Embolic disorders related to pregnancy Venous thrombosis and amniotic fluid embolism

1. MIR UBAID ASHRAF
BSC NURSING STUDENT
4TH YEAR
AMCNMT
KASHMIR
EMBOLIC DISORDERS IN
PREGNENCY

2. EMBOLIC DISORDERS IN PREGNANCY
Embolism is the lodging of an embolus, a blockage –
causing piece of material, inside a blood vessel. The
embolus may be a blood clot(thrombus), a fat
globule(fat embolism), a bubble of air or foreign
material.
Venous thromboembolism and amniotic fluid
embolism are the main embolic disorders associated
with pregnancy

3. Venous thromboembolism
An embolism in which the embolus is a piece of
thrombus is called a thromboembolism
 Venous thrombosis and pulmonary embolism
collectively make up the condition called as venous
thromboembolism.

4. Venous thrombosis
 Thrombosis of the leg and pelvic vein is one of the
common and important complications in the
puerperium. The prevalence is low in Asian and
African countries compared to western countries

5. Causes
 Although the exact cause of venous
thromboembolism remains unclear, three factors
known as Virchow’s triad are believed to play a
significant role in its development.
 Virchow’s triad comprises of endothelial damage,
venous stasis and altered coagulation.

6. altered
coagulatio
n
venous
stasis
endothelial
damage
VIRCHOW’S TRIAD

7. Causes contd.
 Pregnancy is also considered a hypercoagulable
state, as it is accompanied by an increase in clotting
factors that may not return to baseline until longer
than 6 weeks postpartum, increasing the risk of
thrombosis

8. Major causes include:-
 Stasis of blood: Occurs in the pelvic and leg veins as in cases
where the woman has been on prolonged bed rest during pregnancy
and following operative delivery
Alteration in the blood constituents
Infection: Pelvic cellulitis, which causes inflammation of the
venous wall to which a thrombus may be attached
Traumas to the venous wall: Pelvic veins are traumatized
during labor due to the pressure of the fetal head
Other high risk factors such as advancing age, high
parity, use of estrogen, obesity, anemia and heart disease

9. Classification
Puerperal
venous
thrombosis
Phlebothrombosis
Superficial Deep
Thrombophlebitis

10. Phlebothrombosis Thrombophlebitis
 The initial event is
intravascular
thrombosis
 The initial event is
inflammation of the
venous wall to which
the thrombus is
attached

11. Superficial vein thrombosis
 It occurs in pre-existing varicose veins in the legs.
 It usually remains localized
 On rare occasions it may spread upwards to
involve the long saphenous vein and thence to the
femoral vein.
 Detachment of the thrombus, if occurs leads to
pulmonary embolism.
 Onset is within the 1st week

12. Clinical manifestations
Pain and tenderness in affected area
Slight rise in temperature and pulse rate
Overlaying skin looks red due to reaction of the clot
Subsides within a week with obliteration of the vein

13. Deep vein thrombosis
 It is the formation of blood clot in a deep vein mostly
in the legs or pelvis
 It may develop as a primary condition or the deep vein
may be involved
secondarily as an extension
of superficial venous thrombosis.
 Occasionally superficial
and deep vein thrombosis
occurs simultaneously.

15. Symptoms
Pain in the calf or sole
Swelling in the leg
Slight rise in temperature of affected extremity
Slight increase in pulse rate between 7th and 10th day
of postpartum
On examination, there is calf tenderness on deep
pressure and a positive Homan’s sign( pain in the
calf on dorsiflexion of the foot and edema of the leg

17. Investigations
 History taking and physical examination
 Doppler ultrasound to detect the velocity of the
blood flow in the femoral vein
 Phlebography to note the filling defect in the venous
lumen
 Isotopic venography to detect radioactivity

18. Preventive measures
Leg movement and exercises
Elastic stockings
Active breathing exercises
Avoiding sitting with legs dangling down
Intermittent calf muscle compression such as
pneumonic cuff, passive dorsiflexion
Prophylactic anticoagulant therapy
Avoiding the use of estrogens for suppression of
lacation

19. Medical management
Objectives
 Prevent thrombus from growing and fragmenting
 Prevent recurrent thromboemboli and post
thrombotic syndrome

20.  Management measures include:
Bedrest with foot end raised above the heart level
Analgesics to relieve pain
Sedatives to ensure sleep
Antibiotics

21.  Heparin therapy- 15,000 units IV followed by 10,000
units 4-6 hourly and heparin is continued for 7-10
days or even longer, then warfarin orally is commonly
used in addition to heparin and may be continued for
3-6 months as maintenance therapy
 Gentle movement in bed to be started when the pain
subsides about a week
 Caval filter may be inserted, if there is a free floating
thrombus detected by scan or phlebogram

22. Thrombophlebitis
Postpartum thrombophlebitis originates in the
thrombosed veins at the placental site by organisms
such as anaerobic streptococci or Bacteroides
fragilis.
When localised in the pelvis, it is called Pelvic-
thrombophlebitis.
There is no specific clinical feature for pelvic
thrombophlebitis, but it is suspected when pyrexia
continues for more than a week in absence of any
other cause

23. Phlegmasia alba dolens
 Extrapelvic spread may reach to the lungs or kidney(left).
 Retragrade extension to ileofemoral vein produces the
clinicopathological condition of phlegmasia alba dolens or
white leg
Clinical features
 Develops in the 2nd week of postpartum
 Mild fever prior to local manifestations and at times fever
with chills
 Headache, malaise and rising pulse rate
 Affected limb is painful, swollen, white and cold
 Tenderness and induration along the course of femoral vein
 Polymorphonuclear leukocytosis seen on blood count

24.  Prevention and management measures are same as
those outlined for DVT

25. Nursing management for venous thrombosis
Assessing and monitoring anticoagulant therapy
Monitoring and managing potential complications
• Bleeding
• Thrombocytopenia
• Drug interactions
Providing comfort
Compression therapy
• Stockings
• External compression devices and wraps
• Intermittent pneumatic compression devices
Positioning the body and encouraging exercise
Promoting home and community based care

27. Pulmonary embolism
Pulmonary embolism (PE) refers to the obstruction
of the pulmonary artery or one of its branches by a
thrombus that originates somewhere in the venous
system or in the right side of the heart.
Major cause for PE is DVT in the leg or in the pelvis,
with predisposing factors same as for venous
thrombosis

28. Signs and symptoms
 The clinical features depend on the size of the
embolus and on the preceding health status of
mother
SMALL PULMONARY EMBOLISM
o Chest pain
o Dyspnea, coughing, slight hemoptysis
o Pyrexia
o Tachycardia
Any of the above symptoms, however slight, must be
reported to the physician immediately

29. S&s contd.
MAJOR PULMONARY EMBOLISM
• Sudden acute chest pain
• Marked distress, shock or sudden collapse
• Dyspnea, cyanosis
• Pyrexia, tachycardia/bradycardia and hypotension
• Distension of jugular veins
This constitutes an obstetric emergency.
Death usually occurs within a short time from shock
and vagal inhibition

31. Diagnostic procedures
 X-ray of the chest
 Lung scan
 Pulmonary angiography

32. Treatment and management
 Resuscitation- cardiac massage, oxygen therapy and
IV heparin
 IV fluid support
 Blood pressure to be maintained by dopamine or
adrenaline
 Thrombolytic therapy with streptokinase
 Tachycardia is counteracted with digitalis
 Pain may be relieved by IV morphine

33. Management contd.
If the woman doesnot respond to this therapy or if
repeated attacks occur, surgical treatment like
embolectomy, placement of caval filter or ligation of
inferior vena cava and ovarian veins may have to be
done .
Surgical treatment is done following pulmonary
angiography

35. Amniotic fluid embolism
DEFINITION
It is the escape of amniotic fluid into the
maternal circulation. This condition is
usually fatal to the mother as the debris
containing amniotic fluid deposits in the
pulmonary arterioles

36. •The condition occurs when the amniotic fluid enters
the maternal circulation through the tear in the
membranes or placenta. The body responds in two
phases
INITIAL PHASE
Vasospasm occurs causing
hypoxia, hypotension and
cardiovascular collapse
SECOND PHASE
Development of left
ventricular failure
with hemorrhage and
coagulation disorder
followed by
pulmonary edema
•Mortality and morbidity rates are very
high

37. Mechanism
Tear in the membranes or placenta
Thromboplastin rich liquor amnii
enters maternal circulation
Blocks pulmonary arteries
Triggers complex coagulation
mechanism
Leading to disseminated
intravascular coagulation (DIC)
Severe clotting defect with
profuse bleeding per vagina or
through venipuncture sites

38. Predisposing factors
 Amniotic fluid embolism can occur at any stage in
gestation.
 It is mostly associated with labor, though cases in early
pregnancy and postpartum have been reported
 Factors include:
• Tear in the membranes
• Insertion of intrauterine catheter
• Placenta problems
• Operative delivery
• Medically induced labor
• Polyhydramnios
• Advanced maternal age

39. Clinical features
Respiratory distress
Cyanosis
Chest pain
Hypotension
Uterine hypertonia
Seizures
Fetal bradycardia
Cardiopulmonary arrest

40. Diagnosis
 Blood tests, including those that evaluate clotting,
heart enzymes, electrolytes and blood type as well as
CBC
 Electrocardiogram (ECG)
 Pulse oxymetry
 Chest X-ray
 Echocardiography

41. Treatment
Any one of the symptoms is indicative of an acute
emergency and resuscitation must be started at once
Administer oxygen at 8 to 10 L/min by face mask or
resuscitation bag so as to deliver 100% oxygen
Prepare the patient for intubation and mechanical
ventilation
Start IV fluids, blood products and medications to
correct coagulation failure
Check the status of fetus

42. TREATMENT Contd.
When the condition of mother stabilizes, prepare for
an emergency delivery
Reassure the mother and provide emotional support
to her family
Mothers who survive may suffer neurological
impairment

43. Complications
Disseminated intravascular coagulation
Acute renal failure
Brain injury
Maternal death
Infant death

44. Bibliography
 Jacob annamma ,A comprehensive textbbok of
midwifery and gynecology nursing 5th edition ,
Jaypee brothers publication page no.
351,378,379&380
 Suddarth and brunner, textbook of medical
surgical nursing wolters kluwer publication page
no. 600-603, 845-850