pathophysiology of thromboembolism during pregnancy
TRANSCRIPT
05/01/2023 1
Pathophysiology of Thromboembolism
Continued...
05/01/2023 2
Pregnancy is associated with:• 2x fibrinogen• 20 -1,000% factors VII, VIII, IX, X & XII• vWF by 400 % at term
• Prothrombin and factor V remain unchanged • Modest factor XIII and XI• 40% protein S
In contrast
Why is pregnancy at risk?
05/01/2023 3
Pregnancy-specific risk factors • Parity• Postpartum endomyometritis• Operative vaginal delivery • Cesarean delivery 9x in
the risk of thromboembolism compared with vaginal delivery
Risk factors for TE
05/01/2023 4
Compression of the inferior vena cava, and
Pelvic veins by the enlarging uterus Hormone-mediated in DVC 2° to:
Estrogen Local production of prostacyclin and NO
Note: Left leg veins thrombosis > right leg
thrombosis2° lower flow velocities
05/01/2023 5
Non-Obstetrical Risk factors
• Age >35 years • Obesity• Trauma• Immobility• Infection • Smoking
• Nephrotic syndrome• Cancer• Surgery• Prior history of DVT or PE
05/01/2023 6
Introduction• Three primary abnormalities that lead to thrombus
formation (called Virchow's triad)
1. Endothelial injury 2. Vascular stasis
3.Hypercoagulability
05/01/2023 7
Endothelial injury
vascular
stasis
Hypercoagulability
THROMBOSIS
Virchow's
triad
1. Endothelial Injury• Dysfunction or mechanical trauma • Contribute thrombus formation • Heart • Arterial circulation
• Major consequence of endothelial cell injury:• Vasculitis• Endocardial injury
2. Abnormal Blood FlowTurbulence • Cause arterial and cardiac thrombosis by• Endothelial injury or dysfunction• Disrupt laminar flow • Forming countercurrents and local pockets
of stasisStasis • Major contributor in the venous thrombi• Prevent dilution of activated clotting
factors
3. Hypercoagulability• Definition:• Alteration of the coagulation pathways
that predisposes to thrombosis• Also called thrombophilia
• Divided into:1. Primary (genetic)2. Secondary (acquired) disorders
TABLE: Hypercoagulable States1. PRIMARY (GENETIC) Common • Factor V mutation (G1691A mutation; factor V
Leiden) • Prothrombin mutation (G20210A variant) • 5,10-Methylenetetrahydrofolate reductase
(homozygous C677T mutation) • Increased levels of factors VIII, IX, XI, or fibrinogen
Rare • Antithrombin III deficiency • Protein C deficiency • Protein S deficiency
Very Rare • Fibrinolysis defects • Homozygous homocystinuria (deficiency of
cystathione β-synthetase)
2. SECONDARY (ACQUIRED) High Risk for Thrombosis
• Antiphospholipid antibody syndrome• Heparin-induced thrombocytopenia • Prolonged bedrest or immobilization • Myocardial infarction • Atrial fibrillation • Tissue injury (surgery, fracture, burn) • Cancer • Prosthetic cardiac valves • Disseminated intravascular coagulation
Lower Risk for Thrombosis
• Cardiomyopathy • Nephrotic syndrome • Hyperestrogenic states (pregnancy and
postpartum) • Oral contraceptive use • Sickle cell anemia• Smoking
Antiphospholipid Antibody Syndrome (APAS)
Definition:• Xized by arterial or venous thrombosis or
specific pregnancy complications • in women with laboratory evidences of
(APAs) to proteins bound to anionic phospholipids
Previously called Lupus anticoagulant syndrome Antiphospholipid Antibodies (APAs) • Self-recognition Igs• Directed against proteins bound to
phospholipids
clinical manifestations Recurrent thromboses Repeated miscarriages
• Inhibit throphoblastic invasion• placental vessels thrombosis
Cardiac valve vegetations Thrombocytopenia Pulmonary embolism Pulmonary hypertension Stroke Bowel infarction Renal failure
• Renal Microangiopathy
Two forms of APAS : I. Primary APAS• Patients exhibit only a hypercoagulable
state • Lack evidence of autoimmune disorders• Occasionally with certain drugs or
infections II. Secondary APAS• Well-defined autoimmune disease like SLE
DiagnosisThe diagnosis of APAS requires 1. The presence of prior or current vascular
thrombosis, or characteristic obstetric complications
2. At least one laboratory criterion (e.g., anticardiolipin antibodies or lupus anticoagulant
These antibodies must be present on two ormore occasions at least 6 weeks apart fordiagnosis
Factor V Leiden Mutation
Activated Protein C Resistance Most prevalent thrombophilic syndromes Characterized by resistance of plasma To the anticoagulant effects of activated protein C• Heterozygous mutation 20 to 40 % of
nonpregnants with thromboembolic disease• Homozygous inheritance 100-fold
Netherlands
Protein C Deficiency
• With protein S inactivating factors Va and VIIIa • Protein C levels are unchanged during normal
pregnancy Predisposes to coagulation
• Prevalence is 2 to 5 per 1000• Inheritance is autosomal dominant • Risk of thromboembolism in pregnant women
is 3-20 %
Most episodes occur during the puerperium
Antithrombin Deficiency
• One of the most important inhibitors of thrombin in clot formation• The most thrombogenic of the heritable
coagulopathies Homozygous antithrombin deficiency is lethal
!!! Although antithrombin deficiency is rare, Affect 1 in 5000 individuals, Lifetime risk of thrombosis is 50-90 %
50- 60 % during pregnancy , and 33 % during the puerperium
R references
T hank Y ou!!!