By: Hanaa Adnan Rasheed
6th stage Group B1
Supervised by: Prof.Dr. Ayla K. Ghalib
Points to Discuss:
1) Physiology of hemostasis.
2) Coagulation during pregnancy.
3) Thromboembolism in pregnancy:
• Superficial thrombophlebitis.
• Deep vein thrombosis.
• Pulmonary embolism.
Physiology of Hemostasis:
The term hemostasis means prevention of blood
Whenever a vessel is severed or ruptured,
hemostasis is achieved by several mechanisms:
(1) vascular constriction,
(2) formation of a platelet plug,
(3) formation of a blood clot as a result of blood
(4) eventual growth of fibrous tissue into the blood
clot to close the hole in the vessel permanently.(1)
The extrinsic pathway
begins with a traumatized
The intrinsic pathway
begins with trauma to the
blood itself or exposure of
the blood to collagen from
a traumatized blood vessel
Coagulation During Pregnancy:
Plasma Fibrinogen concentration by ~
Factors: V, VII, VIII, IX, X and XII.
Platelet reactivity in 2nd and 3rd TMs till
12wk post partum.
Protein S (an inhibitor of coagulation). (2)
Pregnancy is a hypercoagulable state that
return to normal 4 weeks after delivery. (3)
This hypercoagulability is particularly relevant at
delivery, with placental separation…
At term, around 500ml blood flows through the
placental bed every minute…
Without effective and rapid hemostasis, a woman
could rapidly die from blood loss…
Myometrial contraction FIRST compress BV
supplying placental bed…
Then FIBRIN deposition on pl. bed.(10% of blood
fibrinogen is used for this process!). (3)
Thromboembolism in Pregnancy:
1. Superficial Thrombophlebitis
2. Deep Vein Thrombosis.
3. Pulmonary Embolism.
Venous Thromboembolism (VTE)
Venous thromboembolism (VTE) is the leading
direct cause of maternal death throughout
The incidence of thromboembolic complications,
pulmonary TE and DVT presented during
pregnancy is around 1/1000, with a further
2/1000 women presented in puerperium.
VTE is up to 10 times more common in
pregnancy than in comparable non-pregnant
Pathogenesis of VTE in Pregnancy
1* Superficial Thrombophlebitis
Swelling and tenderness of the involved extremity.
On physical examination, there is erythema,
tenderness, warmth, and a palpable cord over the
course of the involved superficial veins.
Bed rest, pain medications, and local application of
heat are often sufficient treatment.
There is no need for anticoagulants, but anti-
inflammatory agents may be considered. (5)
2* Deep Vein Thrombosis:
50% of cases are
DVT is much more common in
the left than the right leg.
Pain in the calf in association
with dorsiflexion of the foot
(positive Homans’ sign) .
Dull ache, tingling, tightness,
especially when walking. (5)
Treatment of VTE in Pregnancy:
Acute Phase Treatment:
• Thrombolytic Therapy:
• Streptokinase and TPA.
• Cannot be
pregnancy except in life
• Skocked patient with
• Iliofemoral venous
• Unfractionated Heparin:
• 40.000 IU/day
• IV infusion
• For (3-7) days
• Monitor by APTT (1.5-
• Fractionated or LMWH:
• Cross placenta
• If given in pregnancy it
must be stopped at 36
• Monitor by PT and INR
(target 2.0 – 3.0).
• Duration of action: 3 days
• S.E: bleeding tendency &
Teratogenic Effects of
• CNS abnormalities.
• ↑abortion and premature
• Chondroplasia punctata.
• Nasal hypoplasia.
• Anti-thrombin III deficiency
• Protein C deficiency
• Protein S deficiency
• Factor V Leiden
• Prothrombin gene variant
• Antiphospholipid syndrome (2)
Antiphospholipid syndrome (APS)
Antiphospholipid antibodies are circulating
antibodies to negatively charged phospholipids.
They include lupus anticoagulant and
Antiphospholipid antibody syndrome is defined
as the presence of at least one antibody in
association with arterial or venous thrombosis with
or without one or more obstetric complication
(unexplained fetal demise after 10 weeks’
gestation or severe preeclampsia or fetal growth
restriction before 34 weeks’ gestation).
Treatment: LMWH and Aspirin. If Hx of
1. Arthur C. Guyton. Guyton Textbook of Medical
Physiology. Elsevier Saunders. 11th edition.
2006. pages (419-468).
2. Edmonds D. Keith. Dewhurst’s Textbook of
Obstetrics and Gynecology. Blackwell
publishing. 7th edition. 2007. pages (270-281).
3. Philip N. Baker. Obstetrics by Ten Teachers.
Hodder Arnold. 18th edition. 2006. Pages (286-
4. Reducing the Risk of Thrombosis and
Embolism During Pregnancy and Puerperium.
RCOG green top guideline. American College
of Obstetricians and gynecologists. No.37a.
November 2009. pages (1-35).
5. Neville F. Hacker, Josephe C. Gambone and
Calvin J. Hobel. Hacker and Moore’s
Essentials of Obstetrics and Gynecology.
Elseviers Saunders. 5th edition. 2010. pages
6. Cunningham F. Gary, Kenneth J. Levendo,
Steven L. Bloom et al. Williams Obstetrics.
Mc Graw Hill. 24th edition. 2014. Pages