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DR SANIAH SENIK
Pakar Perubatan Keluarga UD 54
Klinik Kesihatan Maran
Pahang
VTE IN PRIMARY CARESIGN AND SYMPTOM OF
DVT AND PE
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DVT +PE=VTE
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Pulmonary Embolism
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DIAGNOSIS
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Deep Vein Thrombosis
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DVT & PE
Clinical diagnosis is not easy
VERY IMPORTANT to look for risk factor
May need Thromboprophylaxis – pharmacological or non pharmacology for prevention.
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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)
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Virchow’s Triad
Rudolf virchow – 1800
“Omnis cellulae cellula”
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Antenatal Risk Assessment
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Maternal MedicalProblem
BMI
Smoking
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Diagnosis of VTE In pregnancy commonly involves the ilio-femoral
vessels of lower limbs
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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.
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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
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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
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Investigation
FBC
RP
LFT
ABG
PT APTT
D Dimer – not recommended inpregnancy
Pulseoxymetry
Compression duplex Ultrasound
Venogram- rarely utilized in pregnancy
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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.
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PULMONARY EMBOLISM
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In reality – obstetric emergency call for help
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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.
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Pulmonary embolism SOB
Chest pain
Cough
HR more than 16 per minute
HR more than 100 per minute
Cyanosis
Collapse
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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.
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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
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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
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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.
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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
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S1Q3T3
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CXR FINDINGS Hampton’s Hump:
-wedge-shaped configuration at lung peripherydueto infarcted lung
Westermark sign:
-pulmonary oligemia
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END OF PART ONE
THANK YOU
HAPPY NURSESDAY
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DR SANIAH SENIK
Pakar Perubatan Keluarga UD 54
Klinik Kesihatan Maran
Pahang
VTE IN PRIMARY CAREMANAGEMENT OF DVT AND
PE
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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
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LIFE THREATENING PULMONARY EMBOLISM
MANAGEMENT &
OUTCOMES
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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.
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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
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After assessment , the case should be discussed with Obstetrician
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Thromboembolic Disease in Pregnancy and the Puerperium:Acute Management
Green-top Guideline No. 37bApril 2015
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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.
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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]
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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]
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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]
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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.
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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.
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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.
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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
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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
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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
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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
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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
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TED stockings
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Intermittent Pneumatic Compression Devices
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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
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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.
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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
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Antenatal Patiet with intermediate or high risk shouldbe
referred immediately to FMS or Obstetrician
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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
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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
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TERIMA KASIH