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  1. 1. Vascular problems in Gynecology and Obstetrics Dr. UMA GUPTA MD(OBG)FICMCH,Sr.Specialist,VPCIMS,LUCKNOW(UP)INDIA Dr.N.K.GUPTA, M.Ch,CTVS,Associate Prof,ERA’s LUCKNOW MEDICAL COLLEGE,LUCKNOW.INDIA [email_address] [email_address] 10/21/10 DrU.Gupta,Dr.N.K.Gupta
  2. 2. Vascular surgery evolution <ul><li>The first elective operation for treatment of an aneurysm was reported by the most famous surgeon in Greek antiquity,ANTYLLUS, in the 2 nd century. </li></ul><ul><li>AMBROSE PARE(1510-1590), mainly contributed –principles wound care-aneurysm operations. </li></ul><ul><li>After a century,RICHARD WISEMAN(1625-1686)”Father of English Surgery”described aneurysm in arm. </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  3. 3. contd <ul><li>Sutures should be made with very fine needles while the wall is somewhat stretched.Stenosis or occlusion only occurs-faulty technique-which is still valid 100 years later. </li></ul><ul><li>In 1910, he demonstrated that blood vessels could be kept in cold storage for long periods before transplanting them. </li></ul><ul><li>Carrel won the noble prize for this work in 1912 “in recognition of his work on vascular suture and transplantation of blood vessel.” </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  4. 4. <ul><li>AntiPhospholipid Antibody Syndrome </li></ul><ul><li>Raynaud’s disease </li></ul><ul><li>Vasculitis </li></ul>Arterial Disorders 10/21/10 DrU.Gupta,Dr.N.K.Gupta
  5. 5. Venous Disorders <ul><li>Varicose Veins </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta <ul><li>Deep Vein Thrombosis/ PE </li></ul><ul><li>Superficial Thrombophlebitis </li></ul>
  6. 6. AntiPhospholipid Antibody Syndrome <ul><li>Arterial and Venous thrombosis </li></ul><ul><li>History- </li></ul><ul><ul><li>First noted in pts positive for syphilis </li></ul></ul><ul><ul><li>1952- clotting disorder asso. with SLE </li></ul></ul><ul><ul><li>1957- linked to recurrent pregnancy loss </li></ul></ul><ul><ul><li>1963 & 1972 – term “Lupus anticoagulant” </li></ul></ul><ul><ul><li>1983 – Dr Graham Hughes – association between APL antibodies and arterial and venous thrombosis </li></ul></ul><ul><ul><li>1985 – ELISA test for detection of ACA </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta syn. Hughes Syndrome
  7. 7. AntiPhospholipid Antibody Syndrome <ul><li>PRIMARY </li></ul><ul><li>SECONDARY </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta <ul><li>Mechanism: </li></ul><ul><li>AUTOIMMUNE PHENOMENON ??? </li></ul><ul><ul><li>Tissue injury – Inflammation, Ischemia, trauma </li></ul></ul>Classes Of Antibodies – a) Anticardiolipin Antibody (IgG,IgA,IgM) b) Lupus Anticoagulant c) Antibodies against specific molecules e.g. β -2-glycoprotein Types:
  8. 8. AntiPhospholipid Antibody Syndrome <ul><li>Prevalence 2-4% </li></ul><ul><ul><ul><li>50% - Primary APLAS </li></ul></ul></ul><ul><ul><ul><li>SLE – 30% will develop APLAS </li></ul></ul></ul><ul><li>ACA five times more common than Lupus Anticoagulant </li></ul><ul><li>Primary APLAS – 10% SLE, Mixed Conn. Tissue Ds </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  9. 9. AntiPhospholipid Antibody Syndrome <ul><li>RISKS ASSOCIATED : </li></ul><ul><ul><li>MISCARRIAGES </li></ul></ul><ul><ul><li>PRETERM LABOR </li></ul></ul><ul><ul><li>PRE-ECLAMPSIA </li></ul></ul><ul><ul><li>LOW BIRTH WEIGHT </li></ul></ul><ul><ul><li>THROMBOCYTOPENIA (20-40%) </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  10. 10. AntiPhospholipid Antibody Syndrome <ul><li>WHEN TO EVALUATE </li></ul><ul><ul><ul><li>Unexplained still birth/fetal death after 10 wks </li></ul></ul></ul><ul><ul><ul><li>Severe IUGR prior to term </li></ul></ul></ul><ul><ul><ul><li>Severe pre-eclampsia at <34 wks gestation </li></ul></ul></ul><ul><ul><ul><li>Unexplained arterial/venous thrombosis in any territory </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  11. 11. AntiPhospholipid Antibody Syndrome <ul><li>TREATMENT </li></ul><ul><ul><li>Anticoagulation – Heparin  Oral </li></ul></ul><ul><ul><ul><li>Long term  Life Long ( risks – 3% chance per year of major h’hage, 1/5 th fatal) </li></ul></ul></ul><ul><ul><li>Anti-platelet drugs – Aspirin </li></ul></ul><ul><ul><li>LMWH </li></ul></ul><ul><ul><li>Pregnancy – Heparin / LMWH </li></ul></ul><ul><li>PROPHYLAXIS (APLAS without thrombotic problems) </li></ul><ul><ul><li>Aspirin </li></ul></ul><ul><ul><li>Lifestyle Modification </li></ul></ul><ul><ul><li>Control of Risk factors – HTN, Smoking, Cholesterol levels, Weight control </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  12. 12. AntiPhospholipid Antibody Syndrome <ul><li>Special Prenatal/Birth/Neonatal Considerations </li></ul><ul><li>Ideally, one should seek medical advice before becoming pregnant. </li></ul><ul><li>Once pregnancy is achieved </li></ul><ul><ul><li>to see Obstetrician - to decide on the need for treatment </li></ul></ul><ul><ul><li>frequent office visits will be needed to: </li></ul></ul><ul><ul><ul><li>Screen for preeclampsia, </li></ul></ul></ul><ul><ul><ul><li>Fetal Monitoring </li></ul></ul></ul><ul><ul><ul><li>Ultrasound examinations to check the growth of the baby. </li></ul></ul></ul><ul><li>For patients on heparin </li></ul><ul><ul><li>extra blood tests may be needed to adjust the dose depending on the type of heparin being used, and the past history of the patient. </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  13. 13. AntiPhospholipid Antibody Syndrome <ul><li>PREGNANCY: </li></ul><ul><ul><li>Pre Pregnancy Counselling </li></ul></ul><ul><ul><li>Heparin (s/c)± Low Dose Aspirin </li></ul></ul><ul><ul><li>LMWH </li></ul></ul><ul><ul><li>Aspirin ± Prednisone X X X X </li></ul></ul><ul><ul><li>Low Dose Aspirin </li></ul></ul><ul><ul><li>Intravenous Immune Globulin (IVIG) </li></ul></ul><ul><ul><li>Immunosupression </li></ul></ul><ul><ul><li>Steroids Catastrophic </li></ul></ul><ul><ul><li>Plasmapheresis </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  14. 14. Raynaud’s disease <ul><li>1862 – Maurice Raynaud </li></ul><ul><li>Prevalence – 3-5% </li></ul><ul><li>Episodic events – vasoconstriction (digital arteries, precapillary arterioles & cutaneous AV shunts) </li></ul><ul><li>vs Acrocyanosis </li></ul><ul><li>Exaggeration of the physiologic response to cold temperature or stress. </li></ul><ul><li>Manifestation of generalised vasospastic disorder.e.g.pts who have Prinzemetal’s angina, migraines, or scleroderma. </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  15. 15. Raynaud’s disease <ul><li>H/o sensitivity to cold/ episodic pallor or cyanosis </li></ul><ul><li>Triphasic reaction </li></ul><ul><li>Involves- fingers, toes, tip of the nose, ear lobes. </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta (white> blue > red ) PRIMARY* SECONDARY SYMMETRIC ASYMMETRIC ABSENCE OF PAINFUL ISCHAEMIC -TISSUE NECROSIS SKIN LESIONS -ULCERATION C/f s.o. CONN. TISSUE -GANGRENE DISORDERS (arthritis,myalgia, -SECONDARY CAUSE abnormal lung fn,fever etc) H/o drug use/toxic agent NORMAL NAIL FOLD CAPILLARIES MICROVASCULAR DS NORMAL ESR ESR  NEGATIVE ANA TEST ANA ± *Adapted from LeRoy and Medsger
  16. 16. Raynaud’s disease <ul><li>Complete evaluation – to R/o underlying cause </li></ul><ul><ul><li>H/o or current drug use </li></ul></ul><ul><ul><li>H/o repetitive trauma e.g.vibratory tools </li></ul></ul><ul><ul><li>Positional changes triggering the event. e.g.Tho Outl Obst. </li></ul></ul><ul><ul><li>Carpel tunnel syndrome </li></ul></ul><ul><ul><li>Neurapathic conditions </li></ul></ul><ul><ul><li>Malignancy </li></ul></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><li>Dysproteinemias </li></ul></ul><ul><ul><li>Vasculitis </li></ul></ul><ul><ul><li>Emboli </li></ul></ul><ul><ul><li>Vascular Occlusive disease </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  17. 17. Raynaud’s disease <ul><li>NonPharmacological </li></ul><ul><ul><ul><li>Avoidance of cold temp / prolong vibrations </li></ul></ul></ul><ul><ul><ul><li>Reduce emotional stress </li></ul></ul></ul><ul><ul><ul><li>Avoid Smoking </li></ul></ul></ul><ul><li>Calcium channel Blockers </li></ul><ul><li>Other Agents </li></ul><ul><ul><ul><li>Sympatholytic drugs </li></ul></ul></ul><ul><ul><ul><li>ARBs </li></ul></ul></ul><ul><ul><ul><li>Fluoxetine </li></ul></ul></ul><ul><ul><ul><li>I.V. Prostaglandins </li></ul></ul></ul><ul><li>Awaited </li></ul><ul><ul><ul><li>Cilostazole </li></ul></ul></ul><ul><ul><ul><li>Sildenafil </li></ul></ul></ul><ul><ul><ul><li>Bosentan (endothelin receptor inhibitor) </li></ul></ul></ul><ul><li>Sympathectomy </li></ul><ul><ul><ul><li>Proximal ??? </li></ul></ul></ul><ul><ul><ul><li>Localised Digital √ √ </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta Treatment
  18. 18. Vasculitis <ul><li>AutoImmune Disease </li></ul><ul><li>Inflammation of the blood vessels </li></ul><ul><li>Symptoms – depend on which blood vessels are inflamed </li></ul><ul><ul><li>Fatigue </li></ul></ul><ul><ul><li>Sleep disturbances </li></ul></ul><ul><ul><li>Memory Loss </li></ul></ul><ul><ul><li>Emotional Liability </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Low Thyroid Function </li></ul></ul><ul><ul><li>G I disturbances </li></ul></ul><ul><ul><li>Headaches/Chemical Sensitivity </li></ul></ul><ul><ul><li>Fungal Infections </li></ul></ul><ul><ul><li>Low Blood Sugar </li></ul></ul><ul><ul><li>Pain – Tingling/Ringing ears/Cold Toes/Cold Fingers </li></ul></ul><ul><ul><li>Overdoing </li></ul></ul><ul><ul><li>Fluttering Heart/Tachycardia/Panic Attacks/Mitral valve Prolapse </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  19. 19. Vasculitis <ul><li>IMMUNE SYSTEM MALFUNCTION </li></ul><ul><ul><ul><li>CONSUMPTION OF ASPARTATE (IN DIET DRINKS/ARTIFICIAL SWEETNERS etc.) </li></ul></ul></ul><ul><ul><ul><li>CHLORINATED AND FLORIDATED WATER ??? </li></ul></ul></ul><ul><ul><li>POOR CELLULAR COMMUNICATION </li></ul></ul><ul><ul><ul><li>HEAVY MOL WT CARBOHYDRATES (LONG CHAINED) </li></ul></ul></ul><ul><ul><ul><ul><li>PROVIDE INGREDIENTS FOR CELL MARKERS </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HIGHLY ANTI-INFLAMMATORY </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CODING CAPACITY BETTER THAN AMINO ACIDS * </li></ul></ul></ul></ul><ul><ul><li>OVER ACTIVATED, OUT OF BALANCE IMMUNE SYSTEM </li></ul></ul><ul><ul><ul><li>Stress </li></ul></ul></ul><ul><ul><ul><li>Infections – Bacterial , Fungal (Candida), Viral (e.g.Herpes) </li></ul></ul></ul><ul><ul><ul><li>Toxins – produced by infecting organism, from environment </li></ul></ul></ul><ul><ul><ul><li>Liver dysfunction </li></ul></ul></ul><ul><ul><ul><li>Steroids </li></ul></ul></ul><ul><ul><ul><li>Enzyme deficiency – Digestive/Metabolic </li></ul></ul></ul><ul><ul><ul><li>Hypercoagulation/ HypoOxygenation </li></ul></ul></ul><ul><ul><ul><li>Glutathione Deficiency </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta *Acta Anatomica
  20. 20. Vasculitis <ul><li>Management </li></ul><ul><ul><li>Weighing the available options </li></ul></ul><ul><ul><ul><li>Steroids </li></ul></ul></ul><ul><ul><ul><li>Chemotherapeutic Agents </li></ul></ul></ul><ul><ul><li>Antioxidants/ Digestive Enzymes </li></ul></ul><ul><ul><li>Treat underlying disorder </li></ul></ul><ul><ul><li>Lifestyle modification </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  21. 21. Venous Disorders <ul><li>Varicose Veins </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta <ul><li>Deep Vein Thrombosis/ PE </li></ul><ul><li>Superficial Thrombophlebitis </li></ul>
  22. 22. Varicose Veins <ul><li>Pregnancy </li></ul><ul><ul><li>Increased blood volume </li></ul></ul><ul><ul><li>Pressure on veins </li></ul></ul><ul><ul><li>Relaxation effect of hormones </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  23. 23. 10/21/10 DrU.Gupta,Dr.N.K.Gupta
  24. 24. 10/21/10 DrU.Gupta,Dr.N.K.Gupta
  25. 25. Varicose Veins <ul><li>Management </li></ul><ul><ul><li>Non Operative </li></ul></ul><ul><ul><ul><li>Self resolving (within six weeks) </li></ul></ul></ul><ul><ul><li>After 6 weeks </li></ul></ul><ul><ul><ul><li>if problematic/ unacceptable </li></ul></ul></ul><ul><ul><ul><ul><li>Graduated Compression Stockings </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Surgery </li></ul></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  26. 26. Varicose Veins 10/21/10 DrU.Gupta,Dr.N.K.Gupta Before Treatment After Treatment
  27. 27. Varicose Veins 10/21/10 DrU.Gupta,Dr.N.K.Gupta
  28. 28. Superficial Thrombophlebitis 10/21/10 DrU.Gupta,Dr.N.K.Gupta <ul><li>Benign /Self limiting Disease </li></ul><ul><li>Can progress to DVT(11%) </li></ul><ul><li>Associated with Abnormalities </li></ul><ul><li>in blood coagulation </li></ul>
  29. 29. Superficial Thrombophlebitis <ul><li>Traumatic </li></ul><ul><li>Varicose Veins </li></ul><ul><li>Oral contraceptives </li></ul><ul><li>Pregnancy </li></ul><ul><li>Infection (e.g. Staph., Pseud., Kleb., Anaerobes) </li></ul><ul><li>Migratory (e.g. Cancer, Vasculitis, Buerger’s) </li></ul><ul><li>Mondor’s Disease </li></ul><ul><li>Unusual forms </li></ul><ul><ul><li>palmar digital veins </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  30. 30. Superficial Thrombophlebitis <ul><li>Diagnosis </li></ul><ul><ul><li>Painful cord like structure </li></ul></ul><ul><ul><li>Redness along the vein </li></ul></ul><ul><ul><li>Tenderness </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><li>Investigations </li></ul><ul><ul><li>Duplex scan </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  31. 31. Superficial Thrombophlebitis <ul><li>Management </li></ul><ul><ul><li>Underlying disorder </li></ul></ul><ul><ul><li>Remove offending agents (e.g.IV cannula) </li></ul></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><ul><li>NSAIDs </li></ul></ul><ul><ul><li>Anticoagulation </li></ul></ul><ul><ul><li>Excision of the suppurating vein </li></ul></ul><ul><ul><li>Application of massive warm wet compresses </li></ul></ul><ul><ul><li>Elevation of the extremity </li></ul></ul><ul><ul><li>Immobilization </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  32. 32. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>LEADING CAUSE OF DEATH </li></ul><ul><li>1-3 /1000 PREGNANCIES </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  33. 33. <ul><li>Pathophysiology- </li></ul><ul><ul><li>5 times higher in pregnancy </li></ul></ul><ul><ul><ul><li> venous stasis of pregnancy </li></ul></ul></ul><ul><ul><ul><li>Physiological changes asso. with pregnancy </li></ul></ul></ul>VENOUS THROMBOEMBOLISM DURING PREGNANCY 10/21/10 DrU.Gupta,Dr.N.K.Gupta
  34. 34. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Pathophysiology- </li></ul><ul><ul><li>Independent risk factors </li></ul></ul><ul><ul><ul><li>Prolong Bed rest </li></ul></ul></ul><ul><ul><ul><li>Multiparity (>3) </li></ul></ul></ul><ul><ul><ul><li>Advanced Maternal Age (>35yrs) </li></ul></ul></ul><ul><ul><ul><li>Overweight </li></ul></ul></ul><ul><ul><ul><li>Personal or family history of VTE </li></ul></ul></ul><ul><ul><ul><li>Pre-eclampsia </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  35. 35. VENOUS THROMBOEMBOLISM DURING PREGNANCY 10/21/10 DrU.Gupta,Dr.N.K.Gupta <ul><li>Pathophysiology- </li></ul><ul><ul><li>Alteration in Coagulation/Fibrinolytic System </li></ul></ul><ul><ul><ul><li>Factor II, VII, X  (middle of Pregnancy) </li></ul></ul></ul><ul><ul><ul><li>Fibrin </li></ul></ul></ul><ul><ul><ul><li>Protein S </li></ul></ul></ul><ul><ul><ul><li>Protein C </li></ul></ul></ul><ul><ul><ul><li>Fibrinolytic System inhibited (mostly 3rd trimester) </li></ul></ul></ul>
  36. 36. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Diagnosis </li></ul><ul><ul><li>Calf veins or Ilio-femoral segment </li></ul></ul><ul><ul><li>Predilection for Left side </li></ul></ul><ul><ul><li>S/s </li></ul></ul><ul><ul><ul><li>Swelling </li></ul></ul></ul><ul><ul><ul><li>Tenderness </li></ul></ul></ul><ul><ul><ul><li>Skin Discolouration </li></ul></ul></ul><ul><ul><ul><li>Warm to touch </li></ul></ul></ul><ul><ul><ul><li>Unusual firmness /hardness in the leg </li></ul></ul></ul><ul><ul><ul><li>Calf discomfort on dorsiflexion </li></ul></ul></ul><ul><ul><ul><li>Prominent tender cord like subcut. vein </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  37. 37. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Diagnostic tests </li></ul><ul><ul><li>Venography </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  38. 38. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Diagnostic tests </li></ul><ul><ul><li>Duplex Ultrasonography </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  39. 39. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Diagnostic tests </li></ul><ul><ul><li>Spiral CT Venography </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta No filling of calf veins Opacification of collaterals
  40. 40. <ul><li>Diagnostic tests </li></ul><ul><ul><li>Nuclear Imaging </li></ul></ul><ul><ul><li>IPG </li></ul></ul><ul><ul><li>MRI </li></ul></ul><ul><ul><li>D-dimer </li></ul></ul>VENOUS THROMBOEMBOLISM DURING PREGNANCY 10/21/10 DrU.Gupta,Dr.N.K.Gupta
  41. 41. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Radiation Exposure </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta Procedure Fetal radiation dose (mrads) CXR <1 Limited Venography <50 Perfusion Lung Scan 6-12 Ventilation Lung Scan 1-19 CT Chest 30 Pulm Angio (femoral) 221-374 Pulm Angio (brachial) <50
  42. 42. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Blood Tests </li></ul><ul><ul><li>Factor V Leiden </li></ul></ul><ul><ul><li>Protein C </li></ul></ul><ul><ul><li>Protein S </li></ul></ul><ul><ul><li>ACA and LA antibodies </li></ul></ul><ul><ul><li>Activated Protein C resistance (APC-R) </li></ul></ul><ul><ul><li>AntiThrombin III </li></ul></ul><ul><ul><li>Homocystein </li></ul></ul><ul><ul><li>Prothrombin gene mutation </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  43. 43. Pulmonary Embolism <ul><li>Major nonobstetric cause of maternal mortality </li></ul><ul><li>Cause of Death </li></ul><ul><ul><li>2 / 100,000 maternities </li></ul></ul><ul><li>Maximum – Peripartum </li></ul><ul><li>More after operative intervention </li></ul><ul><li>Subtle presentation </li></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  44. 44. Pulmonary Embolism <ul><li>Diagnostic tests </li></ul><ul><ul><li>Pulmonary Angiography </li></ul></ul><ul><ul><li>Spiral CT Scan </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  45. 45. Pulmonary Embolism 10/21/10 DrU.Gupta,Dr.N.K.Gupta <ul><li>Diagnostic tests </li></ul><ul><ul><li>Nuclear Imaging (Ventilation-Perfusion Scan) </li></ul></ul>
  46. 46. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Management </li></ul><ul><ul><li>Medical/Pharmacological </li></ul></ul><ul><ul><ul><li>Anticoagulation </li></ul></ul></ul><ul><ul><ul><li>Anti-platelet agents </li></ul></ul></ul><ul><ul><li>Surgical </li></ul></ul><ul><ul><ul><li>Venous Thrombectomy </li></ul></ul></ul><ul><ul><ul><li>Thrombolysis </li></ul></ul></ul><ul><ul><li>Endovascular </li></ul></ul><ul><ul><ul><li>IVC Filter placement </li></ul></ul></ul><ul><ul><li>Others </li></ul></ul><ul><ul><ul><li>Hydration </li></ul></ul></ul><ul><ul><ul><li>Early Mobilization </li></ul></ul></ul><ul><ul><ul><li>Graduated Compression Stockings </li></ul></ul></ul><ul><ul><ul><li>Pneumatic compression devices </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  47. 47. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Medical/Pharmacological </li></ul><ul><ul><li>Unfractionated Heparin/LMWH </li></ul></ul><ul><ul><li>Oral Anticoagulation </li></ul></ul><ul><ul><li>Antiplatelet agents </li></ul></ul><ul><ul><li>New Molecules </li></ul></ul><ul><ul><ul><li>Direct Thrombin Inhibitors </li></ul></ul></ul><ul><ul><ul><ul><li>Lepirudin, D esirudin, Argatroban, Ximelagatran </li></ul></ul></ul></ul><ul><ul><ul><li>Statins </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  48. 48. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Surgical </li></ul><ul><ul><li>Venous Thrombectomy – </li></ul></ul><ul><ul><ul><li>Ilio-femoral DVT </li></ul></ul></ul><ul><ul><li>Pulmonary Embolectomy </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  49. 49. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Surgical </li></ul><ul><ul><li>Thrombolysis </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  50. 50. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Endovascular </li></ul><ul><ul><li>IVC Filter placement </li></ul></ul><ul><ul><ul><li>Temporary </li></ul></ul></ul><ul><ul><ul><li>Permanent </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  51. 51. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><ul><li>Others </li></ul></ul><ul><ul><ul><li>Hydration </li></ul></ul></ul><ul><ul><ul><li>Early Mobilization </li></ul></ul></ul><ul><ul><ul><li>Graduated Compression Stockings </li></ul></ul></ul><ul><ul><ul><li>Pneumatic compression devices </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  52. 52. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>PROPHYLAXIS </li></ul><ul><ul><li>Risk Assessment </li></ul></ul><ul><ul><li>Present status </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  53. 53. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>PROPHYLAXIS </li></ul><ul><ul><li>Past h/o DVT in pregnancy, no other thrombotic risk factors </li></ul></ul><ul><ul><ul><li>Antenatal thrombo-prophylaxis </li></ul></ul></ul><ul><ul><ul><ul><li>S/c Heparin+/- GCS </li></ul></ul></ul></ul><ul><ul><ul><li>S/c Heparin/LMWH  Warfarin (INR 2-2.5) </li></ul></ul></ul><ul><ul><ul><li>GCS 6-12 wks (if anticoagulation contraindicated) </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta BMJ 1992
  54. 54. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>PROPHYLAXIS </li></ul><ul><ul><li>Known inherited/acquired thrombophilia </li></ul></ul><ul><ul><ul><li>Postpartum +/- Antepartum thromboprophylaxis </li></ul></ul></ul><ul><ul><ul><li>Individual consideration </li></ul></ul></ul><ul><ul><li>No past h/o DVT/Thrombophilia, but with other risk factors in combination </li></ul></ul><ul><ul><ul><li>Postpartum thromboprophylaxis </li></ul></ul></ul><ul><ul><ul><ul><li>S/c Heparin </li></ul></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta BMJ 1992
  55. 55. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>PROPHYLAXIS IN CAESERIAN SECTION </li></ul><ul><ul><li>Low Risk </li></ul></ul><ul><ul><ul><li>Elective C-section – uncomplicated pregnancy </li></ul></ul></ul><ul><ul><ul><li>No risk factors </li></ul></ul></ul><ul><ul><li>Moderate Risk </li></ul></ul><ul><ul><ul><li>Age, Weight, Parity, Varicose Veins, Immobility, Sepsis, Pre-eclampsia, Emergency C-section, Major Current Illness </li></ul></ul></ul><ul><ul><li>High Risk </li></ul></ul><ul><ul><ul><li>3 or more mod risk factors, Extended major pelvic/abd surgery e.g.Caeserian hysterectomy </li></ul></ul></ul><ul><ul><ul><li>Personal/family H/o DVT/PE/thrombophilia, Paraparesis </li></ul></ul></ul><ul><ul><ul><li>Pt with APLAS </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  56. 56. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>PROPHYLAXIS IN CAESERIAN SECTION </li></ul><ul><ul><li>Low Risk </li></ul></ul><ul><ul><ul><li>Early Mobilization </li></ul></ul></ul><ul><ul><ul><li>Hydration </li></ul></ul></ul><ul><ul><li>Moderate Risk </li></ul></ul><ul><ul><ul><li>One of variety of prophylactic measures </li></ul></ul></ul><ul><ul><ul><ul><li>Subcutaneous Heparin </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mechanical devices </li></ul></ul></ul></ul><ul><ul><li>High Risk </li></ul></ul><ul><ul><ul><li>Heparin Prophylaxis +/- Leg Stockings </li></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta Report of the RCOG Working Party on prophylaxis (and management) against Thromboembolism in Gynaecology and Obstetrics. London: Royal College of Obstetricians and Gynaecologists, 1995
  57. 57. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Key Points </li></ul><ul><ul><li>Even 1 st trimester carries risk of thrombosis (2/3 rd antepartum deaths) </li></ul></ul><ul><ul><li>Additional risk factors/ family history / known thrombophilia may indicate thromboprophylaxis </li></ul></ul><ul><ul><li>Close attention should be paid to any pregnant woman c/o leg/chest symptoms for e/o DVT/PE </li></ul></ul><ul><ul><li>All women undergoing C-section should be assessed for prophylaxis against VTE </li></ul></ul><ul><ul><li>Midwives, GPs & other medical staff should take particular attention of women with chest or leg symptoms after vaginal delivery </li></ul></ul><ul><ul><li>Women with risk factors for DVT should be carefully screened and considered for thromboprophylaxis </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  58. 58. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><li>Prevention: </li></ul><ul><ul><li>Weight control </li></ul></ul><ul><ul><li>Avoid prolong immobility </li></ul></ul><ul><ul><li>Leg elevation </li></ul></ul><ul><ul><li>Avoid OCPs containing high dose of Estrogens </li></ul></ul><ul><ul><li>Adequate hydration </li></ul></ul><ul><ul><li>Avoid Smoking/Alcohol intake </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  59. 59. VENOUS THROMBOEMBOLISM DURING PREGNANCY <ul><ul><li>VTE is an uncommon but very serious complication of pregnancy </li></ul></ul><ul><ul><li>Pregnant women are at increased risk for VTE, and may present in subtle ways </li></ul></ul><ul><ul><li>Suspected VTE in pregnancy should be investigated thoroughly </li></ul></ul><ul><ul><li>Risk of VTE can be reduced in appropriate patients with judicious use of anticoagulants </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta Take Home Message
  60. 60. Vascular Control in Gynaecological Surgery <ul><li>MODALITIES AVAILABLE </li></ul><ul><ul><li>Open Vascular </li></ul></ul><ul><ul><li>Endovascular </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  61. 61. Vascular Control in Gynaecological Surgery <ul><li>OPEN VASCULAR </li></ul><ul><ul><li>Uterine artery Ligation </li></ul></ul><ul><ul><li>Ovarian Artery ligation </li></ul></ul><ul><ul><li>Internal Iliac Artery Ligation </li></ul></ul><ul><ul><li>Common Iliac artery control </li></ul></ul><ul><ul><li>Control over Aorta </li></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  62. 62. Vascular Control in Gynaecological Surgery <ul><li>ENDOVASCULAR </li></ul><ul><ul><li>Balloon Occlusion </li></ul></ul><ul><ul><li>Stent Graft </li></ul></ul><ul><ul><li>Embolisation – </li></ul></ul><ul><ul><ul><ul><ul><li>Coil </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Foam particles etc. </li></ul></ul></ul></ul></ul>10/21/10 DrU.Gupta,Dr.N.K.Gupta
  63. 63. 10/21/10 DrU.Gupta,Dr.N.K.Gupta Thank you

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