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Dr Unnikrishnan PDr Unnikrishnan P

P.G.StudentP.G.Student

Medical College, TrivandrumMedical College, Trivandrum

Maternal CollapseMaternal Collapse

due to Embolismdue to Embolism

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THROMBOEMBOLISMTHROMBOEMBOLISM

AMNIOTIC FLUID EMBOLISMAMNIOTIC FLUID EMBOLISM

VENOUS AIR EMBOLISMVENOUS AIR EMBOLISM

Anaestesiologist is often involved in theAnaestesiologist is often involved in the

resuscitation of patients with embolicresuscitation of patients with embolic

disordersdisorders

IMPORTANT CAUSESIMPORTANT CAUSES

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VENOUS

.

THROMBO EMBOLISM

.

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Deep Vein Thrombosis [DVT] & PulmonaryDeep Vein Thrombosis [DVT] & Pulmonary

Thrombo Embolism [PTE] are the importantThrombo Embolism [PTE] are the important

manifestationsmanifestations

DVT is the most common etiology forDVT is the most common etiology for

Pulmonary Thrombo EmbolismPulmonary Thrombo Embolism

1515--24% of women with untreated DVT24% of women with untreated DVT

experience a pulmonary embolusexperience a pulmonary embolus

PTE accounts for 15% of direct maternalPTE accounts for 15% of direct maternal

mortalitymortality

VENOUS THROMBOEMBOLISMVENOUS THROMBOEMBOLISM

CHESTNTS OBSTETRIC ANESTHESIA, 4/e[2009],p:837,838

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Venous stasisVenous stasis

Vascular damage: caesarean > vaginalVascular damage: caesarean > vaginal

Obstetric conditions:Obstetric conditions:PIHPIH

Multiple pregnancyMultiple pregnancy

AETIOLOAETIOLO

VIRCHOWS TRIAD : HYPERCOAGULABILITY, STASIS, ENDOTHELIAL INJURY

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Increasing ageIncreasing age

Prolonged immobilizationProlonged immobilization

ObesityObesity

ThrombophiliaThrombophilia

Previous thromboembolismPrevious thromboembolism

Cesarean deliveryCesarean delivery

RISK FACTORSRISK FACTORS

ASRA GUIDELINES [THIRD EDITION];Reg Anesth Pain Med 2010

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PATHOPH SIOLOPATHOPH SIOLO

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PATHOPH SIOLOPATHOPH SIOLO

PaO

P(A-a)O

IMPAIRED GAS EXCHANGE

[DEAD SPACE,SHUNT,HYPOXEMIA,DECREASED DIFFUSION]

V/Q MISMATCH

ALVEOLAR HYPER VENTILATION

AIRWAY RESISTANCE

COMPLIANCE[EDEMA, HEMORRHAGE,LOSS OF SURFACTANT]

ATELECTASIS

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CLINICAL FEATURES: S MPTOMSCLINICAL FEATURES: S MPTOMS

DYSPNOEAPALPITATION

ANXIETY

CHEST PAIN [PLEURITIC]

COUGH

HEMOPTYSIS

SYNCOPE

COLLAPSE

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CLINICAL FEATURES: SI NSCLINICAL FEATURES: SI NS

TACHYPNOEA

CREPITATION

ED BREATH SOUNDS

FEVER

TACHYCARDIA

ACCENTUATED S

JUGULAR VENOUS DISTENSION

LEFT PARASTERNAL HEAVE

HEPATIC ENLARGEMENT

THROMBOPHLEBITIS/ FEATURES OF DVT

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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 ofDVT 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 4 - PE likely. Consider diagnostic imaging.

Score 4 or less - PE unlikely. ConsiderD-dimerto rule out PE.

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ECEC

DIA NOSTIC EVALUATIONDIA NOSTIC EVALUATION

RV STRAIN PATTERN

RIGHT AXIS DEVIATION

P-PULMONALET INVERSION IN V-V

SUPRAVENTRICULAR ARRHYTHMIAS

SQT PATTERN:

DEEP S IN L DEEP Q IN L T INVERSION IN L

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CHEST XCHEST X--RARA

DIA NOSTIC EVALUATIONDIA NOSTIC EVALUATION

BLANCHING / OLIGEMIC AREA

WESTERMARKS SIGN

HAMPTONS HUMP

ELEVATED HEMIDIAPHRAGM

FOCAL INFILTRATES

PLEURAL EFFUSIONATELECTASIS

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HAMPTONS HUMP

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INVASIVE HEMOD NAMIC MONITORININVASIVE HEMOD NAMIC MONITORIN

ARTERIAL BLOOD AS ANAL SISARTERIAL BLOOD AS ANAL SIS

ELISA FOR DELISA FOR D--DIMERDIMER

DIA NOSTIC EVALUATIONDIA NOSTIC EVALUATION

NORMAL TO LOW PULMONARY ARTERY OCCLUSSION

PRESSURE

INCREASED MEAN PULMONARY ARTERY PRESSURE

INCREASED CVP

WIDENED P(A-a)O

REDUCED PaO

REDUCED PaCO

HIGH SENSITIVITY ESPECIALLY WHEN COMBINED WITH A USG

OF LEG

LOW SPECIFICITY, SINCE D-DIMER APPEARS IN NORMAL

PREGNANCY SINCE SECOND TRIMESTER

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VENTILATION PERFUSION SCANVENTILATION PERFUSION SCAN