Thromboembolic ds in pregnancyghhjjjk.pptx

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1. THROMBEMBOLIC DISORDERS IN PREGNANCY Ishita gupta

2. Increase in clotting factors (fibrinogen, VIII, IXandX ) Decreased fibrinolytic activity Decrease in endogenous anticoagulants like antithrombin III and protein S Venous stasis During delivery

3. ADDITIONAL RISK FACTORS PREEXISTING : Previous venous thromboembolism Congenital thrombophilia Acquired thrombophilia Age over 35 years Obesity Parity >4 Sickle cell disease SLE

4. ADDITIONAL RISK FACTORS DURING PREGNANCY : Operative delivery, especially caesarean section Immobilisation Prolonged labour Surgery in pregnancy Ovarian hyperstimulation syndrome Hyperemesis Severe infections and puerperal sepsis Preeclampsia Dehydration Haemorrhage and anaemia Multifetal gestation

5. DEEP VEIN THROMBOSIS

6. CLINICAL FEATURES swelling redness pain calf muscle tenderness claudication

7. INVESTIGATIONS Ultrasound and Doppler: non invasive, beneficial in diagnosing iliofemoral thrombosis. Venography: gold standard, abdominal shielding should be used. Impedance plethysmography is extremely accurate for the lower iliac, femoral and popliteal veins. It CT and MRI D-dimers: false positive rate is high.

8. USG

9. VENOGRAPHY

10. MANAGEMENT

11. MANAGEMENT UNFRACTIONATED HEPARIN Can be given as IV bolus followed by IV infusion. Doses of heparin as high as 40,000 units in 24 hours may be necessary. IV anticoagulation should be maintained for at least 5-7 days , followed by subcutaneous heparin. MONITORING: APTT and platelet count weekly, risk of HIT [heparin induced thrombocytopaenia ]. APTT should be measured 4-6 hours after the loading dose, 6 hours after any dose change and then, at least daily when in the therapeutic range. THERAPEUTIC TARGET APTT is usually 1.5-2.5 times the average laboratory control value.

12. MANAGEMENT LMWH Enoxaparin or Clexane: 1 mg/kg twice daily Stopped 24 hrs before delivery, restart 6-12 hr after delivery Avoid regional anaesthesia - hematoma MONITORING: Anti-Xa levels, at extremes of body weight, >0.1 U/ml

13. MANAGEMENT WARFARIN Commenced simultaneously with enoxaparin after delivery Given for a minimum of 6 weeks MONITORING: INR 2-3 , stop heparin

14. MANAGEMENT LMWH Enoxaparin or Clexane: 1 mg/kg twice daily Stopped 24 hrs before delivery, restart 6-12 hr after delivery Avoid regional anaesthesia - hematoma MONITORING: Anti-Xa levels, at extremes of body weight, >0.1 U/ml

15. COMPLICATIONS Haemorrhage Heparin induced thrombocytopaenia Heparin induced osteoporosis

16. PULMONARY EMBOLISM

17. CLINICAL FEATURES

18. INVESTIGATIONS Chest X-ray to rule out other causes ECG: right axis deviation and T wave -inversion Low oxygen saturation with pulse oximetry Arterial blood gas : hypoxemia and hypocapnia Ventilation-perfusion scan : ventilation perfusion mismatch Pulmonary angiography in severe cases, but is invasive Multidetector spiral CT pulmonary angiography

19. MANAGEMENT Similar to that of deep vein thrombosis with high doses of IV infusion of heparin A loading dose of 80 units/kg followed by an IV infusion of 18 units/kg/hour Other treatment modalities: vena caval filters thrombolytic therapy pulmonary embolectomy in massive embolism

20. THROMBOPROPHYLAXIS RISK CATEGORY RISK FACTORS High risk • Recurrent TE • Previous TE with thrombophilia • Previous TE with family history TE in current pregnancy Low risk •· One episode of previous TE w/o thrombophilia of family history • Thrombophilia without previous thrombosis Additional risk Obesity C- Section Grand multiparity Age above 35 years Preeclampsia Prolonged immobilisation

21. If total score ≥4 antenatally, consider thrombop-rophylaxis from the first trimester. If total score 3 antenatally, consider thromboprophylaxis from 28 weeks. If total score ≥2 postnatally, consider thromboprophylaxis for at least 10 days.  If admitted to hospital antenatally, consider thromboprophylaxis. If prolonged admission (≥3 days) or readmission to hospital within the puerperium consider thromboprophylaxis

22. THROMBOPROPHYLAXIS AGENTS USED: LMWH: Enoxaparing 40mg/day

23. CEREBRAL VENOUS THROMBOSIS

24. CLINICAL FEATURES Severe headache Drowsiness Convulsions Aphasia Visual Disturbance Focal neurological deficits

25. PREDISPOSING FACTORS Preeclampsia Thrombophilia Sepsis Dehydration

26. INVESTIGATIONS MRI with venography

27. MANAGEMENT Heparin – anticoagulation ASM- Seizure Antibiotics- Septic thrombophlebitis