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Venous Thromboembolism in Obstetrics


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SALSO Series - Venous Thromboembolism in Obstetrics

Published in: Health & Medicine

Venous Thromboembolism in Obstetrics

  2. 2. PHYSIOLOGY <ul><li>Pregnancy is a hypercoagulable state </li></ul><ul><li>Increased in factor VIII, IX, X, fibrinogen </li></ul><ul><li>Decreased fibrinolytic activity, anti thrombin and protein S fall </li></ul><ul><li>Venous stasis in pregnancy </li></ul><ul><li>Pregnancy increases risk to 6 folds (from first trimester till 6 weeks post partum) </li></ul><ul><li>Caesarean sections further increases the risk approximately 10-20 folds </li></ul>
  3. 3. Confidential Enquiry into Maternal Death 2000-2002 (13.1 maternal deaths per 100 000 maternities) <ul><li>Psychiatric* 44:1000 000 </li></ul><ul><li>Cardiac disease 22 </li></ul><ul><li>Thrombo-embolism 15 </li></ul><ul><li>Haemorrhage 8.5 </li></ul><ul><li>Ectopic 7.5 </li></ul><ul><li>Hypertension 7.0 </li></ul><ul><li>Epilepsy 7.0 </li></ul><ul><li>Sepsis 7.0 </li></ul>
  4. 4. Death from thrombo-embolic disease in pregnancy in UK CEMACH 2004
  5. 5. Thrombo-embolism (2000-2002) <ul><li>30 deaths in last triennium </li></ul><ul><li>25 pulmonary embolus and 5 cerebral vein thrombosis </li></ul><ul><li>4 antepartum (3 in first tri’; 1 in third tri’) </li></ul><ul><li>1 in labour </li></ul><ul><li>17 postpartum (7 vaginal delivery; 10 after C section) </li></ul><ul><li>3 more after miscarriage in early pregnancy </li></ul>
  6. 6. Risk factors for venous thromboembolism in pregnancy and the puerperium
  7. 7. Cont…
  8. 8. Thrombo-prophylaxis <ul><li>Antenatal and 6 weeks postpartum </li></ul><ul><li>Previous DVT and thrombophilia/strong FH </li></ul><ul><li>Previous DVT related to pregnancy </li></ul><ul><li>Recurrent DVTs </li></ul><ul><li>(Single unprovoked DVT) </li></ul><ul><li>(DVT within 12m on OCP) </li></ul><ul><li>(Three or more persistent risk factors) </li></ul><ul><li>Just 6 weeks postpartum </li></ul><ul><li>Single previous provoked DVT </li></ul><ul><li>Asymptomatic thrombophilia </li></ul>
  9. 9. <ul><li>3-5 days postpartum </li></ul><ul><li>-Age > 35 or BMI > 30 plus other risk eg: immobility, PE </li></ul><ul><li>- the presence of two other persisting risk factors </li></ul>
  10. 10. Thrombo-prophylaxis
  11. 11. Advice on Preventing Deep Vein Thrombosis for Pregnant Women Travelling by Air
  12. 12. Thromboprophylaxis in women having CS <ul><li>Slight increase risk </li></ul><ul><li>El. CS in uncomplicated pregnancy, no other risk factor </li></ul><ul><li>Bld group other than O </li></ul><ul><li>Action: early mobilisation and hydration </li></ul>
  13. 13. Mode rate increase risk <ul><li>Maternal age > 35 </li></ul><ul><li>Parity 4or more </li></ul><ul><li>Obesity > 80 kg </li></ul><ul><li>Gross varicose veins </li></ul><ul><li>PE </li></ul><ul><li>Em CS </li></ul><ul><li>Immobility before surgery > 4 days </li></ul><ul><li>Sickle cell disease, major intercurrent illness or infection </li></ul><ul><li>Action: use heparin or TED stockings </li></ul>
  14. 14. High risk <ul><li>3 or more moderate risks </li></ul><ul><li>Personal or family history of thrombosis </li></ul><ul><li>Acquired or inherited thrombophilia </li></ul><ul><li>Major surgery – Caesarean hysterectomy </li></ul><ul><li>Action; use heparin and TED stockings </li></ul>
  15. 15. Clinical Greentop Guidelines
  16. 16. Cont….
  17. 17. Cont… <ul><li>Epidural anaesthesia can be sited only after discussion with a senior anaesthetist, in keeping with local </li></ul><ul><li>T o minimise the risk of epidural haematoma, regional techniques should not be used until at least 12 hours after the previous prophylactic dose or at least 24 hours after the last therapeutic dose of LMWH. </li></ul><ul><li>LMWH should not be given for at least four hours after the epidural catheter has been inserted or removed and the cannula should not be removed within 10–12 hours of the most recent injection. </li></ul><ul><li>For delivery by elective caesarean section, the woman should receive a thromboprophylactic dose of LMWH on the day before delivery. </li></ul><ul><li>On the day of delivery, the morning dose should be omitted and the operation performed that morning. </li></ul><ul><li>The thromboprophylactic dose of LMWH should be given by three hours postoperatively (or four hours after insertion or removal of the epidural catheter, if appropriate). </li></ul>
  18. 19. Diagnosis of TED <ul><li>High index of suspicion is needed </li></ul><ul><li>The classical features of DVT is unreliable </li></ul><ul><li>In pregnancy 85% DVTs in left leg </li></ul><ul><li>Ileo-femoral vessels > femoral or lower leg </li></ul>
  19. 20. PTE <ul><li>High index of suspicion </li></ul><ul><li>Sudden onset dyspnoea </li></ul><ul><li>Pleuritic chest pain </li></ul><ul><li>Cough, hemoptysis </li></ul><ul><li>Sudden collapse </li></ul><ul><li>A small PE can become a big one! </li></ul><ul><li>Signs- tachypnea, tachycardia, raised JVP, loud S2, pleural rub, fever </li></ul>
  20. 21. Clinically obvious left leg DVT
  21. 22. Investigations of DVT/PE <ul><li>Doppler ultrasound; include ileo-femoral vessels </li></ul><ul><li>CXR and ECG </li></ul><ul><li>V/Q scan </li></ul><ul><li>Spiral CT scan </li></ul><ul><li>Pulmonary angiogram </li></ul><ul><li>D-dimer </li></ul><ul><li>Thrombophilia screen </li></ul>
  22. 23. Non-compressible femoral vein due to thrombosis
  23. 24. V-Q scan showing almost complete absence of perfusion of right lung and reduced perfusion of lower two thirds of left lung
  24. 25. CT scan showing massive pulmonary embolus
  25. 26. Pulmonary Angiogram showing massive right pulmonary embolus
  26. 27. Treatment while waiting results of Investigation <ul><li>If DVT suspected, treat until diagnosis confirmed </li></ul><ul><li>LMW heparin (like unfractionated heparin) is safe in pregnancy and during breast-feeding </li></ul><ul><li>Heparin associated with thrombocytopenia (HIT – rare), osteopaenia. </li></ul><ul><li>No need for anti-Xa assay with prophylactic dose </li></ul><ul><li>Warfarin is not safe during pregnancy, but safe during breast-feeding </li></ul><ul><li>In pregnancy renal clearance of heparin increased </li></ul>
  27. 28. Management of TED in pregnancy <ul><li>Treat for 6 months or until 6 weeks after delivery, whichever is the longer. </li></ul><ul><li>Controversial whether or not to lower the dose of heparin after 6-8 weeks </li></ul><ul><li>Obs anaesthetists involved peri-partum </li></ul><ul><li>Thrombophilia screen, involve hematologist. </li></ul><ul><li>Recurrent PE with ileofemoral thrombosis may require vena caval filters. </li></ul>
  28. 29. Clinical Green Top Guidelines
  29. 30. Prevention of post-thrombotic syndrome
  30. 31. Management of large, pulmonary embolus causing haemodynamic instability <ul><li>Oxygen to keep SaO2 >/=95% </li></ul><ul><li>Lie patient flat </li></ul><ul><li>Fluid challenge to optimise right heart filling </li></ul><ul><li>May need ventilating </li></ul><ul><li>Thrombolysis (rT–PA or streptokinase) for haemo-dynamically unstable massive PE. </li></ul><ul><li>Pulmonary catheter agitation </li></ul><ul><li>Pulmonary embolectomy </li></ul>
  31. 32. <ul><li>AMNOTIC FLUID AND AIR EMBOLISM </li></ul>
  32. 33. AFE <ul><li>It is unpredictable, unpreventable </li></ul><ul><li>Has high morbidity and mortality(80%) to mother and fetus (if occurs antenatally) </li></ul><ul><li>50% die within 1H of onset of symptoms </li></ul><ul><li>Survivors 50% develop coagulopathy, high risk of long term nerological impairment </li></ul><ul><li>70% acute fetal distress </li></ul>
  33. 34. Associated factors <ul><li>Precipitate labour </li></ul><ul><li>Polyhydramious </li></ul><ul><li>Hypertonic uterine contraction with(out) oxytocin </li></ul><ul><li>Induction or augmentation of labour </li></ul><ul><li>Increasing age (dramatic increase after 35) </li></ul>
  34. 35. <ul><li>IUD </li></ul><ul><li>Placenta acreta </li></ul><ul><li>Chorioamniotis </li></ul><ul><li>Uterine rupture </li></ul><ul><li>More common in male fetus </li></ul><ul><li>*Can occur up to 48h after delivery </li></ul>
  35. 36. Signs and symptoms <ul><li>Prodromal symptoms eg. Shivering </li></ul><ul><li>Maternal hypoxemia, cyanosis, cardiovascular collapse </li></ul><ul><li>Severe coagulation defect </li></ul><ul><li>Fetal distress </li></ul><ul><li>Fitting </li></ul><ul><li>Dyspneoa & tachycardia </li></ul>
  36. 37. Differential diagnosis <ul><li>Anaphylactic reaction </li></ul><ul><li>PE </li></ul><ul><li>Eclampsia </li></ul><ul><li>AMI </li></ul><ul><li>Septic shock </li></ul><ul><li>Placental abruptio </li></ul><ul><li>Aspiration </li></ul><ul><li>Aortic dissection </li></ul>
  37. 38. Management <ul><li>Call for help/ red alert </li></ul><ul><li>Assess severity, ABC ± CPR </li></ul><ul><li>Consider perimortem if no response to CPR </li></ul><ul><li>Send bld ix- FBC, GXM,U&E, LFT, clotting, FDP </li></ul><ul><li>Correct coagulation defect, involve hematologist </li></ul>
  38. 39. <ul><li>Treat hypotension w crystalloid, bld products, use vasoconstrictor if necessary </li></ul><ul><li>Involve anaesthetist / incentivist </li></ul><ul><li>Invasive monitoring </li></ul><ul><li>Assess fetal wellbeing , delivery if necessary </li></ul><ul><li>Identify any neurological deficit and refer to neurologist </li></ul>
  39. 40. <ul><li>AIR EMBOLISM </li></ul>
  40. 41. Venous air embolism <ul><li>VAE is transient, benign, and common–especially in association with cesarean delivery. </li></ul><ul><li>It occurs in more than 65% of patients undergoing cesarean delivery with regional anesthesia, and in more than 90% of patients receiving general anesthesia. </li></ul><ul><li>Patient positioning during abdominal delivery may affect the incidence of VAE, so that steep Trendelenburg and uterine exteriorization should be avoided. </li></ul>
  41. 42. Cont… <ul><li>Signs of VAE include hypotension and hypoxemia in 10% and 30% of patients, respectively. </li></ul><ul><li>Symptoms include chest pain in 23% of patients. </li></ul><ul><li>Precordial Doppler monitoring can be implemented intraoperatively to detect VAE. </li></ul><ul><li>Monitoring of expired nitrogen is another way to assess for VAE. </li></ul><ul><li>A massive air embolus can be treated with position changes, 100% forced inspiratory oxygen (FIO2), rapid administration of intravenous (IV) fluids, and expediting delivery while minimizing instrumentation. </li></ul>
  42. 43. Other conditions a/w VAE <ul><li>Venous cathetrisation </li></ul><ul><li>Epidural </li></ul><ul><li>Cases of fatal VAE have been reported following antepartum oral sex. </li></ul>
  43. 44. <ul><li>Thank you </li></ul>