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Thromboembolic disease In obstetrics and Gynaecology
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Aboubakr Elnashar
UK: Pulmonary embolism (PE) is the most common
cause of maternal mortality (16.5%)
(TED, PIH, Haemorrhage).
Egypt: PE represents 6% of maternal mortality
(Haemorrhage, PIH, TED).
Aboubakr Elnashar
Aboubakr Elnashar
Pregnancy and childbirth are associated
with 10 fold increased risk of TED
{ Stasis.
Increased coagulation factors.
Trauma during delivery}.
Aboubakr Elnashar
All women should undergo an assessment of risk factors for VTE in
early pregnancy or before pregnancy &
should be repeated if the woman is admitted to hospital or develops other intercurrent problems.
Aboubakr Elnashar
At booking
Age over 35 years.
Obesity :BMI>30.
Past history of
DVT/PE.
Family history of TED.
Anti-phospholipid
syndrome. During pregnancy
•Dehydration: HG,GE,
diarrhoea.
•Prolonged bed rest.
•Immobilisation.
•Pre-eclampsia
•Gross varicose veins.
At & after delivery
•Prolonged active labour >12
hours.
•Emergency C/S.
•Caesarean hysterectomy.
•Prolonged bed rest
•Immobilisation.
Aboubakr Elnashar
Aboubakr Elnashar
Women with a previous VTE should have:
1. Careful history documented and
2. Undergo screening for both inherited and acquired thrombophilia,
ideally before pregnancy.
Aboubakr Elnashar
A) During pregnancy.
B) Following C/S.
C) Following vaginal deliveries.
D) During travelling by air.
Aboubakr Elnashar
A) Thrombo-prophylaxis during
pregnancy
Women with past history of TED during a previous pregnancy or puerperium should receive heparin/LMWH.
With no added risk factors --- heparin/LMWH before the time of the previous TED till 6 weeks postpartum.
With multiple episodes of TED heparin/LMWH throughout pregnancy till 6 weeks postpartum (shift to oral after delivery).
Aboubakr Elnashar
B) Thrombo-prophylaxis following C/S (RCOG guidelines).
1) Low risk group:
Elective C/S
Uncomplicated pregnancy.
No added risk factors.
Early mobilisation and hydration.
Aboubakr Elnashar
2) Moderate risk group
Patients with any one of:
Age >35 years
Obesity >80Kg.
Parity 4 or more.
Active labour >12 hs
Gross varicose veins.
Current infection(>4days).
Pre-eclampsia.
Immobility
Major current illness: heart or lung disease, cancer, IBD, NS.
Aboubakr Elnashar
3) High risk group
3 or more moderate risk factors.
Major surgery: caesarean hysterectomy.
Past or family history of DVT/PE.
Thrombophilia, immobile patients .
Antiphospholipid syndrome.
Heparin/LMWH + leg stockings for 5 days.
Aboubakr Elnashar
C) Thrombo-prophylaxis following vaginal delivery
1) Low risk: uncomplicated delivery
Early mobilisation & avoid dehydration.
2) Moderate risk: 2 risk factors.
Heparin/LMWH sc daily till discharge.
3) High risk: 4 or more risk factors.
Heparin/LMWH sc+ Elastic stokings till discharge
Aboubakr Elnashar
Timing
Antenatal thromboprophylaxis:
as early in pregnancy as practical.
Postpartum prophylaxis:
as soon as possible after delivery provided that there
is no postpartum haemorrhage.
Postpartum haemorrhage
should be fitted with thromboembolic deterrent
stockings.
B
Aboubakr Elnashar
Regional analgesia:
LMWH should be withheld until four hours after
insertion or removal of the epidural catheter (or six
hours if either insertion or removal were traumatic).
The first postpartum dose can be given after insertion but before removal of the epidural catheter.
Aboubakr Elnashar
Duration of postpartum thromboprophylaxis
High risk: 6 w
Lower risk: 3-5 days
{The prothrombotic changes of pregnancy do not
revert completely to normal until several weeks
after delivery}
Aboubakr Elnashar
D) Thrombo-prophylaxis during travelling by air
Risk factor Short haul flight
<4 hours
Long haul flight
>4hours
No added
risk
Move around cabin
Avoid dehydration
Minimise coffee
The same+
Well fitted below knee
elastic stockings.
Added risk
factors
The same +
Well fitted below knee
elastic stockings.
LMWH pre-flight and
the day after
Or 75 mg Aspirin 3 days
before & on day of travel.
Aboubakr Elnashar
Aboubakr Elnashar
Dose
• Unfractionated heparin: 5000-10000 u /12 h.
• LMWH:
Dalteparin (Fragmin): 2500-5000 u /24 h.
Enoxoparin (Clexane): 20-40 u /24 h.
Tinzaparin (Innohip) : 3500-4500 u /24 h.
• Oral anticoagulants are indicated in patients with
cardiac valve replacement only.
Heparin
Aboubakr Elnashar
Aboubakr Elnashar
Monitoring
Heparin: APTT.
LMWH by Xa (not available in Egypt).
(Monitoring is not required for short term treatment).
Platelet count every 2 weeks.
Oral anticoagulants by INR (International
normalization Ratio), usually weekly.
Aboubakr Elnashar
Contraindications to heparins
Haemorrhagic disorders: haemophilia.
Thrombocytopenia.
Peptic ulcer.
Recent cerebral hge.
Severe hypertension.
Severe liver disease.
Aboubakr Elnashar
Side effects of prolonged heparin therapy
Haemorrhage.
Skin necrosis at injection sites.
Thrombocytopenia.
Osteoporosis.
Hypersensitivity reactions.
Aboubakr Elnashar
Systematic reviews and retrospective studies have concluded that LMWH is a safe alternative to unfractionated heparin as an anticoagulant during pregnancy and from a safety perspective LMWH is preferred.
Aboubakr Elnashar
Low-dose aspirin
75 mg daily
Safe in pregnancy, although its use for thromboprophylaxis in this setting has never been assessed by RCT.
Meta-analysis of trials in surgical and medical patients shows a significant reduction in DVT and PE with antiplatelet prophylaxis.
Aboubakr Elnashar
May be appropriate in situations where the risk of
VTE is increased but is not deemed high enough to
warrant the use of antenatal LMWH
e.g.women with previous provoked VTE without
thrombophilia.
Aboubakr Elnashar
Warfarin
During pregnancy, especially between
6 and 12 weeks: should be avoided if
possible, because
1. 5% risk of teratogenesis
2. increases the risk of miscarriage,
3. fetal and maternal haemorrhage,
4. neurological problems in the baby and
stillbirth.
Aboubakr Elnashar
After delivery and for breastfeeding; safe, although it requires :
1. Close monitoring,
2. Frequent visits to an anticoagulant clinic
Warfarin carries an increased risk of:
1. Postpartum haemorrhage and
2. Perineal haematoma compared with LMWH.
Aboubakr Elnashar
It is not appropriate for women requiring only three to five days of postpartum prophylaxis.
If the woman chooses to commence warfarin postpartum, this can usually be initiated on the second or third postnatal day.
The dosage regimens are the same as for women converting to warfarin postpartum following an acute VTE in pregnancy.
Aboubakr Elnashar
Graduated elastic compression stockings
There are no trials to support such practice but
the British Society for Hematology guidelines
give a grade C recommendation (evidence
level IV) that:
All women with previous VTE or a thrombophilia
should be encouraged to wear class-II
graduated elastic compression below knee
stockings throughout their pregnancy and for
6–12 weeks after delivery.
Aboubakr Elnashar
Class-I thromboelastic stockings are appropriate for hospital inpatients at increased risk of VTE and may be combined with LMWH.
Their use is also recommended for pregnant women traveling by air.
Aboubakr Elnashar
The pregnancy-associated prothrombotic changes in
the coagulation system are maximal immediately
following delivery.
Therefore, it is desirable to continue LMWH during
labour or delivery in women receiving antenatal
thromboprophylaxis with LMWH.
Care during labour and delivery for
women on thromboprophylaxis
Aboubakr Elnashar
For women receiving high prophylactic or
therapeutic doses of LMWH:
the dose of heparin should be
withheld if the woman goes into labour or
reduced to its thromboprophylactic dose on the
day before induction of labour or elective CS and
continued in this dose during labour.
Aboubakr Elnashar
Regional anaesthesia can be sited only after discussion with a senior anaesthetist, & with the woman before labour or CS.
To minimize the risk of epidural hematoma, regional techniques should not be used until at least 12 hours after the previous prophylactic dose of LMWH.
When a woman presents while on a therapeutic regimen of LMWH, regional techniques should not be employed for at least 24 hours after the last dose of LMWH.
LMWH should not be given for at least 4 hrs after the epidural catheter has been inserted or removed and the cannula should not be removed within 10–12 hrs of the most recent injection.
Aboubakr Elnashar
Aboubakr Elnashar
Aboubakr Elnashar
DVT is suspected by:
Acute leg pain,
Swelling, redness &
tenderness.
Aboubakr Elnashar
PE is suspected by
Acute chest pain,
shortness of breath.
Haemoptysis,
Hypotension and
Cyanosis occur in massive PE.
Aboubakr Elnashar
ECG, Oxygen saturation& CXR are
not specific.
The clinical diagnosis is very
difficult, but
If suspected, start treatment till
objective tests are available.
Aboubakr Elnashar
Objective testing for TED
DVT: Duplex ultrasound scan.
PE: ventilation/perfusion scan.
Chest X-ray and X-ray venography carry a very
small risk of radiation exposure to the fetus and should be used when indicated.
Aboubakr Elnashar
Aboubakr Elnashar
Pulmonary angiography & VP scan
Multiple intravascular filling
defects in the right pulmonary
artery on angiogram.
There are several bilateral segmental
perfusion defects without matched
ventilation defects in the same
territories (mismatch). Aboubakr Elnashar
Management of acute episodes of VTE
1. Therapeutic doses of Heparins for at least 5 days.
(Consult other specialities).
IV loading dose followed by continuous IV infusion or intermittent SC injection.
5000-10000 u loading dose followed by
15-25 u/kg/h iv infusion or
15000 u sc/12 h.
Aboubakr Elnashar
Monitoring (consult other specialities)
Daily monitoring by APTT, adjust dose
accordingly.
Continue tt throughout pregnancy at a
maintenance dose.
Continue till 6 w postpartum (shift to oral
after delivery).
Aboubakr Elnashar
2. LMWH (therapeutic doses).
Enoxaparin (clexane) 20, 40, 60, 80,100 120, 150 mg/syringe.
Dose: 1-1.5 mg/kg(150 u/kg) sc every 24 h.
Tinzaparin (Innohep) 2500, 3500, 4500, 20000 u/syringe.
Dose: 175 u/kg sc every 24 h.
Dalteparin (Fragmin) 2500, 5000, 10000, 12500, 15000, 18000 u/syringe.
Dose: 200 u/kg sc (maximally 18000 u/day).
Aboubakr Elnashar
Response to treatment
Immediate improvement in DVT/PE.
Patients with persistent hypotension,
cyanosis carry a bad prognosis.
Thrombolytic therapy by streptokinase.
Surgical treatment.
Aboubakr Elnashar
Aboubakr Elnashar
Risk assessment based upon:
A) Type of surgery.
B) Risk factor in the patient.
Aboubakr Elnashar
A) Type of Surgery
Low risk surgery:
Minor operations (<30 minutes).
Moderate risk surgery:
>30 minutes.
High risk surgery
All cancer/extended pelvic surgery.
Aboubakr Elnashar
B) Risk factor in the patient
The same risk factors mentioned under obstetrics.
Age>40 years.
BMI>30.
Immobility.
Thrombophilia.
Previous DVT/PE.
Aboubakr Elnashar
Thrombo-prophylaxis
1. Minor surgery & no risk factors
Early mobilization &
avoid dehydration.
2. Moderate surgery and no risk factors
Low dose prophylaxis (20 mg clexane) prior to surgery and daily till discharge.
Aboubakr Elnashar
3. Prolonged surgery and/or high risk factors High dose prophylaxis (40-80 mg clexane) prior
to surgery & daily till discharge. Compression stockings during
surgery/comfortable positions. Elastic stockings following surgery. Early mobilization and hydration.
Aboubakr Elnashar
Management of patients on Anticoagulants undergoing surgery
Patients on oral anticoagulants
Admit to hospital 3-4 days prior to surgery.
Stop oral anti-coagulant and start
heparin/LMWH on admission.
Surgery when INR between 1-2.
Start oral anticoagulant after oral feeding +
heparin/LMWH for few days.
Aboubakr Elnashar
Patients on heparin/LMWH
Stop LMWH on the night prior to surgery
or morning dose of heparin.
Start few hours after surgery.
Start oral +heparin for few days.
Continue on oral when INR>2.
Aboubakr Elnashar
Antidotes
Protamin zinc for heparin.
Vit K for oral anticoagulants.
No effective antidote for LMWH.
(may be fresh blood transfusion).
Aboubakr Elnashar
Thromboprophylaxis in OHSS
Women with multiple risk factors for VTE and at risk of OHSS undergoing ovulation induction may also be considered for thromboprophylaxis.
Women with OHSS require thromboprophylaxis for at least the period of inpatient stay.
Aboubakr Elnashar
Aboubakr Elnashar