Management of Thromboembolic Disease in Pregnancy and Puerperium

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Management of Thromboembolic Disease in Pregnancy and Puerperium

Transcript of Management of Thromboembolic Disease in Pregnancy and Puerperium

  • Prof Aboubakr ElnasharAboubakr Elnashar
  • Main direct cause of maternal death in the UK 10 times more common in pregnant than in nonpregnant Occur at any stage of pregnancy but the puerperium is the time of highest risk. The subjective, clinical assessment is unreliable in pregnancy Aboubakr Elnashar
  • DVT is suspected by: Acute leg pain, Swelling, Redness Tenderness. PTE is suspected by Acute chest pain Shortness of breath. Haemoptysis Hypotension Cyanosis occur in massive PTE. Aboubakr Elnashar
  • Outline Diagnosis Diagnosis of DVT Diagnosis of PTE 1. Chest X-ray 2. Compression duplex Doppler 3. Ventilationperfusion lung scan 4. CT pulmonary angiogram 5. Alternative Treatment A. Antenatal Baseline investigations Initial treatment Monitoring Massive life-threatening PTE Additional therapies Maintenance treatment Oral anticoagulant B. Intrapartum Anticoagulant in women at high risk of hge C. Postnatal Post-thrombotic leg syndromeAboubakr Elnashar
  • Any woman with S&S suggestive of VTE should have objective testing & treatment with LMWH until the diagnosis is excluded, unless treatment is strongly contraindicated. Aboubakr Elnashar
  • Diagnosis of DVT Compression duplex US Positive Continue AC Negative High C Susp Continue AC US after w Negative Discontinue AC Low C susp Discontinue AC Aboubakr Elnashar
  • Aboubakr Elnashar
  • 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 Aboubakr Elnashar
  • Duplex US: Thrombus with some blood flowing around the clot. (+lack of compressibility of the vein and distal distension during valsalva manoeuvre) The main test used to exclude or diagnose DVT Simple, painless test with a high degree of accuracy. Aboubakr Elnashar
  • Aboubakr Elnashar
  • Diagnosis of PTE 1. Chest X-ray: Normal 2. Compression duplex Doppler If both tests are negative with persistent clinical suspicion 3. Ventilationperfusion (V/Q) lung scan or Computed tomography pulmonary angiogram (CT PA): depend on local availability: Normal but the clinical suspicion is high. 4. Alternative or repeat testing: Anticoagulant treatment should be continued until PTE is definitively excluded. Aboubakr Elnashar
  • Chest X-ray Normal in over 50% Abnormal features caused by PTE: Atelectasis Effusion Focal opacities Regional oligaemia or pulmonary oedema. The radiation dose to the fetus at any stage of pregnancy is negligible. Aboubakr Elnashar
  • Posteroanterior & lateral chest radiograph: Findings are normal, usual finding in patients with PTE Aboubakr Elnashar
  • Posteroanterior roentgenogram of chest: Rt lower lobe consolidation & Rt pleural effusion. Aboubakr Elnashar
  • Value: 1. May identify other pul disease: pneumonia, pneumothorax or lobar collapse. 2. If abnormal with a high clinical suspicion of PTE: CT PA should be performed. 3. If normal: Bilateral Doppler US leg studies: diagnosis of DVT may indirectly confirm a diagnosis of PTE {anticoagulant therapy is the same for both conditions} further investigation unnecessary: limit radiation doses to the mother & her fetus. Aboubakr Elnashar
  • CT PA First-line investigation for non-massive PTE in nonpregnant (Br. Thoracic Soc). Advantages over radionuclide (V/Q) : 1. Better sensitivity & specificity (at least in nonpregnant women) 2. Lower radiation dose to the fetus (