Thrombophlebitis and Thrombosis in Postpartum

 Description

1. Thrombophlebitis is an inflammation of the vascular endothelium with clot formation on the vessel wall.
2. A thrombus forms when blood components (platelets and fibrin) combine to form an aggregate body (clot).
3. Pulmonary embolism occurs when a clot travelling through the venous system lodges within the pulmonary circulatory system, causing occlusion or infarction.
4. The incidence of postpartum thrombophlebitis is 0.1% to 1%, when not treated, 24% of these develop pulmonary embolism, with a fatality rate of 15%.

Etiology

Predisposing risk factors include:

1. History of thrombophlebitis
2. Obesity
3. History of cesarean delivery
4. History of forceps delivery
5. Maternal age older than 35
6. Multiparity
7. Lactation suppression with estrogens
8. Varicosities
9. Anemia and blood dyscrasias

Pathophysiology

1. The three major causes of thrombus formation and inflammation are venous stasis, hypercoagulable blood, and injury to the innermost layer of the blood vessel.
2. Both venous stasis (in pelvis and lower extremities) and hypercoagulable blood are present during pregnancy.
3. The level of most coagulation factors (especially fibrinogen, and factors III, VII, and X) are increased during pregnancy. This increase is accompanied by a decrease in plasminogen and antithrombin III, which cause clots to disintegrate.
4. Injury to the innermost layer of the vessel is probably not contributory, in general, during pregnancy. However, the possibility exists if the birth is by cesarean section.

Assessment Findings

1. Common clinical manifestations

• Superficial thrombophlebitis within the saphenous vein system manifests as midcalf pain, tenderness, redness, and warmth along the vein.
• DVT symptoms include muscle pain, the presence of humans sign (ie, pain in the calf on passive dorsiflexion of the foot, possibly caused by DVT). However, the presence of Homans sign is no longer believed to be conclusive because the pain may result from other causes such as strained muscles or contusions.
• Pelvic thrombophlebitis, typically occurring 2 weeks after delivery, is marked by chills, fever, malaise, and pain.
• Femoral thrombophlebitis, generally occurring 10 to 14 days after delivery, produces chills, fever, malaise, stiffness, and pain.
• Pulmonary embolism is heralded by sudden intense chest pain with severe dyspnea followed by tachypnea, pleuritic pain, apprehension, cough, tachycardia, hemoptysis, and temperature above 38°C (100.4°F).

2. Laboratory and diagnostic study findings

• Venography accurately diagnoses DVT. There are risks associated with the radiopaque dye that is used.
• Real-time and color Doppler ultrasound will diagnose deep venous thrombosis.
• Impedance plethysmography measures changes in venous blood volume and flow.

Nursing Management

1. Promote resolution of symptoms and prevent the development of embolus.

• Assess vital signs.
• Assess extremities for signs of inflammation, swelling, and the presence of Homans sign.
• Administer anticoagulant therapy as prescribed, and observe for signs of bleeding and allergic reactions, Note: Keep the antidote protamine sulfate available in case of a severe heparin overdose. Usually, protamine sulfate solution is administered intravenously at a rate no greater than 50 mg every 10 minutes (see Drug Chart)
• Caution: Do not administer estrogens for lactation suppression, because estrogens may encourage clot formation.
• Prepare the client for diagnostic studies (ie, venography and Doppler ultrasound), as indicated.
• Implement measures to prevent complications of bed rest (e.g., bed placed in Trendelenburg position, use of footboard, passive or active range of motion exercises, frequent shifts in position, and adequate fluid intake and output).

Drug Chart Medications Used for Postpartum Complications

Classifications	Used for	Selected Interventions
Anticoagulants Heparin sodium injection (Hepalean) Lovenox	Blocks the conversion of prothrombin to thrombin and fibrinogen to fibrin thus decreasing clotting ability Inhibits thrombus and clot formation	Heparin IV should be administered as a “piggy back” infusion. Heparin SQ is given deep into the site (abdomen), sites are rotated, do not aspirate, apply pressure (do not massage). Used to prevent and treat pulmonary embolism and thrombosis.
Warfarin sodium (Coumadin, Warfilone)	Interferes with hepatic synthesis of vitamin K –dependent clotting factors (II,VII, IX, X)	Women on anticoagulopathy therapy should no be given estrogen or aspirin. Obtain baseline coagulation studies. Obtain serial coagulation studies while the client is on therapy. Keep protamine sulfate readily available in case of heparin overdose. Assess client for bleeding from nose, gums, hematuria, and blood in stool. Observe color and amount of lochia. Institute pad count. Avoid IM injections to avoid formation of hematomas. Inform the client that this drug does not pass into breast milk. Monitor for the following side effects; hemorrhage, bruising urticaria, and thrombocytopenia. Women on anticoagulant therapy should not be given estrogen or aspirin. Obtain baseline coagulation studies while on therapy. Keep AquaMEPHYTON (vitamin K) on hand in case of Coumadin overdose. Assess client for bleeding from nose, gums, hematuria, and blood in stool. Observe color and amount of lochia. Institute a pad count. Avoid IM injections to avoid formation of hematomas. Inform the client that this drug passes into breast milk and its use is contraindicated during pregnancy. Monitor the following side effects: hemorrhage, fever, nausea, and cramps.
Oxytoxic methylergonovine maleate (methergine) (PO, IM, IV)	Directly stimulates uterine and vascular smooth muscle Promotes uterine contraction Used for prevention and treatment of postpartum or postabortion hemorrhage caused by uterine atony or subinvolution.	Obtain a baseline calcium level. Advise the client that this medication will cause menstrual-like cramps. Assess for numb fingers and toes, cold, chest pain, nausea, vomiting, muscle pain, and weakness. May cause decreased serum prolactin. IV administration is used for emergency dosage only. Administer at a rate of 0.2 mg over at least 1 minute. DO NOT MIX THIS DRUG WITH ANY OTHER DRUG. Use solution only if it is clear and colorless, with no precipitate. May store at room temperature for 60 days. The drug deteriorates with age. Monitor for the following side effects: dyspnea, palpitations, diaphoresis, chest pain, hypotension, and headache.