Obstetrics and Gynecology Venous Thrombosis
Introduction
Introduction to gynecological venous thrombosis Deep vein thrombosis is a serious complication of obstetrics and gynecology patients, and if a pulmonary embolism occurs, it will endanger the patient's life. Venous thrombosis (venous thromboembolic disease) includes two types: 1 thrombophlebitis, which is the inflammatory reaction of the intima of the vein wall for various reasons, thrombosis, thrombus and wall adhesion It is not easy to fall off. 2 Venous thrombosis (venous thrombosis), generally believed to be mainly due to slow blood flow and blood clots caused by thrombosis, mostly located in the deep vein, thrombus and tube wall adhesion is light, easy to fall off caused by pulmonary embolism, after thrombosis, most Stimulates the venous inflammatory response, making the thrombus and the wall more densely attached. Some scholars believe that these two lesions may be different stages of a disease, sometimes difficult to distinguish, so they are collectively referred to as venous thrombosis. basic knowledge The proportion of the disease: the incidence rate of pregnant women is about 0.05% Susceptible people: mostly occur in women Mode of infection: non-infectious Complications: sudden death
Cause
Etiology and obstetrics venous thrombosis
(1) Causes of the disease
As early as the mid-19th century, Virchow proposed three factors, including slow blood flow, venous intimal damage and hypercoagulability. This theory is still widely recognized.
1. Slow blood flow Normal blood flows in blood vessels, which form red blood cells, white blood cells and platelets flow in the central axis of blood vessels, and plasma flows between the formed blood vessels and the blood vessel wall. If the blood flow rate is slow, there is blood in the blood. The formation can be stagnant in the blood vessel wall, which creates an opportunity for thrombosis. First, white blood cells, then platelets accumulate around the bloodstream, so that platelets adhere to the intima of the blood vessels, accumulate as the core of thrombosis, and finally form a thrombus, simple blood. A slow flow factor does not cause thrombosis. If other factors exist, such as trauma, shock, and congestive heart failure, thrombosis can be promoted. Age, obesity, and malignant tumors are also considered to be unfavorable factors.
2. Venous intimal injury The venous intima is damaged for various reasons, the collagen or basement membrane underneath is exposed, and the blood contacts the damaged endothelium, causing endogenous or exogenous thromboplastin. Formation and platelet aggregation, promote thrombosis, common causes such as intravenous input of irritating solution, chemical damage to the intima; repeated puncture intravenous or intravenous indwelling catheter caused by mechanical damage; venous lumen Intra- or extraluminal inflammation damage the intima, as well as hypoxia, shock can cause endometrial damage.
3. Changes in blood components in hypercoagulable state, such as increased clotting factor, activation or abnormality, making it hypercoagulable is an important factor in the formation of venous thrombosis. Individual clotting factors or a small amount of clotting factors are activated without causing thrombosis. The body has its own protective mechanism. Under normal circumstances, coagulation and anticoagulation are maintained in a dynamic balance to keep the blood flowing. If other adverse conditions such as slow blood flow occur, thrombosis is easy to occur. The patient's original basic conditions, differences in personal reactions and other factors constitute the complexity of venous thrombosis. Some patients have developed venous thrombosis, but no obvious cause can be found. In-depth study.
(two) pathogenesis
Under normal circumstances, the blood flow to the heart of the lower extremity venous blood, relying on the contraction force generated by the heart beat, the pump generated by the muscles around the vein, the negative pressure suction in the chest during respiratory exercise, and there are many venous valves on the wall of the vein. It can prevent blood from flowing backwards, so that the blood continuously flows to the heart, the lower limbs are shallow, the deep vein system has a venous valve, the valve base is attached to the vein wall, and there is a valve pocket, where the blood flow slowly forms a vortex, which often causes thrombosis. The site, especially the deep veins of the lower leg, is initially deposited by platelets, followed by layered platelets, fibrin and white blood cells forming a mechanical white thrombus, white thrombus and vein wall adhesion, blood flow direction of the venous The expansion and expansion, due to the expansion and adhesion to the side wall, block the venous lumen, it will lead to the reverse direction of the opposite direction, deep vein thrombosis mostly originated from the calf gastrocnemius vein, the incidence accounted for 46% to 98%; origin Yu Yu, 60% of the femoral vein and pelvic veins, also believe that there may be multiple origins, can originate from different parts, clinically seen Most of the patients involved the entire limb, with the calf gastrocnemius venous plexus and the thigh root sac, the femoral vein is a good site, the outcome after thrombosis will be based on the speed of blood flow, changes in the coagulation system, the strength of anticoagulant factors, etc. The growth and decline of various complicated factors, thrombus or stop progress, absorption dissipated or continue to proliferate and expand, 60% of patients with thrombosis and proliferation do not interfere with blood flow, but early thrombosis, only at the origin of the blood vessel wall attached, easy to fall off, lung The serious consequences of embolization, severe pulmonary embolism can be used as the first symptom in the clinical, after deep vein thrombosis, if the venous valve is damaged, it can affect its function, resulting in lower extremity venous thrombosis syndrome: venous hypertension Venous blood through the traffic branch to the superficial venous reflux, superficial varicose veins, subcutaneous congestion, ulcer formation, difficult to heal.
1. In gynecological postoperative venous thrombosis, postoperative blood flow and blood components may lead to thrombosis, which is more unfavorable for patients with high risk factors of hemagglutination. The muscles of lower limbs are relaxed after anesthesia. Slowly, the patient took the bladder lithotomy position during vaginal surgery, the position of the two legs was uncomfortable, the leg frame was not well supported, and there was no soft pad at the armpit, especially in the case of longer operation time, the lower extremity vein was compressed, and the reflux was not smooth. The vein wall is vulnerable to injury, long operation time, excessive blood transfusion or excessive blood loss, insufficient blood volume, dehydration, etc. can cause increased blood viscosity, promote thrombosis, increase the number of platelets during surgery or postoperative period, clotting time Shortening, 50% of patients have gradual increase in platelet count within 1 to 10 days after surgery, the average volume increases, adhesion and aggregation increase, and the release response is enhanced. This change is particularly evident in patients with postoperative venous thrombosis. A large amount of tissue destruction, release of coagulation activating enzyme, can activate the exogenous coagulation pathway, and the level of antithrombin, protein C and plasminogen in patients after large surgery , retroperitoneal lymph node dissection, so that the iliac vessel wall and surrounding tissue damage easily promote iliac vein thrombosis, coupled with long-term bed rest after surgery, abdominal distension, intestinal paralysis, the iliac vein and inferior vena cava reflux blocked, the patient is in slow blood flow, high coagulation Status, if the basic conditions are poor, such as age, obesity, history of radiotherapy and history of venous thrombosis, the possibility of deep vein thrombosis increases, gynecologic tumor patients are relatively high risk, general malignant tumor patients can be considered to be hypercoagulable Chronic disseminated intravascular coagulation and venous thrombosis can occur, and both cases can exist simultaneously in the same patient. In vitro experiments show that tumor tissue and cultured cancer cells can release blood coagulation activating enzyme-like substances; tumor necrosis itself can also be released Intracellular coagulation activating enzyme; tumor patients have increased platelet count, adhesion and aggregation; ovarian cancer, endometrial cancer and cervical cancer patients have significantly reduced release of vascular plasminogen activator, and other factors such as slow blood flow , infection, malnutrition, surgical trauma, radiotherapy, chemotherapy, coagulation and anti-tumor in cancer patients The fragile balance is easily destroyed and causes venous thrombosis. The deep venous thrombosis after advanced ovarian cancer and vulvar cancer can reach 45%. In a group of 3906 patients with early cervical cancer undergoing radical hysterectomy, postoperative pulmonary embolism is found. It is the main cause of death. Pulmonary embolism is also the main cause of death after abdominal hysterectomy for uterine diseases. The incidence rate is 23. Han et al. (1999) reported 1988-1998, 5 cases of gynecological surgery in 10 years. Acute pulmonary embolism, the incidence rate of 3.5 , of which 4 cases of vaginal surgery (3 cases of uterine prolapse, 1 case of anterior and posterior vaginal wall bulging) occurred 1 to 7 days after the occurrence of pulmonary embolism, rescue is invalid, all died, another 1 Abdominal hysterectomy for uterine fibroids, survival, Lin Baoxing et al (2001) reported from January 1990 to December 1999, 2372 cases of hysterectomy in 10 years, 15 cases of deep venous thrombosis after operation, the incidence rate 0.6%, Jin Li et al (1999) reported 11 cases of patients with deep venous thrombosis after gynecologic oncology in 15 years, 8 cases of malignant tumors (4 cases of endometrial cancer, 3 cases of ovarian cancer, invasion) 1 case of sexual mole, a case of benign tumor, 3 In old age, obesity, primary pelvic malignancies, particularly endometrial cancer after surgery complicated by deep vein thrombosis, a risk factor for deep vein thrombosis disease.
2. Pregnancy, puerperal venous thrombosis gestational venous thrombosis can occur during pregnancy or puerperium, but more common in puerperium, due to maternal body in order to adapt to placental exfoliation during childbirth, prevent postpartum hemorrhage, blood coagulation system and resistance Corresponding physiological changes occurred in the coagulation system. In addition to the decrease of coagulation factors XI and XII, coagulation factors II, V, VII, VIII, IX, and X increased, especially in the third month after pregnancy, plasma fibrin It is 50% higher than non-pregnant women and 4~5g/L at the end of pregnancy. The fibrinolytic system, which is the main anticoagulant system, is inhibited by the inhibition of plasminogen inhibitors, the fibrinolytic activity is decreased, and the proteolytic time of prolonged proteins is prolonged. Condensed protein S (PS) levels and active gestational decline, can be reduced to 40% to 60% of normal levels, maintained at a low level throughout pregnancy and puerperium, these physiological changes make pregnant women's blood high Condensed state, in addition to increased blood volume during pregnancy, venous dilatation, increased uterus compression of the inferior vena cava, poor blood return, lower extremity venous pressure, lower extremity edema, varicose veins Exacerbation, Doppler examination showed that the deep venous blood flow velocity of both lower limbs during pregnancy and puerperium slowed down, indicating the presence of deep venous stasis, if pregnancy complicated with hypertensive disorder of pregnancy, diabetes, placental abruption, varicose veins, etc., stenosis, wall damage and ischemia, hypoxia causes endothelial cells to release tissue factor to promote coagulation, surgical production, especially cesarean section, and thrombophlebitis can reach 3 to 19 times of vaginal delivery, due to long-term puerperium In bed or infection, the potential risk of thrombosis can be further increased. Endometritis during puerperium increases the risk of infectious thrombophlebitis in the ovarian vein and pelvic vein.
Foreign literature reports that the incidence of venous thrombosis in pregnancy is the same as that in non-pregnancy, and the incidence of puerperium is 3 to 10 times higher than that in non-pregnancy. The incidence of deep vein thrombosis in pregnancy is 0.130.5, and the period of puerperium is 0.611.5; The incidence of pulmonary embolism during pregnancy was 0.01, and the puerperium was 0.5. In the 23 years of Beijing Obstetrics and Gynecology Hospital (20th to 80s of the 20th century), 38 cases of thrombophlebitis occurred in the puerperium, including 30 cases of lower extremity superphlebitis. There were 6 cases of deep phlebitis, 1 case of pulmonary embolism and 1 case of pelvic vein embolism, the incidence rate was 0.25. Ma Shuiqing (1999) reported Peking Union Medical College Hospital from 1984 to 1997, and received pregnancy (4 cases) and puerperium (8 cases) deep A total of 12 patients with venous thrombosis, the incidence rate of 0.72 , Dong Yuying (2000) reported 12 cases of obstetric venous thrombosis in Shanghai First People's Hospital (1989 ~ 1996) (1 case for pregnancy, 11 cases for puerperium), The incidence rate is 1.1.
Recent studies have found that anti-thrombin (AT) deficiency, protein C (PC) deficiency, protein S (PS) deficiency and factor V Leiden mutation are the main causes of hereditary thrombotic tendency (thrombophilia), is to increase pregnancy venous thrombosis An important factor, antithrombin (AT) is the most important physiological anticoagulant in the body. It has inhibitory effects on various coagulation factors, especially Xa, IXa, XIa and thrombin. Thrombin deficiency is 0.50.2 in the general population. It is a very strong risk factor for venous thrombosis. It has early onset, extensive thrombosis, and easy recurrence. Pregnancy can increase the incidence of venous thrombosis in women with AT deficiency by 20%. , 9.3% to 19.3% of pregnant venous thrombosis patients found AT defects, pregnant women with AT deficiency have a high risk of venous thrombosis (30.8%), protein C (PC) is a physiological anticoagulant, vitamin K Dependent anticoagulant factor, synthesized by the liver, activated by thrombin, activated protein C (APC) is mainly inactivated by factors Va, VIIIa, followed by activation of plasmin, heterozygous PC defects The general population has a disease of 0.15 %0.8%, PC defects accounted for 1.3% to 14% of venous thrombosis in pregnancy, more common in recurrent venous thrombosis, and a history of venous thrombosis in patients with venous thrombosis increased by 3 times. The risk of venous thrombosis in pregnant women with PC deficiency is 12.5%. Protein S (PS) is a vitamin K-dependent anticoagulant. In liver endothelial cells, megakaryocyte synthesis, protein S is activated protein C inactivation factor Va, VIIIa The cofactor has decreased in pregnancy, PS deficiency is a weak risk factor in venous thrombosis, and the risk of venous thrombosis in pregnant women with PS deficiency is 10.9%. The occurrence of factor VLeiden mutation varies by region and race. The incidence of Caucasians is 3% to 7%, and that of Asians is <1%. The mutation of Arg506 is lost after mutation of Factor V Leiden, and its resistance to lysis of APC is called active protein C resistance (APC). -R), still maintain procoagulant activity, blood hypercoagulable state, 95% of APC-R in non-pregnant women have factor VLeiden mutation, women with venous thrombosis have factor V Leiden mutation 25.2%, factor V Leiden Pregnant pregnant women have a pregnant vein The chance of thrombosis is 0.25%. The anti-cardiolipin antibody (AP) or lupus anticoagulant (LA) positive in pregnant women is an acquired thrombotic tendency, which can increase the risk of venous thrombosis during pregnancy or puerperium. Most of deep vein thrombosis Occurred during the puerperium period, the expected rate is 25%, and anti-phospholipid antibodies or lupus anticoagulant factors can cause acquired APC-R.
3. Oral contraceptives Oral contraceptives contain estrogen and progesterone, which came out in the late 1950s. Since the 1960s, foreign countries have reported an increase in thromboembolic disease in women, causing widespread concern, and later found deep venous thrombosis. Pulmonary embolism, cerebral embolism, coronary embolism and estrogen dose, the ethinyl estradiol (EE) contained in it is reduced to less than 50g, no serious cardiovascular disease is found, the study believes that estrogen in oral contraceptives It has an effect on the blood coagulation and anticoagulant system, which increases the blood coagulation factors VII, VIII, IX, X, does not affect the number of platelets, but its function is affected, platelet aggregation is obviously enhanced, in addition, the antithrombin content and activity are decreased, oral contraceptives The increase of fibrinogen in the plasma of users has a dose-dependent dose and a slight increase in plasma prothrombin. The oral contraceptives (I, II) contain 35 g of ethinyl estradiol in China, and few thrombosis in domestic reports. Disease, but for safety, oral contraceptives are contraindicated in patients with thrombotic diseases, an international venous thromboembolism and compound oral contraceptives in 1995 Central case-control study of the risk of developing oral contraceptive-related idiopathic venous thromboembolism (including deep vein thrombosis and pulmonary embolism), from 21 centers in Africa, Asia, Europe and Latin America, 1143 The age of 22 to 44 years old, the control group of 2998 people of the same age, the results showed that the risk of venous thrombosis increased by taking oral contraceptives, the odds ratio in Europe is 4.15 (95% confidence interval 3.09 ~ 5.59), in development The national chance ratio is 3.25 (95% confidence interval 2.594.28). The incidence of deep vein thrombosis is greater than that of pulmonary embolism. The risk of the first 4 months of the drug is significantly increased, regardless of the length of medication. The natural disappearance of the month, the risk of developing venous thrombosis is not related to the age of the person taking the drug, hypertension (except for gestational hypertension) and smoking, but the body mass index (BMI) is independent in both the European and non-European groups. High-risk factors, the chance of developing venous thrombosis in people with BMI>25kg/m2 is greater than that in people with lower BMI, and the risk of morbidity among women with a history of pregnancy-induced hypertension in European group , Although the research center reported combined contraceptive pill related to the incidence of venous thrombosis somewhat lower than previously reported, but the risk of oral contraceptives venous thrombosis is yes.
Prevention
Obstetrics and gynecology vein thrombosis prevention
1. Prevention of venous thrombosis after gynecological surgery Detailed medical history, understanding of the history of personal or family venous thrombosis and other risk factors for thrombosis, correction of anemia, dehydration, control of heart disease, diabetes, oral contraceptives The patient is stopped 3 to 4 weeks before surgery, and the patient is advised to avoid pressure on the lower limbs during surgery. In particular, patients undergoing bladder lithotomy should be gentle in operation, reduce tissue damage and stimulation of pelvic vessels, intraoperatively, surgically. After maintaining water and electrolyte balance, timely correcting dehydration, encouraging patients to turn over after surgery, doing foot flexion and extension exercises, early wake-up activities, postoperative patients with leg discomfort should be carefully examined, alert to early symptoms of deep venous thrombosis of the calf, vein Infusion care should be taken to avoid the input of drugs that are irritating to the veins. Long-term infusions should pay attention to the aseptic treatment of venipuncture.
According to the size of the operation, the length of time, the basic condition of the patient and the unfavorable factors of thrombosis, comprehensive consideration, postoperative prophylactic anticoagulant therapy for patients with high risk factors can help reduce deep venous thrombosis and pulmonary embolism According to a comparative study of 6851 surgical patients in 34 units, the incidence of deep vein thrombosis and pulmonary embolism was 25.9% in the control group and 8.6% in the heparin prophylaxis group. Heparin prophylactic treatment was reported. The risk of thrombosis is reduced by 70%, and fatal pulmonary embolism is reduced by 50%. Both unfractionated heparin or low molecular weight heparin can be used. The following uses are available: unfractionated heparin 5000U/12h or 5000U/8h, subcutaneous injection; low molecular weight heparin enoxaparin 20mg/ d or 40mg / d, subcutaneous injection; low molecular weight heparin dalteparin 2500U / d or 5000U / d, subcutaneous injection, Jin Li et al (1999) reported that patients with gynecological tumors with high risk factors before surgery, postoperative prophylactic anticoagulant therapy On the first day after operation (20h after operation), low-molecular-weight heparin was evaded by 100U/kg once daily, subcutaneous injection was performed at the umbilical cord, and 10 to 12 days was a course of treatment. Only 1 case appeared. Mouth hematoma, no other adverse reactions, to obtain initial results.
2. Prevention and prevention of obstetric venous thrombosis should start from prenatal examination, strengthen pregnancy care and management, pay attention to the history of personal and family venous thrombosis, and actively prevent pregnancy complications during pregnancy, such as hypertensive disorder of pregnancy, heart disease, Diabetes, etc., correctly handle the labor process, strictly control the indications of cesarean section, prevent puerperal infection, encourage early activities after birth or postoperative, do foot flexion and extension exercises, have a history of venous thrombosis, hereditary or acquired thrombosis tendency Pregnant women, because of their high risk of recurrence, advocate prophylactic anticoagulant therapy, from gestation to 6 weeks postpartum, especially those with additional risk factors, such as age > 35 years, obesity, prolonged bed rest or inactivity during pregnancy or Cesarean section, etc., using unfractionated heparin or low molecular weight heparin, heparin therapy during pregnancy should be discontinued after labor, so as not to increase the risk of bleeding, heparin anticoagulant therapy after 4-8 hours postpartum, family history or history of personal venous thrombosis The incidence of venous thrombosis in pregnant women is high, but asymptomatic carriers have a significantly reduced risk of developing venous thrombosis, such as PC defects or PS defects, pregnancy Prophylactic heparin therapy can be given during the puerperium period when the disease is not given during pregnancy, but it is different for asymptomatic AT-deficient carriers. Because of the high risk of pregnancy complicated with thrombosis, it is recommended to give preventive treatment in early pregnancy. .
Complication
Obstetrics and gynecology venous thrombosis complications Complications
Cardio-cerebral vascular embolism occurs when the embolus falls off, and even sudden death.
Symptom
Obstetrics and gynecology venous thrombosis symptoms Common symptoms Primary dysmenorrhea puerperal infection Hypoxemia Sudden pulmonary embolism Relaxation heat hypotension
1. Superficial vein thrombophlebitis venous thrombosis phlebitis in the veins involved in the local red, swollen, painful, hot inflammation, check the veins can touch the cord, began to be soft, until the surface inflammation subsided After that, the strips become hard, the superficial thrombophlebitis has a mild systemic reaction, local symptoms are obvious, and there is obvious pain and tenderness. The pain is relieved or disappeared within 2 to 4 weeks. It is not difficult to diagnose according to the medical history and examination. Generally only need to improve the circulation, with elastic bandages or mild analgesics and local heat, the patient can move, only to give anticoagulants when deep venous thrombosis is suspected.
2. Deep venous thrombosis is most common in the musculoskeletal plexus of the calf and intestines. It grows and spreads to the patellofemoral system, often in the left lower limb. It usually occurs after surgery. The symptoms start from the calf and then involve the thigh. More insidious, consciously behind the calf mild pain, heavy feeling, aggravation when standing, dorsiflexion of the dorsiflexion (Htoman sign positive), due to local symptoms, often covered by other postoperative discomfort, and did not pay attention, until When the thrombus enlargement involves the iliac vein, the corresponding symptoms are noticed. Some of the calf vein thrombosis is absorbed or mechanized, and the symptoms disappear, but they are never found.
The iliac vein thrombosis forms the common vein of the iliac crest, and the thrombus formation in the range from the external iliac vein to the common femoral vein can be secondary to the expansion of the venous plexus of the calf muscle or is primary, and the left side is more common on the left side. With the right common iliac artery crossing the left common iliac vein (the ankle), it is subject to different degrees of compression, affecting the venous return. Once the iliac vein is thrombus, it will cause obvious symptoms, the affected lower limb pain, swelling Superficial varicose veins, elevated body temperature (<38.5 °C), severe pain, located in the affected side of the groin area corresponding to the local femoral vein tenderness, peripheral pulsation is not affected, if the thrombus is confined to the iliac vein, after The treatment subsided rapidly. If the retrograde extension of the thrombus involved the entire lower extremity vein, the symptoms subsided slowly, the swelling was obvious, and the thrombosis anteriorly extended to invade the inferior vena cava caused by the inferior vena cava syndrome. If the thrombus falls off, pulmonary embolism can occur, and the iliac vein thrombosis can be seen. The limbs are obviously swollen, especially in the inguinal triangle and the suprapubic region. The thickness of the affected side and the healthy side are very different. The difference between the thighs is 4-6 cm, and the calf is 2 4cm, walk along the femoral vein parts have tenderness.
3. Infectious pelvic thrombophlebitis is most common after puerperal infection or infective abortion, and can also be seen after postoperative infection. A small number of patients with tubal ovarian abscess are mainly caused by anaerobic bacilli or anaerobic infection. The infection originates from the uterus or the attachment. The inflammation spreads over the pelvic vein. It is usually the ovarian vein and the internal iliac vein. The affected endometrial damage causes thrombosis. The thrombus expansion may involve the common iliac vein and even the inferior vena cava. Retrograde expansion may involve . Femoral vein, lesions are often unilateral, can also be bilateral involvement, first postpartum or postoperative infection, and then pelvic thrombophlebitis, manifested as chills and high fever alternating relaxation heat, pulse continues to increase, patients The general condition is better, no signs of poisoning, no lower abdominal pain or only mild pain and tenderness. No positive findings or palpable mass in pelvic examination, which is ineffective for general antibiotic treatment, rapid treatment of intravenous heparin, and fever of ovarian veins. Appear early, more than 1 week, the treatment effect is good, the recovery is faster, about 6 days can be fever, only antibiotic treatment can be reached Healing, venous or iliac vein involvement, late fever, more than 2 weeks later, clinically have thigh pain, swelling, tender embolism symptoms, antibiotics and heparin anticoagulant therapy, recovery is also slow, fever duration Longer, average 13 days of fever, ovarian venous thrombophlebitis, can occur 2 to 5 days after delivery, sudden abdominal pain, with signs of acute abdomen, elevated body temperature, mostly on the right side, often due to the proposed appendicitis An open laparotomy was found to be diagnosed as ovarian venous thrombosis. Generally, non-invasive examination showed no ovarian vein or internal iliac vein. The past diagnosis was confirmed by surgery, or it was judged by the therapeutic effect of heparin. It is very inaccurate. 11 cases of pelvic thrombophlebitis confirmed by CT and/or MRI have been reported. The affected ovarian vein, internal iliac vein, common iliac vein and inferior vena cava can be clearly seen, and 6 cases of ovarian venous thrombophlebitis are found. Treated with antibiotics alone, these 6 cases can not be diagnosed if they are judged by the efficacy of heparin.
Pulmonary embolism pulmonary embolism is a serious complication of venous thrombosis, rapid onset, can be fatal in a short time, embolism of pulmonary embolism 75% ~ 90% from the lower extremity vein, early limbs or pelvic vein thrombosis early, the thrombus is easy to fall off After the embolus falls off, it reaches the heart and lung through the venous circulation, and blocks the pulmonary blood vessels to form pulmonary embolism. The clinical symptoms of pulmonary embolism vary from transient shortness to acute pulmonary heart disease and even sudden death. The number of pulmonary vascular occlusions, the rate of occurrence and the underlying condition of the patient's heart and lungs.
Pulmonary vascular bed occlusion >25% to 30% of the average pulmonary artery pressure may be slightly increased; >50% of patients may have persistent pulmonary hypertension; blockage of up to 85% can be sudden death, larger pulmonary embolism can cause bronchospasm, alveolar Reduced surfactant, alveolar collapse and lung ventilation / blood flow ratio imbalance, patients with varying degrees of hypoxemia, hypocapnia and alkaliemia.
Clinical manifestations are acute, often occur when a long-term sudden wake-up activity or toileting force occurs, clinical symptoms are obvious and there are few positive signs, common symptoms: sudden difficulty breathing, sudden death, cyanosis, right heart failure, hypotension, extremities Wet cold; chest pain, chest tightness, panic, cough, hemoptysis or foam or pink sputum, syncope, etc., check for increased breathing, cyanosis, tachycardia, jugular vein engorgement, etc., cardiac auscultation has galloping, lung lesions dry , wet voice and wheezing sound, pleural friction sound and pulmonary vascular murmur.
Examine
Obstetrics and gynecology vein thrombosis examination
1. D-dimer of deep venous thrombosis: D-dimer concentration increases when venous thrombosis occurs, and less than 0.5 mg/L may exclude this disease.
2. Pulmonary embolism: typical blood gas abnormalities are hypoxia and excessive oxygen exchange leading to low PaO2 and low PaCO2.
3. Deep vein thrombosis
(1) Doppler ultrasonography: it is a commonly used non-invasive examination method. Ultrasound examination of blood flow rate, according to the reason of blood flow changes caused by intraluminal thrombus, the probe is placed at the proximal end of the venous thrombus, in the thrombus If the distal end is pressurized, if the signal of the venous blood flow rate is not detected, it means that there is a blockage between the two. This is a simple and effective method, and the accuracy of the gastrocnemius venous thrombosis can be repeatedly checked.
Some scholars have reported that the use of co1or Doppler flow imaging (CDFI) to detect deep venous thrombosis of the lower extremities has achieved satisfactory results, can accurately observe the location of the thrombus, and dynamically display various thrombus in real time. Morphology, type; intraluminal obstruction, blood flow status; lumen diameter and lesion changes in the vessel wall, providing a large amount of information for clinical diagnosis, observation of treatment effects and estimation of prognosis provide objective indicators, this examination is safe, non-invasive, No contraindications; the image is intuitive, clear and easy to identify, and is an ideal method for diagnosing deep venous thrombosis of lower extremities.
(2) Impedance plethysmograpHy: Impedance plethysmography is the non-invasive, the most widely used diagnostic method. This method can cause changes in the electrical impedance of the lower limbs according to the change of venous blood volume. The obstruction method is the limb pair. The volumetric response of temporary venous occlusion, the diagnosis of venous thrombosis depends on the change of venous volume and emptying rate after unblocking, bundling 50totrr at the proximal end of the thigh or filling up to the maximum point, that is, the electrical signal reaches the platform, then the sleeve With rapid deflation, the blood of normal limbs can be quickly drained, the volume is reduced, the extension of the external flow wave, suggesting venous thrombosis, the effect on the examination of deep vein thrombosis of the lower leg is very good, the sensitivity is 91%, the shortcoming is that it can not be embolized After the sequela is identified.
(3) venography (venography): venography contrast injection of the contrast agent from the dorsal vein of the foot, direct observation of the lower extremity venous system, the most accurate method for the diagnosis of venous thrombosis and its extent of involvement, if the injection of contrast agent in the femoral vein can be Observing the iliac crest system, the embolization appears as a filling defect or no development, and a thrombus that is free to drift or extend into the iliac vein is a potential risk sign. Intravenous pressure or contrast agent removal from parallel veins can cause false positive results. The same method can inject radionuclides, record the flow of radionuclides with a gamma scintillation counter, delaying the continuous "hot spot" can reflect the accumulation of radionuclides at the thrombus, venography can produce complications such as pain, chemical phlebitis It can also produce allergic reactions, can not be traced observation, pregnant women should not be used.
(4) 125I-fibrenogen scan-ning: clinical use requires a bedside extractable scintillation counter, oral sodium iodide 100 ~ 150mg 24 hours before the experiment to block thyroid uptake of nuclear iodine Function, 125I-labeled fibrinogen is injected into the vein, that is, combined with the thrombus, the site where the lower limbs are concentrated is calculated, and the percentage of radioactivity exceeds the heart is measured. If the increase is 20% or more, the thrombus is detected. This experiment can be used for several days. The limb tracking scan is particularly sensitive to the thrombosis of the calf and gastrocnemius venous plexus shortly after surgery, and the effect on the femoral, hernia, and iliac vein thrombosis is not good.
(5) Others: The measurement of lower extremity venous pressure, temperature recording method, real-time two-dimensional ultrasound imaging, CT or MRI are helpful for diagnosis.
4. Pulmonary embolism
(1) Most of the chest radiographs are normal or only mild abnormalities, mostly occurring in 12 to 36 hours. Common manifestations: pulmonary infiltration or infarction, elevation of diaphragm due to lung collapse, widening and thickening of pulmonary artery , right atrial enlargement and so on.
(2) Electrocardiogram: generally normal or only sinus tachycardia, common changes have QRS axis right deviation, right chest and I, IIIa, V, F lead T wave inversion or ST segment depression, more meaningful The ECG change is Sl Q2-T3, and partial or complete right bundle branch block and right ventricular hypertrophy may also occur.
(3) Other:
1 radionuclide lung scan: has become the most widely used method for screening pulmonary embolism, found that the sensitivity of local perfusion defects caused by vascular occlusion is high, but perfusion abnormalities can also be seen in other diseases, so most patients need to do other an examination.
2CT and MRI techniques: great value for screening for pulmonary embolism, providing information about pulmonary vascular structures and mediastinum, hilar and lung parenchyma.
3 pulmonary angiography: if the risk of operation is very low, pulmonary angiography can not diagnose the rate or the incomplete rate of examination is 3% and 1%, respectively, sensitive to clinically significant pulmonary embolism, can also find more than 7 days of pulmonary embolism, the above A modern diagnostic method can be appropriately selected according to the condition and unit conditions.
Diagnosis
Diagnostic and differential diagnosis of gynecological venous thrombosis
According to the medical history, symptoms, signs and above laboratory tests and auxiliary examinations, the location, extent and patency of thrombophlebitis can be diagnosed.
Different from pelvic congestion syndrome.
