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V enous complications in pregnancy and puerperium

V enous complications in pregnancy and puerperium. ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU MD, PhD. Venous Disorders. Varicose Veins. Superficial Venous Thrombosis ( Thrombophlebitis ). Deep Vein Thrombosis (DVT) P ulmonary Thrombo e mbolism (PTE). Varicose Veins. Pregnancy

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V enous complications in pregnancy and puerperium

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  1. Venous complications in pregnancy and puerperium ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU MD, PhD

  2. Venous Disorders Varicose Veins • Superficial Venous Thrombosis (Thrombophlebitis) • Deep Vein Thrombosis (DVT) • Pulmonary Thromboembolism (PTE)

  3. Varicose Veins Pregnancy Increased blood volume Pressure on veins Relaxation effect of hormones

  4. Varicose Veins Management Non Operative Self resolving (within six weeks) After 6 weeks if problematic/ unacceptable Graduated Compression Stockings Surgery

  5. Varicose Veins Before Treatment After Treatment

  6. Varicose Veins

  7. Superficial Venous Thrombosis (Thrombophlebitis) • Benign /Self limiting Disease • 1% of patients; always in existing varicous veins • Can progress to deep vein thrombosis (11%) • Associated with abnormalities in blood coagulation

  8. Superficial Thrombophlebitis Etiologic factors Traumatic Varicose Veins Pregnancy Infection (e.g. Staph., Pseud., Klebs., Anaerobes)

  9. Superficial Thrombophlebitis Diagnosis Painful cord like structure Redness along the vein Tenderness Fever Investigations Duplex ultrasonography (duplex scan)

  10. Superficial Thrombophlebitis Management Underlying disorder Remove offending agents (e.g. IV cannula) Antibiotics NSAIDs Excision of the suppurating vein Elevation of the extremity Anticoagulants ?

  11. DEEP VENOUS THROMBOEMBOLISM DURING PREGNANCY LEADING CAUSE OF DEATH 2 /1000 PREGNANCIES 5 times higher in pregnancy  venous stasis of pregnancy Physiological changes associated with pregnancy

  12. DEEP VENOUS THROMBOEMBOLISM DURING PREGNANCY - Pathophysiology Independent risk factors Prolonged bed rest Multiparity (>3) Advanced maternalage (>35yrs) Overweight Personal or family history of VTE Pre-eclampsia Alteration in Coagulation / Fibrinolytic System Factor II, VII, X  (middle of pregnancy) Fibrin Protein S Protein C Fibrinolytic System inhibited (mostly 3rd trimester)

  13. DEEP VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnosis Calf veins or ilio-femoral segment Predilection for left side Signs and symptoms swelling tenderness skin discoloration warm to touch unusual firmness /hardness in the leg calf discomfort on dorsiflexion (Homans’ sign) prominent tender cord like subcutaneous vein

  14. VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnostic tests Venography (Phlebography)

  15. VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnostic tests 2. Duplex ultrasonography

  16. Duplex US: combines Doppler flow information & conventional imaging information. Shows how blood is flowing through vessels & measures the speed of blood flow  Estimate the diameter of a blood vessel as well as the amount of obstruction

  17. VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnostic tests 3. Spiral CT Venography No filling of calf veins Opacification of collaterals

  18. Diagnostic tests 4. Impedance plethysmography (IPG) 5. MRI 6. D-dimertest → fibrin degradation product (or FDP) = a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis → contains two crosslinked D fragments of the fibrinogen protein D-dimer concentration → to help diagnose thrombosisanddisseminated intravascular coagulation. VENOUS THROMBOEMBOLISM DURING PREGNANCY

  19. Pulmonary Embolism Major nonobstetric cause of maternal mortality Cause of Death 2 / 100,000 maternities Maximum – Peripartum More after operative intervention Subtle presentation

  20. DVT is suspected by: Acute leg pain, Swelling, Redness Tenderness. PTE is suspected by Acute chest pain Shortness of breath. Haemoptysis Hypotension Cyanosis occur in massive PTE. Thromboembolic disease in pregnancy and puerperium

  21. Pulmonary Embolism Diagnostic tests Pulmonary Angiography Spiral CT Scan

  22. Pulmonary Embolism • Diagnostic tests • 3.Nuclear Imaging (Ventilation-Perfusion Scan)

  23. VENOUS THROMBOEMBOLISM DURING PREGNANCY PROPHYLAXIS Risk Assessment Present status

  24. VENOUS THROMBOEMBOLISM DURING PREGNANCY Management Medical/Pharmacological Anticoagulation Anti-platelet agents Surgical Venous Thrombectomy (Ilio-femoral DVT), Pulmonary Embolectomy Thrombolysis Endovascular Inferior vena cava filter placement (IVC Filter placement) Others Hydration Early Mobilization Graduated Compression Stockings Pneumatic compression devices

  25. VENOUS THROMBOEMBOLISM DURING PREGNANCY Medical/Pharmacological Unfractionated Heparin/LMWH Oral Anticoagulation Antiplatelet agents New Molecules Direct Thrombin Inhibitors (Lepirudin, Desirudin,Argatroban,Ximelagatran) Surgical – Thrombolysis

  26. VENOUS THROMBOEMBOLISM DURING PREGNANCY PROPHYLAXIS IN CESARIAN SECTION Low Risk Early Mobilization Hydration Moderate Risk One of variety of prophylactic measures Subcutaneous Heparin Mechanical devices High Risk Heparin Prophylaxis +/- Leg Stockings

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