Thromboembolic disease In obstetrics and Gynaecology

1. Aboubakr Elnashar

2.  UK: Pulmonary embolism (PE) is the most common
cause of maternal mortality (16.5%)
(TED, PIH, Haemorrhage).
 Egypt: PE represents 6% of maternal mortality
(Haemorrhage, PIH, TED).
Aboubakr Elnashar

3. Aboubakr Elnashar

4. Pregnancy and childbirth are associated
with 10 fold increased risk of TED
 { Stasis.
 Increased coagulation factors.
 Trauma during delivery}.
Aboubakr Elnashar

5.  All women should undergo an assessment of risk
factors for VTE in
early pregnancy or before pregnancy &
should be repeated if the woman is admitted to
hospital or develops other intercurrent problems.
Aboubakr Elnashar

6. At booking
 Age over 35 years.
 Obesity :BMI>30.
 Past history of
DVT/PE.
 Family history of TED.
 Anti-phospholipid
syndrome.
During pregnancy
•Dehydration: HG,GE,
diarrhoea.
•Prolonged bed rest.
•Immobilisation.
•Pre-eclampsia
•Gross varicose veins.
At & after delivery
•Prolonged active labour >12
hours.
•Emergency C/S.
•Caesarean hysterectomy.
•Prolonged bed rest
•Immobilisation.
Aboubakr Elnashar

7. Aboubakr Elnashar

8.  Women with a previous VTE should have:
1. Careful history documented and
2. Undergo screening for both inherited and acquired
thrombophilia,
ideally before pregnancy.
Aboubakr Elnashar

9. A) During pregnancy.
B) Following C/S.
C) Following vaginal deliveries.
D) During travelling by air.
Aboubakr Elnashar

10. A) Thrombo-prophylaxis during
pregnancy
 Women with past history of TED during a previous
pregnancy or puerperium should receive
heparin/LMWH.
With no added risk factors --- heparin/LMWH before
the time of the previous TED till 6 weeks postpartum.
With multiple episodes of TED heparin/LMWH
throughout pregnancy till 6 weeks postpartum (shift to
oral after delivery).
Aboubakr Elnashar

11. B) Thrombo-prophylaxis following C/S
(RCOGguidelines).
1) Low risk group:
 Elective C/S
 Uncomplicated pregnancy.
 No added risk factors.
Early mobilisation and hydration.
Aboubakr Elnashar

12. 2) Moderate risk group
Patients with any one of:
 Age >35 years
 Obesity >80Kg.
 Parity 4 or more.
 Active labour >12 hs
 Gross varicose veins.
 Current infection(>4days).
 Pre-eclampsia.
 Immobility
 Major current illness: heart or lung disease,
cancer, IBD, NS.
Aboubakr Elnashar

13. 3) High risk group
3 or more moderate risk factors.
 Major surgery: caesarean hysterectomy.
 Past or family history of DVT/PE.
 Thrombophilia, immobile patients .
 Antiphospholipid syndrome.
Heparin/LMWH + leg stockings for 5 days.
Aboubakr Elnashar

14. C) Thrombo-prophylaxis following vaginal delivery
1) Low risk: uncomplicated delivery
 Early mobilisation & avoid dehydration.
2) Moderate risk: 2 risk factors.
 Heparin/LMWH sc daily till discharge.
3) High risk: 4 or more risk factors.
 Heparin/LMWH sc+ Elastic stokings till discharge
Aboubakr Elnashar

15. Timing
 Antenatal thromboprophylaxis:
as early in pregnancy as practical.
 Postpartum prophylaxis:
as soon as possible after delivery provided that there
is no postpartum haemorrhage.
 Postpartum haemorrhage
should be fitted with thromboembolic deterrent
stockings.
B
Aboubakr Elnashar

16.  Regional analgesia:
LMWH should be withheld until four hours after
insertion or removal of the epidural catheter (or six
hours if either insertion or removal were traumatic).
The first postpartum dose can be given after insertion
but before removal of the epidural catheter.
Aboubakr Elnashar

17. Duration of postpartum thromboprophylaxis
 High risk: 6 w
 Lower risk: 3-5 days
{The prothrombotic changes of pregnancy do not
revert completely to normal until several weeks
after delivery}
Aboubakr Elnashar

18. D) Thrombo-prophylaxis
during travelling by air
Risk factor Short haul flight
<4 hours
Long haul flight
>4hours
No added
risk
Move around cabin
Avoid dehydration
Minimise coffee
The same+
Well fitted below knee
elastic stockings.
Added risk
factors
The same +
Well fitted below knee
elastic stockings.
LMWH pre-flight and
the day after
Or 75 mg Aspirin 3 days
before & on day of travel.
Aboubakr Elnashar

19. Aboubakr Elnashar

20. Dose
• Unfractionated heparin: 5000-10000 u /12 h.
• LMWH:
Dalteparin (Fragmin): 2500-5000 u /24 h.
Enoxoparin (Clexane): 20-40 u /24 h.
Tinzaparin (Innohip) : 3500-4500 u /24 h.
• Oral anticoagulants are indicated in patients with
cardiac valve replacement only.
Heparin
Aboubakr Elnashar

21. Aboubakr Elnashar

22. Monitoring
 Heparin: APTT.
 LMWH by Xa (not available in Egypt).
(Monitoring is not required for short term treatment).
 Platelet count every 2 weeks.
 Oral anticoagulants by INR (International
normalization Ratio), usually weekly.
Aboubakr Elnashar

23. Contraindications to heparins
 Haemorrhagic disorders: haemophilia.
 Thrombocytopenia.
 Peptic ulcer.
 Recent cerebral hge.
 Severe hypertension.
 Severe liver disease.
Aboubakr Elnashar

24. Side effects of prolonged heparin therapy
 Haemorrhage.
 Skin necrosis at injection sites.
 Thrombocytopenia.
 Osteoporosis.
 Hypersensitivity reactions.
Aboubakr Elnashar

25.  Systematic reviews and retrospective studies have
concluded that LMWH is a safe alternative to
unfractionated heparin as an anticoagulant during
pregnancy and from a safety perspective LMWH is
preferred.
Aboubakr Elnashar

26. Low-dose aspirin
75 mg daily
 Safe in pregnancy, although its use for
thromboprophylaxis in this setting has never
been assessed by RCT.
 Meta-analysis of trials in surgical and medical
patients shows a significant reduction in DVT
and PE with antiplatelet prophylaxis.
Aboubakr Elnashar

27. May be appropriate in situations where the risk of
VTE is increased but is not deemed high enough to
warrant the use of antenatal LMWH
e.g.women with previous provoked VTE without
thrombophilia.
Aboubakr Elnashar

28. Warfarin
 During pregnancy, especially between
6 and 12 weeks: should be avoided if
possible, because
1. 5% risk of teratogenesis
2. increases the risk of miscarriage,
3. fetal and maternal haemorrhage,
4. neurological problems in the baby and
stillbirth.
Aboubakr Elnashar

29.  After delivery and for breastfeeding; safe, although it
requires :
1. Close monitoring,
2. Frequent visits to an anticoagulant clinic
 Warfarin carries an increased risk of:
1. Postpartum haemorrhage and
2. Perineal haematoma compared with LMWH.
Aboubakr Elnashar

30.  It is not appropriate for women requiring only three
to five days of postpartum prophylaxis.
 If the woman chooses to commence warfarin
postpartum, this can usually be initiated on the
second or third postnatal day.
 The dosage regimens are the same as for women
converting to warfarin postpartum following an
acute VTE in pregnancy.
Aboubakr Elnashar

31. Graduated elastic compression stockings
 There are no trials to support such practice but
the British Society for Hematology guidelines
give a grade C recommendation (evidence
level IV) that:
All women with previous VTE or a thrombophilia
should be encouraged to wear class-II
graduated elastic compression below knee
stockings throughout their pregnancy and for
6–12 weeks after delivery.
Aboubakr Elnashar

32.  Class-I thromboelastic stockings are appropriate for
hospital inpatients at increased risk of VTE and may be
combined with LMWH.
 Their use is also recommended for pregnant women
traveling by air.
Aboubakr Elnashar

33.  The pregnancy-associated prothrombotic changes in
the coagulation system are maximal immediately
following delivery.
 Therefore, it is desirable to continue LMWH during
labour or delivery in women receiving antenatal
thromboprophylaxis with LMWH.
Care during labour and delivery for
women on thromboprophylaxis
Aboubakr Elnashar

34.  For women receiving high prophylactic or
therapeutic doses of LMWH:
the dose of heparin should be
withheld if the woman goes into labour or
reduced to its thromboprophylactic dose on the
day before induction of labour or elective CS and
continued in this dose during labour.
Aboubakr Elnashar

35.  Regional anaesthesia can be sited only after
discussion with a senior anaesthetist, & with the
woman before labour or CS.
 To minimize the risk of epidural hematoma, regional
techniques should not be used until at least 12 hours
after the previous prophylactic dose of LMWH.
 When a woman presents while on a therapeutic
regimen of LMWH, regional techniques should not be
employed for at least 24 hours after the last dose of
LMWH.
 LMWH should not be given for at least 4 hrs after the
epidural catheter has been inserted or removed and
the cannula should not be removed within 10–12 hrs
of the most recent injection.
Aboubakr Elnashar

36. Aboubakr Elnashar

37. Aboubakr Elnashar

38. DVT is suspected by:
 Acute leg pain,
 Swelling, redness &
 tenderness.
Aboubakr Elnashar

39. PE is suspected by
 Acute chest pain,
 shortness of breath.
 Haemoptysis,
 Hypotension and
 Cyanosis occur in
massive PE.
Aboubakr Elnashar

40.  ECG, Oxygen saturation& CXR are
not specific.
 The clinical diagnosis is very
difficult, but
 If suspected, start treatment till
objective tests are available.
Aboubakr Elnashar

41. Objective testing for TED
 DVT: Duplex ultrasound scan.
 PE: ventilation/perfusion scan.
 Chest X-ray and X-ray venography carry a very
small risk of radiation exposure to the fetus and
should be used when indicated.
Aboubakr Elnashar

42. Aboubakr Elnashar

43. Pulmonary angiography & VP scan
Multiple intravascular filling
defects in the right pulmonary
artery on angiogram.
There are several bilateral segmental
perfusion defects without matched
ventilation defects in the same
territories (mismatch).
Aboubakr Elnashar

44. Management of acute episodes of VTE
1. Therapeutic doses of Heparins for at least 5
days.
(Consult other specialities).
 IV loading dose followed by continuous IV
infusion or intermittent SC injection.
 5000-10000 u loading dose followed by
 15-25 u/kg/h iv infusion or
 15000 u sc/12 h.
Aboubakr Elnashar

45. Monitoring (consult other specialities)
 Daily monitoring by APTT, adjust dose
accordingly.
 Continue tt throughout pregnancy at a
maintenance dose.
 Continue till 6 w postpartum (shift to oral
after delivery).
Aboubakr Elnashar

46. 2. LMWH (therapeutic doses).
Enoxaparin (clexane) 20, 40, 60, 80,100 120, 150
mg/syringe.
 Dose: 1-1.5 mg/kg(150 u/kg) sc every 24 h.
Tinzaparin (Innohep) 2500, 3500, 4500, 20000
u/syringe.
 Dose: 175 u/kg sc every 24 h.
Dalteparin (Fragmin) 2500, 5000, 10000, 12500,
15000, 18000 u/syringe.
 Dose: 200 u/kg sc (maximally 18000 u/day).
Aboubakr Elnashar

47. Response to treatment
 Immediate improvement in DVT/PE.
 Patients with persistent hypotension,
cyanosis carry a bad prognosis.
 Thrombolytic therapy by streptokinase.
 Surgical treatment.
Aboubakr Elnashar

48. Aboubakr Elnashar

49. Risk assessment based upon:
 A) Type of surgery.
 B) Risk factor in the patient.
Aboubakr Elnashar

50. A) Type of Surgery
Low risk surgery:
 Minor operations (<30 minutes).
Moderate risk surgery:
 >30 minutes.
High risk surgery
 All cancer/extended pelvic surgery.
Aboubakr Elnashar

51. B) Risk factor in the
patient
The same risk factors mentioned
under obstetrics.
 Age>40 years.
 BMI>30.
 Immobility.
 Thrombophilia.
 Previous DVT/PE.
Aboubakr Elnashar

52. Thrombo-prophylaxis
1. Minor surgery & no risk factors
 Early mobilization &
 avoid dehydration.
2. Moderate surgery and no risk factors
 Low dose prophylaxis (20 mg clexane) prior to surgery and
daily till discharge.
Aboubakr Elnashar

53. 3. Prolonged surgery and/or high risk factors
 High dose prophylaxis (40-80 mg clexane) prior
to surgery & daily till discharge.
 Compression stockings during
surgery/comfortable positions.
 Elastic stockings following surgery.
 Early mobilization and hydration.
Aboubakr Elnashar

54. Management of patients on
Anticoagulants undergoing surgery
Patients on oral anticoagulants
 Admit to hospital 3-4 days prior to surgery.
 Stop oral anti-coagulant and start
heparin/LMWH on admission.
 Surgery when INR between 1-2.
 Start oral anticoagulant after oral feeding +
heparin/LMWH for few days.
Aboubakr Elnashar

55. Patients on heparin/LMWH
 Stop LMWH on the night prior to surgery
or morning dose of heparin.
 Start few hours after surgery.
 Start oral +heparin for few days.
 Continue on oral when INR>2.
Aboubakr Elnashar

56. Antidotes
 Protamin zinc for heparin.
 Vit K for oral anticoagulants.
 No effective antidote for LMWH.
(may be fresh blood transfusion).
Aboubakr Elnashar

57. Thromboprophylaxis in OHSS
 Women with multiple risk factors for VTE and at
risk of OHSS undergoing ovulation induction
may also be considered for
thromboprophylaxis.
 Women with OHSS require thromboprophylaxis
for at least the period of inpatient stay.
Aboubakr Elnashar

58. Aboubakr Elnashar