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COMPILATION ON PUERPERAL VENOUS THROMBOSIS PUERPERAL VENOUS THROMBOSIS AND PULMONARY EMBOLISM AND PULMONARY EMBOLISM BY SHAMBHULING HEBBALLI III rd BAMS. A.M.V. HUBLI.

27 Purpureal Venous Thrombosis and Pulmonary Embolism by Shambuling Hebballi

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COMPILATION ON PUERPERAL VENOUS THROMBOSIS AND PULMONARY EMBOLISM BY

SHAMBHULING HEBBALLI

III rd BAMS.

A.M.V. HUBLI.DEPT. OF PRASOOTI & STREEROGA,

A.M.V. HUBLI. UNDER GUIDANCE OF

DR. J. MUMMIGATTI.

BSc,BSAM,BAMS

HOD,DEPT. OF PRASOOTI & STREEROGA,

A.M.V. HUBLIDR.C.P. DIXIT.

BSAM,BAMS.PROFESSOR.

DR.ANITA MARIBASHETTI.

MD(AYU)

LECTURER.

PUERPERAL VENOUS THROMBOSIS AND PULMANARY EMBOLISM

INDEX

1. Introduction

2. Etiopathogenesis

3. Deep vein thrombosis

a) Dignosis

b) Symptoms

c) Investigation.

4. Pelvic thrombo Phlebitis

5. Clinical feature

6. Poeventive measure

7. Management

(Pulmonary embolism

a) Introduction

b) Sligns & Symptoms

c) Diagnosis

d) Management

PUERPERAL VENOUS THROMBOSIS AND PULMNARY EMBOLISM

Introduction

The thrombosis of log vein and pelvic is one of the common and important complication in perpurium especially in the western the prevalence is however low in Asian and African countries.

Venous thrombo embolic disease include

Deep vein thrombosis cileombosis cileofemoral.

Thrombophlebitis superficial and deep veins.

Septic pelvic thrombophlebitis.

Pulmonary embolus.

Etiopathogenesis:

1) In normal pregnancy there is rise in concentration of coagulation factors I, II, III, IV, V, VI, VII, VIII, IX, X, XII plasma fibrinolytic inhibitors are produced by the placenta and the level of protein sis markedly decreased..

2) Alteration in blood constitutuents increased number of young platelets at their adhesiveness.

3) Venous stasis is increased due to compression of gravid uterus to the inferior vena cava and iliac vein this stasis causes damage to endothelial cells.

4) Thrambophilias are hypercoaguable states in pregnancy that increases risk of venous thrombosis it may be inherited or acquired. Inherited thrombophilias all the genetic condition associated with the deficiency of anti thrmoboin III protein C protein S others are factor V leiden mutation and hyper homocysteinemia. Aquired thrombophilias are due to presence of lupus anticoagulanter and antipospolipid antibodies.

5) Other acquired risk factors for thrombosis are

a. Advanced age and perity.

b. Operative delivery.

c. Obesity

d. Anamia

e. Heart diseases

f. Infection pelvic cellulities.

g. Trauma to venous wall

Deep vein thrombosis:

Diagnosis: Clinical diagnosis unreliable in majority it remains asymptomatic.

Symptom include: Pain in calf muscle and rise in remprature odema of legs on examination a symmefric leg. Odema (diffrance in circumference) between affected and normal leg more than 2cm is significant a positive Homans sign pain in caff on dorsiflexion of foot may be present.

Investigation:

The following biophysical tests are employed to confirm the diagnosis. Doppler ultrasound to detect the changes the velocity of blood flow in the femoral vein by nothing the alteration of charecterstic whoosh sound which is audible from patent vein partial occtusion or presence of big collateral circulation may give rise false +ve result. It is non invasive method and can be performed even with the portable unite with puplex Doppler ultrasound and DVT real time ultrasoundgraphy, can defect intramural thrombus and is helpful to study the blood flow through the veins diagnostic cirtaria of DVT with ultrasound all (a) soft tissue mass within the venous lumen. (b) non compressibility of vein.

Venography By injuctin non ionic water soluble radio opaque dye to note the filling defect in venous lumen is realiable method if carefully interpreted venagram is restricted in pregnancy and if needed performed using and abdominal shield, with lead aprons.

Fibrinogen scanning I251 fibrinogen scaning is not recommended.for DVT diagnosis in pregnancy due to the risk iof radiation exposure to the fetus cabauf 2 racls radio labeled iodine crosses the placenta it is taken by the fetus thyroid gland it is also secreted in the breast milk.

Pelvic thromboplebities:

Postpartum thromboplebitis is originates n the thrombosed vein at the placental site by organism such as anacrobic styeptocoai or bacteroids fragili. When localized in the pelvis it is called pelvic thromboplebitis. There is no specific clinical features of pelvic thrombophlebitis but it should be suspected in a case where the pyrexia continues for more than a week inspite antibiotic therapy.

Extra pelvic speed

1) Through right ovarian vein into inferior venacava, and thence to the lungs.

2) Through the left ovarian vein to the left renal vein and thence to the left kidney.

3) Retrograde extension toilio femoral veins to produce the clinical pathological entity of phlegmasia alba dolen;s or white leg plegmasia alba dolens (syn white leg). It is the clinicopathological condition usually caused by retrograde extension of pelvic thrombophlebit to involve iliofemoral vein. The femoral vein may be directly effected from accident cellulites the condition seledom met now adays.

Clinical features:

1) It usually develop second week of perpurium.

2) Mild pyrexia is common prior to the dramatic local manifestations. At times the fever may by high with cells and rigor.

3) Evidences of constitatinal distrabances such as head ache malasia and rising pulse rate or features of toxaemia may be present..

4) The effected leg is swollen painfull white cold the pain is due to arterial spasm asaresulted irritation from the near by thrombosed vein.

5) Blood count shows polymorphonecleum leucocytesis.

The diagnosis may be made by ultrasound may be made by ultrasound computed tomography (CT) scan or by magnetic resonance imaging (MRI) atrial of heparine therapy may be considered when the symptom improve with heaparine therapy diagnosis is confirmed.

Prophylaxis for venous thromboembalism (VIE) in pregnancy and perpeurium:

Preventive measure include:

Prevention of trauma sepsis anaemia in pregnancy and labour dehydration during delivery should be avoided.

Use of elastic compression stocking and intermittent phecmatic compression during surgery.

Leg exercise early ambulation are encouraged following operative delivery.

Women at risk of venous thromboembolism during pregnancy have been grauped in to different catogories depending on presence of risk factors. Thrombo prophylaxis to such a women depends on specific risk factors and the category.

1) The low risk women has no personal and family history of VTE and are heterozygous for factor V leidenm meutation such a women need no thrmboprophylaxis.

2) High risk women is one who has preveous VTE or VTE in present pregnancy or anti thrombin III deficiency such a women need low moleaulary it heparine prophylaxis throught pregnancy and post partum 6 weeks women with antitrombine III deficiency can be treated with antithrombin III concentrate prophylactically.

Management:

1) The patient is put to bed rest with the foot end rised in effected level of heart.

2) Pain in effected area can be releved by analgesics.

3) Appropriate antibiotics are to be administered.

4) Anticoagulants. (a) Heaparine 15000 units are administererd intravenously followed by 10000 units 4 to 6 hourly for four to 6 injection when the blood coagulation is likely to be depressed to the therapeutic level. Heaparien is continued for at keast 7-10 days or even longer if thromboplastine time (APTT) to 1.5-2.5 times indicates effectiove and safe anticoagulant low molecular lit heaparine (LMWH) can be used safly in pregnancy. Enoxaparine 40mg daily is given. It does not crose the placenta. (b) A drug of coamarin series warferine is commonly used orally with an ovarlapp of at least 3 days with heparine the initial daily does of 7mg for 2 days is adequate for induction subsequent mainteanance does depend upon international normalized ratio (INR) which should be within the range of 2-3 daily maintenance dose of wartarin is sually 5 to 9mg to be taken at the same time each day the anticoagulant therapy should be continued till all evedabce of disease have disappeared which generally takes 3-6 months neighter anticoagulant should prevent the mother from breast feeding.

5) As soon as pain subsides gentie movements is allowed on bed by the end of first week high quality elastic stocking are fitted on the effected leg before metabolism.

6) Vena cava filters are used for patient where anticoagulant therapy is contraindicated vena cava may be completely ligated by Teflon clips.

7) Fibrinolutic agents like streptokinase produce rapid resultion of pulmonary emboli.

8) Venous thrombotomy is needed for massive pulmonary emboli.

Pulmonary Embolism:

Pulmonary embolism is leading cause internal dath in many centres specially in the developed countries after the sharp decline of maternal mortality due to hemorrhage hypertension or in the pelvis is most likely the cause of pulmonary embolism but in about 80-90%, it occurs without any previous clinical manifestation of deep vein thrombosis. The predisposing factors are those already mentioned in venous thrombosis the clinical features depend on size of embolus and on the preceding health status of the patient. The classic symptom of massive pulmonary embolism are sudden collapse with acute chest pain and air hunger death usually occurs within short time from shock and vaginal inhibition.

Signs and symptoms of Pulmonary embolism:

Tachypnoea dyspnoea pleurite chest pain cough tachycardia haemoptysis and rise in temperature > 37C.

Diagnosis X-ray of the chest shows diminished vascular marking in area of infraction elvation of done of diaphragm and often effusion. It is useful to rule out pneamenia and atelectasis.

ECG tachycardia right axis shift.

Arterial blood gas:

Po2 35mm Hg on room air is reassuring < 95% on room air needs further investigation.

Dopher ultrasound:

Can identify a DVT when the test is Tve for DVT anticoagulant therapy should be started.

Lung scan: (ventilation / perfusion scan)

Perfusion scan will detect are of diminished blood flow whrease aredaction in perfusion with mentaince of ventilation indicates pulmonary embolism MRI can be used in pregnancy as the risk of ionizing radiation is absent.