SlideShare a Scribd company logo
1 of 23
Download to read offline
Venous
Thromboembolism in
Pregnancy
Siti Nurul Afiqah binti Johari
10-6-95
Siti Suhaila Mohaad Sariff
10-6-91
Venous Thromboembolism (VTE)
Introduction
One of the many early physiological adaptations of
pregnancy involves changes in the coagulation system,
which promote coagulation and impair fibrinolysis. The
physiological goal is to prepare for the haemostatic
challenge of delivery. A ‘side effect’ of this change is an
increased risk of thrombosis. All pregnant women are
therefore at risk of thrombosis, compared with non-
pregnant women. This risk is manifest from early in the
first trimester until 4−6 weeks post partum.
Why pregnancy has a greater risk?
PHYSIOLOGICAL CHANGES IN THE
COAGULATION SYSTEM DURING PREGNANCY
These changes, which may not completely return to baseline until more than 8 weeks post partum, begin at
conception.
RISK FACTORS FOR VTE IN PREGNANCY
In some women the risks are increased further
because they have one or more additional risk
factors.
So pregnant women should have a risk assessment
for VTE to include the risk factor as listed.
This risk is not static and should be reconsidered in
any case.
A careful hx should be taken from the woman of
any prior or family hx of thromboembolic events.
Pregnancy itself is a
risk factor
Clinical Presentation
Type Signs and Symptoms
Pulmonary embolism • Dyspnea
• Palpitations
• Pleuritic chest pain
• Hemoptysis
• Cyanosis/hypoxia in massive PE
• Tachycardia
• Tachypnea
• Hypotension
• Collapse
• +/- symptoms or signs of DVT
Deep vein thrombosis • DVT in pregnancy usually proximal
• Unilateral leg pain/tenderness
• Swelling in an extremity
• Increase calf/thigh circumference
• Increased temperature
• Prominent superficial veins
• Pitting edema
Differential Diagnosis
• DVT: swelling and lower leg discomfort are
not unusual in a normal pregnancy. Other
possibilities include muscle strain, a ruptured
Baker’s cyst, cellulitis, superficial
thrombophlebitis, ruptured plantaris tendon
and trauma.
• PE: potentially extensive but specifically rule
out chest infection and an intra-abdominal
bleed (look for abdominal signs, shoulder tip
pain from diaphragmatic irritation and a low
JVP).
Management
Massive life treatening PE
• Management by an experienced multidisciplinary team
involving senior obstetrician,physicians and radiologist
for collapsed,shock patient.
• An urgent portable echocardiogram should be
arranged within one hour presentation.
• Immediate thrombolysis should be considered when
massive PE is confirmed or extensive circumstance
occur.
• IV unfractionated heparin.
General points
• In a woman with a past history of VTE or with a known inherited
thrombophilia, it is best to refer her prior to a planned pregnancy
for optimum prophylaxis throughout the pregnancy.
• Medical anticoagulation is the treatment of choice for acute VTE.
Subsequently, surgical interventions may be considered
• Anticoagulation is by far the most common treatment option.
Heparin is the most frequently used drug, being non-toxic to the
fetus (it does not cross the placental barrier). However, its main
disadvantages are that it has to be parentally administered and, in
the long-term, may give rise to heparin-induced osteoporosis and
thrombocytopenia. In some patients, it can also provoke a painful,
localized allergic reaction on administration.
• Warfarin is the other treatment option in the postnatal patient but
it must be avoided antenatally, as it is teratogenic and can also
cause placental abruption and fetal/neonatal hemorrhage.
• In clinically suspected DVT or PE, treatment with unfractionated
heparin or LMWH should be given until the diagnosis is excluded.
Initiating treatment
There are several different types of heparin to choose from:
• LMWH: this is the drug of choice. It has been shown to be
more effective than unfractionated heparin with lower
mortality and fewer hemorrhagic complications in the
initial treatment of DVT in non-pregnant subjects.
• Intravenous unfractionated heparin: this is an extensively
used drug in the acute management of VTE, particularly
massive PE with cardiovascular compromise
• Subcutaneous unfractionated heparin: this has been shown
to be as effective as the intravenous form.
• Additionally, the leg should be elevated and a graduated
elastic compression stocking applied to reduce edema.
Mobilization with graduated elastic compression stockings
should be encouraged.
Maintenance therapy
Pregnancy
• Heparins are the maintenance treatment of choice.
• Subcutaneous LMWH appears to have advantages over aPTT-
monitored unfractionated heparin in the maintenance treatment of
VTE in pregnancy. Women should be taught to self-inject and can then
be managed as outpatients until delivery.
• If unfractionated heparin is used, monitor the platelet count at least
every other day for the first 14 days or until treatment is stopped
(whichever comes first).
• Seek specialist advice if the patient develops heparin-induced
thrombocytopenia or a heparin allergy and requires continuing
anticoagulant therapy. She should be managed with the heparinoid,
danaparoid sodium or fondaparinux, under specialist supervision.
Labour
• When the patient thinks she is going into labour, she should stop injecting and get
in touch with the delivery ward staff that will manage the anticoagulation
throughout labour and immediately post-delivery. Alternatively, planned elective
induction of labour or caesarean section at least 12 hours after prophylactic-dose
LMWH or 24 hours after therapeutic-dose LMWH can be considered. As these
patients are at high risk of hemorrhage, they will be managed with intravenous
unfractionated heparin throughout this time. Regional anaesthetic or analgesic
techniques should not be undertaken until at least 24 hours after the last dose of
therapeutic LMWH.
Postpartum
• Depending on the patient's individual circumstances, she may be managed with
ongoing heparin treatment or warfarin postpartum. If she opts for warfarin, this
needs to be avoided until at least day three postpartum with an INR check at day
two of warfarin treatment: aim for an INR between 2 and 3. Continue heparin
treatment until there have been two successive readings of an INR >2. Although
these drugs are detectable in breast milk, all are safe for use during breast-feeding
because warfarin metabolites are inactive and heparin is not absorbed through the
gastrointestinal tract.
• Postnatal review for women who develop VTE during pregnancy or the puerperium
should, whenever possible, be at an obstetric medicine clinic or a joint obstetric
hematology clinic.
Stopping treatment
• In theory, therapy should be continued for six
months as would be the case for non-pregnant
patients. However, the postpartum state is a
period of physiological fluctuation of coagulation
factors. Therefore, current advice is to continue
therapy for at least 6-12 weeks postpartum or
until at least three months of therapy have been
completed. At that point, the patient should be
assessed for the presence of ongoing risk factors
for a VTE prior to making the decision to stop
anticoagulation therapy.
Prevention: prophylaxis
Guidance from the Royal College of Obstetricians and Gynecologists’
suggests:Antenatally
• Regardless of their VTE risk, dehydration and immobilization of the patient should be avoided
throughout pregnancy.
• Women at high risk of VTE in pregnancy should be offered pre-pregnancy counseling and a
prospective management plan for thromboprophylaxis in pregnancy. Those who become
pregnant before receiving such counseling should be referred to a nominated expert early in
pregnancy.
• All women with previous VTE should receive postpartum prophylaxis, as this is the time of
highest risk.
• In addition, women whose original VTE was unprovoked, idiopathic or related to estrogen, or
who have other risk factors, a family history of VTE in a first-degree relative or a documented
thrombophilia require LMWH antenatally and for six weeks postpartum.
• Women with recurrent VTE may already be on warfarin. They should be advised to stop
warfarin and change to LMWH as soon as pregnancy is confirmed, ideally within two weeks
of the missed period and before the sixth week of pregnancy. Women not on warfarin should
be advised to start LMWH as soon as they have a positive pregnancy test.
• Women with asymptomatic inherited or acquired thrombophilia only, may be managed with
close surveillance antenatally and be considered for LMWH for at least seven days
postpartum. Exceptions are women with antithrombin deficiency, those with more than one
thrombophilic defect (including homozygosity for factor V Leiden) or those with additional
risk factors where antenatal prophylaxis should be considered.
Intrapartum
• Women taking LMWH should be advised that, if they bleed
vaginally or contractions begin, they should not inject any further
doses. They should be assessed in hospital and further doses be
prescribed by medical staff.
Postpartum
• All women with obesity (BMI greater than 40 kg/m2) should be
considered for prophylactic LMWH for seven days after delivery.
Other postnatal risks include prolonged labour, immobility,
infection, hemorrhage and blood transfusion.
• All women who have had an emergency Caesarean section should
be considered for LMWH for seven days after delivery. All women
who have had an elective caesarean section who have one or more
additional risk factors should be considered for LMWH for seven
days after delivery.
• In addition, properly applied graduated compression stockings are
recommended for women travelling long-distance for more than
four hours, women who are still outpatients but have prior VTE
(usually combined with LMWH), women who are hospitalized and
have a contra-indication to LMWH and those who are hospitalized
post-caesarean section (combined with LMWH) and considered to
be at particularly high risk of VTE.
References:
1.http://www.aafp.org/afp/2008/0615/p1709.html
2.http://atvb.ahajournals.org/content/29/3/326.full
3.http://patient.info/doctor/venous-thromboembolism-in-pregnancy#ref-3

More Related Content

What's hot

Hypertensive disorders in pregnancy
Hypertensive disorders in pregnancyHypertensive disorders in pregnancy
Hypertensive disorders in pregnancyMarwan Alhalabi
 
Venous Thromboembolism and Pregnancy
Venous Thromboembolism and PregnancyVenous Thromboembolism and Pregnancy
Venous Thromboembolism and PregnancyRavulJindal
 
Management of hyperemesis gravidarum rcog 2016
Management of hyperemesis gravidarum  rcog 2016Management of hyperemesis gravidarum  rcog 2016
Management of hyperemesis gravidarum rcog 2016Dr Meenakshi Sharma
 
Tolac trial of labour after section
Tolac trial of labour after sectionTolac trial of labour after section
Tolac trial of labour after sectionKawita Bapat
 
Hypertension in pregnancy
Hypertension in pregnancyHypertension in pregnancy
Hypertension in pregnancyRashna Sharmin
 
Management of Sickle Cell Disease in Pregnancy
Management of Sickle Cell Disease in PregnancyManagement of Sickle Cell Disease in Pregnancy
Management of Sickle Cell Disease in PregnancyApollo Hospitals
 
Bad obstetric history
Bad obstetric historyBad obstetric history
Bad obstetric historylimgengyan
 
Thrombocytopenia during pregnancy
Thrombocytopenia during pregnancyThrombocytopenia during pregnancy
Thrombocytopenia during pregnancyAboubakr Elnashar
 
Preterm Premature Rupture Of Membranes (PPROM)
Preterm Premature Rupture Of Membranes (PPROM)Preterm Premature Rupture Of Membranes (PPROM)
Preterm Premature Rupture Of Membranes (PPROM)Abdullatif Al-Rashed
 
Diabetes Mellitus in Pregnancy
Diabetes Mellitus in PregnancyDiabetes Mellitus in Pregnancy
Diabetes Mellitus in Pregnancymeducationdotnet
 
Post menopausal bleeding
Post menopausal bleedingPost menopausal bleeding
Post menopausal bleedingdr.hafsa asim
 
Manual vacuum aspiration
Manual vacuum aspirationManual vacuum aspiration
Manual vacuum aspirationAdams Obaike
 
Magnesium Sulphate in Eclampsia
Magnesium Sulphate in EclampsiaMagnesium Sulphate in Eclampsia
Magnesium Sulphate in EclampsiaAde Wijaya
 
Acute abdomen during pregnancy
Acute abdomen during pregnancyAcute abdomen during pregnancy
Acute abdomen during pregnancytariggally
 
Tocolysis for preterm labour: RCOG Guidelines
Tocolysis for preterm labour: RCOG GuidelinesTocolysis for preterm labour: RCOG Guidelines
Tocolysis for preterm labour: RCOG GuidelinesAboubakr Elnashar
 

What's hot (20)

Hypertensive disorders in pregnancy
Hypertensive disorders in pregnancyHypertensive disorders in pregnancy
Hypertensive disorders in pregnancy
 
Venous Thromboembolism and Pregnancy
Venous Thromboembolism and PregnancyVenous Thromboembolism and Pregnancy
Venous Thromboembolism and Pregnancy
 
Management of hyperemesis gravidarum rcog 2016
Management of hyperemesis gravidarum  rcog 2016Management of hyperemesis gravidarum  rcog 2016
Management of hyperemesis gravidarum rcog 2016
 
Tolac trial of labour after section
Tolac trial of labour after sectionTolac trial of labour after section
Tolac trial of labour after section
 
Cardiac disease in pregnancy
Cardiac disease in pregnancyCardiac disease in pregnancy
Cardiac disease in pregnancy
 
Hypertension in pregnancy
Hypertension in pregnancyHypertension in pregnancy
Hypertension in pregnancy
 
Molar pregnancy
Molar pregnancyMolar pregnancy
Molar pregnancy
 
Management of Sickle Cell Disease in Pregnancy
Management of Sickle Cell Disease in PregnancyManagement of Sickle Cell Disease in Pregnancy
Management of Sickle Cell Disease in Pregnancy
 
Bad obstetric history
Bad obstetric historyBad obstetric history
Bad obstetric history
 
Thrombocytopenia during pregnancy
Thrombocytopenia during pregnancyThrombocytopenia during pregnancy
Thrombocytopenia during pregnancy
 
Preterm Premature Rupture Of Membranes (PPROM)
Preterm Premature Rupture Of Membranes (PPROM)Preterm Premature Rupture Of Membranes (PPROM)
Preterm Premature Rupture Of Membranes (PPROM)
 
Postdate pregnancy
Postdate pregnancyPostdate pregnancy
Postdate pregnancy
 
Diabetes Mellitus in Pregnancy
Diabetes Mellitus in PregnancyDiabetes Mellitus in Pregnancy
Diabetes Mellitus in Pregnancy
 
Post menopausal bleeding
Post menopausal bleedingPost menopausal bleeding
Post menopausal bleeding
 
Manual vacuum aspiration
Manual vacuum aspirationManual vacuum aspiration
Manual vacuum aspiration
 
Prom and pprom
Prom and ppromProm and pprom
Prom and pprom
 
Magnesium Sulphate in Eclampsia
Magnesium Sulphate in EclampsiaMagnesium Sulphate in Eclampsia
Magnesium Sulphate in Eclampsia
 
Galactorrhea
GalactorrheaGalactorrhea
Galactorrhea
 
Acute abdomen during pregnancy
Acute abdomen during pregnancyAcute abdomen during pregnancy
Acute abdomen during pregnancy
 
Tocolysis for preterm labour: RCOG Guidelines
Tocolysis for preterm labour: RCOG GuidelinesTocolysis for preterm labour: RCOG Guidelines
Tocolysis for preterm labour: RCOG Guidelines
 

Similar to Venous thromboembolism of pregnancy

GP update presentation
GP update presentationGP update presentation
GP update presentationSadia Bhatti
 
Thromboprophylaxis need of hour for indian women
Thromboprophylaxis need of hour for indian womenThromboprophylaxis need of hour for indian women
Thromboprophylaxis need of hour for indian womenLifecare Centre
 
Prevention of Venous Thrombo-Embolism
Prevention of Venous Thrombo-EmbolismPrevention of Venous Thrombo-Embolism
Prevention of Venous Thrombo-Embolismlimgengyan
 
thromboprophylaxis [Autosaved].pptx
thromboprophylaxis [Autosaved].pptxthromboprophylaxis [Autosaved].pptx
thromboprophylaxis [Autosaved].pptxAthraaALAnizy
 
Thrombophilia & Thromboembolism in Pregnancy & Puerperium
Thrombophilia & Thromboembolism in Pregnancy & PuerperiumThrombophilia & Thromboembolism in Pregnancy & Puerperium
Thrombophilia & Thromboembolism in Pregnancy & PuerperiumJagannath Mishra
 
early pregnancy bleeding.pptx
early pregnancy bleeding.pptxearly pregnancy bleeding.pptx
early pregnancy bleeding.pptxmernahazazah
 
Ectopic pregnancy post graduate
Ectopic pregnancy  post graduateEctopic pregnancy  post graduate
Ectopic pregnancy post graduateOsama Warda
 
CVS Drugs in pregnancy-Dr. Swapan Sur.pptx
CVS Drugs in pregnancy-Dr. Swapan Sur.pptxCVS Drugs in pregnancy-Dr. Swapan Sur.pptx
CVS Drugs in pregnancy-Dr. Swapan Sur.pptxhakimnasir3
 
NX-DIAGNOSIS-FOR-POST-OP-CS-DELIVERY-LOVELY.pptx
NX-DIAGNOSIS-FOR-POST-OP-CS-DELIVERY-LOVELY.pptxNX-DIAGNOSIS-FOR-POST-OP-CS-DELIVERY-LOVELY.pptx
NX-DIAGNOSIS-FOR-POST-OP-CS-DELIVERY-LOVELY.pptxbbaltazarjanice
 
THROMBOPROPHYLAXIS DURING PREGNANCY, LABOUR AND AFTER DELIVERY
THROMBOPROPHYLAXIS  DURING PREGNANCY, LABOUR  AND AFTER DELIVERYTHROMBOPROPHYLAXIS  DURING PREGNANCY, LABOUR  AND AFTER DELIVERY
THROMBOPROPHYLAXIS DURING PREGNANCY, LABOUR AND AFTER DELIVERYAboubakr Elnashar
 
Molar Pregnancy or Hydatidiform mole.pptx
Molar Pregnancy or Hydatidiform mole.pptxMolar Pregnancy or Hydatidiform mole.pptx
Molar Pregnancy or Hydatidiform mole.pptxSamson Peter Mvandal
 
Thromboprophylaxis in pregnancy and puerperium
Thromboprophylaxis in pregnancy and puerperiumThromboprophylaxis in pregnancy and puerperium
Thromboprophylaxis in pregnancy and puerperiumManju Puri
 
Bleeding in early pregnancy (miscarriage).pptx
Bleeding in early pregnancy (miscarriage).pptxBleeding in early pregnancy (miscarriage).pptx
Bleeding in early pregnancy (miscarriage).pptxNkosinathiManana2
 

Similar to Venous thromboembolism of pregnancy (20)

GP update presentation
GP update presentationGP update presentation
GP update presentation
 
Thromboprophylaxis need of hour for indian women
Thromboprophylaxis need of hour for indian womenThromboprophylaxis need of hour for indian women
Thromboprophylaxis need of hour for indian women
 
Prevention of vte
Prevention of vtePrevention of vte
Prevention of vte
 
Prevention of Venous Thrombo-Embolism
Prevention of Venous Thrombo-EmbolismPrevention of Venous Thrombo-Embolism
Prevention of Venous Thrombo-Embolism
 
thromboprophylaxis [Autosaved].pptx
thromboprophylaxis [Autosaved].pptxthromboprophylaxis [Autosaved].pptx
thromboprophylaxis [Autosaved].pptx
 
Ectopic Pregnancy
Ectopic PregnancyEctopic Pregnancy
Ectopic Pregnancy
 
Thrombophilia & Thromboembolism in Pregnancy & Puerperium
Thrombophilia & Thromboembolism in Pregnancy & PuerperiumThrombophilia & Thromboembolism in Pregnancy & Puerperium
Thrombophilia & Thromboembolism in Pregnancy & Puerperium
 
Obstetric embolism
Obstetric embolismObstetric embolism
Obstetric embolism
 
early pregnancy bleeding.pptx
early pregnancy bleeding.pptxearly pregnancy bleeding.pptx
early pregnancy bleeding.pptx
 
Ectopic pregnancy post graduate
Ectopic pregnancy  post graduateEctopic pregnancy  post graduate
Ectopic pregnancy post graduate
 
CVS Drugs in pregnancy-Dr. Swapan Sur.pptx
CVS Drugs in pregnancy-Dr. Swapan Sur.pptxCVS Drugs in pregnancy-Dr. Swapan Sur.pptx
CVS Drugs in pregnancy-Dr. Swapan Sur.pptx
 
Abruptio placenta
Abruptio placentaAbruptio placenta
Abruptio placenta
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancy
 
NX-DIAGNOSIS-FOR-POST-OP-CS-DELIVERY-LOVELY.pptx
NX-DIAGNOSIS-FOR-POST-OP-CS-DELIVERY-LOVELY.pptxNX-DIAGNOSIS-FOR-POST-OP-CS-DELIVERY-LOVELY.pptx
NX-DIAGNOSIS-FOR-POST-OP-CS-DELIVERY-LOVELY.pptx
 
THROMBOPROPHYLAXIS DURING PREGNANCY, LABOUR AND AFTER DELIVERY
THROMBOPROPHYLAXIS  DURING PREGNANCY, LABOUR  AND AFTER DELIVERYTHROMBOPROPHYLAXIS  DURING PREGNANCY, LABOUR  AND AFTER DELIVERY
THROMBOPROPHYLAXIS DURING PREGNANCY, LABOUR AND AFTER DELIVERY
 
Molar Pregnancy or Hydatidiform mole.pptx
Molar Pregnancy or Hydatidiform mole.pptxMolar Pregnancy or Hydatidiform mole.pptx
Molar Pregnancy or Hydatidiform mole.pptx
 
Thromboprophylaxis in pregnancy and puerperium
Thromboprophylaxis in pregnancy and puerperiumThromboprophylaxis in pregnancy and puerperium
Thromboprophylaxis in pregnancy and puerperium
 
Hellp syndrome
Hellp syndromeHellp syndrome
Hellp syndrome
 
Bleeding in early pregnancy (miscarriage).pptx
Bleeding in early pregnancy (miscarriage).pptxBleeding in early pregnancy (miscarriage).pptx
Bleeding in early pregnancy (miscarriage).pptx
 
birth after CS.pptx
birth after CS.pptxbirth after CS.pptx
birth after CS.pptx
 

More from Siti Nurul Afiqah Johari (13)

Pulmonary Embolism in Geriatrics
Pulmonary Embolism in GeriatricsPulmonary Embolism in Geriatrics
Pulmonary Embolism in Geriatrics
 
Benign Skin Tumor
Benign Skin TumorBenign Skin Tumor
Benign Skin Tumor
 
Rheumatological Emergencies
Rheumatological EmergenciesRheumatological Emergencies
Rheumatological Emergencies
 
Vte in pregnancy (written)
Vte in pregnancy (written)Vte in pregnancy (written)
Vte in pregnancy (written)
 
Diagnosis of Acute Pancreatitis
Diagnosis of Acute PancreatitisDiagnosis of Acute Pancreatitis
Diagnosis of Acute Pancreatitis
 
Chest emergencies
Chest emergenciesChest emergencies
Chest emergencies
 
Anemia in elderly
Anemia in elderlyAnemia in elderly
Anemia in elderly
 
Male Hypogonadism
Male HypogonadismMale Hypogonadism
Male Hypogonadism
 
Otc drugs
Otc drugsOtc drugs
Otc drugs
 
Itp
ItpItp
Itp
 
Atopic derma
Atopic dermaAtopic derma
Atopic derma
 
Turner syndrome
Turner syndromeTurner syndrome
Turner syndrome
 
Treatment of refractory ascites
Treatment of refractory ascitesTreatment of refractory ascites
Treatment of refractory ascites
 

Recently uploaded

Screening for colorectal cancer AAU.pptx
Screening for colorectal cancer AAU.pptxScreening for colorectal cancer AAU.pptx
Screening for colorectal cancer AAU.pptxtadehabte
 
SCHOOL HEALTH SERVICES.pptx made by Sapna Thakur
SCHOOL HEALTH SERVICES.pptx made by Sapna ThakurSCHOOL HEALTH SERVICES.pptx made by Sapna Thakur
SCHOOL HEALTH SERVICES.pptx made by Sapna ThakurSapna Thakur
 
SYNDESMOTIC INJURY- ANATOMICAL REPAIR.pptx
SYNDESMOTIC INJURY- ANATOMICAL REPAIR.pptxSYNDESMOTIC INJURY- ANATOMICAL REPAIR.pptx
SYNDESMOTIC INJURY- ANATOMICAL REPAIR.pptxdrashraf369
 
PHYSIOTHERAPY IN HEART TRANSPLANTATION..
PHYSIOTHERAPY IN HEART TRANSPLANTATION..PHYSIOTHERAPY IN HEART TRANSPLANTATION..
PHYSIOTHERAPY IN HEART TRANSPLANTATION..AneriPatwari
 
SGK HÓA SINH NĂNG LƯỢNG SINH HỌC 2006.pdf
SGK HÓA SINH NĂNG LƯỢNG SINH HỌC 2006.pdfSGK HÓA SINH NĂNG LƯỢNG SINH HỌC 2006.pdf
SGK HÓA SINH NĂNG LƯỢNG SINH HỌC 2006.pdfHongBiThi1
 
Giftedness: Understanding Everyday Neurobiology for Self-Knowledge
Giftedness: Understanding Everyday Neurobiology for Self-KnowledgeGiftedness: Understanding Everyday Neurobiology for Self-Knowledge
Giftedness: Understanding Everyday Neurobiology for Self-Knowledgeassessoriafabianodea
 
Plant Fibres used as Surgical Dressings PDF.pdf
Plant Fibres used as Surgical Dressings PDF.pdfPlant Fibres used as Surgical Dressings PDF.pdf
Plant Fibres used as Surgical Dressings PDF.pdfDivya Kanojiya
 
Culture and Health Disorders Social change.pptx
Culture and Health Disorders Social change.pptxCulture and Health Disorders Social change.pptx
Culture and Health Disorders Social change.pptxDr. Dheeraj Kumar
 
Exploring the Variety of Private Blood Tests in the UK
Exploring the Variety of Private Blood Tests in the UKExploring the Variety of Private Blood Tests in the UK
Exploring the Variety of Private Blood Tests in the UKPrivate GP London
 
SGK HÓA SINH ENZYM 2006 CHỊ THU RẤT HAY.pdf
SGK HÓA SINH ENZYM 2006 CHỊ THU RẤT HAY.pdfSGK HÓA SINH ENZYM 2006 CHỊ THU RẤT HAY.pdf
SGK HÓA SINH ENZYM 2006 CHỊ THU RẤT HAY.pdfHongBiThi1
 
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...Badalona Serveis Assistencials
 
L1.INTRODUCTION to ENDOCRINOLOGY MEDICINE.pptx
L1.INTRODUCTION to ENDOCRINOLOGY MEDICINE.pptxL1.INTRODUCTION to ENDOCRINOLOGY MEDICINE.pptx
L1.INTRODUCTION to ENDOCRINOLOGY MEDICINE.pptxDr Bilal Natiq
 
CEHPALOSPORINS.pptx By Harshvardhan Dev Bhoomi Uttarakhand University
CEHPALOSPORINS.pptx By Harshvardhan Dev Bhoomi Uttarakhand UniversityCEHPALOSPORINS.pptx By Harshvardhan Dev Bhoomi Uttarakhand University
CEHPALOSPORINS.pptx By Harshvardhan Dev Bhoomi Uttarakhand UniversityHarshChauhan475104
 
Presentation on General Anesthetics pdf.
Presentation on General Anesthetics pdf.Presentation on General Anesthetics pdf.
Presentation on General Anesthetics pdf.Prerana Jadhav
 
Big Data Analysis Suggests COVID Vaccination Increases Excess Mortality Of ...
Big Data Analysis Suggests COVID  Vaccination Increases Excess Mortality Of  ...Big Data Analysis Suggests COVID  Vaccination Increases Excess Mortality Of  ...
Big Data Analysis Suggests COVID Vaccination Increases Excess Mortality Of ...sdateam0
 
PNEUMOTHORAX AND ITS MANAGEMENTS.pdf
PNEUMOTHORAX   AND  ITS  MANAGEMENTS.pdfPNEUMOTHORAX   AND  ITS  MANAGEMENTS.pdf
PNEUMOTHORAX AND ITS MANAGEMENTS.pdfDolisha Warbi
 
METHODS OF ACQUIRING KNOWLEDGE IN NURSING.pptx by navdeep kaur
METHODS OF ACQUIRING KNOWLEDGE IN NURSING.pptx by navdeep kaurMETHODS OF ACQUIRING KNOWLEDGE IN NURSING.pptx by navdeep kaur
METHODS OF ACQUIRING KNOWLEDGE IN NURSING.pptx by navdeep kaurNavdeep Kaur
 
Myelin Oligodendrocyte Glycoprotein antibody associated disease (MOGAD)
Myelin Oligodendrocyte Glycoprotein antibody associated disease (MOGAD)Myelin Oligodendrocyte Glycoprotein antibody associated disease (MOGAD)
Myelin Oligodendrocyte Glycoprotein antibody associated disease (MOGAD)MohamadAlhes
 
Aditi Jagtap (Daughter of Ranjit Jagtap).pdf
Aditi Jagtap (Daughter of Ranjit Jagtap).pdfAditi Jagtap (Daughter of Ranjit Jagtap).pdf
Aditi Jagtap (Daughter of Ranjit Jagtap).pdfAditi Jagtap Pune
 
Role of medicinal and aromatic plants in national economy PDF.pdf
Role of medicinal and aromatic plants in national economy PDF.pdfRole of medicinal and aromatic plants in national economy PDF.pdf
Role of medicinal and aromatic plants in national economy PDF.pdfDivya Kanojiya
 

Recently uploaded (20)

Screening for colorectal cancer AAU.pptx
Screening for colorectal cancer AAU.pptxScreening for colorectal cancer AAU.pptx
Screening for colorectal cancer AAU.pptx
 
SCHOOL HEALTH SERVICES.pptx made by Sapna Thakur
SCHOOL HEALTH SERVICES.pptx made by Sapna ThakurSCHOOL HEALTH SERVICES.pptx made by Sapna Thakur
SCHOOL HEALTH SERVICES.pptx made by Sapna Thakur
 
SYNDESMOTIC INJURY- ANATOMICAL REPAIR.pptx
SYNDESMOTIC INJURY- ANATOMICAL REPAIR.pptxSYNDESMOTIC INJURY- ANATOMICAL REPAIR.pptx
SYNDESMOTIC INJURY- ANATOMICAL REPAIR.pptx
 
PHYSIOTHERAPY IN HEART TRANSPLANTATION..
PHYSIOTHERAPY IN HEART TRANSPLANTATION..PHYSIOTHERAPY IN HEART TRANSPLANTATION..
PHYSIOTHERAPY IN HEART TRANSPLANTATION..
 
SGK HÓA SINH NĂNG LƯỢNG SINH HỌC 2006.pdf
SGK HÓA SINH NĂNG LƯỢNG SINH HỌC 2006.pdfSGK HÓA SINH NĂNG LƯỢNG SINH HỌC 2006.pdf
SGK HÓA SINH NĂNG LƯỢNG SINH HỌC 2006.pdf
 
Giftedness: Understanding Everyday Neurobiology for Self-Knowledge
Giftedness: Understanding Everyday Neurobiology for Self-KnowledgeGiftedness: Understanding Everyday Neurobiology for Self-Knowledge
Giftedness: Understanding Everyday Neurobiology for Self-Knowledge
 
Plant Fibres used as Surgical Dressings PDF.pdf
Plant Fibres used as Surgical Dressings PDF.pdfPlant Fibres used as Surgical Dressings PDF.pdf
Plant Fibres used as Surgical Dressings PDF.pdf
 
Culture and Health Disorders Social change.pptx
Culture and Health Disorders Social change.pptxCulture and Health Disorders Social change.pptx
Culture and Health Disorders Social change.pptx
 
Exploring the Variety of Private Blood Tests in the UK
Exploring the Variety of Private Blood Tests in the UKExploring the Variety of Private Blood Tests in the UK
Exploring the Variety of Private Blood Tests in the UK
 
SGK HÓA SINH ENZYM 2006 CHỊ THU RẤT HAY.pdf
SGK HÓA SINH ENZYM 2006 CHỊ THU RẤT HAY.pdfSGK HÓA SINH ENZYM 2006 CHỊ THU RẤT HAY.pdf
SGK HÓA SINH ENZYM 2006 CHỊ THU RẤT HAY.pdf
 
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...
Presentació "Real-Life VR Integration for Mild Cognitive Impairment Rehabilit...
 
L1.INTRODUCTION to ENDOCRINOLOGY MEDICINE.pptx
L1.INTRODUCTION to ENDOCRINOLOGY MEDICINE.pptxL1.INTRODUCTION to ENDOCRINOLOGY MEDICINE.pptx
L1.INTRODUCTION to ENDOCRINOLOGY MEDICINE.pptx
 
CEHPALOSPORINS.pptx By Harshvardhan Dev Bhoomi Uttarakhand University
CEHPALOSPORINS.pptx By Harshvardhan Dev Bhoomi Uttarakhand UniversityCEHPALOSPORINS.pptx By Harshvardhan Dev Bhoomi Uttarakhand University
CEHPALOSPORINS.pptx By Harshvardhan Dev Bhoomi Uttarakhand University
 
Presentation on General Anesthetics pdf.
Presentation on General Anesthetics pdf.Presentation on General Anesthetics pdf.
Presentation on General Anesthetics pdf.
 
Big Data Analysis Suggests COVID Vaccination Increases Excess Mortality Of ...
Big Data Analysis Suggests COVID  Vaccination Increases Excess Mortality Of  ...Big Data Analysis Suggests COVID  Vaccination Increases Excess Mortality Of  ...
Big Data Analysis Suggests COVID Vaccination Increases Excess Mortality Of ...
 
PNEUMOTHORAX AND ITS MANAGEMENTS.pdf
PNEUMOTHORAX   AND  ITS  MANAGEMENTS.pdfPNEUMOTHORAX   AND  ITS  MANAGEMENTS.pdf
PNEUMOTHORAX AND ITS MANAGEMENTS.pdf
 
METHODS OF ACQUIRING KNOWLEDGE IN NURSING.pptx by navdeep kaur
METHODS OF ACQUIRING KNOWLEDGE IN NURSING.pptx by navdeep kaurMETHODS OF ACQUIRING KNOWLEDGE IN NURSING.pptx by navdeep kaur
METHODS OF ACQUIRING KNOWLEDGE IN NURSING.pptx by navdeep kaur
 
Myelin Oligodendrocyte Glycoprotein antibody associated disease (MOGAD)
Myelin Oligodendrocyte Glycoprotein antibody associated disease (MOGAD)Myelin Oligodendrocyte Glycoprotein antibody associated disease (MOGAD)
Myelin Oligodendrocyte Glycoprotein antibody associated disease (MOGAD)
 
Aditi Jagtap (Daughter of Ranjit Jagtap).pdf
Aditi Jagtap (Daughter of Ranjit Jagtap).pdfAditi Jagtap (Daughter of Ranjit Jagtap).pdf
Aditi Jagtap (Daughter of Ranjit Jagtap).pdf
 
Role of medicinal and aromatic plants in national economy PDF.pdf
Role of medicinal and aromatic plants in national economy PDF.pdfRole of medicinal and aromatic plants in national economy PDF.pdf
Role of medicinal and aromatic plants in national economy PDF.pdf
 

Venous thromboembolism of pregnancy

  • 1. Venous Thromboembolism in Pregnancy Siti Nurul Afiqah binti Johari 10-6-95 Siti Suhaila Mohaad Sariff 10-6-91
  • 3. Introduction One of the many early physiological adaptations of pregnancy involves changes in the coagulation system, which promote coagulation and impair fibrinolysis. The physiological goal is to prepare for the haemostatic challenge of delivery. A ‘side effect’ of this change is an increased risk of thrombosis. All pregnant women are therefore at risk of thrombosis, compared with non- pregnant women. This risk is manifest from early in the first trimester until 4−6 weeks post partum.
  • 4. Why pregnancy has a greater risk?
  • 5. PHYSIOLOGICAL CHANGES IN THE COAGULATION SYSTEM DURING PREGNANCY These changes, which may not completely return to baseline until more than 8 weeks post partum, begin at conception.
  • 6. RISK FACTORS FOR VTE IN PREGNANCY In some women the risks are increased further because they have one or more additional risk factors. So pregnant women should have a risk assessment for VTE to include the risk factor as listed. This risk is not static and should be reconsidered in any case. A careful hx should be taken from the woman of any prior or family hx of thromboembolic events.
  • 7. Pregnancy itself is a risk factor
  • 8. Clinical Presentation Type Signs and Symptoms Pulmonary embolism • Dyspnea • Palpitations • Pleuritic chest pain • Hemoptysis • Cyanosis/hypoxia in massive PE • Tachycardia • Tachypnea • Hypotension • Collapse • +/- symptoms or signs of DVT Deep vein thrombosis • DVT in pregnancy usually proximal • Unilateral leg pain/tenderness • Swelling in an extremity • Increase calf/thigh circumference • Increased temperature • Prominent superficial veins • Pitting edema
  • 9. Differential Diagnosis • DVT: swelling and lower leg discomfort are not unusual in a normal pregnancy. Other possibilities include muscle strain, a ruptured Baker’s cyst, cellulitis, superficial thrombophlebitis, ruptured plantaris tendon and trauma. • PE: potentially extensive but specifically rule out chest infection and an intra-abdominal bleed (look for abdominal signs, shoulder tip pain from diaphragmatic irritation and a low JVP).
  • 10.
  • 11.
  • 12.
  • 13.
  • 14. Management Massive life treatening PE • Management by an experienced multidisciplinary team involving senior obstetrician,physicians and radiologist for collapsed,shock patient. • An urgent portable echocardiogram should be arranged within one hour presentation. • Immediate thrombolysis should be considered when massive PE is confirmed or extensive circumstance occur. • IV unfractionated heparin.
  • 15. General points • In a woman with a past history of VTE or with a known inherited thrombophilia, it is best to refer her prior to a planned pregnancy for optimum prophylaxis throughout the pregnancy. • Medical anticoagulation is the treatment of choice for acute VTE. Subsequently, surgical interventions may be considered • Anticoagulation is by far the most common treatment option. Heparin is the most frequently used drug, being non-toxic to the fetus (it does not cross the placental barrier). However, its main disadvantages are that it has to be parentally administered and, in the long-term, may give rise to heparin-induced osteoporosis and thrombocytopenia. In some patients, it can also provoke a painful, localized allergic reaction on administration. • Warfarin is the other treatment option in the postnatal patient but it must be avoided antenatally, as it is teratogenic and can also cause placental abruption and fetal/neonatal hemorrhage. • In clinically suspected DVT or PE, treatment with unfractionated heparin or LMWH should be given until the diagnosis is excluded.
  • 16. Initiating treatment There are several different types of heparin to choose from: • LMWH: this is the drug of choice. It has been shown to be more effective than unfractionated heparin with lower mortality and fewer hemorrhagic complications in the initial treatment of DVT in non-pregnant subjects. • Intravenous unfractionated heparin: this is an extensively used drug in the acute management of VTE, particularly massive PE with cardiovascular compromise • Subcutaneous unfractionated heparin: this has been shown to be as effective as the intravenous form. • Additionally, the leg should be elevated and a graduated elastic compression stocking applied to reduce edema. Mobilization with graduated elastic compression stockings should be encouraged.
  • 17. Maintenance therapy Pregnancy • Heparins are the maintenance treatment of choice. • Subcutaneous LMWH appears to have advantages over aPTT- monitored unfractionated heparin in the maintenance treatment of VTE in pregnancy. Women should be taught to self-inject and can then be managed as outpatients until delivery. • If unfractionated heparin is used, monitor the platelet count at least every other day for the first 14 days or until treatment is stopped (whichever comes first). • Seek specialist advice if the patient develops heparin-induced thrombocytopenia or a heparin allergy and requires continuing anticoagulant therapy. She should be managed with the heparinoid, danaparoid sodium or fondaparinux, under specialist supervision.
  • 18. Labour • When the patient thinks she is going into labour, she should stop injecting and get in touch with the delivery ward staff that will manage the anticoagulation throughout labour and immediately post-delivery. Alternatively, planned elective induction of labour or caesarean section at least 12 hours after prophylactic-dose LMWH or 24 hours after therapeutic-dose LMWH can be considered. As these patients are at high risk of hemorrhage, they will be managed with intravenous unfractionated heparin throughout this time. Regional anaesthetic or analgesic techniques should not be undertaken until at least 24 hours after the last dose of therapeutic LMWH. Postpartum • Depending on the patient's individual circumstances, she may be managed with ongoing heparin treatment or warfarin postpartum. If she opts for warfarin, this needs to be avoided until at least day three postpartum with an INR check at day two of warfarin treatment: aim for an INR between 2 and 3. Continue heparin treatment until there have been two successive readings of an INR >2. Although these drugs are detectable in breast milk, all are safe for use during breast-feeding because warfarin metabolites are inactive and heparin is not absorbed through the gastrointestinal tract. • Postnatal review for women who develop VTE during pregnancy or the puerperium should, whenever possible, be at an obstetric medicine clinic or a joint obstetric hematology clinic.
  • 19. Stopping treatment • In theory, therapy should be continued for six months as would be the case for non-pregnant patients. However, the postpartum state is a period of physiological fluctuation of coagulation factors. Therefore, current advice is to continue therapy for at least 6-12 weeks postpartum or until at least three months of therapy have been completed. At that point, the patient should be assessed for the presence of ongoing risk factors for a VTE prior to making the decision to stop anticoagulation therapy.
  • 20. Prevention: prophylaxis Guidance from the Royal College of Obstetricians and Gynecologists’ suggests:Antenatally • Regardless of their VTE risk, dehydration and immobilization of the patient should be avoided throughout pregnancy. • Women at high risk of VTE in pregnancy should be offered pre-pregnancy counseling and a prospective management plan for thromboprophylaxis in pregnancy. Those who become pregnant before receiving such counseling should be referred to a nominated expert early in pregnancy. • All women with previous VTE should receive postpartum prophylaxis, as this is the time of highest risk. • In addition, women whose original VTE was unprovoked, idiopathic or related to estrogen, or who have other risk factors, a family history of VTE in a first-degree relative or a documented thrombophilia require LMWH antenatally and for six weeks postpartum. • Women with recurrent VTE may already be on warfarin. They should be advised to stop warfarin and change to LMWH as soon as pregnancy is confirmed, ideally within two weeks of the missed period and before the sixth week of pregnancy. Women not on warfarin should be advised to start LMWH as soon as they have a positive pregnancy test. • Women with asymptomatic inherited or acquired thrombophilia only, may be managed with close surveillance antenatally and be considered for LMWH for at least seven days postpartum. Exceptions are women with antithrombin deficiency, those with more than one thrombophilic defect (including homozygosity for factor V Leiden) or those with additional risk factors where antenatal prophylaxis should be considered.
  • 21. Intrapartum • Women taking LMWH should be advised that, if they bleed vaginally or contractions begin, they should not inject any further doses. They should be assessed in hospital and further doses be prescribed by medical staff. Postpartum • All women with obesity (BMI greater than 40 kg/m2) should be considered for prophylactic LMWH for seven days after delivery. Other postnatal risks include prolonged labour, immobility, infection, hemorrhage and blood transfusion. • All women who have had an emergency Caesarean section should be considered for LMWH for seven days after delivery. All women who have had an elective caesarean section who have one or more additional risk factors should be considered for LMWH for seven days after delivery. • In addition, properly applied graduated compression stockings are recommended for women travelling long-distance for more than four hours, women who are still outpatients but have prior VTE (usually combined with LMWH), women who are hospitalized and have a contra-indication to LMWH and those who are hospitalized post-caesarean section (combined with LMWH) and considered to be at particularly high risk of VTE.
  • 22.