Vascular Problems

Vascular problems in Gynecology and Obstetrics Dr. UMA GUPTA MD(OBG)FICMCH,Sr.Specialist,VPCIMS,LUCKNOW(UP)INDIA Dr.N.K.GUPTA, M.Ch,CTVS,Associate Prof,ERA’s LUCKNOW MEDICAL COLLEGE,LUCKNOW.INDIA [email protected] [email protected]

08/01/09

DrU.Gupta,Dr.N.K.Gupta

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Vascular surgery evolution 

The first elective operation for treatment of an aneurysm was reported by the most famous surgeon in Greek antiquity,ANTYLLUS, in the 2nd century.



AMBROSE PARE(1510-1590), mainly contributed – principles wound care-aneurysm operations.



After a century,RICHARD WISEMAN(16251686)”Father of English Surgery”described aneurysm in arm.

08/01/09

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contd 



Sutures should be made with very fine needles while the wall is somewhat stretched.Stenosis or occlusion only occurs-faulty technique-which is still valid 100 years later. In 1910, he demonstrated that blood vessels could be kept in cold storage for long periods before transplanting them.

Carrel won the noble prize for this work in 1912 “in recognition of his work on vascular suture and 08/01/09 DrU.Gupta,Dr.N.K.Gupta 

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Arterial Disorders 

AntiPhospholipid Antibody Syndrome



Raynaud’s disease



Vasculitis

08/01/09

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Venous Disorders 

Varicose Veins

 Superficial Thrombophlebitis  Deep Vein Thrombosis/ PE

08/01/09

DrU.Gupta,Dr.N.K.Gupta

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AntiPhospholipid Antibody Syndrome syn. Hughes Syndrome

 

Arterial and Venous thrombosis History    



08/01/09

First noted in pts positive for syphilis 1952- clotting disorder asso. with SLE 1957- linked to recurrent pregnancy loss 1963 & 1972 – term “Lupus anticoagulant” 1983 – Dr Graham Hughes – association between APL antibodies and arterial and venous thrombosis 1985 – ELISA test for detection of ACA DrU.Gupta,Dr.N.K.Gupta

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AntiPhospholipid Antibody Syndrome

Types: 

PRIMARY



SECONDARY

Mechanism:

 AUTOIMMUNE PHENOMENON ??? Tissue injury – Inflammation, Ischemia, trauma Classes Of Antibodies – a) Anticardiolipin Antibody (IgG,IgA,IgM) b) Lupus Anticoagulant c) Antibodies against specific molecules e.g.β-2-glycoprotein 08/01/09

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AntiPhospholipid Antibody Syndrome 

Prevalence 2-4%  50% - Primary APLAS  SLE – 30% will develop APLAS



ACA five times more common than Lupus Anticoagulant



Primary APLAS – 10% SLE, Mixed Conn. Tissue Ds 08/01/09

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AntiPhospholipid Antibody Syndrome 

RISKS ASSOCIATED:     

08/01/09

MISCARRIAGES PRETERM LABOR PRE-ECLAMPSIA LOW BIRTH WEIGHT THROMBOCYTOPENIA (20-40%)

DrU.Gupta,Dr.N.K.Gupta

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AntiPhospholipid Antibody Syndrome 

WHEN TO EVALUATE

08/01/09



Unexplained still birth/fetal death after 10 wks



Severe IUGR prior to term



Severe pre-eclampsia at <34 wks gestation



Unexplained arterial/venous thrombosis in any territory DrU.Gupta,Dr.N.K.Gupta

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AntiPhospholipid Antibody Syndrome 

TREATMENT 

Anticoagulation – Heparin → Oral 

  



Long term → Life Long ( risks – 3% chance per year of major h’hage, 1/5th fatal)

Anti-platelet drugs – Aspirin LMWH Pregnancy – Heparin / LMWH

PROPHYLAXIS   

08/01/09

(APLAS without thrombotic problems)

Aspirin Lifestyle Modification Control of Risk factors – HTN, Smoking, Cholesterol levels, Weight control DrU.Gupta,Dr.N.K.Gupta

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AntiPhospholipid Antibody Syndrome

Special Prenatal/Birth/Neonatal Considerations  

Ideally, one should seek medical advice before becoming pregnant. Once pregnancy is achieved  

to see Obstetrician - to decide on the need for treatment frequent office visits will be needed to:   



Screen for preeclampsia, Fetal Monitoring Ultrasound examinations to check the growth of the baby.

For patients on heparin 

extra blood tests may be needed to adjust the dose depending on the type of heparin being used, and the past history of the patient.

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AntiPhospholipid Antibody Syndrome 

PREGNANCY:         

08/01/09

Pre Pregnancy Counselling Heparin (s/c)± Low Dose Aspirin LMWH Aspirin ± Prednisone X X X X Low Dose Aspirin Intravenous Immune Globulin (IVIG) Immunosupression Steroids Catastrophic Plasmapheresis DrU.Gupta,Dr.N.K.Gupta

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Raynaud’s disease 1862 – Maurice Raynaud  Prevalence – 3-5%  Episodic events – vasoconstriction (digital arteries, precapillary arterioles & cutaneous AV shunts) vs Acrocyanosis  Exaggeration of the physiologic response to cold temperature or stress.  Manifestation of generalised vasospastic disorder.e.g.pts who have Prinzemetal’s angina, migraines, or scleroderma. 

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Raynaud’s disease   

H/o sensitivity to cold/ episodic pallor or cyanosis Triphasic reaction (white>blue>red) Involves- fingers, toes, tip of the nose, ear lobes. PRIMARY*

SECONDARY

SYMMETRIC

ASYMMETRIC

ABSENCE OF

PAINFUL ISCHAEMIC SKIN LESIONS

-TISSUE NECROSIS

-GANGRENE

C/f s.o. CONN. TISSUE DISORDERS (arthritis,myalgia,

-SECONDARY CAUSE

abnormal lung fn,fever etc)

-ULCERATION

H/o drug use/toxic agent NORMAL NAIL FOLD CAPILLARIES MICROVASCULAR DS NORMAL ESR 08/01/09 NEGATIVE

ESR ↑

ANA TEST DrU.Gupta,Dr.N.K.GuptaANA ±

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*Adapted from LeRoy and Medsger

Raynaud’s disease 

Complete evaluation – to R/o underlying cause           

08/01/09

H/o or current drug use H/o repetitive trauma e.g.vibratory tools Positional changes triggering the event. e.g.Tho Outl Obst. Carpel tunnel syndrome Neurapathic conditions Malignancy Hypothyroidism Dysproteinemias Vasculitis Emboli Vascular Occlusive disease

DrU.Gupta,Dr.N.K.Gupta

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Raynaud’s disease

Treatment 

NonPharmacological   

 

Calcium channel Blockers Other Agents    



Sympatholytic drugs ARBs Fluoxetine I.V. Prostaglandins

Awaited   



Avoidance of cold temp / prolong vibrations Reduce emotional stress Avoid Smoking

Cilostazole Sildenafil Bosentan (endothelin receptor inhibitor)

Sympathectomy 

08/01/09



Proximal ??? Localised Digital DrU.Gupta,Dr.N.K.Gupta √√

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Vasculitis 

AutoImmune Disease



Inflammation of the blood vessels



Symptoms – depend on which blood vessels are inflamed             

08/01/09

Fatigue Sleep disturbances Memory Loss Emotional Liability Depression Low Thyroid Function G I disturbances Headaches/Chemical Sensitivity Fungal Infections Low Blood Sugar Pain – Tingling/Ringing ears/Cold Toes/Cold Fingers Overdoing Fluttering Heart/Tachycardia/Panic Attacks/Mitral valve Prolapse DrU.Gupta,Dr.N.K.Gupta

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Vasculitis 

IMMUNE SYSTEM MALFUNCTION  



CONSUMPTION OF ASPARTATE (IN DIET DRINKS/ARTIFICIAL SWEETNERS etc.) CHLORINATED AND FLORIDATED WATER ???

POOR CELLULAR COMMUNICATION 

HEAVY MOL WT CARBOHYDRATES (LONG CHAINED)   



OVER ACTIVATED, OUT OF BALANCE IMMUNE SYSTEM        

08/01/09

PROVIDE INGREDIENTS FOR CELL MARKERS HIGHLY ANTI-INFLAMMATORY CODING CAPACITY BETTER THAN AMINO ACIDS *

Stress Infections – Bacterial , Fungal (Candida), Viral (e.g.Herpes) Toxins – produced by infecting organism, from environment Liver dysfunction Steroids Enzyme deficiency – Digestive/Metabolic Hypercoagulation/ HypoOxygenation Glutathione Deficiency DrU.Gupta,Dr.N.K.Gupta

*Acta Anatomica

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Vasculitis 

Management 

Weighing the available options Steroids  Chemotherapeutic Agents 

  

08/01/09

Antioxidants/ Digestive Enzymes Treat underlying disorder Lifestyle modification

DrU.Gupta,Dr.N.K.Gupta

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Venous Disorders 

Varicose Veins

 Superficial Thrombophlebitis  Deep Vein Thrombosis/ PE

08/01/09

DrU.Gupta,Dr.N.K.Gupta

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Varicose Veins 

08/01/09

Pregnancy 

Increased blood volume



Pressure on veins



Relaxation effect of hormones

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08/01/09

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08/01/09

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Varicose Veins 

Management 

Non Operative 



Self resolving (within six weeks)

After 6 weeks 

if problematic/ unacceptable 



08/01/09

Graduated Compression Stockings Surgery DrU.Gupta,Dr.N.K.Gupta

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Varicose Veins

Before Treatment 08/01/09

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After Treatment 26

Varicose Veins

08/01/09

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Superficial Thrombophlebitis  Benign /Self limiting Disease  Can progress to DVT(11%)  Associated with Abnormalities in blood coagulation

08/01/09

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Superficial Thrombophlebitis        

Traumatic Varicose Veins Oral contraceptives Pregnancy Infection (e.g. Staph., Pseud., Kleb., Anaerobes) Migratory (e.g. Cancer, Vasculitis, Buerger’s) Mondor’s Disease Unusual forms 

palmar digital veins

08/01/09

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Superficial Thrombophlebitis 

Diagnosis    



Painful cord like structure Redness along the vein Tenderness Fever

Investigations 

08/01/09

Duplex scan

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Superficial Thrombophlebitis 

Management         

08/01/09

Underlying disorder Remove offending agents (e.g.IV cannula) Antibiotics NSAIDs Anticoagulation Excision of the suppurating vein Application of massive warm wet compresses Elevation of the extremity Immobilization DrU.Gupta,Dr.N.K.Gupta

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VENOUS THROMBOEMBOLISM DURING PREGNANCY 

LEADING CAUSE OF DEATH



1-3 /1000 PREGNANCIES

08/01/09

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VENOUS THROMBOEMBOLISM DURING PREGNANCY



Pathophysiology

5 times higher in pregnancy ↑ venous stasis of pregnancy  Physiological changes asso. with pregnancy 

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Pathophysiology

Independent risk factors Prolong Bed rest  Multiparity (>3)  Advanced Maternal Age (>35yrs)  Overweight  Personal or family history of VTE  Pre-eclampsia 

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Pathophysiology

Alteration in Coagulation/Fibrinolytic System Factor II, VII, X ↑ (middle of Pregnancy)  Fibrin  Protein S  Protein C  Fibrinolytic System inhibited (mostly 3rd trimester) 

08/01/09

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Diagnosis  

Calf veins or Ilio-femoral segment Predilection for Left side

S/s

Swelling  Tenderness  Skin Discolouration  Warm to touch  Unusual firmness /hardness in the leg  Calf discomfort on dorsiflexion  Prominent tender cord like subcut. vein DrU.Gupta,Dr.N.K.Gupta 

08/01/09

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Diagnostic tests 

08/01/09

Venography

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Diagnostic tests 

08/01/09

Duplex Ultrasonography

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Diagnostic tests 

Spiral CT Venography

No filling of calf veins 08/01/09

Opacification of collaterals

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Diagnostic tests    

08/01/09

Nuclear Imaging IPG MRI D-dimer

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Radiation Exposure

Procedure CXR Limited Venography Perfusion Lung Scan Ventilation Lung Scan CT Chest Pulm Angio (femoral) Pulm Angio (brachial) 08/01/09

Fetal radiation dose (mrads) <1 <50 6-12 1-19 30 221-374 <50 DrU.Gupta,Dr.N.K.Gupta

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VENOUS THROMBOEMBOLISM DURING PREGNANCY  Blood Tests        

08/01/09

Factor V Leiden Protein C Protein S ACA and LA antibodies Activated Protein C resistance (APC-R) AntiThrombin III Homocystein Prothrombin gene mutation DrU.Gupta,Dr.N.K.Gupta

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Pulmonary Embolism 



Major nonobstetric cause of maternal mortality Cause of Death 

 

 08/01/09

2 / 100,000 maternities

Maximum – Peripartum More after operative intervention Subtle presentation

DrU.Gupta,Dr.N.K.Gupta

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Pulmonary Embolism 

Diagnostic tests 

Pulmonary Angiography



Spiral CT Scan

08/01/09

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Pulmonary Embolism  Diagnostic tests Nuclear Imaging

08/01/09

(Ventilation-Perfusion Scan)

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VENOUS THROMBOEMBOLISM DURING PREGNANCY  Management 

Medical/Pharmacological  



Surgical  



IVC Filter placement

Others    

08/01/09

Venous Thrombectomy Thrombolysis

Endovascular 



Anticoagulation Anti-platelet agents

Hydration Early Mobilization Graduated Compression Stockings Pneumatic compression devices DrU.Gupta,Dr.N.K.Gupta

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VENOUS THROMBOEMBOLISM DURING PREGNANCY



Medical/Pharmacological 

Unfractionated Heparin/LMWH



Oral Anticoagulation



Antiplatelet agents



New Molecules 

Direct Thrombin Inhibitors 

08/01/09



Lepirudin, Desirudin, Argatroban, Ximelagatran DrU.Gupta,Dr.N.K.Gupta

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VENOUS THROMBOEMBOLISM DURING PREGNANCY



Surgical 

Venous Thrombectomy – 



08/01/09

Ilio-femoral DVT

Pulmonary Embolectomy

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Surgical 

08/01/09

Thrombolysis

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VENOUS THROMBOEMBOLISM DURING PREGNANCY 

Endovascular 

08/01/09

IVC Filter placement 

Temporary



Permanent

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Others

 Hydration  Early

Mobilization  Graduated Compression Stockings  Pneumatic compression devices

08/01/09

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VENOUS THROMBOEMBOLISM DURING PREGNANCY 

PROPHYLAXIS 

Risk Assessment



Present status

08/01/09

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

PROPHYLAXIS 

Past h/o DVT in pregnancy, no other thrombotic risk factors 

Antenatal thrombo-prophylaxis 

S/c Heparin+/- GCS

S/c Heparin/LMWH → Warfarin (INR 2-2.5)  GCS 6-12 wks (if anticoagulation contraindicated) 

08/01/09

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BMJ 1992 53



VENOUS THROMBOEMBOLISM DURING PREGNANCY

PROPHYLAXIS 

Known inherited/acquired thrombophilia  



Postpartum +/- Antepartum thromboprophylaxis Individual consideration

No past h/o DVT/Thrombophilia, but with other risk factors in combination 

Postpartum thromboprophylaxis 

08/01/09

S/c Heparin

DrU.Gupta,Dr.N.K.Gupta

BMJ 1992 54

VENOUS THROMBOEMBOLISM DURING PREGNANCY



PROPHYLAXIS IN CAESERIAN SECTION 

Low Risk  



Moderate Risk 



Elective C-section – uncomplicated pregnancy No risk factors Age, Weight, Parity, Varicose Veins, Immobility, Sepsis, Pre-eclampsia, Emergency C-section, Major Current Illness

High Risk 

 08/01/09

3 or more mod risk factors, Extended major pelvic/abd surgery e.g.Caeserian hysterectomy Personal/family H/o DVT/PE/thrombophilia, Paraparesis DrU.Gupta,Dr.N.K.Gupta 55 Pt with APLAS

VENOUS THROMBOEMBOLISM DURING PREGNANCY



PROPHYLAXIS IN CAESERIAN SECTION 

Low Risk Early Mobilization  Hydration 



Moderate Risk 

One of variety of prophylactic measures  



Subcutaneous Heparin Mechanical devices

High Risk 

Heparin Prophylaxis +/- Leg Stockings

Report08/01/09 of the RCOG Working Party on prophylaxis (andDrU.Gupta,Dr.N.K.Gupta management) against Thromboembolism in Gynaecology and Obstetrics. 56 London: Royal College of Obstetricians and Gynaecologists, 1995



VENOUS THROMBOEMBOLISM DURING PREGNANCY

Key Points 











Even 1st trimester carries risk of thrombosis (2/3rd antepartum deaths) Additional risk factors/ family history / known thrombophilia may indicate thromboprophylaxis Close attention should be paid to any pregnant woman c/o leg/chest symptoms for e/o DVT/PE All women undergoing C-section should be assessed for prophylaxis against VTE Midwives, GPs & other medical staff should take particular attention of women with chest or leg symptoms after vaginal delivery Women with risk factors for DVT should be carefully screened and considered for thromboprophylaxis

08/01/09

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

VENOUS THROMBOEMBOLISM DURING PREGNANCY

Prevention:      

Weight control Avoid prolong immobility Leg elevation Avoid OCPs containing high dose of Estrogens Adequate hydration Avoid Smoking/Alcohol intake

08/01/09

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VENOUS THROMBOEMBOLISM DURING PREGNANCY Take Home Message 







08/01/09

VTE is an uncommon but very serious complication of pregnancy Pregnant women are at increased risk for VTE, and may present in subtle ways Suspected VTE in pregnancy should be investigated thoroughly Risk of VTE can be reduced in appropriate patients with judicious use of anticoagulants DrU.Gupta,Dr.N.K.Gupta

59

Vascular Control in Gynaecological Surgery 

MODALITIES AVAILABLE 

Open Vascular



Endovascular

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Vascular Control in Gynaecological Surgery 

OPEN VASCULAR     

08/01/09

Uterine artery Ligation Ovarian Artery ligation Internal Iliac Artery Ligation Common Iliac artery control Control over Aorta

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Vascular Control in Gynaecological Surgery 

ENDOVASCULAR   

Balloon Occlusion Stent Graft Embolisation –  

08/01/09

Coil Foam particles etc.

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08/01/09

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