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Updated: Jan 31 2020

Thromboembolic Disease

  • Snapshot
    • A 34 year-old female, gravida 1, para 1, presents to the emergency department with progressive shortness of breath and pleuritic chest pain. One week ago, she underwent an uncomplicated Cesarean delivery of a healthy 4000 g male (8 lbs and 13 oz) with Apgar scores 9 and 10 at 1 and 5 minutes. Her symptoms started last night as she went to bed, and she decided to present this morning due to worsening of her symptoms. Her past medical history and family history are unremarkable. She takes only a multivitamin daily. Her temperature is 98.6°F (37°C), blood pressure 138/80, pulse is 110/min, respirations are 26/min, and oxygen saturation is 87% on room air. A CT angiogram of the chest is performed, revealing filling defects in the pulmonary vasculature. She is immediately started on supplementation oxygen and intravenous heparin. (Pulmonary embolism)
  • Introduction
    • Overview
      • pregnancy related venous thromboembolism (VTE) is the development of a thrombus (blood clot) in a vein that dislodges, becoming an embolus, during pregnancy or during the intrapartum, antepartum or postpartum period
      • includes deep venous thrombosis (DVT) and pulmonary embolism (PE)
  • Epidemiology
    • Incidence
      • 1.7 cases of VTE per 1,000 deliveries in the US
      • 50-80% of pregnancy related VTE occur postpartum
      • leading cause of maternal mortality
    • Demographics
      • usually occurs in women during 3rd trimester or within 6 weeks postpartum
      • risk for VTE is highest during the first week postpartum
    • Risk factors
      • previous VTE
      • cesarean delivery
      • multiple gestation
      • high parity
      • underlying thrombophilia (e.g., factor V Leiden)
      • pre-pregnancy body mass index (BMI) > 30 kg/m2
      • smoking
      • immobilization
    • Pathogenesis
      • combination of physiologic changes during pregnancy and pathologic trauma during delivery provoke risk factors for the Virchow triad of DVT (hypercoagulability, venous stasis, endothelial dysfunction)
        • pregnancy induces increased production and circulation of coagulation factors and fibrinogen, resulting in a hypercoagulable state
        • venous stasis occurs due to compression of pelvic veins by a gravid uterus during pregnancy and delivery
        • intrapartum trauma and pelvic surgery result in endothelial damage
  • Presentation
    • History
      • patient develops acute onset shortness of breath and dyspnea
    • Symptoms
      • unilateral leg swelling or pain
      • dyspnea
      • pleuritic chest pain
      • cough
      • syncope in severe PE
      • buttock or groin pain in iliofemoral thrombosis
    • Physical exam
      • tachypnea
      • tachycardia
      • hypotension in severe PE
  • Imaging

    • Compression ultrasonography of proximal veins
      • indication
        • imaging study of choice to rule out DVT
          • Sensitivity and specificity >90%
    • Chest radiography
      • indication
        • used in the initial evaluation of all pregnant patients with suspected PE
    • V/Q scan
      • indication
        • imaging study of choice in the diagnostic evaluation of PE in pregnant patients with normal chest radiographs
      • comments
        • especially useful as pregnant women tend to be young and healthy with less cardiopulmonary pathology than with PE in the general population, thus fewer V/Q scans tend to have indeterminant results
    • Chest CT angiography
      • indication
        • imaging study of choice in the diagnostic evaluation of PE in postpartum patients, or pregnant patients with abnormal chest radiograph or indeterminant V/Q scans
  • Studies
    • D-dimer
      • limited utility in VTE during pregnancy or postpartum as D-dimer is normally increased during and after pregnancy
      • has a high negative predictive value in VTE if low
  • Differential
    • Pregnancy
      • key distinguishing features
        • will present with progressive symptoms (tachypnea, dyspnea, tachycardia) that are mild or moderate rather than acute or severe symptoms
        • will have no abnormalities on imaging
    • Peripartum cardiomyopathy
      • key distinguishing factors
        • will present with progressive symptoms, orthopnea, lower extremity swelling, and heart exam abnormalities (S3)
        • will have echocardiogram abnormalities not consistent with PE
    • Septic pelvic thrombophlebitis
      • key distinguishing factors
        • will have persistent fever following delivery
  • Treatment
    • Management approach
      • VTE in pregnancy is managed similarly to VTE outside of pregnancy except warfarin is avoided in pregnant patients
    • Medical
      • subcutaneous low molecular weight heparin (LMWH)
        • indications
          • considered first-line treatment for DVT and PE in pregnant or postpartum women
          • prophylaxis in pregnant women with history of VTE during pregnancy or known thrombophilia starting first trimester until 6 weeks postpartum
        • comments
          • LMWH prefered over unfractionated heparin due to lower risk of maternal osteoporosis and thrombocytopenia
      • thrombolytic therapy
        • indications
          • performed in patients with PE who are hemodynamically unstable
    • Surgical
      • embolectomy
        • indications
          • for patients with PE who are hemodynamically unstable and thrombolytic therapy is contraindicated or those who fail thrombolysis
      • inferior vena cava (IVC) filter
        • indications
          • for patients with PE who have a contraindication to or failure of medical anticoagulation
  • Complications
    • Superficial thrombophlebitis
    • Recurrent pulmonary embolism
  • Prognosis
    • 25% of DVT progress to PE in untreated women
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