VVenous complications enous complications in pregnancy and in pregnancy and

puerperiumpuerperium

ASSOCIATE PROFESSOR ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU IOLANDA ELENA BLIDARU

MD, PhDMD, PhD

Venous DisordersVenous Disorders

Varicose VeinsVaricose Veins

Deep Vein Thrombosis (DVT)Deep Vein Thrombosis (DVT)

PPulmonary ulmonary ThromboThromboeembolismmbolism (PTE)(PTE)

SuperficialSuperficial Venous Venous Thrombosis (ThrombophlebitisThrombosis (Thrombophlebitis))

Varicose VeinsVaricose Veins

PregnancyPregnancy

– Increased blood volumeIncreased blood volume

– Pressure on veinsPressure on veins

– Relaxation effect of hormonesRelaxation effect of hormones

Varicose VeinsVaricose Veins ManagementManagement

– Non OperativeNon Operative Self resolvingSelf resolving (within six weeks) (within six weeks)

– After 6 weeksAfter 6 weeks if problematic/ unacceptableif problematic/ unacceptable

– Graduated Compression Graduated Compression StockingsStockings

– SurgerySurgery

Varicose VeinsVaricose Veins

Before Treatment After Treatment

Varicose VeinsVaricose Veins

Superficial Superficial Venous Venous Thrombosis Thrombosis (Thrombophlebitis)(Thrombophlebitis)

Benign /Self limiting DiseaseBenign /Self limiting Disease

1% 1% of patients; always in of patients; always in existing varicous veinsexisting varicous veins

Can progress to deep vein Can progress to deep vein thrombosis (11%)thrombosis (11%)

Associated with abnormalities Associated with abnormalities

in blood coagulationin blood coagulation

Superficial ThrombophlebitisSuperficial Thrombophlebitis

Etiologic factorsEtiologic factors TraumaticTraumatic Varicose VeinsVaricose Veins PregnancyPregnancy Infection Infection (e.g. Staph., Pseud., Klebs., Anaerobes)(e.g. Staph., Pseud., Klebs., Anaerobes)

Superficial ThrombophlebitisSuperficial Thrombophlebitis

DiagnosisDiagnosis– Painful cord like structurePainful cord like structure– Redness along the veinRedness along the vein– TendernessTenderness– FeverFever

InvestigationsInvestigations– Duplex ultrasonography (duplex scan)Duplex ultrasonography (duplex scan)

Superficial ThrombophlebitisSuperficial Thrombophlebitis

ManagementManagement– Underlying disorderUnderlying disorder– Remove offending agents Remove offending agents (e.g. IV cannula)(e.g. IV cannula)

– AntibioticsAntibiotics– NSAIDsNSAIDs– Excision of the suppurating vein Excision of the suppurating vein – Elevation of the extremityElevation of the extremity– Anticoagulants ?Anticoagulants ?

DEEP DEEP VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM DURING PREGNANCYDURING PREGNANCY

LEADING CAUSE OF LEADING CAUSE OF DEATH DEATH

2 /1000 PREGNANCIES2 /1000 PREGNANCIES

5 times higher in 5 times higher in pregnancypregnancy

venous stasis of venous stasis of pregnancypregnancy

Physiological changes Physiological changes associated with associated with pregnancypregnancy

DEEP DEEP VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM

DURING PREGNANCY - DURING PREGNANCY - PathophysiologyPathophysiology

Independent risk Independent risk factorsfactors

Prolonged Prolonged bbed rested rest Multiparity (>3)Multiparity (>3) Advanced Advanced

mmaternal aternal aage ge (>35yrs)(>35yrs)

OverweightOverweight Personal or family Personal or family

history of VTEhistory of VTE Pre-eclampsiaPre-eclampsia

Alteration in Alteration in Coagulation / Coagulation / Fibrinolytic SystemFibrinolytic System Factor II, VII, X Factor II, VII, X (middle (middle

of pregnancy)of pregnancy) FibrinFibrin Protein SProtein S Protein CProtein C Fibrinolytic System Fibrinolytic System

inhibited (mostly 3rd inhibited (mostly 3rd trimester)trimester)

DEEP DEEP VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM DURING PREGNANCYDURING PREGNANCY

DiagnosisDiagnosis– Calf veins or Calf veins or iilio-femoral segmentlio-femoral segment– Predilection for left sidePredilection for left side

SSigns and symptomsigns and symptoms swellingswelling tendernesstenderness skin discolorationskin discoloration warm to touchwarm to touch unusual firmness /hardness in the legunusual firmness /hardness in the leg calf discomfort on dorsiflexion (calf discomfort on dorsiflexion (HHomans’ sign)omans’ sign) prominent tender cord like subcutprominent tender cord like subcutaneousaneous vein vein

VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM DURING PREGNANCYDURING PREGNANCY

Diagnostic testsDiagnostic tests

1.1.Venography Venography (Phlebography)(Phlebography)

VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM DURING PREGNANCYDURING PREGNANCY

Diagnostic testsDiagnostic tests2. Duplex 2. Duplex uultrasonographyltrasonography

Duplex US:

combines Doppler flow information & conventional imaging information .

Shows how blood is flowing through vessels & measures the speed of blood flow  

Estimate the diameter of a blood vessel as well as the amount of obstruction

VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM DURING PREGNANCYDURING PREGNANCY

Diagnostic testsDiagnostic tests 3. Spiral CT Venography3. Spiral CT Venography

No filling of calf veins Opacification of collaterals

Diagnostic testsDiagnostic tests

4. 4. Impedance plethysmography Impedance plethysmography (IPG)(IPG)5. MRI5. MRI6. D-dimer6. D-dimer testtest

→ → fibrin degradation product fibrin degradation product (or FDP)(or FDP) = = a small protein a small protein fragment present in the blood after a blood clot is degraded by fragment present in the blood after a blood clot is degraded by fibrinolysis fibrinolysis → → contains two crosslinked D fragments of the fibrinogen contains two crosslinked D fragments of the fibrinogen proteinprotein

D-dimer concentration D-dimer concentration →→ to help diagnose to help diagnose thrombosisthrombosis andand disseminated intravascular disseminated intravascular coagulationcoagulation..

VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM DURING PREGNANCYDURING PREGNANCY

Pulmonary EmbolismPulmonary Embolism

Major nonobstetric Major nonobstetric cause of maternal cause of maternal mortalitymortality

Cause of DeathCause of Death– 2 / 100,000 maternities2 / 100,000 maternities

Maximum – PeripartumMaximum – Peripartum More after operative More after operative

interventionintervention Subtle presentationSubtle presentation

DVT is suspected byDVT is suspected by:: Acute leg pain,Acute leg pain, Swelling, Redness Swelling, Redness Tenderness. Tenderness.

PTE is suspected byPTE is suspected by Acute chest painAcute chest pain Shortness of breath.Shortness of breath. HaemoptysisHaemoptysis HypotensionHypotension Cyanosis occur in massive PTE.Cyanosis occur in massive PTE.

Thromboembolic disease in Thromboembolic disease in pregnancy and puerperiumpregnancy and puerperium

Pulmonary EmbolismPulmonary Embolism

Diagnostic testsDiagnostic tests

1.1.Pulmonary AngiographyPulmonary Angiography

2.2.Spiral CT ScanSpiral CT Scan

Pulmonary EmbolismPulmonary Embolism Diagnostic testsDiagnostic tests

3.Nuclear Imaging 3.Nuclear Imaging (Ventilation-Perfusion Scan)(Ventilation-Perfusion Scan)

VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM DURING PREGNANCYDURING PREGNANCY

PROPHYLAXISPROPHYLAXIS

– Risk AssessmentRisk Assessment

– Present statusPresent status

VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM DURING PREGNANCYDURING PREGNANCY ManagementManagement

– Medical/PharmacologicalMedical/Pharmacological AnticoagulationAnticoagulation Anti-platelet agentsAnti-platelet agents

– SurgicalSurgical Venous Thrombectomy (Ilio-femoral DVT), Pulmonary Venous Thrombectomy (Ilio-femoral DVT), Pulmonary

EmbolectomyEmbolectomy ThrombolysisThrombolysis

– EndovascularEndovascular Inferior vena cava filter placement Inferior vena cava filter placement (IVC Filter (IVC Filter

placement)placement)– OthersOthers

HydrationHydration Early MobilizationEarly Mobilization Graduated Compression StockingsGraduated Compression Stockings Pneumatic compression devicesPneumatic compression devices

VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM DURING PREGNANCYDURING PREGNANCY Medical/Medical/

PharmacologicalPharmacological– Unfractionated Unfractionated

Heparin/LMWHHeparin/LMWH

– Oral AnticoagulationOral Anticoagulation

– Antiplatelet agentsAntiplatelet agents

– New MoleculesNew Molecules

Direct Thrombin Inhibitors Direct Thrombin Inhibitors

((Lepirudin,Lepirudin, D Desirudin,esirudin,

Argatroban,Argatroban, Ximelagatran)Ximelagatran)

Surgical – Surgical – ThrombolysisThrombolysis

VENOUS VENOUS THROMBOEMBOLISM THROMBOEMBOLISM DURING PREGNANCYDURING PREGNANCY PROPHYLAXIS IN CESARIAN SECTIONPROPHYLAXIS IN CESARIAN SECTION

– Low RiskLow Risk Early Mobilization Early Mobilization HydrationHydration

– Moderate RiskModerate Risk One of variety of prophylactic measuresOne of variety of prophylactic measures

– Subcutaneous HeparinSubcutaneous Heparin– Mechanical devicesMechanical devices

– High RiskHigh Risk Heparin Prophylaxis +/- Leg StockingsHeparin Prophylaxis +/- Leg Stockings