THROMBOEMBOLISM IN PREGNANCY

PROF. ROZINA MUSTAFA

HOD
OBSTETRICS & GYNECOLOGY
FRPMC, FAISAL BASE HOSPITAL
 LEARNING OBJECTIVES
At the end of the session, final year student should be able to:

• Define thromboembolism
• Discuss the hematological changes in pregnancy.
• Enumerate the risk factors.
• Explain the clinical features.
• Enlist the diagnostic test for VTE.
• Describe the treatment & prevention.
• Discuss the antenatal assessment & management of VTE.
• Discuss the postpartum assessment & management of VTE.
• Discuss the pulmonary embolism.
 INTRODUCTION

• Leading cause of maternal death.

• Venous thromboembolism is 10 times more common in pregnancy.

• Incidence of non-fatal pulmonary embolism & DVT in pregnancy is 0.1% in developed

countries.

• Following delivery this incidence increases to around 1-2% & further increased
following Emergency C. section.
 Hematological changes in pregnancy
• Pregnancy is a hypercoagulable state.

• Altered thrombotic & fibrinolytic systems.

• Increase clotting factors VIII,IX,X & fibrinogen levels.

• Reduce in protein S & anti-thrombin (AT) III concentrations.

• These changes reduce hemorrhage following delivery BUT predispose to

thromboembolism---further increased by venous stasis in lower limbs due to
gravid uterus (pressure on IVC), immobility.
 RISK FACTORS

Pre-existing Specific to pregnancy

• Obesity (>80 Kg) • Multiple gestation

• Increased maternal age (>35 years)
• Underlying medical conditions
• Previous thromboembolism
• BMI >30kg/m2
• Smoker
• Thrombophilia
• Severe varicose veins
• Malignancy
• Preeclampsia
• Grand multiparous
• C-section especially emergency
• Damage to pelvic veins
• Sepsis
• Prolonged bed rest
 SYMPTOMS OF DVT
• Commonest symptom is pain in calf with varying degrees of redness or
swelling.
• Unilateral symptoms ---alarming sign.(women’s legs often swollen
during pregnancy)
• Calf is tender to gentle touch.
 DIAGNOSIS
• Clinical diagnosis is unreliable.
• 1st investigation is compression ultrasound, diagnose proximal thrombosis (high
sensitivity & specificity).
• Venography is invasive (injection & X-rays)—excellent visualization of veins both
below & above the knee.
 Treatment
• During Pregnancy: LMWH---Rx of choice---safe, easy to administer
Weight < 50 kg = 20 mg enoxaparin
50 – 90 kg = 40 mg
91- 130 kg = 60 mg
131 - 170 kg = 80 mg
>170 kg = 0.6 mg/kg/day
• After Delivery: Convert to warfarin (check INR)
• Breast feeding: Warfarin & LMWH are safe.
• Graduated Elastic stockings ---initial Rx—continue for 2 years to prevent post-thrombotic
syndrome.
• Warfarin---prolongs PT (crosses placenta---limb & facial defects in 1 st trimester. Fetal
intracerebral hemorrhage in 2nd & 3rd trimester)
• Newer Anticoagulants not licensed to use in pregnancy: lepi-fondaparinux ( direct factor Xa inhibitor)
 PREVENTION
• Thrombosis assessment should be performed early in pregnancy on all patients .

• Assess need for antenatal thromboprophylaxis.

• If admission—assess additional risk factors.

• Managing patients where possible as outpatients & limiting bed rest.

• Thromboembolic stockings.

• Prophylactic LMWH for at risk patients.

Antenatal assessment & management (at booking & repeated if admitted)

Need A/N prophylaxis

with LMWH
Previous VTE except a
single event related to HIGH RISK
major surgery
Refer to expert team
 Antenatal assessment & management (at booking & repeated if admitted)

1. Hospital admission
2. Single previous VTE related to
major surgery
3. High risk thrombophilia + no
VTE
4. Medical co-morbidities Consider A/N
INTERMEDIATE
(Cancer, heart failure, active
prophylaxis with
SLE, IBD/inflammatory RISK
polyarthropathy, nephrotic LMWH
syndrome, type 1 DM with
nephropathy, sickle cell disease,
current IVDU)
5. Any surgery
6. OHSS (1st Trimester only)
Antenatal assessment & management (at booking & repeated if admitted)
BMI > 30 kg/m2
Age > 35 years
Parity >3
Multiple preg Prophylaxis
4 or > risk
IVF/ART from 1st
factors
Smoker Trimester
Gross varicose veins
Current preeclampsia Prophylaxis
3 risk
Immobility (paraplegia) from 28
factors
Low risk thrombophilia weeks
Family H/O VTE in 1st degree
relative

<3 risk LOWER RISK

factors 1. Mobilization
2. Avoidance of
dehydration
Postnatal assessment & management (to be assessed on delivery suite)

Any previous VTE

Anyone required A/N LMWH
High risk thrombophilia
Low risk thrombophilia + Family Hx

HIGH
RISK

At least 6 weeks
postnatal LMWH
 Postnatal assessment & management (to be assessed on delivery suite)

C-section in labor
BMI >40 kg /m2
Readmission/prolonged hospital
stay > 3 days
Surgery in puerperium except At least 10 days postnatal LMWH
immediate repair of perineum INTERMEDIATE RISK (IF persisting or > 3 risk factors ---
Medical co-morbidities (Cancer, extend prophylaxis with LMWH
heart failure, active SLE,
IBD/inflammatory poly-arthropathy,
nephrotic syndrome, type 1 DM
with nephropathy, sickle cell
disease, current IVDU)
Postnatal assessment & management (to be assessed on delivery suite)

Age >35 years

BMI >30 kg /m2 At least 10 days
Parity > 3 2 or > risk postnatal LMWH
Smoker factors (If persisting or > 3
El. C-section INTERMED risk factors ---
Family H/O VTE IATE RISK extend prophylaxis
Low risk thrombophilia with LMWH
Gross varicose veins
Current systemic infection
Immobility
Current preeclampsia
Multiple preg
Preterm delivery in present preg <2 risk
factors Early mobilization &
Stillbirth in this preg
avoidance of risk
Midcavity rotational/ operative delivery LOW RISK factors
Prolonged labor > 24 hours
PPH >1 L or blood transfusion
 Pulmonary Embolism
• Difficult to diagnose
• Mild breathlessness, inspiratory chest pain, tachycardia >90 bpm, T= 37.50 C.
• Sudden cardiorespiratory collapse if massive.
• ECG, Chest X-ray & Arterial blood gases (insufficient investigations to diagnose PE)
• Exclude lower limbs DVT by Ultrasound: if +ve, Rx with presumptive diagnosis of PE.
• If investigations normal BUT clinical high suspicion of PE---Ventilation perfusion scan (V/Q)
OR computed tomography pulmonary angiogram (CTPA)---considered potentially dangerous
to fetus.
Thank you