Vascular Problems

Vascular problems in
Gynecology and Obstetrics
Dr. UMA GUPTA MD(OBG)FICMCH,Sr.Specialist,VPCIMS,LUCKNOW(UP)INDIA
Dr.N.K.GUPTA, M.Ch,CTVS,Associate Prof,ERA’s LUCKNOW MEDICAL

COLLEGE,LUCKNOW.INDIA
umankgupta@yahoo.com
drnkgupta2000@yahoo.com
08/01/09 DrU.Gupta,Dr.N.K.Gupta 1
Vascular surgery evolution
 The first elective operation for treatment of an
aneurysm was reported by the most famous
surgeon in Greek antiquity,ANTYLLUS, in the 2nd
century.
 AMBROSE PARE(1510-1590), mainly contributed –

principles wound care-aneurysm operations.
 After a century,RICHARD WISEMAN(1625-

1686)”Father of English Surgery”described
aneurysm in arm.
contd
 Sutures should be made with very
fine needles while the wall is
somewhat stretched.Stenosis or
occlusion only occurs-faulty
technique-which is still valid 100
years later.
 In 1910, he demonstrated that
blood vessels could be kept in cold
storage for long periods before
transplanting them.
 Carrel won the noble prize for
this work in 1912 “in
recognition of his work on
vascular
08/01/09
suture and
DrU.Gupta,Dr.N.K.Gupta 3
Arterial Disorders
 AntiPhospholipid Antibody Syndrome
 Raynaud’s disease
 Vasculitis
Venous Disorders
 Varicose Veins
 Superficial Thrombophlebitis
 Deep Vein Thrombosis/ PE
AntiPhospholipid Antibody
Syndrome
syn. Hughes Syndrome
 Arterial and Venous thrombosis
 History-
 First noted in pts positive for syphilis
 1952- clotting disorder asso. with SLE
 1957- linked to recurrent pregnancy loss
 1963 & 1972 – term “Lupus anticoagulant”
 1983 – Dr Graham Hughes – association
between APL antibodies and arterial and venous
thrombosis
 1985 – ELISA test for detection of ACA
Syndrome
Types:
 PRIMARY  SECONDARY
Mechanism:
 AUTOIMMUNE PHENOMENON ???

Tissue injury – Inflammation, Ischemia, trauma
Classes Of Antibodies –
a) Anticardiolipin Antibody (IgG,IgA,IgM)
b) Lupus Anticoagulant
c) Antibodies against specific molecules e.g.β-2-glycoprotein
Syndrome
 Prevalence 2-4%
 50% - Primary APLAS
 SLE – 30% will develop APLAS
 ACA five times more common than Lupus

Anticoagulant
 Primary APLAS – 10% SLE, Mixed Conn.

Tissue Ds
Syndrome
 RISKS ASSOCIATED:
 MISCARRIAGES
 PRETERM LABOR
 PRE-ECLAMPSIA
 LOW BIRTH WEIGHT
 THROMBOCYTOPENIA (20-40%)
Syndrome
 WHEN TO EVALUATE
 Unexplained still birth/fetal death after 10 wks
 Severe IUGR prior to term
 Severe pre-eclampsia at <34 wks gestation
 Unexplained arterial/venous thrombosis in any

territory
Syndrome
 TREATMENT
 Anticoagulation – Heparin → Oral
 Long term → Life Long ( risks – 3% chance per year of
major h’hage, 1/5th fatal)
 Anti-platelet drugs – Aspirin
 LMWH
 Pregnancy – Heparin / LMWH
 PROPHYLAXIS (APLAS without thrombotic problems)
 Aspirin
 Lifestyle Modification
 Control of Risk factors – HTN, Smoking, Cholesterol
08/01/09 levels, Weight control
DrU.Gupta,Dr.N.K.Gupta 11
Syndrome
Special Prenatal/Birth/Neonatal Considerations
 Ideally, one should seek medical advice before
becoming pregnant.
 Once pregnancy is achieved
 to see Obstetrician - to decide on the need for treatment
 frequent office visits will be needed to:
 Screen for preeclampsia,
 Fetal Monitoring
 Ultrasound examinations to check the growth of the baby.
 For patients on heparin
 extra blood tests may be needed to adjust the dose
depending on the type of heparin being used, and the past
history of the patient.
Syndrome
 PREGNANCY:
 Pre Pregnancy Counselling
 Heparin (s/c)± Low Dose Aspirin
 LMWH
 Aspirin ± Prednisone X X X X
 Low Dose Aspirin
 Intravenous Immune Globulin (IVIG)
 Immunosupression
 Steroids Catastrophic
 Plasmapheresis
Raynaud’s disease
 1862 – Maurice Raynaud
 Prevalence – 3-5%
 Episodic events – vasoconstriction (digital
arteries, precapillary arterioles &
cutaneous AV shunts)
vs Acrocyanosis
 Exaggeration of the physiologic response
to cold temperature or stress.
 Manifestation of generalised vasospastic
disorder.e.g.pts who have Prinzemetal’s
angina, migraines, or scleroderma.
Raynaud’s disease
 H/o sensitivity to cold/ episodic pallor or cyanosis
 Triphasic reaction (white>blue>red)
 Involves- fingers, toes, tip of the nose, ear lobes.
PRIMARY* SECONDARY
SYMMETRIC ASYMMETRIC
ABSENCE OF PAINFUL ISCHAEMIC
-TISSUE NECROSIS SKIN LESIONS
-ULCERATION C/f s.o. CONN. TISSUE
-GANGRENE DISORDERS (arthritis,myalgia,
-SECONDARY CAUSE abnormal lung fn,fever etc)
H/o drug use/toxic agent

NORMAL NAIL FOLD CAPILLARIES MICROVASCULAR DS
NORMAL ESR ESR ↑
NEGATIVE
08/01/09 ANA TEST DrU.Gupta,Dr.N.K.GuptaANA ± 15
*Adapted from LeRoy and Medsger
Raynaud’s disease
 Complete evaluation – to R/o underlying cause
 H/o or current drug use
 H/o repetitive trauma e.g.vibratory tools
 Positional changes triggering the event. e.g.Tho Outl Obst.
 Carpel tunnel syndrome
 Neurapathic conditions
 Malignancy
 Hypothyroidism
 Dysproteinemias
 Vasculitis
 Emboli
 Vascular Occlusive disease
Raynaud’s disease
Treatment
 NonPharmacological
 Avoidance of cold temp / prolong vibrations
 Reduce emotional stress
 Avoid Smoking
 Calcium channel Blockers
 Other Agents
 Sympatholytic drugs
 ARBs
 Fluoxetine
 I.V. Prostaglandins
 Awaited
 Cilostazole
 Sildenafil
 Bosentan (endothelin receptor inhibitor)
 Sympathectomy
 Proximal ???
08/01/09  Localised Digital DrU.Gupta,Dr.N.K.Gupta
√√ 17
Vasculitis
 AutoImmune Disease
 Inflammation of the blood vessels
 Symptoms – depend on which blood vessels are inflamed
 Fatigue
 Sleep disturbances
 Memory Loss
 Emotional Liability
 Depression
 Low Thyroid Function
 G I disturbances
 Headaches/Chemical Sensitivity
 Fungal Infections
 Low Blood Sugar
 Pain – Tingling/Ringing ears/Cold Toes/Cold Fingers
 Overdoing
 Fluttering Heart/Tachycardia/Panic Attacks/Mitral valve
Prolapse
Vasculitis
 IMMUNE SYSTEM MALFUNCTION
 CONSUMPTION OF ASPARTATE (IN DIET DRINKS/ARTIFICIAL
SWEETNERS etc.)
 CHLORINATED AND FLORIDATED WATER ???
 POOR CELLULAR COMMUNICATION
 HEAVY MOL WT CARBOHYDRATES (LONG CHAINED)
 PROVIDE INGREDIENTS FOR CELL MARKERS
 HIGHLY ANTI-INFLAMMATORY
 CODING CAPACITY BETTER THAN AMINO ACIDS *
 OVER ACTIVATED, OUT OF BALANCE IMMUNE SYSTEM
 Stress
 Infections – Bacterial , Fungal (Candida), Viral (e.g.Herpes)
 Toxins – produced by infecting organism, from environment
 Liver dysfunction
 Steroids
 Enzyme deficiency – Digestive/Metabolic
 Hypercoagulation/ HypoOxygenation
 Glutathione Deficiency
*Acta Anatomica
Vasculitis
 Management
 Weighing the available options
 Steroids
 Chemotherapeutic Agents
 Antioxidants/ Digestive Enzymes

 Treat underlying disorder
 Lifestyle modification
Venous Disorders
 Varicose Veins
 Superficial Thrombophlebitis
 Deep Vein Thrombosis/ PE
Varicose Veins
 Pregnancy
 Increased blood volume
 Pressure on veins
 Relaxation effect of hormones
Varicose Veins
 Management
 Non Operative
 Self resolving (within six weeks)
 After 6 weeks
 if problematic/ unacceptable
 Graduated Compression
Stockings
 Surgery
Varicose Veins
Before Treatment After Treatment
Varicose Veins
Superficial Thrombophlebitis
 Benign /Self limiting Disease
 Can progress to DVT(11%)
 Associated with Abnormalities
in blood coagulation
 Traumatic
 Varicose Veins
 Oral contraceptives
 Pregnancy
 Infection (e.g. Staph., Pseud., Kleb., Anaerobes)
 Migratory (e.g. Cancer, Vasculitis, Buerger’s)
 Mondor’s Disease
 Unusual forms
 palmar digital veins
 Diagnosis
 Painful cord like structure
 Redness along the vein
 Tenderness
 Fever
 Investigations
 Duplex scan
 Management
 Underlying disorder
 Remove offending agents (e.g.IV cannula)
 Antibiotics
 NSAIDs
 Anticoagulation
 Excision of the suppurating vein
 Application of massive warm wet compresses
 Elevation of the extremity
 Immobilization
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 LEADING CAUSE OF
DEATH
 1-3 /1000
PREGNANCIES
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Pathophysiology-
 5 times higher in pregnancy

 ↑ venous stasis of pregnancy
 Physiological changes asso. with pregnancy
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Independent risk factors
 Prolong Bed rest
 Multiparity (>3)
 Advanced Maternal Age (>35yrs)
 Overweight
 Personal or family history of VTE
 Pre-eclampsia
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Alteration in Coagulation/Fibrinolytic System
 Factor II, VII, X ↑ (middle of Pregnancy)
 Fibrin
 Protein S
 Protein C
 Fibrinolytic System inhibited (mostly 3rd trimester)
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Diagnosis
 Calf veins or Ilio-femoral segment
 Predilection for Left side
S/s
 Swelling
 Tenderness
 Skin Discolouration
 Warm to touch
 Unusual firmness /hardness in the leg
 Calf discomfort on dorsiflexion
 Prominent tender cord like subcut. vein

VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Diagnostic tests
 Venography
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Duplex Ultrasonography
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Spiral CT Venography
No filling of calf veins Opacification of collaterals
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Nuclear Imaging
 IPG
 MRI
 D-dimer
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Radiation Exposure
Procedure Fetal radiation dose (mrads)
CXR <1
Limited Venography <50
Perfusion Lung Scan 6-12
Ventilation Lung Scan 1-19
CT Chest 30
Pulm Angio (femoral) 221-374
Pulm Angio (brachial) <50
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Blood Tests
 Factor V Leiden
 Protein C
 Protein S
 ACA and LA antibodies
 Activated Protein C resistance (APC-R)
 AntiThrombin III
 Homocystein
 Prothrombin gene mutation
Pulmonary Embolism
 Major nonobstetric
cause of maternal
mortality
 Cause of Death
 2 / 100,000 maternities
 Maximum – Peripartum
 More after operative
intervention
 Subtle presentation
Pulmonary Embolism
 Pulmonary Angiography
 Spiral CT Scan
Pulmonary Embolism
 Diagnostic tests
Nuclear Imaging (Ventilation-Perfusion Scan)
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Management
 Medical/Pharmacological
 Anticoagulation
 Anti-platelet agents
 Surgical
 Venous Thrombectomy
 Thrombolysis
 Endovascular
 IVC Filter placement
 Others
 Hydration
 Early Mobilization
 Graduated Compression Stockings
 Pneumatic compression devices
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Medical/Pharmacological
 Unfractionated Heparin/LMWH
 Oral Anticoagulation
 Antiplatelet agents
 New Molecules
 Direct Thrombin Inhibitors
 Lepirudin, Desirudin, Argatroban, Ximelagatran

VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Surgical
 Venous Thrombectomy –
 Ilio-femoral DVT
 Pulmonary Embolectomy
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Surgical
 Thrombolysis
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Endovascular
 IVC Filter placement
 Temporary
 Permanent
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Others
 Hydration
 EarlyMobilization
 Graduated Compression Stockings
 Pneumatic compression devices
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 PROPHYLAXIS
 Risk Assessment
 Present status
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 PROPHYLAXIS
 Past h/o DVT in pregnancy, no other
thrombotic risk factors
 Antenatal thrombo-prophylaxis
 S/c Heparin+/- GCS
 S/c Heparin/LMWH → Warfarin (INR 2-2.5)
 GCS 6-12 wks (if anticoagulation contraindicated)
BMJ 1992
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 PROPHYLAXIS
 Known inherited/acquired thrombophilia
 Postpartum +/- Antepartum thromboprophylaxis
 Individual consideration
 No past h/o DVT/Thrombophilia, but with
other risk factors in combination
 Postpartum thromboprophylaxis
 S/c Heparin
BMJ 1992
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 PROPHYLAXIS IN CAESERIAN SECTION
 Low Risk
 Elective C-section – uncomplicated pregnancy
 No risk factors
 Moderate Risk
 Age, Weight, Parity, Varicose Veins, Immobility, Sepsis,
Pre-eclampsia, Emergency C-section, Major Current
Illness
 High Risk
 3 or more mod risk factors, Extended major pelvic/abd
surgery e.g.Caeserian hysterectomy
 Personal/family H/o DVT/PE/thrombophilia, Paraparesis
08/01/09 Pt with APLAS DrU.Gupta,Dr.N.K.Gupta 55
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 PROPHYLAXIS IN CAESERIAN SECTION
 Low Risk
 Early Mobilization
 Hydration
 Moderate Risk
 One of variety of prophylactic measures
 Subcutaneous Heparin
 Mechanical devices
 High Risk
 Heparin Prophylaxis +/- Leg Stockings
Report08/01/09
of the RCOG Working Party on prophylaxis (andDrU.Gupta,Dr.N.K.Gupta
management) against Thromboembolism in Gynaecology and Obstetrics. 56
London:
Royal College of Obstetricians and Gynaecologists, 1995
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Key Points
 Even 1st trimester carries risk of thrombosis (2/3rd
antepartum deaths)
 Additional risk factors/ family history / known thrombophilia
may indicate thromboprophylaxis
 Close attention should be paid to any pregnant woman c/o
leg/chest symptoms for e/o DVT/PE
 All women undergoing C-section should be assessed for
prophylaxis against VTE
 Midwives, GPs & other medical staff should take particular
attention of women with chest or leg symptoms after
vaginal delivery
 Women with risk factors for DVT should be carefully
screened and considered for thromboprophylaxis
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
 Prevention:
 Weight control
 Avoid prolong immobility
 Leg elevation
 Avoid OCPs containing high dose of Estrogens
 Adequate hydration
 Avoid Smoking/Alcohol intake
VENOUS
THROMBOEMBOLISM
DURING PREGNANCY
Take Home Message
 VTE is an uncommon but very serious

complication of pregnancy
 Pregnant women are at increased risk for VTE,
and may present in subtle ways
 Suspected VTE in pregnancy should be
investigated thoroughly
 Risk of VTE can be reduced in appropriate
patients with judicious use of anticoagulants
Vascular Control in
Gynaecological Surgery
 MODALITIES AVAILABLE
 Open Vascular
 Endovascular
Vascular Control in
 OPEN VASCULAR
 Uterine artery Ligation

 Ovarian Artery ligation
 Internal Iliac Artery Ligation
 Common Iliac artery control
 Control over Aorta
Vascular Control in
 ENDOVASCULAR
 Balloon Occlusion
 Stent Graft
 Embolisation –
 Coil
 Foam particles etc.

Vascular Problems

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Vascular Problems

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Vascular problems in

Gynecology and Obstetrics

Dr. UMA GUPTA MD(OBG)FICMCH,Sr.Specialist,VPCIMS,LUCKNOW(UP)INDIA

Dr.N.K.GUPTA, M.Ch,CTVS,Associate Prof,ERA’s LUCKNOW MEDICAL

 AMBROSE PARE(1510-1590), mainly contributed –

 After a century,RICHARD WISEMAN(1625-

 AntiPhospholipid Antibody Syndrome

 Deep Vein Thrombosis/ PE

 AUTOIMMUNE PHENOMENON ???

 ACA five times more common than Lupus

 Primary APLAS – 10% SLE, Mixed Conn.

 Unexplained still birth/fetal death after 10 wks

 Severe IUGR prior to term

 Severe pre-eclampsia at <34 wks gestation

 Unexplained arterial/venous thrombosis in any

H/o drug use/toxic agent

 Antioxidants/ Digestive Enzymes

 Deep Vein Thrombosis/ PE

 Increased blood volume

 Relaxation effect of hormones

Before Treatment After Treatment

 Benign /Self limiting Disease

 Can progress to DVT(11%)

 Associated with Abnormalities

 5 times higher in pregnancy

 Advanced Maternal Age (>35yrs)

 Personal or family history of VTE

 Fibrinolytic System inhibited (mostly 3rd trimester)

 Unusual firmness /hardness in the leg

 Calf discomfort on dorsiflexion

 Prominent tender cord like subcut. vein

No filling of calf veins Opacification of collaterals

Nuclear Imaging (Ventilation-Perfusion Scan)

 IVC Filter placement

 Pneumatic compression devices

 VTE is an uncommon but very serious

 Uterine artery Ligation

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