Venous Thrombo-embolism In Pregnancy

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Venous Thrombo-embolism In Pregnancy

• By
• Prof.Osman Donia

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INTRODUCTION AND INCIDENCE

• Pregnancy is a known hyper-coagulable state, with
  a five-fold risk of venous thromboembolism over
  the non-pregnant condition
• 0.5 and 3 of every 1000 pregnancies are
  complicated by symptomatic deep venous thrombosis
  (DVT).
• 25 may develop pulmonary embolism (PE), of which
  up to 15 are fatal.

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AETIOLOGY

• Increase in the levels of coagulation factors
  VII, VIII, IX, and X.
• Increased fibrinogen levels.
• Increased platelet activation.
• Decreased protein-S and Antithrombin III
  concentrations.
• Venous stasis in the lower limbs due to pressure
  by the gravid uterus

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THROMBOPHILIA

• Acquired thrombophilia
• This is mostly associated with the
  antiphospholipid syndrome (APS). APS is the
  combination of lupus anticoagulant (LAC) with or
  without, anticardiolipin antibodies (ACA), with a
  history of recurrent miscarriage and or
  thrombosis.
• Inherited thrombophilias
• Protein-C, protein-S, and Antithrombin III
  deficiency.

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Risk factors for DVT / PE during pregnancy

• Maternal age gt 35 years.
• Pre-pregnancy weight gt 80 kg.
• Pre-existing Thrombophilia.
• Previous DVT.
• Severe varicose veins (V.Vs).
• Prolonged bed rest.
• Multi foetal pregnancies.
• Severe pre-eclampsia.
• Caesarean section delivery.
• Sepsis, especially pelvic.

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DEEP VEIN THROMBOSIS (DVT)

• CLINICAL DIAGNOSIS
• DVT usually presents clinically with pain in the
  calf muscles associated with varying degrees of
  redness, hotness, or swelling, especially
  unilateral oedema.

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DEEP VEIN THROMBOSIS (DVT)

• INVESTIGATIONS
• Colour Doppler Ultrasound It allows assessment
  of the deep veins between the knee and the iliac
  veins and also allows for the dynamic assessment
  of femoral and iliac veins. It is currently the
  preferred first-line method for investigating a
  suspected case of DVT during pregnancy being an
  accurate, non-invasive procedure.
• Venography This allows excellent visualization
  of veins both below and above the knee. However
  it is an invasive procedure, requiring the
  injection of a contrast medium and the use of
  X-ray. This method is not preferable during
  pregnancy.

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DEEP VEIN THROMBOSIS (DVT)

• MANAGEMENT
• Anticoagulant therapy
• 1. Heparin and LMW heparin derivatives The
  preferred initial line of treatment, as they do
  not cross the placenta, are not teratogenic, and
  their effect can be stopped within hours by
  withholding further doses. Heparin prolongs the
  activated partial thromboplastin time (APTT),
  while calcium heparins affect factor X activity.
• These drugs are regarded relatively safe however
  prolonged therapy for more than 6 months may be
  associated with idiosyncratic reaction,
  thrombocytopenia and higher risk of osteoporosis.
  

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DEEP VEIN THROMBOSIS (DVT)

• 2. Oral anticoagulants Warfarin prolongs the
  prothrombin time (PT). The drug crosses the
  placenta and can cause limb and facial defects in
  the first trimester, and fetal intracerebral
  haemorrhage in the third trimesters. Recently
  some centres use it in the 2nd trimester.

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DEEP VEIN THROMBOSIS (DVT)

• Anticoagulant prophylaxis
• Women with a history of DVT occurring during or
  following a previous pregnancy are given
  prophylactic LMW heparin derivatives during
  subsequent pregnancies at least in the last
  trimester that extends at least to the end of the
  puerperium.
• Women with a history of DVT occurring in the
  non-pregnant state should be screened for
  thrombophilias, and offered anticoagulant
  prophylaxis at least starting from the second
  trimester.
• Some women will require full anticoagulation
  throughout pregnancy as those with artificial
  heart valves and cases of APS with recurrent
  DVTs, or cases with a definite history of
  previous pulmonary embolism.

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PULMONARY EMBOLISM (PE)

• PE is one of the fatal consequences of
  undiagnosed or improperly managed cases of DVT.
• Clinical presentation
• The most common presentation is mild
  breathlessness with inspiratory chest pain.
• Associated tachycardia, hypoxia, pleural rubs and
  sometimes ECG changes will settle the clinical
  diagnosis.
• A history of recent DVT event or the presence of
  clinical evidence of pelvic or lower limb DVT is
  an important clue for diagnosis and immediate
  management.

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PULMONARY EMBOLISM (PE)

• Management
• Once suspected, early intervention by full I.V.
  anticoagulant therapy may be life saving. Full
  I.V. heparinization is immediately started, with
  supportive oxygen therapy.
• Definitive diagnosis is then required via
  ventilation / perfusion scan or pulmonary
  angiography. A positive diagnosis of PE will have
  a major impact regarding long-term
  anticoagulation.

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THANK YOU