DISCUSSION

OBSTETRIC BLOOD CLOT EMBOLISM

DIAGNOSIS
Any women with signs & symptoms suggestive of venous thromboembolism (VTE) should have objective testing performed avoid risks, inconvenience and costs of inappropriate anticoagulation. Individual hospitals should have an agreed protocol for the objective diagnosis of suspected VTE during pregnancy. Must be noted that many hospitals in Malaysia will lack the resources for speedy diagnosis of a patient with acute VTE. Often a clinical diagnosis will be made.

 The subjective, clinical assessment of deep vein thrombosis (DVT) and pulmonary thromboembolism (PTE) unreliable. Less than half of women with clinically suspected VTE have the diagnosis confirmed when objective testing is employed.

SIGNS & SYMPTOMS OF VTE

DVT PTE

Leg pain or discomfort Swelling Tenderness Increased temperature and oedema Lower abdominal pain Elevated white cell count

Dyspnoea Chest pain Haemoptysis Faintness Raised JVP Focal signs in chest Symptoms & signs associated with DVT

 Some of these symptoms and signs are commonly found in normal pregnancy. In order to avoid the risks, inconvenience and costs of inappropriate anticoagulation, diagnostic imaging should be performed promptly in pregnant women with suspected DVT & PTE.

DVT

Ultrasound X-ray venography

PTE

Ventilation-perfusion lung scanning or angiography Spiral CT or MRI, if chest x-ray is abnormal

 In principle, in clinically suspected VTE, treatment with unfractionated heparin (UFH) or low molecular weight heparins (LMWH) should be given until the diagnosis is excluded by objective testing. Treatment regimens for DVT and PTE are similar because the two conditions are manifestations of the same disease process. Anticoagulation remains the standard treatment.

D-DIMER FOR SCREENING FOR VTE PRIOR TO OBJECTIVE DIAGNOSIS

D-dimer is now used as a screening test for VTE in the non-pregnant. In non-pregnant: - Low absence of VTE and further objective tests are not performed - Increased thrombosis may be present and an objective diagnostic test should be performed In pregnancy: - D-dimer can be elevated due to physiological changes in the coagulation system and if there is a concomitant problem such as pre-eclampsia. - Positive D-dimer test in pregnancy is not necessarily consistent with VTE and objective diagnostic is still required. - Low level : Likely to suggest no VTE.

AWARENESS & PROPHYLAXIS

Epidemiological observations have shown that incidence of postpartum thromboembolism has fallen but not that of antenatal complications. Attributable to: - The trend towards younger mothers and smaller families - The reduction in the incidence of the elderly grand multipara and trauma operative delivery - Early ambulation and better diagnosis and treatment

 The increase in proportion of antenatal complications could be due to increased rates of admission to hospital and the use of bed rest in the management of antepartum haemorrhage. Other pregnancy related risk factors include the following:

a) Operative delivery Risk of fatal PTE following csection is 10x higher than vaginal delivery. b) Age and parity Risk of thromboembolism is greater w/ increasing age & parity. c) Obesity d) Restricted activity conditions complicating pregnancy (hypertension, diabetes, PP, multiple pregnancy, heart disease prolonged bed rest. e) Others Previous thromboembolism, lupus anticoagulant, ABO blood group.

RISK ASSESMENT (RCOG)

Low Risk - Elective caesarean section-uncomplicated pregnancy and no other risk factors Moderate Risk - Age > 35 - Obesity (>80kg) - Para 4 or more - Gross varicose veins - Current infection - Pre-eclampsia - Immobility prior to surgery (>4 days) - Major current illness - Emergency caesarean section in labour

 High Risk - A patient with 3 or more moderate risk factors - Extended major pelvic or abdominal surgery, e.g. caesarean hysterectomy - Patients with personal or family history of deep vein thrombosis; pulmonary embolism or thrombophilia; paralysis of lower limbs - Patients with antiphospholipid antibody (cardiolipin antibody or lupus anticoagulant)

 Low risk: Early mobilisation and hydration Moderate risk: Low dose standard heparin 5000 IU (12 hourly), LMWH High risk: Standard heparin, LMWH, graduated elastic compression stockings

Low Molecular Weight Heparin (LMWH)

LMWH is given subcutaneously and does not require monitoring and is as effective and at least as safe as UFH in the treatment of DVT and PE.
LMWHs Enoxaprin (Clexane) Nadroparin (Fraxiparine) Tinzaparine (Innohep) Treatment 1 mg/kg twice daily 0.1 ml/kg twice daily 175 units/kg once daily

Recommended duration of treatment is 7-14 days for patients who will subsequently be continued on warfarin.

AMNIOTIC FLUID EMBOLISM (AFE)

 Amniotic fluid embolism is an uncommon condition but has high maternal morbidity and mortality rates. Previously the condition had a poor outcome with mortality rates being quoted as between 80-90%. More recent population based surveys as well as from AFE Registries quote a mortality rate of 16-30% The changing mortality rates are probably a result of better intensive care and recognition of the fact that milder cases do occur.

 Although most cases of AFE eventually lead to maternal collapse, it can be preceded by fetal collapse. The sudden deterioration of the fetal heart rate associated with very poor outcome for the baby despite a prompt response should raise the possibility of AFE. When a baby is born in unexpectedly poor condition after sudden deterioration, the mother should have a check on her coagulation screen and continued careful observation.

 The suggestion that AFE may in some way be related to anaphylaxis has led to a number of reports describing tryptase levels. A high tryptase level was taken as supporting the view of anaphylaxis playing a role in AFE. However case reports have been conflicting and there have been case reports suggesting: complement activation rather than mast cell degranulation play a role in AFE. There is still no test to diagnose AFE. It is still a diagnosis of exclusion.

RECOMMENDATIONS

 Awareness of the need for thromboprophylaxis for at risk cases should continue to be inculcated in medical officers. Obstetric departments can formulate quality assurance checklists to evaluate the number of at risk mothers who actually receive thromboprophylaxis. The risk assessment checklist as proposed by RCOG can be used in this regard. Objective tests should be performed to evaluate all cases of suspected DVT and PTE.

 D-dimer assays can be used as a quick test to help decide on cases which may require objective testing. An amniotic fluid registry could help improve our understanding of this condition. This registry could be set up under the CEMD secretariat. Medical officers need to be aware of a possible AFE if the baby is born in a sudden unexpectedly poor condition. A multidisciplinary approach to resuscitation of the collapsed patient provides the best results. These must be universal application of the red alert system as proposed in the 1991 CEMD Report.