Thrombo-embolic disorders
D.Moraa
BscN/MSN(Midwifery)
Thrombus
• Definition: Collection of blood factors primarily
platelets and fibrin on a vessel wall. Forms
whenever blood flow is impeded.
• Common in pregnancy and postpartum
• Three common thrombo-embolitic disorders
include:-
• - Superficial venous thrombophlebitis
-Deep vein thrombosis
-Pulmonary emboli
Etiology
• Thrombi form when blood flow is impaired
• It enlarges with layering of platelets, fibrin and
blood cells as the blood flows past the clot
• Normally associated with thrombophlebitis
• There are three major causes of thrombosis
- Venous stasis
- Hyper-coagulation
- Injury to the endothelial surface of the vessel
a. Venous stasis
• Initiated during pregnancy
• During pregnancy there is compression of the
large vessels of the legs and pelvis by the the
enlarging uterus leading to venous stasis.
• Worsened by long periods of standing and
inactivity-pooling and stasis of blood in the
lower extremities.
b. Hyper coagulation
• The fibrinolytic and coagulation changes during
pregnancy usually persist into the post-partum
period.
• Coagulation factors are elevated while the
fibrinolytic system that causes clots to disintegrate is
suppressed.
• This results in an increase that promote clot
formation and a decrease in factors that prevent
clot formation.
• Hence the risk for thrombus formation is increased.
c.Blood vessel injury
• Injury to the endothelium of the blood vessel
• May occur during CS and trigger a pelvic vein
thrombosis.
Predisposing factors to thrombus formation
• Inactivity
• Obesity
• History of previous thrombosis
• Diabetes meltus
• Higher maternal age
• Trauma
• Prolonged labor
Types of thrombo-embolitic disorders
1. Superficial venous thrombosis
• Limited to the calf area
• Associated with varicose veins
• Can also affect arms incase of iv Rx
• S&S include: redness swelling ,tenderness and
warmth. If palpated the vein feels hard and cord like.
• Management includes analgescs, bed rest and ted
stockings. Elavation of lower extermities is
encouraged.
2. Deep venous thrombosis
• Involves veins from the foot to the ileofemoral
region.
• S&S mostly absent and they usually occur due to an
inflammatory process and obstruction of the
venous system
• S&S include: Swelling of the affected limb(more
than 2cm larger than the opposite leg),erythema,
heat, tenderness, pain and decreased peripheral
pulses .
Diagnosis
• Radiological and laboratory
Radiologic
• Doppler ultrasound
• MRI
• Venography
Laboratory
• D-dimers
Management
• Initial rx
• Bed rest
• Elevate affected limb to promote venous
return
• Anticoagulant therapy – prevents extension of
the thrombus by delaying clotting time of the
blood. (heparin iv or SC)
• Analgesics
Mgmt ctd’
• Antibiotic therapy
• Moist heat
• Lab works to determine Response (%) to the
drug.
• If on heparin monitor aPTT(1.2-2.5 times the
control) and platelet count
• Encourage gradual ambulation
Subsequent treatment
• If pregnant give heparin till delivery
• Postpartum initiate warfarin while mother is
still on heparin (monitor INR)
• Follow up
• Avoid constrictive clothing around the affected
limb
• Avoid prolonged periods of sitting
• Watch out for bleeding
Discharge teaching
• Warfarin is administered btn 6weeks-6
months postpartum.
• Avoid constrictive clothing around the
affected limb.
• Avoid standing for long periods
• Frequent short walks or movement of legs if
sitted for long periods
• Monitor for bleeding
• Explain the treatment regimen and drug interactions
• Avoid OTC eg asprin and use of herbs
• Explain need for lab works
• Teach on avoidance of large amounts of foods rich in
vitamin K as it may interfere with coagulation eg brocoli,
cabbage and spinach.
• Use of contraceptives to avoid pregnancy as warfarin is
ateratogenic
• Soft brush
• Avoid activities that can cause injury due to possibility of
excessive bleeding.
• Avoid alcohol as it inhibits metabolism of oral
anticoagulants.
3.Pulmonary embolism
• One of the leading causes of maternal
mortality
PATHOPHYSIOLOGY:
Occurs when fragments of a blood clot dislodge
and are carried to the lungs. Can also consist of
amniotic fluid. The emboli lodges in a vessel and
partially or completely obstructs the flow of
blood into the lungs.
Signs and symptoms of PE.
• Depends on how much pulmonary blood flow is obstructed. The clinical
S&S include:-
1. Tachycardia
2. tachypnea
3. chest pain
4. Air hunger
5. Dyspnea
6. Pallor and cyanosis
Rales
Cough with hemopytsis
Abdominal pain
Atelectasis
Pleural effusion
Diagnosis
• Pulse oxymetry-low saturation
• Arterial blood gases-decreased partial
pressure of oxygen
• CXR-eclestasis and pleural effusion
• Ultrasound-DVT
• Angiography-emboli
Management
• Emergency
• ICU
• GOAL: Dissolving the goal and maintain
pulmonary circulation
• Oxygenation
• Analgescs (narcotic)
• Bed rest-elevate head of head to reduce
dyspnea
• Pulse oxymetry and arterial blood gas analysis
• Heparin
• Dopamine- prevents hypotension
• Thrombolytic medication such as
thrombokinase
• embolectomy
Nursing considerations
• Assessment-vitals signs and signs of PE
• Oxygenation 8-10l of oxygen
• Drug administration
Prevention
• Regular activity
• Avoid prolonged standing or sitting in one position
• Do not cross legs
• Hydration
• Avoid smoking
• Use of padded stirrups
• Ambulate post delivery
• Td stockings
• Prophylactic for high risk women.
Pueperial infection
• One of the causes of maternal death.
• Def: temperature of 38°c or higher in the first
24 hours.
• Occurs in day 2-10 following delivery
Effect of normal anatomy and physiology of
infection
• Reproductive parts are interconnected hence
microorganisms can move from vagina –
cervix-uterus-fallopian tubes-ovaries –
peritoneal cavity.
• Increased vascularization during pregnancy
increases the risk of bacteria invasion and
spread.
•
• Physiologic changes during child-birth increase
the risk of infection.
a). Acidity of vagina is reduced by amniotic fluid,
blood and lochia which are alkaline. This
encourages growth of bacteria.
b). Endometrial lining necrosis and presence of
lochia encourage growth of bacteria.
c). Presence of lacerations allow bacteria to enter
the tissues.
RISK FACTORS
• Can be divided into antepartum, intrapartum
and postpartum
• a). Antepartum
-poor nutrition
-diabetes
-low socio economic status
-anemia
b). Intra-partum risk factors
• Catheterization
• Retained POCs
• Haemmorrhage
• Unnecessary excess Ves
• Prolonged labor
• Prolonged rupture of membranes
• CS
c). Postpartum risk factors
• Trauma
• History of previous infections
• Presence of pathogens on the genital tract
• PPH
• Retained POCs
• Poor hygiene
1. Endometritis
• Refers to infection of the endometrial lining of
the uterus.
Etiology
Caused by normal flora in the cervix and vagina
Both aerobic and anaerobic organisms involved
Such as E-coli, klebsiella pneumoniae.
Clinical S&S
• Fever (temp above 38within 36 hours of birth
• Chills
• Malaise
• Anorexia
• Abdominal pain
• Uterine tenderness and subinvolution
• Purulent foul smelling discharge
• Tachy cardia
Investigations
• Laboratory
- Full blood count-leukocytosis
- Culture
- Urinalsis
- ultrasound
Management
GOAL:
