Thromboembolism in Pregnancy

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Venous thromboembolism in pregnancy is a clinical emergency that has been associated with significant risk for maternal and fetal morbidity and mortality. The adaptation of the maternal hemostatic system to pregnancy predisposes women to an increased risk of thromboembolism. A timely diagnosis of deep venous thrombosis is crucial because up to 24% of patients with untreated deep venous thrombosis develop a pulmonary embolism. Recent clinical guidelines identify compression venous ultrasound as the best way to diagnose deep venous thrombosis in pregnancy and CT pulmonary angiography as the best way to diagnose pulmonary embolism in pregnancy. Therapy involves supportive care and anticoagulation with unfractionated or low molecular weight heparin, depending on the clinical scenario.

Section snippets

Physiology and pathophysiology of hemostasis in pregnancy

The adaptation of the maternal hemostatic system to pregnancy predisposes women to an increased risk of venous thromboembolism. Pregnancy produces the components of Virchow's triad, including an increase in vascular stasis, changes in the coagulation system, and vascular injury. Other risk factors for thrombosis involve inherited thrombophilias, including mutations in the factor V Leiden and prothrombin genes; deficiencies in protein C, protein S, and antithrombin III; and acquired maternal

Diagnosis of deep vein thrombosis

Clinicians must have a high baseline index for suspicion of deep venous thrombosis in pregnancy because many of the common clinical signs and symptoms, such as lower extremity edema, are also common findings in normal pregnancy. A timely diagnosis of deep venous thrombosis is crucial because up to 24% of patients with untreated deep venous thrombosis will develop a pulmonary embolism [37]. A life-threatening pulmonary embolism usually originates from a clot in the deep veins of the pelvis and

Diagnosis of pulmonary embolus

Timely diagnosis of pulmonary embolus in pregnancy is critical because of the potential for a catastrophic maternal and fetal outcome if overlooked. If the clinical suspicion is high, consideration should be given to empiric anticoagulation until the workup is completed [7]. Likewise, a precise diagnosis is vital to prevent unnecessary treatment of pulmonary embolism because treatment is associated with side effects for both the mother and fetus. Accurate imaging is essential, but fetal

Treatment of venous thromboembolism in pregnancy

Whether manifested as a deep venous thrombosis or pulmonary embolism, acute venous thromboembolism in pregnancy requires immediate medical therapy. Initial steps in the management of pulmonary embolism include oxygen support, blood pressure stabilization, and an assessment of the patient's cardiovascular and respiratory status [7], [53]. Consultation with the intensive care unit service may be appropriate and transfer to the intensive care unit should be considered, depending on nursing and

Summary

Venous thromboembolism is one of the most critical clinical emergencies an obstetrician/gynecologist will confront. An understanding of the physiology and pathophysiology of hemostasis and thrombosis in pregnancy is essential and allows the clinician to predict which patients are at highest risk. Prompt recognition and diagnosis of venous thromboembolism with contemporary imaging modalities allow for the timely initiation of appropriate therapy to prevent further maternal and fetal morbidity.

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