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THROMBOEMBOLITI
C DISEASES IN
PREGNANCY
MOHAMED AHMED
BMS 5.2
FPRRH
8th NOV ,2019

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INTRODUCTION
• During pregnancy ,women have fivefold increased risk of venous
thromboembolism (VTE) compare with non pregnant women.
• VTE mainly comprising of deep venous thrombosis (DVT) and
pulmonary embolism (PE) remain a leading cause of maternal death
in developed world.
• VTE can occur at any stage of pregnancy but puerperium is the time
of highest risk.
• Numerous changes in the coagulation system account for the
hypercoagulable state associated with pregnancy.

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EPIDEMIOLOGY
• Thromboembolic diseases include thrombophlebitis,
phlebothrombosis, septic pelvic thrombophlebitis and pulmonary
embolism. They are a major cause of morbidity and mortality in the
world.
• DVT and PE are distinct but related aspects of vascular venous
thromboembolism.
• Incidence of thromboembolism is 0.2% in ante-natal period and 0.6%
in postpartum. The incidence rises to 1-2% post caesarian section.
Pulmonary embolism has a mortality rate of 15% in 50% of patients
with DVT. Unfortunately only 5-10% are symptomatic.

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• Pregnancy increases risk x 5-10 fold
• 0.86/1000 deliveries
• 0.71/1000 (DVT) : 0.15/1000 (PE)
• Left leg>80%
• Ileofemoral more common than calf vein (72% versus 9%)
• Increased with age, caesarian section, bed rest and prior history of
DVT/PE)

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 Fibrinolytic System
• After formation of clot there is stimulation of Tissue plasminogen
activator and urokinase
• These converts plasminogen to the active plasmin allowing fibrinolysis
to occur after degradation of fibrin to fibrin degradation products
• In pregnancy there is increased level of tissue plasminogen activator
inhibitor 1 and 2 causing hypofibrinolysis contributing to
hypercoagulability status in normal pregnancy

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Risk factors and pathophysiology
• Prior hx of DVT
• Prolonged immobilization
• Major pelvic surgery
• Cesarean section
• Multifetal gestation
• Preeclampsia
• Peurperial infection
• Hemorrhage
• Dehydration
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Virchow’s triad of predisposing factors
1.Hypercoagulability
2. Venous stasis
3. Damage to vessel walls

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Hypercoagulability
• Pregnancy has a significant effect on the proteins in the coagulation
system.
• Almost all clotting factors are increase during pregnancy ; the most
marked effect being on fibrinogen levels which increases twofold to
threefold during pregnancy .
• Lesser effects are seen on the anticoagulant or fibrinolytic system
whereby there is little change in the level of AT III and protein c during
pregnancy . Protein S level however are noted to decrease during
pregnancy
• All these changes in the coagulation system increase the tendancy
towards thrombus formation
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Venous stasis
• Pregnancy is known to have a marked effect on blood return from the
lower extremities
• The enlarging gravid uterus obstructs blood return through the
inferior vena cava , with a subsequent increase in pressure and stasis
below the level of obstruction
• Additionally , the increase in circulating blood volumes add to the
venous distention

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Vessel damage
• The distention of the veins of the pelvis and lower extremities has the
potential to damage the endothelium
• Additionally , the damage to the venous wall during parturition or as a
result of postpartum infection can occur
• All these factors increase the tendancy toward thrombus formation

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DEEP VEIN THROMBOSIS
• Deep vein thrombosis (DVT) is the formation of blood clot (thrombus)
within a deep vein , most commonly the legs
• The major percentage of cases are located in the iliofemoral veins
without the involvement of the calf veins
• Thrombosis associate with pulmonary embolism during pregnancy
frequently originates in the iliac vein

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Clinical presentation of DVT
• The signs and symptoms usually depend on the degree of occlusion and intensity of
inflammatory response
• Usually thrombosis involve the lower extremity with abrupt onset, with pain and edema
of the leg and the thigh .
• The damaged leg has >2cm calf circumference difference with the normal one .
• The thrombus typically involves much of the deep venous system to the iliofemoral region.
• Most of the cases during pregnancy are left sided. This is due to the compression of the
left iliac vein by the right iliac and ovarian artery , both of which cross the vein only on the
left side .
• Reflex arterial spasm causes a pale ,cool extremities with diminished pulsations.
• Homans sign is positive .
• Capillary refill less than 2 seconds due to venous congestion
• Other signs and symptoms are fever ,malaise , fatigue and anorexia
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HOMANS’ SIGN

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INVESTIGATIONS FOR DVT

• None invasive methods should be used first.

• Compression ultrasonography to assess the venous system of the lower
extremities is currently the most widely used investigation
• It is the first line test to detect deep-vein thrombosis.
• Introduction of ultrasonography supplemented by color flow Doppler imaging
does allow visualization of all the vessels of the lowe extremity.

• Impedance plethysomography (IPG) is a simple, non-invasive technique that

has been shown to be both sensitive and specific. It is an ideal noninvasive
test for following patients serially who are believed to be at high risk.

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• MRI is useful in diagnosis of iliofemoral and pelvic vein thrombosis in
peuperium with very high sensitivity and specificity
• Venography is definitive test for evaluating DVT ( contrast agent are
injected to the venous system of the lower extremities and venous
syste of the leg and pelvis are evaluated both fluoroscopically and
radiographically.
• Others test include:
• D-dimer

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PULMONARY EMBOLUS
• it complicates 1 in every 750-2500 pregnancies
• Onset of dyspnea in patien with DVT suggest Pulmonary embolus
• Immediate result to P.E is the obstruction to pulmonary arterial
outflow.
• In adition to alteration of blood flow based purely on mechanical
obstruction by the thrombus , there is a concomitant vasoconstriction
Of additional small vessels thought to be mediated by the release of
serotonin from embolized platelets

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 clinical presentation
• Acute onset of dyspnea
• Difficult to assess
• Associated with tachypnea, lower extremities discomfort, ,substernal chest
pain
• Hemoptysis and pleuritic chest pain is unusual

• Massive PE presents with

• Shock
• Refractory hypoxemia
• Right ventricular dysfunction on ECHOCARDIOGRAM is a medical emergency!!

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RECOMMENDED TESTS FOR
PULMONARY EMBOLI.
• ELECTROCARDIOGRAM(ECG)- common abnormality shown is T wave
inversion and RIGHT BUNDLE BLOCK
• CHEST X-RAY – abnormalities include
• Atelectasis, effusion , focal opacities, regional oligaemia or pulmonary oedema
• Loss of vascular marking
• PULMONARY ANGIOGRAPHY- detcts blood clots and other blockages
in the blood flow in the lung

• ARTERIAL BLOOD GAS-May show hypoxia

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MANAGEMENT OF
THROMBOEMBOLIC DISEASES
• GOALS OF MANAGEMENT
• Arrest of the growth of thrombus
• Prevention of pulmonary embolus

Main stay of treatment is anticoagulation. (heparin and warfarin)

• Other modalities have a limited role i.e surgery

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Conservative management
• Initial bed rest indicate for all patients with thrombosis.
• Elevation of the leg is helpful in relieving edema
• Local heat is helpful in alleviating pain
• Elastic stocking are fitted to reduce edema .
• If pulmonary embolism is suspected ,additional treatment with
oxygen therapy is indicated maintaining the PaO2 above 70mmHg or
oxygen saturation above 95%

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ANTICOAGULATION
• HEPARIN- high molecular weight mucopolysaccharide obtained from
the mucus of the lung and gut of swine and cattle(MW 12000) hence
does not cross placenta
• Half life- 30-60 minutes(short)
• Anticoagulant activity- interaction with antithrombin at III. The effect
of AT III which normaly inhibits the activity of the activated
protease(clotting factor), including thrombin and factor Xa., is
markedly accelerated in the presence of heparin.
• It is the anticoagulant of CHOICE in pregnancy.

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• Side effects of heparin
1. Hemorrhage
2. Osteoprosis
3. Heparin associated thrombocytopenia. After 5 days of high dose
therapy- check palatelet levels.

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• Low molecular weight heparin
• Although small in size, it cannot cross the placenta and is save for
pregnancy
• It has fewer hemorrhage complications
• LMWH has been shown to have fewer hemorrhagic complications
than standard heparin

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WARFARIN
• The most widely used anticoagulant
• Easily crosses the placenta
• The anticoagulant effect is due to its ability to compete with vitamin-K
clotting factors (II ,IV ,IX and X)
• Bleeding complications are more frequent with warfarin than with
heparin
• The long half-life and its mechanism of action makes good control
more difficult
• Contraindicated in pregnancy

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THANK YOU
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