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10/10/2016 1
Pathophysiology
of Thromboembolism
is associated with:
• 2x fibrinogen
• 20 -1,000% factors VII, VIII, IX, X & XII
• vWF by 400 % at term
• Prothrombin and factor V remain unchanged
• Modest factor XIII and XI
• 40% protein S
10/10/2016 2
Why is pregnancy at risk?
• Parity
• Postpartum endomyometritis
• Operative vaginal delivery
• Cesarean delivery 9x in the risk of
thromboembolism compared with vaginal delivery
10/10/2016 3
Risk factors for TE
 Compression of the inferior vena cava, and
 Pelvic veins by the enlarging uterus
 Hormone-mediated in DVC 2° to:
 Estrogen
 Local production of prostacyclin and
 NO
Note:
Left leg veins thrombosis > right leg thrombosis
2° lower flow velocities
10/10/2016 4
• Age >35 years
• Obesity
• Trauma
• Immobility
• Infection
• Smoking
• Nephrotic syndrome
• Cancer
• Surgery
• Prior history of DVT or PE
10/10/2016 5
Introduction
10/10/2016 6
Endothelial injury
THROMBOSIS
10/10/2016 7
1. Endothelial Injury
• Dysfunction or mechanical trauma
• Contribute thrombus formation
• Heart
• Arterial circulation
• Major consequence of endothelial cell injury:
• Vasculitis
• Endocardial injury
Abnormal Blood Flow
Turbulence
• Cause arterial and cardiac thrombosis by
• Endothelial injury or dysfunction
• Disrupt laminar flow
• Forming countercurrents and local pockets of stasis
Stasis
• Major contributor in the venous thrombi
• Prevent dilution of activated clotting factors
3.
• Definition:
• Alteration of the coagulation pathways that
predisposes to thrombosis
• Also called thrombophilia
• Divided into:
1. Primary (genetic)
2. Secondary (acquired) disorders
TABLE: Hypercoagulable States
Common
• Factor V mutation (G1691A mutation; factor V Leiden)
• Prothrombin mutation (G20210A variant)
• 5,10-Methylenetetrahydrofolate reductase (homozygous
C677T mutation)
• Increased levels of factors VIII, IX, XI, or fibrinogen
Rare
• Antithrombin III deficiency
• Protein C deficiency
• Protein S deficiency
Very Rare
• Fibrinolysis defects
• Homozygous homocystinuria (deficiency of cystathione β-
synthetase)
2. SECONDARY (ACQUIRED)
High Risk for Thrombosis
• Antiphospholipid antibody syndrome
• Heparin-induced thrombocytopenia
• Prolonged bedrest or immobilization
• Myocardial infarction
• Atrial fibrillation
• Tissue injury (surgery, fracture, burn)
• Cancer
• Prosthetic cardiac valves
• Disseminated intravascular coagulation
Lower Risk for Thrombosis
• Cardiomyopathy
• Nephrotic syndrome
• Hyperestrogenic states (pregnancy and postpartum)
• Oral contraceptive use
• Sickle cell anemia
• Smoking
Antiphospholipid Antibody Syndrome
(APAS)
Definition:
• Xized by arterial or venous thrombosis or specific
pregnancy complications
• in women with laboratory evidences of (APAs) to
proteins bound to anionic phospholipids
 Previously called Lupus anticoagulant syndrome
 Antiphospholipid Antibodies (APAs)
• Self-recognition Igs
• Directed against proteins bound to phospholipids
clinical manifestations
 Recurrent thromboses
 Repeated miscarriages
• Inhibit throphoblastic invasion
• placental vessels thrombosis
 Cardiac valve vegetations
 Thrombocytopenia
 Pulmonary embolism
 Pulmonary hypertension
 Stroke
 Bowel infarction
 Renal failure
• Renal Microangiopathy
Two forms of APAS :
I. Primary APAS
• Patients exhibit only a hypercoagulable state
• Lack evidence of autoimmune disorders
• Occasionally with certain drugs or infections
II. Secondary APAS
• Well-defined autoimmune disease like SLE
Diagnosis
The diagnosis of APAS requires
1. The presence of prior or current vascular
thrombosis, or characteristic obstetric complications
2. At least one laboratory criterion (e.g.,
anticardiolipin antibodies or lupus
anticoagulant
Factor V Leiden Mutation
 Activated Protein C Resistance
 Most prevalent thrombophilic syndromes
 Characterized by resistance of plasma
 To the anticoagulant effects of activated
protein C
• Heterozygous mutation 20 to 40 % of nonpregnants
with thromboembolic disease
• Homozygous inheritance 100-fold
Protein C Deficiency
• With protein S inactivating factors Va and VIIIa
• Protein C levels are unchanged during normal
pregnancy
 Predisposes to coagulation
• Prevalence is 2 to 5 per 1000
• Inheritance is autosomal dominant
• Risk of thromboembolism in pregnant women is
3-20 %
 Most episodes occur during the puerperium
Antithrombin Deficiency
• One of the most important inhibitors of thrombin
in clot formation
• The most thrombogenic of the heritable
coagulopathies
 Homozygous antithrombin deficiency is lethal !!!
 Although antithrombin deficiency is rare,
 Affect 1 in 5000 individuals,
 Lifetime risk of thrombosis is 50-90 %
 50- 60 % during pregnancy , and
 33 % during the puerperium
Pathophysiology of thromboembolism during pregnancy

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Pathophysiology of thromboembolism during pregnancy

  • 2. is associated with: • 2x fibrinogen • 20 -1,000% factors VII, VIII, IX, X & XII • vWF by 400 % at term • Prothrombin and factor V remain unchanged • Modest factor XIII and XI • 40% protein S 10/10/2016 2 Why is pregnancy at risk?
  • 3. • Parity • Postpartum endomyometritis • Operative vaginal delivery • Cesarean delivery 9x in the risk of thromboembolism compared with vaginal delivery 10/10/2016 3 Risk factors for TE
  • 4.  Compression of the inferior vena cava, and  Pelvic veins by the enlarging uterus  Hormone-mediated in DVC 2° to:  Estrogen  Local production of prostacyclin and  NO Note: Left leg veins thrombosis > right leg thrombosis 2° lower flow velocities 10/10/2016 4
  • 5. • Age >35 years • Obesity • Trauma • Immobility • Infection • Smoking • Nephrotic syndrome • Cancer • Surgery • Prior history of DVT or PE 10/10/2016 5
  • 8. 1. Endothelial Injury • Dysfunction or mechanical trauma • Contribute thrombus formation • Heart • Arterial circulation • Major consequence of endothelial cell injury: • Vasculitis • Endocardial injury
  • 9. Abnormal Blood Flow Turbulence • Cause arterial and cardiac thrombosis by • Endothelial injury or dysfunction • Disrupt laminar flow • Forming countercurrents and local pockets of stasis Stasis • Major contributor in the venous thrombi • Prevent dilution of activated clotting factors
  • 10. 3. • Definition: • Alteration of the coagulation pathways that predisposes to thrombosis • Also called thrombophilia • Divided into: 1. Primary (genetic) 2. Secondary (acquired) disorders
  • 11. TABLE: Hypercoagulable States Common • Factor V mutation (G1691A mutation; factor V Leiden) • Prothrombin mutation (G20210A variant) • 5,10-Methylenetetrahydrofolate reductase (homozygous C677T mutation) • Increased levels of factors VIII, IX, XI, or fibrinogen Rare • Antithrombin III deficiency • Protein C deficiency • Protein S deficiency
  • 12. Very Rare • Fibrinolysis defects • Homozygous homocystinuria (deficiency of cystathione β- synthetase)
  • 13. 2. SECONDARY (ACQUIRED) High Risk for Thrombosis • Antiphospholipid antibody syndrome • Heparin-induced thrombocytopenia • Prolonged bedrest or immobilization • Myocardial infarction • Atrial fibrillation • Tissue injury (surgery, fracture, burn) • Cancer • Prosthetic cardiac valves • Disseminated intravascular coagulation
  • 14. Lower Risk for Thrombosis • Cardiomyopathy • Nephrotic syndrome • Hyperestrogenic states (pregnancy and postpartum) • Oral contraceptive use • Sickle cell anemia • Smoking
  • 15. Antiphospholipid Antibody Syndrome (APAS) Definition: • Xized by arterial or venous thrombosis or specific pregnancy complications • in women with laboratory evidences of (APAs) to proteins bound to anionic phospholipids  Previously called Lupus anticoagulant syndrome  Antiphospholipid Antibodies (APAs) • Self-recognition Igs • Directed against proteins bound to phospholipids
  • 16. clinical manifestations  Recurrent thromboses  Repeated miscarriages • Inhibit throphoblastic invasion • placental vessels thrombosis  Cardiac valve vegetations  Thrombocytopenia  Pulmonary embolism  Pulmonary hypertension  Stroke  Bowel infarction  Renal failure • Renal Microangiopathy
  • 17. Two forms of APAS : I. Primary APAS • Patients exhibit only a hypercoagulable state • Lack evidence of autoimmune disorders • Occasionally with certain drugs or infections II. Secondary APAS • Well-defined autoimmune disease like SLE
  • 18. Diagnosis The diagnosis of APAS requires 1. The presence of prior or current vascular thrombosis, or characteristic obstetric complications 2. At least one laboratory criterion (e.g., anticardiolipin antibodies or lupus anticoagulant
  • 19. Factor V Leiden Mutation  Activated Protein C Resistance  Most prevalent thrombophilic syndromes  Characterized by resistance of plasma  To the anticoagulant effects of activated protein C • Heterozygous mutation 20 to 40 % of nonpregnants with thromboembolic disease • Homozygous inheritance 100-fold
  • 20. Protein C Deficiency • With protein S inactivating factors Va and VIIIa • Protein C levels are unchanged during normal pregnancy  Predisposes to coagulation • Prevalence is 2 to 5 per 1000 • Inheritance is autosomal dominant • Risk of thromboembolism in pregnant women is 3-20 %  Most episodes occur during the puerperium
  • 21. Antithrombin Deficiency • One of the most important inhibitors of thrombin in clot formation • The most thrombogenic of the heritable coagulopathies  Homozygous antithrombin deficiency is lethal !!!  Although antithrombin deficiency is rare,  Affect 1 in 5000 individuals,  Lifetime risk of thrombosis is 50-90 %  50- 60 % during pregnancy , and  33 % during the puerperium

Hinweis der Redaktion

  1. Despite the presence of the sigmoid colon promoting uterine dextrorotation, ultrasound findings indicate lower flow velocities in the left leg veins throughout pregnancy.[32] This would explain why multiple studies have confirmed that the incidence of thrombosis is much greater in the left leg than in the right leg
  2. Endothelium need not be denuded or physically disrupted to contribute to the development of thrombosis!
  3. f the inherited causes of hypercoagulability, point mutations in the factor V gene and prothrombin gene are the most common.
  4. A syndrome characterized by arterial or venous thrombosis or specific pregnancy complications in women with laboratory evidence of antibodies (APAs) to proteins bound to anionic phospholipids Lupus anticoagulant syndrome The antiphospholipid antibodies (APAs) are a class of self-recognition immunoglobulins directed against proteins bound to negatively charged (anionic) phospholipids. Anticardiolipin antibodies and the lupus anticoagulants represent the two most widely employed end points, but other applicable tests include anti-b2 glycoprotein antibodies
  5. . Fetal loss is attributable to antibody-mediated inhibition of t-PA activity necessary for trophoblastic invasion of the uterus *placental vessels thrombosis resulting in infarction and placental insufficiency
  6. Primarysecondary forms. Individuals with a well-defined autoimmune disease, such as systemic lupus erythematosus ( Chapter 6 ), are designated as having secondary antiphospholipid syndrome (hence the earlier term lupus anticoagulant syndrome). In primary antiphospholipid syndrome, patients exhibit only the manifestations of a hypercoagulable state and lack evidence of other autoimmune disorders; occasionally this Primarysecondary forms. Individuals with a well-defined autoimmune disease, such as systemic lupus erythematosus ( Chapter 6 ), are designated as having secondary antiphospholipid syndrome (hence the earlier term lupus anticoagulant syndrome). In primary antiphospholipid syndrome, patients exhibit only the manifestations of a hypercoagulable state and lack evidence of other autoimmune disorders; occasionally this happens in association with certain drugs or infections. A particularly aggressive form (catastrophic antiphospholipid syndrome) characterized by widespread small-vessel thrombi and multi-organ failure has a 50% mortality. happens in association with certain drugs or infections. A particularly aggressive form (catastrophic antiphospholipid syndrome) characterized by widespread small-vessel thrombi and multi-organ failure has a 50% mortality.
  7. * The antiphospholipid antibodies (APAs) are a class of self-recognition immunoglobulins directed against proteins bound to negatively charged (anionic) phospholipids. * Anticardiolipin antibodies and the lupus anticoagulants represent the two most widely employed end points, but other applicable tests include anti-b2 glycoprotein antibodies, and anti-prothrombin and anti-annexin antibodies.
  8. This missense mutation in the factor V gene results in resistance to degradation by activated protein CHomozygous inheritance of two aberrant copies is rare and increases the risk of thrombosis by more than 100-fold Also called Activated Protein C Resistance Most prevalent of the known thrombophilic syndromes Characterized by resistance of plasma to the anticoagulant effects of activated protein C Heterozygous mutation 20 to 40 % of nonpregnants with thromboembolic disease Homozygous inheritance risk of thrombosis by 100-fold
  9. Known as antithrombin III