Puerperal Venous Thrombosis

Thrombosis of leg veins and pelvic veins is one of the common and important complications in puerperium, especially in the western countries. The prevalence is, however, low in Asian and African countries. Thrombosis is an intravascular formation of the blood clot.

Types of Thrombosis

1. Phlebothrombosis : i. Superficial ii. Deep
2. Thrombophlebitis : i. Non-suppurative ii. Suppurative

Etiology

• Stasis of blood in the pelvic and leg veins. This is more so when the patient has been kept in prolonged rest during pregnancy and following operative delivery.
• Alteration in the blood constituents.
• Infection: pelvic cellulitis produces inflammation of the venous wall to which a thrombus may be attached.
• Trauma to the venous wall-, pelvic veins are traumatized due to the pressure of the head.
• Other high-risk factors are ;
  • Advanced age and parity.
  •  Cesarean section.
  • Use of estrogen in the suppression of lactation.
  • Obesity
  • Anemia
  • Heart disease
  • Immobility and trauma to the leg etc.

Superficial vein thrombosis

Superficial thrombosis usually occurs in a pre-existing varicose vein in the legs. It usually remains localized, but on rare occasions, it may spread upwards to involve the long saphenous vein and hence to the femoral vein.

Clinical features

• Onset is within one week.
• Pain and tenderness in the affected area.
•  Slight rise in temperature along with the rise in pulse rate.
• Overlying skin looks red which is due to a reaction of the clot rather than to the bacterial infection.

Deep vein thrombosis

It is thrombosis of the deep vein of a calf, thigh, or pelvis, clot formation in the absence of infection. The clot is attached at one end to the wall of the vein. This risk of embolism is great. Deep vein thrombosis is usually manifest during the first 2 weeks after delivery.

Clinical features

• It may remain asymptomatic in a majority of cases.
• Pain and discomfort in the calf and thigh.
• Pitting edema which can be idethe notified by the measurement around the affected legs, an increase in girth of the leg up.to 2-3 cm larger than the non-affected part.
• Temperature may be slightly raised.

Investigation

• Doppler ultrasound to detect the change in the velocity of blood flow in the femoral vein.
• Phlebography: injecting radio-opaque dye to note the filling defect in the venous lumen is a reliable method carefully interpreted.

Prevention

• The three important predisposing factors ie. trauma, sepsis, and anemia should be prevented and to be treated effectively after detection.
• Mechanical methods of prophylaxis include elastic compression ststockingsnd intermittent pneumatic compression dedevicesuring surgery.
• Leg exercise and early ambulation are encouraged especially following operative delivery.
• For high-risk cases, heparin 5000 units subcutaneously twice daily for 1 week postpartum and thereafter switch on to warfarin for 6 weeks.

Management

• The patient is put on bed rest with the foot end raised above the heart level.
• Pain in the affected area may be relieved with analgesics.
  •  Leg is elevated with a protected pillow to aid lymphatic drainage and reduce edema.
  • Sleep is ensured with a tab. Phenobarbital 30-60 mg or diazepam 5 mg.
• Appropriate antibiotics are to be administered to prevent secondary infection.
• As soon as the pain subsides, gentle movement is allowed on a bed by the end of the first week.
• Restriction of movement until clotting time has shown signs of improvement.
•  Anticoagulants
•  Heparin 15,000 units are administered IV followed by 10,000 units, 4-6 hourly for 4-6 injections when the blood coagulation is likely to be depressed to the therapeutic level.
• Warfarin oral drugs, a daily dose of 10 mg for 2 days is adequate for induction.
• Antidote of heparin is protamine sulfate solution at the dose of 1 ml to 1000 units of heparin.