Professional Documents
Culture Documents
2007
Prof Aboubakr Elnashar
Email: elnashar53@hotmail.com
•Main direct cause of maternal death in the
UK
Swelling, Redness
Tenderness.
PTE is suspected by
Acute chest pain
Shortness of breath.
Haemoptysis
Hypotension
Limited <500
venography
Unilateral 3140
venography
without abdominal
shield
Perfusion lung 60-120
scan (technetium
99m)
Ventillation lung
scan 40-90
Xenon-133 10-350
Technetium
CT PA 99m 60-1000
Pulmonary
angiography <500
Brachial route 2210-3740
D-dimer testing
a marker of coagulation or blood clotting
• Nonpregnant:
Rapid & inexpensive.
Useful for excluding DVT if the results are normal.
With highly sensitive assay: false negative: 4%
With a moderately sensitive assay: false
negative: 17%
• Pregnancy:
-High level:
10.Physiological changes in the coagulation
system: levels become ‘abnormal’ at term & in
the postnatal period.
11.Pre-eclampsia.
-low level: likely to suggest that there is no VTE.
Should not be performed to diagnose acute
Baseline blood investigations
4.Full blood count, coagulation screen, urea &
electrolytes & liver function tests.
{Anticoagulant therapy can be influenced by
renal & hepatic function}
2. Thrombophilia screen prior to therapy is not
routinely recommended.
{Results will not influence immediate
management but it can influence the duration &
intensity of anticoagulation, e.g. when
antithrombin deficiency or antiphosphilipid
syndrome is identified}.
Effects of pregnancy & thrombus on the results of
a thrombophilia screen:
•Protein S levels: fall in normal pregnancy:
extremely difficult to make a diagnosis of protein
S deficiency during pregnancy.
•Activated protein C (APC) resistance is found
with the APC sensitivity ratio test in 40% of
pregnancies {physiological changes in the
coagulation system}.
•Antithrombin: reduced when extensive thrombus
is present, e.g. nephrotic syndrome & pre-
eclampsia
•Protein C and S: reduced in liver disease
Initial anticoagulant treatment of VTE
•Clinically suspected DVT or PTE:
LMWH should be given until the diagnosis is
excluded by objective testing, unless treatment is
strongly contraindicated.
•LMWHs:
Do not cross the placenta.
Safe alternative to UFH during pregnancy
(Systematic reviews).
Equically effective to UFH in the initial treatment
of PTE (meta-analysis of RCT).
•ADVANTAGES OF LMWHS OVER UFH:
More effective.1
:Lower .2
a. Hgic complications
b. Mortality than UFH in treatment of DVT
. in nonpregnant women((Meta-analyses of RCT
c. Recurrent VTE (1.15% for LMWH; 5% for UFH)
d. Bleeding. This is important in obstetric practice where PPH
remains the most common cause of severe obstetric morbidity.
e. Thrombocytopenia
f. Osteoporosis.
•Therapeutic dose of LMWH
2 SC divided doses with dosage titrated against the
woman’s booking or most recent weight. (1mg/k,
bd)
In nonpregnant women, the recommended therapeutic doses of LMWH varies according to the
manufacturer (enoxaparin 1.5 mg/kg once daily; dalteparin 10,000–18,000 units once daily
depending on body weight; tinzaparin 175 units/kg once daily).
In view of recognised alterations in the pharmacokinetics of dalteparin and enoxaparin during
pregnancy, a twice-daily dosage regimen is recommended for these LMWHs in the treatment of VTE
in pregnancy (enoxaparin 1 mg/kg twice daily; dalteparin 100 units/kg twice daily).
Preliminary biochemical data from a relatively small number of women suggests that once-daily
administration of tinzaparin (175 units/kg) may be appropriate in the treatment of VTE in
pregnancy, but this has not yet been substantiated with published clinical outcome data on safety
and efficacy in contrast to twice-daily dosing of enoxaparin and dalteparin
Monitoring LMWH therapy
2.Peak anti-Xa activity:
not recommended except in
at extremes of b wt (<50 kg & >90 kg)
complicating factors (renal
impairment or recurrent VTE).
2. Platelet count: should not be
carried out (unless UFH has been
given).
Management of massive life-threatening
PTE
Collapsed, shocked
Team of senior physicians, obstetricians &
radiologists, who should decide on an individual
basis whether a woman receives
IV UFH, thrombolytic therapy or thoracotomy and
surgical embolectomy.
•IV UFH:
Preferred {rapid effect & extensive experience of
its use in this situation}.
Dose
● loading dose: 80 units/kg, followed by a
continuous IV infusion of 18 units/kg/h
● if a woman has received thrombolysis, the
loading dose should be omitted & an infusion
Monitoring:
2.APTT:
4–6 h after the loading dose, 6 h after any dose
change & then at least daily when in the
therapeutic range.
Therapeutic target APTT ratio: 1.5–2.5 times the
average laboratory control value.
2. anti-Xa level:
In late pregnancy: an apparent heparin resistance
{increased fibrinogen & factor VIII, which
influence the APTT}: unnecessarily high doses of
heparin: hgic problem: It may be useful to
determine the anti-Xa level as a measure of
heparin dose.
With UFH, a lower level of anti-Xa is considered
therapeutic (target range 0.35–0.70 units/ml or
2. An urgent portable echocardiogram or CT PA
within 1 h of presentation should be arranged.
If massive PTE is confirmed or, in extreme
circumstances prior to confirmation, immediate
thrombolysis.
Indication:
Severe PTE with haemodynamic compromise.
{more effective than heparin therapy in reducing clot
burden & rapidly improving haemodynamics, but no
impact on long-term survival compared to heparin or
LMWH }
Types:
No agent is superior to the others: streptokinase,
urokinase, recombinant tissue plasminogen activator.
Side effects:
1. Non-fatal maternal bleeding (2.9%). Most around
catheter & puncture sites, no reports of intracranial
bleeding
3. If the woman is not suitable for
thrombolysis or is moribund, a
discussion with the cardiothoracic
surgeons with a view to urgent
thoracotomy should be undertaken.
Additional therapies
1. Leg should be elevated & graduated
elastic compression stocking {reduce
oedema}.
2. Mobilization with graduated elastic
compression stockings.
3. Temporary inferior vena caval filter in
the perinatal period for:
1. Iliac vein VTE {reduce the risk of PTE}
2. Proven DVT & continuing PTE despite
adequate anticoagulation.
•Early mobilisation with compression therapy
2.Does not increase developing of PTE: no need
for bed rest in a stable patient on anticoagulant
treatment with acute DVT.
3.Pain & swelling improved faster
4.Prevent post-thrombotic syndrome.
•Compression stockings.
•Below-knee: for patients without thigh or knee
swelling.
•Class II: for patients with persisting leg oedema
after DVT.