AN OVERVIEW TO THROMBOEMBOLIC DISORDERS IN PREGNANCY

1. THROMBO
EMBOLIC
DISORDERS IN
PREGNANCY
PRESENTED BY,
MRS.JASMI MANU
HEAD OF THE DEPARTMENT
OBS/GYN DEPARTMENT
FACULTY OF NURSING ,RAMA
UNIVERSITY,KANPUR

2. TERMINOLOGIES
1. Thrombus: a stationary blood clot caused by coagulation of blood in heart or
artery or in vein.
2. Embolus: a substance carried by the bloodstream until it causes obstruction
by blocking a blood vessel.
3. Embolism: obstruction of a blood vessel by a travelling blood clot or particle.
4. Phlebitis: inflammation of a vein , usually in the leg , which tends to lead to
the formation of a thrombus.
5. Phlebothrombosis: obstruction of vein by a blood clot , without local
inflammation.
6. Thrombophlebitis: the formation of a clot , associated with inflammation of
the lining of a vein.

3. Thromboembolism
1. A past or family history of thrombosis.
2. Immobility due to displacement, paralysis or medical condition.
3. Pre-eclampsia.
4. Postoperatively in particular following emergency caesarean section.
5. Following epidural anesthesia where the legs have been immobile.
6. Antiphospholipid syndrome, cardiolipin antibody, or lupus anticoagulant.
7. Congenital deficiency of antithrombin III , protein c, some sickle cell anaemias.
8. Obesity, age more than 35 , parity more than 4.
9. Severe varicose veins.
10. Current other infection or illness.

4. Venous thrombosis
1. Stasis of blood in the pelvic and legs veins.
2. Alteration in the blood constituents.
3. Infection.
4. Traumas to the pelvic venous wall during labour .
5. Other high risk factors ; such as
– Advancing age , high parity , use of estrogen,
obesity, woman with high BMI , anemia, heart diseases,
womens using combined oral contraceptives ( COC).

5. TYPES :
The puerperal venous thrombosis is classified as;
1. Phlebothrombosis : superficial , deep.
2. Thrombophlebitis.

6. Superficial vein thrombosis
Clinical features:
1. The onset is within first week.
2. They are characterized by ; pain, swelling, tenderness of
affected vein.
3. Slight pyrexia from 4 or 10 day.
4. Slight rise in pulse rate.
5. The overlaying skin looks red due to reaction of clot.
6. Redness & pain .

7. Management of superficial thrombosis:
1. Pain management , local application of heat. (eg. Thermal
blanket)
2. Elevation of lower extremities.
3. Anti-inflammatory agents.
4. Bed rest.
5. Gradually begin to ambulate as when the symptoms disappear.
6. Toe-to-groin elastic stockings.
7. Instruct to avoid standing for prolong periods.

8. Deep vein thrombosis (DVT)
Incidence: DVT is 1 in 2000 ante partum patient & 1 in 700 postpartum patient.
Clinical features:
•Symptoms:-
1. Pain in the calf or sole.
2. Swelling in the leg.
3. Often slight rise of temperature & pulse rate between the 7 & 10 day of
postpartum.

9. On Examination:-
1. Calf tenderness on deep pressure.
2. Positive Homan’s sign.
3. (pain in the calf or thigh on dorsiflexion of foot ).
4. Swelling of the leg ; ie. 2/3 cm larger than the non-
affected leg.

10. Investigation
1. Venogram.
2. MRI.
3. Doppler ultrasound.

11. MANAGEMENT
Preventive measures for the high risk situations developing DVT;
1. Leg movement & exercises.
2. Use of elastic stockings.
3. Active breathing exercise.
4. Avoid sitting with legs dangling down.
5. Intermittent calf muscle compression.
6. Prophylactic anticoagulant therapy.
7. Avoiding use of estrogen for suppression of lactation.
8. Avoiding use of COC- PILLS in early peurperium

12. Treatment measures for DVT:-
1. Mobilization may or may not be restricted.
2. Bed rest with foot end raised.
3. Analgesics to relieve pain .
4. Antibiotics.
5. Anti- coagulant therapy
* Heparin.
*Oral warfarin.

13. THROMBOPHLEBITIS
1. Postpartum thrombophlebitis originates in the thrombosed veins at the
placental site by organisms such as anaerobic streptococci or bacteroides
(pragilis).
2. When localized in the pelvic , it is called pelvic thrombophlebitis.
3. There is no specific clinical features for pelvic thrombophlebitis , but is
suspected when pyrexia continues for more than a week in absence of any
other causes in postnatal mothers.
4. Extra pelvic spread may reach to the lungs or kidney.
5. Retrograde extension to ileo- femoral vein produces the clinico- pathological
condition of “ PHLEGMACIA ALBA DOLENS “ or “ WHITE LEG “.

14. Clinical features:
1. Usually developes in the second week of postpartum.
2. Mild fever with or without chills.
3. Headache, malaise and rising pulse rate.
4. Affected leg seems painful, swollen, white & cold.
5. Tenderness and induration.
6. Polymorphonuclear leukocytosis seen on blood count.

15. PULMONARY EMBOLISM
Signs & symptoms of small pulmonary embolism are as;
1. Chest pain.
2. Dyspnoea.
3. Coughing , slight haemoptysis.
4. Pyrexia.
5. Tachycardia.

16. Sign & symptoms of major pulmonary embolism are as;
1. Sudden acute chest pain.
2. Marked distress.
3. Shock or sudden collapse.
4. Dyspnoea, cyanosis.
5. Pyrexia.
6. Tachycardia / bradycardia, hypotension.

17. INVESTIGATION :-
1. Ecg
2. ABG ( arterial blood gas shows an oxygen tension below
80 mmHg.
3. Computed helical tomography. [ lung scan ]
4. Pulmonary angiography.
5. Chest X-ray.
6. a 99m Tc ventilation – perfusion scan.
7. Embolectomy.

18. MANAGEMENT & TREATMENT:
1. Emergency medical aid must be summoned.
2. Resuscitation – cardiac massage.
3. Oxygen should be given in need.
4. Iv –fluid .
5. An intravenous Heparin should be administered.
6. Blood pressure to be maintained by dopamine / adrenaline.
7. Tachycardia is counteracted with Digitalis.
8. Pain may be relieved by intravenous morphine or diamorphine.
9. Thrombolytic therapy with streptokinase.
10. Surgical Embolectomy.
11. Antenatal & postnatal Exercises;

19. SPECIAL EXERCISES FOR
PREGNANCY & PUERPERIUM
ANTENATAL EXERCISES:
1. Foot and leg exercise.
2. Breathing exercise.
POSTNATAL EXERCISES:
1. Circulatory exercises.
2. Leg raising exercises.