1.
Thrombosis
and
Thrombophlebitis
Prepared By:
Reena Bhagat
Senior Nursing Instructor
Maternal Health Nursing
BPKIHS

2.
Introduction
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CONTD..
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CONTD..
When thrombophlebitis occurs in the postpartal period, it
is usually an extension of an endometrial infection.
It tends to occur because:
 A woman’s fibrinogen level is still elevated from
pregnancy, leading to increased blood clotting.
 Dilatation of lower extremity veins is still present as a
result of pressure of the fetal head during pregnancy
and birth.
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CONTD.
 The relative inactivity of the period or a prolonged
time spent in delivery or birthing room stirrups
leads to pooling, stasis, and clotting of blood in the
lower extremities.
 Obesity from increased weight before pregnancy
and pregnancy weight gain can lead to relative
inactivity and lack of exercise.
 The woman smokes cigarettes.
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CONTD.
A postpartum thrombophlebitis may occur in the veins of leg,
thigh or pelvis. Thrombophlebitis is classified as
 Superficial vein disease (SVD) or
 Deep vein thrombosis (DVT).
 If a part or all of a clot from DVT detaches, it may cause
pulmonary embolism, obstructing the blood flow through
a pulmonary arteries to the lungs, which may be fatal.
 The most common time for a thrombophlebitis to develop
is between postpartum days 10-20. three embolic
conditions are of concern in the postpartum period.
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Incidence and Etiology
 The incidence of thromboembolic disease in the
postpartum varies from approx. 0.5-3 per 1000 women.
 The incidence of thromboembolism condition has
decreased as a result of early ambulation after birth,
but it still occurs.
 The major causes are the result of venous stasis and
hypercoagulation, both of which are present in
pregnancy and continue into the postpartum period.
 Other risk factors include cesarean, history of venous
thrombosis or varicosities, obesity, maternal age
greater than 35, multiparty and smoking.
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Clinical Manifestation
Superficial venous thrombosis is the most frequent
forms of postpartum thrombophlebitis. It is
characterized by pain, tenderness in lower extremities.
 She may experience chills or have an elevated body
temperature, as elevated pulse and/or hypotension.
 If pain or tenderness occurs in her leg, visualization
may reveal a warm, red, enlarged or hardened vein
of superficial venous thrombosis.
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CONTD.
Deep vein thrombosis is more common in pregnancy.
It is characterized by:
 Unilateral leg pain, calf tenderness and swelling.
 Physical examination reveals redness and warmth,
but the woman may also have a large amount of clot
and have few symptoms.
 A positive Homan’s sign may be present by further
evaluation is needed because the calf pain may be
attributed to other causes such as strained muscle
resulting from the birthing position.
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CONTD..
Pulmonary embolism is a thrombotic complication in
which clot dislodges and is carried to pulmonary artery,
obstructing blood flow to the lungs. Most of these
originates as thrombi in deep leg veins and dislodges
spontaneously.
 The condition occurs without warning and is a life
threatening.
 It is characterized by dyspnea and tachypnea. Other
signs and symptoms frequently seen include
apprehension, cough, tachycardia, hemoptysis,
elevated temperature and pleurititic ( chest pain).
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Investigations
The following biophysical tests are employed to confirm
the diagnosis:
 Physical examination is not a sensitive diagnostic
indicators for thrombosis.
 Blood to determine hemoglobin and hematocrit values.
 Non-invasive diagnostic methods are commonly used.
They include:
a. Doppler ultrasound to detect the changes in the
velocity of blood flow in the femoral vein by noting the
alteration of the characteristic ‘whoosh’ sound which is
audible from a patent vein.
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CONTD..
b.Venography by injecting nonionic water soluble radiopaque
dye to note the filling defect in the venous lumen is a reliable
method, if carefully interpreted. Venogram is restricted in
pregnancy; due to the risk of radiation and contrast allergy.
 Cardiac auscultation may reveal murmurs with pulmonary
embolism.
 ECG are usually normal.
 Arterial PO2 may be lower than normal.
 Ventilation/perfusion scan, Doppler ultrasound and
pulmonary arteriogram may be used for diagnosis.
 Phlebography( study structure and functions of veins)
 Magnetic resonance imaging (MRI)
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Pelvic Thrombophlebitis:
Postpartum thrombophlebitis originates in the thrombosed
veins at the placental site by organisms such as anaerobic
Streptococci or Bacteroides (fragilis). When localized in
the pelvis, it is called pelvic thrombophlebitis.
There is no specific clinical feature of pelvic
thrombophlebitis, but it should be suspected in cases
where the pyrexia continues for more than a week in spite
of antibiotic therapy.
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CONTD..
Extra pelvic spread:
(1) Through the right ovarian vein into inferior vena
cava and thence to the lungs,
(2) Through the left ovarian vein to the left renal vein
and thence to the left kidney,
(3) Retrograde extension to iliofemoral veins to produce
the clinicopathological entity of ‘phlegmasia alba
dolens’ or white leg.
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CONTD..
Clinical features:
(1) It usually develops on the second week of puerperium.
(2) Mild pyrexia is common prior to the dramatic local
manifestations. At times, the fever may be high with
chills and rigor.
(3) Evidences of constitutional disturbances such as
headache, malaise and rising pulse rate or features of
toxemia may be present.
(4) The affected leg is swollen, painful, white and cold. The
pain is due to arterial spasm as a result of irritation from
the nearby thrombosed vein.
(5) Blood count shows polymorphonuclear leucocytosis.
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Medical Management
 Superficial venous thrombosis is treated with analgesics
( NSAIDS).
• Rest with elevation of the affected legs.
• Use of elastic stockings.
• Local application of heat may be used.
 Deep vein thrombosis
• Initially treated with anticoagualant( usually continuous
iv heparin) therapy.
• Bed rest with affected leg elevated and analgesia.
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CONTD.
• After symptoms have decreased, the woman may be
fitted with elastic stockings use when is allowed to
ambulate.
• IV heparin therapy continuous for 5-7 days.
• Oral anticoagulant therapy( warfarin) is started
during this time and will continue for approx. 3
months.
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CONTD.
 Pulmonary embolism
 Continuous IV heparin therapy is used for
pulmonary embolism until symptoms have resolved.
 Intermittent subcutaneous heparin or oral
anticoagulant therapy is usually continued for 6
months.
 Antibiotics may be given for infectious process.
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Midwifery Interventions
In the hospital setting midwifery care of woman with a
thrombosis consists of assessment, inspection and
palpation of affected area.
 Palpation of peripheral pulses:
• Checking Homan’s signs, measuring and comparison
of leg circumferences, inspection for sign of bleeding.
• Monitoring sign of pulmonary embolism, including
chest pain, coughing, dyspnea and tachypnea;
respiratory status for the presence of crackles.
• Lab reports are monitored for prothrombin or partial
prothrombin times.
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CONTD..
• The woman and her family are assessed for their level
of understanding about diagnosis and their ability to
cope during the unexpected period of recovery.
 Interventions include explanations and education about
the diagnosis and treatment.
 The woman will need assistance with personal care as
long as she is on bed rest. Family should be encouraged
to participate in the care.
 While woman is on bed rest, she should eb encouraged
to change positions frequently but not to place the
knees in sharply flexed position that could cause
pooling of blood in the lower extremities.
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CONTD..
 She should be cautious not to rub the affected area
because this action could cause the clot to dislodge.
Once the woman is allowed to ambulate, she is taught
how to prevent venous congestion by putting on the
elastic stockings before getting out of bed.
 Heparin and warfarin are administered as ordered
and the physician is notified if clotting time are
outside the therapeutic level.
 If the woman is breastfeeding, she is assured that
neither heparin nor warfarin is excreted is significant
quantities in breast milk. So, encourage for breast
feeding.
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CONTD..
 Instruct woman and her family about safe care
practices to prevent bleeding and Injury while she is
on anticoagulant therapy, such as using a soft
toothbrush and using an electrical razor.
 She also need information about need for follow up to
monitor clotting time and to make sure the correct
dose of anticoagulant therapy is maintained
 The woman should also use a reliable method of
contraception if taking warfarin because this
medication is considered teratogenic.
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Prophylaxis for Venous Thromboembolism
(VTE) in Pregnancy and Puerperium
Preventive measures include:
 Prevention of trauma, sepsis, anemia in pregnancy and
labor. Dehydration during delivery should be avoided.
 Use of elastic compression stocking and intermittent
pneumatic compression devices during surgery.
 Leg exercises, early ambulation are encouraged
following operative delivery.
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Management
(1) The patient is put to bed rest with the foot end raised
above the heart level.
(2) Pain on the affected area may be relieved with
analgesics.
(3) Appropriate antibiotics are to be administered.
(4) Anticoagulants:
a. Heparin 15,000 units are administered intravenously
followed by 10,000 units, 4–6 hourly for four to six
injections when the blood coagulation is likely to be
depressed to the therapeutic level.
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Pulmonary Embolism (PE)
 If a blood clot (thrombus) forms in the one of the
body's veins (deep vein thrombosis or DVT), it has the
potential to break off and enter the circulatory system
and travel or embolize) through the heart and become
lodged in the one of the branches of the pulmonary
artery of the lung.
 A pulmonary embolus clogs the artery that provides
blood supply to part of the lung The embolus not only
prevents the exchange of oxygen and carbon dioxide.
but it also decreases blood supply to the lung tissue
itself, potentially causing lung tissue to die (infarct).
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CONTD..
Pulmonary embolism is one of the leading causes of
maternal death. It is a dreaded complication of deep vein
thrombosis.
Risk factors
 Prolonged immobilization or alterations in normal blood
flow(stasis).
 Increased clotting potential of the blood
(hypercoagulability)
 Any damage to the walls of the veins.
 Extended travel (sitting in a car, airplane, train, etc.)
 Hospitalization or prolonged bed rest
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Signs and Symptoms
Pulmonary embolism symptoms vary greatly, depending
on how much of the lung is involved, the size of the clot
and the overall health of the patient.
Signs and symptoms includes:
 Shortness of breath. Chest pain.
 Cough. (bloody or blood-streaked sputum)
 Wheezing
 Clammy or bluish-colored skin Rapid or irregular
heartbeat.
 Rapid or irregular heartbeat.
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Diagnosis
Diagnosis can be verified by:
 Lung scans:(Ventilation/Perfusion scan) Perfusion
scan will detect areas of diminished blood flow
whereas a reduction in perfusion with maintenance of
ventilation indicates pulmonary embolism
 Blood gas studies
 X-ray films
 Pulmonary angiography is accurate to the diagnosis
but has got high risks of complications.
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Management
Immediate medical and midwifery interventions are
necessary.
• The woman with a pulmonary embolism requires
intensive care and crisis intervention by an
interdisciplinary emergency team.
• The head of the bed is elevated to facilitate breathing
and oxygen is administered by face mask.
• Initiate intravenous fluids.
• Monitor 02 saturation by pulse oximetry.
• Assess vital signs, arterial blood gases frequently.
• A pulmonary artery catheter may be placed.
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CONTD.
 Dopamine for pressure support, morphine for
analgesia, and other emergency drug may he
administered.
 Critical care midwifery is necessary and ideally
collaboration between the intensive care unit and
obstetrical care will be provided.
 Oxygen therapy: Oxygen therapy is administered to
correct is administered to correct the hypoxemia,
relieve the pulmonary the hypoxemia, relieve the
pulmonary vascular vasoconstriction, and reduce the
vascular vasoconstriction, and reduce the pulmonary
hypertension.
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CONTD..
Using elastic compression stockings Using elastic
compression stockings or intermittent pneumatic leg
compression intermittent pneumatic leg compression
devices reduces venous stasis.
These measures compress the superficial veins and
increase the superficial veins and increase the viscosity of
blood in the deep viscosity of blood in the deep veins by
veins by redirecting the blood through the deep veins.
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CONTD.
 Elevating the leg (above the level of the heart) also
increases venous flow.
 Anticoagulant therapy (heparin, warfarin sodium) has
traditionally been the primary method for managing
acute deep vein method for managing acute deep vein
thrombosis and pulmonary embolism.
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References
 Dutta DC. Textbook of Obstetric including Perinatology and
Contraception. 7th ed. Jaypee Brothers Medical Publishers (P)
Ltd. New Delhi, India: 2013; Page No.: 439-442.
 Pilliterri.
 Myles Textbook of Midwives, 16th edition, United Kingdom,
Churchill Livingstone Elsevier ltd., 2014, Page No. 629-634
 Subedi DP. A Textbook of Midwifery Nursing(Postpartum Care)
Part III. First ed. Reprint:2020. Akshav Publication Kathmandu;
Page No. 128-133.
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