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Thrombo-embolic disease in obstetrics (Risk of deep vein thrombosis and…
Thrombo-embolic disease in obstetrics
Hemostasis changes during pregnancy: (Hypercoagulative status )
↑ factors of coagulation system
↓ anticoagulants
advantages: protects from bleeding
disadvantages: predisposes to thrombosis
↑ E2 during pregnancy → changes in coagulation system
Platelets in pregnancy
10% of pregnant women present thrombocytopenia
Thrombocytopenia – below 150x103/l
Level of antytrombin (AT)
It is higher in women than in men
No changes during pregnancy
↓ during labor
↓ in preeclampsia
Protein C during pregnancy: does not change
Protein S ↓ → decreased active form / increased binded form
Risk of deep vein thrombosis and pulmonary embolism in pregnancy
Main cause of mortality of pregnant women
Reasons of deep vein thrombosis during pregnancy:
Surgery during pregnancy
Hyperstimulation syndrome
Injuries, Neoplasms
Genetic defects in coagulation system
Higher risk
Antiphospholipid antibodies
Lupus Anticoagulant
Anticardiolipin antibodies
Genetic causes of high risk of thrombo-embolic disease
Mutation of factor V (Leiden)
Mutation of protrombin gene
Insufficiency of protein S
Insufficiency of protein C
Insufficiency of antithrombin III
Other factors increasing the risk of thrombo-embolic disease
Hyperemesis gravidarum, Obesity
Inflammation in bowel
Long-term peripheral intravenous catheters
Mutation Leiden type of factor V gene
G 1691 A
most common mutation
20% deep vein thrombosis
50% family thrombosis
OBSTETRICAL COAGULOPATHIES
Defects of hemostasis during pregnancy or peripartum period
Congenital coagulation problem
Disturbancies related to abnormal pregnancy or delivery
Efficiency of hemostasis depends on:
Vessels’ condition
Number and quality of platelets
Sufficiency of coagulation
Sufficiency of fibrynolysis
Prophylaxis
Mechanical
Elastic stockins
Pneumatic pressure
Stimulation of shin muscles contractions
Filters for vena cava inferior
Venous thrombo-embolic disease
deep vein thombosis
pulmonary thromboembolism
post-thrombotic syndrome
Etiology of venous thrombo-embolic disease (Virchow triad)
Leasion of the vessel wall
Disturbance in blood flow
Hypercoagulative status
Risk factors of thrombo-embolic disease
Age > 40 years, Obesity, Lower extremities varices, Immobilization, Heart stroke, History – venous embolism
Pregnancy and puerperium, Surgery >30 min (minor pelvis, lower extremities), Neoplasms, Trombophilias, Estrogens (OC, HRT)
Symptoms
Swelling
Pain during palpation
Pain of lower extremity
Increased diameter of superficial vessels
Deep vein thrombosis
diagnosis
US of lower extremities' veins
increased leukocytosis
increased D-dimer
decreased AT
differential diagnosis
Erisypelas
Lymphatic edema
Inflammation of the sciatic nerve
Lymphangitis
Ultrasound examination
Visualisation of main veins in lower extremities – femoral, popliteal vein
Congenital defects of the vessels – the most common thrombosis is in shin veins
Pulmonary thromboembolism
symptoms
Anxiety, Dyspnoea, Chest pain, Cough, Fever, Haemoptysis, Tachycardia, Tachypnoe
happens in normal pregnancy
Dyspnoea + tachypnoe
lower limb edema
fainting
hypoxemia (in lying position)
pulmonary embolism
Diagnosis
symptoms
dyspnea, collapse, chest pain, haematoptysis, faint
CT
Oral anticoagulants in pregnancy
cross placenta
do not cross to breast milk
have teratogenic effect – warfarin embriopathy (6-12 weeks GA)
bleeding to CNS of the fetus
maternal bleeding during delivery
Influence of warfarin on the fetal CNS
Bleeding to CNS of the fetus:
increased frequency of pregnancy losses
increased frequency of fetal demise (29.7-33.6%)
Indications for prophylactic heparin treatment during pregnancy
One episode of thrombo-embolic disease before pregnancy, correlated to one transient risk factor and absent other additional risk factors like immobilisation or obesity in presence – observation and introducing heparin therapy after delivery
One episode of thrombo-embolic disease related to pregnancy, estrogen use or present one additional risk factor
Patients with one episode of thrombo-embolic disease in history not treated presently and in petients with no episode of thrombo-embolic disease but with diagnosed thrombophilia
One episode of thrombo-embolic disease in history and confirmed thrombophilia or thromboembolism in family – doubled prophylactic dose
At least two episodes of thrombo-embolic disease or in chronic anticoagulants treatment – therapeutic doses
At least one episode of thrombo-embolic disease and presence of lupus anticoagulant or increased titers of antiphospholipid antibodies – treatment doses and acethylosalicylic acid
Anticoagulants during pregnancy
Unfractioned heparin
Low molecular weight heparin
Warfarin
Heparinoid (sodium danaparoid)
Dekstran, Thrombin inhibitors (hirudin)
Advantages of unfractioned and low weight molecular heparins
do not cross placenta
have no teratogenic effect
do not cause blood loss in the fetus
do not cause bleeding to placenta
Low weight molecular heparins have superiority over unfractioned heparin in pregnancy
less thrombocytopenia
only once a day
lower risk of osteoporosis
less allergies