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Venous thromboembolism (VTE) in obstetrics

Venous thromboembolism (VTE) in obstetrics. Dr.Roaa H. Gadeer MD. Objectives. Incidence Pathogenesis Predisposing factors Clinical Presentations Prophylaxis Management choices Antepartum Postpartum. Incidence. Deep venous thrombosis antepartum: 0.5-3 per 1000 pregnancies

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Venous thromboembolism (VTE) in obstetrics

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  1. Venous thromboembolism (VTE) in obstetrics Dr.Roaa H. Gadeer MD

  2. Objectives • Incidence • Pathogenesis • Predisposing factors • Clinical Presentations • Prophylaxis • Management choices • Antepartum • Postpartum

  3. Incidence • Deep venous thrombosis • antepartum: 0.5-3 per 1000 pregnancies • postpartum: 0.5-18 per 1000 pregnancies • High recurrent risk: 7-13% • pulmonary embolus • untreated DVT: 24% have PE, 15% mortality • treated DVT: 5% have PE, 1-2% mortality

  4. Number of pregnancy deaths from 1982-1992 in Canada

  5. Pathogenesis of VTE in pregnancy Stasis Hypercoagulation Vessel wall abnormality

  6. Predisposing factors associated with pregnancy

  7. Major risk factors • previous hx of DVT/PE: 7-13% risk of recurrence • thrombophilias • trauma or infection • age > 35 • obesity • long hospitalization • dehydration/shock • immobility before the operation >4 days • chemotherapy

  8. Thrombophilias • Congenital: • resistance to activated protein C (factor V leiden) • hyperhomocysteinemia (controversial) • protein S, C deficiency: 2-4% risk, 18-20% risk during postpartum • antithrombin III deficiency: 25-55% risk • Prothrombin G20210A

  9. Thrombophilias • Acquired: • antiphospholipid syndrome (APLS): role to cause VTE is uncertain

  10. Prevalence in population

  11. Clinical Presentations • Superficial venous thrombosis • Typically associated with superficial varicosities and IV catheterization • DX and management similar to non-pregnant women

  12. Clinical Presentations 2. DVT • Presentations largely depends on the degree of occlusion • Lt>Rt (80%) • Early puerperium (why?)

  13. Clinical Presentations • Symptoms of DVT • calf pain, tenderness, swelling, cord, + Homan’s sign • discoloration • 50% thought to have DVT have negative U/S

  14. Clinical Presentations 3. PE • Leading cause of perinatal maternal loss in developed countries • Declining incidence

  15. Symptoms of PE and DVT • Symptoms of PE: • tachypnea 80% • dyspnea 81% • pleuritic pain 72% • apprehension 60% • cough 54% • tachycardia 43% • T > 37.5C 35%* in those with proven PE

  16. Investigations for PE: • CXR nondiagnostic, excludes other causes of hypoxemia • ABG’s A-a gradient, maybe normal in >20% • Doppler & US • Ventilation/perfusion Lung (V/Q) scan 0.2 rads to fetus • 95% correlation with venography • Spiral CT (non invasive)

  17. Investigations for PE: • contrast venography, gold standard, 0.25 rads to fetus for legs • pulmonary angiography, gold standard, 0.25 rads to fetus, 1% maternal morbidity, 1/2000 mortality

  18. Diagnosis • Use US plus V/Q scan • No known human effects for fetal exposure < 5 rads • If therapy will be altered by an invasive diagnostic procedure, the benefit far overweighs the risk to mother and fetus given 15-40% mortality for untreated PE

  19. PE Prevalence • Reports suggest equal distribution between antenatal and postnatal period • Higher mortality in the post partum period • Can be asymptomatic DVT until embloization develop

  20. Recommendations for thromboprophylaxis • Antepartum • all pregnant women who had previous VTE should be tested for thrombophilia factors; • for single episode of prior VTE with transient risk factors: surveillance (1C) • for single episode of idiopathic VTE: surveillance or UFH or prophylactic LMWH dose (1C) • for single episode of VTE and thrombophilia (except protein S): surveillance (except decreased antithrombin) or UFH or prophylactic LMWH dose (1C)

  21. Antepartum continues: • known thrombophilia: surveillance (except decreased antithrombin) or UFH or prophylactic LMWH dose (1C) • recurrent episodes of VTE: adjusted dose of UFH or adjusted dose of LMWH (1C) • > 3 moderate risk factors: surveillance or UFH or prophylactic LMWH dose (1C)

  22. Recommendations for thromboprophylaxis • Postpartum • Warfarin should be offered to all postpartum women who had previous VTE (1C)

  23. Low molecular weight heparin • Adjusted dose LMWH: enoxaparin 1 mg/kg sc q12h, dalteparin 200 IU/kg sc q24h Advantages: • possibly less risk of • thrombocytopenia • osteoporosis • more predictable therapeutic effect • OD or BID administration • monitor anti-Xa levels in third trimester

  24. Low molecular weight heparin Disadvantages: • more difficult to reverse • drug cost higher but no need for hospitalization

  25. IV Heparin • inhibits thrombin by activating AT-III, prevents conversion of fibrinogen to fibrin • need baseline CBC, INR PTT • initial 5000 IU bolus, then 1000-1500 IU/hr, INR & PTT q6hr PTT therapeutic level 1.5-2.5, then INR/PTT q24h • Advantages: • doesn’t cross placenta • not excreted in breast milk

  26. IV Heparin • rapidly reversible (protamine sulfate 1mg/100units) • no increase in perinatal mortality or morbidity over control • Disadvantages: • bleeding in 4-8% • osteoporosis (15,000U/d > 5 months) • thrombocytopenia (by day 4) • Cost and compliance

  27. Warfarin • easily crosses placenta • up to 70% fetal complications if in 1st trimester • IUGR, chondrodysplasia punctata • multiple congenital anomalies • 20-30% complication rate in 2nd-3rd trimester • Long half life

  28. Management during peripartum • Therapy throughout pregnancy and 8-12 weeks post partum • IV Heparin and LMWH should be held once labor is established in order to use local anesthesia • If therapeutic PTT is required in labor, patient should be switched to IV heparin • Therapeutic PTT may increase the incidence of hematomas but not PPH

  29. Management during peripartum • Avoid trauma or C/S at delivery • midline episiotomy if necessary • avoid tears • Resume heparin 6 hrs postpartum • Start Warfarin when oral intake tolerated • Avoid OCP, estrogen • Consult!

  30. Take home message • Thromboprophylaxis is recommended for previous VTE hx and a known thrombophilia; idiopathic VTE, recurrent VTE, and more than 3 major risk factors for VTE (II B) • Diagnosis of VTE is clinical suspicion + lab tests, never hesitate to order V/Q scan spiral CT or angiography if the result will change management • Treatment is long term: till postpartum 8-12 weeks. Considering side effects of different drugs, cost, local anesthesia, avoiding instrument delivery

  31. THANK YOU

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