Deep Vein Thrombosis and Pulmonary Embolus Amy H. Picklesimer MD, MSPH Daniel Clarke-Pearson MD asics Descrip!ion "orma!

ion o# blood clo!s o# $aryin% si&e 'i!hin !he deep $eins, mos! commonly in !he lo'er e(!remi!ies or pel$is. These clo!s ha$e !he po!en!ial !o emboli&e !o !he lun% 'i!h po!en!ially li#e-!hrea!enin% conse)uences. Epidemiolo%y *ncidence o# DVT+ ,.-./+0,,,, pre%nancies *ncidence o# PE+ ,.,1.,.2+0,,,, pre%nancies

E)ually di$ided be!'een an!epar!um and pos!par!um period An!ena!ally, e)ually di$ided amon% !rimes!ers

3isk "ac!ors Clinical risk #ac!ors+ o Ad$anced ma!ernal a%e

o o o o o o o o o

*ncreased pari!y Mul!iple %es!a!ion Trauma, especially or!hopedic in4uries Sur%ery, includin% cesarean deli$ery Prolon%ed immobili!y, as 'i!h bedres! *nd'ellin% cen!ral $enous ca!he!ers Tra$el 567 hours8 Dehydra!ion Smokin%

Pa!holo%ic risk #ac!ors+

o o o o o o o o

*nheri!ed !hrombophilia 5see belo'8 Prior DVT or pulmonary embolism An!iphospholipid an!ibodies 9upus an!icoa%ulan! :besi!y Mali%nancy ;ephro!ic syndrome Myeloproli#era!i$e disorders

<ene!ics /,= o# pa!ien!s 'i!h $enous !hromboembolism in pre%nancy 'ill be #ound !o ha$e an inheri!ed !hrombophilia. Plasma #ac!ors+
o o o o o

"ac!or V 9eiden mu!a!ion Pro!hrombin mu!a!ion 5<>,>0,A8 Pro!ein C de#iciency Pro!ein S de#iciency An!i!hrombin *** de#iciency

Me!abolic de#ec!s+
o o

Hyperhomocys!einemia MTH"3 de#iciency

*mpaired clo! lysis 5rare8+

o o

Dys#ibrino%enemia Plasmino%en de#iciency

Aler! The risk #or DVT is - !imes hi%her durin% pre%nancy and !he pos!par!um period !han in !he nonpre%nan! s!a!e. Pa!hophysiolo%y The classic !riad is kno'n as Vircho' !riad+ Vessel 'all in4ury+ o Vessel dama%e caused durin% deli$ery

Venous s!asis+
o o

Mechanical impedance o# $enous re!urn caused by !he %ra$id u!erus *ncreased $ein dis!ensibili!y caused by hormonal chan%es

Chan%es in local clo!!in% #ac!ors+

o

;ormal pre%nancy is charac!eri&ed by pro%ressi$e increases in clo!!in% #ac!ors, a decrease in Pro!ein S and resis!ance !o ac!i$a!ed Pro!ein C.

Dia%nosis Si%ns and Symp!oms His!ory DVT+ o :#!en asymp!oma!ic

o

Pain or !enderness

9imb s'ellin%

PE+
o o o

Tachypnea, dyspnea Tachycardia Pleuri!ic pain, cou%h, hemop!ysis

Physical E(am Canno! reliably dia%nose or e(clude DVT Asymme!ric limb s'ellin%, 6> cm lar%er !han opposi!e side

?arm!h or ery!hema o# skin o$er area o# !hrombosis 5rare8 Homan si%n+ Cal# pain 'i!h dorsi#le(ion o# !he #oo!, -,= sensi!i$i!y 9isker si%n+ Pain on percussion o# medial !ibia ancro#! or Moses si%n+ Pain on compression o# cal# a%ains! !ibia in an!eropos!erior plane

Tes!s 9abs

aseline labs+ C C, coa%ula!ion pro#ile. D-dimer assay is no! use#ul. Ele$a!ions are #ound in normal pre%nancy. Ar!erial blood %asses may be misleadin%. 3espira!ory alkalosis is common in normal pre%nancy. E$alua!ion #or inheri!ed !hrombophilias in pre%nancy+
o

Tes!s !ha! are reliable in pre%nancy+

"ac!or V 9eiden 5PC3 !es!s8 Pro!hrombin Mu!a!ion 5<>,>0,A8 An!i!hrombin *** MTH"3 de#iciency Pro!ein C 5>nd-%enera!ion !es!s8 9upus an!icoa%ulan! An!icardiolipin an!ibodies

Tes!s !ha! are al!ered by pre%nancy+

Pro!ein S 5le$els reduced 7,.@,=8 Pro!ein C 50s!-%enera!ion !es!s only8 Hyperhomocys!einemia 5le$els reduced8

Aler! The op!imal !ime !o !es! #or inheri!ed !hrombophilias is remo!e #rom acu!e e$en!s and pre%nancy. *ma%in% Doppler AS o# lo'er e(!remi!ies+ o Sensi!i$i!y and speci#ici!y 61-=
o o

;onin$asi$e, no #e!al risk ?ill no! iden!i#y clo!s in pel$ic $eins or in#erior $ena ca$a

M3*+
o o

Can de!ec! clo!s in pel$ic $eins ;o ad$erse e$en!s in pre%nancy repor!ed, bu! sa#e!y remains unpro$en

Con!ras! $eno%raphy+ no! commonly used in pre%nancy Spiral CT scannin%+

o

Hi%h sensi!i$i!y and speci#ici!y #or pulmonary embolism in e(perienced hands 3adia!ion e(posure BVCD scan

VCD scan+
o o

Accuracy depends on pre!es! probabili!y 9o' 5-,, mrad8 radia!ion e(posure !o #e!us

Di##eren!ial Dia%nosis Physiolo%ic chan%es o# pre%nancy Musculoskele!al pain

Super#icial $enous !hrombosis Celluli!is Compar!men! syndrome

Trea!men! <eneral Measures *den!i#yin% candida!es #or prophyla(is+ o Pa!ien!s 'i!h a sin%le pre$ious episode o# DVT associa!ed 'i!h an iden!i#iable, !ransien! risk #ac!or 5e(cludin% pre%nancy and oral con!racep!i$e use8 do no! re)uire prophyla(is durin% pre%nancy.
o

Pa!ien!s 'i!h a sin%le pre$ious episode o# DVT o# uncer!ain e!iolo%y, and pa!ien!s kno'n !o ha$e inheri!ed !hrombophilias should recei$e prophyla(is durin% pre%nancy and #or a! leas! / mon!hs pos!par!um.

Pa!ien!s on lon%-!erm an!icoa%ula!ion !herapy due !o mul!iple prior episodes o# !hrombosis or hi%h-risk !hrombophilias should con!inue !o recei$e !herapeu!ic does o# ei!her A"H or 9M?H.

DVT may be mana%ed ou!pa!ien!, bu! all pa!ien!s 'i!h PE should be hospi!ali&ed. An!icoa%ula!ion is !he primary !herapy.
o

Precau!ions 'i!h an!icoa%ula!ion+

A$oid *M in4ec!ions Moni!or C C, includin% pla!ele!s ;ecro!ic skin lesions may de$elop a! in4ec!ion si!es

P./2Pre%nancy-Speci#ic *ssues y Trimes!er 0s! !rimes!er+ o ?ar#arin is !era!o%enic, 'i!h a peak e##ec! be!'een 2.0> 'eeks %es!a!ion.

/rd !rimes!er+
o

A"H is pre#erred in !he la!e /rd !rimes!er as deli$ery approaches because i! has a shor!er hal#-li#e and i!s e##ec!s are more reliably re$ersed 'i!h pro!amine sul#a!e. Pa!ien!s on 9M?H should be s'i!ched !o A"H no la!er !han /2 'eeksE %es!a!ion.

3isks #or Mo!her 9ar%e PE may lead !o cardio$ascular ins!abili!y or dea!h. An!icoa%ula!ion carries addi!ional risks #or 'omen 'ho ha$e preeclampsia, pep!ic ulcer disease, * D, noncompliance and poor #ollo'-up.

Ase o# A"H #or 62 'eeks can increase !he risk o# os!eoporosis.

3isks #or "e!us 9ar%e PE may lead !o ma!ernal hypo(ia and #e!al dis!ress. There is no increased risk #or abrup!ion #or pa!ien!s recei$in% an!icoa%ula!ion. Medica!ion 5Dru%s8 A"H+ o *ni!ial mana%emen!+ F, ACk% *V bolus, #ollo'ed by con!inuous in#usion s!ar!in% a! 0F ACk%Ch and ad4us!ed !o main!ain aPTT o# 0.-.> !imes con!rol.
o

Main!enance+ To!al number o# uni!s re)uired o$er >7 hours o# *V in#usion %i$en SC in > di$ided doses.

Due !o $ariable dose-response rela!ionships, par!icularly in pre%nan! 'omen, re)uires #re)uen! moni!orin% !o main!ain aPTT in !herapeu!ic ran%e May be res!ar!ed 0> hours a#!er cesarean deli$ery or @ hours a#!er uncomplica!ed $a%inal deli$ery

9M?H+
o o o

Ei!her 0 m%Ck% SC b.i.d. or 0.- m%Ck%Cd SC May be ini!ia!ed in an ou!pa!ien! se!!in% More predic!able dose-response rela!ionship. "ac!or GA le$els should be measured 7 hours a#!er dosin% once each !rimes!er, due !o 'ei%h! increases durin% pre%nancy.

?ar#arin+
o

Does no! cross in!o breas! milk. May be sa#ely used pos!par!um.

Thromboly!ic a%en!s ha$e been used 'i!h success in small series o# pre%nan! 'omen 'i!h li#e-!hrea!enin% PE.

Aler! 9M?H should be held #or >7 hours be#ore adminis!ra!ion o# epidural or spinal anes!hesia because o# !he risk #or spinal hema!oma. Pa!ien!s recei$in% A"H may under%o spinal or epidural anes!hesia once PTT normali&es. Sur%ery ?hen an!icoa%ulan!s and !hromboly!ics are con!raindica!ed, #il!erin% de$ices can be inser!ed in!o !he $ena ca$a !o H!rapI emboli be#ore !hey reach !he lun%s. Very lar%e clo!s can be sur%ically remo$ed in cer!ain circums!ances. "ollo'up Disposi!ion *ssues #or 3e#erral Vascular sur%ery or in!er$en!ional radiolo%y should be consul!ed #or pa!ien! 'i!h lar%e clo!s or cardio$ascular ins!abili!y. Pro%nosis >,= o# un!rea!ed pro(imal 5e.%., abo$e !he cal#8 DVTs pro%ress !o PE, and 0,.>,= o# !hose are #a!al. ?i!h a%%ressi$e an!icoa%ulan! !herapy, mor!ali!y is decreased -.0,-#old. DVT con#ined !o !he in#rapopli!eal $eins has a small risk o# emboli&a!ion, bu! !hese can propa%a!e in!o !he pro(imal sys!em and !here#ore should be !rea!ed in pre%nancy. Complica!ions PE 5#a!al in 0,.>,=8 Ar!erial embolism 5parado(ical emboli&a!ion8 'i!h AV shun!in%

Chronic $enous insu##iciency

Pos!phlebi!ic syndrome 5pain and s'ellin% in a##ec!ed limb 'i!hou! ne' clo! #orma!ion8 Trea!men!-induced hemorrha%e So#! !issue ischemia associa!ed 'i!h massi$e clo! and hi%h $enous pressures+ Phle%masia cerulea dolens 5rare bu! is a sur%ical emer%ency8

Pa!ien! Moni!orin% Dura!ion o# !rea!men!+ All e$en!s durin% pre%nancy should be !rea!ed 'i!h #ull an!icoa%ula!ion #or a minimum o# @ mon!hs. 9o'-risk pa!ien!s may !hen be con$er!ed !o prophylac!ic !herapy #or !he remainder o# pre%nancy, !hrou%h deli$ery, and #or @.0> 'eeks pos!par!um. Hi%h-risk condi!ions should be !rea!ed 'i!h #ull an!icoa%ula!ion !hrou%hou! pre%nancy, deli$ery, and @.0> 'eeks pos!par!um #or a !o!al !rea!men! !ime o# @.0F mon!hs+ Ac!i$e cancer, con!inued immobili&a!ion, pro!ein CCS de#iciency, and ele$a!ed "ac!or V***

Very hi%h-risk condi!ions should be con!inued inde#ini!ely on an!icoa%ula!ion+ recurren! DVT, PE, or o!her !hrombo!ic e$en!, li#e-!hrea!enin% e$en! 5lar%e pulmonary embolism, limb-!hrea!enin% DVT8, cerebral or $isceral $ein !hrombosis, an!i!hrombin de#iciency, homo&y%ous "ac!or V 9eiden, an!iphospholipid an!ibodies 'i!h e$en!, combined clo!!in% disorders 5"ac!or V 9eiden 'i!h ele$a!ed homocys!eine8.

Mo!her *n$es!i%a!e si%ni#ican! bleedin% 5hema!uria or <* hemorrha%e8, because an!icoa%ulan! !herapy may unmask a pre-e(is!in% lesion 5e.%., cancer, pep!ic ulcer disease, ar!erio$enous mal#orma!ion8. "e!us ;o addi!ional #e!al moni!orin% is re)uired. iblio%raphy a!es SM. Trea!men! and prophyla(is o# $enous !hromboembolism durin% pre%nancy. Thromb 3es. >,,>J0,F5>-/8+12.0,@. "ranchini M, e! al. *nheri!ed !hrombophilia. Cri! 3e$ Clin 9ab Sci. >,,@J7/5/8+>71. >1,. ;i4keu!er M, e! al. Dia%nosis o# deep $ein !hrombosis and pulmonary embolism in pre%nancy+ A sys!ema!ic re$ie'. K Thromb Haemos!. >,,@J75/8+71@.-,,. Miscellaneous See Heredi!ary ThrombophiliasJ An!i!hrombin De#iciencyJ "ac!or V 9eidenJ Pro!ein C De#iciencyJ Pro!ein S De#iciencyJ Pro!hrombin >,>0, 5Mu!a!ion8J Pulmonary Embolism Abbre$ia!ions L aPTTMAc!i$a!ed par!ial !hromboplas!in !ime L * DM*rri!able bo'el disease L 9M?HM9o' molecular 'ei%h! heparin L MTH"3MMe!hylene !e!rahydro#ola!e reduc!ase L P:PMPro%es!in-only pill L PTMPro!hrombin !ime L A"HMAn#rac!iona!ed heparin

Codes *CD1-CM L @20 Venous complica!ions in pre%nancy and !he puerperium L @20.1/ Anspeci#ied $enous complica!ion, an!epar!um condi!ion or complica!ion L @20.17 Anspeci#ied $enous complica!ion, pos!par!um condi!ion or complica!ion L @2/ :bs!e!rical pulmonary embolism L @2/.>/ :bs!e!rical blood clo! embolism, an!epar!um condi!ion or complica!ion L @2/.>7 :bs!e!rical blood clo! embolism, pos!par!um condi!ion or complica!ion Pa!ien! Teachin% ?omen 'i!h personal or #amily his!ory o# !hrombosis should be o##ered screenin% #or inheri!ed or ac)uired !hrombophilias 5clo!!in% disorders8. Pre$en!ion Con!racep!ion is impor!an! in 'omen 'i!h his!ory o# DVTCPE or 'i!h inheri!ed !hrombophilias because o# increased risk 'i!h pre%nancy, bu! es!ro%en- con!ainin% hormonal con!racep!i$es are con!raindica!ed because o# po!en!ial addi!i$e risks+ L *ncreased risk o# $enous !hromboembolism has no! been demons!ra!ed 'i!h pro%es!in-only con!racep!i$es+ . Depo! medro(ypro%es!erone ace!a!e . P:P . Subcu!aneous implan! . 9e$onor%es!rel *AD