Deep vein thrombosis and pulmonary embolism in pregnancy
Authors:
J. Mannová 1; M. Penka 2; P. Štourač 3
Authors‘ workplace:
Anesteziologicko resuscitační oddělení, Nemocnice Havlíčkův Brod
1; Oddělení klinické hematologie, Fakultní nemocnice Brno, Lékařská fakulta Masarykovy univerzity, Brno
1,2; Klinika dětské anesteziologie a resuscitace, Fakultní nemocnice Brno, Lékařská fakulta Masarykovy
univerzity, Brno
3
Published in:
Anest. intenziv. Med., 28, 2017, č. 2, s. 93-100
Category:
Plicní embolie je v současnosti ve vyspělých zemích nejčastější příčinou mateřské mortality. Během gravidity je samotné riziko hluboké žilní trombózy zvýšeno 5–7krát a narůstá v případě přítomnosti dalších rizikových faktorů. V těhotenství při volbě diagnostických a terapeutických postupů je důležité jejich správné a včasné zahájení, i když jsou vždy zvažována i rizika pro matku a plod. V diagnostice hluboké žilní trombózy se uplatňuje žilní ultrazvukové vyšetření, které má dobrou výpovědní hodnotu. V rámci diagnostiky plicní embolie vyšetření D-dimerů má jen limitovanou výpovědní hodnotu. CT plicní angiografie je preferovanou metodou u hemodynamicky nestabilní pacientky, u ostatních těhotných žen bývá upřednostňována ventilačně perfuzní scintigrafie z důvodu nižšího rizika pro matku. V terapii žilní trombembolické nemoci jsou indikovány přednostně nízkomolekulární hepariny. Trombolýza, jakožto terapie s vyššími riziky, je určena pro léčbu masivní plicní embolie (PE) s hemodynamickou nestabilitou.
Overview
Pulmonary embolism (PE) is the leading cause of maternal mortality in the developed world. During gravidity the incidence of deep vein thrombosis (DVT) is five to seven times higher and can be increased by other risk factors. Despite concerns for foetal teratogenicity and oncogenicity and maternal risks associated with diagnostic testing, and potential adverse effects of pharmacological treatment, an accurate diagnosis of pulmonary embolism and a timely therapeutic intervention are crucial. Compression ultrasonography is a non-invasive test with high sensitivity for the diagnosis of symptomatic deep vein thrombosis. For the diagnosis of pulmonary embolism, D-Dimer testing has only limited diagnostic value in gravidity. V/Q scans are generally preferred because of lower radiation dose to the mother, on the other hand, CT pulmonary angiography is the first-line test to detect PE in the haemodynamically unstable pregnant women. Low-molecular-weight heparin is currently the therapy of choice for venous thromboembolism. Thrombolysis is reserved for massive life-threatening pulmonary embolism with haemodynamic compromise. The peripartum management of pulmonary embolism in pregnant women is always a great challenge for the multidisciplinary team. When venous thromboembolism (VTE) is diagnosed near term, consideration should be given to the placement of a retrievable inferior vena cava (IVC) filter. Reversal of anticoagulation without IVC filter protection is strongly discouraged in the 2-week period after VTE diagnosis. If the therapy of pulmonary embolism is started earlier, planned delivery with induction of labour or Caesarean Section at term with short-term discontinuation of low-molecular-weight heparin minimizes the risk of bleeding and permits neuroaxial anaesthesia / analgesia.
Keywords:
pregnancy – venous thromboembolism – diagnosis - treatment – peripartum management
Sources
1. Greer IA. Pregnancy Complicated by Venous Thrombosis. N Engl J Med. 2015, 373, 540–547.
2. Stone SE, Timothy A, Morris MD. Pulmonary embolism during and after pregnancy. Crit Care Med. 2005, 33, Suppl 10.
3. Bourjeily G, Paidas M, Khalil H, et al. Pulmonary embolism in pregnancy. Lancet, 2010, 375, 500–512.
4. Greer IA. Thrombosis in pregnancy: updates in diagnosis and management, Hematology, 2012, 203–207.
5. James AH. Venous Thromboembolism in Pregnancy, Arteriocler Thromb Vasc Biol. 2009, 29, 326–331.
6. Gherman RB, Goodwin TM, Leung B, et al. Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy. Obstet Gynecol. 1999, 94, 730–734.
7. Marik PE, Plante LA. Venous Thromboembolism Disease and Pregnancy. N Engl J Med, 2008, 359, 2025–2033.
8. James AH, Tapson VF, Golddhaber SZ. Thrombosis during pregnancy and the postpartum period. Am J Obstet Gynecol. 2005, 193, 216–219.
9. Kamel H, Navi BB, Sriram N, et al. Risk of a thrombotic event after the 6-week post-partum period. N Engl J Med, 2014, 370, 1307–1315.
10. Khan KS, Wojdyla D, Say L, et al. WHO analysis of causes of maternal death: a systematic review. Lancet, 2006, 367, 1066–1074.
11. Simpson EL, Lawrenson RA, Nightingale AL et al. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. Br J Obstet Gyneacol, 2001, 108, 56–60.
12. Kjellberg U, Andersson NE, Rosen S, et al. APC resistance and other haemostasis variables during pregnancy and puerperium. Thromb Haemost. 1999, 81, 527–531.
13. Clark P, Brennand J, Conkie JA, et al. Activated protein C sensitivity, protein C, protein S and coagulation in normal pregnancy. Thromb Haemost. 1998, 79, 1166–1170.
14. Chan WS, Spenecer FA, Lee AY, et al. Safety of withholding anticoagulation in pregnant women with suspected deep vein thrombosis following negative serial compression ultrasound and iliac vein imaging. CMAJ, 2013, 185:E194-E200.
15. Regitz-Zagrosek V, Blomstrom LC, Borghi C, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy. The Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J, 2011, 32, 3147–3197.
16. Konstantinides SV, Torbicki A, Angellli G, et al. ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J, 2014, 1–48.
17. Kline JA, Kabrhel Ch. Emergency Evaluation for Pulmonary Embolism, Part 2, Diagnostic Approach. J Emergency Medicine, 2015, 1–14.
18. Greer JA, Nelson-Piercy C. Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy. Blood, 2005, 106, 401–407.
19. Romualdi E, Dentali F, Rancan E, et al. Anticoagulant therapy for venous thrombembolism during pregnancy: a systematic review and a meta-analysis of the literature. J Thromb Haemost. 2013, 11, 270–281.
20. Knol HM, Schultinge L, Veeger NJGM, et al. The risk of postpartum hemorrhage in women using high dose of low-molecular-weight heparins during pregnancy. Thromb Res, 2012, 130, 334–338.
21. Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prvention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 2012, 141:2, Suppl:e691S-736S.
22. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th: American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 2012, 141, 2 Suppl:e419S-e494S.
23. Dulíček P, Penka M, Binder T, et al. Návrh antitrombotické profylaxe a péče o trombofilní stavy v gynekologii a porodnictví. Doporučení pro klinickou praxi, 2006; www.thrombosis.cz.
24. Tang AW, Greer IA. A systematic review on the use of new anticoagulants in pregnancy. Obstet Med. 2013, 6, 64–71.
25. Königsbrügge O, Langer M, Hayde M, et al. Oral anticoagulation with rivaroxaban during pregnancy: a case report. Thrombosis and Haemostasis, 2014, 1, 12–15.
26. Kahn SR, Shapiro S, Wells PS, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet, 2014, 383, 880–888.
27. te Raa GD, Ribbert LSM, Snijder RJ, et al. Treatment options in massive pulmonary embolism during pregnancy a case-report and review of literature. Thromb Res, 2009, 124, 1–5.
28. Leonhardt G, Gaul Ch, Nietsch HH, et al. Thrombolytic therapy in pregnancy. J Thromb Thrombolysis, 2006, 21, 271–276.
29. Ahearn GS, Hadjiilidas D, Gover J, et al. Massive pulmonary embolism during pregnancy successfully treated with recombinant tissue plasminogen activator: a case report and review of treatment options. Arch Intern Med. 2002, 162, 1221–1227.
30. Turrentine MA, Braems RMM. Use of thrombolytics for the treatment of thromboembolic disease during pregnancy. Obstet Gyn Surv, 1995, 50, 534–541.
31. Condliffe R, Elliot ChA, Hughes RJ, et al. Management dilemmas in acute pulmonary embolism. Review Thorax, 2013, thoraxjnl-2013-20467.
32. Gartman EJ. The use of thrombolytic therapy in pregnancy. Obstet Med. 2013, 6, 105–111.
33. Shaikh N, Ummunnisa F, Aboobacker N, et al. Peripartum pulmonary embolism Anesthetic and surgical considerations. J Obstetr and Gyn. 2013, 3, 158–164.
Labels
Anaesthesiology, Resuscitation and Inten Gynaecology and obstetrics Intensive Care MedicineArticle was published in
Anaesthesiology and Intensive Care Medicine
2017 Issue 2
Most read in this issue
- Deep vein thrombosis and pulmonary embolism in pregnancy
- Inhalational application of furosemide – the breathlessness panacea?
- Dexmedetomidine and its use in anaesthesia and intensive care
- The physician and the law II – forensic medical experts and expert institutions