Prevention of DVT/PE

Noornadia bt Yahaya
050100841
Overview
Introduction
Epidemiology
Risk factor for DVT/PE
Prevention of DVT/ PE
Introduction
DVT describes the formation of blood clots in blood
vessels. Most cases  blood clots form in the large
veins of the legs and pelvis.
Blood clots that break away from blood vessels may
travel through the blood vessels of pregnant women
and reach the lungs. In the lungs, blood clots can
impair oxygen flow to the rest of the body. This is
called a pulmonary embolism.
A pulmonary embolism is a medical emergency, and
it’s life threatening
Epidemiology
The incidence of VTE in different group of pt varies
greatly in literature
Risk of PE in absent of prophylaxis is estimated 5 % in
higher risk group
DVT of the lower extremities during pregnancy occurs
at a rate of 0.13 to 0.61 per thousand pregnancy
Thromboembolism risk is increased 5 fold in pregnancy
DVT occurs equally in all trimester
D V T may lead to pulmonary embolism, the most
common cause of maternal deaths in the developed
country
• Endothelial injury
• Stasis
• Hypercoagulability
Pathophysiology
Immobility
•Prolonged travel and sitting, such as long airplane flights ("economy
class syndrome"), car, or train travel
Hospitalization
•Surgery
•Trauma to the lower leg with or without surgery or casting
•Pregnancy, including 6-8 weeks post partum
•Obesity

Hypercoagulability (coagulation of blood faster than usual)

•Medications (for example, birth control pills, estrogen)
•Smoking
•Genetic predisposition
•Polycythemia (increased number of red blood cells)
Cancer

Trauma to the vein

•Fracture to the leg
•Bruised leg
•Complication of an invasive procedure of the vein
 Physiology , Risk Factor??
Virchow’s triad : all factors exaggerated in
pregnancy !!!
Hypercoagulability : clotting fx I, II, VII, IX, X
fibrinolysis
Natural anticoagulant ( Protein C & S)
Stasis : Venous stasis resulting from pressure of the gravid
uterus on inferior vena cava
Venous tone
Intravascular volume distend vein

Endothelial injury: The trauma of operative delivery 

vascular injury  Postpartum DVT
 Risk Factors
Thrombophillia
Increased parity ( > 4 )
Operative or difficult instrumental delivery (Major abdominal/pelvic surgery)
Prolonged immobility
Previous thrombo embolism
Personal history or first-degree relative with a history of VTE
Active cancer or cancer treatment
Age over 60 years
Critical care admission
Dehydration
Obesity (body mass index [BMI] over 30 kg/m2)
One or more significant medical comorbidities (for example: heart disease; metabolic,
endocrine or respiratory pathologies; acute infectious diseases; inflammatory
conditions)
Use of HRT, OCP
Varicose veins with phlebitis
Large pelvic mass
 Venous Thrombosis: Manifestations
 Sometimes asymptomatic (up to 50%)
because of incomplete vein occlusion
or collateral circulation

 Most common signs:

 Pain in calf or leg
 Swelling of lower limb
 Deep muscle tenderness
 Redness
 Fever
 Fatigue
 Elevated white blood cell count
 Pulmonary embolism
Symptom Sign
Classical triad : Tachypnea
Chest pain Tachycardia
Cough Phlebitis
Hemoptysis
Edema
Dyspnea
Cardiac murmur
Syncope
diaphoresis
Clinical diagnosis
HRT & VTE
Exogenous oestrogens are associated with an increased
risk of VTE.
The presence of multiple risk factor may suggest that
HRT is best avoided.
In the absence of underlying thrombophilic defect or in
cases of VTE occurring more than a year earlier, HRT
can be prescribed.
Transdermal therapy is recommended in such a
situation.
 Cont’…
However, HRT is best avoided in patients in whom
thrombophilia has been identified
With regards to patient on HRT undergoing surgery,
appropriate assessment of the thrombotic risk should be
made.
There is no indication to routinely stop HRT prior to
surgery provided appropriate thromboprophylaxis, such as
low molecular weight heparin or low dose heparin is
employed
 OCP & VTE
The combined OCP is associated with changes in the
coagulation system prothrombotic.
There is a higher risk of VTE in OCP users due to the
higher oestrogen content compared to HRT
In patients undergoing elective surgery, the decision to
stop OCP 4-6 weeks before surgery must be balanced
against the risk of unwanted pregnancy
 Cont’….
Absence of other risk factors, there is insufficient
evidence to support a policy to routinely stop the
combined OCP prior to elective surgery.
Emergency surgery  Thromboprophylaxis
recommended
For patients undergoing uncomplicated minor or
intermediate procedures (e.g. curettage or laparoscopy)
 no evidence to support stopping the combined pill or
the use of thromboprophylaxis
Pregnancy
Heparin has been widely used for thromboprophylaxis
and treatment.
 Neither unfractionated standard heparin nor low
molecular weight heparin crosses the placenta.
Thus there is no risk of foetal haemorrhage or
teratogenicity effect.
Caesarian section
Caesarian section increases the risk of
thromboembolism by approximately 10 fold. Patients
should have their risk stratified to determine what
prophylaxis is needed
VTE Prophylaxis
Mechanical
Pharmacological
Mechanical prophylaxis
Mechanical methods may also be combined with
pharmacological prophylaxis to increase efficacy in
high-risk patients.
Do not increase the risk of bleeding, mechanical
methods may be preferred in patients at increased risk
of bleeding from pharmacological prophylaxis.
Eg
Anti-embolism stockings (thigh or knee length)
Intermittent pneumatic compression devices (thigh or
knee length).
 Anti embolism stocking
Anti-embolism compression
stockings are commonly
referred to as TED hose
They are used to support the
venous and lymphatic
drainage of the leg.
Pre-caution
 Ensure that patients who need anti-embolism stockings have their legs
measured and that the correct size of stocking is provided. Anti-
embolism stockings should be fitted and patients shown how to use
them by staff trained in their use.
 Use anti-embolism stockings that provide graduated compression and
produce a calf pressure of 14–15 mmHg
 Encourage patients to wear their anti-embolism stockings day and night
until they no longer have significantly reduced mobility.
 Remove anti-embolism stockings daily for hygiene purposes and to
inspect skin condition. Inspect the skin two or three times per day.
 Discontinue the use of anti-embolism stockings if there is marking,
blistering or discolouration of the skin, pain or discomfort.
 Intermitten pneumatic device
Technique to prevent thrombosis in
bedridden patients. It uses an
inflatable device that squeezes the
calf when it inflates, preventing
pools of blood forming behind the
valves in the veins, thus mimicking
the effects of walking.
Pharmacological
These include:
Standard unfractionated heparin (usually in low
dosage)
Low molecular weight heparins or heparinoids
Oral anticoagulants
Unfractionate heparin LMW Oral anticoagulant
heparin/heparinoid
•SC in a dose of 5000U •SC for prophylaxis of •The recommended
every 12 hours after the VTE. therapeutic range is 2.0 to
surgery. 2.5
•They are effective as
• Meta-analyses have once-daily injections •Used when heparin is
revealed that low dose contraindicated
heparin reduces the •LMWH is less likely to
incidence of all DVT and produce heparin-induced •require daily monitoring
PE. thrombocytopaenia and (INR) or the prothrombin
osteoporosis than time.
unfractionated heparin
Thromboprophylaxis dose (LMWH)

Weight (kg) Enoxaparin Dalteparin Tinzaparin

<50 20mg/kg/day 2500units/day 3500u/kg/day

50-90 40mg/kg/day 5000units/day 4500u/kg/day

91-130 60mg/kg/day 7500units/day 7000u/kg/day

131-170 80mg/kg/day 10000units/day 9000u/kg/day

DURATION OF PROPHYLAXIS

1. Specific antithrombotic prophylaxis should be continued

for at least 5 days or until hospital discharge if this is
earlier than 5 days.
2. In high-risk patients, prophylaxis should be continued until
illness and immobility have resolved, or until hospital
discharge if this is earlier.
3. After hospital discharge, increased risk of VTE may
continue for several weeks in patients with continuing risk
factors .In such patient, consideration should be given by
the doctor to continue prophylaxis after discharge.
4. If the hospital team recommends prophylaxis after
discharge, they should communicate with the patient prior
to discharge.
Surgical patient
 Advise patients to consider stopping oestrogen-containing
oral contraceptives or hormone replacement therapy
4 weeks before elective surgery. If stopped, provide advice
on alternative contraceptive methods.
 Consider regional anaesthesia for individual patients, in
addition to other methods of VTE prophylaxis, as it carries
a lower risk of VTE than general anaesthesia.
 Extend pharmacological VTE prophylaxis to 28 days
postoperatively for patients who have had major cancer
surgery in the abdomen or pelvis