Vascular Problems

8/8/2019 Vascular Problems

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12/11/2010 DrU.Gupta,Dr.N.K.Gupta 1

Vascular problems inVascular problems inGynecology and ObstetricsGynecology and Obstetrics

Dr. UMA GUPTA MD(OBG)FICMCH,Sr.Specialist,VPCIMS,LUCKNOW(UP)INDIADr. UMA GUPTA MD(OBG)FICMCH,Sr.Specialist,VPCIMS,LUCKNOW(UP)INDIA

Dr.N.K.GUPTA, M.Ch,CTVS,Associate Prof,ERAs LUCKNOW MEDICALDr.N.K.GUPTA, M.Ch,CTVS,Associate Prof,ERAs LUCKNOW MEDICAL

COLLEGE,LUCKNOW.INDIACOLLEGE,LUCKNOW.INDIA

[email protected]@yahoo.com

[email protected]@yahoo.com


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Vascular surgery evolutionVascular surgery evolution

The firstelective operation fortreatmentofan aneurysmThe firstelective operation fortreatmentofan aneurysmwasreported bythe most famoussurgeon in Greekwasreported bythe most famoussurgeon in Greekantiquity,ANTYLLUS, in the 2antiquity,ANTYLLUS, in the 2ndnd century.century.

AMBROSE PARE(1510AMBROSE PARE(1510--1590),mainly contributed1590),mainly contributed principles wound careprinciples wound care--aneurysm operations.aneurysm operations.

Aftera century,RICHARD WISEMAN(1625Aftera century,RICHARD WISEMAN(1625--1686)Father1686)FatherofEnglish Surgerydescribed aneurysm in arm.ofEnglish Surgerydescribed aneurysm in arm.


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contdcontd Suturesshould be made with very fineSuturesshould be made with very fine

needles while the wall issomewhatneedles while the wall issomewhatstretched.Stenosis or occlusion onlystretched.Stenosis or occlusion onlyoccursoccurs--faultytechniquefaultytechnique--which iswhich isstillstillvalid 100years later.valid 100years later.

In 1910, he demonstrated thatbloodIn 1910, he demonstrated thatbloodvessels could be kept in cold storage forvessels could be kept in cold storage forlongperiods before transplantingthem.longperiods before transplantingthem.

Carrel won the noble prize forthisCarrel won the noble prize forthis

work in 1912work in 1912in recognition of hisin recognition of hiswork on vascularsuture andwork on vascularsuture andtransplantation of blood vessel.transplantation of blood vessel.


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AntiPhospholipid AntibodySyndromeAntiPhospholipid AntibodySyndrome

Raynauds diseaseRaynauds disease

VasculitisVasculitis

Arterial DisordersArterial Disorders


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Venous DisordersVenous Disorders

Varicose VeinsVaricose Veins

Deep Vein Thrombosis/ PEDeep Vein Thrombosis/ PE

Superficial ThrombophlebitisSuperficial Thrombophlebitis


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AntiPhospholipid Antibody SyndromeAntiPhospholipid Antibody Syndrome

Arterial and VenousthrombosisArterial and Venousthrombosis

HistoryHistory-- Firstnoted in ptspositive forsyphilisFirstnoted in ptspositive forsyphilis

19521952-- clotting disorderasso. with SLEclotting disorderasso. with SLE

19571957-- linked to recurrentpregnancy losslinked to recurrentpregnancy loss

1963 & 19721963 & 1972 term Lupusanticoagulantterm Lupusanticoagulant

1983

1983

DrGra

ham

Hug

hesDr

Gra

ham

Hug

hes

associ

ation be

tween

APL

associ

ation be

tween

APL

antibodiesand arterial and venousthrombosisantibodiesand arterial and venousthrombosis

19851985 ELISAtest for detection ofACAELISAtest for detection ofACA

syn. Hughes Syndrome


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PRIMARYPRIMARY SECONDARYSECONDARY

Mechanism:

AUTOIMMUNE PHENOMENON ???AUTOIMMUNE PHENOMENON ???

Tissue injuryTissue injury Inflammation, Ischemia, traumaInflammation, Ischemia, trauma

Classes Of Antibodies

a) Anticardiolipin Antibody (IgG,IgA,IgM)

b) Lupus Anticoagulant

c) Antibodies against specific molecules e.g.-2-glycoprotein

Types:


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PrevalencePrevalence 22--4%4%50%50% -- PrimaryAPLASPrimaryAPLASSLESLE 30% will developAPLAS30% will developAPLAS

ACAACAfive timesmore common thanfive timesmore common than LupusLupus

AnticoagulantAnticoagulant

PrimaryAPLASPrimaryAPLAS 10%10% SLE,Mixed Conn. TissueSLE,Mixed Conn. TissueDsDs


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RISKS ASSOCIATEDRISKS ASSOCIATED::

MISCARRIAGESMISCARRIAGES PRETERM LABORPRETERM LABOR

PREPRE--ECLAMPSIAECLAMPSIA

LOW BIRTH WEIGHTLOW BIRTH WEIGHT

THROMBOCYTOPENIA(20THROMBOCYTOPENIA(20--40%)40%)


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WHEN TOEVALUATEWHEN TOEVALUATE

Unexplained still birth/fetal death after10 wksUnexplained still birth/fetal death after10 wks

Severe IUGRpriorto termSevere IUGRpriorto term

Severe preSevere pre--eclampsiaat


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TREATMENTTREATMENT AnticoagulationAnticoagulation HeparinHeparin pp OralOral

LongtermLongtermpp Life Long(risksLife Long(risks 3% chance peryear ofmajor3% chance peryear ofmajor

hhage,1/5hhage,1/5thth

fatal)fatal) AntiAnti--plateletdrugsplateletdrugs AspirinAspirin

LMWHLMWH

PregnancyPregnancy Heparin / LMWHHeparin / LMWH

PROPHYLAXISPROPHYLAXIS (APLAS withoutthrombotic problems)(APLAS withoutthrombotic problems) AspirinAspirin

Lifestyle ModificationLifestyle Modification

Control ofRisk factorsControl ofRisk factors HTN,Smoking,Cholesterol levels,HTN,Smoking,Cholesterol levels,WeightcontrolWeightcontrol


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Special Prenatal/Birth/Neonatal ConsiderationsSpecial Prenatal/Birth/Neonatal Considerations

Ideally, one should seek medical advice before becomingIdeally, one should seek medical advice before becomingpregnant.pregnant.

Once pregnancy isachievedOnce pregnancy isachieved to see Obstetricianto see Obstetrician -- to decide on the need fortreatmentto decide on the need fortreatment frequentoffice visits will be needed to:frequentoffice visits will be needed to:

Screen forpreeclampsia,Screen forpreeclampsia, Fetal MonitoringFetal Monitoring Ultrasound examinationsto check the growth ofthe baby.Ultrasound examinationsto check the growth ofthe baby.

Forpatients on heparinForpatients on heparin extra blood testsmay be needed to adjustthe dose depending onextra blood testsmay be needed to adjustthe dose depending on

the type of heparin beingused,and the pasthistory ofthe patient.the type of heparin beingused,and the pasthistory ofthe patient.


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PREGNANCY:PREGNANCY: Pre PregnancyCounsellingPre PregnancyCounselling Heparin (s/c)Heparin (s/c) Low Dose AspirinLow Dose Aspirin LMWHLMWH AspirinAspirin PrednisonePrednisone XXXXXXXX Low Dose AspirinLow Dose Aspirin

IntravenousImmune Globulin (IVIG)IntravenousImmune Globulin (IVIG) ImmunosupressionImmunosupression SteroidsSteroids CatastrophicCatastrophic PlasmapheresisPlasmapheresis


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18621862 Maurice RaynaudMaurice Raynaud PrevalencePrevalence 33--5%5% EpisodicEpisodic eventsevents vasoconstriction (digitalvasoconstriction (digital

arteries,precapillaryarterioles & cutaneousAVarteries,precapillaryarterioles & cutaneousAVshunts)shunts)

vsAcrocyanosisvsAcrocyanosis Exaggeration ofthe physiologic response to coldExaggeration ofthe physiologic response to cold

temperature orstress.temperature orstress. Manifestation ofgeneralised vasospasticManifestation ofgeneralised vasospastic

disorder.e.g.pts who have Prinzemetalsangina,disorder.e.g.pts who have Prinzemetalsangina,migraines, orscleroderma.migraines, orscleroderma.


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H/o sensitivityto cold/ episodic pallor or cyanosisH/o sensitivityto cold/ episodic pallor or cyanosis Triphasic reactionTriphasic reaction InvolvesInvolves-- fingers,toes,tip ofthe nose, ear lobes.fingers,toes,tip ofthe nose, ear lobes.

(white>(white>blueblue>>redred))

PRIMARY* SECONDARY

SYMMETRIC ASYMMETRIC

ABSENCE OF PAINFUL ISCHAEMIC

-TISSUE NECROSIS SKIN LESIONS

-ULCERATION C/f s.o. CONN. TISSUE

-GANGRENE DISORDERS(arthritis,myalgia,-SECONDARY CAUSE abnormallung fn,fever etc)

H/o druguse/toxic agent

NORMAL NAIL FOLD CAPILLARIES MICROVASCULAR DS

NORMAL ESR ESRo

NEGATIVE ANA TEST ANA *Adapted from LeRoy and Medsger


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Complete evaluationComplete evaluation to R/o underlying causeto R/o underlying cause H/o or currentdruguseH/o or currentdruguse H/o repetitive trauma e.g.vibratorytoolsH/o repetitive trauma e.g.vibratorytools Positional changestriggeringthe event. e.g.Tho Outl Obst.Positional changestriggeringthe event. e.g.Tho Outl Obst. Carpel tunnel syndromeCarpel tunnel syndrome Neurapathic conditionsNeurapathic conditions MalignancyMalignancy HypothyroidismHypothyroidism DysproteinemiasDysproteinemias VasculitisVasculitis EmboliEmboli VascularOcclusive diseaseVascularOcclusive disease


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NonPharmacologicalNonPharmacological Avoidance of cold temp/prolong vibrationsAvoidance of cold temp/prolong vibrations Reduce emotional stressReduce emotional stress Avoid SmokingAvoid Smoking

Calcium channel BlockersCalcium channel Blockers OtherAgentsOtherAgents Sympatholytic drugsSympatholytic drugs ARBsARBs FluoxetineFluoxetine I.V. ProstaglandinsI.V. Prostaglandins

AwaitedAwaited CilostazoleCilostazole SildenafilSildenafil Bosentan (endothelin receptor inhibitor)Bosentan (endothelin receptor inhibitor)

SympathectomySympathectomy Proximal ???Proximal ??? Localised Digital Localised Digital

TreatmentTreatment


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VasculitisVasculitis AutoImmune DiseaseAutoImmune Disease

Inflammation ofthe blood vesselsInflammation ofthe blood vessels

SymptomsSymptoms depend on which blood vesselsare inflameddepend on which blood vesselsare inflamed FatigueFatigue Sleep disturbancesSleep disturbances Memory LossMemory Loss Emotional LiabilityEmotional Liability DepressionDepression Low Thyroid FunctionLow Thyroid Function GI disturbancesGI disturbances Headaches/Chemical SensitivityHeadaches/Chemical Sensitivity Fungal InfectionsFungal Infections Low Blood SugarLow Blood Sugar PainPain Tingling/Ringing ears/Cold Toes/Cold FingersTingling/Ringing ears/Cold Toes/Cold Fingers OverdoingOverdoing FlutteringHeart/Tachycardia/Panic Attacks/Mitral valve ProlapseFlutteringHeart/Tachycardia/Panic Attacks/Mitral valve Prolapse


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IMMUNESYSTEMMALFUNCTIONIMMUNESYSTEMMALFUNCTION CONSUMPTIONOFASPARTATE(INDIET DRINKS/ARTIFICIALCONSUMPTIONOFASPARTATE(INDIET DRINKS/ARTIFICIAL

SWEETNERS etc.)SWEETNERS etc.) CHLORINATEDANDFLORIDATED WATER ???CHLORINATEDANDFLORIDATED WATER ???

POORCELLULARCOMMUNICATIONPOORCELLULARCOMMUNICATION HEAVYMOL WT CARBOHYDRATESHEAVYMOL WT CARBOHYDRATES(LONGCHAINED)(LONGCHAINED)

PROVIDEINGREDIENTSFORCELL MARKERSPROVIDEINGREDIENTSFORCELL MARKERS HIGHLYANTIHIGHLYANTI--INFLAMMATORYINFLAMMATORY CODINGCAPACITYBETTER THANAMINOACIDS *CODINGCAPACITYBETTER THANAMINOACIDS *

OVERACTIVATED,OUT OFBALANCEIMMUNESYSTEMOVERACTIVATED,OUT OFBALANCEIMMUNESYSTEM StressStress InfectionsInfections Bacterial ,Fungal (Candida), Viral (e.g.Herpes)Bacterial ,Fungal (Candida), Viral (e.g.Herpes) ToxinsToxins produced by infecting organism, from environmentproduced by infecting organism, from environment Liver dysfunctionLiver dysfunction SteroidsSteroids Enzyme deficiencyEnzyme deficiency Digestive/MetabolicDigestive/Metabolic Hypercoagulation/HypoOxygenationHypercoagulation/HypoOxygenation Glutathione DeficiencyGlutathione Deficiency

*Acta Anatomica


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ManagementManagement Weighingthe available optionsWeighingthe available options

SteroidsSteroids

Chemotherapeutic AgentsChemotherapeutic Agents

Antioxidants/Digestive EnzymesAntioxidants/Digestive Enzymes

Treatunderlying disorderTreatunderlying disorder Lifestyle modificationLifestyle modification


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Venous DisordersVenous Disorders


Deep Vein Thrombosis/ PEDeep Vein Thrombosis/ PE



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PregnancyPregnancy

Increased blood volumeIncreased blood volume

Pressure on veinsPressure on veins

Relaxation effect of hormonesRelaxation effect of hormones


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ManagementManagement

Non OperativeNon Operative SelfresolvingSelfresolving (within six weeks)(within six weeks)

After6 weeksAfter6 weeks ifproblematic/unacceptableifproblematic/unacceptable

Graduated Compression StockingsGraduated Compression Stockings

SurgerySurgery


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Before Treatment After Treatment


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Benign /Self limiting DiseaseBenign /Self limiting Disease

Can progress to DVT(11%)Can progress to DVT(11%)

Associated with AbnormalitiesAssociated with Abnormalities

in blood coagulationin blood coagulation


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TraumaticTraumaticVaricose VeinsVaricose Veins

Oral contraceptivesOral contraceptives PregnancyPregnancy InfectionInfection (e.g.Staph., Pseud.,Kleb.,Anaerobes)(e.g.Staph., Pseud.,Kleb.,Anaerobes) MigratoryMigratory(e.g.Cancer, Vasculitis,Buergers)(e.g.Cancer, Vasculitis,Buergers) MondorsDiseaseMondorsDisease Unusual formsUnusual forms

palmar digital veinspalmar digital veins


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DiagnosisDiagnosis Painful cord like structurePainful cord like structure

Rednessalongthe veinRednessalongthe vein TendernessTenderness

FeverFever

InvestigationsInvestigations Duplex scanDuplex scan


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ManagementManagement Underlying disorderUnderlying disorder

Remove offendingagentsRemove offendingagents(e.g.IV cannula)(e.g.IV cannula)

AntibioticsAntibiotics NSAIDsNSAIDs

AnticoagulationAnticoagulation

Excision ofthe suppurating veinExcision ofthe suppurating vein

Application ofmassive warm wetcompressesApplication ofmassive warm wetcompresses

Elevation ofthe extremityElevation ofthe extremity

ImmobilizationImmobilization


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VENOUS THROMBOEMBOLISM DURINGVENOUS THROMBOEMBOLISM DURING

PREGN

ANCY

PREGN

ANCY

LEADINGCAUSEOFLEADINGCAUSEOF

DEATHDEATH

11--3/10003/1000PREGNANCIESPREGNANCIES


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PathophysiologyPathophysiology--

5times higher in pregnancy5times higher in pregnancy oo venousstasis ofpregnancyvenousstasis ofpregnancy

Physiological changesasso. with pregnancyPhysiological changesasso. with pregnancy


PREGN

ANCY

PREGN

ANCY


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PREGN

ANCY

PREGN

ANCY

PathophysiologyPathophysiology-- Independentrisk factorsIndependentrisk factors

ProlongBed restProlongBed rest Multiparity(>3)Multiparity(>3)

Advanced Maternal Age (>35yrs)Advanced Maternal Age (>35yrs)

OverweightOverweight

Personal or family history of VTEPersonal or family history of VTE PrePre--eclampsiaeclampsia


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PREGN

ANCY

PREGN

ANCY

PathophysiologyPathophysiology-- Alteration in Coagulation/Fibrinolytic SystemAlteration in Coagulation/Fibrinolytic System

FactorII, VII,XFactorII, VII,Xoo (middle of Pregnancy)(middle of Pregnancy)

FibrinFibrin

Protein SProtein S

Protein CProtein C

Fibrinolytic System inhibitedFibrinolytic System inhibited (mostly3rd trimester)(mostly3rd trimester)


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PREGN

ANCY

PREGN

ANCY

DiagnosisDiagnosis Calf veins orIlioCalf veins orIlio--femoral segmentfemoral segment

Predilection for LeftsidePredilection for LeftsideS/sS/s

SwellingSwelling

TendernessTenderness

Skin DiscolourationSkin Discolouration

Warmto touchWarmto touch

Unusual firmness/hardness in the legUnusual firmness/hardness in the leg

Calf discomforton dorsiflexionCalf discomforton dorsiflexion

Prominenttender cord like subcut. veinProminenttender cord like subcut. vein


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PREGN

ANCY

PREGN

ANCY

Diagnostic testsDiagnostic tests

VenographyVenography


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PREGN

ANCY

PREGN

ANCY

Diagnostic testsDiagnostic tests Duplex UltrasonographyDuplex Ultrasonography


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PREGN

ANCY

PREGN

ANCY

Diagnostic testsDiagnostic tests Spiral CT VenographySpiral CT Venography

No filling of calf veins Opacification of collaterals


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NuclearImagingNuclearImaging IPGIPG

MRIMRI

DD--dimerdimer


PREGN

ANCY

PREGN

ANCY


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PREGN

ANCY

PREGN

ANCY

Radiation ExposureRadiation Exposure

Procedure Fetal radiation dose (mrads)

CXR


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PREGN

ANCY

PREGN

ANCY

Blood TestsBlood Tests Factor V LeidenFactor V Leiden Protein CProtein C Protein SProtein S ACAand LAantibodiesACAand LAantibodies Activated Protein Cresistance (APCActivated Protein Cresistance (APC--R)R)

AntiThrombin IIIAntiThrombin III HomocysteinHomocystein Prothrombin gene mutationProthrombin gene mutation


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Pulmonary EmbolismPulmonary Embolism

Major nonobstetric cause ofMajor nonobstetric cause ofmaternal mortalitymaternal mortality

Cause ofDeathCause ofDeath 2/100,000maternities2/100,000maternities

MaximumMaximum PeripartumPeripartum

More after operativeMore after operative

interventionintervention Subtle presentationSubtle presentation


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PulmonaryAngiographyPulmonaryAngiography

Spiral CT ScanSpiral CT Scan


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Nuclear ImagingNuclear Imaging (Ventilation(Ventilation--Perfusion Scan)Perfusion Scan)


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PREGN

ANCY

PREGN

ANCY

ManagementManagement Medical/PharmacologicalMedical/Pharmacological

AnticoagulationAnticoagulation AntiAnti--plateletagentsplateletagents

SurgicalSurgicalVenous ThrombectomyVenous Thrombectomy ThrombolysisThrombolysis

EndovascularEndovascular IVCFilterplacementIVCFilterplacement

OthersOthers HydrationHydration EarlyMobilizationEarlyMobilization Graduated Compression StockingsGraduated Compression Stockings Pneumatic compression devicesPneumatic compression devices


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PREGN

ANCY

PREGN

ANCY

Medical/PharmacologicalMedical/Pharmacological Unfractionated Heparin/LMWHUnfractionated Heparin/LMWH

Oral AnticoagulationOral Anticoagulation

AntiplateletagentsAntiplateletagents

New MoleculesNew Molecules DirectThrombin InhibitorsDirectThrombin Inhibitors

Lepirudin,Lepirudin, DDesirudin,esirudin, Argatroban,Argatroban, XimelagatranXimelagatran

StatinsStatins


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PREGN

ANCY

PREGN

ANCY

SurgicalSurgicalVenous ThrombectomyVenous Thrombectomy

IlioIlio--femoral DVTfemoral DVT

PulmonaryEmbolectomyPulmonaryEmbolectomy


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PREGN

ANCY

PREGN

ANCY

SurgicalSurgical ThrombolysisThrombolysis


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PREGN

ANCY

PREGN

ANCY

EndovascularEndovascular

IVCFilterplacementIVCFilterplacement

TemporaryTemporary

PermanentPermanent


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PREGNANCYPREGNANCY

OthersOthers HydrationHydration

EarlyMobilizationEarlyMobilization

Graduated Compression StockingsGraduated Compression Stockings

Pneumatic compression devicesPneumatic compression devices


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PREGNANCYPREGNANCY

PROPHYLAXISPROPHYLAXIS Pasth/o DVT in pregnancy, no otherPasth/o DVT in pregnancy, no other

thrombotic risk factorsthrombotic risk factorsAntenatal thromboAntenatal thrombo--prophylaxisprophylaxis

S/c Heparin+/S/c Heparin+/-- GCSGCS

S/c Heparin/LMWHS/c Heparin/LMWHpp Warfarin (INR2Warfarin (INR2--2.5)2.5)

GCS6GCS6--12 wks12 wks(ifanticoagulation contraindicated)(ifanticoagulation contraindicated)

BMJ 1992


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PREGNANCYPREGNANCY

PROPHYLAXISPROPHYLAXIS Known inherited/acquired thrombophiliaKnown inherited/acquired thrombophilia

Postpartum +/Postpartum + /-- AntepartumthromboprophylaxisAntepartumthromboprophylaxis

Individual considerationIndividual consideration

No pasth/o DVT/Thrombophilia, butwithNo pasth/o DVT/Thrombophilia, butwithotherrisk factors in combinationotherrisk factors in combination PostpartumthromboprophylaxisPostpartumthromboprophylaxis

S/c HeparinS/c Heparin

BMJ 1992


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PREGNANCYPREGNANCY

PROPHYLAXISINCAESERIANSECTIONPROPHYLAXISINCAESERIANSECTION Low RiskLow Risk

Elective CElective C--sectionsection uncomplicated pregnancyuncomplicated pregnancy

No risk factorsNo risk factors

Moderate RiskModerate Risk Age, Weight, Parity, Varicose Veins,Immobility,Sepsis, PreAge, Weight, Parity, Varicose Veins,Immobility,Sepsis, Pre--

eclampsia,EmergencyCeclampsia,EmergencyC--section,MajorCurrentIllnesssection,MajorCurrentIllness

High RiskHigh Risk 3 ormore mod risk factors,Extended majorpelvic/abd surgery3 ormore mod risk factors,Extended majorpelvic/abd surgery

e.g.Caeserian hysterectomye.g.Caeserian hysterectomy

Personal/familyH/o DVT/PE/thrombophilia, ParaparesisPersonal/familyH/o DVT/PE/thrombophilia, Paraparesis

Ptwith APLASPtwith APLAS


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PREGNANCYPREGNANCY

PROPHYLAXISINCAESERIANSECTIONPROPHYLAXISINCAESERIANSECTION Low RiskLow Risk

EarlyMobilizationEarlyMobilization HydrationHydration

Moderate RiskModerate Risk One of variety ofprophylactic measuresOne of variety ofprophylactic measures

SubcutaneousHeparinSubcutaneousHeparin Mechanical devicesMechanical devices

High RiskHigh Risk Heparin Prophylaxis +/Heparin Prophylaxis +/-- LegStockingsLegStockings

Report of the RCOG Working Party on prophylaxis (and management) against Thromboembolism in Gynaecology and Obstetrics. London:Royal College of Obstetricians and Gynaecologists, 1995


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PREGNANCYPREGNANCY

Key PointsKey Points Even 1Even 1stst trimester carriesrisk ofthrombosis(2/3trimester carriesrisk ofthrombosis(2/3rdrd antepartumantepartum

deaths)deaths) Additional risk factors/ family history/ known thrombophiliamayAdditional risk factors/ family history/ known thrombophiliamay

indicate thromboprophylaxisindicate thromboprophylaxis Close attention should be paid to anypregnantwoman c/o leg/chestClose attention should be paid to anypregnantwoman c/o leg/chest

symptoms for e/o DVT/PEsymptoms for e/o DVT/PE All women undergoingCAll women undergoingC--section should be assessed forprophylaxissection should be assessed forprophylaxis

againstVTEagainstVTE

Midwives,GPs & othermedical staffshould take particularattentionMidwives,GPs & othermedical staffshould take particularattentionof women with chestor legsymptomsafter vaginal deliveryof women with chestor legsymptomsafter vaginal delivery Women with risk factors forDVT should be carefullyscreened andWomen with risk factors forDVT should be carefullyscreened and

considered forthromboprophylaxisconsidered forthromboprophylaxis


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PREGNANCYPREGNANCY

Prevention:Prevention: WeightcontrolWeightcontrol

Avoid prolong immobilityAvoid prolong immobility

Leg elevationLeg elevation

Avoid OCPs containing high dose ofEstrogensAvoid OCPs containing high dose ofEstrogens

Adequate hydrationAdequate hydration

Avoid Smoking/Alcohol intakeAvoid Smoking/Alcohol intake


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PREGNANCYPREGNANCY

VTE isan uncommon butveryserious complication ofVTE isan uncommon butveryserious complication ofpregnancypregnancy

Pregnantwomen are at increased risk for VTE,andPregnantwomen are at increased risk for VTE,andmaypresent in subtle waysmaypresent in subtle ways

Suspected VTE in pregnancyshould be investigatedSuspected VTE in pregnancyshould be investigatedthoroughlythoroughly

Risk of VTE can be reduced in appropriate patientsRisk of VTE can be reduced in appropriate patientswith judicioususe ofanticoagulantswith judicioususe ofanticoagulants

Take Home MessageTake Home Message


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Vascular Control in Gynaecological SurgeryVascular Control in Gynaecological Surgery

MODALITIESAVAILABLEMODALITIESAVAILABLE

Open VascularOpen Vascular

EndovascularEndovascular


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OPEN VASCULAROPEN VASCULAR

Uterine artery LigationUterine artery Ligation Ovarian Artery ligationOvarian Artery ligation

Internal Iliac Artery LigationInternal Iliac Artery Ligation

Common Iliac artery controlCommon Iliac artery control

Control overAortaControl overAorta


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ENDOVASCULARENDOVASCULAR

Balloon OcclusionBalloon Occlusion

StentGraftStentGraft

EmbolisationEmbolisation CoilCoil

Foamparticles etc.Foamparticles etc.


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