Thromoembolic Disorders

Thrombo-embolic
disorders in
pregnancy
Soha AlBeitawi
Infertility & Reproductive Medicine Specialist

Assistant prof.
EBOG, JBOG, MD
 6-10X ↑ risk of VTE during pregnancy
 Physiological goal is to prepare for the hemostatic challenge of delivery. A
‘side effect’ of this change is an ↑ risk of thrombosis
 Risk of thrombosis from 1st trimester until 4-6 weeks PP, highest risk PP
 Confidential Enquiry into maternal deaths:

 2/3 of antenatal fatal PTE were in the 1st trimester
 > 50% of postnatal VTE deaths were after vaginal delivery
Physiological changes in coagulation system during
pregnancy:
 hormones + mechanical obstruction+ ↓ mobility  ↓ venous flow

 ↑ factors VII, VIII, X, VWF,, fibrinogen
+  hypercoagulable state
 ↓ free protein S
 Return to NL  ????
> 8 weeks PP
Risk Factors:
Pre-existing Obstetric Transient
Age > 35 MG Hyperemesis
Obesity (BMI> 30) ART OHSS
Parity > 3 PET Dehydration
Previous VTE CS, instrumental Long Haul travel
Thrombophilia PPH > 1 L Surgical procedure
Gross V.V Prolonged labor Infection: PN
Paraplegia Immobility
SCD
Medical: IBD, NoS
 Risk assessment at
Booking Whenever
Intrapartum postpartum
needed
Clinical features:
 Lt sided > Rt (9:1)
 ileofemoral > popliteofemoral
 Swelling
 Redness of calf, unreliable in pregnancy
 Pain
 Tenderness
 Leg edema (may often be asymmetrical) is common in pregnancy without
DVT
 SOB, pleuritic chest pain (particularly if sudden onset)  should be
investigated
 Cough
 Hemoptysis
 Collapse if large PE
 Tachypnea, tahycardia
 ↑ JVP
 Loud S2
 Fever
Diagnosis of acute VTE Doppler:
1. Direct imaging of clot
2. Lack of compressebilty of the vein
 Clinical Diagnosis is unreliable 3. Absence of distal distension of the vein
during valsalva manoeuvere
If suspected  investigate promptly
DVT:
 1st investigation :  Compression US (high S&S for proximal VTE)
 If high clinical suspicion + negative scan  ????
Continue Tx & repeat scan in 1 week

If imaging reports: low risk but high
PE: clinical suspicion  ????
 ECG
 CXR To exclude other respiratory causes
 ABG
 LL US  if +  Tx
If all are NL & persistent clinical suspicion of PE 

 V/Q scan or
 CTPA
CTPA V/Q scan
Preferred when: chronic lung
disease or abnormal CXR
1/1,000,000 Higher risk of childhood CA up to
age of 15 year (1/280,000)
Higher lifetime risk of women
breast CA 14% if pregnant or
breast feeding
D- Dimer
 (+) D dimer in pregnancy cannot be used as diagnostic tool ,
why ???
 ↑ in:
1. NL pregnancy Low level of D Dimer in pregnancy
2. PET as in non-pregnant suggest that
3. Threatened miscarriage there is NO VTE
4. APH
Ante-natal
thromboprophylaxis
(RCOG/ 2015)
Post- natal
thromboprophylaxis
(RCOG/ 2015)
Suggested thromboprophylactic doses for antenatal and postnatal LMWH
Weight Enoxaparin Dalteparin Tinzaparin (75 u/kg/day)

 < 50 kg 20 mg daily 2500 units daily 3500 units daily
 50–90 kg 40 mg daily 5000 units daily 4500 units daily
 91–130 kg 60 mg daily* 7500 units daily 7000 units daily*
 131–170 kg 80 mg daily* 10 000 units daily 9000 units daily*
 > 170 kg 0.6 mg/kg/day* 75 u/kg/day 75 u/kg/day*
 High prophylactic dose for women weighing 50–90 kg

40 mg 12 hourly 5000 units 12 hourly 4500 units 12 hourly
*may be given in 2 divided doses

 Screening for inherited & acquired thrombophilia is recommended in
women with:
Personal Hx
Or of VTE within or outside pregnancy- unprovoked
Strong FHx
Low dose aspirin 75 mg ??
 of benefit in DVT prevention in surgical & medical patients

 NO RCT in pregnancy
 Use in women with ↑ risk but not high enough to justify LMWH, ??
controversial
Graduated Elastic Stocking (GES)
 ↓ venous stasis in LL by:
1. ↓ the diameter of the common femoral vein &
2. ↑ rate of blood flow
 There is evidence that below knee stockings are as effective as full length,
their use may increase compliance
Complications:
1. PE
2. Phlebitic syndrome affect 70% of DVT
3. Deep venous insufficiency patients within 5 years
Leg swelling, V.V, atrophic changes, skin ulceration
Treatment of VTE:
 LMWH Tx of choice (1mg/kg BID enoxaparin)
 Don’t cross placenta
 Routine measurement of anti-Xa activity is NO longer recommended, except
in: extreme body weight (<50, >90) or with complicating factor: renal impairment, recurrent VTE
 Following delivery : convert to warfarin or remain on LMWH

 NOTE: avoid warfarin until at least 5 days or more in patient at risk of PPH
Additional therapies:
 Leg elevation
 GES
 Mobilization
Continue therapeutic dose
 The remainder of pregnancy
 At least 6 weeks postnatal
 Until at least 3 month of total duration

Warfarin
 Crosses placenta
 Teratogenic in 1st trimester
 Warfarin embryopathy (if taken b/n 6-12 weeks)
 ↑ risk of miscarriage & stillbirth
 Risk of fetal intracerebral Hmg ( if used in 3rd trimester)
 Used for women with metal prosthetic heart valve.
Fondaparinux
 Selective factor Xa inhibitor
 Not licensed for use in pregnancy
 Considered if : heparin allergy or heparin induced TCP
Before anti-coagulant
 CBC
 Coagulation screen
 KFT
 LFT
UFH
 PLT count every 2-3 days from D4 to 14 or until heparin is stopped
 Calcium + vitamin D supplement
for those who require long term therapy
Delivery
 Stop LMWH once in labor
 Discontinue LMWH maintenance therapy 24 hours before planned

delivery
 NO regional anesthesia at least 24 hours after the last dose of therapeutic
LMWH
 NO LMWH 4 hours after use if spinal anesthesia or after epidural removal
 NO removal of epidural catheter within 12 hours of most recent injection

 If therapeutic doses LMWH:
1. Wound drains (abdominal & rectus sheath)

2. Interrupted skin closure

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Thrombo-embolic

Infertility & Reproductive Medicine Specialist

 Confidential Enquiry into maternal deaths:

 hormones + mechanical obstruction+ ↓ mobility  ↓ venous flow

Continue Tx & repeat scan in 1 week

If all are NL & persistent clinical suspicion of PE 

Weight Enoxaparin Dalteparin Tinzaparin (75 u/kg/day)

 High prophylactic dose for women weighing 50–90 kg

*may be given in 2 divided doses

 of benefit in DVT prevention in surgical & medical patients

 Following delivery : convert to warfarin or remain on LMWH

 At least 6 weeks postnatal

 Until at least 3 month of total duration

 Discontinue LMWH maintenance therapy 24 hours before planned

 NO LMWH 4 hours after use if spinal anesthesia or after epidural removal

 NO removal of epidural catheter within 12 hours of most recent injection

1. Wound drains (abdominal & rectus sheath)

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