Thrombo embolic disorders in postnatal period, causes, types, management, nursing management

2. “
In most parts of the world this is overshadowed by other complications of
pregnancy which amount for a much grater proportion of maternal mortality and
morbidity. In developed countries, however, as mortality from other causes has
been reduced, thromboembolism has emerged as a leading cause of maternal
death. Physiological adaptation of pregnancy involves changes in the coagulation
system, which promote coagulation system and impair fibrinolysis. A side effect of
this change is an increased risk of Thrombosis, compared with non-pregnant
women. Here, we will discuss about Thromboembolic Disorders in Post-natal
Period.
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Introduction

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Definition
Thromboembolic Disorder is the formation of clots (Thrombus) in blood
vessels that breaks loose and carried by the blood stream to plug
another vessels.
The clot may plug a vessel in the lungs (Pulmonary Embolism),
brain (stroke), gastrointestinal tract, kidneys or legs.

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Incidence and Background
Thromboembolic disorders remains one of the main direct causes of maternal
death in UK and other developed countries.
• It is leading non-obstetrical cause of maternal mortality.
• Incidence of 0.05%-0.3%
• The risk of thromboembolism during pregnancy and the postpartum
period is 10 times grater than that for non-pregnant patients.
• Mortality rate of 15%.
• 1 in 100,000 women of childbearing age.
• 1/1000 pregnancies in women under the age of 35.
• 4/1000 pregnancies in women over the age of 35.
• Risk per day is actually greatest in the weeks following delivery.
• 10-20% of VTEs are PEs.

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• Presentation is similar to non-pregnant patients with DVT or PE.
• PTE occurs most often secondary to DVT occur after-
 Superficial vein thrombosis
 Puerperal septic vein thrombosis
 Puerperal ovarian vein thrombosis
• Most of them occur between 15-20 weeks of gestation.
• Superficial vein thrombosis
0.15% can occur during the antepartum period and incidence increases 8 fold into
postpartum period.
• Puerperal ovarian vein thrombosis
0.025%
• Septic pelvic vein thrombosis
0.1%
Continued-

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Related anatomy and physiology

8. Anticoagulant and Fibrinolytic Pathways
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9. Changes in Pregnancy
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10. Classification of TED
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11. Thromboembolic Disorders in Post-natal Mothers
Thrombosis of the leg veins and pelvic veins is one of the most common and important
complications in puerperium period especially in Western countries.
 Venous Thromboembolism
Venous Thromboembolism is a condition in which a blood clot forms most often in
deep veins of the leg, groin or arm (known as DVT-Deep Vein Thrombosis). Risk
for postpartum venous thromboembolism is highest during the first 3 weeks after
delivery.
Pregnancy & Puerperium one well established risk factors for venous
thromboembolism (VTE), a disease that includes pulmonary embolism (PE) &
Deep Vein Thrombosis (DVT)
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12. Pathogenesis
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13. Risk Factors
 High Risk:
 Previous VTE (Venous
Thrombo-embolism)
 Thrombophilia
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14. Risk Factors
 Intermediate risk:
 Heart Disease
 SLE (Systemic Lupus Erythromatosus)
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15. Risk Factors
 Low Risk:
 Age>35 years
 Obesity (BMI>35)
 Parity ≥3
 Immobility
 Dehydration
 Hyperemesis
 Multiple Pregnancy
 Surgical Procedure preferred
is- LUCS (Lower Uterine
Cesarean Section)
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16. I. Deep Vein Thrombosis
Deep Vein Thrombosis or DVT is a blood clot that forms in a deep vein inside the body.
DVT usually occurs in a deep leg vein that runs through the muscle of the calf and the
thigh. Blood clots from when blood thickness and clumps together.
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17. Deep Vein Thrombosis
 Symptoms:
 Pain in calf muscle.  Edematous legs
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Clinical diagnosis is unreliable. It remains asymptomatic.

18. Deep Vein Thrombosis
 Rise in skin temperature
 A positive Homan’s Sign
 On examination asymmetric leg
edema ( Difference in
circumference between the affected
and the normal leg more than 2 cm)
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19. Deep Vein Thrombosis
 Investigations:
 Venous USG- It is done by placing the transduces over the femoral vein and
then gradually it is moved to the great saphenous vein, the popliteal vein
& to its branches with the deep veins of the calf.
 Doppler USG- The most accurate ultrasound criteria for diagnosis of
venous thrombosis.
 Venography- By injecting non-ionic water soluble radio-opaque dye to note
the filling defect in the venous lumen is a reliable method if case is fully
interpreted. Venogram is restricted in pregnancy due to the risk of radiation
and contrast allergy.
 Magnetic Resonance Imaging- It is helpful to detect thrombosis in pelvic,
iliac, femoral vein. The sensitivity and specificity of MRI in the diagnosis of
DVT are 100% and the accuracy is 96%.
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Doppler USG
Venous USG
MRI

21. II. Pelvic Thrombophlebitis
Postpartum Thrombophlebitis originates in the thrombosed veins at the placental site by
organism such as streptococci or bacteroides (fragilis), when it is localized in the pelvis,
it is called pelvic thrombophlebitis.
 Extra-pelvic Spread:
i. Through the right ovarian vein into
Inferior vena cava and then to the lung.
ii. Through the right ovarian vein to the left
renal vein and then to left kidney.
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22. Pelvic Thrombophlebitis
 Clinical Features:
There is no specific clinical features of pelvic thrombophlebitis, but it should be
suspected in cases where the pyrexia continues for more than a week inspite of antibiotic
therapy.
 It usually develops on the 2nd week of puerperium.
 Mild pyrexia is common prior to the dramatic local manifestation.
 Fever, chills and rigor.
 Headache, Tachycardia,features of toxemia.
 The affected leg is swallowen, painful, white & cold.
 Polymorphonuclear Leukocytosis.
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23. Pelvic Thrombophlebitis
 Investigations:
 Venous USG
 CT scan
 MRI
 Heparin Therapy (When the symptoms
improve with heparin, diagnosis is confirmed)
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CT SCAN

24. III. Pulmonary Embolism
Pulmonary Embolism is a blockage in one of the pulmonary arteries in the lungs. In most
cases, Pulmonary Embolism is caused by blood clots that travel to the lungs from deep
veins in the legs or rarely, from veins in other parts of the body (deep vein thrombosis).
It is the leading cause of maternal death in many developing countries.
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25. Pulmonary Embolism
 Sign and Symptoms:
 Tachypnea (>20b/m)
 Dyspnea
 Cough
 Tachycardia (>100b/m)
 Hemoptyosis and increased temperature.
 Pleuritic Chest Pain
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Pleuritic Chest Pain

26. Pulmonary Embolism
 Diagnosis:
 X-Ray of Chest- Shows diminished vascular marking in areas of infraction.
 ECG- Tachycardia, ST changes, Right Bundle Branch Block.
 ABG- PO2 >85 mmHg, saturation <95%
 D-dimer- A negative D-Dimer value.
 Doppler Ultrasound- Can identify a DVT.
 Lung Scan- Ventilation/Perfusion Scan detect areas of diminished blood
flow.
 Magnetic Resonance Angiography
 Pulmonary Angiography
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MR Angiography & Pulmonary Angiography

28. Management
 Active Treatment:
• Resuscitation-
 Cardiac Massage
 Oxygen Therapy
 IV heparin bolus dose of 5000 IU and morphine 15 mg are given.
 LMWH (enoxaparin 1 mg/kg,S/C×BD) maybe used.
 Anticoagulant continued for 6 weeks to 6 months.
 IV fluid support is continued and blood pressure is monitored if
needed Dopamine or Adrenaline.
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29. Management
 Embolectomy
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 Surgical Management

30. Video Reference….
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31. Management
 Placement of inferior caval filter or ligation of inferior vena cava and ovarian
veins.
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32. Management
 A low risk woman who has – no family history of VTE and is heterozygous for
factor-V mutation.
 Management-
 Need no thromboprophylaxis.
 Early mobilization is needed.
 Hydration to be maintained properly.
 A woman with high risk-
 Management-
 Low molecular weight heparin (LMWH) prophylaxis needs
throughout pregnancy and postpartum 6 weeks
 Immediate Risk woman with 3 or more risk factors-
 Management- Management at puerperium period not only means
manage after delivery. VTE is such a condition which needs early
diagnosis and treat it throughout pregnancy to prevent massive
complications during puerperium. 32

33. Gross Management
 The patient is put to bedrest with the foot end raised above the heart level.
 Analgesics must be used to relieve pain or affected area.
 Administration of the anticoagulant therapy should be continued till all evidences
of the disease have disappeared which generally take 3-6 months. The
anticoagulant therapy is safe for breastfeeding.
 As soon as the pain subsides, gentle movement is allowed on bed by the end of 1st
week.
 High quality elastic stockings are fitted on the affected leg before mobilization.
 Inferior Vena Cava filters are used for patient with recurrent pulmonary
embolism or where anticoagulant therapy is contraindicated
 Venous thrombolectomy is needed for massive illio-femoral vein thrombosis.
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34. Nursing Management
 In postnatal period good observation of the mother must be done.
 When pain is present then analgesics must be given.
 Making the client wear prescribed compression stocking to help circulation in the
leg.
 Elevation of affected extremity.
 Drink plenty of water.
 Leg exercise must be shown to the mother.
 LMWH is given to reduce risk of a pulmonary embolism and reduce risk of
developing another clot in the leg.
 Antibiotic must be administered as per doctor’s order.
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35. Prevention
 Prevention of trauma,sepsis,anemia in pregnancy and labour.
 Dehydration during delivery should be avoided.
 Use of elastic compression stocking and intermittent pneumatic compression
devices during surgery.
 Leg exercise, early ambulation are encouraged following operative delivery.
 A high risk woman is one who has previous venous thromboembolism or anti-
thrombin deficiency she needs low-molecular weight heparin throughout
pregnancy and post-partum 6 weeks.
 Regardless of their venous thrombo-embolism immobilization of the patient should
be avoided throughout pregnancy.
 Mothers should be encouraged for early mobilization during postnatal period.
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36. Complication
 Venous-
 Deep Vein Thrombosis
 Portal Vein Thrombosis
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37. Complications
 Renal Vein Thrombosis  Cerebral Venous Sinus Thrombosis
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38. Complications
 Arterial-
 Pulmonary Embolism
 Stroke
 Dysrhythmias
 Pulmonary HTN
 Coronary Artery Puncture
 Myocardial Infraction
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Coronary Artery Puncture

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Myocardial Infraction & Dysrhythmia

40. Health Teaching
 Mother should be advised to bed rest with the foot end raised above the heart level.
 Elastic stocking must be fitted on the affected legs
 When pain present then as per doctor’s order analgesics can be taken.
 When pain is relieved then gentle movement is allowed on bed by the end of 1st
week.
 Must wear loose fitting cloths.
 Psychological support should be given.
 Leg exercise should be performed and early ambulation is encouraged.
 Don’t drink alcohol and take light meals.
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THANKS!
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