Deep venous thrombosis

By Dr Kabare .
 Epidemiology
• Thromboembolic diseases include thrombophlebitis,
phlebothrombosis, septic pelvic thrombophlebitis and
pulmonary embolism. They are a major cause of
morbidity and mortality in the world.

• DVT and PE are distinct but related aspects of vascular

venous thromboembolism.

• Incidence of thromboembolism is 0.2% in ante-natal

period and 0.6% in postpartum. The incidence rises to
1-2% post caesarian section. Pulmonary embolism has a
mortality rate of 15% in 50% of patients with DVT.
Unfortunately only 5-10% are symptomatic.
 Pregnancy and venous
thromboembolic disease
• Pregnancy increases risk x 5-10 fold
• 0.86/1000 deliveries
• 0.71/1000 (DVT) : 0.15/1000 (PE)
• Left leg>80%
• Ileofemoral more common than calf vein
(72% versus 9%)
• Increased with age, caesarian section, bed
rest and prior history of DVT/PE
 Pathophysiology
Virchow’s Triad
• Disorder of blood vessel wall
• Disorder in blood flow (stasis)
• Abnormality of blood constituents

××Recap the clot forming physiological

cascade and the fibrinolysis cascade
 Pregnancy and Virchow’s Triad
• Venous stasis – changes in tone and
obstruction
• Vascular damage at time of delivery
• APTT, PS (free and total), APCr
• FVIII:C, VWF, Fibrinogen
• PAI-1 and PAI-2
 Venous thrombosis – A
multifactorial disease
Predisposing factors:
A. Patient factors:
– Age>40 risk increase exponentially with age
• Obesity (BMI > 30kg/m2
• Varicose veins or venous thrombophlebitis
• Previous D.V.T.
• Oral contraceptives & Hormone replacement therapy;
oestrogen is responsible for D.V.T.
• Pregnancy: due to
(i) Hormonal changes
(ii) Pressure on veins by fetus
 Venous thrombosis – a
multifactorial disease cont….
• Highest incidence in puerperium especially just
after childbirth
• Dehydration: increase blood viscosity
• Immobility: Stasis of blood
• Long distance travel: due to
(i) Inactivity
(ii) Dehydration
• Due to these factors blood becomes more sticky
specially if journey is for more than 5 hours
 Venous thrombosis – a
multifactorial disease cont….
B. Surgical conditions: (5)
• surgery taking more than half an hour
duration
• Abdominal, pelvis, orthopedic surgery to
lower limb
• Increased use of central venous line has
caused more involvement of upper limbs
in D.V.T.
 Venous thrombosis – a
multifactorial disease cont….
C. Medical Conditions
• M.I./Heart failure
• Inflammatory bowel disease
• Malignancy and/or its treatment
• Nephrotic syndrome
• Behcet’s syndrome
• Homocysteinemia
• Major injuries/paralysis
 Venous thrombosis – a
multifactorial disease cont….
D. Hematological Disorders

• Primary proliferative polycyathemia

• Essential thrombocythemia
• Myelofibrosis/Myeloproliferative diseases
• Paraoxysmal nocturnal hemoglobinuria
 Venous thrombosis – a
multifactorial disease cont….
E. Anti-Coagulant Deficiences:
• Antithrombin III: such patients are also
relatively resistant to heparin Therapy
• Factor II Leiden: Genetic polymorphism
of P.T. gene
• Factor V Leiden: Mutation leading to APC
resistance
• Heparin cofactor II
• Prothrombin G20210 A mutation
 Venous thrombosis – a
multifactorial disease cont….
F. Increased Clotting factors:
• XI and VIII

G. Antiphospholipid Antibodies:
• Lupus anticoagulant
• Anti-Cardiolipin antibodies
 Signs and Symptoms

D.V.T. of iliac, femoral or popliteal vein

• leg swelling, warmth, erythema, increased, tissue turgor,

distention of superficial veins and appearance of
prominent venous collaterals. In some patients
deoxyhemoglobin in straight veins gives it a cyanotic hue
called ‘Phlegmasia cerulea dolens’.

• In markedly edematous legs, interstitial tissue pressure

may exceed capillary perfusion pressure causing pallor –
‘Phlegmasia alba dolens’.
 Signs and Symptoms

D.V.T. of calf vein:

• Commonest complaint calf pain especially when

standing or walking

• There may be tenderness or warmth, increased tissue

turgor or modest swelling. Homan’s Signs: positive C/I
due to PE.

• 50% of clients are asymptomatic

 Diagnosis
• Clinical Diagnosis unreliable due to differential
diagnosis but serial limb measurements are
suggestive of diagnosis and treatment follow-up
• Screening investigations – impedance
plethysmography
• Definitive diagnosis – Doppler ultrasound, CT
scan, MRI
• PE – ventilation perfusions scan
*** venograms and pulmonary angiograms not
done in pregnancy
 Differential Diagnosis
• Muscle rupture • Nerve compression

• Trauma • Arthritis

• Hemorrhage • Tendonitis

• Ruptured popliteal cyst • Fractures

• Lymphedema • Arterial occlusive

disorders
• Post phlebitis syndrome
• Simple muscle strains
• Streptococcal skin
infections
 Supportive Management

• Bed rest with elevation of the affected limb

• Exercise
• Fluids
• Avoid Deep Palpation
• Compression stocking
• analgesics
Specific Medical Treatment
1. HEPARIN
• Acute phase heparin administration – it acts
indirectly by activating plasma Anti-thrombin III.
Dose :i.v. bolus 7500-10000 IU followed by
continuous infusion so that 1000-1500 IU/Hr is
maintained. Deep S.C. injection of 10,000-20,000 U
every 8-12 hrs can also be given. This treatment is
maintained for at least 5-7 days visa a vie clinical
symptoms
• Test used to monitor heparin therapy include
coagulation time, activated partial thromboplastin
time, thrombin clotting time, and heparin assay.
Heparin should not be given if the platelet count is
below 50,000/µL. The partial thromboplastin time
should be 1.5-2 times the control value during
heparin therapy.
• Heparin is administered in the first trimester of
pregnancy as warfarin causes embroyopathy

* S/E of heparin include: thrombocytopenia,

osteoporosis and fatty necrosis

* Antidote of heparin, protamine sulphate 1mg per

100 units

Heparin must be stopped at least one day prior to

delivery
• Low molecular weight heparin is equally effective
used in fixed OD or BD doses for 6-14 days. (eg
clexane)
• Advantages of low molecular weight heparin
includes:
• Increased binding of plasma proteins or endothelium in
turn leading to
• Increased bioavailability
• Predictable anticoagulant response
• Affinity for macrophages resulting in increase half life
• Affinity for platelets and platelet factor 4 binding to
osteoblasts
• No monitoring required
• No hospitalization require
• Convenient O.D. doses
• Decreased incidence of thrombocytopenia
• Osteopenia Unknown
2. WARFARIN
• It is oral anticoagulant acts by indirectly
interfering with the synthesis of Vit. K dependent
clotting factors in liver, 5-15 mg is started during
first week of heparin therapy as early as the first
day if aPTT is in therapeutic range. Dose
adjusted accordingly to P.T. INR should be
maintained 1.5-2.5 times control. Heparin can
then be withdrawn
* Embryopathy includes: nasal hypoplasia, skeletal
abnormalities, and multiple central nervous
system abnormalities.
• Antidote vitamin K 5mg I.V.
• Warfarin must be avoided in the first trimester
and after 36 weeks gestation.
3. PROPHYLAXIS
• Extend use of warfarin throughout
pueperium

• Introduction of anticoagulant therapy in the

next pregnancy 2 weeks prior to symptoms
of previous pregnancy

• Use of LMWH in clients with cardiac

prosthesis and on bed rest during pregnancy

• Avoid use of estrogen containing

contraceptives
THANK YOU
Questions?
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