Highlights the predisposition of the pregnant patient to embolic disorders and about the management guidelines of such disorders.

1. Maternal Collapse due to Embolism Dr Unnikrishnan P P.G.Student Medical College, Trivandrum

2. IMPORTANT CAUSES THROMBOEMBOLISM AMNIOTIC FLUID EMBOLISM VENOUS AIR EMBOLISM Anaestesiologist is often involved in the resuscitation of patients with embolic disorders

4. VENOUS THROMBOEMBOLISM Deep Vein Thrombosis [DVT] & Pulmonary Thrombo Embolism [PTE] are the important manifestations DVT is the most common etiology for Pulmonary Thrombo Embolism 15-24% of women with untreated DVT experience a pulmonary embolus PTE accounts for 15% of direct maternal mortality CHESTNT’S OBSTETRIC ANESTHESIA, 4/e[2009],p:837,838

5. AETIOLOGY Changes in coagulation SHNIDER AND LEVINSONS ANESTHESIA FOR OBSTETRICS,4/e

6. AETIOLOGY Venous stasis Vascular damage: caesarean > vaginal Obstetric conditions: PIH Multiplepregnancy

7. RISK FACTORS Increasing age Prolonged immobilization Obesity Thrombophilia Previous thromboembolism Cesarean delivery ASRA GUIDELINES [THIRD EDITION];RegAnesth Pain Med 2010

8. PATHOPHYSIOLOGY

9. PATHOPHYSIOLOGY

10. CLINICAL FEATURES: SYMPTOMS

11. CLINICAL FEATURES: SIGNS

12. The Wells score clinically suspected DVT - 3.0 points alternative diagnosis is less likely than PE - 3.0 points Tachycardia - 1.5 points immobilization/surgery in previous four weeks - 1.5 points history of DVT or PE - 1.5 points hemoptysis - 1.0 points malignancy (treatment for within 6 months, palliative) - 1.0 points Traditional interpretation Score >6.0 - High Score 2.0 to 6.0 - Moderate Score <2.0 - Low Alternate interpretation Score > 4 - PE likely. Consider diagnostic imaging. Score 4 or less - PE unlikely. Consider D-dimer to rule out PE.

13. DIAGNOSTIC EVALUATION ECG

14. DIAGNOSTIC EVALUATION CHEST X-RAY

15. HAMPTON’S HUMP

16. DIAGNOSTIC EVALUATION INVASIVE HEMODYNAMIC MONITORING ARTERIAL BLOOD GAS ANALYSIS ELISA FOR D-DIMER

17. DIAGNOSTIC EVALUATION VENTILATION PERFUSION SCAN

18. DIAGNOSTIC EVALUATION SPIRAL CT

19. DIAGNOSTIC EVALUATION PULMONARY ANGIOGRAPHY INVASIVE INTRALUMINAL FILLING DEFECT MAGNETIC RESONANCE VENOGRAPHY

20. DIAGNOSTIC EVALUATION ECHOCARDIOGRAPHY COMPRESSION USG

21. PROPHYLAXIS Decreases the risk 10 fold Begun when the high risk period begins and continued for 5-10 days UFH : 5000 U subcutaneously Q12H Enoxaparin : 40 mg subcutaneously Q24H Ensure availability of FFP at the time of delivery

22. THERAPY - DVT UNFRACTIONATED HEPARIN [UFH]# #Sipes SL,Venous thromboembolic disease in pregnancy ;Semin Perinatol 1990 #American College of Obst & Gyn Comm. on practice;ACOG Practice bulletin no:19,AUG2000

23. THERAPY - DVT LOW MOLECULAR WEIGHT HEPARIN [LMWH] Enoxaparin 40 MG OD-BD [1 MG = 100 U] PROPHYLAXIS 30-80 MG BD THERAPEUTIC ANTICOAGULATION Dalteparin 2500-5000 U OD-BD THROMBOPROPHYLAXIS 100 U/KG BD THERAPEUTIC ANTICOAGULATION #Sipes SL,Venous thromboembolic disease in pregnancy ;Semin Perinatol 1990 #American College of Obst & Gyn Comm. on practice;ACOG Practice bulletin no:19,AUG2000

24. PULMONARY EMBOLISM-TREATMENT: GOALS

25. PULMONARY EMBOLISM-TREATMENT # #American College of Obst & Gyn Comm. on practice;ACOG Practice bulletin no:19,AUG2000 #Weiner CP et al; management of thromboembolic disease during pregnancy; Clinical ObstetGynecol 1985

26. CONTRA INDICATIONS- ANTICOAGULATION

27. INFERIOR VENACAVAL INTERRUPTION Transvenous implantation of an IVC filter

28. THROMBOLYSIS

29. THROMBOLYSIS Monitoring of coagulation: Thrombin time [Most sensitive] aPTT FDP Complications: Maternal hemorrhage, Placental abruption

30. THROMBOLYSIS STREPTOKINASE UROKINASE RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR [ rt- PA ]

31. SURGICAL EMBOLECTOMY

32. ANAESTHETIC IMPLICATIONS- ANTICOAGULATED PATIENT

34. AMNIOTIC FLUID EMBOLISM INCIDENCE 1 IN 8000- 1 IN 30,000 25-80% MATERNAL MORTALITY 50% FOETAL DEATH

35. PATHOPHYSIOLOGY HOW DOES IT STARTS?

36. BIPHASIC RESPONSE FIRST PHASE[30 MIN] SECOND PHASE

37. “ANAPHYLACTOID SYNDROME OF PREGNANCY”

38. CLINICAL FEATURES More details: AFE Registry Criteria by Clark et al 1983-1995

39. DIFFERENTIAL DIAGNOSIS

40. DIAGNOSIS

41. DIAGNOSIS

42. MANAGEMENT

43. MANAGEMENT

44. MANAGEMENT

46. VENOUS AIR EMBOLISM Malinow et al published the first study of VAE during cesarean delivery in 1987¹ Subclinical VAE occurred in 97% of patients receiving GA for cesarean delivery² VAE occurred in approx 67% of patients receiving neuraxial anesthesia³ 1.Malinow AM et al,Anesthesiology 1987 2.Lew TWK et al, VAE during CS,Anesth Analg 1993 3.Handler JS,VAE during CS RegAnesth 1990

47. PATHOPHYSIOLOGY Pressure gradient as small as -5 cm of H₂O

48. PATHOPHYSIOLOGY RISK FACTORS EXTERIORISATION OF UTERUS

49. PATHOPHYSIOLOGY

50. PATHOPHYSIOLOGY Paradoxical Air Embolism may occur in case of intracardiac defects

51. CLINICAL FEATURES Morbidity and mortality depends on CLINICAL FEATURES

52. MONITORING / DIAGNOSIS Trans esophageal echo Doppler Ultrasound ETCO₂ ETN₂ PULMONARY ARTERY PRESSURE CVP ECG

53. MANAGEMENT PREVENT FURTHER AIR ENTRY

54. MANAGEMENT TREAT INTRAVASCULAR AIR

55. PREVENTION 5-10⁰ HEAD UP TILT WHEN UTERUS IS EXTERIORIZED PRECORDIAL DOPPLER MONITORING IN HIGH RISK CASES ADEQUATE HYDRATION TO RAISE CVP AND LA PRESSURE

57. Shnider and Levinsons anesthesia for obstetrics,4/e

58. Why Mothers Die 2004-2005 Report; the Confidential Review of Maternal Deaths in Kerala

59. ASA Abstracts, Cardiac Arrest during Labor: Amniotic Fluid Embolism with Thrombus in Patent Foramen Ovale. AparnaDalal, M.D., Mark Shulman, M.D. Anesthesiology, Caritas St. Elizabeth's Medical Center, Boston, MA, Anesthesiology 2008; 109 A1337

60. Martin SR, Foley MR. Intensive care in obstetrics: an evidence-based review. Am J Obstet Gynecol. 2006 Sep;195(3):673-89.

61. Porat S, Leibowitz D, Milwidsky A, Valsky DV, Yagel S, AntebyEY.Transient Intracardiac thrombi in Amniotic fluid embolism.BCOG. 2004 May;111(5):506-10.