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  1. 1. Thrombosis and Thrombophlebitis Prepared By: Reena Bhagat Senior Nursing Instructor Maternal Health Nursing BPKIHS
  2. 2. Introduction 1/31/2023 Reena Bhagat 2
  3. 3. 1/31/2023 Reena Bhagat 3
  4. 4. CONTD.. 1/31/2023 Reena Bhagat 4
  5. 5. 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. 1/31/2023 Reena Bhagat 5
  6. 6. 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. 1/31/2023 Reena Bhagat 6
  7. 7. 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. 1/31/2023 Reena Bhagat 7
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  9. 9. 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. 1/31/2023 Reena Bhagat 9
  10. 10. 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. 1/31/2023 Reena Bhagat 10
  11. 11. 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. 1/31/2023 Reena Bhagat 11
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  13. 13. 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). 1/31/2023 Reena Bhagat 13
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  15. 15. 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. 1/31/2023 Reena Bhagat 15
  16. 16. 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) 1/31/2023 Reena Bhagat 16
  17. 17. 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. 1/31/2023 Reena Bhagat 17
  18. 18. 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. 1/31/2023 Reena Bhagat 18
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  20. 20. 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. 1/31/2023 Reena Bhagat 20
  21. 21. 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. 1/31/2023 Reena Bhagat 21
  22. 22. 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. 1/31/2023 Reena Bhagat 22
  23. 23. 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. 1/31/2023 Reena Bhagat 23
  24. 24. 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. 1/31/2023 Reena Bhagat 24
  25. 25. 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. 1/31/2023 Reena Bhagat 25
  26. 26. 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. 1/31/2023 Reena Bhagat 26
  27. 27. 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. 1/31/2023 Reena Bhagat 27
  28. 28. 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. 1/31/2023 Reena Bhagat 28
  29. 29. 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. 1/31/2023 Reena Bhagat 29
  30. 30. 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). 1/31/2023 Reena Bhagat 30
  31. 31. 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 1/31/2023 Reena Bhagat 31
  32. 32. 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. 1/31/2023 Reena Bhagat 32
  33. 33. 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. 1/31/2023 Reena Bhagat 33
  34. 34. 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. 1/31/2023 Reena Bhagat 34
  35. 35. 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. 1/31/2023 Reena Bhagat 35
  36. 36. 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. 1/31/2023 Reena Bhagat 36
  37. 37. 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. 1/31/2023 Reena Bhagat 37
  38. 38. 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. 1/31/2023 Reena Bhagat 38
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