<br />
  39. 39. DIFFERENTIAL DIAGNOSIS<br />
  40. 40. DIAGNOSIS<br />
  41. 41. DIAGNOSIS<br />
  42. 42. MANAGEMENT<br />
  43. 43. MANAGEMENT<br />
  44. 44. MANAGEMENT<br />
  45. 45.
  46. 46. VENOUS AIR EMBOLISM<br />Malinow et al published the first study of VAE during cesarean delivery in 1987¹<br />Subclinical VAE occurred in 97% of patients receiving GA for cesarean delivery²<br />VAE occurred in approx 67% of patients receiving neuraxial anesthesia³<br />1.Malinow AM et al,Anesthesiology 1987<br />2.Lew TWK et al, VAE during CS,Anesth Analg 1993<br />3.Handler JS,VAE during CS RegAnesth 1990<br />
  47. 47. PATHOPHYSIOLOGY<br />Pressure gradient as small as -5 cm of H₂O<br />
  48. 48. PATHOPHYSIOLOGY<br />RISK FACTORS<br />EXTERIORISATION OF UTERUS<br />
  49. 49. PATHOPHYSIOLOGY<br />
  50. 50. PATHOPHYSIOLOGY<br />Paradoxical Air Embolism may occur in case of intracardiac defects<br />
  51. 51. CLINICAL FEATURES<br />Morbidity and mortality depends on <br />CLINICAL FEATURES<br />
  52. 52. MONITORING / DIAGNOSIS<br />Trans esophageal echo<br />Doppler Ultrasound<br />ETCO₂<br />ETN₂<br />PULMONARY ARTERY PRESSURE<br />CVP<br />ECG<br />
  53. 53. MANAGEMENT<br />PREVENT FURTHER AIR ENTRY<br />
  54. 54. MANAGEMENT<br />TREAT INTRAVASCULAR AIR<br />
  55. 55. PREVENTION<br />5-10⁰ HEAD UP TILT WHEN UTERUS IS EXTERIORIZED<br />PRECORDIAL DOPPLER MONITORING IN HIGH RISK CASES<br />ADEQUATE HYDRATION TO RAISE CVP AND LA PRESSURE<br />
  56. 56. REFERENCES<br /><ul><li>Chestnut’s Obstetric Anesthesia Principles and Practice, David H. Chestnut,[2009] 4/e
  57. 57. Shnider and Levinsons anesthesia for obstetrics,4/e
  58. 58. Why Mothers Die 2004-2005 Report; the Confidential Review of Maternal Deaths in Kerala
  59. 59. ASA Abstracts, Cardiac Arrest during Labor: Amniotic Fluid Embolism with Thrombus in Patent Foramen Ovale. AparnaDalal, M.D., Mark Shulman, M.D. Anesthesiology, Caritas St. Elizabeth's Medical Center, Boston, MA, Anesthesiology 2008; 109 A1337
  60. 60. Martin SR, Foley MR. Intensive care in obstetrics: an evidence-based review. Am J Obstet Gynecol. 2006 Sep;195(3):673-89.
  61. 61. Porat S, Leibowitz D, Milwidsky A, Valsky DV, Yagel S, AntebyEY.Transient Intracardiac thrombi in Amniotic fluid embolism.BCOG. 2004 May;111(5):506-10.
  62. 62. Saad A, El-Husseini N, Nader GA, Gharzuddine W. Echocardiographically detected mass "in transit" in early amniotic fluid embolism. Eur J Echocardiogr. 2006 Aug;7(4):332-5. Epub 2005 Aug 10.</li></li></ul><li>.<br />Thanks!<br />

×