Thromboembolic Disease PDF

Dr Henan Aljebory 2019
Objectives
1-To know which pregnant woman at higher risk
of DVT
2-Tobe able to diagnose DVT &PE
3- To have an idea about drugs used in the
treatment of VTE and their effects on the fetus
4-How to prevent VTE
Thromboembolic Disease (TED)
TED has remained major cause of maternal death

mainly due to acute massive pulmonary embolism
(fatalTED) Non fatal TED is associated with significant
morbidity such as recurrent thromboembolism
(12%),secondary pulmonary hypertension ,post
thrombosis syndrome(chronic pain , leg
odema,varicouse vein and atrophic ulcer with skin
changes)In addition to risk of drugs to both mother and
fetus.
Pathophysiology
The major predisposing factors to (VTD) are the

activation of blood coagulation, venous stasis and endothelial
injury (Virchows triad).Pregnancy is a hyper coaguable state
because of an alteration in thrombosis and fibrinolytic
systems .There is increase in level of fibrinogen and factors
5,7,8,10,12 with reduction in antithrombin ,protein S and
reduction of platelet .Fibrinolysis is inhibited with decreased
plasminogen activator inhibitor.All these changes related to
raised level of oestrogen .The risk of VTE is raised with
pregnancy to around 1/1000 and is greater in the post partum
period due to the above changes, enlarging uterus diminishes
the venous return from the legs with increasing venous
stasis .These factors often combined with antenatal
immobilization ,prolonged
labour.,dehydration ,excessive blood loss and possible
C/S explain the risk of VTE being increased to 15fold
with pregnancy and puerperium and 10 folds after
C/S(1%)
.
Risk factors of DVT/PE

Pre-existing (maternal age >35, obesity.>80kg, smoking, sever
varicous veins, malignancy, thromophilia, and previous
thomboembolism).
Specific to pregnancy (multiple gestation, PET, grand
multiparty>4, C/S, pelvic surgery, sepsis and prolonged bed
rest).
Diagnosis of DVT
The majority of (DVT) occurring during pregnancy are in the

left leg with pain in the affected leg, swelling ,fever and
erythematic. Positive Homans sign is unreliable
Investigations
In clinically suspected VTE treatment with low molecular

weight heparin should be given until the diagnosis is excluded
by objective testing
• D-dimer VTE is associated with increased level of blood

D-dimer , now it is used for screening D-dimer increasing
with advancing gestation Apositive testing is of no
significance in VET in pregnancy but a low level suggest
there is no VET
2
• Venography The gold stander in VET diagnosis ,a
adequately visualizes calf & deep veins (below &above
knee).Disadvantage , invasive ,requiring the injection of
contrast and the use of X-ray & 5% risk of causing
thrombosis
• Duplex colure ultrasound: is now the first line method of

investigating suspected DVT widely available, allowing
non invasive assessment of deep vein between the knee
and iliac vein. calf veins are often poorly visualized,
however it is known that a thrombus confined purely to the
calf vein with no extension is very unlikely to give rise to
aPE , if the ultrasound is negative and there is a high level
of clinical suspicion, the patient should be anticoagulated
and the ultrasound repeated in a week.
Management
Before commencing anticoagulant treatment, blood should
be taken for aFBC, clotting, renal and liver function tests and
thrombophilia screen should be done although difficult to
interpreted in pregnancy.
Low molecular weight heparin (LMWH) by subcutaneous
Injection is the treatment of choice in both pregnant and non-
pregnant population.
Treatment of VTE occurring in relation to preg.should continues

for at least 6-12weeks after delivery. heparin does not cross the
placenta , is not teratogenic & does not cause anticoagulant
effect in the fetus . Complications of long term heparin are
osteopenia , thrombocytopenia and allergic skin reaction at site
of injection . The advantage of LMWH is longer plasma half
life allowing once-a-day dosing .If prophylactic doses are
employed ,reduce to a prophylactic level for the duration of lab
our .Protamin sulphate can be used to reverse the effect of
heparin if needed .Heparin prolonged the APTT which is used to
asses the activity of unfractionated heparin .Factor assay use to
asses (LMWH) .Heparin can be IV &SC .
3
Warferin given orally &prolong the PT .cross the placenta &can
cause limb & facial defect in the first trimester & fetal
intracerebral hemorrhage in second and third trimester. it is use
is largely confined to women at highest risk of VTE requiring
full anticoagulant. If it is used exposure should be limited to the
Second and third trimester.teratogenic effect of warferin
chondrodysplasia punctata (nasal hypoplasia, saddle nose,
frontal bossing, short limbs, mental retardation, cataract and
optic atrophy).In the first trimester.Warferinacts in the liver by
inhibiting the synthesis of vit.K dependent coagulant (+
2,7 9,10) &protein S. There is no agent available which can
rapidly reverse the effect of warferin and reversal by stopping
therapy and giving vit.k which might take up to 5days for
reversal.
Pulmonary Embolism
This can occur with or without preceding DVT, symptoms range
from minimal disturbance to sudden collapse & death,
depending on the size &site of emboli.
Signs&Symptoms
Dyspnoea, chest pain, cough, haemoptysis pyrexia, tachycardia,

cyanosis, raised jugular venous pressure, pleural rub &signs of
right ventricular failure.
Investigations
• Arterial blood gas analysis (hypoxia &hypercapenia )
• ECD inverted Twave&aterial arrhythmia are suggestive. In

pregnancy normal ECG to have RT axis deviation & T-
inversion & Q- wave in lead 2 .
• CXR abnormal in 70-80%
4
• Ventelation-Perfution scan (V/Q) is very sensitive but not
specific, if there's high or medium probability
anticoagulant should be started.
Spiral computed tomography (CT) is a diagnostic tool .The risk

of radiation to the fetus is minimum.
Thrombophilia
A predisposition to thrombosis secondary to persistent
hypercoaguabl state can be inherited or acquired
hypercoaguability include (protein C, protein S, antithrombin 3
deficiency and factor v Leiden (resistant to activated protein C)
Squired thrombophilia associated with Antiphospholipid
syndrome and other syndromes. All women with history of DVT
should be screened for thrombophilia ,if positive anticoagulant
should be given through out preg. , labor post partum up to 6
weeks.

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Dr Henan Aljebory 2019

Thromboembolic Disease (TED)

TED has remained major cause of maternal death

The major predisposing factors to (VTD) are the

Risk factors of DVT/PE

The majority of (DVT) occurring during pregnancy are in the

In clinically suspected VTE treatment with low molecular

• D-dimer VTE is associated with increased level of blood

• Duplex colure ultrasound: is now the first line method of

Treatment of VTE occurring in relation to preg.should continues

Dyspnoea, chest pain, cough, haemoptysis pyrexia, tachycardia,

• Arterial blood gas analysis (hypoxia &hypercapenia )

• ECD inverted Twave&aterial arrhythmia are suggestive. In

• CXR abnormal in 70-80%

Spiral computed tomography (CT) is a diagnostic tool .The risk

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