Venous complications in pregnancy and puerperium ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU MD, PhD

Venous Disorders Varicose Veins Varicose Veins  Deep Vein Thrombosis (DVT)  P ulmonary Thrombo e mbolism (PTE)  Superficial Venous Thrombosis (Thrombophlebitis )

Varicose Veins Pregnancy Pregnancy –Increased blood volume –Pressure on veins –Relaxation effect of hormones

Varicose Veins Management Management –Non Operative  Self resolving (within six weeks) –After 6 weeks  if problematic/ unacceptable –Graduated Compression Stockings –Surgery

Varicose Veins Before TreatmentAfter Treatment

Varicose Veins

Superficial Venous Thrombosis (Thrombophlebitis)  Benign /Self limiting Disease  1% of patients; always in existing varicous veins  Can progress to deep vein thrombosis (11%)  Associated with abnormalities in blood coagulation in blood coagulation

Superficial Thrombophlebitis Etiologic factors Traumatic Traumatic Varicose Veins Varicose Veins Pregnancy Pregnancy Infection (e.g. Staph., Pseud., Klebs., Anaerobes) Infection (e.g. Staph., Pseud., Klebs., Anaerobes)

Superficial Thrombophlebitis Diagnosis Diagnosis –Painful cord like structure –Redness along the vein –Tenderness –Fever Investigations Investigations –Duplex ultrasonography (duplex scan)

Superficial Thrombophlebitis Management Management –Underlying disorder –Remove offending agents (e.g. IV cannula) –Antibiotics –NSAIDs –Excision of the suppurating vein –Elevation of the extremity –Anticoagulants ?

DEEP VENOUS THROMBOEMBOLISM DURING PREGNANCY LEADING CAUSE OF DEATH LEADING CAUSE OF DEATH 2 /1000 PREGNANCIES 2 /1000 PREGNANCIES 5 times higher in pregnancy 5 times higher in pregnancy   venous stasis of pregnancy  Physiological changes associated with pregnancy

DEEP VENOUS THROMBOEMBOLISM DURING PREGNANCY - Pathophysiology Independent risk factors  Prolonged bed rest  Multiparity (>3)  Advanced maternal age (>35yrs)  Overweight  Personal or family history of VTE  Pre-eclampsia Alteration in Coagulation / Fibrinolytic System  Factor II, VII, X  (middle of pregnancy)  Fibrin  Protein S  Protein C  Fibrinolytic System inhibited (mostly 3rd trimester)

DEEP VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnosis Diagnosis –Calf veins or ilio-femoral segment –Predilection for left side Signs and symptoms  swelling  tenderness  skin discoloration  warm to touch  unusual firmness /hardness in the leg  calf discomfort on dorsiflexion (Homans’ sign)  prominent tender cord like subcutaneous vein

VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnostic tests Diagnostic tests 1.Venography (Phlebography)

VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnostic tests Diagnostic tests 2. Duplex ultrasonography

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnostic tests Diagnostic tests 3. Spiral CT Venography No filling of calf veinsOpacification of collaterals

Diagnostic tests Diagnostic tests 4. Impedance plethysmography (IPG) 5. MRI 6. D-dimer test → fibrin degradation product (or FDP) = a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis → contains two crosslinked D fragments of the fibrinogen protein D-dimer concentration → to help diagnose thrombosis and disseminated intravascular coagulation. VENOUS THROMBOEMBOLISM DURING PREGNANCY

Pulmonary Embolism Major nonobstetric cause of maternal mortality Major nonobstetric cause of maternal mortality Cause of Death Cause of Death –2 / 100,000 maternities Maximum – Peripartum Maximum – Peripartum More after operative intervention More after operative intervention Subtle presentation Subtle presentation

DVT is suspected by: Acute leg pain, Acute leg pain, Swelling, Redness Swelling, Redness Tenderness. Tenderness. PTE is suspected by Acute chest pain Acute chest pain Shortness of breath. Shortness of breath. Haemoptysis Haemoptysis Hypotension Hypotension Cyanosis occur in massive PTE. Cyanosis occur in massive PTE. Thromboembolic disease in pregnancy and puerperium

Pulmonary Embolism Diagnostic tests Diagnostic tests 1.Pulmonary Angiography 2.Spiral CT Scan

Pulmonary Embolism  Diagnostic tests 3.Nuclear Imaging (Ventilation-Perfusion Scan)

VENOUS THROMBOEMBOLISM DURING PREGNANCY PROPHYLAXIS PROPHYLAXIS –Risk Assessment –Present status

VENOUS THROMBOEMBOLISM DURING PREGNANCY Management Management –Medical/Pharmacological  Anticoagulation  Anti-platelet agents –Surgical  Venous Thrombectomy (Ilio-femoral DVT), Pulmonary Embolectomy  Thrombolysis –Endovascular  Inferior vena cava filter placement (IVC Filter placement) –Others  Hydration  Early Mobilization  Graduated Compression Stockings  Pneumatic compression devices

VENOUS THROMBOEMBOLISM DURING PREGNANCY Medical/Pharmacological Medical/Pharmacological –Unfractionated Heparin/LMWH –Oral Anticoagulation –Antiplatelet agents –New Molecules  Direct Thrombin Inhibitors (Lepirudin, Desirudin, Argatroban, Ximelagatran) Surgical – Thrombolysis Surgical – Thrombolysis

VENOUS THROMBOEMBOLISM DURING PREGNANCY PROPHYLAXIS IN CESARIAN SECTION PROPHYLAXIS IN CESARIAN SECTION –Low Risk  Early Mobilization  Hydration –Moderate Risk  One of variety of prophylactic measures –Subcutaneous Heparin –Mechanical devices –High Risk  Heparin Prophylaxis +/- Leg Stockings