DAY 5
📅 Nov 14 (Thu)
🩺 Thromboembolic Disorders
DME 211: DVT, PE, DIC, AFE
- DVT: Risk factors, Signs (Homans' sign), Prophylaxis
- PE: Symptoms, Diagnosis, Management
- DIC: Consumptive coagulopathy
- AFE: Amniotic Fluid Embolism
🦵 REMEMBER: DVT = Unilateral leg swelling, pain, warmth. Heparin prophylaxis!
🎯 KEY POINT: DIC = Clotting AND bleeding. Triggered by sepsis, abruption, PPH!
"Pregnancy is hypercoagulable. Be vigilant for clots!"
"Guard your heart above all else." - Proverbs 4:23
1. THROMBOEMBOLIC DISORDERS IN PREGNANCY - OVERVIEW
📚 Definition:
Thromboembolic disorders are conditions involving abnormal blood clot formation (thrombosis) and migration (embolism). Pregnancy is a HYPERCOAGULABLE STATE - the risk increases 4-5 fold!
⚠️ EXAM CRITICAL: Thromboembolism is a LEADING CAUSE OF MATERNAL MORTALITY in developed countries and rising in Uganda due to improved diagnosis. Know this topic!
🧬 Why Pregnancy is Hypercoagulable - Virchow's Triad:
🧠 MNEMONIC: "VIRCHOW'S TRIAD IN PREGNANCY"
Vascular stasis: IVC compressed by gravid uterus → venous pooling in legs
Increased coagulability: ↑Factor I, VII, VIII, X; ↓Protein S, Antithrombin III
Rough endothelium: Vessel injury during delivery, surgery
Changes in blood flow: Slower circulation in lower limbs
Hematocrit changes: Physiologic anemia → sludging
Obesity factor: Many pregnant women gain excessive weight
Water retention: Edema compresses veins
ALL 3 FACTORS = INCREASED CLOT RISK!
Vascular stasis: IVC compressed by gravid uterus → venous pooling in legs
Increased coagulability: ↑Factor I, VII, VIII, X; ↓Protein S, Antithrombin III
Rough endothelium: Vessel injury during delivery, surgery
Changes in blood flow: Slower circulation in lower limbs
Hematocrit changes: Physiologic anemia → sludging
Obesity factor: Many pregnant women gain excessive weight
Water retention: Edema compresses veins
ALL 3 FACTORS = INCREASED CLOT RISK!
💡 EXAM ALERT: Highest risk periods: 3rd trimester and postpartum (first 6 weeks)! Risk remains elevated up to 12 weeks postpartum.
2. DEEP VEIN THROMBOSIS (DVT)
📚 Definition:
DVT is the formation of a blood clot in a deep vein, usually in the lower extremities (iliac, femoral, popliteal veins). In pregnancy, LEFT LEG IS 90% MORE AFFECTED due to compression of left iliac vein by right iliac artery (May-Thurner syndrome).
🔴 Risk Factors - The "PREGNANCY CLOTS" Mnemonic:
🧠 MNEMONIC: PREGNANCY CLOTS
Previous DVT/PE (strongest predictor!)
Restricted mobility (bedrest, long travel)
Excessive weight (obesity BMI >30)
Grand multiparity (>5 births)
Nulliparity with severe hyperemesis
Age >35 years
Nephrotic syndrome (protein loss)
Cesarean section (especially emergency)
Young mother with smoking history
Clotting disorders (Factor V Leiden, Protein S deficiency)
Long labor (>12 hours)
Obesity (weight gain >15kg)
Trauma (vascular injury)
Sepsis (endothelial damage)
Previous DVT/PE (strongest predictor!)
Restricted mobility (bedrest, long travel)
Excessive weight (obesity BMI >30)
Grand multiparity (>5 births)
Nulliparity with severe hyperemesis
Age >35 years
Nephrotic syndrome (protein loss)
Cesarean section (especially emergency)
Young mother with smoking history
Clotting disorders (Factor V Leiden, Protein S deficiency)
Long labor (>12 hours)
Obesity (weight gain >15kg)
Trauma (vascular injury)
Sepsis (endothelial damage)
🌍 UGANDA CONTEXT: Traditional practice of postpartum bedrest ("omukyalo") increases DVT risk! Teach early ambulation within 6-12 hours after delivery.
📋 Clinical Features - The "DVT LEG" Signs:
🦵 MNEMONIC: "DVT LEG IS DANGEROUS"
Dilated superficial veins (prominent)
Venous pain (deep, aching)
Tenderness along vein (especially calf)
Limb swelling (unilateral, measure thigh/calf circumference!)
Erythema (warm, red skin)
Girth difference (>2cm compared to other leg)
Increased temperature (warm to touch)
Severe pain on movement
Don't see swelling? Check thighs too! (iliac DVT)
Abdominal pain if iliac vein involved
No weight-bearing comfort
Get help fast!
Embolus risk if untreated!
Right leg possible but 90% left
Observe for pulmonary symptoms
Urgent treatment needed
Signs may be subtle in pregnancy (edema normal)
Dilated superficial veins (prominent)
Venous pain (deep, aching)
Tenderness along vein (especially calf)
Limb swelling (unilateral, measure thigh/calf circumference!)
Erythema (warm, red skin)
Girth difference (>2cm compared to other leg)
Increased temperature (warm to touch)
Severe pain on movement
Don't see swelling? Check thighs too! (iliac DVT)
Abdominal pain if iliac vein involved
No weight-bearing comfort
Get help fast!
Embolus risk if untreated!
Right leg possible but 90% left
Observe for pulmonary symptoms
Urgent treatment needed
Signs may be subtle in pregnancy (edema normal)
🔍 Homans' Sign - The Classic Test:
⚠️ HOMANS' SIGN: Passive dorsiflexion of foot → calf pain.
SENSITIVITY: Only 30-40% (poor!)
SPECIFICITY: Poor - may be positive in muscle strain
EXAM TIP: NEVER rely on Homans' sign alone! Confirm with Doppler ultrasound.
SAFETY: Don't perform if suspected DVT - risk of dislodging clot!
SENSITIVITY: Only 30-40% (poor!)
SPECIFICITY: Poor - may be positive in muscle strain
EXAM TIP: NEVER rely on Homans' sign alone! Confirm with Doppler ultrasound.
SAFETY: Don't perform if suspected DVT - risk of dislodging clot!
🩺 Diagnosis of DVT:
- Clinical suspicion: Based on signs & risk factors
- Doppler ultrasound: GOLD STANDARD (non-invasive, safe in pregnancy)
- D-dimer: Elevated but NOT reliable in pregnancy (normally elevated!)
- Venography: Rarely used (radiation risk)
💉 Management of DVT:
🚨 MNEMONIC: "HEPARIN SAVES LEGS"
Heparin - LOW MOLECULAR WEIGHT HEPARIN (LMWH) is drug of choice!
• Enoxaparin 40mg SC daily (prophylaxis)
• Enoxaparin 1mg/kg SC BD (treatment)
Elevate leg (reduce edema)
Pain management (paracetamol, not NSAIDs)
Active movement (once stable)
Refer to hospital if massive
INR monitoring NOT needed with LMWH
No warfarin in pregnancy (teratogenic!)
Start immediately if suspected
Leg compression stockings (TED stockings)
Encourage ambulation when pain subsides
Give for minimum 3 months
Stop 24 hours before induction/c-section
Heparin - LOW MOLECULAR WEIGHT HEPARIN (LMWH) is drug of choice!
• Enoxaparin 40mg SC daily (prophylaxis)
• Enoxaparin 1mg/kg SC BD (treatment)
Elevate leg (reduce edema)
Pain management (paracetamol, not NSAIDs)
Active movement (once stable)
Refer to hospital if massive
INR monitoring NOT needed with LMWH
No warfarin in pregnancy (teratogenic!)
Start immediately if suspected
Leg compression stockings (TED stockings)
Encourage ambulation when pain subsides
Give for minimum 3 months
Stop 24 hours before induction/c-section
🌍 UGANDA CONTEXT: LMWH (Clexane) is expensive! Many facilities use unfractionated heparin (UFH) 5000 IU SC BD. UFH requires APTT monitoring but is cheaper. Know both protocols!
🛡️ DVT Prophylaxis - Who Needs It?
| Risk Category | Prophylaxis | Duration |
|---|---|---|
| Low risk (no factors) | Early ambulation, leg exercises | Throughout pregnancy & 6 weeks PP |
| Moderate risk (1-2 factors) | LMWH 40mg SC daily | From 28 weeks to 6 weeks PP |
| High risk (3+ factors, previous DVT) | LMWH 40-60mg SC daily | From diagnosis/conception to 6 weeks PP |
| Post-cesarean | LMWH 40mg SC daily | 7 days (or until mobile) |
💡 EXAM ALERT: High-risk prophylaxis = Start as soon as pregnancy confirmed! Don't wait until 28 weeks if multiple risk factors!
3. PULMONARY EMBOLISM (PE)
📚 Definition:
PE is the blockage of pulmonary arteries by thrombus (usually from DVT). It's a MEDICAL EMERGENCY with mortality up to 30% if untreated!
Pathophysiology: DVT → clot dislodges → travels to right heart → blocks pulmonary circulation → ventilation-perfusion mismatch → hypoxia → right heart failure → death
🚨 EXAM CRITICAL: PE is the most common preventable cause of maternal death post-cesarean! Always suspect after sudden collapse!
📋 Clinical Features - The "PE SOB" Presentation:
🫁 MNEMONIC: "PE TAKES BREATH AWAY"
Pleuritic chest pain (sharp, worse with breathing)
Extreme dyspnea (sudden, severe shortness of breath)
Tachycardia (HR >100 bpm)
Anxious, restless, sense of impending doom
Kussmaul's sign (JVP elevated)
Expiratory wheezing, crackles on auscultation
Syncope (fainting, collapse)
Oxygen saturation <90% (despite O2)
Blood-tinged sputum (hemoptysis)
Blood pressure drops (shock)
Right heart failure signs (distended neck veins)
Elevated respiratory rate (>20/min)
Agitation, confusion
Thrombophlebitis signs in leg (DVT source)
Hypotension (late sign = massive PE)
SUDDEN COLLAPSE + DYSPNEA = PE UNTIL PROVEN OTHERWISE!
Pleuritic chest pain (sharp, worse with breathing)
Extreme dyspnea (sudden, severe shortness of breath)
Tachycardia (HR >100 bpm)
Anxious, restless, sense of impending doom
Kussmaul's sign (JVP elevated)
Expiratory wheezing, crackles on auscultation
Syncope (fainting, collapse)
Oxygen saturation <90% (despite O2)
Blood-tinged sputum (hemoptysis)
Blood pressure drops (shock)
Right heart failure signs (distended neck veins)
Elevated respiratory rate (>20/min)
Agitation, confusion
Thrombophlebitis signs in leg (DVT source)
Hypotension (late sign = massive PE)
SUDDEN COLLAPSE + DYSPNEA = PE UNTIL PROVEN OTHERWISE!
🔍 Diagnosis of PE:
- Clinical suspicion: Based on sudden onset dyspnea + risk factors
- ECG: Sinus tachycardia, S1Q3T3 pattern (rare), right heart strain
- Chest X-ray: Usually normal (rules out other causes)
- ABG: Low PaO2, low PaCO2 (hyperventilation)
- D-dimer: Elevated but unreliable in pregnancy
- CT Pulmonary Angiography: GOLD STANDARD (but radiation risk)
- V/Q Scan: Alternative if available (less radiation)
- Echocardiography: Right ventricular strain
⚠️ CLINICAL PEARL: In pregnancy, PERFORM BEDSIDECHEST ULTRASOUND if available - look for right heart strain! Don't wait for CT if unstable.
🚨 Emergency Management of PE - "THE PE PROTOCOL":
🚨 MNEMONIC: "PE IS DEADLY - ACT FAST"
Assess ABCs - Airway, Breathing, Circulation
Call for HELP - Senior doctor, anesthetist
Transfer to ICU/HDU immediately
Fast IV access (2 large bore cannulas)
Anticoagulation:
• LMWH Enoxaparin 1mg/kg SC BD (start immediately!)
• Or Unfractionated heparin IV bolus 80 IU/kg, then infusion
Support BP: Crystalloids, vasopressors if needed
Thigh-high compression stockings (prevent more clots)
Delivery considerations:
• If unstable: EMERGENCY CS under heparin cover
• Stop heparin 24h before delivery if time permits
• Regional anesthesia contraindicated on full heparin
Echocardiogram: Assess right heart function
Alveolar support: High-flow O2, intubation if needed
DVT prophylaxis in future pregnancies
Assess ABCs - Airway, Breathing, Circulation
Call for HELP - Senior doctor, anesthetist
Transfer to ICU/HDU immediately
Fast IV access (2 large bore cannulas)
Anticoagulation:
• LMWH Enoxaparin 1mg/kg SC BD (start immediately!)
• Or Unfractionated heparin IV bolus 80 IU/kg, then infusion
Support BP: Crystalloids, vasopressors if needed
Thigh-high compression stockings (prevent more clots)
Delivery considerations:
• If unstable: EMERGENCY CS under heparin cover
• Stop heparin 24h before delivery if time permits
• Regional anesthesia contraindicated on full heparin
Echocardiogram: Assess right heart function
Alveolar support: High-flow O2, intubation if needed
DVT prophylaxis in future pregnancies
💊 Anticoagulation in Pregnancy - Key Points:
- DO NOT USE WARFARIN: Teratogenic (fetal bleeding, warfarin embryopathy)
- LMWH IS DRUG OF CHOICE: Does not cross placenta, safe for baby
- Monitoring: Anti-Xa levels not routinely needed with LMWH
- Dose adjustment: Increase as pregnancy advances (weight-based)
- Postpartum: Continue 6 weeks minimum
🌍 UGANDA CONTEXT: Thromboprophylaxis is UNDERUTILIZED! Many maternal deaths post-cesarean are preventable with LMWH. Advocate for heparin availability in your facility!
⚕️ Massive PE - When to Thrombolyse?
| Clinical Scenario | Management | Uganda Feasibility |
|---|---|---|
| Mild PE (hemodynamically stable) | LMWH SC, monitor | ✅ Standard |
| Moderate PE (some instability) | LMWH SC, ICU care | ✅ With monitoring |
| Massive PE (cardiac arrest, shock) | Thrombolysis (Alteplase) + LMWH | ⚠️ Only at referral hospitals |
| PE + DIC | FFP, cryoprecipitate + heparin | ⚠️ Blood bank dependent |
💡 CRITICAL EXAM POINT: Gap of 5-7 days between DVT diagnosis → PE symptoms! This is clot migration time. Always ask about recent leg pain/swelling.
4. DISSEMINATED INTRAVASCULAR COAGULATION (DIC)
📚 Definition:
DIC is a CONSUMPTIVE COAGULOPATHY - widespread activation of clotting cascade leading to formation of microthrombi throughout circulation, consuming all clotting factors and platelets → paradoxical BLEEDING.
Key concept: Body runs out of clotting factors → hemorrhage everywhere!
🚨 EXAM CRITICAL: DIC is NEVER primary - always secondary to another condition! Find and treat the TRIGGER!
🔴 Triggers in Pregnancy & Postpartum - "The DEADLY 6":
☠️ MNEMONIC: "DIC TRIGGERS ARE OBSTETRIC EMERGENCIES"
DIC - Sepsis (gram-negative endotoxin triggers clotting)
Intrauterine fetal death (dead fetus >4 weeks)
Complications:
Abruption placentae (most common obstetric cause!)
Bleeding: Massive PPH (releases thromboplastin)
Ruptured uterus (tissue factor release)
Uterine inversion
Pre-eclampsia/HELLP syndrome
Trauma (accidents, unsafe abortion)
Infection (chorioamnionitis, endometritis)
Other: AFE, severe malaria
Necrotic tissue (retained placenta)
ABRUPTION + MASSIVE HEMORRHAGE = #1 CAUSE OF OBSTETRIC DIC!
DIC - Sepsis (gram-negative endotoxin triggers clotting)
Intrauterine fetal death (dead fetus >4 weeks)
Complications:
Abruption placentae (most common obstetric cause!)
Bleeding: Massive PPH (releases thromboplastin)
Ruptured uterus (tissue factor release)
Uterine inversion
Pre-eclampsia/HELLP syndrome
Trauma (accidents, unsafe abortion)
Infection (chorioamnionitis, endometritis)
Other: AFE, severe malaria
Necrotic tissue (retained placenta)
ABRUPTION + MASSIVE HEMORRHAGE = #1 CAUSE OF OBSTETRIC DIC!
📋 Pathophysiology - The "Vicious Cycle":
- Trigger released: Tissue factor (e.g., from placenta, dead tissue)
- Clotting cascade activated: Thrombin generated
- Microthrombi formed: In microcirculation (blocks blood flow → organ ischemia)
- Clotting factors consumed: Fibrinogen ↓↓, Platelets ↓↓, Factors V, VIII, XIII ↓
- Fibrinolysis activated: Plasmin breaks down clots → D-dimers ↑↑↑
- Bleeding begins: Every puncture site bleeds, gums bleed, nosebleeds
- Vicious cycle: More bleeding → more tissue factor → more DIC
🩸 Clinical Features - The "DIC DUALITY":
🩸 MNEMONIC: "DIC = CLOTTING + BLEEDING SIMULTANEOUSLY"
🔴 BLEEDING SIGNS:
• Uncontrolled PPH (no clots, just liquid blood)
• Venepuncture sites ooze blood
• Gum bleeding, nosebleeds
• Purpura, petechiae (skin bleeding)
• Hematuria (bloody urine)
• Intracranial bleeding (late, fatal)
🟣 CLOTTING SIGNS:
• Cyanotic digits (blocked circulation)
• Oliguria (renal failure from clots)
• Confusion (cerebral ischemia)
• Respiratory distress (ARDS)
• Jaundice (from hemolysis)
🔴 BLEEDING SIGNS:
• Uncontrolled PPH (no clots, just liquid blood)
• Venepuncture sites ooze blood
• Gum bleeding, nosebleeds
• Purpura, petechiae (skin bleeding)
• Hematuria (bloody urine)
• Intracranial bleeding (late, fatal)
🟣 CLOTTING SIGNS:
• Cyanotic digits (blocked circulation)
• Oliguria (renal failure from clots)
• Confusion (cerebral ischemia)
• Respiratory distress (ARDS)
• Jaundice (from hemolysis)
⚠️ OBSTETRIC PEARL: In DIC, the blood doesn't clot! If you draw blood, it stays liquid in the syringe. Bedside clotting test shows no clot after 10 minutes!
🧪 Diagnosis of DIC:
| Test | Normal Value | DIC Result | Why |
|---|---|---|---|
| PT (Prothrombin Time) | 11-13 seconds | Prolonged (>15s) | Factors consumed |
| APTT | 30-40 seconds | Prolonged (>45s) | Factors consumed |
| Fibrinogen | 2-4 g/L | <1.5 g/L (very low) | Primary factor consumed |
| Platelets | 150-400 x10⁹/L | <100 x10⁹/L (thrombocytopenia) | Consumed in clots |
| D-dimer | <0.5 mg/L | Very high (>4 mg/L) | Massive fibrinolysis |
| Blood film | Normal RBCs | Schistocytes (fragmented) | Microangiopathic hemolysis |
| Bedside clotting test | Clot in 5-10 min | No clot in 10 min | Coagulation failure |
💡 CRITICAL EXAM POINT: LOW FIBRINOGEN is the most specific test for DIC in pregnancy! Normal pregnancy = 4-6 g/L (elevated). In DIC, drops to <2 g/L = diagnostic!
🚨 Emergency Management of DIC - "THE ABC OF DIC":
🩸 MNEMONIC: "TREAT THE TRIGGER, REPLACE, CLOT"
TREAT THE TRIGGER (most important!):
• Abruption → Deliver baby & placenta
• Sepsis → Broad spectrum antibiotics
• PPH → Stop bleeding source
• Retained placenta → Manual removal
REPLACE CLOTTING FACTORS:
• Fresh Frozen Plasma (FFP) 15-20ml/kg (4-6 units)
• Cryoprecipitate 1-2 pools (rich in fibrinogen)
• Platelets if <50 x10⁹/L (1 unit)
• Fibrinogen concentrate if available (4g)
CLOT WITH HEPARIN:
• CONTROVERSIAL! Only if thrombosis dominates
• Low dose heparin 500-1000 IU/hour infusion
• NEVER give if bleeding is dominant
• Stop if no improvement in 4 hours
SUPPORT:
• Maintain BP (crystalloids, inotropes)
• Oxygen (maintain saturation >95%)
• Treat acidosis (NaHCO3 if pH <7.2)
• Replace blood loss (PRBC if Hb <7g/dL)
TREAT THE TRIGGER (most important!):
• Abruption → Deliver baby & placenta
• Sepsis → Broad spectrum antibiotics
• PPH → Stop bleeding source
• Retained placenta → Manual removal
REPLACE CLOTTING FACTORS:
• Fresh Frozen Plasma (FFP) 15-20ml/kg (4-6 units)
• Cryoprecipitate 1-2 pools (rich in fibrinogen)
• Platelets if <50 x10⁹/L (1 unit)
• Fibrinogen concentrate if available (4g)
CLOT WITH HEPARIN:
• CONTROVERSIAL! Only if thrombosis dominates
• Low dose heparin 500-1000 IU/hour infusion
• NEVER give if bleeding is dominant
• Stop if no improvement in 4 hours
SUPPORT:
• Maintain BP (crystalloids, inotropes)
• Oxygen (maintain saturation >95%)
• Treat acidosis (NaHCO3 if pH <7.2)
• Replace blood loss (PRBC if Hb <7g/dL)
🚨 CRITICAL RULE: DIC MANAGEMENT IS A RACE AGAINST TIME! If trigger not removed in 1-2 hours, mortality >50%. DELIVER THE BABY if abruption/sepsis is cause - don't delay!
📉 Monitoring Response to Treatment:
- Every 1 hour: PT/INR, fibrinogen level
- Every 30 min: Bedside clotting test
- Every 15 min: BP, pulse, urine output
- Success signs: Clotting in 5-10 min, fibrinogen rising, bleeding slowing
📊 EXAM STRATEGY: In DIC questions, always write: "Treat the underlying trigger while replacing clotting factors." This single sentence gets 50% of marks!
5. AMNIOTIC FLUID EMBOLISM (AFE)
📚 Definition:
AFE is a rare, catastrophic syndrome caused by amniotic fluid entering maternal circulation, triggering an anaphylactoid reaction and DIC. Mortality: 60-80% - one of the most lethal obstetric emergencies!
Pathophysiology: Amniotic fluid (with fetal cells, debris) enters maternal blood → immune reaction → severe pulmonary hypertension → hypoxia → cardiac arrest → DIC
⚠️ EXAM CRITICAL: AFE is UNPREDICTABLE and UNPREVENTABLE! It can happen in normal labor, during c-section, or postpartum. Sudden collapse is hallmark!
🔴 Clinical Features - The "AFE TRIAD":
- Sudden respiratory distress: Dyspnea, cyanosis, pulmonary edema
- Cardiovascular collapse: Hypotension, cardiac arrest, arrhythmias
- DIC: Massive hemorrhage from all orifices, no clotting
Plus: Seizures, coma, fetal distress (always present)
🚨 MNEMONIC: "AFE = SUDDEN DEATH SCENARIO"
Sudden collapse during labor/delivery
Uncontrollable bleeding (DIC)
Dyspnea severe (air hunger)
DIC labs (low fibrinogen, high D-dimer)
Eclampsia-like seizures
No warning signs (happens in healthy women)
Distraught team (emergency!)
Everything fails (resuscitation difficult)
Associated with:
• Strong uterine contractions
• Ruptured membranes
• Cervical lacerations
• Placenta abruption
Treatment is supportive only
High mortality despite best care
CLASSIC SCENARIO: Woman in active labor suddenly gasps, collapses, turns blue, and starts bleeding profusely from IV site.
Sudden collapse during labor/delivery
Uncontrollable bleeding (DIC)
Dyspnea severe (air hunger)
DIC labs (low fibrinogen, high D-dimer)
Eclampsia-like seizures
No warning signs (happens in healthy women)
Distraught team (emergency!)
Everything fails (resuscitation difficult)
Associated with:
• Strong uterine contractions
• Ruptured membranes
• Cervical lacerations
• Placenta abruption
Treatment is supportive only
High mortality despite best care
CLASSIC SCENARIO: Woman in active labor suddenly gasps, collapses, turns blue, and starts bleeding profusely from IV site.
🚨 Management of AFE - "SUPPORTIVE CARE ONLY":
🆘 MNEMONIC: "AFE = FIGHT FOR LIFE"
Fast resuscitation:
• CPR if cardiac arrest
• Intubation & 100% O2
• Large bore IV access (2 lines)
Inotropes for heart failure:
• Dobutamine, noradrenaline
Give blood products for DIC:
• FFP, cryoprecipitate, platelets
Hysterectomy may be needed:
• If uterus is source of fluid entry
Transfer to ICU if survive initial event
Fetus: Emergency delivery if undelivered
Outcome: Poor (<20% survive neurologically intact)
Reality: Most die within 1 hour
Limited treatment options
Inform relatives early (guarded prognosis)
Family support critical
Expect the worst, hope for the best
Fast resuscitation:
• CPR if cardiac arrest
• Intubation & 100% O2
• Large bore IV access (2 lines)
Inotropes for heart failure:
• Dobutamine, noradrenaline
Give blood products for DIC:
• FFP, cryoprecipitate, platelets
Hysterectomy may be needed:
• If uterus is source of fluid entry
Transfer to ICU if survive initial event
Fetus: Emergency delivery if undelivered
Outcome: Poor (<20% survive neurologically intact)
Reality: Most die within 1 hour
Limited treatment options
Inform relatives early (guarded prognosis)
Family support critical
Expect the worst, hope for the best
🌍 UGANDA CONTEXT: Differentiate AFE from eclampsia and hemorrhagic shock. AFE has sudden respiratory distress + DIC simultaneously. Most rural facilities - diagnosis is clinical, survival is rare.
6. MASTER COMPARISON TABLE
| Feature | DVT | PE | DIC | AFE |
|---|---|---|---|---|
| Primary Problem | Venous clot | Arterial blockage | Coagulation failure | Anaphylactoid reaction |
| Timing | Antepartum, postpartum | Usually postpartum | Peripartum | During labor/delivery |
| Key Symptom | Unilateral leg pain/swelling | Sudden dyspnea | Uncontrolled bleeding | Sudden collapse |
| Diagnosis | Doppler ultrasound | CTPA | Low fibrinogen | Clinical (diagnosis of exclusion) |
| Main Treatment | LMWH | LMWH + O2 | Treat trigger + FFP | Supportive + CPR |
| Mortality | Low if treated | 30% if untreated | 50% if trigger not removed | 60-80% |
| Prevention | LMWH prophylaxis | DVT prophylaxis | Prevent triggers | None (unpredictable) |
LIKELY EXAM QUESTIONS FOR DAY 5
1. FILL-IN-THE-BLANK (2 marks)
The classic triad of amniotic fluid embolism includes respiratory distress, cardiovascular collapse, and ______.
ANSWER: Disseminated intravascular coagulation (DIC)
2. MULTIPLE CHOICE (3 marks)
A post-cesarean mother on day 3 reports sudden shortness of breath and chest pain. Examination shows tachycardia and swollen left leg. The most likely diagnosis is:A) Pulmonary embolism ⭐ CORRECT
B) Postpartum eclampsia
C) Anemia
D) Pneumonia
EXPLANATION: Classic presentation of PE with source (DVT in left leg) + symptoms (SOB, chest pain) + risk factor (cesarean).
3. SHORT ANSWER (5 marks)
Outline the three components of Virchow's triad and explain how pregnancy affects each component.
ANSWER GUIDE: 1 mark per component + 1 mark each for pregnancy effect
• Vascular stasis: IVC compression by uterus - 2 marks
• Hypercoagulability: ↑clotting factors, ↓natural anticoagulants - 2 marks
• Endothelial injury: Delivery trauma, vessel injury - 1 mark
• Vascular stasis: IVC compression by uterus - 2 marks
• Hypercoagulability: ↑clotting factors, ↓natural anticoagulants - 2 marks
• Endothelial injury: Delivery trauma, vessel injury - 1 mark
4. PRACTICAL SCENARIO (10 marks)
A woman with retained placenta for 3 hours has just delivered with manual removal. She is now bleeding profusely with no clots, BP 80/50, HR 130/min. Bedside clotting test shows no clot after 10 minutes. What is the diagnosis? Outline immediate management.
ANSWER:
Diagnosis: DIC secondary to retained placenta - 2 marks
Management:
• Treat trigger: Ensure placenta completely removed - 2 marks
• IV access (2 lines) - 1 mark
• FFP 15-20ml/kg (4-6 units) - 2 marks
• Cryoprecipitate 2 pools - 1 mark
• Platelets if <50 - 1 mark
• Treat shock (fluids, blood) - 1 mark
Diagnosis: DIC secondary to retained placenta - 2 marks
Management:
• Treat trigger: Ensure placenta completely removed - 2 marks
• IV access (2 lines) - 1 mark
• FFP 15-20ml/kg (4-6 units) - 2 marks
• Cryoprecipitate 2 pools - 1 mark
• Platelets if <50 - 1 mark
• Treat shock (fluids, blood) - 1 mark
5. TRUE/FALSE (2 marks each)
a) Homans' sign is highly sensitive for diagnosing DVT in pregnancy.b) Warfarin is the anticoagulant of choice for treating DVT in pregnancy.
c) DIC is characterized by both thrombosis and bleeding.
ANSWERS:
a) FALSE - Only 30-40% sensitive, not reliable
b) FALSE - LMWH is drug of choice, warfarin is teratogenic
c) TRUE - Consumptive coagulopathy causes both
a) FALSE - Only 30-40% sensitive, not reliable
b) FALSE - LMWH is drug of choice, warfarin is teratogenic
c) TRUE - Consumptive coagulopathy causes both
6. LIST QUESTION (8 marks)
List four risk factors for DVT in pregnancy and four triggers for DIC in obstetrics.
ANSWER:
DVT Risk: Previous DVT, cesarean section, obesity, immobility, age>35, multiparity (any 4)
DIC Triggers: Abruptio placentae, massive PPH, sepsis, uterine rupture, IUFD, AFE, pre-eclampsia (any 4)
MARKING: 1 mark per correct answer
DVT Risk: Previous DVT, cesarean section, obesity, immobility, age>35, multiparity (any 4)
DIC Triggers: Abruptio placentae, massive PPH, sepsis, uterine rupture, IUFD, AFE, pre-eclampsia (any 4)
MARKING: 1 mark per correct answer
📊 STATISTICS: DVT/PE questions appear in 85% of midwifery exams, DIC in 90% (especially in PPH scenarios), AFE in 60% (usually as "sudden collapse" scenario). Master the differences!
📚 DAY 5 SUMMARY: THE CLOTTING CATASTROPHES
🎯 The 4 Disorders in 30 Seconds:
🩺 DVT = DEEP CLOTS IN LEGS
Unilateral swelling + pain → LMWH for 3 months
🫁 PE = CLOTS REACH LUNGS
Sudden SOB + chest pain → Oxygen + LMWH FAST
🩸 DIC = RUN OUT OF CLOTTING
Bleeding everywhere → Find trigger + give FFP/cryo
🧬 AFE = MEGA ALLERGIC REACTION
Collapse during labor → CPR rarely works
PREGNANCY = HYPERCOAGULABLE = ALWAYS SUSPECT!
Unilateral swelling + pain → LMWH for 3 months
🫁 PE = CLOTS REACH LUNGS
Sudden SOB + chest pain → Oxygen + LMWH FAST
🩸 DIC = RUN OUT OF CLOTTING
Bleeding everywhere → Find trigger + give FFP/cryo
🧬 AFE = MEGA ALLERGIC REACTION
Collapse during labor → CPR rarely works
PREGNANCY = HYPERCOAGULABLE = ALWAYS SUSPECT!
🎯 The 3 Life-Saving Rules:
- DVT Prophylaxis: Give LMWH to anyone with 2+ risk factors
- PE Suspicion: Sudden collapse = assume PE, give LMWH while investigating
- DIC Management: Treat trigger + replace factors simultaneously
🎯 Drug Safety in Pregnancy:
- SAFE: LMWH (enoxaparin), unfractionated heparin
- UNSAFE: Warfarin (fetal bleeding, teratogenic)
- MONITOR: Bedside clotting test, fibrinogen levels
- DURATION: Minimum 3 months, continue 6 weeks postpartum
⚠️ FINAL EXAM TIP: In any scenario with sudden collapse, think: PE, AFE, or hemorrhagic shock. Distinguish by: PE = dyspnea, AFE = collapse + DIC, Shock = bleeding! This gets full marks!
"Thromboembolism is silent but deadly. Your vigilance is the mother's lifeline - suspect early, treat fast, prevent always!"
"Guard your heart above all else, for it determines the course of your life." - Proverbs 4:23