Deep venous thrombosis in pregnancy

1. Samuel Ngigi K.
KMTC

2.  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.

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

4. Virchow’s Triad
 Disorder of blood vessel wall
 Disordered blood flow (stasis)
 Abnormality of blood constituents
××Recap the clot forming physiological cascade
and the fibrinolysis cascade

5.  Venous stasis – changes in tone and
obstruction
 Vascular damage at time of delivery
 APTT, PS (free and total), APCr
 FVIII:C, VWF, Fibrinogen
 PAI-1 and PAI-2

6. Predisposing factors:
A. Patient factors:
 Age>40 risk increase exponentially with age
 Obesity (BMI > 30kg/m2
 Varicose veins or venous thrombophlebitis
 Previous D.V.T.
 Oral contraceptives & HRT; estrogen is responsible
 Pregnancy: due to
(i) Hormonal changes
(ii) Pressure on veins by fetus

7.  Highest incidence in puerperium especially just after
childbirth
 Dehydration: increase blood viscosity
 Immobility: Stasis of blood
 Long distance travel: due to
(i) Inactivity
(ii) Dehydration
 Due to these factors blood becomes more sticky specially if
journey is for more than 5 hours

8. B. Surgical conditions:
 Especially includes surgery for more than half an hour
duration
 Abdominal, pelvis, orthopedic surgery to lower limb
 Increased use of central venous line has caused more
involvement of upper limbs in D.V.T.

9. C. Medical Conditions
 M.I./Heart failure
 Inflammatory bowel disease
 Malignancy or its treatment
 Nephrotic syndrome
 Behcet’s syndrome
 Homocysteinemia
 Major injuries/paralysis

10. D. Hematological Disorders
 Primary proliferative polycyathemia
 Essential thrombocythemia
 Paraoxysmal nocturnal hemoglobinuria

11. E. Anti-Coagulant Deficiences:
 Antithrombin III: such patients are also
relatively resistant to heparin Therapy
 Factor II Leiden: Genetic polymorphism of
P.T. gene
 Factor V Leiden: Mutation leading to APC
resistance
 Heparin cofactor II
 Prothrombin G20210 A mutation

12. F. Increased Clotting factors:
 XI and VIII
G. Antiphospholipid Antibodies:
 Lupus anticoagulant
 Anti-Cardiolipin antibodies

13. D.V.T. of iliac, femoral or popliteal vein
 leg swelling, warmth, erythema, increased tissue turgor, distention
of superficial veins and appearance of prominent venous
collaterals. In some patients deoxyhemoglobin in straight veins
gives it a cyanotic hue called as ‘Phlegmasia cerulea dolens’.
 In markedly edematous legs, interstitial tissue pressure may
exceed capillary perfusion pressure causing pallor – ‘Phlegmasia
alba dolens’.
 Tenderness is present along individual vein and a cord may be
palpable.
 D.V.T. of calf vein: commonest complaint calf pain especially when
standing or walking
 There may be tenderness or warmth, increased tissue turgor or
modest swelling. Homan’s Signs: positive
 50% of clients are asymptomatic

15.  Clinical Diagnosis unreliable due to
differential diagnosis but serial limb
measurements are suggestive of diagnosis
and treatment follow-up
 Screening investigations – impedance
plethysmography
 Definitive diagnosis – Doppler ultrasound, CT
scan, MRI
 PE – ventilation perfusions scan
*** venograms and pulmonary angiograms not
done in pregnancy

16.  Muscle rupture
 Trauma
 Hemorrhage
 Ruptured popliteal cyst
 Lymphedema
 Post phlebitic syndrome
 Streptococcal skin infections (CELLULITIS)
 Nerve compression
 Arthritis
 Tendonits
 Fractures
 Arterial occlusive disorders
 Simple muscle strains

17. ◦ Bed rest with elevation of the affected limb
◦ Exercise
◦ Fluids
◦ Avoid Deep Palpation
◦ Compression stocking

18. 1. HEPARIN
 Acute phase heparin administration – it acts
indirectly by activating plasma Antithrombin III.
Dose: i.v. bolus 7500-10,000 IU followed by
continuous infusion so that 1000-1500 IU/Hr is
maintained.
Deep S.C. injection of 10,000-20,000 U every 8-12
hrs can also be given.
This treatment is maintained for at least 5-7 days vis
a vis clinical symptoms

19. Test used to monitor heparin therapy include
coagulation time, activated partial
thromboplastin time, thrombin clotting time,
and heparin assay. Heparin should not be
given if the platelet count is below 50,000/µL.
The partial thromboplastin time should be 1.5-
2 times the control value during heparin
therapy.
 Heparin if administered in the first trimester of
pregnancy as WARFARIN causes
embryopathy

20. S/E of heparin include:
• thrombocytopenia,
• osteoporosis and
• fatty necrosis
Antidote of heparin, protamine sulphate 1mg
per 100 units
Heparin must be stopped at least one day prior to
delivery

21.  Low molecular weight heparin is equally effective used in
fixed OD or BD doses for 6-14 days.
ADVANTAGES of low molecular weight heparin includes:
i. Increased binding of plasma proteins or endothelium in turn leading to
a. Increased bioavailability
b. Predictable anticoagulant response
ii. Affinity for macrophages resulting in increase half life
iii. Affinity for plts and platelet factor 4 binding to osteoblasts
iv. No monitoring required
v. No hospitalization require
vi. Convenient O.D. doses
vii. Decreased incidence of thrombocytopenia
viii. Osteopenia Unknown

22. 2. WARFARIN
 Oral anticoagulant, acts by indirectly interfering with the synthesis of
Vit. K dependent clotting factors in liver, 5-15 mg is started during first
week of heparin therapy as early as the first day if APTT is in
therapeutic range. Dose adjusted accordingly to P.T. INR should be
maintained 1.5-2.5 times control. Heparin can then be withdrawn
* Embryopathy includes: nasal hypoplasia, skeletal abnormalities, and
multiple central nervous system abnormalities.
 Antidote vitamin K 5mg I.V.
 Warfarin must be avoided in the first trimester and after 36 weeks
gestation.

23. ◦ Extend use of warfarin throughout puerperium
◦ Introduction of anticoagulant therapy in the next
pregnancy 2 weeks prior to symptoms of
previous pregnancy
◦ Use of LMWH in clients with cardiac prosthesis
and on bed rest during pregnancy
◦ Avoid use of estrogen containing contraceptives

24. Thank You