DR SANIAH SENIK

Pakar Perubatan Keluarga UD 54

Klinik Kesihatan Maran

Pahang

VTE IN PRIMARY CARESIGN AND SYMPTOM OF

DVT AND PE

DVT +PE=VTE

Pulmonary Embolism

DIAGNOSIS

Deep Vein Thrombosis

DVT & PE

Clinical diagnosis is not easy

VERY IMPORTANT to look for risk factor

May need Thromboprophylaxis – pharmacological or non pharmacology for prevention.

Anti-embolism stocking (AES) / Graduated compression stockingAES menghalang 2 daripada Virchow’s Triad iaitu: venous stasis dan trauma kepada endothelial salur darah. Terdapat kaitan langsung antara venous stasis dan trauma pada salur darah.

Venous stasis menghasilkan venodilatationdi mana keadaan ini menyebabkan kecederaan mikro kepada lapisan endothelial dan menjadikan ianya tempat terkumpulnya platelet dan pembentukan thrombi. (Caprini et al., 1994)

Virchow’s Triad

Rudolf virchow – 1800

“Omnis cellulae cellula”

Antenatal Risk Assessment

Maternal MedicalProblem

BMI

Smoking

Diagnosis of VTE In pregnancy commonly involves the ilio-femoral

vessels of lower limbs

Symptoms Swelling of the limbs. Usually unilateral

Pain of the affected limbs-

a difference in leg circumference, redness

Feeling unwell- feeling unwell and decrease inmobility however less reliable inpregnancyo Or Completely Asymptomatic with a

retrospective diagnosis being made following a PE.

Physical Examination Vital Sign : Temperature, PR,RR, BP

Weight, Height, BMI

Oxygen saturation

Calf circumference

Peripheral pulse : Popliteal, Pedal both sides

Skin usually warm

CVS

Lungs- normally clear

Abdomen, Fetal Heart activity

Signs Non – pitting swelling

Increased warmth of affected limbs

Reduced capillary filling

Calf swelling > 3 cm than asymptomatic leg( measured 10 cm below tibial tuberosity)

Fever- may or may notfebrile

Investigation

FBC

RP

LFT

ABG

PT APTT

D Dimer – not recommended inpregnancy

Pulseoxymetry

Compression duplex Ultrasound

Venogram- rarely utilized in pregnancy

DIFFERENTIAL DX FOR DVT

Swelling and lower leg discomfort are not unusual in a normal pregnancy.

Muscle strain, Ruptured Baker’s cyst CellulitisSuperficial ThrombophlebitisRuptured plantaris tendon Trauma.

PULMONARY EMBOLISM

In reality – obstetric emergency call for help

Pulmonary Embolism - PE - Evaluation in the pregnant patient

Difficulty and confusion arises in the work up of PE in the pregnant patient due to 3 things:

The normal physiological changes in pregnancy; dyspnoea, tachycardia and leg swelling are also symptoms that a patient with a PE can present with.

The pre-test probability score, Wells Criteria2, cannot be used in a pregnant patient as they were excluded from the analysis group for criteria validation.

The d-dimer will start to rise in the second trimester and remain elevated for 4-6 weeks post-partum.

Pulmonary embolism SOB

Chest pain

Cough

HR more than 16 per minute

HR more than 100 per minute

Cyanosis

Collapse

Massive pulmonary embolism may cause hypotension, syncope, right-sided heart failure with jugular vein distention, hepatomegaly, left parasternal heave, and accentuated and fixed splitting of the second heart sound.

Eventually LV failure can occur due to poor LV filling and arterial hypoxemia.

Clinical Findings in Pulmonary Embolism

Clinical Finding Pulm Embolism (%)

Tachypnea 89

Dyspnea 81

Pleuritic pain 72

Apprehension 59

Cough 54

Tachycardia 43

Hemoptysis 34

Temperature >37°C 34

investigation ABG may be normal if small embolus

CXR- TRO other causes of SOB

ECG – S1Q3T3- rarely seen in pregnancy. HR increased

in severe cases R axis deviation, RBBB, peak P at lead 11

CTPA- investigation of choices, less radiation risk withhigher sensitivity andspecificity

V/Q scan- the life time risk for paediatric cancers is 5 times more than CTPA

INVESTIGATION & DIAGNOSIS

ECG is abnormal in 90% . Tachycardia is the most common abnormality. Nonspecific T-wave inversions occur in 40%; right axis shift with strain pattern occurs with large embolisms. P pulmonale and supreventricular arrythmias may occur.

Arterial Blood Gases. A pulmonary embolism is unlikely with a PaO2 of >80 mm Hg on room air. However, 11.5% of patients with pulmonary embolism have a PaO2 of 80-90 mm Hg.

Figure 1

Intensive and Critical Care Nursing 2013 29, 48-56DOI: (10.1016/j.iccn.2012.04.001)

Copyright © 2012 Elsevier Ltd Terms and Conditions

S1Q3T3

CXR FINDINGS Hampton’s Hump:

-wedge-shaped configuration at lung peripherydueto infarcted lung

Westermark sign:

-pulmonary oligemia

END OF PART ONE

THANK YOU

HAPPY NURSESDAY

DR SANIAH SENIK

Pakar Perubatan Keluarga UD 54

Klinik Kesihatan Maran

Pahang

VTE IN PRIMARY CAREMANAGEMENT OF DVT AND

PE

Management Of acute VTE Pregnant women suspected to have DVT – should

immediately refer to tertiaryhospital

Women with sudden calf pain and swelling –assessed

forDVT Women with sudden onset of chestsymptoms – chest

pain, SOB or cough – asssessed forPE

LIFE THREATENING PULMONARY EMBOLISM

MANAGEMENT &

OUTCOMES

Nearly 10% of patients die in the first hour.Collapsed, shocked patients need to be managed by ACLS & CARDIAC RESUSCITATIONLong term survival depends on rapid diagnosis and institution of therapy.

1) Adequate Maternal and foetal oxygenation2) Support of maternal circulation including uteroplacentalperfusion 3) Immediate anticoagulation or venous interruption to prevent recurrence of lethal PE.An urgent portable echocardiogram or CTPA within 1 hour of presentation should be arranged.

Patients suspected to have VTE or PTE Acute emergency

Refer immediately to nearest hospital and coded RED

accompanied by medical officer

During transfer:

BP/PR

Pulseoxymeter

Oxygen and high flow mask

Equipment and drugs for maternalresuscitation

After assessment , the case should be discussed with Obstetrician

Thromboembolic Disease in Pregnancy and the Puerperium:Acute Management

Green-top Guideline No. 37bApril 2015

How is acute VTE diagnosed in pregnancy?

Any woman with symptoms and/or signs suggestive of VTE should have objective testing performed expeditiously and treatment with low-molecular-weight heparin (LMWH) given until the diagnosis is excluded by objective testing, unless treatment is strongly contraindicated.

What investigations are needed for the diagnosis of an acute DVT?

Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT.

If ultrasound is negative and there is a low level of clinical suspicion, anticoagulant treatment can be discontinued.

If ultrasound is negative and a high level of clinical suspicion exists, anticoagulant treatment should be discontinued but the ultrasound should be repeated on days 3 and 7. [New 2015]

What investigations are needed for the diagnosis of an acute pulmonary embolism (PE)?

Women presenting with symptoms and signs of an acute PE should have an electrocardiogram(ECG) and a chest X-ray (CXR) performed. [New 2015]

In women with suspected PE who also have symptoms and signs of DVT, compression duplexultrasound should be performed. If compression ultrasonography confirms the presence of DVT,no further investigation is necessary and treatment for VTE should continue. [New 2015]

In women with suspected PE without symptoms and signs of DVT, a ventilation/perfusion (V/Q) lungscan or a computerised tomography pulmonary angiogram (CTPA) should be performed. [New 2015]

When the chest X-ray is abnormal and there is a clinical suspicion of PE, CTPA should be performedin preference to a V/Q scan. [New 2015]

What is the initial treatment of VTE in pregnancy?

In clinically suspected DVT or PE, treatment with low-molecular-weight heparin (LMWH) should becommenced immediately until the diagnosis is excluded by objective testing, unless treatment isstrongly contraindicated.

Should graduated elastic compression stockings be employed in the acute management of VTE in pregnancy?

In the initial management of DVT, the leg should be elevated and a graduated elastic compressionstocking applied to reduce oedema. Mobilisation with graduated elastic compression stockingsshould be encouraged.

All suspected cases of DVT / PE should have treatmentcommenced upon clinical suspicion.

Objective confirmation of DVT can await until modalityand its expertise becomesavailable.

If DVT remains untreated, 15–24% of these patients will develop

PE. PE during pregnancy may be fatal in almost 15% of patients,

and in 66% of these, death will occur within 30 minutes of the

embolic event.

Differential Diagnosis of Pulmonary Embolism

Pneumonia

Exacerbation of COPD

Pulmonary oedema

Acute myocardial infarction

Pneumothorax

Lung metastases

Idiopathic pulmonary hypertension

Fractured ribs

Panic attacks/anxiety

Treatment of choice The treatment of choice for VTE inpregnancy is low

molecular weight heparin (LMWH)

LMWH is superior to UFH in terms ofefficacy.

UFH is associated with more sideeffects.

The following LMWH is recommended in pregnancy:

1. Enoxaparin

2. Tinzaparin

3. Dalteparin

LMWH – treatment dose Enoxaparin: 1 mg/kg subcutaneously every 12 hours

Tinzaparin: 175 IU/kg subcutaneously OD

Dalteparin: 150-200 IU/kg subcutaneously OD (max dose18,000 IU daily)

For DVT, repeat doppler studies after 5 - 7 days ofanticoagulation to check if clot hasresolved!

District hospital should keep LMWH in their hospital

UFH Subcutaneous: 10,000 IU twice daily

IV Infusion:

5000 IU stat bolus followed by 1000 IU/hour bycontinuous IV infusion.

Bolus dose of 80 IU/kg IV stat followed by 18IU/kg/hour by continuous IVinfusion

The dosage adjusted to maintain the aPTT at 1.5 to 2.5

Platelet counts to be monitored daily during IV treatment& weekly for 4 weeks then monthlyduring SC treatment.

Heparin-induced thrombocytopenia is rare

Adjunct treatment Raised affected limbs

Compression stocking for at least 2 years inaffectedlimbs

Analgesia ( avoid NSAIDS especially after 32 weeks POG )

Consider caval filter if :

Recurring despite adequateanticoagulant

Non resolving or worsening emboli

Causing pulmonary embolism

TED stockings

Intermittent Pneumatic Compression Devices

Discharged Plan As part of the discharge plan, offer patients and their

families or carers verbal and written informationon:

#The signs and symptoms of DVT andPE

# The recommended duration of use of VTE prophylaxis at home (if discharged with prophylaxis)

# Ensure that patients who are discharged with pharmacological or mechanical VTE prophylaxis are able to use itcorrectly

# Know who to contact if DVT, PE or adverse events are suspected

Prevention of post DVT limb syndrome 60% of women developed this condition characterized

by chronic swelling andpain

Wearing graduated compression stockings for 2 yearson affected limbs reduces this by more than half.

Referral Procedure PRE – PREGNANCY - patients with risk of VTE should

refer to Pre Pre pregnancy Clinic eg : History of VTE orPE

Protein S or Cdeficiencies

Collagen disease espSLE

Antiphospholipid syndrome

Other risks : elderly, obesity, hypertension,smoker,varicose vein, paraplegia

Training Manual 2014

Antenatal Patiet with intermediate or high risk shouldbe

referred immediately to FMS or Obstetrician

What's Next ?

Treatment of VTE in primary care: building a new approach to patient management with rivaroxabanJune 2015Br J Cardiol 2015;22:78

The NOAC rivaroxaban offers a single-drug approach that will allow general practitioners to implement new cost-effective pathways of care for patients with VTE that may improve patient satisfaction and adherence

Reference Reducing the Risk of Venous Thromboembolism

during Pregnancy and the Puerperium-Green-top Guideline No. 37a April 2015

Training Manual Prevention and treatment ofThromboembolism in Pregnancy and Puerperium

Malaysian CPG Treatment and Prevention of Venous Thromboembolism

TERIMA KASIH