1. Maternal Collapse due to Embolism Dr Unnikrishnan P P.G.Student Medical College, Trivandrum
2. IMPORTANT CAUSES THROMBOEMBOLISM AMNIOTIC FLUID EMBOLISM VENOUS AIR EMBOLISM Anaestesiologist is often involved in the resuscitation of patients with embolic disorders
3.
4. VENOUS THROMBOEMBOLISM Deep Vein Thrombosis [DVT] & Pulmonary Thrombo Embolism [PTE] are the important manifestations DVT is the most common etiology for Pulmonary Thrombo Embolism 15-24% of women with untreated DVT experience a pulmonary embolus PTE accounts for 15% of direct maternal mortality CHESTNT’S OBSTETRIC ANESTHESIA, 4/e[2009],p:837,838
5. AETIOLOGY Changes in coagulation SHNIDER AND LEVINSONS ANESTHESIA FOR OBSTETRICS,4/e
12. The Wells score clinically suspected DVT - 3.0 points alternative diagnosis is less likely than PE - 3.0 points Tachycardia - 1.5 points immobilization/surgery in previous four weeks - 1.5 points history of DVT or PE - 1.5 points hemoptysis - 1.0 points malignancy (treatment for within 6 months, palliative) - 1.0 points Traditional interpretation Score >6.0 - High Score 2.0 to 6.0 - Moderate Score <2.0 - Low Alternate interpretation Score > 4 - PE likely. Consider diagnostic imaging. Score 4 or less - PE unlikely. Consider D-dimer to rule out PE.
21. PROPHYLAXIS Decreases the risk 10 fold Begun when the high risk period begins and continued for 5-10 days UFH : 5000 U subcutaneously Q12H Enoxaparin : 40 mg subcutaneously Q24H Ensure availability of FFP at the time of delivery
22. THERAPY - DVT UNFRACTIONATED HEPARIN [UFH]# #Sipes SL,Venous thromboembolic disease in pregnancy ;Semin Perinatol 1990 #American College of Obst & Gyn Comm. on practice;ACOG Practice bulletin no:19,AUG2000
23. THERAPY - DVT LOW MOLECULAR WEIGHT HEPARIN [LMWH] Enoxaparin 40 MG OD-BD [1 MG = 100 U] PROPHYLAXIS 30-80 MG BD THERAPEUTIC ANTICOAGULATION Dalteparin 2500-5000 U OD-BD THROMBOPROPHYLAXIS 100 U/KG BD THERAPEUTIC ANTICOAGULATION #Sipes SL,Venous thromboembolic disease in pregnancy ;Semin Perinatol 1990 #American College of Obst & Gyn Comm. on practice;ACOG Practice bulletin no:19,AUG2000
25. PULMONARY EMBOLISM-TREATMENT # #American College of Obst & Gyn Comm. on practice;ACOG Practice bulletin no:19,AUG2000 #Weiner CP et al; management of thromboembolic disease during pregnancy; Clinical ObstetGynecol 1985
46. VENOUS AIR EMBOLISM Malinow et al published the first study of VAE during cesarean delivery in 1987¹ Subclinical VAE occurred in 97% of patients receiving GA for cesarean delivery² VAE occurred in approx 67% of patients receiving neuraxial anesthesia³ 1.Malinow AM et al,Anesthesiology 1987 2.Lew TWK et al, VAE during CS,Anesth Analg 1993 3.Handler JS,VAE during CS RegAnesth 1990
55. PREVENTION 5-10⁰ HEAD UP TILT WHEN UTERUS IS EXTERIORIZED PRECORDIAL DOPPLER MONITORING IN HIGH RISK CASES ADEQUATE HYDRATION TO RAISE CVP AND LA PRESSURE
58. Why Mothers Die 2004-2005 Report; the Confidential Review of Maternal Deaths in Kerala
59. ASA Abstracts, Cardiac Arrest during Labor: Amniotic Fluid Embolism with Thrombus in Patent Foramen Ovale. AparnaDalal, M.D., Mark Shulman, M.D. Anesthesiology, Caritas St. Elizabeth's Medical Center, Boston, MA, Anesthesiology 2008; 109 A1337
60. Martin SR, Foley MR. Intensive care in obstetrics: an evidence-based review. Am J Obstet Gynecol. 2006 Sep;195(3):673-89.
61. Porat S, Leibowitz D, Milwidsky A, Valsky DV, Yagel S, AntebyEY.Transient Intracardiac thrombi in Amniotic fluid embolism.BCOG. 2004 May;111(5):506-10.