Vascular problems in Gynecology and Obstetrics

Vascular problems in Gynecology and Obstetrics PowerPoint PPT Presentation

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3/15/2012. DrU.Gupta,Dr.N.K.Gupta. 2. 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(1625-1686)"Father of English Surgery"described aneurysm in arm..

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Vascular problems in Gynecology and Obstetrics

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1. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 1 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]

2. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 2 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(1625-1686)”Father of English Surgery”described aneurysm in arm.

3. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 3 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 transplantation of blood vessel.”

4. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 4 AntiPhospholipid Antibody Syndrome Raynaud’s disease Vasculitis Arterial Disorders

5. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 5 Venous Disorders Varicose Veins

6. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 6 AntiPhospholipid Antibody Syndrome Arterial and Venous thrombosis History- 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

7. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 7 AntiPhospholipid Antibody Syndrome PRIMARY SECONDARY

8. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 8 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


10. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 10 AntiPhospholipid Antibody Syndrome WHEN TO EVALUATE 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

11. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 11 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 (APLAS without thrombotic problems) Aspirin Lifestyle Modification Control of Risk factors – HTN, Smoking, Cholesterol levels, Weight control

12. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 12 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.

13. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 13 AntiPhospholipid Antibody Syndrome PREGNANCY: 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

14. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 14 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.

15. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 15 Raynaud’s disease H/o sensitivity to cold/ episodic pallor or cyanosis Triphasic reaction Involves- fingers, toes, tip of the nose, ear lobes.

16. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 16 Raynaud’s disease Complete evaluation – to R/o underlying cause 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

17. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 17 Raynaud’s disease NonPharmacological Avoidance of cold temp / prolong vibrations Reduce emotional stress Avoid Smoking Calcium channel Blockers Other Agents Sympatholytic drugs ARBs Fluoxetine I.V. Prostaglandins Awaited Cilostazole Sildenafil Bosentan (endothelin receptor inhibitor) Sympathectomy Proximal ??? Localised Digital v v

18. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 18 Vasculitis AutoImmune Disease Inflammation of the blood vessels Symptoms – depend on which blood vessels are inflamed 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

19. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 19 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) PROVIDE INGREDIENTS FOR CELL MARKERS HIGHLY ANTI-INFLAMMATORY CODING CAPACITY BETTER THAN AMINO ACIDS * OVER ACTIVATED, OUT OF BALANCE IMMUNE SYSTEM 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

20. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 20 Vasculitis Management Weighing the available options Steroids Chemotherapeutic Agents Antioxidants/ Digestive Enzymes Treat underlying disorder Lifestyle modification

21. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 21 Venous Disorders Varicose Veins

22. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 22 Varicose Veins Pregnancy Increased blood volume Pressure on veins Relaxation effect of hormones

23. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 23

24. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 24

25. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 25 Varicose Veins Management Non Operative Self resolving (within six weeks) After 6 weeks if problematic/ unacceptable Graduated Compression Stockings Surgery

26. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 26 Varicose Veins

27. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 27 Varicose Veins

28. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 28 Superficial Thrombophlebitis

29. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 29 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

30. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 30 Superficial Thrombophlebitis Diagnosis Painful cord like structure Redness along the vein Tenderness Fever Investigations Duplex scan

31. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 31 Superficial Thrombophlebitis Management 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


33. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 33 Pathophysiology- 5 times higher in pregnancy ? venous stasis of pregnancy Physiological changes asso. with pregnancy VENOUS THROMBOEMBOLISM DURING PREGNANCY

34. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 34 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


36. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 36 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

37. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 37 VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnostic tests Venography

38. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 38 VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnostic tests Duplex Ultrasonography

39. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 39 VENOUS THROMBOEMBOLISM DURING PREGNANCY Diagnostic tests Spiral CT Venography

40. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 40 Diagnostic tests Nuclear Imaging IPG MRI D-dimer VENOUS THROMBOEMBOLISM DURING PREGNANCY

41. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 41 VENOUS THROMBOEMBOLISM DURING PREGNANCY Radiation Exposure

42. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 42 VENOUS THROMBOEMBOLISM DURING PREGNANCY Blood Tests Factor V Leiden Protein C Protein S ACA and LA antibodies Activated Protein C resistance (APC-R) AntiThrombin III Homocystein Prothrombin gene mutation

43. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 43 Pulmonary Embolism Major nonobstetric cause of maternal mortality Cause of Death 2 / 100,000 maternities Maximum – Peripartum More after operative intervention Subtle presentation

44. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 44 Pulmonary Embolism Diagnostic tests Pulmonary Angiography Spiral CT Scan

45. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 45 Pulmonary Embolism

46. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 46 VENOUS THROMBOEMBOLISM DURING PREGNANCY Management Medical/Pharmacological Anticoagulation Anti-platelet agents Surgical Venous Thrombectomy Thrombolysis Endovascular IVC Filter placement Others Hydration Early Mobilization Graduated Compression Stockings Pneumatic compression devices

47. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 47 VENOUS THROMBOEMBOLISM DURING PREGNANCY Medical/Pharmacological Unfractionated Heparin/LMWH Oral Anticoagulation Antiplatelet agents New Molecules Direct Thrombin Inhibitors Lepirudin, Desirudin, Argatroban, Ximelagatran Statins

48. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 48 VENOUS THROMBOEMBOLISM DURING PREGNANCY Surgical Venous Thrombectomy – Ilio-femoral DVT Pulmonary Embolectomy

49. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 49 VENOUS THROMBOEMBOLISM DURING PREGNANCY Surgical Thrombolysis

50. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 50 VENOUS THROMBOEMBOLISM DURING PREGNANCY Endovascular IVC Filter placement Temporary Permanent

51. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 51 VENOUS THROMBOEMBOLISM DURING PREGNANCY Others Hydration Early Mobilization Graduated Compression Stockings Pneumatic compression devices

52. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 52 VENOUS THROMBOEMBOLISM DURING PREGNANCY PROPHYLAXIS Risk Assessment Present status

53. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 53 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)

54. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 54 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 S/c Heparin

55. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 55 VENOUS THROMBOEMBOLISM DURING PREGNANCY PROPHYLAXIS IN CAESERIAN SECTION Low Risk Elective C-section – uncomplicated pregnancy No risk factors Moderate Risk Age, Weight, Parity, Varicose Veins, Immobility, Sepsis, Pre-eclampsia, Emergency C-section, Major Current Illness High Risk 3 or more mod risk factors, Extended major pelvic/abd surgery e.g.Caeserian hysterectomy Personal/family H/o DVT/PE/thrombophilia, Paraparesis Pt with APLAS

56. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 56 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

57. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 57 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

58. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 58 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

59. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 59 VENOUS THROMBOEMBOLISM DURING PREGNANCY 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

60. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 60 Vascular Control in Gynaecological Surgery MODALITIES AVAILABLE Open Vascular Endovascular

61. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 61 Vascular Control in Gynaecological Surgery OPEN VASCULAR Uterine artery Ligation Ovarian Artery ligation Internal Iliac Artery Ligation Common Iliac artery control Control over Aorta

62. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 62 Vascular Control in Gynaecological Surgery ENDOVASCULAR Balloon Occlusion Stent Graft Embolisation – Coil Foam particles etc.

63. 3/15/2012 DrU.Gupta,Dr.N.K.Gupta 63

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