Pulmonary embolism caused by thrombosis in pregnant women. Learning Objectives 1 .

Explain the 3 groups of groups favourable factors causing thrombosis in pregnant women and postpartum women . !escribecription theof clinical and subclinical symptoms and subclinical of pulmonary embolism 3 . !escribe theription of two groups ofare the resuscitation and recommends using anticoagulants for 3 phases of uterus contractions " . #e Perform in cautioousus and thoughtful when diagnosings as well as solving theable situation of pulmonary embolism in pregnant women. Literature review$ Pulmonary embolism % %pulmonary infarction& is the pulmonary artery obstruction %the main artery or small branches of the pulmonary artery && because components such as %blood clot '' air '' fat '' amniotic fluid ..... & ma(e a move on blood current way to pulmonary artery from elsewhere in the body .. 1 .. Pathophysiology !eep vein thrombosis and pulmonary embolism are considered two of the same disease process '' can be preventedion and treatedtment. )n the later stages of pregnancy and postpartum' there areis allfull of favorable factors causing venous thrombosis includinge $$ 1.1 .. *tatus venous stasis$ #lood stasis condition veins of the lower extremities caused by two factors $$ + )ncreased capacity of volume in venous blood related to pregnancy .. ,he s-uashed of the pregnant uterus into the large veins in the lower extremities % %especially the last 3 months && impedes the flow of blood bac( to cause circulatory stasis of the lower extremities' increase the ris( of blood clots forming .. + )mmediately after birth '' the s-uashed vein is released '' the clot moves to the lungs causing pulmonary embolism caused by thrombosis .. 1. .. Endothelial )njury + !amage to blood vessels and changes in the surface of the uterus '' vegetables may play an important role in the formation of venous thrombosis in the period immediately after postpartum .. + ,he intervention procedures such as forcepforceps '' with vacuum extraction or cesarean surgery may increase injury to the uterine artery endothelium and increase the ris( of blood clots .. 1.3 .. *status of risinge in clotting + !uring pregnancy '' there are some gradually increased clotting factors as $$

. /actors )' )) '' 0)) '' 0))) '' )1 and 1 along with a decrease in protein * lead to a hypercoagulable state .. . 2t 3 months of pregnancy has increased the status of activated protein 4 resistance .. . )ncreased activation of factor inhibiting fibrinolysis such as P2) + 1 '' P2) + during pregnancy .. + ,he presence of antiphospholipid antibodies also causepresence of antiphospholipid antibodies also causes thrombosis in pregnant women using oral contraceptives .. .. 5ote in pregnant women + !uring pregnancy and after childbirth' easily formed vein thrombosis' the possibility in pregnant women is higher than non+pregnant women from "+67 times .. + 4omplications of venous thromboembolism from 7.7 6 to 7.1 8 in pregnant women .. ,herefore' the ris( of pulmonary embolism is in a high proportion of pregnant women .. 9sually occurs within or immediately after the birth '' thehigh death rate is highs .. 3 .. *symptoms 1.1 .. 4linical $$ usually not typical + :ardly*hortness of breathe ' or rapidlyrapid breatheing + 4hest pain + 4yanosis + *weating + 2rrhythmias + 4ough or coughing up blood + Other symptoms when having severe pulmonary artery $$ . #lood pressure lowering $$ % %hypertension ; <7 mm:g or decrease = "7 mm:g compared with hypertension bac(ground of prolonged patients = 16 minutes && '' can be rapidly die. . ,here are scenes together with varicose veins '' increased central venous pressure without explaining the reasons for the other % %pneumothorax '' myocardial infarction '' pericardial effusion '' cardiac arrhythmias .... && 1. . *ubclinical$ + 2rterial blood gases$ p: reduce' PaO reduce '' *aO ; <68 '' Pa4O reduces + #blood tests$ !+dimer blood + E4>$ can be readread imaging$ . )maging to increase the burden of right ventricular or 2cute obstructive pulmonary disease caused pulmonary embolism in main artery$ * wave large in !1' ? wave large in !3 '' , reverse in !3 % %*1?3,3 &&. . *inus tachycardia' right axis' right bundle branch bloc(. + 9ltrasound$ .!oppler 4ircuit$ detected lower extremity veins' the inferior vena cava. . Echocardiography$ increased pulmonary artery pressure' can see right ventricular relaxation'... + Pulmonary 1+ray %minimi@e the 1+ray while pregnancy && $$ nonspecific but may exclude other causes % %frost fractures '' pleural effusion ... &&

+ ,a(e blin(ing ventilation A perfusion % %0 A ? scanning && are considered safe for pregnant women '' 4apture flashing is done before perfusion .. Besults shooting normally exclude pulmonary embolism .. + 4, scan rendering the pulmonary artery % %not ta(en during pregnancy && is the gold standard in the diagnosis of pulmonary embolism '' can detect the position switch .. Cay be necessary in case of capture blin(ing ventilation A perfusion not provide sufficient diagnostic information .. + CB) $$ sensitivity and specificity of CB) in the diagnosis of PE is unclear due to the lac( of large studies comparing CB) D pulmonary angiography .. " .. diagnosis!iagnosis ".1 .. !efinitive diagnosis $$ based on + 4linical $$ . :istory of embolism or current have embolism . 4linical signs $$ often non+typical + *ub4linical $$ often non+typical % %pulmonary angiography is the gold standard for the diagnosis of pulmonary embolism && ". .. !ifferential !iagnosis + 2cute heart failure + Pneumothorax + Pleura effusion + Pneumonia + #leeding from the lungs + Bib fractures ".3 .. ,he ris(y factors in pregnant women + 2fter surgery '' tips .. + )njuries '' fractures .. + *tatus rapid weight gain .. + Bestrict movement .. + :eart failure .. + ,here hypercoagulability .. + :emolytic anemia .. 6 .. ,reatment$ 1.1 .. Principles of management $$ + Caintain the concentration of oxygen in arterial blood PaO = 37 mm:g or *aO = <7 8 + Caintaining blood perfusion pressure to ensure the organi@ation + 9sing anticoagulants to limit the formation of venous thrombosis 1. .. Canagement of resuscitation 1. .1 .. Bespiratory resuscitation $$ its objectives *aO = <7 8 + ,he patient sitting in bed '' pillows in the bac( % %without hypotension && + )f the patient is awa(e '' good cooperation $$ . Oxygen mas( with high doses .. . )f no improvement $$ 5on+invasive mechanical ventilation + )f the patient hasis consciousness disorder $$ intubation '' invasive mechanical ventilation with PEEP % %ventilator regimen in patients with 2B!* && .. 1. . .. 4irculatory resuscitation $$ if hypotension

+ )nfusion $$ 677 ml 5a4l 7.< 8 177 ml A h '' if not improve blood pressure need more vasoactive drugs .. + !rugs $$ . 5oradrenaline or dopamine or adrenaline . !obutamin combined noradrenaline 1. .3 .. anticoagulant 5ote$ !o not use warfarin during pregnancy %especially in the first 3 months && because of possible teratogenicity .. !isclaimer anticoagulant below based on the guidance of the 2merican ,horacic *ociety for venous thrombosis in pregnant women .. a. #efore uterus contractions + )f the patient has no blood pressure' no renal failure $$ use of low molecular weight heparin % %!alteparin or enoxaprin& injection subcutaneously .. . Enoxaparin $$ 1mgA(g every 1 hours .. . !alteparin 77 units A (g A day .. + )f the patient has hypotension '' renal failure $$ usually heparin .. . Cedia ,C $$ first dose E7 !0) A (g '' then maintaining 1E !0 A (g A hour in the first 3 hours to achieve therapeutic doses % %2P,, from "7 + 67s '' or anti 1a from 7.3 to 7.F && .. *ubcutaneous )njection $$ 6+F days after transmission or outpatient treatment with a dose of 1F677 dviA1 hours. b .. Ghen uterus contractions + Cust stop anticoagulant therapy before "+33 hours parturition .. + 9se anticoagulant to 3 hours after normal postpartum or after 1 hours following a cesarean suregy. c .. 2fter postpartum$ + Oral medications $$ 4an add 0itamin H antagonists + Ghen switched to oral medications $$ 5eed to user of oral medications and injections for 6 days '' then stop injecting drugs .. Objectives to be achieved )5B from +3 .. + !uration of anticoagulation $$ . 2t least 3 wee(s postpartum .. . ,otal treatment time pulmonary embolism $$ I 2pproximately 3 months $$ no ris( factors for venous obstruction .. I Over 3 months $$ there are ris( factors for venous obstruction. *self+ evaluation *hort answer -uestions from 1+3 1 .. Pulmonary embolism may patients garments includes forms $$ 2. ...................................................... #. ...................................................... .. )n the later stages of pregnancy and postpartum' there are 3 groups of favorable factors causing venous thrombosis are $$ 1 .. ...................................................... .. ...................................................... 3 .. ......................................................

3 .. !uring pregnancy '' " groups of coagulation factors caused increased hypercoagulability areis $$ 2. /actors )' )) '' 0)) '' 0))) '' )1 and 1 along with a reduce in protein * lead to a hypercoagulable state .. #. 2t 3 months of pregnancy there has an increase ind the status of activated protein 4 resistance .. 4. ...................................................... !. ...................................................... ,!ifference between true + false -uestions from "+13 ?uestions$ E * " .. Ghen pregnant '' the capacity of y decreased venous blood decreases. 6 .. ,he compression of the pregnant on the large veins in the lower extremities % %especially the last 3 months && impedes the flow of blood bac( to causinge circulatory stasis of the lower extremities and increase the ris( of blood clots forming .. 3 .. )mmediately after postpartum '' the vein compression is released '' the clot moves to the lungs causing pulmonary embolism caused by thrombosis F .. ,a(e blin(ing ventilation A perfusion % %0 A ? scanning && are considered safe for pregnant women '' performed shooting flashing perfusion before other blin(ing. Besults shooting normally exclude pulmonary embolism .. E .. 4, scan rendering the pulmonary artery % %not ta(en during pregnancy && is the gold standard in diagnosing pulmonary emboli ' and can detect the position switch .. Cay be necessary in case of capture blin(ing ventilation A perfusion not provide sufficient diagnostic information < .. Ghen respiratory resuscitation pulmonary embolism in pregnancy '' if the situation does not improve '' need to non+invasive mechanical ventilation 17 .. )f pregnant women pulmonary embolism hasve consciousness disorders $$ need to intubation '' invasive mechanical ventilation with PEEP 11 .. Pregnant women with pulmonary embolism '' should be use to anticoagulant warfarin %especially in the first 3 months && 1 .. Patients with pulmonary embolism '' when uterus contractions' must to stop anti+ free@e treatment before calving "+33 hours + Beusing anticoagulants after postpartum '' usually 3 hours or 1 hours after cesarean surgery. 13 .. ,ime used to anticoagulant$ at least 1 wee( after postpartum. 4hoose the one best answer for -uestions 1"+16 $$

1" .. #efore uterus contractions '' if the patient has pulmonary embolism without hypotension' no reduce renal $$ use low molecular weight heparin % %enoxaprin && subcutaneously .. Enoxaparin dose $$ every 1 hours $$ 2. 1mgA(g #. mgA(g 4. 3mgA(g !. "mgA(g 16 .. )f the patient has pulmonary embolism hypotension '' reduce renal$ user common heparin '' intravenous $$ ....... early dose... units A (g '' then maintaining 1E !0 A (g A hour in the first 3 hours to achieve therapeutic doses % %2P,, from "7 + 67s '' or anti 1a from 7.3 to 7.F && .. 2. 37 #. F7 4. E7 !. <7