MORTALITY FROM BLOOD

CLOT EMBOLISM-A
WORRYING TREND!

A case

An obese primigravida had a breech

presentation diagnosed at 34 weeks. At just
under 34 weeks she was admitted with
ruptured membranes and underwent
caesarean section. She went home on day 4
with a haemoglobin level of 8.4g%. The next
day, the midwife noted that she was
breathless and had pain in her upper back.
The GP visited her at home. On day 6 she
collapsed at home and despite intensive care
treatment she died 2 weeks later.

Mortality rates /100000 live

births
YEAR

NO.

RATE

1997

0.56

1998

0.75

1999

11

2.14

2000

13

2.51

Introduction

Venous thromboembolism (VTE)

covers a spectrum of disorders
characterized by thrombosis in the
venous circulation with its often
fatal sequelae.

Pathogenesis

Virchows Triad (1860):

Increase in venous stasis

Hypercoagulability
Vascular injury

There is an increasing incidence of

VTE among the Asian population
partly
because
of
greater
awareness
among doctors &
patients
themselves.
The
worldwide incidence exceeds 1 per
1000. Nordstrom M, et al 1992

Warning!!!

All health care providers looking

after or involved in the care of the
pregnant or recently pregnant
mother should consider pain in the
leg, chest pain and dyspnoea in an
otherwise healthy woman to be
due to thrombosis or pulmonary
embolism until proven otherwise
and ensure appropriate treatment
is instituted.

VTE remains the leading cause of

maternal mortality in the UK,
accounting for 36% of direct
deaths.
In
Malaysia,
pulmonary
embolism is the third cause of
maternal deaths.
There are less robust data
relating to non-fatal events.
Overall, a reasonable estimate is
that a thromboembolic event
occurs in 1 in 1500 pregnancies.
Report on CEMD UK, 1998

Report on CEMD Malaysia, 1991 1996

Girling J, 2001

Antenatal DVT occurs in 0.06 to

0.09% of pregnancies, being twice as
common in women over 35 years as
those under 35 years. Girling J, 2001
In the puerperium, DVT is related to
maternal age and mode of delivery.
It is likely that more DVT occur
throughout the antenatal period than
the postnatal period, although the
risk of an event per week is greater in
the latter than the former.
Pulmonary emboli are more common
in
the
puerperium,
especially
following LSCS.

Risk of VTE (expressed per 1000 maternities) in relation to

maternal age, pregnancy and mode of delivery
Thromboembolic
event

Under 35 years

Over 35 years

Antenatal DVT

0.615

1.216

Postnatal DVT

0.304

0.72

Postnatal pulmonary
embolus

0.108

0.405

DVT after
emergency LSCS

0.431

1.248

DVT after elective

LSCS

0.238

0.68

Aetiology

1.
2.
3.

Risk of VTE is increased ten-fold, due

to
prothrombotic
physiological
changes:

Increase in coagulation factors

Decrease in anticoagulants
Impaired fibrinolysis

Peripheral vasodilatation occurs in

normal pregnancy, resulting in fall in
velocity of blood flow. This reaches a
nadir at 34 weeks gestation.
This fall in flow velocity is most
marked in women delivering by LSCS
and to a greater extent in the left
femoral vein compared to the right,
due to compression of the left iliac
vein by the right iliac artery and the
ovarian artery which only crosses
over the vein on the left side.
Hence, there is a predominance of left
sided DVTs in pregnancy (85% vs
15% right sided). Green IA et al, 1997

The risk of VTE is further

increased in obese women, after
LSCS, older women and those
with intercurrent conditions such
as pre-eclampsia, diabetes or
dehydration from any cause.

Those with inherited or acquired

thrombophilias are at particular
risk.

Prevalence rates for thrombophilia in

an European population
Thrombophilic defect

Prevalence (per 1000 population)

100
Factor V Leiden
20-70
Lupus inhibitors
30
Anticardiolipin antibodies
30
Prothrombin 20210A
20
Antithrombin deficiency 2.5-5.5
Protein C deficiency
2.0-3.3
MTHFR C-677 T homozygosity

Pathopysiology of PE

Physical occlusion of the vascular system

Platelet activation within the thrombus
release of 5hydroxytryptamine and
thromboxane A2
pulmonary
vasoconstriction
increased pulmonary
vascular resistance
Increased right ventricular afterload
right
heart failure left ventricular filling reduction
low cardiac output

Diagnosis

Chest and leg symptoms in pregnancy

which may be attributed to VTE must be
investigated.
Data from non-pregnant individuals
suggest that 16% of patients with
untreated DVT develop pulmonary
embolus, and 13% of these die,
although anticoagulation substantially
reduces these risks.
The diagnosis also has important
implications for future pregnancy and
later life.

Diagnosis

The clinical diagnosis of DVT in

pregnancy is not reliable. The diagnosis
was confirmed in less than 10% of
pregnancies with clinical suspicion of
DVT compared with 25% in nonpregnant patients.

Chest X -ray

Although CXR is rarely diagnostic,

it should not be withheld solely
because of pregnancy, and should
be performed with confidence that
the amount of radiation is
negligible (equivalent to a transAtlantic flight) if it will facilitate
management.

Arterial blood gases

Arterial blood gas analysis should be

performed in sitting or left lateral
position.
When supine, caval compression by
the gravid uterus and functional
reduction in pulmonary residual
capacity and closing volume may
easily give a false impression of
hypoxia.

ECG

ECG usually lacks specificity, and

normal pregnancy may result in right
axis deviation, and both T wave
inversion and Q wave in lead III,
findings which outside pregnancy
would suggest pulmonary embolus.
When signs and symptoms suggest
PE, the absence of ECG abnormalities
has a poor negative predictive value.

D-dimers

High negative predictive value in the nonpregnant state.

In pregnancy, D-dimers may be elevated as a
result of the prothrombotic changes which
occur, and therefore are not helpful.
Also elevated in preterm labour, placental
abruption & pre-eclampsia
Simply RED D-dimer (SRDD) assay

There should be a low threshold for

performing either Doppler
ultrasound of the femoral veins or
a V/Q scan.
A spiral/ helical CT scan can be
useful in detection of pulmonary
embolus.

Suspected deep vein thrombosis

CUS

Normal

Abnormal

Clinical suspicion of
iliac vein thrombosis

DVT diagnosed

No

Yes

Serial CUS

Consider duplex doppler

Flow present

No duplex
available

Consider venography or
MRI

Absent flow

Abnormal

DVT diagnosed

Normal

DVT absent

Suspected pulmonary embolism

Algorithm a, b or c
Algorithm a
Helical CT

PE

Normal

Treat PE
ruled out

Algorithm b
V/Q scan

Inconclusive Normal HP
CUS or
PA

PE
PE
ruled out treat

Algorithm c
Bilateral CUS

ND
? PE
CUS, CT
or PA

Normal
Algorithm
a or b

Abnormal
PE
diagnosed

Treatment

If a DVT or pulmonary embolus is

diagnosed (or strongly suspected) in
pregnancy, anticoagulation with heparin
should be commenced.
Warfarin should not be used first line;
not only is it teratogenic in first
trimester, but also as it crosses the
placenta and increases the risk of
haemorrhage in utero.

Treatment of VTE is divided into

acute and chronic phases.
In pregnancy, all women experiencing
an acute VTE event who completed
their chronic phase treatment before
6 weeks postnatal should take
thromboprophylaxis until 6 weeks
after delivery. This time is chosen as
it is thought to represent the end of
the period of increased risk due to
elevated clotting factors.

Acute phase treatment

Traditionally, immediate treatment is

with intravenous infusion of
unfractionated heparin (UH).
However, outpatient treatment with low
molecular weight heparin (LMWH) is
now commonly used and is as effective
as UH in preventing further VTE events.
(LEVEL B EVIDENCE) Thompson AJ et al,2000

Chronic phase treatment

When intravenous infusion of UH is used for

acute phase, chronic phase treatment is
commenced after 5 to 7 days. It is given as
10,000u twice daily subcutaneously.
However, LMWH is now often used in these
circumstances. It is continued in treatment
dose to complete 6 to 12 weeks of therapy, it
is then replaced by a thromboprophylactic
dose which is continued until 6 weeks
postnatally.

As warfarin does not cross the breast,

few women who do not get used to
injecting heparin during pregnancy
may wish to change to warfarin after
delivery, once the risk of postpartum
haemorrhage has passed.
They will however need regular
measurement of prothrombin time.

Antenatal prophylactic and therapeutic doses of

LMWH
Prophylaxis

Enoxaparin

Dalteparin

Tinzaparin

50-90kg

40mg daily

5000u daily

4500u daily

<50kg

20mg daily

2500u daily

3500u daily

>90kg

40mg
12-hourly

5000u
12-hourly

4500u
12-hourly

Therapeutic
dose

1mg/ kg
12-hourly

90u/ kg
12-hourly

90u/ kg
12-hourly

Thrombolysis

In non-pregnant situation, there is no

clear
evidence that
thrombolysis
improves clinical outcomes. Experience
of thrombolytic therapy in pregnancy is
even more limited, and can therefore
only be recommended for use in lifethreatening circumstances.

Follow up

Once anticoagulation is discontinued after 6

weeks postnatal, a thrombophilia screen must
be performed, in order to assess their risk of
recurrence and to plan their future
pregnancies.
Contraception should be discussed, since
oestrogen
containing
combined
oral
contraceptive pill is contraindicated in women
who have had a thrombosis.

THROMBOPROPHYLAXIS

Women with previous VTE should be

offered postpartum prophylaxis with
LMWH. It may be reasonable not to use
antenatal prophylaxis with a single
previous VTE associated with a temporary
risk factor that has resolved. LEVEL C
Women with previous recurrent VTE and a
family history of VTE in a first-degree
relative
should
be
offered
thromboprophylaxis with LMWH and for at
least 6 weeks postpartum. LEVEL C

Women with previous VTE and

thrombophilia should be offered
thromboprophylaxis
with
LMWH
antenatally and for at least 6 weeks
postpartum

Women with asymptomatic inherited

or acquired thrombophilia may qualify
for
antenatal
or
postnatal
thromboprophylaxis, depending on
the specific thrombophilia and the
presence of other risk factors.

Low dose aspirin (75mg) is safe in pregnancy,

although its use for thromboprophylaxis in
this setting has never been assessed by a
controlled trial. Therefore, the use of 75mg
aspirin daily may be appropriate in situations
where the risk of VTE is increasedRCOG, 2004 but is
not deemed high enough to warrant the use of
antenatal LMWH; e.g. women with previous
provoked VTE without thrombophilia. Women
should be advised of the lack of evidence for
benefit of aspirin use for thromboprophylaxis
in pregnancy.
In
such
women,
LMWH
at
a
thromboprophylactic dose can also be given
from the onset of labour until 6 weeks
postnatal.

Risk assessment Low risk

Elective caesarean section

uncomplicated and no other risk factors

Risk assessment moderate

risk

Age > 35 years

Obesity > 80kg
Para 4 or more
Gross varicose veins
Current infection

Pre-eclampsia
Immobility prior to
surgery (> 4 days)
Major current illness
Emergency
caesarean section in
labour

Risk assessment high risk

Patient with 3 or more risk factors

Extended major pelvic surgery
caesarean hysterectomy
Patients with personal or family history
of DVT or PE
Patients with antiphospholipid antibody

Summary of protocol for thromboprophylaxis in

women with previous VTE and/ or thrombophilia
Risk

Previous VTE
and/ or
thrombophilia
status

Prophylaxis

Very high

Previous VTE (
thrombophilia) on
long-term warfarin

Antenatal high
prophylactic or
therapeutic dose
LMWH and at least
six weeks of
postnatal warfarin

Summary of protocol for thromboprophylaxis in

women with previous VTE and/ or thrombophilia
Risk

Previous VTE and/

or thrombophilia
status

Prophylaxis

High

Previous recurrent VTE not on

long-term warfarin

Antenatal and 6 weeks

postnatal prophylactic LMWH

Previous VTE + thrombophilia

Previous VTE + family history

of VTE
Asymptomatic thrombophilia
(antithrombin deficiency,
combined defects,
homozygous FVL or
prothrombin gene defect)

Summary of protocol for thromboprophylaxis in

women with previous VTE and/ or thrombophilia
Risk

Previous VTE and /or Prophylaxis

thrombophilia status

Moderate

Single previous
provoked VTE without
thrombophilia, family
history or other risk
factors
Asymptomatic
thrombophilia (except
antithrombin deficiency,
combined defects,
homozygous FVL or
prothrombin gene
defect)

6 weeks of postnatal
prophylactic LMWH
antenatal low-dose
aspirin

Madam SR
37 year old, Para 7.
Successful induction of labour for
gestational
hypertension
on
06/10/07.
Was on Tab. Labetolol 100mg tds.
Delivered 3.5kg boy, without any
complications.
Discharged with anti-HPT on D1.

Readmitted on 19/10/07 at D13

postnatal.
Acute onset of dyspnoea and right
sided chest pain.
Clinically no pallor, but tachypnoeic
(RR 28/ min).
BP: 128/ 80mmHg.
PR: 120bpm (tachycardic).
Obese (BMI 37).
SpO2: 90%

Generalised rhonchi in both lung fields, reexamination later showed no breath

sounds at right lower lobe and stony
dullness to percussion.
No cardiac arrythmias or murmurs.
ECG: sinus tachycardia.
ABG: respiratory alkalosis.
Hb: 12.6g/ dl
TWC: 25,000
Renal profile: acute renal failure, but
resolved by D4.

Diagnosis: pulmonary embolism

Treated with nebuliser and given s/c

enoxaprine 80mg bd for presumptive
diagnosis of pulmonary embolism.
Spiral CT: There is no filling defect
detected in the main pulmonary trunk,
right & left main pulmonary artery down to
2nd degree bronchus. Extensive right sided
pleural effusion with collapse consolidation
of the posterobasal segment of right lung.

Impression: cannot rule out

pulmonary embolism still.

Right pleural tapping done: 600cc

Pleural

Pleural tap biochemistry: exudative.

Impression: Collapse consolidation

straw coloured fluid.

tap

polymorphs.

FEME:

predominant

right lower lobe lung, cannot rule out

pulmonary embolism
Treated with oxygen support, s/c
enoxaprine decreased to 40mg od
(prophylactic dose).

Lessons from the CEMD:

- Deaths due to suboptimal care:
Failure to appreciate the significant
risk factors
Failure to deliver adequate
prophylaxis
Failure to diagnose and deliver
appropriate treatment

THANK YOU