02 nguyen t hong van ta

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• N. T. H. 34 year old. 2012. Housekeper. Bình Phước

• Time and date: 15g30’ - 15/09/2006

: Multipara, cephalic presentation / two previous

cesarean delivery

• The time of this Cesarean delivery: 9h20

• Anesthesia management: spinal anesthesia

Spinal anesthesia

10h Cesarean delivery

• After close the myometrial, the pateint have cyanotic, tachypnea, and decreased breathsounds

• Signs of right ventricular failure: an split second heart sound, jugular venous distension

• ECG : right-axis shift, P pulmonale, ST-T segment abnormalities, T-wave inversion, supraventricular arrhythmias.

• Cardiac arret

• Make CPR and reanimation

13h55’ Atony uterus: Hysterectomy after cesarean 4h Disorder of coagulation: platelet: 221000, TP: 16%, TCK: 70”, Fib 29mg%, RC (-)

Treatment disorder of coagulation

• ELISA D-Dimer : 530

1.Chest radiographs: an elevated hemidiaphragm, and a peripheral segmental infiltrate

2.Spiral CT: thromboembolie of right segmental pulmonary arteries

3.Echocardiographic: dilation of right ventricular

INCIDENT

− Pulmonary thromboembolism (PTE) occurs in approximately 0.01%--0.05% of all pregnancies.1,2

− The most common etiology is deep vein thrombosis (DVT).

− Deep vein thrombosis occurs in 0.02% to 0.36% of pregnancies.3

1.Weiner CP. Clin Obstet Gynecol 1985; 28:107-18.

2.Gherman RB, Goodwin TM, Leung B, et al. Obstet Gynecol 1999; 94:730-4

3.Rothbard MJ ,Gluck D, Stone ML .NY State Jmed 1976;76:582-4.

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ETIOLOGY

− Pregnancy: twofold - fivefold increase in the relative risk of thromboembolism.4,5

− Result of at least three factors:

1.An increase in venous stasis

2.The hypercoagulable state of pregnancy

3.The vascular injury associated with vaginal or cesarean delivery

4.Stein PD, Hull RD, Kayali F, et al. Am J Med 2004; 117:121-5.

5.Heit J, Kobberveg C, Petterson T, et al. Ann Intern Med 2005; 143:697-706.

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VENOUS STASIS

− Maternal blood volume and cardiac output increase approximately 50% during pregnancy.6

− The gravid uterus compresses the inferior vena cava as well as other anatomic structures .

− Vena caval compression results in venous stasis distal to the compression in the pelvis and lower extremities

6.Palmer SK, Zamudio S, Coffin C, et al.. Obstet Gynecol 1992; 80:1000-6.

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CHANGES IN COAGULATION

• Pregnancy:enhanced platelet turnover, coagulation, and fibrinolysis.

• Increase clotting factors: fibrinogen, V, VII, VIII, IX, X, and XII.

• Parturition accelerates platelet activation, coagulation, and fibrinolysis.7,8

.7.Gerbasi FR, Bottoms S, Farag A, et al. Obstet Gynecol 1990; 75:385-9.

8.Gerbasi FR, Bottoms S, Farag A, et al.. Am J Obstet Gynecol 1990; 162:1158-63

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VASCULAR DAMAGE

− Both vaginal delivery and separation of the placenta result in vascular trauma, leading to an acceleration of coagulation activity.

− Cesarean delivery increase the risk of thromboembolism.

− DVT and PTE are as much as eight times higher after cesarean delivery than after vaginal. 9,10

.

9.Ros HR, Lichtenstein P, Bellocco R, et al. Am J Obstet Gynecol 2002; 186:198-203.

10. Lindqvist P, Dahlback B, Marsal K. . Am Coll Obstet Gynecol 1999; 94:595-9.

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OBSTETRIC CONDITIONS

− Higher risk of PTE in women preeclampsia and multiple gestation (increased relative risks of sevenfold to eightfold, and twofold to threefold, respectively). 11,12,13

− These obstetric conditions or their management are associated with risk factors for thromboembolic disease

11.Ros HR, Lichtenstein P, Bellocco R, et al. Am J Obstet Gynecol 2002; 186:198-203.

12.Lindqvist P, Dahlback B, Marsal K.. Am Coll Obstet Gynecol 1999; 94:595-9.

13.James AH, Tapson VF, Goldhaber SZ. . Am J Obstet Gynecol 2005; 193:216-9.

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COINCIDENTAL DISEASE

− A history of previous thromboembolism increases the risk of PTE during pregnancy 13

− Heart disease (odds ratio [OR], 7.1), smoking (OR, 1.7), obesity (OR,4.4), antiphospholipid antibody syndrome (OR, 15.0), thrombophilias (OR, 25.0 to 50.0).14,15,16

13. Bremme K, Lind H, Blomback M. . Obstet Gynecol 1993; 78:78-83

14.Lindqvist P, Dahlback B, Marsal K. . Am Coll Obstet Gynecol 1999; 94:595-9.

15. Sipes SL, Weiner CP. Semin Perinatol 1990; 14:103-18.

16.Bonnar J. Clin Obstet Gynecol 1981; 8:455-73

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PATHOPHYSIOLOGY

The manifestations and prognosis of PTE depend on

1.The size and number of emboli

2.Concurrent cardiopulmonary function,

3.The rate of clot fragmentation and lysis,

4.The presence or absence of a source for recurrent emboli

5.The location of the embolism17,18

17.Stein PD, Beemath A, Matta F, et al. :. Am J Med 2007; 120:871-9.

18..Spence TH.. In Civetta JM, Taylor RM, Kirby RR, Philadelphia, JB Lippincott, 1988:1091-2

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TREATMENT

Approximately 10% of all patients with a pulmonary embolus die within the first hour. 19

Therapy focuses on providing:1. Dequate maternal and fetal oxygenation2. Support of maternal circulation, including

uteroplacental perfusion3. Immediate anticoagulation or venous

interruption to prevent recurrence of a pulmonary embolus.20

19.Dalen JE, Alpert JS. Cardiovasc Dis 1975; 17:259-70

20.Spence TH. In Civetta JM, Taylor RM, Kirby RR, editors. Critical Care. Philadelphia, JB Lippincott, 1988:1091-2.

.

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TREATMENT

− DEEP VEIN THROMBOSIS

− LMWH for both prophylactic and therapeutic anticoagulation during pregnancy has become common place.21

− LMWH has greater antithrombotic activity (anti-factor Xa) than anticoagulant activity (anti-factor IIa), it does not affect the aPTT.

.

21.American College of Obstetricians and Gynecologists Committee on Practice.. ACOG Practice Bulletin No. 19. Washington, DC, August 2000.

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TREATMENT

Enoxaparin (Lovenox), injected once or twice daily at a dose of 40mg(1mg=100U), for thromboprophylaxis during pregnancy.22

Peak anti-factor Xa activity occurs within 3 to 5 hours of administration, and 50% of the total antifactor Xa activity disappears within 6 hours.23

Both the efficacy and the maternal and fetal safety of LMWH have been established.

22.Eisenach JC. . American Society of Regional Anesthesia. ASRA News 1995;Nov:5-6.

23.American College of Obstetricians and Gynecologists Committee on Practice.. ACOG Practice Bulletin No. 19. Washington, DC, August 2000.

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CONCLUSION

Appropriate treatment of DVT reduces the incidence of PTE to 0.7% to 4.5%, 24,25 and it reduces the mortality rate to 0.7%.25,26

Anesthesia providers are often involved in the resuscitation of patients with embolic disorders

Early recognition, diagnosis, and treatment are necessary to reduce associated morbidity and mortality.

24. Rothbard MJ, Gluck D, Stone ML. . N Y State J Med 1976; 76:582-4

25.Villasanta U.. Am J Obstet Gynecol 1965; 93:142-60.

26. Sipes SL, Weiner CP. Semin Perinatol 1990; 14:103-18.

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VIET NAM VIET NAM

THANK YOU!

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NGUYỄN THỊ HỒNG VÂNVIET NAM

Email: bshongvan_2013@yahoo.com